James Wright

University of Oxford | OX · Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)

Importance: While a gender pay gap in medicine has been well documented, relatively little research has addressed mechanisms that mediate gender differences in referral income for specialists. Objective: To examine gender-based disparities in medical and surgical specialist referrals in Ontario, Canada. Design, setting, and participants: This...

Introduction: Health care system transformations that align with the principles of integrated care require the collaborative efforts of various macro-, meso- and micro-level stakeholders. Understanding the roles of various system actors can improve collaboration in ways that support purposeful health system change. Professional associations (PAs)...

BACKGROUND The COVID-19 pandemic yielded extraordinary stressors and well-being challenges for physicians. OBJECTIVE We sent light-touch SMS messages to improve well-being in Ontario physicians and sought to determine which types of messages were most effective. METHODS We conducted a randomized longitudinal study with three trial arms for compar...

Background: Uptake of virtual care increased substantially during the first year of the COVID-19 pandemic. The aim of this study was to evaluate whether a shift from in-person to virtual visits by primary care physicians was associated with increased use of emergency departments among their enrolled patients. Methods: We conducted an observation...

Background: Studies have estimated that a large backlog of procedures was generated by emergency measures implemented in Ontario, Canada, at the onset of the COVID-19 pandemic, when nonessential and scheduled procedures were postponed. Understanding the impact of the COVID-19 pandemic on the time needed to perform a procedure may help to determine...

The impact of the COVID-19 pandemic on primary care

Objectives To estimate the impact of the SARS-CoV-2 (COVID-19) pandemic on levels of burnout among physicians in Ontario, Canada, and to understand physician perceptions of the contributors and solutions to burnout. Design Repeated cross-sectional survey. Setting Active and retired physicians, residents and medical students in Canada’s largest pr...

Importance Men and women should earn equal pay for equal work. An examination of the magnitude of pay disparities could inform strategies for remediation. Objective To examine gender-based differences in pay within a large, comprehensive physician population practicing within a variety of payment systems. Design, Setting, and Participants This cr...

Background Electronic medical record (EMR) systems have the potential to facilitate appropriate laboratory testing. We examined three common medical tests in primary care—hemoglobin A1c (HbA1c), lipid, and thyroid stimulating hormone (TSH)— to assess whether adoption of a laboratory EMR system in Ontario had an impact on the rate of inappropriate t...

Background: New case-mix tools from the Canadian Institute for Health Information offer a novel way of exploring the prevalence of chronic disease and multimorbidity using diagnostic data. We took a comprehensive approach to determine whether the prevalence of chronic disease and multimorbidity has been rising in Ontario, Canada. Methods: In thi...

Aims To compare changes in gait kinematics and walking speed 24 months after conventional (C-MLS) and minimally invasive (MI-MLS) multilevel surgery for children with diplegic cerebral palsy (CP). Methods A retrospective analysis of 19 children following C-MLS, with mean age at surgery of 12 years five months (seven years ten months to 15 years 11...

Applications of behavioral economics targeted at optimizing laboratory utilization among physicians have been implemented in Ontario through different types of nonfinancial interventions. Strict policy interventions restrict Ontario Health Insurance Plan (OHIP) payment for tests to patients with specific conditions or limit ordering to particular p...

Background: Prior research has consistently shown that the heaviest users account for a disproportionate share of health care costs. As such, predicting high-cost users may be a precondition for cost containment. We evaluated the ability of a new health risk predictive modelling tool, which was developed by the Canadian Institute for Health Inform...

Purpose To report functional mobility in patients with diplegic cerebral palsy (CP) at long-term follow-up after single-event multilevel surgery (SEMLS). The secondary aim was to assess the relationship between functional mobility and quality of life (QoL) in patients previously treated with SEMLS. Methods A total of 61 patients with diplegic CP,...

Purpose Paediatric foot surgery is often performed to restore anatomical shape or range of movement (ROM). The purpose of this study was to determine how foot morphology and ROM are associated with foot function in children aged five to 16 years of age. Methods Participants included 89 patients with foot disorders and 58 healthy controls. In addit...

Objective: Until recently, the options for summarizing Canadian patient complexity were limited to health risk predictive modeling tools developed outside of Canada. This study aims to validate a new model created by the Canadian Institute for Health Information (CIHI) for Canada's health care environment. Research design: This was a cohort stud...

Simple (unicameral) bone cyst (SBC) and aneurysmal bone cyst (ABC) are common benign bone tumors in children and adolescents. Although non-cancerous, they can cause substantive physical and psychosocial problems. Particularly for ABC, they mimic malignant tumors causing understandable anxiety and fear. As such, early and accurate diagnosis is essen...

Musculoskeletal manifestations associated with myelomeningocele (MMC) are common; often resulting in significant functional impairments relating to gait abnormalities, seating imbalance, and skin ulceration. Hip deformities, including soft tissue contractures and dislocation, are seen across neurosegmental levels; the former of which may cause impa...

Introduction: Orthopaedics procedures are frequent and expensive, but highly cost effective in improving the quality of life. The purpose of this study was to determine the number and topics of systematic overviews on the effectiveness of orthopaedic interventions. Methods: We performed a review of PubMed, Ovid Embase, Scopus, OrthoEvidence, and...

Purpose To develop and evaluate the reliability of an explicit set of parameters and criteria for simple bone cysts (SBCs) and evaluate the reliability of single versus serial chronological reading methods Methods Radiographic criteria were developed based on the literature and expert consensus. A single anteroposterior/lateral radiograph from 32...

Background: Congenital idiopathic clubfoot is a condition that affects, on average, approximately 1 in 1,000 infants. One broadly adopted method of management, described by Ponseti, is the performance of a percutaneous complete tenotomy when hindfoot stall occurs. The use of onabotulinum toxin A (BTX-A) along with the manipulation and cast protoco...

Aim: To review the potential predictors of outcome after single-event multilevel surgery (SEMLS) in children with cerebral palsy (CP). Method: A literature search using the following criteria was performed in six electronic databases: (1) children with cerebral palsy; (2) analysed potential predictors of outcome after SEMLS; (3) minimum 12 month...

Background: Up to 40% of patients with idiopathic clubfoot who are treated with the Ponseti method experience recurrence of deformity. Many of these patients receive surgery (e.g., anterior tibial tendon transfer). An alternative approach for recurrent clubfoot is repeat Ponseti casting. The purpose of this study was to evaluate the outcome of rep...

Aims: High-quality clinical research in children's orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children's orthopaedics. Methods: A modified Delphi technique was used, which involved an initial scoping survey, a two-round Del...

Simple bone cyst is a common benign lesion of bone. Although it is considered to be benign (non cancerous), it can cause fractures, deformities and psychosocial problems. Several treatments have been advocated with variable success, and the search for better treatments is ongoing. In this chapter, we have summarised the evidence that underpin curre...

Children with spina bifida manifest several congenital or developmental spine and limb deformities. Hip dislocation and scoliosis are among the most common musculoskeletal deformities in these patients. Surgical correction of these deformities has been advocated to improve function and quality of life. Current evidence shows that surgical reduction...

PurposeHealthcare providers have limited time to spend with scoliosis patients who are considering surgery and their families. The purpose of this study was to evaluate an e-health strategy to increase knowledge and coping in patients with scoliosis who are surgical candidates and their families. Methods We enrolled patients with scoliosis who were...

Treatment options specific to early-onset scoliosis (EOS) have rapidly expanded, and the research base has attempted to keep in step. From the literature, certain outcomes have emerged as adequate reflections of the natural history of this disease. The standard radiographic measures such as Cobb angle and kyphosis are most prevalent, with growing r...

Background: With the alarming statistics concerning the quality of national health care, it is hoped that electronic health records (EHRs) will reduce inefficiencies associated with medical delivery and improve patient safety. This study reports the results of a survey that demonstrates a pattern in EHR system implementation that indicates that hea...

Innovation is important for the improvement of health care. A small grant innovation funding program was implemented by the Hospital for Sick Children (SickKids) for the Perioperative Services group, awarding relatively small funds (approximately $10 000) in order to stimulate innovation. Of 48 applications, 26 (54.2%) different innovation projects...

Disparities exist in access to outpatient pediatric orthopaedic care. The purpose of this study was to assess whether disparities also exist in elective pediatric orthopaedic surgical procedures such as implant removal, and to determine which demographic and socioeconomic factors may be associated with differences in treatment. Children aged 7 to 1...

Background: Previous studies investigating the causes of clubfoot have shown conflicting results, potentially because of retrospective study designs or incomplete assessment of causative factors. The study aim was to examine risk factors for clubfoot in a large prospective Norwegian cohort. Methods: Exposures prior and during pregnancy were iden...

Removal of instrumentation is often recommended as part of treatment for spinal infections, but studies have reported eradication of infection even with instrumentation retention by using serial débridements and adjuvant antibiotic pharmacotherapy. We sought to determine the effect of instrumentation retention or removal on outcomes in children wit...

In 2003, The Journal of Bone & Joint Surgery (American Volume) implemented a requirement for submitted clinical research articles to include a level of evidence rating. The aim of this study was to analyze the agreement between authors and JBJS regarding the level of evidence rating of accepted clinical articles. A random sample of 353 clinical res...

Robert Palisano, Peter Rosenbaum, Stephen Walter, Dianne Russell, Ellen Wood, Barbara Galappi

R. Ganz, T. J. Gill, E. Gautier, K. Ganz, N. Krügel, U. Berlemann

Background Cerebral palsy (CP) is a disease of musculoskeletal system with more than one area affected. Two recognised musculoskeletal problems are hip dislocation and scoliosis. The suggestion is whether these two problems are aetiologically linked or simply a manifestation of CP occurring together independently in severely involved children. Scol...

Ignacio V. Ponseti, and Eugene N. Smoley

Background Although it is often diffi cult to predict long term outcomes with reasonable certainty in children with orthopaedic conditions, it is important to attempt to do so. Erik Severin predicted the outcome in developmental dysplasia of the hip. His work was the continuation of that of his well known professor Henning Waldenstron and was initi...

Background: A child who has an acutely irritable hip can pose a diagnostic challenge. On one hand, missing or delaying a diagnosis of septic arthritis has serious consequences for the patient. On the other hand, operating on a child's joint incorrectly is not free of risk. The purpose of this study was to determine the diagnostic value of presentin...

Defining a classic paper can be done in many ways. While the number of times an article is cited is one approach [1-3], this method may not be the best when for example an original paper such as Pavlov's paper was quoted 3 times only.

Background Prior to 1956, surgical treatment for congenital dislocation of the hip involved open reduction of the hip with some form of buttress or shelf procedure above the acetabulum. In time, it became apparent that the defect that allowed the femoral head to dislocate was not a shallow acetabulum but rather the abnormal direction. Two surgical...

David Stulberg, Daniel R. Cooperman, Richard Wallensten

Background Neonatal hip dislocation and disorder of hip maturation are common and frequently undiagnosed until very late. The implication is enormous for the child, family and the public health and early detection and assessment is important. Clinical examination and surveillance for dysplasia are not sensitive enough and the need for a safe, sensi...

Giovanni Debastiani, Roberto Aldegheri, Lodovico Renzi-Brivio and Giamaolo Trivella

Background Treatment of DDH was reduction and holding the hip reduced using a cast or brace. Four types of methods were recognised before Professor Pavlik started using his harness in 1945: Lorenz method, Hanausek method, Hanausek's and Frejka's blanket. These methods were associated with a high risk of osteonecrosis (28 %). Professor Pavlik attrib...

The concept of evidence based medicine (EBM) probably began with Professor Archie Cochrane, a British medical researcher in the 1970s who wrote in 1979 It is surely a great criticism of our profession that we have not organized a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomized controlled trials [1]....

Background The treatments for Legg-Calve-Perthes disease (LCPD) are controversial and lack evidence. They vary from long term non-weight bearing, abduction cast treatment, combined femoral and pelvic surgical procedures and ignoring the disease altogether (supervised neglect). The authors recruited 39 surgeons from 28 centres in the USA to take par...

Purpose: The purpose of this study was to evaluate whether simple bone cysts (SBC) resolve with age. Methods: Twenty four subjects with SBC who participated in a prior randomized clinical trial but had not healed at trial conclusion were evaluated for cyst healing. The following clinical and radiographic data were evaluated: age, sex, pain (Visu...

To evaluate an intervention for improving antibiotic prophylaxis (AP) guideline compliance to prevent surgical site infections in children. Although appropriate AP reduces surgical site infection, and guidelines improve quality of care, changing practice is difficult. To facilitate behavioral change, various barriers need to be addressed. A multidi...

To the Editor: Sufficient money can almost certainly change clinicians' behavior. What we need to find out is what types of behavior are likely to change (and how much) and whether pay for performance is cost-effective. Kristensen et al. (Aug. 7 issue)1 conclude that results from “a pay-for-performance program in England were not maintained.” Eijke...

Study design: Retrospective comparative study. Objective: To evaluate the outcome of bracing in patients with juvenile idiopathic scoliosis (JIS) at either skeletal maturity or time of scoliosis surgery. Summary of background data: JIS is generally thought to have poor outcomes with high rates of surgical fusion. Methods: All patients with J...

Objective: To investigate the association between antibiotic prophylaxis (AP) and surgical-site infection in pediatric patients. Background: Surgical-site infections (SSIs) are a major cause of postoperative morbidity and mortality. Despite numerous studies in adults, benefit of AP in preventing SSIs in children is uncertain. Methods: Patients...

The purpose of this study was to evaluate the long-term outcome of adults with spina bifida cystica (SBC) who had been treated either operatively or non-operatively for scoliosis during childhood. We reviewed 45 patients with a SBC scoliosis (Cobb angle ≥ 50º) who had been treated at one of two children’s hospitals between 1991 and 2007. Of these,...

Background: Pelvic osteotomies are frequently used as part of the surgical management of bladder exstrophy. The outcomes are often measured on the basis of the residual symphyseal diastasis. The aims of this study were to evaluate and validate a more reliable radiographic measure of ischiopubic rotation, to utilize this measure in analyzing pelves...

Objectives: Even in a publicly funded health care system, access to care may be related to socioeconomic status (SES). For children, delays in surgical procedures can have profound functional, social, and psychological effects with lifelong impact. The purpose of this study was to determine whether SES was related to meeting surgical wait time acc...

Few studies have evaluated the incidence of subsequent operations after tarsal coalition resection. Using administrative databases, we followed up a cohort of patients who had undergone tarsal coalition resection to determine the rates and possible risk factors for subsequent resection or arthrodesis. Patients (aged 8 years or older) who had been t...

Pneumatic tourniquets and chlorhexidine-gluconate (CHG) solution are used in extremity surgery to provide an aseptic, bloodless surgical field. The superiority of CHG over other skin preparation solutions has been demonstrated in randomized controlled trials1,2. While the complication rate from surgical preparations is low, chemical burns can occur...

Stereotype threat, defined as the predicament felt by people in either positive or negative learning experiences where they could conform to negative stereotypes associated with their own group membership, can interfere with learning. The purpose of this study was to determine if a simple orientation session could reduce stereotype threat for ortho...

Background Slipped upper femoral epiphysis (SUFE) was traditionally classifi ed as (1) acute: there are abrupt symptoms and signs developing over a short period of time (<3 weeks), (2) chronic: patients present with pain in the groin, thigh, and knee that varies in duration, often ranging from months to years and (3) acute on chronic: initially, pa...

Background Injuries involving the epiphyseal plate are common and present special problems in diagnosis and management. The risk of growth disturbance and its sequel is usually predictable and may be preventable. In this instructional course lecture, Dr Salter and Dr Harris presented in great depth a classifi cation system based on the mechanism of...

The epidemiology of paediatric supracondylar fracture (SCF) fixation has not been evaluated at a population level. The purpose of this study was to: (1) determine the incidence density rate (IDR) of SCF fixation and (2) determine the rate of and risk factors for re-operation. Using administrative databases, all patients who underwent SCF fixation (...

To measure operating room (OR) performance and efficiency, hospitals need scorecards or dashboards displaying and tracking core performance indicators.1–3 Scorecards should be monitored on an ongoing basis and benchmarked both internally against performance over time and externally against established best practices with the intent of continuous pe...

Background The role of bracing in patients with adolescent idiopathic scoliosis who are at risk for curve progression and eventual surgery is controversial. Methods We conducted a multicenter study that included patients with typical indications for bracing due to their age, skeletal immaturity, and degree of scoliosis. Both a randomized cohort and...

Study design: Descriptive. Objective: To describe the design and development of Bracing in Adolescent Idiopathic Scoliosis Trial (BrAIST). Summary of background data: Bracing has remained the standard of care for the nonoperative treatment of adolescent idiopathic scoliosis since the introduction of the Milwaukee brace in the late 1940s, but i...

Objective: To investigate the effect of patient gender on patient-physician communication in the process of recommendation for total knee arthroplasty (TKA). Methods: Seventy-one physicians (38 family physicians and 33 orthopedic surgeons) in Ontario performed blinded assessments of 2 standardized patients (1 man and 1 woman) with moderate knee...

Scheduling emergency cases among elective surgeries often results in prolonged waits for emergency surgery and delays or cancellation of elective cases. We evaluated the benefits of a dedicated operating room (OR) for emergency procedures available to all surgical services at a large children’s hospital. We compared a 6-month period (January 2009...

Background: There are few long-term studies evaluating tarsal coalition resections. The purpose of this study was to compare patient outcomes following resection of calcaneonavicular (CN) and talocalcaneal (TC) bars and to determine the relationship between the extent of a coalition and the outcome of resection. Methods: Patients younger than 18...

Background: Constipation in children is a commonly encountered problem with a broad variety of causes. Constipation caused by a narrow pelvis has, to our knowledge, not been reported in the human literature. Methods: Retrospective review of patient chart, in depth follow-up appointment with the patient and review of literature. Results: A 15 y...

Quality is a hallmark of health care, although it is difficult to come to a consensus on who gets to define what "quality health care" is. Most health-care workers enter this field with the goal of improving the health of their patients (and the community), and while everyone tries to do the best job possible, we must continuously seek better metho...

Meta-analyses and systematic reviews are increasingly published in the medical and surgical literature and are proliferating in the orthopaedic literature as well. “A systematic review is a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant research, and to collect...

Evidence-based medicine carefully assesses the information available in the literature by assessing both the results and the quality of the underlying studies. Studies are prone to both confounding and bias, and practitioners need to have a basic knowledge of how these factors are affected by various study types. This paper addresses the issues fac...

Evidence-based medicine is a relatively new and sometimes controversial concept when applied to pediatric orthopaedics. This article provides pediatric orthopaedists with some basics to help them understand and apply evidence-based medicine to their clinical practice.

Assessment of health state and health-related quality of life (HR-QOL) are limited by a child's age and cognitive ability. Parent-proxy reports are known to differ from children's reports. Simultaneous assessment using a parent-child dyad is an alternative approach. Our objective was to assess the validity, reliability and responsiveness of a paren...

The treatment of unstable slipped capital femoral epiphysis (SCFE) remains controversial. Surgical dislocation and open reduction has the potential to significantly reduce the rate of avascular necrosis (AVN) by allowing direct preservation of the femoral head blood supply. The purpose of this study was to determine if open reduction of the unstabl...

Randomized controlled trials continue to be at the pinnacle of the evidence hierarchy. With this unique vantage point, they inform medical practice, clinical guidelines, health policy, and reimbursement. Prior to an emphasis on randomized controlled trials, traditional clinical research consisted primarily of uncontrolled case series and expert opi...

RCTs serve as the best means of delivering evidence in support of or against specific treatment strategies. To be valid, such trials require careful planning, rigorous attention to the study protocol during implementation, and thoughtful data analysis and reporting. Dedicated multidisciplinary teams consisting of clinicians, epidemiologists, biosta...

The Canadian Paediatric Surgical Wait Times Project conducted an analysis of the alignment between capacity (supply) and demand for pediatric surgery at nine participating hospitals in five provinces. Demand for surgery was modelled using wait list data by assigning patients into monthly buckets of demand ("demand windows") based on the date on whi...