Locked Plating versus Nailing for Proximal Tibia Fractures: A Multicenter RCT.

OBJECTIVES: The main 2 forms of treatment for extraarticular proximal tibial fractures are intramedullary nailing (IMN) and locked lateral plating (LLP). The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter, randomized controlled trial. SETTING: 16 academic trauma centers. PATIENTS/PARTICIPANTS: 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to IMN, and 47 patients were randomized to LLP. INTERVENTION: IMN or lateral locked plating. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, Bother Index, EQ-5Dindex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number, and complications. RESULTS: Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months postinjury. Similarly, there was no difference in time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support, or complications. CONCLUSIONS: Both IMN and LLP provide for similar outcomes after these fractures. Patients continue to improve over the course of the year after injury but remain impaired even 1 year later. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Are Foot & Ankle Surgeons Being Adequately Compensated for Ankle Fractures? - An Analysis of Relative Value Units.

The current relative value units (RVU)-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs bi-malleolar vs tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation for uni-malleolar versus bi-malleolar versus tri-malleolar ankle fractures. The 2012 to 2017 American College of Surgeons - National Surgical Quality Improvement Program files were queried using current Procedural Terminology (CPT) codes for patients undergoing open reduction internal fixation for uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814), and tri-malleolar (CPT-27822,CPT-27823) ankle fractures. A total of 7830 (37.2%) uni-malleolar, 7826 (37.2%) bi-malleolar and 5391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs, Mean RVU/minute and Reimbursement rate ($/min) and Mean Reimbursement/case for each fracture type were calculated and compared using Kruskal-Wallis tests. The mean total RVU for each fracture type was as follows: (1) Uni-malleolar: 9.99, (2) Bi-malleolar = 11.71 and 3) Tri-malleolar = 12.87 (p < .001). A statistically significant difference was noted in mean operative time (uni-malleolar = 63.2 vs bi-malleolar = 78.6 vs tri-malleolar = 95.5; p < .001) between the 3 groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar = $7.21/min vs bi-malleolar = $6.75/min vs tri-malleolar = $6.10; p < .001). The average reimbursement/case was $358, $420, and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Foot & ankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

Locked Lateral Plating Versus Retrograde Nailing for Distal Femur Fractures: A Multicenter Randomized Trial.

OBJECTIVES: The 2 main forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN: Multicenter randomized controlled trial. SETTING: Twenty academic trauma centers. PATIENTS/PARTICIPANTS: One hundred sixty patients with distal femur fractures were enrolled. One hundred twenty-six patients were followed 12 months. Patients were randomized to plating in 62 cases and intramedullary nailing in 64 cases. INTERVENTION: Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS: Functional scoring including Short Musculoskeletal Functional Assessment, bother index, EQ Health, and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs, and number and type of adverse events. RESULTS: Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months after injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability, and ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS: Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year after injury but remain impaired 1 year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Discharge to inpatient care facilities following hip fracture surgery: incidence, risk factors, and 30-day post-discharge outcomes.

BACKGROUND: Discharge to an inpatient care facility (skilled-care or rehabilitation) has been shown to be associated with adverse outcomes following elective total joint arthroplasties. Current evidence with regard to hip fracture surgeries remains limited. METHODS: The 2015-2016 ACS-NSQIP database was used to query for patients undergoing total hip arthroplasty, hemiarthroplasty and open reduction internal fixation for hip fractures. A total of 15,655 patients undergoing hip fracture surgery were retrieved from the database. Inpatient facility discharge included discharges to skilled-care facilities and inpatient rehabilitation units. Multi-variate regression analysis was used to assess for differences in 30-day post-discharge outcomes between home-discharge versus inpatient care facility discharge, while adjusting for baseline differences between the 2 study populations. RESULTS: A total of 12,568 (80.3%) patients were discharged to an inpatient care facility. Discharge to an inpatient care facility was associated with higher odds of any complication (OR 2.03 [95% CI, 1.61-2.55]; p < 0.001), wound complications (OR 1.79 [95% CI, 1.10-2.91]; p = 0.019), cardiac complications (OR 4.49 [95% CI, 1.40-14.40]; p = 0.012), respiratory complication (OR 2.29 [95% CI, 1.39-3.77]; p = 0.001), stroke (OR 7.67 [95% CI, 1.05-56.29]; p = 0.045, urinary tract infections (OR 2.30 [95% CI, 1.52-3.48]; p < 0.001), unplanned re-operations (OR 1.37 [95% CI, 1.03-1.82]; p = 0.029) and readmissions (OR 1.38 [95% CI, 1.16-1.63]; p < 0.001) following discharge. CONCLUSION: Discharge to inpatient care facilities versus home following hip fracture surgery is associated with higher odds of post-discharge complications, re-operations and readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimise the risk of complications.

Responsible Return to Essential and Non-Essential Surgery During the COVID-19 Pandemic.

Non-essential surgery had largely been suspended during the COVID-19 Pandemic. Enormous amounts of resources were utilized to shift surgical practices to a "disaster footing" with most elective surgeons assuming new roles to offset the anticipated burden from surgical and medical personnel delivering acute care. As the number of COVID-19-infected patients began to plateau in the state of Ohio, a four-phase "Responsible Return to Surgery" approach was adopted in concert with the Ohio Department of Health and the Ohio Hospital Association. This approach was adopted understanding that a simple return to the status quo prior to the COVID-19 pandemic might be harmful to patients, providers, and staff. The discrete phases undertaken at our quaternary care institution for a responsible return to non-essential surgery are outlined with the goal of ensuring timely care, minimizing community transmission, and preserving personal protective equipment. Operationalizing these phases relied upon the widespread use of telehealth, systematic COVID-19 testing, and real-time monitoring of hospital and personal protective equipment resources.

Room Traffic in Orthopedic Surgery: A Prospective Clinical Observational Study of Time of Day.

OBJECTIVE: High rates of operating room (OR) traffic may contribute to surgical air contamination and surgical site infections (SSIs). The purpose of this study was to evaluate room traffic patterns in orthopedic implant procedures to determine the frequency of door openings and if time of day had an effect on room traffic. METHODS: In 2015, OR traffic was assessed in orthopedic implant cases. Room traffic was reported as the number of door openings per minute. Counts of how many people were present in the operating room were noted in 5-minute intervals from the time of sterile case opening to dressing placement. Operative cases were observed and categorized into 3 periods (6:00-9:59, 10:00-13:59, and 14:00-17:59) to assess if time of day affected room traffic. RESULTS: Forty-six cases were observed for the present study. Among all cases, the mean room traffic rate was 35.2 openings per hour (SD, 10; range, 13.2-60.8). One-way analysis of variance revealed no statistically significant difference among groups (6:00-9:59 [n = 29], 10:00-13:59 [n = 10], and 14:00-17:59 [n = 7]) as it relates door openings per minute (room traffic rate) (P = 0.9237) or mean number of people in the OR (P = 0.3560). Pearson correlation revealed no correlation between case start time and room traffic rates (P = 0.6129, r2 = 0.0059) or between case start time and mean number of people in the OR (P = 0.3435, r2 = 0.0214). CONCLUSIONS: Room traffic rates and mean number of people in the OR do not correlate with time of day of case in orthopedic implant procedures.

What Is the Quality of Surgical Care for Patients with Hip Fractures at Critical Access Hospitals?

BACKGROUND: Critical access hospitals (CAHs) play an important role in providing access to care for many patients in rural communities. Prior studies have shown that these facilities are able to provide timely and quality care for patients who undergo various elective and emergency general surgical procedures. However, little is known about the quality and reimbursement of surgical care for patients undergoing surgery for hip fractures at CAHs compared with non-CAH facilities. QUESTIONS/PURPOSES: Are there any differences in 90-day complications, readmissions, mortality, and Medicare payments between patients undergoing surgery for hip fractures at CAHs and those undergoing surgery at non-CAHs? METHODS: The 2005 to 2014 Medicare 100% Standard Analytical Files were queried using ICD-9 procedure codes to identify Medicare-eligible beneficiaries undergoing open reduction and internal fixation (79.15, 79.35, and 78.55), hemiarthroplasty (81.52), and THA (81.51) for isolated closed hip fractures. This database was selected because the claims capture inpatient diagnoses, procedures, charged amounts and paid claims, as well as hospital-level information of the care, of Medicare patients across the nation. Patients with concurrent fixation of an upper extremity, lower extremity, and/or polytrauma were excluded from the study to ensure an isolated cohort of hip fractures was captured. The study cohort was divided into two groups based on where the surgery took place: CAHs and non-CAHs. A 1:1 propensity score match, adjusting for baseline demographics (age, gender, Census Bureau-designated region, and Elixhauser comorbidity index), clinical characteristics (fixation type and time to surgery), and hospital characteristics (whether the hospital was located in a rural ZIP code, the average annual procedure volume of the operating facility, hospital bed size, hospital ownership and teaching status), was used to control for the presence of baseline differences in patients presenting at CAHs and those presenting at non-CAHs. A total of 1,467,482 patients with hip fractures were included, 29,058 of whom underwent surgery in a CAH. After propensity score matching, each cohort (CAH and non-CAH) contained 29,058 patients. Multivariate logistic regression analyses were used to assess for differences in 90-day complications, readmissions, and mortality between the two matched cohorts. As funding policies of CAHs are regulated by Medicare, an evaluation of costs-of-care (by using Medicare payments as a proxy) was conducted. Generalized linear regression modeling was used to assess the 90-day Medicare payments among patients undergoing surgery in a CAH, while controlling for differences in baseline demographics and clinical characteristics. RESULTS: Patients undergoing surgery for hip fractures were less likely to experience many serious complications at a critical access hospital (CAH) than at a non-CAH. In particular, after controlling for patient demographics, hospital-level factors and procedural characteristics, patients treated at a CAH were less likely to experience: myocardial infarction (3% (916 of 29,058) versus 4% (1126 of 29,058); OR 0.80 [95% CI 0.74 to 0.88]; p < 0.001), sepsis (3% (765 of 29,058) versus 4% (1084 of 29,058); OR 0.69 [95% CI 0.63 to 0.78]; p < 0.001), acute renal failure (6% (1605 of 29,058) versus 8% (2353 of 29,058); OR 0.65 [95% CI 0.61 to 0.69]; p < 0.001), and Clostridium difficile infections (1% (367 of 29,058) versus 2% (473 of 29,058); OR 0.77 [95% CI 0.67 to 0.88]; p < 0.001) than undergoing surgery in a non-CAH. CAHs also had lower rates of all-cause 90-day readmissions (18% (5133 of 29,058) versus 20% (5931 of 29,058); OR 0.83 [95% CI 0.79 to 0.86]; p < 0.001) and 90-day mortality (4% (1273 of 29,058) versus 5% (1437 of 29,058); OR 0.88 [95% CI 0.82 to 0.95]; p = 0.001) than non-CAHs. Further, CAHs also had risk-adjusted lower 90-day Medicare payments than non-CAHs (USD 800, standard error 89; p < 0.001). CONCLUSION: Patients who received hip fracture surgical care at CAHs had a lower risk of major medical and surgical complications than those who had surgery at non-CAHs, even though Medicare reimbursements were lower as well. Although there may be some degree of patient selection at CAHs, these facilities appear to provide high-value care to rural communities. These findings provide evidence for policymakers evaluating the impact of the CAH program and allocating funding resources, as well as for community members seeking emergent care at local CAH facilities. LEVEL OF EVIDENCE: Level III, therapeutic study.

Targeted Muscle Reinnervation at the Time of Major Limb Amputation in Traumatic Amputees: Early Experience of an Effective Treatment Strategy to Improve Pain.

BACKGROUND: Orthopaedic trauma etiologies are a common cause for amputation. Targeted muscle reinnervation (TMR) is a technique aimed at reducing or preventing pain and improving function. The purpose of this study was to examine postoperative phantom limb pain and residual limb pain following TMR in orthopaedic trauma amputees. In addition, postoperative rates of opioid and neuromodulator medication use were evaluated. METHODS: Twenty-five patients (60% male) prospectively enrolled in a single-institution study and underwent TMR at the time of major limb amputation (48% nonmilitary trauma, 32% infection secondary to previous nonmilitary trauma, and 20% other, also secondary to trauma). Phantom limb pain and residual limb pain scores, pain temporality, prosthetic use, and unemployment status were assessed at the time of follow-up. The use of opioid and neuromodulator medications both preoperatively and postoperatively was also examined. RESULTS: At a mean follow-up of 14.1 months, phantom limb pain and residual limb pain scores were low, with 92% of the patients reporting no pain or brief intermittent pain only. Pain scores were higher overall for male patients compared with female patients (p < 0.05) except for 1 subscore, and higher in patients who underwent amputation for infection (odds ratio, 9.75; p = 0.01). Sixteen percent of the patients reported opioid medication use at the time of the latest documented follow-up. Fifty percent of the patients who were taking opioids preoperatively discontinued use postoperatively, while 100% of the patients who were not taking opioids preoperatively discontinued postoperative use. None of the patients who were taking neuromodulator medication preoperatively discontinued use postoperatively (0 of 5). The median time to neuromodulator medication discontinuation was 14.6 months, with female patients taking longer than male patients (23 compared with 7 months; p = 0.02). At the time of the latest follow-up, the rate of reported prosthetic use was 85% for lower-extremity and 40% for upper-extremity amputees, with a rate of unemployment due to disability of 36%. CONCLUSIONS: The use of TMR in orthopaedic trauma amputees was associated with low overall pain scores at 2-year follow-up, decreased overall opioid and neuromodulator medication use, and an overall high rate of daily prosthetic use. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Review of State Guidelines for Elective Orthopaedic Procedures During the COVID-19 Outbreak.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic has resulted in widespread cancellation of elective orthopaedic procedures. The guidance coming from multiple sources frequently has been difficult to assimilate as well as dynamic, with constantly changing standards. We seek to communicate the current guidelines published by each state, to discuss the impact of these guidelines on orthopaedic surgery, and to provide the general framework used to determine which procedures have been postponed at our institution. METHODS: An internet search was used to identify published state guidelines regarding the cancellation of elective procedures, with a publication cutoff of March 24, 2020, 5:00 P.M. Eastern Daylight Time. Data collected included the number of states providing guidance to cancel elective procedures and which states provided specific guidance in determining which procedures should continue being performed as well as to orthopaedic-specific guidance. RESULTS: Thirty states published guidance regarding the discontinuation of elective procedures, and 16 states provided a definition of "elective" procedures or specific guidance for determining which procedures should continue to be performed. Only 5 states provided guidelines specifically mentioning orthopaedic surgery; of those, 4 states explicitly allowed for trauma-related procedures and 4 states provided guidance against performing arthroplasty. Ten states provided guidelines allowing for the continuation of oncological procedures. CONCLUSIONS: Few states have published guidelines specific to orthopaedic surgery during the COVID-19 outbreak, leaving hospital systems and surgeons with the responsibility of balancing the benefits of surgery with the risks to public health.

Are Orthopaedic Trauma Surgeons Being Adequately Compensated for Treating Nonunions of the Femoral Shaft?: An Analysis of Relative Value Units.

INTRODUCTION: We evaluated differences in reimbursement rates between native femoral shaft fractures treated with an intramedullary nail versus those undergoing repair of nonunion of femoral shaft fractures. METHODS: The 2016 to 2017 American College of Surgeons-National Surgical Quality Improvement Program database was queried using International Classification of Diseases 10th Edition diagnosis codes and Current Procedural Terminology codes to identify patients undergoing surgery for native femoral shaft fractures and/or repair of nonunion of femoral shaft fracture with/without grafts. RESULTS: The mean total relative value unit (RVU) and surgical time for each group were as follows: (1) native (RVU = 19.70, surgical time = 97.4 minutes), (2) nonunion w/out graft (RVU = 17.23, surgical time = 135.8 minutes), (3) nonunion w/graft (RVU = 18.88, surgical time = 164.5 minutes). Reimbursement rates decreased notably as complexity of case grew (native = $8.74/min versus nonunion w/graft = $6.07/min versus nonunion w/graft = $5.27/min; P < 0.001). The average reimbursement/case was $707 for native femoral shaft fracture, $618 for repair of nonunion w/out graft, and $678 for repair of nonunion with bone graft. DISCUSSION: The study highlights the need for a change in the RVUs assigned to nonunions of the femoral shaft to ensure that the value of physician intensity is retained in future RVU evaluations.

Refining Risk-Adjustment of 90-Day Costs Following Surgical Fixation of Ankle Fractures: An Analysis of Medicare Beneficiaries.

As the current healthcare model transitions from fee-for-service to value-based payments, identifying cost-drivers of 90-day payments following surgical procedures will be a key factor in risk-adjusting prospective bundled payments and ensuring success of these alternative payment models. The 5% Medicare Standard Analytical Files data set for 2005-2014 was used to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar, and trimalleolar ankle fractures. All acute care and post-acute care payments starting from day 0 of surgery to day 90 postoperatively were used to calculate 90-day costs. Patients with missing data were excluded. Multivariate linear regression modeling was used to derive marginal cost impact of patient-level (age, sex, and comorbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy, and syndesmotic fixation), and state-level factors on 90-day costs after surgery. A total of 6499 patients were included in the study. The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 ± $1060. Individuals aged <65 or ≥70 years had significantly higher costs. Procedure-level factors associated with significant marginal cost increases were inpatient surgery (+$5577), trimalleolar fracture (+$1082), and syndesmotic fixation (+$2822). The top 5 comorbidities with the largest marginal cost increases were chronic kidney disease (+$8897), malnutrition (+$7908), obesity (+$5362), cerebrovascular disease/stroke (+$4159), and anemia (+$3087). Higher costs were seen in Nevada (+$6371), Massachusetts (+$4497), Oklahoma (+$4002), New Jersey (+$3802), and Maryland (+$3043) compared with Michigan. With the use of a national administrative claims database, the study identifies numerous patient-level, procedure-level, and state-level factors that significantly contribute to the cost variation seen in 90-day payments after ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in patients with fractures.

The Impact of Metabolic Syndrome on 30-Day Outcomes Following ORIF for Ankle Fractures.

Introduction: Metabolic syndrome (MetS) is associated with significant postoperative morbidity. Despite an increasing prevalence of MetS in the US population, its impact on postoperative outcomes following ankle fractures remains limited. Materials and Methods: The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program database was queried for patients undergoing open reduction with internal fixation (ORIF) for ankle fractures using Current Procedural Terminology codes: 27766, 27769, 27792, 27814, 27822, and 27823. The study cohort was divided into 2 groups: MetS versus No MetS. MetS was identified using a predefined criteria as the coexistence of (1) diabetes mellitus, (2) hypertension, and (3) body mass index ≥30 kg/m2. Results: A total of 1013 (6.7%) MetS underwent ORIF for ankle fractures. Following adjustment for baseline differences, MetS was an independent predictor of experiencing any 30-day complication (odds ratio [OR] = 1.35; P = .020), wound complications (OR = 1.67; P = .024), renal complications (OR = 3.54; P = .022), 30-day readmissions (OR = 1.66; P = .001), 30-day unplanned reoperations (OR = 1.69; P = .009) and decreased odds of home discharge (OR = 0.66; P < .001). Conclusion: Patients with MetS undergoing ORIF for ankle fractures are at an increased risk of experiencing adverse 30-day complications, readmissions, and reoperations. Providers should understand the need of appropriate postoperative surveillance in this high-risk group to minimize the risk of poor outcomes. Level of Evidence: Level III.

Clostridium difficile colitis in patients undergoing surgery for hip fractures: an analysis of 17,474 patients.

BACKGROUND: We compiled evidence from a large national surgical database to identify the incidence, risk factors and postoperative impact of Clostridium difficile infection (CDI) in patients undergoing hip fracture repair. METHODS: We identified 17,474 patients who underwent hip fracture repairs in 2015 using the ACS-NSQIP database. Interventions studied were open reduction/Internal fixation, total hip arthroplasty or hemiarthroplasty being performed for traumatic hip fractures. Outcomes studied were incidence, preoperative and postoperative risk factors for occurrence of CDI were studied using descriptive and statistical analysis. RESULTS: A total of 92 patients (0.53%) developed CDI within 30 days of the operation. Following adjustment using multi-variate logistic regression, preoperative and hospital-associated factors associated with development of CDI were smoking (OR 1.75 [95% CI 1.03-2.99]), hypertension (OR 1.70 [95% CI 1.01-2.85]), hyponatraemia (OR 1.65 [95% CI 1.04-2.63]), prior systemic inflammatory response syndrome (SIRS) (OR 2.18 [95% CI 1.32-3.59]) and a length of stay >7 days (OR 1.98 [95% CI 1.11-3.53]. Postoperative factors associated with occurrence of CDI were occurrence of a deep surgical site infection (SSI) (OR 5.89 [95% CI 1.31-26.6]), a stay in the hospital >30 days (OR 6.56 [95% CI 2.56-16.9]) and unplanned reoperations (OR 2.78 [95% CI 1.29-5.99]). CONCLUSION: As we move toward an era of bundled-payment models, identification of risk factors associated with the occurrence of postoperative complications, such as CDI, will help curb excess healthcare utilisation and costs associated with the management of this complication.

Outpatient Versus Inpatient Surgical Fixation of Isolated Ankle Fractures: An Analysis of 90-Day Complications, Readmissions, and Costs.

Despite increasing interest toward managing isolated ankle fractures in an outpatient setting, evidence of its safety remains largely limited. The 2007 to 2014 Humana Administrative Claims database was queried to identify patients undergoing open reduction internal fixation for unimalleolar, bimalleolar, or trimalleolar isolated closed ankle fractures. Two cohorts (outpatient versus inpatient) were then matched on the basis of age, sex, race, region, fracture type (uni-/bi-/trimalleolar) and Elixhauser Comorbidity Index to control for selection bias. Multivariate regression analyses were performed to report independent impact of outpatient-treated ankle fracture surgery on 90-day complications, readmission, and emergency department visit rates. Independent-samples t test was used to compare global 90-day costs between cohorts. A total of 5317 inpatient-treated and 6941 outpatient-treated closed ankle fractures were included in the final cohort. After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia (2.3% versus 4.0%; p < .001), myocardial infarction (0.9% versus 1.8%; p = .005), acute renal failure (2.2% versus 5.3%; p < .001), urinary tract infections (7.4% versus 12.3%; p < .001), and pressure ulcers (0.9% versus 2.0%; p = .001). Outpatient ankle fractures also had lower rates of 90-day readmissions (9.7% versus 14.1%; p < .001) and emergency department visits (13.8% versus 16.2%; p = .028). Last, overall 90-day costs for outpatient ankle fractures were nearly $9000 lower than costs for inpatient ankle fractures ($12,923 versus $21,866; p < .001). Based on our findings, it appears that outpatient treatment of ankle fractures can be deemed safe and feasible in a select cohort of patients.

Contourable craniofacial mesh plate osteosynthesis of patellar fractures: A new, low-profile fixation technique.

PURPOSE: Patellar fractures are challenging orthopaedic injuries that can be difficult to treat due to the complexity of fracture patterns, the high stresses at the patellofemoral joint, and subcutaneous location of the patella. Hardware prominence and need for hardware removal are two of the most common complications after surgical fixation of patellar fractures. There is an ever present need for low profile fixation constructs that are also biomechanically stable. MATERIALS AND METHODS: We present an alternative technique of patella fixation with a low profile titanium mesh plate typically used in craniofacial skeletal trauma. Four patients at our institution underwent mesh plate fixation of patella fractures. RESULTS: All four patients had union without any post-operative complications. All four patients regained preoperative range of motion without residual pain or disability. CONCLUSIONS: Mesh plate fixation of patellar fractures is an alternative to standard tension band technique, especially in comminuted fractures. The craniofacial mesh plate is very low profile, provides stable fixation that allows for early range of motion, and has the potential to reduce post-operative complications like hardware removal.

Transfer status in geriatric hip fracture surgery - An independent risk factor associated with 30-day mortality, re-operations and complications.

BACKGROUND: A significant proportion of patients undergoing hip fracture surgery are transferred from other locations. With no current orthopedic literature present, we sought to study the impact of transfer location on 30-day outcomes following geriatric hip fracture surgery. MATERIALS & METHODS: The 2015-2016 ACS-NSQIP database was queried using CPT codes to retrieve records of geriatric patients undergoing hip fracture surgery (total hip arthroplasty/THA, hemiarthroplasty/HA and open reduction internal fixation/ORIF). Transfer status was defined into four groups - 1) No transfer (admitted from home), 2) From acute care hospital, 3) From nursing home/chronic care facility and 4) From outside emergency department (ED). Patients with missing data were excluded. A total of 31,218 patients were included in the final cohort. RESULTS: Out of 31,218 patients - 23,659 (75.8%) were admitted from home, 1574 (5.0%) from acute care hospitals, 3299 (10.6%) from nursing home/chronic care facilities and 2686 (8.6%) from outside EDs. Following adjusted analysis, transfer from nursing home vs. home was associated with higher odds of 30-day mortality (OR 1.57 [95% 1.36-1.80]; p < 0.001), 30-day re-operations (OR 1.36 [95% CI 1.10-1.68]; p = 0.005), septic shock (OR 1.58 [95% CI 1.07-2.32]; p = 0.021), sepsis (OR 1.45 [95% CI 1.05-1.99]; p = 0.023) and urinary tract infection (OR 1.21 [95% CI 1.02-1.42]; p = 0.025). Additionally, transfer from outside ED vs. home was also associated with higher odds of 30-day mortality (OR 1.26 [95% CI 1.06-1.50]; p = 0.010).Transfer from any location (acute care hospital, nursing home and outside ED) was significantly associated with higher odds of non-home discharge (p < 0.001). CONCLUSION: Transfer status is an important risk factor associated with 30-day mortality and morbidity in geriatric patients undergoing hip fracture surgery. The findings stress the need for recognition of these patients as being a high-risk group to allow enhanced medical optimization in an attempt to minimize the risk of poor outcomes.

30-day adverse events, length of stay and re-admissions following surgical management of pelvic/acetabular fractures.

INTRODUCTION: Pelvic/acetabular fractures are associated with significant morbidity, mortality and cost to the society. We sought to utilize a national surgical database to assess the incidence and factors associated with prolonged length of stay (LOS), non-home discharge destination, 30-day adverse events and readmissions following surgical fixation of pelvic/acetabular fractures. MATERIALS & METHODS: The 2011-2016 ACS-NSQIP database files were queried using CPT codes (27215, 27217, 27218, 27226, 27227, 27228) for patients undergoing open reduction/internal fixation (ORIF) for pelvic/acetabular fractures. Patients undergoing additional procedures for associated fractures (vertebral fractures, distal radius/ulna fractures or femoral neck/hip fractures) were excluded from the analysis to ensure that a relevant population of patients with isolated pelvic/acetabular injuries were included in the analysis. A total of 572 patients were included in the final cohort. Severe adverse events (SAE) were defined as: death, ventilator use >48 h, unplanned intubation, stroke, deep venous thrombosis, pulmonary embolism, cardiac arrest, myocardial infarction, acute renal failure, sepsis, septic shock, re-operation, deep SSI and organ/space SSI. Minor adverse events (MAE) included - wound dehiscence, superficial SSI, urinary tract infection (UTI) and progressive renal insufficiency. An extended LOS was defined as >75th centile (>9days). RESULTS: Factors associated with AAE were partially dependent functional health status pre-operatively (p = 0.020), transfusion ≥1 unit of packed RBCs (p = 0.001), and ASA > II (p < 0.001). Experiencing a SAE was associated with congestive heart failure (CHF) pre-operatively [p = 0.005), total operative time >140 min (p = 0.034) and Hct <36 pre-operatively (p = 0.003). MAE was associated with transfusion≥1 unit of packed RBCs (p = 0.022) and ASA > II (p = 0.007). Patients with an ASA > II (p = 0.001), total operative time>140 min (p < 0.001) and Hct <36 (p = 0.006) were more likely to have a LOS >9 days. Male gender (p = 0.026), prior history of CHF (p = 0.024), LOS >9 days (p = 0.030) and >10% bodyweight loss in last 6 months before the procedure (p = 0.002) were predictors of 30-day mortality. CONCLUSION: Patients with ASA grade > II, greater co-morbidity burden and prolonged operative times were likely to experience adverse events and have a longer length of stay. Surgeons can utilize this data to risk stratify patients so that appropriate pre-operative and post-operative medical optimization can take place.

Timing of complications following surgery for geriatric hip fractures.

INTRODUCTION: Despite abundant literature present on complications following hip fracture surgery, few studies have focused on the timing of these complications. MATERIALS AND METHODS: The 2015-2016 American College of Surgeons - National Surgical Quality Improvement Program database was queried for patients ≥65 years of age undergoing hip fracture surgery, due to trauma, using CPT-Codes for total hip arthroplasty (27130), Hemiarthroplasty (27125) and Open Reduction/Internal Fixation (ORIF) (27236, 27244, 27245). For each complication being studied, the median time to diagnosis was determined along with the interquartile range (IQR). Cox-regression analyses were used to assess complication timings between various surgeries. RESULTS: A total of 31,738 were included in the final cohort. The median time of occurrence (days) for myocardial infarction was 2 [IQR 1-6], pneumonia 4 [IQR 2-12], stroke/CVA 3 [IQR 1-10], pulmonary embolism 5 [IQR 2-14], urinary tract infection (UTI) 8 [IQR 2-15], deep venous thrombosis (DVT) 9 [IQR 4-17], sepsis 11 [IQR 5-19], death 12 [IQR 6-20], superficial surgical site infection (SSI) 16 [IQR 12-22], deep SSI 23 [IQR 15-24] and organ/space SSI 19 [IQR 15-23]. Undergoing a THA vs. ORIF for hip fracture was associated a relatively early occurrence of pneumonia (day 3 [IQR 1-5.25]; p = 0.029) and urinary tract infection (day 4 [IQR 1-13]; p = 0.035) and a later occurrence of organ/space SSI (day 23.5 [IQR 19.5-26.75]; p = 0.002). CONCLUSION: Orthopaedic trauma surgeons can utilize this data to optimize care strategies during the time-periods of highest risk to prevent complications from occurring early on in the course of post-operative care.

Urinary tract infection (UTI) at time of geriatric hip fracture surgery increases the risk of experiencing adverse 30-day outcomes.

INTRODUCTION: Pre-operative urinary tract infection (UTI) may be associated with a high rate of complications following surgeries. Few studies have investigated the clinical impact of a pre-operative UTI on post-operative outcomes following surgeries for hip-fracture in geriatric patients. METHODS: The 2015-2016 ACS-NSQIP database was queried for patients undergoing hip fracture surgery using CPT-Codes for Total Hip Arthroplasty (27130), Hemiarthroplasty (27125) and Open Reduction/Internal Fixation (ORIF) (27236, 27244, 27245). Only patients ≥65 years of age undergoing surgery due to a traumatic hip fracture were included in the study. RESULTS: Out of 31,621 patients undergoing surgical treatment for a hip fracture, 410 (1.3%) had UTI at the time of the surgery. Following adjusted logistic regression analysis, UTI present at the time of surgery was associated with a longer length of stay>5 days (OR 5.46 [95% CI 2.27-13.1]; p = 0.008), any complication (OR 1.33 [95% CI 1.49-1.63]; p = 0.007), infectious complications (OR 1.71 [95% CI 1.19-2.47]; p = 0.004), non-infectious complications (OR 1.28 [95% CI 1.04-1.58]; p = 0.021), 30-day unplanned re-operations (OR 1.96 [95% CI 1.25-3.06]; p = 0.003) and 30-day readmissions (OR 2.04 [95% CI 1.57-2.66]; p < 0.001). With regards to infectious complications, presence of a UTI at time of surgery was a significant independent predictor of sepsis (OR 2.44 [95% CI 1.24-4.80]; p = 0.010) and septic shock (OR 4.05 [95% CI 2.03-8.08]; p < 0.001). CONCLUSIONS: Patients undergoing hip-fracture surgery with a concurrent UTI at the time of surgery have more adverse 30-day outcomes as compared to hip fracture patients who do not present with a UTI. Despite adjustment for a delay in the time to surgery, the impact of UTI on post-operative outcomes remained significant. While it is difficult to eradicate a UTI in a non-elective population, the findings stress the need for clinical optimization and potential need for early recognition/management of UTI in patients who sustain a hip fracture to minimize the risk of adverse outcomes.

The role of sociodemographics in the occurrence of orthopaedic trauma.

INTRODUCTION: We sought to determine the effects of sociodemographic factors on the occurrence of orthopaedic injuries in an adult population presenting to a level 1 trauma center. MATERIALS AND METHODS: We conducted a retrospective chart review of patients who received orthopaedic trauma care at a level 1 academic trauma center. RESULTS: 20,919 orthopaedic trauma injury cases were treated at an academic level 1 trauma center between 01 January 1993 and 27 August 2017. Following application of inclusion/exclusion criteria, a total of 14,654 patients were retrieved for analysis. Out of 14,654 patients, 4602 (31.4%) belonged to low socioeconomic status (SES), 4961 (32.0%) to middle SES and 5361 (36.6%) to high SES. Following adjustment for age, sex, race, insurance status and injury severity score (ISS), patients belonging to middle SES vs. low SES (OR 0.77 [95% CI 0.63-0.94]; p = 0.009) or high SES vs. low SES (OR 0.77 [95% CI 0.62-0.95]; p = 0.016) had lower odds of receiving a penetrating injury as compared to a blunt injury. CONCLUSION: The results from this study indicate that a link exists between sociodemographic factors and the occurrence of orthopaedic injuries presenting to a level 1 trauma center. The most common cause of injury varied within age groups, by sex, and within the different socioeconomic groups.