Predictors of Episode-of-Care Costs for Ankle Fractures.

Ankle fractures are one of the most resource-consuming traumatic orthopedic injuries. Few studies have successfully evaluated the episode-of-care costs (EOCC) of common traumatic orthopedic injuries. The objective of this study was to determine the EOCC associated with the surgical management of ankle fractures. A retrospective cohort study of 105 consecutive patients who underwent open reduction internal fixation of an isolated ankle fracture at a Canadian Level-1 trauma center was conducted. Episode-of-care costs were generated using an activity-based costing framework. The median global episode-of-care cost for ankle fracture surgeries performed at the studied institution was $3,487 CAD [IQR 880] ($2,685 USD [IQR 616]). Patients aged 60 to 90 years had a significantly higher median EOCC than younger patients (p = .01). Supination-adduction injuries had a significantly higher median EOCC than other injury patterns (p = .01). The median EOCC for patients who underwent surgery within 10 days of their injury ($3,347 CAD [582], $2,577 USD [448]) was significantly lower than the cost for patients who had their surgery delayed 10 days or more after the injury ($3,634 CAD [776], $2,798 USD [598]) (p = .03). Patient sex, anesthesia type, ASA score and surgeon's fellowship training did not affect the EOCC. This study provides valuable data on predictors of EOCC in the surgical management of ankle fractures. Delaying simple ankle fracture cases due to operating time constraints can increase the total cost and burden of these fractures on the healthcare system. In addition, this study provides a framework for future episode-of-care cost analysis studies in orthopedic surgery.

Hospital episode-of-care costs for hip fractures: an activity-based costing analysis.

Background: Despite the large impact of hip fracture care on hospital budgets, accurate episode-of-care costs (EOCC) calculations for this injury remains a challenge. The objective of this article was to assess EOCC for geriatric patients with hip fractures using an activity-based costing methodology and identify intraoperative, perioperative, and patient-specific factors associated with higher EOCC. Material and Methods: This is a retrospective cohort study involving a total of 109 consecutive patients with hip fracture treated surgically at a Canadian level-1 trauma center from April 2018 to February 2019. Clinical and demographic data were extracted through the institution's centralized data warehouse. Data acquisition also included direct and indirect costs per episode of care, adverse events, and precise temporal data. Results: The median total EOCC was $13,113 (interquartile range 6658), excluding physician fees. Out of the total cost, 75% was attributed to direct costs, which represented a median expenditure of $9941. The median indirect cost of the EOCC was $3322. Based on the multivariate analysis, patients not operated within the 48 hours guidelines had an increased length of stay by 5.7 days (P = 0.003), representing an increase in EOCC of close to 5000$. Higher American Society of Anesthesiology (ASA) scores were associated with elevated EOCC. Conclusion: The cost of managing a patient with geriatric hip fracture from arrival in the emergency department to discharge from surgical ward represented $13,113. Main factors influencing the EOCC included adherence to the 48-hour benchmark surgical delay and ASA score. High-quality costing data are vital in assessing health care spending, conducting cost effectiveness analyses, and ultimately in guiding policy decisions. Level of Evidence: Level III (3), retrospective cohort study.

Novel digital continuous sensor for monitoring of compartment pressure: a case report.

Case: The American Academy of Orthopaedic Surgeons has recently identified continuous intracompartmental pressure monitoring as 1 of the few means to assist in ruling out acute compartment syndrome (ACS). There are very few methods that allow this measurement. This manuscript describes the use of a new digital monitoring system for ACS in 3 patients. This minimally invasive device, the MY01 (NXTSENS, Montreal, Canada) is capable of continuously and precisely measuring variations in intracompartmental pressure. Conclusion: MY01 detected the occurrence of ACS at early-stage and expedited the timing of surgery for 2 patients. This tool also objectively excluded a suspected diagnosis of ACS in a medically comorbid patient, obviating the need for unnecessary fasciotomies and potential complications.

A Meta-analysis Comparing External Fixation against Open Reduction and Internal Fixation for the Management of Tibial Plateau Fractures.

Aim: This article aims to compare the outcomes between open reduction and internal fixation (ORIF) and external fixation (ExFix) in tibial plateau fractures. Background: Open reduction and internal fixation and external fixation are common methods for managing tibial plateau fractures without a consensus of choice. Materials and methods: PubMed, Cochrane Library, Ovid, CINAHL®, Scopus, and Embase were searched. Clinical studies in humans comparing ExFix and ORIF for tibial plateau fractures were included. Case reports, pathological, and biomechanical studies were excluded. Two investigators reviewed the studies independently, and any discrepancies were resolved. The quality and heterogeneity of each study were assessed in addition to calculating the odds ratio (OR) of the surgical outcomes and complications at a 95% confidence interval, with p <0.05 as statistical significance. Results: Of the 14 included studies, one was a randomised trial, one was a prospective study, and 12 were retrospective studies. The 865 fractures identified across the studies constituted 458 (52.9%) in the ExFix group and 407 (47.1%) in the ORIF group. Most studies indicated a better outcome for ORIF as compared to ExFix. Open reduction and internal fixation had a lower incidence of superficial infection and postoperative osteoarthritis, while ExFix revealed a lower proportion with heterotopic ossification (HTO). Conclusion: ExFix has a higher rate of superficial infections and osteoarthritis, whereas ORIF has a higher incidence of HTO. Larger studies are needed to compare outcomes and investigate the findings of this study further. Clinical significance: This up-to-date meta-analysis on tibial plateau management will help surgeons make evidence-based decisions regarding the use of ORIF versus ExFix. How to cite this article: Naja AS, Bouji N, Eddine MN, et al. A Meta-analysis Comparing External Fixation against Open Reduction and Internal Fixation for the Management of Tibial Plateau Fractures. Strategies Trauma Limb Reconstr 2022;17(2):105-116.

Cancellations and delays of emergent orthopedic operations at a Canadian level 1 trauma centre.

BACKGROUND: Day-of surgery cancellation (DOSC) is considered to be a very inefficient use of hospital resources and results in emotional stress for the patient. To examine opportunities to minimize the incidence of preventable cancellations - an indicator of quality of care - we assessed the incidence of and reasons for DOSCs over 3 months among inpatients and outpatients at a trauma orthopedic service. METHODS: This was a prospective study of 2 cohorts of patients, inpatients and outpatients, scheduled for emergent orthopedic surgery at a Canadian tertiary level 1 trauma centre from Jan. 1 to Mar. 31, 2020. Patient demographic characteristics, injury characteristics, delays until surgery and reasons for DOSCs were recorded. RESULTS: A total of 185 patients (100 males and 85 females with a mean age of 54 yr) were included in the study. There were 98 outpatients and 87 inpatients. Seventy-five (40%) of the scheduled procedures in the outpatient group and 34 (30%) of those in the inpatient group were cancelled. In both groups, more than 85% of the cancellations were because of prioritization of a more urgent orthopedic or nonorthopedic surgical case. The average operative delay for the outpatient group was 11.4 days, compared to 3.8 days for the inpatient group (p < 0.001). CONCLUSION: High DOSC rates were observed among both outpatients and inpatients. The main reason for delaying surgery was prioritization of a more urgent surgical case. Providing the orthopedic trauma service with a dedicated OR opened 6 days per week, along with extended hours of OR services to 1700 daily, might be effective at minimizing DOSCs.

Augmented-reality-guided insertion of sliding hip screw guidewire: a preclinical investigation.

BACKGROUND: The sliding hip screw (SHS) is frequently used in the management of hip fractures; successful placement depends on accurate positioning of the lag screw in the femoral head guided by fluoroscopy. We proposed to leverage the capabilities of augmented reality (AR) to overlay virtual images of the desired guidewire trajectory directly onto the surgical field to guide the surgeon during SHS guidewire insertion. METHODS: Using a commercially available AR headset and software, we performed preprocedural planning using computed tomography scans to identify the optimal trajectory for SHS guidewire insertion in the neck of a Sawbones femur model. The images of the scanned femurs containing the virtual guidewire trajectory were overlaid on the physical models such that the user could see a composite view of the computer-generated images and the physical environment. Two second-year orthopedic residents each inserted 15 guidewires under AR guidance and 15 guidewires under fluoroscopy. RESULTS: Of the 30 guidewires inserted under AR guidance, 24 (80%) were within the femoral neck, and 16 (53%) were fully enclosed within the femoral head. Nine (56%) of the 16 perforations were due to insertions that were too far along the planned trajectory. Thirteen (81%) of the successful attempts with AR had an appropriate position, compared to 25/26 (96%) with fluoroscopy. It took significantly less time to perform the procedure using fluoroscopy than AR (p < 0.05). Fluoroscopy required on average 18.7 shots. CONCLUSION: Augmented reality provides an opportunity to aid in guidewire insertion in a preplanned trajectory with less radiation exposure in a sterile environment, but technical challenges remain to be solved to enable widespread adoption.

Time-to-Incision for Hip Fractures in a Canadian Level-1 Trauma Centre: Are We Respecting the Guidelines?

Background: Surgical intervention within 48 hours is recommended for hip fractures in the elderly in order to reduce post-operative complications and lower mortality rates. The purpose of this retrospective study is to explore the causes of surgical delays for acute geriatric hip fractures. Methods: This is a retrospective cohort study involving a total of 109 consecutive geriatric patients who sustained proximal femur fractures ("hip fractures"), who subsequently underwent definitive fixation. Clinical, demographic, and direct costing data were extracted via a modern system and electronic medical records on a centralized data warehouse. Surgical delays and length of stay were analyzed according to clinical variables. Results: The established benchmark of a time-to-surgery of less than 48 hours was respected for 63 (57.8%) patients. Patients on oral anticoagulant (ACO) waited significantly longer, on average 58 hours compared to 44 for non-anticoagulated patients (p = .007). Patients with higher ASA scores waited significantly longer (p = .0018). More importantly, patients treated within 48 hours were discharged significantly earlier, on average after 10 days compared to 16 days for patients who waited more than 48 hours before receiving surgical treatment (p = .003), regardless of the pre-operative waiting time. Conclusion: Fewer than 60% of patients received surgery within the 48-hour benchmark after being admitted for an acute hip fracture in a Level-1 trauma centre. Patients with more comorbidities waited longer and stayed longer in the hospital after surgery. Implementing strategic, evidence-based changes should be done using this data to improve care of this vulnerable population.

Volar Distal Radioulnar Joint Dislocation Associated with Acute Median Nerve Neuropathy and a Distal Radius Fracture.

Volar distal radioulnar (DRUJ) dislocations are uncommon and can easily be missed. We present a rare case of an irreducible volar DRUJ dislocation associated with a distal radius fracture and acute median nerve neuropathy at the wrist. An attempt to reduce the DRUJ dislocation in the emergency department had failed. The patient was then taken to the operating room requiring a carpal tunnel release, as well as an open reduction and internal fixation of the distal radius fracture and repair of the volar distal radioulnar ligament. We also review some of the volar DRUJ case reports in the literature.

Intramedullary Versus Extramedullary Fixation for Unstable Intertrochanteric Fractures: A Prospective Randomized Controlled Trial.

BACKGROUND: The use of intramedullary devices for the management of intertrochanteric fractures has steadily increased without good evidence of their clinical efficacy. This prospective randomized multicenter study was designed to compare the clinical and radiographic outcomes of patients who had been treated with a traditional extramedullary hip screw for an unstable (AO/OTA 31-A2) intertrochanteric hip fracture with those of patients who had been treated with the newer intramedullary device for the same injury. METHODS: The Lower Extremity Measure (LEM) was used as the primary hip-specific outcome tool. The Functional Independence Measure (FIM), the timed "Up & Go" (TUG) test, as well as a timed two-minute walk test were used as secondary clinical outcome tools. Specific radiographic parameters were collected to assess for fracture movement, heterotopic ossification, and implant failure. RESULTS: No significant differences were noted between the intramedullary and extramedullary treatment arms with regard to either the primary or the secondary clinical outcome tools. The radiographic parameters favored the intramedullary treatment arm, which had less femoral neck shortening. CONCLUSIONS: While the use of the intramedullary devices led to better radiographic outcomes in this study, this did not translate to improved functional outcomes.

Attempting primary closure for all open fractures: the effectiveness of an institutional protocol.

BACKGROUND: Immediate primary closure of open fractures has been historically believed to increase the risk of wound infection and fracture nonunion. Recent literature has challenged this belief, but uncertainty remains as to whether primary closure can be used as routine practice. This study evaluates the impact of an institutional protocol mandating primary closure for all open fractures. METHODS: We retrospectively reviewed all open fractures treated in a single level 1 trauma centre in a 5-year period. Prior to the study, a protocol was adopted standardizing management of open fractures and advocating primary closure of all wounds as a necessary goal of operative treatment. Patient and fracture characteristics, type of wound closure and development of infectious and bone healing complications were evaluated from time of injury to completion of outpatient follow-up. RESULTS: A total of 297 open fractures were treated, 255 (85.8%) of them with immediate primary closure. Type III open injuries accounted for 24% of all injuries. Wounds that were immediately closed had a superficial infection rate of 11% and a deep infection rate of 4.7%. Both proportions are equivalent to or lower than historical controls for delayed closure. Fracture classification, velocity of trauma and time to wound closure did not correlate significantly with infection, delayed union or nonunion. CONCLUSION: Attempting primary closure for all open fractures is a safe and efficient practice that does not increase the postoperative risk of infection and delayed union or nonunion.

CONTEXTE: On a de tout temps cru que la fermeture primaire immédiate des fractures ouvertes accroissait le risque d'infection de la plaie et de non soudure osseuse. La littérature récente remet cette position en question, mais on ignore encore si la fermeture primaire peut être utilisée de routine. Cette étude évalue l'impact d'un protocole d'établissement imposant la fermeture primaire de toutes les fractures ouvertes. MÉTHODES: Nous avons passé en revue de manière rétrospective toutes les fractures ouvertes traitées dans un seul centre de traumatologie de Niveau 1 au cours d'une période de 5 ans. Avant l'étude, un protocole a été adopté pour standardiser la prise en charge des fractures ouvertes et promouvoir la fermeture primaire de toutes les plaies comme objectif imposé du traitement opératoire. Les caractéristiques des patients et des fractures, les types de fermeture de plaie et les complications infectieuses ou liées à la guérison osseuse ont été évalués à partir du moment de la blessure et jusqu'à la fin du suivi en clinique externe. RÉSULTATS: En tout, 297 fractures ouvertes ont été traitées, 255 d'entre elles (85,8 %), au moyen d'une fermeture primaire immédiate. Les traumatismes ouverts de Type III comptaient pour 24 % de toutes les blessures. Les plaies qui ont été refermées immédiatement ont présenté un taux d'infection superficielle de 11 % et un taux d'infection profonde de 4,7 %. Ces 2 proportions sont équivalentes ou inférieures à ce qui a été observé chez les témoins historiques chez qui la fermeture de plaie a été reportée. La classification des fractures, la vitesse de l'impact à l'origine des traumatismes et le temps écoulé avant la fermeture des plaies n'ont pas été en corrélation significative avec l'infection et le retard de soudure osseuse ou la non soudure osseuse. CONCLUSION: Tenter d'appliquer une fermeture primaire à toutes les fractures ouvertes est une pratique sécuritaire et efficace qui n'accroît pas le risque d'infection postopératoire, de retard de soudure osseuse ou de non soudure osseuse.

Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide.

OBJECTIVES: The purpose of this study was to determine which screws could be safely inserted percutaneously into a proximal humerus locking plate using a new external aiming guide without injuring the axillary nerve. We also sought to evaluate that all the screws could be accurately inserted ina locked position with the external guide. METHODS: Eight cadaveric specimens were implanted with a proximal humerus locking plate using a minimally invasive direct-lateral deltoid splitting approach using an attached external aiming guide for screw insertion. The anatomic proximity of the axillary nerve to the guidewires and screws was measured following soft tissue dissection and inspection of the nerve. RESULTS: The two superior holes (C1 and C2) were proximal to the axillary nerve with an average distance of 15.1 mm. Screw F was on average 6.6 mm distal to the axillary nerve but within 2 mm of the nerve in two specimens. In all specimens, the locking screws were appropriately seated in a locked position using the external aiming guide. CONCLUSIONS: This study suggests that percutaneous fixation of a proximal humerus locking plate with an external aiming guide can be safely used for proximal humerus fractures. The limited number of screws that can be inserted into the proximal fragment using the current external guide arm may compromise fixation of more unstable fractures. Therefore, the indications for percutaneous locking plate fixation of the proximal humerus using an external aiming guide should be limited to stable fracture patterns that can be anatomically reduced.

Pressure mapping as an outcome measure for spinal surgery in patients with myelomeningocele.

STUDY DESIGN: A retrospective analysis of prospectively collected data on a cohort of 19 myelomeningocele patients undergoing spino-pelvic deformity surgery. OBJECTIVE: To examine if greater curve correction with third generation spinal implants correlate with improved pressure distribution and resolution, or prevention of skin ulcerations in myelomeningocele patients. SUMMARY OF BACKGROUND DATA: Children born with myelomeningocele have often complex spino-pelvic deformities leading to skin ulcerations. METHODS: A cohort of 19 consecutive wheelchair dependent patients with myelodisplastic spinal deformities, who underwent spinal surgery, was prospectively followed with regular pressure mappings for a minimum of 2 years. Standard spino-pelvic radiologic measurements were obtained. Sitting pressure mappings were obtained over the study period using the Force Sensitive Applications from Vista Medical (Winnipeg, Manitoba, Canada). Statistical analysis was done using SAS (SAS Institute Inc, Cary, NC). Paired t-test and Wilcox on Signed Rank test was used where applicable. Significance was taken to be P<0.05. RESULTS: Surgery significantly corrected radiographic parameters, specifically, Cobb angle (52%), pelvic obliquity (89%), and to a lesser degree pelvic tilt. Stratifying the data based on fixation type showed that the M-W construct was able to significantly correct pelvic obliquity. While significant changes in radiographic variables were observed after surgery, this was not the case with the various pressure mapping variables. Only minor changes after surgery were observed in the average pressure, maximum pressure, and variable coefficient of pressure. What was observed was an improvement in the overall distribution from anterior/posterior and right/left. While the values only approached statistical significance (P=0.053) for right/left, however, this did not appear to be clinically significant regarding skin ulceration. CONCLUSION: Despite significant surgical corrections in radiographic parameters, these resulted in small changes in pressure distributions and do not appear to influence skin ulceration in the myelomeningocele patient. Pressure mapping may not be a useful tool in predicting outcome of spinal surgery. Factors which were proven to influence pressure distribution are the sagittal pelvic orientation and also achieving coronal spine balance.

Percutaneous humeral plating of fractures of the proximal humerus: results of a prospective multicenter clinical trial.

OBJECTIVES: To evaluate the safety and functional outcome of a recently described surgical technique of percutaneous plating for proximal humerus fractures. DESIGN: Prospective clinical trial. SETTING: : Two urban Level 1 university trauma centers. PATIENTS: From February 2002 to December 2003, 34 consecutive patients underwent surgery by 5 trauma surgeons from 2 teaching hospitals. Twenty-seven patients had 1-year follow-up. INTERVENTION: The technique involved 2 minimal incisions with a lateral deltoid split and a more distal shaft incision. A proximal humerus-specific locking plate was implemented. MAIN OUTCOME MEASUREMENTS: DASH (disabilities of the arm, shoulder, and hand) and Constant-Murley evaluation scores were used for functional evaluation. The presence of complications was noted. RESULTS: Specifically, there were no axillary nerve injury injuries and no loss of reduction. The average Constant score at 1 year was 82 and the DASH score was 26. CONCLUSION: This study demonstrated that the functional outcome results correspond to a normal age-adjusted score signifying an acceptable result.

Fibular fixation as an adjuvant to tibial intramedullary nailing in the treatment of combined distal third tibia and fibula fractures: a biomechanical investigation.

OBJECTIVE: Distal third tibia fractures have classically been treated with standard plating, but intramedullary (IM) nailing has gained popularity. Owing to the lack of interference fit of the nail in the metaphyseal bone of the distal tibia, it may be beneficial to add rigid plating of the fibula to augment the overall stability of fracture fixation in this area. This study sought to assess the biomechanical effect of adding a fibular plate to standard IM nailing in the treatment of distal third tibia and fibula fractures. METHODS: Eight cadaveric tibia specimens were used. Tibial fixation consisted of a solid titanium nail locked with 3 screws distally and 2 proximally, and fibular fixation consisted of a 3.5 mm low-contact dynamic compression plate. A section of tibia and fibula was removed. Testing was accomplished with an MTS machine. Each leg was tested 3 times; with and without a fibular plate and with a repetition of the initial test condition. Vertical displacements were tested with an axial load up to 500 N, and angular rotation was tested with torques up to 5 N*m. RESULTS: The difference in axial rotation was the only statistically significant finding (p = 0.003), with fibular fixation resulting in 1.1 degrees less rotation through the osteotomy site (17.96 degrees v. 19.10 degrees ). Over 35% of this rotational displacement occurred at the nail-locking bolt interface with the application of small torsional forces. CONCLUSION: Fibular plating in addition to tibial IM fixation of distal third tibia and fibula fractures leads to slightly increased resistance to torsional forces. This small improvement may not be clinically relevant.

A new intramedullary nail device for the treatment of intertrochanteric hip fractures: Perioperative experience.

BACKGROUND: Traditional short nail fixation devices used for intertrochanteric (IT) fractures of the femur have several surgeon and patient benefits. However, these devices have had a high incidence of complications. A new intramedullary device designed to overcome these shortcomings has become commercially available. The goal of this study was to compare this intramedullary nail device with the traditional dynamic hip screw. METHOD: A prospective cohort study with 60 IT hip fractures was performed. Thirty patients treated with the trochanteric fixation nail (TFN) were compared with 30 patients treated with the dynamic hip screw (DHS) during the same time period. Implant selection was dictated by surgeon randomization. Primary outcomes planned for this study were immediate measures of operative blood loss, surgical time, and incidence of operative complications. Secondary outcome of return to preoperative ambulatory status was also recorded. Follow-up for secondary outcomes was conducted at an average of 6 months after surgery. Perioperative, functional, and radiologic outcome measures were collected. RESULT: No intra- or perioperative complications occurred with the new nail device. Operative time was 10 minutes shorter with TFN (50.7 minutes) compared with DHS (60.4 minutes). No Trendelenburg gait was noted in either group. No femur fractures or distal locking difficulties occurred in the TFN group. Twelve of 17 (71%) TFN patients returned to prefracture ambulation 6 months after surgery compared with only 6 of 18 (33%) DHS patients (p = 0.09). CONCLUSION: The rate of femoral fractures for short femoral nails was decreased compared with historical controls. Improved early mobilization was noted in TFN group.

Knee joint laxity in a native Canadian Indian population.

BACKGROUND: Clinical observation of increased laxity has been noted in native Canadians. Comparative studies support the possible relationship between joint hypermobility and the development of osteoarthritis or other joint ailments. If joint laxity predisposes to osteoarthritis, there may be far-reaching consequences to the general Native population. METHODS: A cohort of 52 Native Canadians (NC) and 52 non-Native Canadians (NNC) were evaluated for knee laxity. All patients had no prior history of knee injury or complaints of symptoms related to knee pathology at the time of the examination. Bilateral knee examination was performed. Objective laxity was measured using the KT-1000 tensiometer. Subjective findings were also recorded. RESULTS: Comparison for instability between the groups (NC and NNC) revealed that the NC group had significantly greater laxity on both right and left sides for all knee ligament grading (p < or = 0.0001). The values for displacement during KT-1000 measurements were significantly greater in the NC group for all forces (p < or = 0.0001). Presence of all the following were also significantly greater in the NC group: pivot shift (p < or = 0.001); medial and lateral collateral ligament opening (p < or = 0.001); posterior cruciate drawer test (p < or = 0.001). INTERPRETATION: This prospective matched cohort reveals that there is a significant joint hypermobility in this Native Canadian population.