The cost-effectiveness of the arthroscopic Bankart versus open Latarjet in the treatment of primary shoulder instability.

BACKGROUND: The purpose of this study was to conduct a cost-effectiveness analysis of the arthroscopic Bankart and the open Latarjet in the treatment of primary shoulder instability. METHODS: This cost-effectiveness study used a Markov decision chain and Monte-Carlo simulation. Existing literature was reviewed to determine the survivorship and complication rates of these procedures. Health utility states (EQ-5D and quality-adjusted life-years) of the Bankart and Latarjet were prospectively collected. Using these variables, the Monte-Carlo simulation was modeled 100,000 times. RESULTS: In reviewing the literature, the overall recurrence rate is 14% after the arthroscopic Bankart and 8% after the open Latarjet. Postoperative health utility states were equal between the 2 procedures (mean EQ-5D, 0.930; P = .775). The Monte-Carlo simulation showed that the Bankart had an incremental cost-effectiveness ratio of $4214 and the Latarjet had an incremental cost-effectiveness ratio of $4681 (P < .001). CONCLUSION: Both the arthroscopic Bankart and open Latarjet are highly cost-effective; however, the Bankart is more cost-effective than the Latarjet, primarily because of a lower health utility state after a failed Latarjet. Ultimately, the clinical scenario may favor Latarjet (ie, critical glenoid bone loss) in certain circumstances, and decisions should be made on a case by case basis.

Flexible Intramedullary Nails for Femur Fractures in Pediatric Patients Heavier Than 100 Pounds.

BACKGROUND: Flexible intramedullary nailing (FIMN) of femoral shaft fractures in children >100 pounds remains controversial. The purpose of this study is to assess the relationship between patient weight and alignment at radiographic union following Ender's FIMN of pediatric femoral shaft fractures. METHODS: An IRB approved, retrospective review of all patients who sustained a femoral shaft fracture treated by retrograde, stainless-steel Ender's FIMN was performed at a level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. Patient weight was measured on presentation to the emergency room. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation. RESULTS: A total of 261 children underwent Ender's FIMN for femoral shaft fractures during the study period. There were 24 patients who weighed ≥100 lbs and 237 patients who weighed <100 lbs. There were no significant differences in sex (75% vs. 73% male), fracture stability (42.6% vs. 41.7% length unstable), or fracture patterns between the 2 groups. The ≥100 lbs group was significantly older (10.6 vs. 8.0 y, P<0.001). There were no significant differences in final coronal angulation (1.5 vs. 3.0 degrees), sagittal angulation (2.8 vs. 3.1 degrees), or shortening (3.4 vs. 3.5 mm) between the 2 groups. There were significantly more nail removals in the <100 lbs group (81.4% vs. 66.7%, P<0.01). Four percent of the population (10 patients) weighed ≥120 lbs and aside from age (11.4 vs. 8.1 y, P<0.01), there were no significant demographic or fracture pattern differences between this group and the remaining population. This heaviest group demonstrated no significant difference in shortening (3.3 vs. 3.5 mm), coronal angulation (0.8 vs. 3.0 degrees), or sagittal angulation (0.7 vs. 3.2 degrees) at radiographic union when compared with the lighter patients. CONCLUSIONS: Stainless-steel Ender's FIMN is an effective treatment for pediatric femoral shaft fractures in patients ≥100 pounds with excellent radiographic outcomes and no increased risk for malunion. LEVEL OF EVIDENCE: Therapeutic Level III.

Digital Tomography for Detection of Acute Occult Scaphoid Fractures.

Diagnosis of occult scaphoid fractures remains a challenge. Traditional management consisting of 2 weeks of immobilization and repeat radiographs results in unnecessary immobilization of many patients without fracture. Magnetic resonance imaging (MRI) is sensitive but expensive. Digital tomography (DT) is an imaging technique that provides fine-cut visualization with minimal radiation exposure and may be used when there is high clinical suspicion despite negative findings on initial radiographs. The authors compared the ability of DT vs MRI to detect acute occult scaphoid fractures. This was an institutional review board-approved, prospective series. Adults for which clinical suspicion for acute scaphoid fracture (presenting within 96 hours of trauma) and negative findings on initial radiographs existed were included. Both a wrist tomogram and MRI were obtained. Wrists were immobilized and reevaluated at 10 to 14 days with repeat radiographs as a control. Studies were interpreted by a radiologist in a blinded fashion. Forty consecutive extremities in 39 patients met the inclusion criteria. Six (15%) of the 40 scaphoids were determined to be fractured on repeat radiographs. Digital tomogram yielded positive findings in 4 of these. Magnetic resonance imaging yielded positive findings in 8 (20%) of the 40 extremities. Sensitivities were 67% and 100% for digital tomogram and MRI, respectively (P=.0001). The positive predictive value was 100% for DT and MRI. The authors found that DT detects more occult scaphoid fractures than initial standard radiographs but is less sensitive than MRI. This is the first study to compare DT with MRI. Digital tomography can be used to augment radiographs and may increase diagnostic efficiency, minimize unnecessary immobilization, and reduce health care costs. [Orthopedics. 2017; 40(6):e1092-e1095.].

Redefining Optimal Nail to Medullary Canal Diameter Ratio in Stainless Steel Flexible Intramedullary Nailing of Pediatric Femur Fractures.

PURPOSE: The ideal canal fill for flexible intramedullary fixation of pediatric femoral shaft fractures is considered to be 80% based upon relatively few clinical studies. The purpose of this study is to assess the relationship between the summed nail to intramedullary canal diameter (ND/MCD) ratio and alignment at radiographic union following flexible intramedullary nailing (FIMN) of pediatric femoral shaft fractures. METHODS: An Internal Review Board approved, retrospective review of a consecutive series of patients who sustained a femoral shaft fracture treated by retrograde, stainless steel FIMN was performed at a single level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. ND/MCD ratio was calculated using the sum of the known nail diameters and the measured isthmic diameter. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation. ND/MCD ratio was analyzed to determine correlative factors with final radiographic outcomes. RESULTS: In total, 261 children underwent retrograde FIMN at an average age of 8.2 years (range, 2.2 to 17.0 y). ND/MCD ratio of ≥80% was seen in 108 (41.4%) patients. When compared with those with <80% ND/MCD ratio, there were no significant differences in age (8.8 vs. 8.0 y), sex (76.9% vs. 71.0% males), or body mass index (18.5 vs. 17.2 kg/m). There were significantly more length unstable fractures in the <80% ND/MCD ratio group (49.4% vs. 29.7%; P<0.01). Radiographic outcome was no different with respect to coronal angulation (2.7 vs. 3.0 degrees), sagittal angulation (3.0 vs. 3.2 degrees), or shortening (2.5 vs. 4.1 mm). ND/MCD ratio of ≥70% was seen in 176 (67.4%) patients and, when compared with the <70% ND/MCD ratio group, there were no differences in shortening (3.3 vs. 3.9 mm), coronal angulation (2.8 vs. 3.0 degrees), or sagittal angulation (3.0 vs. 3.4 degrees). Finally, 6.9% of the population (18 patients) had ND/MCD ratios <60% and did not demonstrate a significant increase in shortening, coronal, or sagittal angulation compared with groups with higher ND/MCD ratios. No group had an increased rate of infection, implant removal, nonunion, or need for reoperation. CONCLUSIONS: In a large series of consecutive patients treated with retrograde stainless steel FIMN there does not appear to be any correlation between the ND/MCD ratio and radiographic outcome. Stainless steel flexible IM nails seem to maintain fracture alignment without an increase in complications at lower ND/MCD ratios than previously reported as "optimal." LEVEL OF EVIDENCE: Level III.

Think time: A novel approach to analysis of clinicians' behavior after reduction of drug-drug interaction alerts.

OBJECTIVES: Pharmacologic interaction alerting offers the potential for safer medication prescribing, but research reveals persistent concerns regarding alert fatigue. Research studies have tried various strategies to resolve this problem, with low overall success. We examined the effects of targeted alert reduction on clinician behavior in a resource constrained hospital. METHODS: A physician and a pharmacy informaticist reduced alert levels of several drug-drug interactions (DDI) that clinicians almost always overrode with approval from and knowledge of the medical staff. This study evaluated the behavioral changes in prescribers and non-prescribers as measured by "think time", a new metric for evaluating the resolution time for an alert, before and after suppression of selected DDI alerts. RESULTS: The user-seen DDI alert rate decreased from 9.98% of all orders to 9.20% (p=0.0001) with an overall volume reduction of 10.3%. There was no statistical difference in the reduction of cancelled (-10.00%) vs. proceed orders (-11.07%). Think time decreased overall by 0.61s (p<0.0001). Think time unexpectedly increased for cancelled orders 1.00s which while not statistically significant (p=0.28) is generally thought to be clinically noteworthy. For overrides, think time decreased 0.67s which was significant (p<0.0001). Think time lowered for both prescribers and non-prescribers. Targeted specialists had shorter think times initially, which shortened more than non-targeted specialists. CONCLUSIONS: Targeted DDI alert reductions reduce alert burden overall, and increase net efficiency as measured by think time for all prescribers better than for non-prescribers. Think time may increase when cancelling or changing orders in response to DDI alerts vs. a decision to override an alert.

Measuring the operational impact of digitized hospital records: a mixed methods study.

BACKGROUND: Digitized (scanned) medical records have been seen as a means for hospitals to reduce costs and improve access to records. However, clinical usability of digitized records can potentially have negative effects on productivity. METHODS: Data were collected during follow-up outpatient consultations in two NHS hospitals by non-clinical observers using a work sampling approach in which pre-defined categories of clinician time usage were specified. Quantitative data was analysed using two-way ANOVA models and the Mann-Whitney U test. A focus group was held with clinicians to qualitatively explore their experiences using digitized medical records. The quantitative and qualitative results were synthesized. RESULTS: Four hundred six consultations were observed. Using paper records, there was a significant difference in consultation times between hospitals (p = 0.016) and a significant difference in consultation times between specialties within hospitals (p = 0.003). Using digitized records there was a significant difference in consultation times between specialties within a hospital (p = 0.001). Excluding outliers, there was no significant difference between consultation times using digitized records compared with consultations using paper records in the same hospital, either at site (p > =0.285) or specialty level (p > =0.122). With digitized records at site A, two out of three specialties showed a significant increase in time spent searching computer records (p < =0.010, Δ = 01:50-07:10) and one specialty had a corresponding reduction in time spent searching paper records (p = 0.015, Δ = -00:28). Site B showed a notable increase in direct patient care (p < 0.001, Δ = 04:20-06:00) and time spent searching computer records (p < =0.043, Δ = 00:10-01:40) and reductions in the other time categories. The focus group confirmed that the most recent clinical letter was a vital document in the patient record, often containing most of the required information. Concerns were expressed about consistency of scanning practice, causing uncertainty about what could be relied upon to exist in the digitized record. Benefits of digitized records included: access from multiple locations, better prepared ward rounds, improved inpatient handovers and an improved timeline of patient events. Limitations of digitized records included: increased complexity of creating a patient summary, display of specialised content such as hand-drawn diagrams, inability to quickly flick through the pages to find relevant content. CONCLUSIONS: Digitized medical records can be implemented without detrimental operational impact. Inherent differences between specialties can outweigh the differences between paper and digitized records. Clear and consistent operational processes are vital for the reliability and usability of digitized medical records. Divergent views about usability (such as whether patient summary information is better or worse) may reflect familiarity with features of the digitized record.

Clinical Validation of the Glenoid Track Concept in Anterior Glenohumeral Instability.

BACKGROUND: Glenoid and humeral bone loss are well-described risk factors for failure of arthroscopic shoulder stabilization. Recently, consideration of the interactions of these types of bone loss (bipolar bone loss) has been used to determine if a lesion is "on-track" or "off-track." The purpose of this study was to study the relationship of the glenoid track to the outcomes of arthroscopic Bankart reconstructions. METHODS: Over a 2-year period, 57 shoulders that were treated with an isolated, primary arthroscopic Bankart reconstruction performed at a single facility were included in this study. The mean patient age was 25.5 years (range, 20 to 42 years) at the time of the surgical procedure, and the mean follow-up was 48.3 months (range, 23 to 58 months). Preoperative magnetic resonance imaging was used to determine glenoid bone loss and Hill-Sachs lesion size and location and to measure the glenoid track to classify the shoulders as on-track or off-track. Outcomes were assessed according to shoulder stability on examination and subjective outcome. RESULTS: There were 10 recurrences (18%). Of the 49 on-track patients, 4 (8%) had treatment that failed compared with 6 (75%) of 8 off-track patients (p = 0.0001). Six (60%) of 10 patients with recurrence of instability were off-track compared with 2 (4%) of 47 patients in the stable group (p = 0.0001). The positive predictive value of an off-track measurement was 75% compared with 44% for the predictive value of glenoid bone loss of >20%. CONCLUSIONS: The application of the glenoid track concept to our cohort was superior to using glenoid bone loss alone with regard to predicting postoperative stability. This method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Big Data, Big Problems: Incorporating Mission, Values, and Culture in Provider Affiliations.

This article explores how integration of data from clinical registries and electronic health records produces a quality impact within orthopedic practices. Data are differentiated from information, and several types of data that are collected and used in orthopedic outcome measurement are defined. Furthermore, the concept of comparative effectiveness and its impact on orthopedic clinical research are assessed. This article places emphasis on how the concept of big data produces health care challenges balanced with benefits that may be faced by patients and orthopedic surgeons. Finally, essential characteristics of an electronic health record that interlinks musculoskeletal care and big data initiatives are reviewed.

Computerised Provider Order Entry Adoption Rates Favourably Impact Length of Stay.

Background Research regarding return on investment for electronic health records (EHRs) is sparse.Objective To extend previously established research and examine rigorously whether increasing the adoption of computer-based provider/prescriber order entry (CPOE) leads to a decrease in length of stay (LOS), and to demonstrate that the two are inversely and bidirectionally proportional even while other efforts to decrease LOS are in place.Method The study assessed CPOE, LOS and case mix index (CMI) data in a community hospital in the United States, using a mature and nearly fully deployed vendor product EHR. CPOE rates and LOS over 7 years were determined on a per-patient, per-visit and per-discipline basis and compared with concomitant CMI data.Results An inverse relationship of CPOE to LOS was correlated for 13 disciplines out of 19, and organisation wide for all disciplines combined during the first 5 years of study. During the subsequent 2 years, both CPOE and LOS plateaued, except in eight disciplines where CPOE rates at first declined and LOS concurrently rose slightly, and then returned to the baseline plateau levels. CMI increased during the entire period of evaluation. An inflection point at approximately 60% CPOE adoption predicted the greatest improvement in lowering of LOS.Conclusions Rising and falling rates of CPOE correlated with reductions and rises in LOS, respectively. CPOE appeared statistically to be an independent factor in affecting LOS, over and above other efforts to shorten LOS, thus contributing to lower costs and improved efficiency outcomes as measured by LOS, even as CMI rises.

Outcomes After Surgical Treatment of Adolescent Intra-articular Distal Humerus Fractures.

BACKGROUND: To determine the radiographic and clinical outcomes of the surgical management of adolescent intra-articular distal humerus fractures. METHODS: We performed a retrospective review of the clinical and radiographic outcomes of 31 consecutive adolescent patients surgically treated for acute distal humerus intra-articular fractures. Nine patients returned for objective measures of range of motion, strength testing, and completion of validated outcome scores including the Mayo Elbow Performance Score (MEPS); The Disabilities of the Arm, Shoulder, and Hand Score (DASH); and the SF-36. RESULTS: The average age at the time of injury was 13.5 years (range, 12 to 16 y) with a mean follow-up of 1.22 years (range, 9 d to 5.5 y). Multiple surgical approaches were performed. Overall, the active range of motion for our patients was 10.7 to 133.9 degrees with a mean arc of 123.4 degrees. AO classification type C2 and C3 injuries lost significantly more motion than other fracture patterns. Twelve patients sustained perioperative nerve palsies that resolved by final follow-up; seven of these nerve injuries were iatrogenic and sustained during a Bryan-Morrey tricepital slide approach. Eight patients required implant removal; 7 of these patients had prominent olecranon screws after an olecranon osteotomy. Including postoperative neuropathies, there were 20 complications in 15 patients. Thirteen complications in 9 patients required a return to the operating room. Of the 9 patients who returned for objective testing, there was no statistically significant loss of range of motion or strength of the injured extremity when compared with the uninjured limb. The MEPS revealed 6 excellent, 1 good, and 2 fair results. The average DASH score was 5.1 (range, 0 to 19.1) and the physical (average 55.7; range, 47.4 to 59.0) and mental components (average 54.2; range, 29.8 to 63.4) of the SF-36 were comparable. CONCLUSIONS: After surgical intervention for an adolescent intra-articular distal humerus fracture, one can expect no significant loss of motion or strength. The reported outcomes are not all excellent. The peri-operative complication rates are high and may be related to surgical approach and fracture pattern. LEVEL OF EVIDENCE: Level IV.

Autograft Versus Allograft Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Clinical Study With a Minimum 10-Year Follow-up.

BACKGROUND: The use of allografts for anterior cruciate ligament (ACL) reconstruction in young athletes is controversial. No long-term results have been published comparing tibialis posterior allografts to hamstring autografts. PURPOSE: To evaluate the long-term results of primary ACL reconstruction using either an allograft or autograft. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: From June 2002 to August 2003, patients with a symptomatic ACL-deficient knee were randomized to receive either a hamstring autograft or tibialis posterior allograft. All allografts were from a single tissue bank, aseptically processed, and fresh-frozen without terminal irradiation. Graft fixation was identical in all knees. All patients followed the same postoperative rehabilitation protocol, which was blinded to the therapists. Preoperative and postoperative assessments were performed via examination and/or telephone and Internet-based questionnaire to ascertain the functional and subjective status using established knee metrics. The primary outcome measures were graft integrity, subjective knee stability, and functional status. RESULTS: There were 99 patients (100 knees); 86 were men, and 95% were active-duty military. Both groups were similar in demographics and preoperative activity level. The mean and median ages of both groups were identical at 29 and 26 years, respectively. Concomitant meniscal and chondral pathologic abnormalities, microfracture, and meniscal repair performed at the time of reconstruction were similar in both groups. At a minimum of 10 years (range, 120-132 months) from surgery, 96 patients (97 knees) were contacted (2 patients were deceased, and 1 was unable to be located). There were 4 (8.3%) autograft and 13 (26.5%) allograft failures that required revision reconstruction. In the remaining patients whose graft was intact, there was no difference in the mean Single Assessment Numeric Evaluation, Tegner, or International Knee Documentation Committee scores. CONCLUSION: At a minimum of 10 years after ACL reconstruction in a young athletic population, over 80% of all grafts were intact and had maintained stability. However, those patients who had an allograft failed at a rate over 3 times higher than those with an autograft.

Improved Immediate and Continued-Care Outcomes for Stroke through Community-Wide Data.

Strokes account for 1 of every 18 deaths in North America, and remain a major burden cost-wise and clinically for societies globally. Quicker and more clinically astute care for stroke leads to improved outcomes for the patient, families and the healthcare system at large. The intervention shared illustrates how a locally-programmable EMR with inherent community-wide communications capabilities leads to proven better outcomes for all. The impacts range from initial hospital encounter through acute-care treatment, and then more broadly into post-discharge care community-wide. Implications for all healthcare communities are established.

Optimal Care Mother-Baby and Outcomes through Community-wide Data Sharing, Interoperability and Connectivity.

The power of interoperable systems with data/information integration, central to achieving the goals of Telehealth, is illustrated through mutually beneficial sharing between Labor & Delivery (L&D) and Obstetrics (OBs) Clinics. Data shared between L&D and OB brought improved practice patterns and outcomes, and increased satisfaction at both. Staffing and skillsets were significantly improved by knowing complications arriving and anticipated volumes. OBs increased clinic efficiencies and improved patient-direct care time with improved clinical and cost outcomes.

Redefining "Critical" Bone Loss in Shoulder Instability: Functional Outcomes Worsen With "Subcritical" Bone Loss.

BACKGROUND: Glenoid bone loss is a common finding in association with anterior shoulder instability. This loss has been identified as a predictor of failure after operative stabilization procedures. Historically, 20% to 25% has been accepted as the "critical" cutoff where glenoid bone loss should be addressed in a primary procedure. Few data are available, however, on lesser, "subcritical" amounts of bone loss (below the 20%-25% range) on functional outcomes and failure rates after primary arthroscopic stabilization for shoulder instability. PURPOSE: To evaluate the effect of glenoid bone loss, especially in subcritical bone loss (below the 20%-25% range), on outcomes assessments and redislocation rates after an isolated arthroscopic Bankart repair for anterior shoulder instability. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Subjects were 72 consecutive anterior instability patients (73 shoulders) who underwent isolated anterior arthroscopic labral repair at a single military institution by 1 of 3 sports medicine fellowship-trained orthopaedic surgeons. Data were collected on demographics, the Western Ontario Shoulder Instability (WOSI) score, Single Assessment Numeric Evaluation (SANE) score, and failure rates. Failure was defined as recurrent dislocation. Glenoid bone loss was calculated via a standardized technique on preoperative imaging. The average bone loss across the group was calculated, and patients were divided into quartiles based on the percentage of glenoid bone loss. Outcomes were analyzed for the entire cohort, between the quartiles, and within each quartile. Outcomes were then further stratified between those sustaining a recurrence versus those who remained stable. RESULTS: The mean age at surgery was 26.3 years (range, 20-42 years), and the mean follow-up was 48.3 months (range, 23-58 months). The cohort was divided into quartiles based on bone loss. Quartile 1 (n = 18) had a mean bone loss of 2.8% (range, 0%-7.1%), quartile 2 (n = 19) had 10.4% (range, 7.3%-13.5%), quartile 3 (n = 18) had 16.1% (range, 13.5%-19.8%), and quartile 4 (n = 18) had 24.5% (range, 20.0%-35.5%). The overall mean WOSI score was 756.8 (range, 0-2097). The mean WOSI score correlated with SANE scores and worsened as bone loss increased in each quartile. There were significant differences (P < .05) between quartile 1 (mean WOSI/SANE, 383.3/62.1) and quartile 2 (mean, 594.0/65.2), between quartile 2 and quartile 3 (mean, 839.5/52.0), and between quartile 3 and quartile 4 (mean, 1187.6/46.1). Additionally, between quartiles 2 and 3 (bone loss, 13.5%), the WOSI score increased to rates consistent with a poor clinical outcome. There was an overall failure rate of 12.3%. The percentage of glenoid bone loss was significantly higher among those repairs that failed versus those that remained stable (24.7% vs 12.8%, P < .01). There was no significant difference in failure rate between quartiles 1, 2, and 3, but there was a significant increase in failure (P < .05) between quartiles 1, 2, and 3 (7.3%) when compared with quartile 4 (27.8%). Notably, even when only those patients who did not sustain a recurrent dislocation were compared, bone loss was predictive of outcome as assessed by the WOSI score, with each quartile's increasing bone loss predictive of a worse functional outcome. CONCLUSION: While critical bone loss has yet to be defined for arthroscopic Bankart reconstruction, our data indicate that "critical" bone loss should be lower than the 20% to 25% threshold often cited. In our population with a high level of mandatory activity, bone loss above 13.5% led to a clinically significant decrease in WOSI scores consistent with an unacceptable outcome, even in patients who did not sustain a recurrence of their instability.

Outcomes of long-arm casting versus double-sugar-tong splinting of acute pediatric distal forearm fractures.

INTRODUCTION: The traditional treatment after closed reduction of distal radius (DR) and distal both bone (DBB) forearm fractures has been application of a long-arm cast (LAC) or a short-arm cast (SAC). Splinting is another option that avoids the potential complications associated with casting. The purpose of this study is to evaluate the maintenance of reduction of DR or DBB fractures placed in a double-sugar-tong splint (DSTS) compared with a LAC in a pediatric population. METHODS: This is an IRB-approved, prospective, randomized trial. Patients aged 4 to 12 years with DR or DBB fractures treated at a single institution between 2010 and 2012 were enrolled. After reduction, fractures were placed into either a LAC or a DSTS. Radiographs were reviewed at initial injury, postreduction, and at set intervals for angulation, displacement, and apposition, as well as cast index and 3-point index. The DSTS was overwrapped into a cast after week 1. The immobilization device was changed to a SAC at week 4 or 6. Total duration of immobilization was 6 to 8 weeks. RESULTS: Seventy-one patients were enrolled with 37 in the LAC and 34 in the DSTS. Average age was 8.73 years (range, 4 to 12) with 43 being males. There were 28 isolated DR and 43 DBB fractures. There were no week-to-week differences between the 2 groups in regards to sagittal alignment, coronal alignment, apposition, or displacement. Sagittal alignment at immediate postreduction and week 2 showed that the DSTS was slightly better (average 2.0 vs. 5.0 degrees, respectively, P=0.04). For the entire treatment period there was an increased risk of loss of reduction of ≥10 degrees in the LAC group versus the DSTS group (7 patients vs. 2 patients, respectively, P=0.0001), and of meeting the criteria for remanipulation (10 patients vs. 5 patients, respectively, P=0.01). At cast removal, there was no difference between groups. CONCLUSIONS: Although there were significant differences between the 2 groups with regards to risk of reduction loss, the DSTS and LAC were comparable in maintenance of reduction at the time of cast removal. Both the DSTS and LAC are appropriate immobilization devices for these pediatric fractures. LEVEL OF EVIDENCE: Level II-prospective, comparative study.

The impact of tort reform and quality improvements on medical liability claims: a tale of 2 States.

The purpose of this study was to determine the effect of tort reform and quality improvement measures on medical liability claims in 2 groups of hospitals within the same multihospital organization: one in Texas, which implemented medical liability tort reform caps on noneconomic damages in 2003, and one in Louisiana, which did not undergo significant tort reform during the same time period. Significant reduction in medical liability claims per quarter in Texas was found after tort reform implementation (7.27 to 1.4; P<.05). A significant correlation was found between the increase in mean Centers for Medicare & Medicaid Services performance score and the decrease in the frequency of claims observed in Louisiana (P<.05). Although tort reform caps on noneconomic damages in Texas caused the largest initial decrease, increasing quality improvement measures without increasing financial burden also decreased liability claims in Louisiana. Uniquely, this study showed that increasing patient quality resulted in decreased medical liability claims.

The Effect of Syndesmosis Screw Removal on the Reduction of the Distal Tibiofibular Joint: A Prospective Radiographic Study.

BACKGROUND: Injury to the tibiofibular syndesmosis is frequent with rotational ankle injuries. Multiple studies have shown a high rate of syndesmotic malreduction with the placement of syndesmotic screws. There are no studies evaluating the reduction or malreduction of the syndesmosis after syndesmotic screw removal. The purpose of this study was to prospectively evaluate syndesmotic reduction with CT scans and to determine the effect of screw removal on the malreduced syndesmosis. METHODS: This was an IRB-approved prospective radiographic study. Patients over 18 years of age treated at 1 institution between August 2008 and December 2011 with intraoperative evidence of syndesmotic disruption were enrolled. Postoperative CT scans were obtained of bilateral ankles within 2 weeks of operative fixation. Syndesmotic screws were removed after 3 months, and a second CT scan was then obtained 30 days after screw removal. Using axial CT images, syndesmotic reduction was evaluated compared to the contralateral uninjured ankle. Twenty-five patients were enrolled in this prospective study. The average age was 25.7 (range, 19 to 35), with 3 females and 22 males. RESULTS: Nine patients (36%) had evidence of tibiofibular syndesmosis malreduction on their initial postoperative axial CT scans. In the postsyndesmosis screw removal CT scan, 8 of 9 or 89% of malreductions showed adequate reduction of the tibiofibular syndesmosis. There was a statistically significant reduction in syndesmotic malreductions ( t = 3.333, P < .001) between the initial rate of malreduction after screw placement of 36% (9/25) and the rate of malreduction after all screws were removed of 4% (1/25). CONCLUSIONS: Despite a high rate of initial malreduction (36%) after syndesmosis screw placement, 89% of the malreduced syndesmoses spontaneously reduced after screw removal. Syndesmotic screw removal may be advantageous to achieve final anatomic reduction of the distal tibiofibular joint, and we recommend it for the malreduced syndesmosis. LEVEL OF EVIDENCE: Level IV, prognostic case series.

A computerized order entry system was adopted with high user satisfaction at an orthopedic teaching hospital.

BACKGROUND: Computerized provider order entry (CPOE) has been considered essential for the reduction of medical errors and increased patient safety. Assessment of staff perception regarding a CPOE system is important for satisfaction and adoption. Incorporation of user feedback can greatly improve the functionality of a system and promote user satisfaction. QUESTIONS/PURPOSES: This study aims to develop an informatics staff satisfaction survey instrument and to understand what components of computerized prescriber order entry (CPOE) contribute to staff satisfaction and its variability over time. METHODS: The 22-question survey was developed by a multidisciplinary group and focused on patient data including demographics, orders, medications, laboratory, and radiology data. The questions were designed to understand if clinicians (1) could easily access the information needed to properly take care of patients, (2) could act upon the information once acquired, (3) could obtain the information clearly, and (4) were alerted to potential errors. The survey was distributed just prior to "go-live," 6 and 12 months after go-live. Responses were given on a five-point Likert scale. RESULTS: The survey results post-implementation showed user satisfaction with CPOE. Satisfaction regarding the ease of obtaining orders, medication, and lab data had a significant improvement at 6 and 12 months post-implementation, p < 0.001. Satisfaction that the computerized order entry system provided information needed to take care of their patients improved, p < 0.01. At 1 year post-implementation, user satisfaction declined from 6 months earlier but still demonstrated an overall increase in satisfaction from pre-implementation. CONCLUSION: Compared prior to go-live, clinicians are satisfied or very satisfied across multiple spheres and multiple disciplines. At all time points, clinicians were able to obtain information required to take care of their patients. However, post-go-live, it was easier to obtain and act upon as well as more clear and understandable.

Return to an athletic lifestyle after osteochondral allograft transplantation of the knee.

BACKGROUND: Osteochondral allograft transplantation (OATS) is a treatment option that provides the ability to restore large areas of hyaline cartilage anatomy and structure without donor site morbidity and promising results have been reported in returning patients to some previous activities. However, no study has reported on the durability of return to activity in a setting where it is an occupational requirement. HYPOTHESIS: Osteochondral allograft transplantation is less successful in returning patients to activity in a population in which physical fitness is a job requirement as opposed to a recreational goal. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review was conducted of 38 consecutive OATS procedures performed at a single military institution by 1 of 4 sports medicine fellowship-trained orthopaedic surgeons. All patients were on active duty at the time of the index procedure, and data were collected on demographics, return to duty, Knee Injury and Osteoarthritis Outcome Score (KOOS), and ultimate effect on military duty. Success was defined as the ability to return to the preinjury military occupational specialty (MOS) with no duty-limiting restrictions. RESULTS: The mean lesion size treated was 487.0 ± 178.7 mm(2). The overall rate of return to full duty was 28.9% (11/38). An additional 28.9% (11/38) were able to return to limited activity with permanent duty modifications. An alarming 42.1% (16/38) were unable to return to military activity because of their operative knee. When analyzed for return to sport, only 5.3% (2/38) of patients were able to return to their preinjury level. Eleven patients underwent concomitant procedures. Statistical power was maintained by analyzing data in aggregate for cases with versus without concomitant procedures. When the 11 undergoing concomitant procedures were removed from the data set, the rate of return to full activity was 33.3% (9/27), with 22.3% (6/27) returning to limited activity and 44.4% (12/27) unable to return to activity. In this subset, 7.4% (2/27) were able to return to a preinjury level of sport. The KOOS values were significantly higher in the full activity group when compared with the limited and no activity groups (P < .01). Branch of service was a significant predictor of outcome, with Marine Corps and Navy service members more likely to return to full activity compared with Army and Air Force members. A MOS of combat arms was a significant predictor of a poor outcome. All patients demonstrated postoperative healing of their grafts as documented in their medical chart, and no patient in the series required revision for problems with graft incorporation. CONCLUSION: Osteochondral allograft transplantation for the treatment of large chondral defects in the knee met with disappointing results in an active-duty population and was even less reliable in returning this population to preinjury sport levels. Branch of service and occupational type predicted the return to duty, but other traditional predictors of outcome such as rank and years of service did not. The presence of concomitant procedures did not have an effect on outcome with respect to activity or sport level with the numbers available for analysis.

Quality in orthopaedic surgery--an international perspective: AOA critical issues.

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 methods and techniques for achieving better outcomes. The passion for continuous improvement is fundamental, but passion is not sufficient by itself. There is substantial opportunity to improve quality and reduce cost in health care. Multidisciplinary teams that include physicians, nurses, and other ancillary care providers have led to decreased waiting times to see specialists and have also led to better management of chronic disease. By including ancillary care, providers can increase cancer-screening rates and have the potential to decrease readmissions. Moreover, the addition of hospitalists and physician assistants can produce quality and efficiency outcomes that are commensurate with those enjoyed by traditional house staff. However, truly improving performance is difficult due to questions about how we define "quality," design care processes, measure inputs and outputs, develop multi-stakeholder collaborations, and develop incentive programs for delivering "good" care. There is a definite need for more thorough and robust studies of the impact of pay-for-performance programs, with the inclusion of ancillary care providers. Current research has not shown that there is not enough evidence to be able to determine what incentive structure might "work" in a particular health-care system. Payment systems will continue to evolve to incentivize greater collaboration among providers to yield higher-quality, lower-cost care. Future efforts will necessitate the need for strong physician leadership in helping to develop an optimal care team that is as patient-centered as possible. Technology adds dimensions of capability to making improvement real and systematic, as well as providing safer care with fewer errors and better adherence to proven best practices. The drive for quality with technology produces better clinical outcomes and maximizes efficiencies and financial metrics of organizational performance. Technology also adds capabilities for capturing key metrics and reporting them back to clinicians and others. Improved data transparency informs those who can actually do things differently to produce better results and outcomes. While health-care entities strive to focus on quality of care, measuring and reporting such care in a meaningful way are difficult. The best chance of improving overall care for patients is through the adoption of systems that improve coordination and continuity, not by health-care staff working harder. Only through collaboration and integration can health care incorporate a culture for improving quality and patient safety.