A predictive model for increased hospital length of stay following geriatric hip fracture.

BACKGROUND: The purpose of this study was to identify the risk factors that are significantly associated with hospital length of stay (LOS) following geriatric hip fracture and to use these significant variables to develop a LOS calculator. MATERIALS AND METHODS: This was a retrospective study examining 614 patients treated for geriatric hip fracture between January 2000 and December 2009 at an urban, Level 1 trauma center. A negative binomial regression analysis was used to identify perioperative variables associated with hospital LOS. RESULTS: 614 patients met the inclusion criteria, presenting with a mean age of 78 (±10) years. The most common pre-operative comorbidity was hypertension, followed by diabetes and COPD. After controlling for all collected comorbidities as well as demographics and operative variables, hypertension (IRR: 1.10, p = 0.029) and disseminated cancer (IRR: 1.24, p = 0.007) were found to be significantly associated with LOS. In addition, two demographic/presenting variables, admission to the medicine service (IRR: 1.48, p < 0.001) and male sex (IRR: 1.09, p = 0.034), were shown to be independent risk factors for prolonged LOS. These variables were synthesized into a LOS formula, which estimated LOS to within 3 days of the true length of stay for 0.758 of the series (95% confidence interval: 0.661 to 0.855). CONCLUSIONS: This study identified several comorbidity and perioperative variables that were significantly associated with LOS following geriatric hip fracture surgery. The resulting LOS model may have utility in the risk stratification of orthopaedic trauma patients presenting with hip fracture.

Management of Femoral Defects Greater Than 5 cm Following Open Femur Fractures: A 12-Year Retrospective Review.

This study sought to evaluate the outcomes of patients with osseous defects exceeding 5 cm following open femur fractures. Size of the osseous defect, method of internal fixation (plate vs. intramedullary nail), patient demographics, medical comorbidities, and surgical complications were collected. Twenty-seven of the 832 open femur fracture patients had osseous defects exceeding 5 cm. Mean osseous defect size was 8 cm, and each patient had an average of four operations including initial debridement. Average time from injury to bone grafting was 123.7 days. The overall complication rate was 48.1% (n = 13). The most common complications were infection (26.0%, n = 7) and nonunion (41.0%, n = 11). Smoking, diabetes, ASA score, and defect size did not independently increase the risk of a complication. Management of open femur fractures with osseous defects greater than 5 cm is associated with high complication rate, driven primarily by infection and nonunion. (Journal of Surgical Orthopaedic Advances 27(3):203-208, 2018).

Open treatment of ankle fracture as inpatient increases risk of complication.

BACKGROUND: Ankle fracture is one of the most common injuries treated by orthopaedic surgeons, and its incidence is only expected to rise with an aging population. It is also associated with often costly complications, yet there is little literature on risk factors, especially modifiable ones, driving these complications. The aim of this study is to reveal whether inpatient treatment after ankle fracture is associated with higher incidence of postoperative complications. As the USA moves towards a bundled payment healthcare system, it is imperative that orthopaedists maximize patient outcome and quality of care while also reducing overall costs. MATERIALS AND METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program database to compare complication rates between inpatient and outpatient treatment of ankle fracture. We collected patient demographics, comorbidities, and postoperative complications from both groups, then compared treatments using a multinomial logistic regression model. RESULTS: We identified 7383 patients, with 2630 (36%) in the outpatient and 2630 (36%) in the inpatient group. Of these, 104 (4.0%) inpatients compared with 52 (2.0%) outpatients developed a complication (p < 0.001). CONCLUSIONS: Inpatients developed major complications including deep wound infection and pulmonary embolism, as well as minor complications such as pneumonia and urinary tract infection, at significantly greater rates. As reimbursement models begin to incorporate value-based care, orthopaedic surgeons need to be aware of factors associated with increased incidence of postoperative complications. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Patients at Increased Risk of Major Adverse Events Following Operative Treatment of Distal Radius Fractures: Inpatient versus Outpatient.

Purpose The purpose of this study was to compare complication rates following inpatient versus outpatient distal radius fracture ORIF and identify specific complications that occur at increased rates among inpatients. Methods Using the 2005-2013 ACS-NSQIP, we collected patient demographics, comorbidities, surgical characteristics, and 30-day postoperative complications following isolated ORIF of distal radius fractures. A propensity score matched design using an 8-to-1 "greedy" matching algorithm in a 1:4 ratio of inpatients to outpatients was utilized. Rates of minor, major, and total complications were compared. A multinomial logistic regression model was then used to assess the odds of complications following inpatient surgery. Results Total 4,016 patients were identified, 776 (19.3%) of whom underwent inpatient surgery and 3,240 (80.3%) underwent outpatient surgery. The propensity score matching algorithm yielded a cohort of 629 inpatients who were matched with 2,516 outpatients (1:4 ratio). After propensity score matching, inpatient treatment was associated with increased rates of major and total complications but not with minor complications. There was an increased odds of major complications and total complications following inpatient surgery compared with outpatient surgery. There was no difference in odds of minor complications between groups. Conclusion Inpatient operative treatment of distal radius fractures is associated with significantly increased rates of major and total complications compared with operative treatment as an outpatient. Odds of a major complication are six times higher and odds of total complications are two and a half times higher following inpatient distal radius ORIF compared with outpatient. Quality improvement measures should be specifically targeted to patients undergoing distal radius fracture ORIF in the inpatient setting.

Outcomes of Distal Femur Nonunions Treated With a Combined Nail/Plate Construct and Autogenous Bone Grafting.

In this study, we sought to retrospectively evaluate union and infection rates after treatment of distal femur nonunions using a combined nail/plate construct with autogenous bone grafting obtained from the ipsilateral femur using a reamer irrigator aspirator system. Ten (10) patients treated at a Level I trauma center for nonunion of a femoral fracture using a combined nail/plate construct from 2004 to 2014 were included in the study. Union rate and postoperative infection rates were recorded. Mean interval from index surgery to nonunion repair was 12 months (range 4-36 months). Follow-up at 24 months indicated that the entire cohort of 10 patients achieved clinical union and radiographic union based on radiograph union score in tibias (RUST) criteria. Treatment of distal femur nonunions with a combined nail/plate construct and autogenous bone grafting results in a high rate of union with a low complication rate.

Drivers of hospital length of stay in 56,000 orthopaedic trauma patients: The impact of postoperative cardiac events.

PURPOSE: To determine whether postoperative cardiac complications following orthopaedic trauma treatment are associated with longer lengths of stay. METHODS: This was a retrospective cohort study. We analyzed orthopaedic trauma patients in the United States for whom data was collected in the ACS-NSQIP database between the years of 2006 and 2013. The patient population included 56,217 orthopaedic trauma patients meeting any 1 of the 89 CPT codes selected in the ACS-NSQIP database. The main outcome measure was hospital length of stay following orthopaedic trauma treatment. RESULT: Of the 56,217 orthopaedic trauma patients, 749 (1.3%) developed postoperative adverse cardiac events. There was a significant difference in total length of stay (p < 0.001): patients with cardiac complications on average stayed 10.6 days compared to 5.2 days for patients who did not experience such cardiac complications. This amounted to a difference of $24,316 in total hospital costs. Through multiple linear regression modeling controlling for multiple patient and surgical factors, the presence of cardiac complications significantly added 1.5 days in total hospital stay (p < 0.05). CONCLUSION: Orthopaedic trauma patients sustaining postoperative cardiac events have significantly longer hospital lengths of stay when compared to those who do not develop cardiac complications. This difference amounts to significantly higher health care costs.

Predicting the post-operative length of stay for the orthopaedic trauma patient.

PURPOSE: Length of stay (LOS) is a major driver of cost and quality of care. A bundled payment system makes it essential for orthopaedic surgeons to understand factors that increase a patient's LOS. Yet, minimal data regarding predictors of LOS currently exist. Using the ACS-NSQIP database, this is the first study to identify risk factors for increased LOS for orthopaedic trauma patients and create a personalized LOS calculator. METHODS: All orthopaedic trauma surgery between 2006 and 2013 were identified from the ACS-NSQIP database using CPT codes. Patient demographics, pre-operative comorbidities, anatomic location of injury, and post-operative in-hospital complications were collected. To control for individual patient comorbidities, a negative binomial regression model evaluated hospital LOS after surgery. Betas (ß), were determined for each pre-operative patient characteristic. We selected significant predictors of LOS (p < 0.05) using backwards stepwise elimination. RESULTS: 49,778 orthopaedic trauma patients were included in the analysis. Deep incisional surgical site infections and superficial surgical site infections were associated with the greatest percent change in predicted LOS (ß = 1.2760 and 1.2473, respectively; p < 0.0001 for both). A post-operative LOS risk calculator was developed based on the formula: [Formula: see text]. CONCLUSIONS: Utilizing a large prospective cohort of orthopaedic trauma patients, we created the first personalized LOS calculator based on pre-operative comorbidities, post-operative complications and location of surgery. Future work may assess the use of this calculator and attempt to validate its utility as an accurate model. To improve the quality measures of hospitals, orthopaedists must employ such predictive tools to optimize care and better manage resources.

Incidence and predictive risk factors of postoperative sepsis in orthopedic trauma patients.

BACKGROUND: Postoperative sepsis is associated with high mortality and the national costs of septicemia exceed those of any other diagnosis. While numerous studies in the basic orthopedic science literature suggest that traumatic injuries facilitate the development of sepsis, it is currently unclear whether orthopedic trauma patients are at increased risk. The purpose of this study was thus to assess the incidence of sepsis and determine the risk factors that significantly predicted septicemia following orthopedic trauma surgery. MATERIALS AND METHODS: 56,336 orthopedic trauma patients treated between 2006 and 2013 were identified in the ACS-NSQIP database. Documentation of postoperative sepsis/septic shock, demographics, surgical variables, and preoperative comorbidities was collected. Chi-squared analyses were used to assess differences in the rates of sepsis between trauma and nontrauma groups. Binary multivariable regressions identified risk factors that significantly predicted the development of postoperative septicemia in orthopedic trauma patients. RESULTS: There was a significant difference in the overall rates of both sepsis and septic shock between orthopedic trauma (1.6%) and nontrauma (0.5%) patients (p < 0.001). For orthopedic trauma patients, ventilator use (OR = 15.1, p = 0.002), history of pain at rest (OR = 2.8, p = 0.036), and prior sepsis (OR = 2.6, p < 0.001) were significantly associated with septicemia. Statistically predictive, modifiable comorbidities included hypertension (OR = 2.1, p = 0.003) and the use of corticosteroids (OR = 2.1, p = 0.016). CONCLUSIONS: There is a significantly greater incidence of postoperative sepsis in the trauma cohort. Clinicians should be aware of these predictive characteristics, may seek to counsel at-risk patients, and should consider addressing modifiable risk factors such as hypertension and corticosteroid use preoperatively. Level of evidence Level III.

Outcomes of Distal Femur Nonunions Treated with a Combined Nail/Plate Construct and Autogenous Bone Grafting.

SummaryIn this study, we sought to retrospectively evaluate union and infection rates after treatment of distal femur nonunions using a combined nail/plate construct with autogenous bone grafting. 10 patients treated at a Level I Trauma Center for nonunion of a femoral fracture using a combined nail/plate construct from 2004 to 2014 were included in the study. Union rate and postoperative infection rate were recorded.10 patients underwent treatment for nonunion of the distal femur. Mean interval from index surgery to nonunion repair was 12 months (range 4-36 months). All 10 patients achieved union at an average of 3.9 months (range 2.3-8 months) after initial nonunion repair. Treatment of distal femur nonunions with a combined nail/plate construct and autogenous bone grafting results in a high rate of union with a low complication rate. This technique combines two straightforward procedures familiar to orthopaedic trauma surgeons and offers distinct advantages including: availability of adequate bone graft volume, absence of donor site morbidity, and increased construct stability that may permit earlier weight-bearing.