Minimal Clinically Important Difference (MCID) for the Short Musculoskeletal Function Assessment (SMFA) in Severe Lower Extremity Trauma: Pooled Data from 7 Multicenter, Prospective Clinical Trials.

BACKGROUND: The Short Musculoskeletal Function Assessment (SMFA) is a well validated, widely used patient-reported outcome (PRO) measure for orthopaedic patients. Despite its widespread use and acceptance, this measure does not have an agreed upon minimal clinically important difference (MCID). The purpose of the present study was to create distributional MCIDs with use of a large cohort of research participants with severe lower extremity fractures. METHODS: Three distributional approaches were used to calculate MCIDs for the Dysfunction and Bother Indices of the SMFA as well as all its domains: (1) half of the standard deviation (one-half SD), (2) twice the standard error of measurement (2SEM), and (3) minimal detectable change (MDC). In addition to evaluating by patient characteristics and the timing of assessment, we reviewed these calculations across several injury groups likely to affect functional outcomes. RESULTS: A total of 4,298 SMFA assessments were collected from 3,185 patients who had undergone surgical treatment of traumatic injuries of the lower extremity at 60 Level-I trauma centers across 7 multicenter, prospective clinical studies. Depending on the statistical approach used, the MCID associated with the overall sample ranged from 7.7 to 10.7 for the SMFA Dysfunction Index and from 11.0 to 16.8 for the SMFA Bother Index. For the Dysfunction Index, the variability across the scores was small (<5%) within the sex and age subgroups but was modest (12% to 18%) across subgroups related to assessment timing. CONCLUSIONS: A defensible MCID can be found between 7 and 11 points for the Dysfunction Index and between 11 and 17 points for the Bother Index. The precise choice of MCID may depend on the preferred statistical approach and the population under study. While differences exist between MCID values based on the calculation method, values were consistent across the categories of the various subgroups presented. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of clinical and radiographic outcomes of arthroscopic-assisted percutaneous fixation versus open reduction internal fixation of lateral tibial plateau fractures.

PURPOSE: Treatment for tibial plateau fractures continues to evolve but maintains primary objectives of anatomic reduction of the joint line and a rapid recovery course. Arthroscopic-assisted percutaneous fixation (AAPF) has been introduced as an alternative to traditional open reduction internal fixation (ORIF). The purpose of the study is to compare clinical and radiographic outcomes in patients with low-energy Schatzker type I-III tibial plateau fractures treated with AAPF versus ORIF. METHODS: A retrospective chart review was performed at a level 1 trauma centre to compare outcomes of 120 patients (57 AAPF, 63 ORIF) with low-energy lateral Schatzker type I-III tibial plateau fractures who underwent tibial plateau fixation between 2009 and 2018. Demographic information, injury characteristics, and surgical treatment were recorded. The main outcome measurements included reduction step-off, joint space narrowing, time to weight bearing, and implant removal. RESULTS: There was no difference in age, gender distribution, BMI, ASA, Schatzker classification distribution, initial displacement, blood loss, and reduction step-off between the two groups (p > 0.05). Shorter tourniquet time (74.1 ± 21.7 vs 100.0 ± 21.0 min; p < 0.001), shorter time to full weight bearing (47.8 ± 15.2 vs. 69.1 ± 17.2 days; p < 0.001), and lower rate of joint space narrowing (3.5% vs. 28.6% with more than 1 mm, p < 0.001) were associated with the AAPF cohort, with no difference in pain, knee range of motion, or implant removal rate between the two cohorts. CONCLUSION: AAPF may be a viable alternative to ORIF for the management of low-energy tibial plateau fractures with outcomes not inferior compared to the traditional ORIF method.

Outcomes of arthroscopic-assisted lateral tibial plateau fixation: a systematic review.

PURPOSE: The purpose of this study is to evaluate and summarize the current literature on outcomes of arthroscopic-assisted tibial plateau fixation (AATPF) when applied for only lateral tibial plateau fractures. METHODS: A comprehensive search of nine databases was conducted: ClinicalTrials.gov, Cochrane Library via Wiley, Embase and MEDLINE via Ovid, Global Index Medicus, PubMed, Scopus, SPORTDiscus via EBSCO, and Web of Science Core Collection. The study was performed in concordance with PRISMA guidelines. Studies eligible for inclusions included Schatzker I-III lateral tibial plateau fractures with a minimum of 6-month follow-up. Data extraction was performed by two authors independently using a predesigned form. RESULTS: A total of 17 studies, 7 prospective and 10 retrospective, including 565 patients (age 15-82 years old) treated with AATPF were included in this review with follow-up ranging from 6 to 138 months. All 10 studies that used categorical functional outcomes demonstrated excellent/very good or good outcomes in > 90% of patients. When compared to patients managed with the traditional open reduction internal fixation (ORIF), patients treated with AATPF had statistically significantly better range of motion mean difference [5.21° (95% CI - 2.50 to 12.92, p < 0.0001)], lower blood loss [66.19 mL (95% confidence interval (CI) 32.54-99.84 mL, p < 0.0001)], shorter hospital stay [- 1.41 days (95% CI - 3.39 to 0.58 days, p < 0.0001)], better Hospital Special Surgery score [11.31 (95% CI 6.49-16.12, p < 0.0001)], and higher Rasmussen radiographic score [1.26 (95% CI - 0.72 to 3.23, p < 0.0001)]. CONCLUSION: AATPF is a promising treatment of lateral tibial plateau fractures with some advantages over the traditional ORIF. LEVEL OF EVIDENCE: Therapeutic Level III.

Intramedullary Nail and Plate Combination Technique for Peri-Implant Both-Bone Forearm Fractures.

A 35-year-old female patient with cerebellar ataxia presented with a right periprosthetic both-bone forearm fracture after a ground-level fall. Her surgical history was significant for multiple both-bone forearm fractures treated by open reduction and internal fixation. Subsequent treatment with a combination of intramedullary nailing and plate fixation for each bone provided successful fracture union while allowing immediate return to weight-bearing and range of motion. This case report demonstrates that intramedullary nailing and plate fixation of both-bone forearm fractures provides complete protection of the radius and ulna in recurrent, peri-implant both-bone forearm fractures. This technique is a valuable treatment option in the setting of a patient at risk for recurrent injury of the forearm.

Adjusting for Variation in Patient-Reported Outcome Measures Is Needed to Improve Care After Total Knee Arthroplasty.

INTRODUCTION: Limited quantitative information exists about the patient and surgeon factors driving variation in patient-reported outcome measure (PROM) scores, limiting the use of these data in understanding and improving quality. The overall goal of this study was to learn how to adjust PROM scores to enable both individual and group quality improvement. METHODS: Observational study in which preoperative Oxford Knee Score (OKS) and Patient Reported Outcomes Measurement System (PROMIS)-10 measures were prospectively obtained through patient survey from 1,173 of 1,435 possible patients before total knee arthroplasty and from 810 of the 1,173 patients at 12 months postoperatively (response rates = 81.7% and 69.0%). Regression analyses identified the relative contribution of patient and surgeon risk factors to OKS change from baseline to 12 months. Variation in patient scores and surgeon performance was described and quantified. Adjusted outcomes were used to calculate an observed and expected score for each surgeon. RESULTS: (1) Moderate variation was observed in pre-/post-OKS change among the surgeons (n = 16, mean change = 15.5 ± 2.2, range = 12.1-21.1). Forty-five percent of the variance in OKS change was explained by the factors included in our model. (2) Patient preoperative OKS and PROMIS physical score, race, and BMI were markedly associated with change in OKS, but other patient factors, surgeon volume, and years of experience were not. (3) Eight surgeons had observed scores greater than expected after adjustment, providing an opportunity to learn what strategies were associated with better outcomes. DISCUSSION: Traditional age/sex adjustment of patient mix would have had no effect on mean PROM scores by surgeon. An adjustment model that includes the factors found to be markedly associated with outcomes will allow care systems to identify individual surgeon care management strategies potentially important for improving patient outcomes.

Arthroscopically Assisted Percutaneous Screw Fixation of Tibial Plateau Fractures.

Tibial plateau fractures account for approximately 1% to 2% of fractures in adults1. These fractures exhibit a bimodal distribution as high-energy fractures in young patients and low-energy fragility fractures in elderly patients. The goal of operative treatment is restoration of joint stability, limb alignment, and articular surface congruity while minimizing complications such as stiffness, infection, and posttraumatic osteoarthritis. Open reduction and internal fixation with direct visualization of the articular reduction or indirect evaluation with fluoroscopy has traditionally been the standard treatment for displaced tibial plateau fractures. However, there has been concern regarding inadequate visualization of the articular surface with open tibial plateau fracture fixation, contributing to a fivefold increase in conversion to total knee arthroplasty2. In addition, the risk of wound complications and infection has been reported to be as high as 12%3,4. Knee arthroscopy with percutaneous, cannulated screw fixation provides a less invasive procedure with excellent visualization of the articular surface and allows for accurate reduction and fracture fixation compared with traditional open reduction and internal fixation techniques1. Recent studies of arthroscopically assisted percutaneous screw fixation of tibial plateau fractures have reported excellent early clinical and radiographic outcomes and low complication rates3,5,6. Description: This technique involves the use of both arthroscopy and fluoroscopy to facilitate reduction and fixation of the tibial plateau fracture. Through a minimally invasive technique, the depressed articular joint surface is targeted with use of preoperative computed tomography (CT) scans and intraoperative biplanar fluoroscopy. Reduction is then directly visualized with arthroscopy and fixation is performed with use of fluoroscopy. Lastly, restoration of the articular surface is confirmed with use of arthroscopy after definitive fixation. Modifications can be made as needed. Alternatives: The traditional method for fixation of displaced tibial plateau fractures is open reduction and internal fixation. Articular reduction can be visualized directly with an open submeniscal arthrotomy and an ipsilateral femoral distractor or indirectly with fluoroscopy. Rationale: Visualization of the articular surface is essential to achieve anatomic reduction of the joint line. Inspection of the posterior plateau is difficult with an open surgical approach. Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture may allow for improved restoration of articular surfaces through enhanced visualization. Less soft-tissue dissection is associated with lower morbidity and may result in less damage to the blood supply, lower rates of infection and wound complications, faster healing, and better mobility for patients. In our experience, this technique has been successful in patients with severe osteoporosis and comminution of depressed fragments. If total knee arthroplasty is required, we have also observed less damage to the blood supply and fewer surgical scars with use of this surgical technique. Expected Outcomes: Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture facilitates anatomical reduction through a less invasive approach. Patients undergoing this method of tibial plateau fracture fixation are able to engage earlier in rehabilitation2. Studies have shown early postoperative range of motion, excellent patient-reported outcomes, and minimal complications7,8. Important Tips: Arthroscopically assisted fixation can be applied to a variety of tibial plateau fractures; however, the minimally invasive approach is best suited for patients with isolated lateral tibial plateau fractures (Schatzker I to III) and a cortical envelope that can be easily restored. The cortical envelope refers to the outer rim of the tibial plateau. Fracture pattern and ligamentotaxis determine the cortical envelope, which can be evaluated on preoperative CT scans. In our experience, even depressed segments with a high degree of comminution may be treated with use of this technique with satisfactory results.Articular depression should be targeted with use of a preoperative CT scan and intraoperative fluoroscopy and arthroscopy.The surgeon should be careful not to "push up" in 1 small area; rather, a "joker" elevator or bone tamp should be utilized, moving anterior to posterior, which can be frequently assessed with arthroscopy.The intra-articular pressure of the arthroscopy irrigation fluid should be low (≤45 mm Hg or gravity flow), and the operative extremity should be monitored for compartment syndrome throughout the procedure. Acronyms and Abbreviations: ACL = anterior cruciate ligamentK-wires = Kirschner wiresORIF = open reduction and internal fixationAP = anteroposteriorCR = computed radiography.

Personalized outcomes for hip and knee replacement: the patients point of view.

BACKGROUND: Patient reported outcome measures (PROMs) are increasingly being incorporated into clinical and surgical care for assessing outcomes. This study examined outcomes important to patients in their decision to have hip or knee replacement surgery, their perspectives on PROMs and shared decision-making, and factors they considered important for postoperative care. METHODS: A cross-sectional study employing survey methods with a stratified random sample of adult orthopedic patients who were scheduled for or recently had hip or knee replacement surgery. RESULTS: In a representative sample of 226 respondents, patients identified personalized outcomes important to them that they wanted from their surgery including the ability to walk without pain/discomfort, pain relief, and returning to an active lifestyle. They preferred a personalized outcome (54%) that they identified, compared to a PROM score, for tracking progress in their care and thought it important that their surgeon know their personal outcomes (63%). Patients also wanted to engage in shared decision-making (79%) about their post-surgical care and identified personal factors important to their aftercare, such as living alone and caring for pets. CONCLUSIONS: Patients identified unique personalized outcomes they desired from their care and that they wanted their orthopedic surgeons to know about. Asking patients to identify their personalized outcomes could add value for both patients and surgeons in clinical care, facilitating more robust patient involvement in shared decision-making.

Unplanned Emergency and Urgent Care Visits After Outpatient Orthopaedic Surgery.

INTRODUCTION: This study sought to determine (1) incident risk, (2) chief report, (3) risk factors, and (4) total cost of unplanned healthcare visits to an emergency and/or urgent care (ED/UC) facility within 30 days of an outpatient orthopaedic procedure. METHODS: This was a retrospective database review of 5,550 outpatient surgical encounters from a large metropolitan healthcare system between 2012 and 2016. Statistical analysis consisted of measuring the ED/UC incident risk, respective to the procedures and anatomical region. Patient-specific risk factors were evaluated through multigroup comparative statistics. RESULTS: Of the 5,550 study patients, 297 (5.4%) presented to an ED/UC within 30 days of their index procedure, with 23 (0.4%) needing to be readmitted. Native English speakers, patients older than 45 years, and nonsmokers had significant reduced relative risk of unplanned ED or UC visit within 30 days of index procedure (P < 0.01). In addition, hand tendon repair/graft had the greatest risk incidence for ED/UC visit (11.0%). Unplanned ED/UC reimbursements totaled $146,357.34, averaging $575.65 per visit. DISCUSSION: This study provides an evaluation of outpatient orthopaedic procedures and their relationship to ED/UC visits. Specifically, this study identifies patient-related and procedural-related attributes that associate with an increased risk for unplanned healthcare utilization.