Suture Button versus Screw Fixation for Distal Tibiofibular Injury and Expected Value Decision Analysis.

Patient preference for fixation technique of syndesmotic injury in the presence of an ankle fracture is not known. This study followed a five-step process for expected value decision analysis: decision tree, outcome probabilities, expected patient values, foldback analysis, and sensitivity analysis. Outcome variables were "well" (cases that did not require further procedures or suffer any complications related to surgery), surgical site infection (SSI), loss of reduction (LOR), hardware removal (HWR), and malreduction. The systematic review included 22 studies including 358 patients who underwent suture button fixation and 739 who underwent screw fixation. Outcome probabilities for suture button fixation were 76.4% well, 6.2% SSI, 5.4% LOR, 10.4% HWR, and 1.6% malreduction. Outcome probabilities for screw fixation were 47.1% well, 4.3% SSI, 8.1% LOR, 30.7% HWR, and 9.8% malreduction. After the survey and foldback analysis, overall utility values for suture button and screw fixation were 7.46 and 4.78, respectively. One-way sensitivity analysis revealed that the overall utility value for suture button fixation was greater than the utility value of screw fixation under all circumstances except when the rate of malreduction for suture button fixation was theoretically elevated to 85%. Level of evidence: therapeutic, level IV.

Implementation of a Multidisciplinary "Code Hip" Protocol is Associated with Decreased Time to Surgery and Improved Patient Outcomes.

BACKGROUND: The purpose of this study is to report outcomes data based on the implementation of a "Code Hip" protocol, a multidisciplinary approach to the care of fragility hip fracture patients focussing on medical optimization and early operative intervention. We hypothesized that implementation of this protocol would decrease time from presentation to surgical intervention and improve outcomes based on short term post-operative data. METHODS: A retrospective chart review was performed on all patients aged greater than 65 years old with a fragility hip fracture from October 2015 through June 2018. In addition to demographic and patient factors, we recorded time to surgery, type of surgical interventions performed, ability to ambulate in the post-operative period, 90-day post-operative complications and overall hospital cost. RESULTS: There were 114 patients in the pre-Code Hip cohort and 132 patients in the post-Code Hip cohort. Demographic factors were not different between the 2 cohorts. Time from presentation to surgery in the post-Code Hip cohort was shorter at 23.1 ± 16.4 hours versus 33.2 ± 27.2 hours (p < 0.001). 30.3% of patients in the post-Code Hip cohort had at least one post-operative complication compared to 42.1% in the pre-Code Hip cohort (RR = 0.72, CI = 0.51 -1.01, p = 0.05). The post-Code Hip cohort had a significantly lower rate of hospital readmission (p = 0.04), unplanned reoperation (p = 0.02), surgical site infection (p = 0.03), and sepsis (p = 0.05). Total hospital cost per patient decreased from an average of $14,079 +/- $10,305 pre-Code Hip cohort to $11,744 +/- $4,174 per patient in the post-Code Hip cohort (p = 0.02). CONCLUSIONS: Implementation of our Code Hip protocol, which invokes a multidisciplinary approach to the elderly patient with a fragility hip fracture, is associated with shorter times from presentation to surgery, increased ability to ambulate post-operatively, decreased short term post-operative complication, and decreased hospital costs. LEVEL OF EVIDENCE: Therapeutic Level III.

Orthopaedic care provided by the 14th combat support hospital in support of humanitarian and disaster relief after hurricane Maria in Puerto Rico.

On September 20, 2017 Hurricane Maria, a category 4 hurricane, made landfall on the eastern coast of Puerto Rico. This was preceded by Hurricane Irma, a category 5 hurricane, which passed just off the coast 13 d prior. The destruction from both Hurricane Irma and Maria precipitated a coordinated federal response which included the Federal Emergency Management Agency (FEMA) and the United States military. The United States Army dispatched the 14th Combat Support Hospital (CSH) to Humacao, a city on the eastern side of the island where Maria made landfall. The mission of the 14th CSH was to provide medical humanitarian aid and conduct disaster relief operations in support of the government of Puerto Rico and FEMA. During the 14th CSH deployment to Puerto Rico, 1157 patients were evaluated and treated. Fifty-seven operative cases were performed to include 23 orthopaedic cases. The mean age of the orthopaedic patients treated was 45.7 years (range 13-76 years). The most common operation was irrigation and debridement of open contaminated and/or infected wounds. Patients presented a mean 10.8 d from their initial injury (range 1-40 d). Fractures and infections were the most common diagnoses with the greatest delay in treatment from the initial date of injury. The deployment of the 14th CSH to Puerto Rico was unique in its use of air transport, language and local customs encountered, as well as deployment to a location outside the continental United States. These factors coupled with the need for rapid deployment of the 14th CSH provided valuable experience which will undoubtedly enable future success in similar endeavors.