Are Orthopaedic Trauma Surgeons Adequately Compensated for Longer Procedures? An Analysis of Relative Value Units and Operative Times From the American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: The physician work relative value unit (wRVU) scale is the primary determinant of compensation. Operative time, technical skill, effort, and surgical complexity contribute to wRVU allocation. The aim of this study was to identify the relationship between these factors and reimbursement for trauma procedures. METHODS: The National Surgical Quality Improvement Program database was queried for orthopaedic trauma procedures from 2016 to 2018. Physician wRVU data were obtained from the 2020 Centers for Medicare & Medicaid Services fee schedule. The primary outcome measured was mean wRVU per minute of operative time (wRVU/min). Wilcoxon rank sum test and quantile regression were used to determine the association between wRVU, operative time, complication rate, upper or lower extremity procedure, and wRVU/min. RESULTS: Sixty-three current procedural terminology codes or 107,171 cases were queried. Median wRVU/min was significantly lower for longest 50% of procedures (0.119 vs. 0.160, P < 0.001) and higher for the top 50% with regard to complication rate (0.161 vs. 0.124, P < 0.001). Upper extremity procedures were reimbursed less than lower extremity (0.110 vs. 0.145, P < 0.001). Quintile regression showed that adjusted for complication rate, median wRVU/min decreased by 0.0005 (95% confidence interval: 0.0007-0.0003, R1 = 0.27, P < 0.001) for every additional minute of operative time. CONCLUSIONS: The 2020 wRVU scale does not allocate sufficient wRVUs to orthopaedic trauma procedures with longer mean operative time or to procedures performed on the upper extremity. There is a negative correlation between operative time and hourly reimbursement, equating to a decrease of $64.96/h per hour of operation.

Improved Implant Positioning of Cephalomedullary Nail for Trochanteric Fractures Using the Stryker ADAPT Navigation System.

BACKGROUND: Tip-apex distance (TAD) of greater than 25 mm increases the risk of cephalomedullary nail (CMN) cutout for trochanteric hip fractures. The Stryker ADAPT navigation system provides intraoperative feedback to guide implant positioning. This study compares lag screw positioning using the ADAPT to conventional methods and investigates if the use of ADAPT impacts operating room efficiency. METHODS: Retrospective review of 82 consecutive patients who underwent Stryker Gamma3 CMN for a peritrochanteric hip fracture. Study groups were assigned based on use of ADAPT navigation. Primary outcome was TAD. Secondary outcomes were lag screw position, operative time, and radiation dose. Univariate analysis of covariance was used to compare primary outcome measures, controlling for fracture classification. RESULTS: 41 patients were assigned to each group. When comparing ADAPT and conventional groups mean TAD was 14.45±3.68 and 16.41±3.78 mm (p = 0.023). A higher portion of ADAPT nails (85.4% vs 63.4%, p = 0.024) were center- center within the femoral head compared to conventional methods. There were no significant differences with regards to operative time, fluoroscopy time, or radiation dose. CONCLUSION: ADAPT navigation provides intraoperative feedback to achieve improved lag screw positioning, leading to improved TAD. The overall improvement in TAD does not likely reach clinical significance. The system requires minimal setup in the operating room, does not impact workflow, and the user interface is straight forward.

Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post-COVID-19 World.

OBJECTIVES: (1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING: One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS: One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION: The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS: Inpatient and 30-day mortality, major, and minor complications. RESULTS: Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION: The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective.

OBJECTIVES: To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN: Prospective cohort study. SETTING: Seven musculoskeletal care centers within New York City and Long Island. PATIENTS/PARTICIPANTS: One hundred thirty-eight recent and 115 historical hip fracture patients. INTERVENTION: Patients with hip fractures occurring between February 1, 2020, and April 15, 2020, or between February 1, 2019, and April 15, 2019, were prospectively enrolled in an orthopaedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs), or COVID negative (C-). MAIN OUTCOME MEASUREMENTS: Hospital quality measures, inpatient complications, and mortality rates. RESULTS: Seventeen (12.2%) patients were confirmed C+ by testing, and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared with Cs and C- cohorts, had an increased mortality rate (35.3% vs. 7.1% vs. 0.9%), increased length of hospital stay, a greater major complication rate, and a greater incidence of ventilator need postoperatively. CONCLUSIONS: COVID-19 had a devastating effect on the care of patients with hip fracture during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in patients with hip fracture complicated by COVID-19. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Cortical Mechanisms of Central Fatigue and Sense of Effort.

The purpose of this study was to investigate cortical mechanisms upstream to the corticospinal motor neuron that may be associated with central fatigue and sense of effort during and after a fatigue task. We used two different isometric finger abduction protocols to examine the effects of muscle activation and fatigue the right first dorsal interosseous (FDI) of 12 participants. One protocol was intended to assess the effects of muscle activation with minimal fatigue (control) and the other was intended to elicit central fatigue (fatigue). We hypothesized that high frequency repetitive transcranial magnetic stimulation (rTMS) of the supplementary motor area (SMA) would hasten recovery from central fatigue and offset a fatigue-induced increase in sense of effort by facilitating the primary motor cortex (M1). Constant force-sensation contractions were used to assess sense of effort associated with muscle contraction. Paired-pulse TMS was used to assess intracortical inhibition (ICI) and facilitation (ICF) in the active M1 and interhemispheric inhibitory (IHI) was assessed to determine if compensation occurs via the resting M1. These measures were made during and after the muscle contraction protocols. Corticospinal excitability progressively declined with fatigue in the active hemisphere. ICF increased at task failure and ICI was also reduced at task failure with no changes in IHI found. Although fatigue is associated with progressive reductions in corticospinal excitability, compensatory changes in inhibition and facilitation may act within, but not between hemispheres of the M1. rTMS of the SMA following fatigue enhanced recovery of maximal voluntary force and higher levels of ICF were associated with lower sense of effort following stimulation. rTMS of the SMA may have reduced the amount of upstream drive required to maintain motor output, thus contributing to a lower sense of effort and increased rate of recovery of maximal force.

The emerging role of elbow arthroscopy in chronic use injuries and fracture care.

Arthroscopy is emerging as an invaluable tool for diagnosing and treating elbow pathology. In addition to the advantages of less scarring, decreased risk of infection, less postoperative pain, and a more thorough visualization of the elbow joint, arthroscopy is particularly well suited to the treatment of athletes trying to minimize rehabilitation and inactivity. Indications for elbow arthroscopy now extend well beyond diagnosis and loose body removal, and include the treatment of impingement, arthritis, contractures, fragment stabilization for osteochondritis dessicans, and treatment of certain fractures. This article reviews the basic principles and techniques of elbow arthroscopy and their application to common sports-related conditions, such as valgus overload syndrome, medial collateral ligament insufficiency, and the various causes of lateral elbow pain. Newer applications of elbow arthroscopy in fracture care are addressed as well.

The pathophysiology of patellofemoral arthritis.

Faced with a patient suffering from patellofemoral arthritis, the surgeon must determine the pathophysiology of the condition, because different causes demand different treatments. Possible causes include malalignment, patellofemoral dysplasia, patellofemoral instability, patellofemoral trauma, obesity, osteoarthritis, inflammatory arthritis, and a genetic predisposition. Arthritis secondary to malalignment, dysplasia, instability, or trauma is less likely than arthritis secondary to the other causes to progress to femorotibial arthritis.

Patellar tilt: the physical examination correlates with MR imaging.

Patella malalignment is a recognized cause of knee pain, tilt being one of its more common forms. Although patellar tilt has been described both on the physical examination and on computerized imaging, to date the correlation between the two has not been established. A strong correlation would strengthen the value of each. Moreover, in situations where tilt cannot be clinically assessed (e.g. obesity), CT or MR imaging could be an adequate substitute for the clinical determination of tilt. We propose to correlate the physical examination with the magnetic resonance examination by way of an MR Tilt Angle. This angle is measured in a manner similar to the assessment of tilt on the physical examination, in that a line is drawn across the medial and lateral borders of the patella and referenced off the posterior femoral condyles. Most tilt angles use the slope of the lateral facet as a measure of tilt. These tilt angles paradoxically diminish as patellar tilt increases, a potential source of confusion. In this study, we use an MRI tilt angle that increases in the same direction as the actual tilt, which is more intuitive. We examined 30 patients with tilt and 51 patients without tilt. Patients with significant tilt on the physical examination can be expected to have an MRI Tilt Angle that is 10 degrees or greater whereas an angle of less than 10 degrees is associated with the absence of significant tilt on the physical examination. This MRI Tilt Angle fills the need for an easy, objective, intuitive measure of tilt and is an excellent adjunct to the physical examination.