The Effect of Resident Involvement in Hip Fracture Surgery: An Analysis of a Single Institution Before and After the Addition of an Orthopaedic Surgical Residency.

INTRODUCTION: Hip fractures are common injuries that are associated with serious morbidity/mortality in the elderly and represent a substantial financial burden to healthcare systems. Previous studies demonstrated that resident involvement in orthopaedic surgeries is associated with increased surgical time and cost, with equivocal or worse outcomes. This study evaluated outcomes of hip fracture surgery at one institution, before and after the introduction of an orthopaedic residency program. METHODS: A retrospective chart review divided patients who underwent hip fracture surgery between January 2015 and January 2018 into two groups based on resident involvement. Outcomes including surgical time, length of stay (LOS), readmission rate, and direct/indirect costs were compared as were the American Society of Anesthesiologists physical status score and procedure conducted. RESULTS: Six hundred sixty-two hip fracture surgeries were performed in 36 months. Residents were engaged in 303 cases (45.8%) with no notable differences in the two groups regarding American Society of Anesthesiologists score, procedure conducted, or readmission rate. With resident involvement, surgical time was significantly longer (91.2 versus 78.9 minutes, P -value = 0.004), whereas LOS was significantly shorter (5.2 versus 5.6 days, P -value = 0.003). Finally, there were significant reductions in direct costs (8% reduction; P < 0.001) and OR implant costs (12% reduction; P < 0.001), but significant increase in indirect costs (7% increase; P < 0.001). DISCUSSION: Surgical experience is critical in orthopaedic training. There are concerns regarding potential negative effects of resident involvement on surgical outcomes and healthcare costs. While resident involvement was associated with slightly increased surgical times and indirect costs, it also led to decreased LOS and direct costs. We believe this is the first study to compare patient outcomes at one institution before and after resident involvement. Our findings demonstrated, compared with attendings alone, resident involvement resulted in an overall improvement rather than compromise in patient care.

Relation of tranexamic acid therapy to length of stay in the hip fracture population.

Tranexamic acid (TXA) is a medication that is routinely used to minimize blood loss during surgery. There is minimal literature evaluating the effects of TXA in hip fractures in regards to length of stay, readmission rates, and location of discharge. This study included adult patients who were admitted for hip fracture that required surgery over a 22-month period (May 2017-February 2019). A total of 525 hip fractures were operated on during this time period. Retrospective analysis was performed on patients treated with TXA (n = 27) vs those who were not (n = 498). Primary outcomes were length of stay, disposition after discharge, need for transfusion, mobilization with therapy, and readmission rates. TXA during hip fractures reduced median length of stay in the hip fracture cohort to 3 vs 5 days (P < 0.01). Patients were more likely to be discharged home as opposed to a nursing facility. Patients who received TXA during their hip fracture surgery were less likely to need transfusions while admitted (P < 0.01). No increased readmission rates were seen within 30 days after discharge (P = 0.59). In conclusion, when indicated, TXA appears to be safe for utilization in hip fracture surgery, resulting in decreased length of stay, less transfusions, and no increase in readmission rates.

Relation of mobilization after hip fractures on day of surgery to length of stay.

This study examined whether evaluation by physical therapy on the day of surgery impacts length of stay in patients with hip fractures. A total of 528 adult patients with hip fracture requiring surgery were prospectively included in the study over a 22-month period. The median length of stay of mobilized patients was 4.0 days, vs 5.0 days in nonmobilized patients (P = 0.0158). Of the 259 mobilized patients, 64 were discharged home (24.71%) vs 47 (17.84%) in the nonmobilized cohort (P = 0.0434), with no increase in readmission rates. In conclusion, mobilization on the day of surgery reduced length of stay by 1 day, with a higher percentage of patients being discharged home.

A Community Orthopaedic Residency Approach to Education and Training During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic has rapidly affected all facets of everyday life including the practice of medicine. Hospital systems and medical practices have evolved to protect patients, physicians, and staff and conserve personal protective equipment and resources. Orthopaedic practices have been specifically affected by social distancing and stay at home guidelines, limiting in-office practice and elective surgery restrictions. This, in turn, has had an effect on resident education. Previous literature has been published regarding how academic programs have adjusted to these changes. However, the effects on smaller orthopaedic residencies with nonacademic faculty has not been discussed. The orthopaedic residency at Baylor University Medical Center of Dallas is a fifteen-resident program with a combination of hospital employed and private practice faculty. We adjusted our resident education in mid-March 2020 to keep residents safe while trying to maximize surgical and clinical education and outside research. GOALS: Our goals were to come up with a plan allowed for continuing high-level patient care and resident education while protecting residents and limiting burnout. MODEL: We devised a four-team system with five-day call periods. Interactions between teams were strictly minimized. We also moved to a web-based academic curriculum and devised a system for safe resident participation in surgical cases. The model has been adjusted based on attending and resident feedback. CONCLUSION: Until we develop effective treatments or vaccination for COVID-19, there is a possibility that it will be an ongoing threat. Resident education must also adapt to the changing environment while continuing to provide residents safe opportunities for patient care, didactic education, and research. We believe we have come up with a sustainable, adaptable model for resident education during this challenging time.

James Pat Evans, MD, 1930-2019.

This biographical sketch of Dr. J. Pat Evans commemorates the life and contributions of one of the most influential sports surgeons in the history of orthopedic surgery, drawing on articles written in remembrance of him and his contributions to orthopedic surgery and sports medicine.

Ruth Jackson, MD, 1902-1994.

This article commemorates Dr. Ruth Jackson for her contributions to orthopedic surgery and her status as a trailblazer for women in orthopedic surgery, becoming the first female member of the American Academy of Orthopedic Surgeons. She died on August 28, 1994, at the age of 91.

Robert Wilson Jackson, MD (1932-2010).

This article commemorates the life and contributions of one of the most influential sports surgeons in the history of orthopedic surgery, Dr. Robert Jackson.

Psychological morbidity and functional impairment following traumatic pelvic injury.

Pelvic injuries often result from high-energy trauma and lead to significant functional impairment. While the physical outcomes of these injuries have been widely studied, the psychological consequences remain largely unexplored. The purpose of this study was to examine psychosocial and functional outcomes of patients with pelvic trauma in the year after injury. The sample (N = 32) consisted of adult patients with traumatic pelvic injures, as defined by ICD-9 codes, who were admitted to a Level I Trauma Center for at least 24 h. Participants were primarily female (53%) with a mean age of 48.7 years (SD = 17.9). Demographic, injury-related, and psychosocial data (e.g., posttraumatic stress disorder (PTSD), depression, alcohol use, quality of life, pain, return to work) were gathered at the time of hospitalization as well as at 3-, 6-, and 12 month follow-ups. Mixed regression models were used to examine the outcome variables over time. There were significant decreases in pain and alcohol use at each follow-up compared to baseline. However, despite the decrease, the levels of pain and alcohol use remained high. Physical and mental health also decreased significantly, indicating worsened functioning and lowered quality of life. Neither PTSD nor depression changed significantly over time, indicating that participants' symptoms were not likely to improve. These data suggest that sustaining a traumatic pelvic injury increases the risk of diminished quality of life, both mentally and physically. Even one-year post-injury, participants experienced moderate physical pain and higher levels of PTSD, depression, and problematic alcohol use than would be expected in the general population. These findings highlight the need for an interdisciplinary approach to treating patients with pelvic injuries, including psychological screening and intervention in acute care and throughout recovery.

Relation of length of stay and other hospital variables to posttraumatic stress disorder and depression after orthopedic trauma.

Posttraumatic stress disorder (PTSD) and depression are common following orthopedic trauma. This study examined the relationship between injury- and hospital-related variables and PTSD and depression at baseline and 12 months after orthopedic trauma. This longitudinal, prospective cohort study examined adult orthopedic trauma patients admitted ≥24 hours to a level I trauma center. Non-English/Spanish-speaking and cognitively impaired patients were excluded. The Primary Care PTSD screen and PTSD Checklist-Civilian version assessed PTSD, and the Patient Health Questionnaire 8-Item assessed depression. Demographic and hospital-related variables were examined (e.g., hospital length of stay, Injury Severity Score, Glasgow Coma Scale). For 160 participants, PTSD prevalence was 23% at baseline and 21% at 12 months. Depression prevalence was 28% at baseline and 29% at 12 months. Ventilation (P = 0.023, P = 0.006) and prolonged length of stay (P = 0.008, P = 0.003) were correlated with baseline PTSD and depression. Injury etiology (P = 0.008) and Injury Severity Score (P = 0.013) were associated with baseline PTSD. Intensive care unit admission (P = 0.016, P = 0.043) was also correlated with PTSD at baseline and 12 months. Ventilation (P = 0.002, P = 0.040) and prolonged length of stay (P < 0.001, P = 0.001) were correlated with 12-month PTSD and depression. Early and continued screenings with potential interventions could benefit patients' physical and mental rehabilitation after orthopedic injury.

Prospective Evaluation of Posttraumatic Stress Disorder in Injured Patients With and Without Orthopaedic Injury.

OBJECTIVES: The study purposes were to prospectively evaluate occurrence of posttraumatic stress (PTS) symptoms at hospital admission and 6 months later in patients with orthopaedic injury; to explore differences in PTS symptoms in those with and without orthopaedic injury; and to determine whether PTS symptoms are influenced by orthopaedic injury type. DESIGN: Prospective, longitudinal observational study. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Two hundred fifty-nine participants admitted for at least 24 hours. MAIN OUTCOME MEASUREMENTS: The Primary Care Posttraumatic Stress Disorder (PTSD) Screen (PC-PTSD) measured PTSD symptoms during hospitalization. The PTSD Checklist-Civilian Version (PCL-C) measured PTS symptoms at 6 months. RESULTS: In orthopaedic patients, 28% had PTS at 6 months, compared with 34% of nonorthopaedic patients. Odds ratios (ORs) were calculated to determine the influence of pain, physical and mental function, depression, and work status. At 6 months, if the pain score was 5 or higher, the odds of PTS symptoms increased to 8.38 (3.55, 19.8) (P < 0.0001). Those scoring below average in physical function were significantly more likely to have PTS symptoms [OR = 7.60 (2.99, 19.32), P < 0.0001]. The same held true for mental functioning and PTS [OR = 11.4 (4.16, 30.9), P < 0.0001]. Participants who screened positive for depression had a 38.9 (14.5, 104) greater odds (P < 0.0001). Participants who did not return to work after injury at 6 months were significantly more likely to have PTS [OR = 16.5 (1.87, 146), P = 0.012]. CONCLUSIONS: PTSD is common in patients after injury, including those with orthopaedic trauma. At 6 months, pain of 5 or greater, poor physical and mental function, depression, and/or not returning to work seem to be predictive of PTSD. Orthopaedic surgeons should identify and refer for PTSD treatment given the high incidence postinjury. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Does caring for trauma patients lead to psychological stress in surgeons?

BACKGROUND: Symptoms identical to posttraumatic stress disorder (PTSD) have been shown to occur in caregivers of trauma patients. Secondary traumatic stress (STS) characterizes those who exhibit PTSD symptoms related to indirect exposure to a stressor. We hypothesized that caring for trauma patients is associated with symptoms of PTSD/STS. METHODS: Surgeons in various specialties (n = 133) were surveyed from January to May 2012 at two regional surgical conferences. Symptoms of PTSD were identified using the Secondary Traumatic Stress Scale (STSS) using specific diagnostic criteria to measure the psychological impact of exposure to trauma patients. Resilience was measured using the Connor-Davidson Resilience Scale 10 items. The amount of time caring for trauma patients was used as a measure of risk exposure. The relationship between STSS, resilience, and exposure to trauma patients was measured with p < 0.05 considered significant. RESULTS: Twenty-eight surgeons (22%) met diagnostic symptom criteria for PTSD as measured by the STSS. Approximately two thirds of the surgeons (86 of 133, 65%) exhibited at least one symptom of STS. However, the magnitude of exposure to trauma patients was similar between surgeons with and without PTSD symptoms (p = 0.2177). Higher resilience scores were associated with lower STS scores (r = -0.369, p < 0.0001). Most importantly, surgeons who met symptom criteria for PTSD exhibited significantly lower resilience scores (31 [3.4] vs. 34 [3.9], p < 0.0001). CONCLUSION: Symptoms of PTSD as measured by the STSS were reported in two thirds of study participants but did not correlate with time spent for caring for trauma patients. One in five reported symptoms consistent with a PTSD. Lower resilience scores correlated with risk of symptoms and may be used to identify those surgeons most at risk. Efforts to better identify, address, and moderate these psychological consequences of surgical care may improve both the emotional well-being and the vocational performance of surgeons.

The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma.

BACKGROUND: Urgent débridement of open fractures has been considered to be of paramount importance for the prevention of infection. The purpose of the present study was to evaluate the relationship between the timing of the initial treatment of open fractures and the development of subsequent infection as well as to assess contributing factors. METHODS: Three hundred and fifteen patients with severe high-energy lower extremity injuries were evaluated at eight level-I trauma centers. Treatment included aggressive débridement, antibiotic administration, fracture stabilization, and timely soft-tissue coverage. The times from injury to admission and operative débridement as well as a wide range of other patient, injury, and treatment-related characteristics that have been postulated to affect the risk of infection within the first three months after injury were studied, and differences between groups were calculated. In addition, multivariate logistic regression models were used to control for the effects of potentially confounding patient, injury, and treatment-related variables. RESULTS: Eighty-four patients (27%) had development of an infection within the first three months after the injury. No significant differences were found between patients who had development of an infection and those who did not when the groups were compared with regard to the time from the injury to the first débridement, the time from admission to the first débridement, or the time from the first débridement to soft-tissue coverage. The time between the injury and admission to the definitive trauma treatment center was an independent predictor of the likelihood of infection. CONCLUSIONS: The time from the injury to operative débridement is not a significant independent predictor of the risk of infection. Timely admission to a definitive trauma treatment center has a significant beneficial influence on the incidence of infection after open high-energy lower extremity trauma.

Use of a midline anterior incision for isolated medial tibial plateau fractures.

A technique using an anterior midline incision with a medial parapatellar arthrotomy and a medial full-thickness skin flap for the open reduction and internal fixation of isolated medial tibial plateau fractures is presented. The approach is advocated as an alternative to a posteromedial approach when medial tibial plateau fractures are present alone. The anterior approach is simple and familiar for orthopaedic surgeons. It offers good visualization, simplifies reduction, and provides a functional scar if future procedures are necessary.

Health-care costs associated with amputation or reconstruction of a limb-threatening injury.

BACKGROUND: Recent reports have suggested that functional outcomes are similar following either amputation or reconstruction of a severely injured lower extremity. The goal of this study was to compare two-year direct health-care costs and projected lifetime health-care costs associated with these two treatment pathways. METHODS: Two-year health-care costs were estimated for 545 patients with a unilateral limb-threatening lower-extremity injury treated at one of eight level-I trauma centers. Included in the calculation were costs related to (1) the initial hospitalization, (2) all rehospitalizations for acute care related to the limb injury, (3) inpatient rehabilitation, (4) outpatient doctor visits, (5) outpatient physical and occupational therapy, and (6) purchase and maintenance of prosthetic devices. All dollar figures were inflated to constant 2002 dollars with use of the medical service Consumer Price Index. To estimate projected lifetime costs, the number of expected life years was multiplied by an estimate of future annual health-care costs and added to an estimate of future costs associated with the purchase and maintenance of prosthetic devices. RESULTS: When costs associated with rehospitalizations and post-acute care were added to the cost of the initial hospitalization, the two-year costs for reconstruction and amputation were similar. When prosthesis-related costs were added, there was a substantial difference between the two groups ($81,316 for patients treated with reconstruction and $91,106 for patients treated with amputation). The projected lifetime health-care cost for the patients who had undergone amputation was three times higher than that for those treated with reconstruction ($509,275 and $163,282, respectively). CONCLUSIONS: These estimates add support to previous conclusions that efforts to improve the rate of successful reconstructions have merit. Not only is reconstruction a reasonable goal at an experienced level-I trauma center, it results in lower lifetime costs.

Demographic, social and economic variables that affect lower extremity injury outcomes.

While behavioral, demographic and vocational factors are commonly know as risk factors for sustaining a traumatic injury, less is known about the social, demographic and economic determinants of outcome following injury. The Lower Extremity Assessment Project (LEAP) identified a prospective cohort of 601 patients who were admitted to eight level I trauma centers in the United States for treatment of severe lower extremity trauma. Prospective data was accumulated on these individuals throughout their initial hospitalization and at regular follow-up intervals including a cohort at seven years post-injury. The results of the LEAP investigations showed that even at five to seven years following injury, reconstruction for the treatment of injuries to the lower extremity typically result in functional outcomes equivalent to those of the amputation. Clearly, factors other than the traditional variables such as fracture healing, joint function, and ability to ambulate have a profound effect on the patient's estimation of improvement. The purpose of this report is to summarize the data from the LEAP study and other investigations related to demographic, social and behavioral factors which impact outcome following lower extremity injury.

Early predictors of long-term work disability after major limb trauma.

BACKGROUND: A better understanding of the factors influencing return to work (RTW) after major limb trauma is essential in reducing the high costs associated with these injuries. METHODS: Patients (n = 423) who underwent amputation or reconstruction after limb threatening lower extremity trauma and who were working before the injury were prospectively evaluated at 3, 6, 12, 24, and 84 months. Time to first RTW was assessed. For individuals working at 84 months, the percentage of time limited in performance at work was estimated using the Work Limitations Questionnaire. RESULTS: Estimates of the cumulative proportion returning to work at 3, 6, 12, 24, and 84 months were 0.12, 0.28, 0.42, 0.51, and 0.58. Patients working at 84 months were, on average, limited in their ability to perform the demands of their job 20 to 25% of the time. In the context of a Cox proportional hazards model, differences in RTW outcomes by treatment (amputation versus reconstruction) were not statistically significant. Factors that were significantly associated (p < 0.05) with higher rates of RTW include younger age, being White, higher education, being a nonsmoker, average to high self efficacy, preinjury job tenure, higher job involvement, and no litigation. Early (3 month) assessments of pain and physical functioning were significant predictors of RTW. CONCLUSIONS: Return to work after severe lower extremity trauma remains a challenge. Although the causal pathway from injury to impairment and work disability is complex, this study points to several factors that influence RTW that suggest strategies for intervention.

Recombinant human BMP-2 and allograft compared with autogenous bone graft for reconstruction of diaphyseal tibial fractures with cortical defects. A randomized, controlled trial.

BACKGROUND: Currently, the treatment of diaphyseal tibial fractures associated with substantial bone loss often involves autogenous bone-grafting as part of a staged reconstruction. Although this technique results in high healing rates, the donor-site morbidity and potentially limited supply of suitable autogenous bone in some patients are commonly recognized drawbacks. The purpose of the present study was to investigate the benefit and safety of the osteoinductive protein recombinant human bone morphogenetic protein-2 (rhBMP-2) when implanted on an absorbable collagen sponge in combination with freeze-dried cancellous allograft. METHODS: Adult patients with a tibial diaphyseal fracture and a residual cortical defect were randomly assigned to receive either autogenous bone graft or allograft (cancellous bone chips) for staged reconstruction of the tibial defect. Patients in the allograft group also received an onlay application of rhBMP-2 on an absorbable collagen sponge. The clinical evaluation of fracture-healing included an assessment of pain with full weight-bearing and fracture-site tenderness. The Short Musculoskeletal Function Assessment (SMFA) was administered before and after treatment. Radiographs were used to document union, the presence of extracortical bridging callus, and incorporation of the bone-graft material. RESULTS: Fifteen patients were enrolled in each group. The mean length of the defect was 4 cm (range, 1 to 7 cm). Ten patients in the autograft group and thirteen patients in the rhBMP-2/allograft group had healing without further intervention. The mean estimated blood loss was significantly less in the rhBMP-2/allograft group. Improvement in the SMFA scores was comparable between the groups. No patient in the rhBMP-2/allograft group had development of antibodies to BMP-2; one patient had development of transient antibodies to bovine type-I collagen. CONCLUSIONS: The present study suggests that rhBMP-2/allograft is safe and as effective as traditional autogenous bone-grafting for the treatment of tibial fractures associated with extensive traumatic diaphyseal bone loss. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure?

OBJECTIVE: To measure the failure rate of percutaneous iliosacral screw fixation of vertically unstable pelvic fractures and particularly to test the hypothesis that fixations in which the posterior injury is a vertical fracture of the sacrum are more likely to fail than fixations with dislocations or fracture-dislocations of the sacroiliac joint. DESIGN: Retrospective review. SETTING: Level 1 trauma center. METHODS: All patients with pelvic fractures admitted between January 1, 1993, and December 31, 1998, were identified from the trauma registry. Hospital records were used to identify patients treated with iliosacral screws. Radiologic studies were examined to identify patients who had unequivocally vertically unstable pelvic fractures. Immediate postoperative and follow- up anteroposterior, inlet, and outlet radiographs from a minimum of 12 months postinjury were examined. Position, length, and numbers of iliosacral screws and any evidence of screw failure (eg, bending or breakage) were recorded. Residual postoperative displacement and late displacement of the posterior pelvis were measured. The main outcome measure was failure, defined as at least 1cm of combined vertical displacement of the posterior pelvis compared with immediate postoperative position. The main analysis was for association between fracture pattern and failure. Patient demographic data, iliosacral screw position, and anterior pelvic fixation method also were studied. RESULTS: The study group comprised 62 patients with unequivocally vertically unstable pelvic fractures in whom the posterior injury was treated with closed reduction and percutaneous iliosacral screw fixation. Of patients, 32 had dislocations or fracture-dislocations of the sacroiliac joint, and 30 had vertical fractures of the sacrum. Fixation failed in four patients, all with vertical sacral fractures and all within the first 3 weeks after surgery. These four patients required revision fixation. In two further cases with vertical sacral fractures, there was evidence that the fracture had only barely been held by the fixation, but these fractures healed, and followup radiographs did not meet the displacement criteria for failure. A vertical sacral fracture pattern was associated significantly with failure (Fisher exact test, P = 0.04); the excess risk of failure compared with sacroiliac joint injury was 13% (95% confidence interval 1% to 25%). There was no significant association between failure and anterior fixation method, iliosacral screw arrangement or length, or any demographic or injury variable. CONCLUSIONS: Percutaneous iliosacral screw fixation is a useful technique in the management of vertically unstable pelvic fractures, but a vertical sacral fracture should make the surgeon more wary of fixation failure and loss of reduction.

Occurrence, Distribution, and Polymerase Chain Reaction-Based Detection of Resistance to Sterol Demethylation Inhibitor Fungicides in Populations of Blumeriella jaapii in Michigan.

ABSTRACT The intensive use of site-specific fungicides in agricultural production provides a potent selective mechanism for increasing the frequency of fungicide-resistant isolates in pathogen populations. Practical resistance occurs when the frequency and levels of resistance are great enough to limit the effectiveness of disease control in the field. Cherry leaf spot (CLS), caused by the fungus Blumeriella jaapii, is a major disease of cherry trees in the Great Lakes region. The site-specific sterol demethylation inhibitor fungicides (DMIs) have been used extensively in the region. In 2002, CLS control failed in a Michigan orchard that had used the DMI fenbuconazole exclusively for 8 years. That control failure and our observations from around the state suggested that practical resistance had developed in B. jaapii. Field trial data covering 1989 to 2005 for the DMIs fenbuconazole and tebuconazole supported observations of reduced efficacy of DMIs for controlling CLS. To verify the occurrence of fungicide-resistant B. jaapii, monoconidial isolates were collected in two surveys and tested using a fungicide-amended medium. In one survey, 137 isolates from sites with different DMI histories (no known history, mixed or alternated with other fungicides, and exclusive use) were tested against 12 concentrations of fenbuconazole, tebuconazole, myclobutanil, and fenarimol. Isolates from sites with no prior DMI use were DMI sensitive (DMI(S) = no colony growth at 0.2 mug/ml a.i.) whereas the isolates from the site with prior exclusive use showed growth at DMI concentrations 3 to >100 times higher, and were rated as DMI resistant (DMI(R)). A second survey examined 1,530 monoconidial isolates, including 1,143 from 62 orchard sites in Michigan, where DMIs had been used to control CLS. Resistance to fenbuconazole was detected in 99.7% of the orchard isolates. All isolates from wild cherry trees were sensitive and isolates from feral and dooryard trees showed a range of sensitivities. A polymerase chain reaction (PCR)-based detection method for identifying B. jaapii and DMI(R) was developed and tested. The species-specific primer pair (Bj-F and Bj-R) based on introns in the CYP51 gene of B. jaapii, and the DMI(R)-specific primer pair (DMI-R-Bj-F and DMI-R-Bj-R) based on an insert found upstream of CYP51 in all DMI(R) isolates, provided an accurate and rapid method for detecting DMI(R) B. jaapii. The PCR-based identification method will facilitate timely decision making and continued monitoring of DMI(R) subpopulations in response to management programs.