Comparison of Operative and Non-Operative Management of Elderly Fragility Pelvic Ring Fractures.

OBJECTIVES: To compare outcomes of nonoperative and percutaneous fixation of geriatric fragility lateral compression I (LC1) pelvic ring fractures. METHODS: Design: Retrospective. SETTING: Two level one trauma centers. PATIENT SELECTION CRITERIA: Included were patients 60 years of age or older with an isolated LC1 pelvic ring fracture managed nonoperatively or those who failed mobilization and were managed operatively with percutaneous sacral fixation after failing to mobilize. Patients with high energy mechanisms of injury or polytrauma were excluded.Outcome Measures and Comparisons: The primary outcome was pain as measured by Visual Analog Scale (VAS) after treatment. Secondary outcomes included length of stay (LOS), discharge disposition, mortality, readmission rates, and complications. RESULTS: In total, 231 patients were included with a mean age of 79.5 years (range 60-100). One hundred eighty-five(80.0%) patients were female. Sixty-two (26.8%) patients received percutaneous sacral fixation after failed mobilization, and 169 (73.2%) were managed nonoperatively. In the operative group, the median time to surgery was hospital day four. Nonoperative patients were older (81.5 ± 10.0 years vs. 74.2 ± 9.4 years, p<0.01), and had a shorter hospital LOS (4.8 ± 6.2 days) than the operative group (10.6 ± 9.5 days, p<0.01). Patients in the operative group had more pain (VAS 7.9 ± 3.0) than the nonoperative group (VAS 6.6 ± 3.0) (p=0.01) on admission, but had similar pain control post-operatively (VAS 4.4 ± 3.0) compared to the nonoperative group (VAS 4.5 ± 3.6) on the equivalent hospital day (p=0.91). Thus, patients in the operative group experienced more improvement in pain (VAS 3.3 ± 2.7) compared to the nonoperative group (VAS 1.9 ± 3.9) after treatment (p=0.02). Ninety-day mortality (p=0.21) and readmission rates (p=0.27) were similar for both groups. Two patients in the operative cohort sustained nerve injuries, while one patient in the nonoperative group had a nonunion and underwent surgery. CONCLUSIONS: Patients who undergo percutaneous surgical fixation for low energy LC1 injuries have similar discharge disposition, mortality, complication rates, and readmission rates compared to patients treated nonoperatively. Percutaneous surgical fixation may provide significant pain relief for patients who failed conservative management. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preoperative CT Scan is not Associated with Shorter Surgical Time or Improved Patient Outcomes for Trimalleolar Ankle Fractures.

Background: Posterior malleolar involvement can drastically affect patient outcomes. Literature has supported the use of preoperative Computed Tomography (CT) to assess posterior malleolar fracture morphology. The purpose of this study is to determine whether preoperative CT is associated with significant improvement in surgical time, postoperative complications, reoperation rates in trimalleolar ankle fractures. Surgeons were also asked to complete survey regarding use of CT scans to gauge utility preoperatively. Methods: Adult patients with trimalleolar ankle fractures who underwent operative fixation between 2018-2020 were retrospectively reviewed. Primary outcomes included surgical time, postoperative complications, and reoperations. Secondary outcome was presence of posterior malleolar fixation. 15 surgeons who performed ankle ORIF were surveyed to gain information regarding why or why not preoperative CT scan was obtained. Results: 288 patients with trimalleolar ankle fractures were included, 94 had preoperative CT scans (32.6%). No significant differences found in patient age, gender, BMI, smoking status between the groups that did and did not have preoperative CT scan. No significant differences were observed in AO/OTA classification between groups. Average surgical time was significantly higher in group that received a preoperative CT (114 without CT vs. 145 with CT, p<0.05). Complications (10.3% no CT vs 7.4% with CT, p=0.55) and reoperations (6.7% without CT vs. 7.4% with CT, p=0.16) not significantly different between groups. No significant difference was observed in rate of posterior malleolus fixation between groups (43.8% without CT vs 39.4% with CT; p=0.52). Of surveyed surgeons, 87% reported they don't routinely obtain preoperative CT scan for trimalleolar ankle fractures. Most common reasons for preoperative scans were deciding on approach/positioning, assessing for impaction, determining the size of the posterior malleolus. Conclusion: Although preoperative CT scans are obtained in one third of patients with operative trimalleolar ankle fractures, we did not find an improvement in surgical time, complications, and reoperation. Level of Evidence: III.

Outcomes of operatively managed periprosthetic distal femur fractures compared to fractures in patients with native knees.

Introduction: With the increasing incidence of total knee arthroplasty (TKA), there is an expected rise in rate of periprosthetic fractures in the coming years. It is unclear how the outcomes of patients with distal femur fractures (DFF) and a total knee arthroplasty compare to patients of the same age group with native knees (NK). Materials and methods: A retrospective review was completed for distal femur fractures treated with surgical fixation from January 2019-March 2021. We excluded patients <50 years old, non-ambulatory patients, revision surgeries, and patients with less than 90 days of follow-up. A chart review was performed to collect age, gender, BMI, smoking status, American Society of Anesthesiology (ASA) classification, fracture type, fixation method, time to full weight bearing, and complications. Comparisons between the TKA vs native knee groups were performed using t-test, chi-square, and Fisher's exact test where appropriate. Results: 138 patients were included in our study with a mean age of 74 years. 69 DFF ipsilateral to a TKA were included in the study group and 71 DFF were included in the native knee group. Age, sex, BMI, smoking status, and ASA class were similar between the groups. All patients with periprosthetic femur fractures had 33A AO/OTA fracture classification. Patients with native knees were more likely to receive dual implant fixation, 15.5% compared to 4.3% (p = 0.02). Full weight bearing was achieved at 8.5 vs 8.6 weeks between the NK and TKA groups (p = 0.64). The complication rate was 16.9% in the NK group vs. 7.2% in the TKA group (p = 0.21). Conclusion: Patients with periprosthetic femur fractures have similar time to weight bearing and complications rate with patients with distal femur fracture in native knees. We found a higher utilization rate of dual implant fixation in the native knee group.

Post-traumatic Acetabulum Open Reduction Internal Fixation in a Patient with a BMI of 77: A Case Report.

CASE: We present the case of a 25-year-old man with body mass index of 77 who underwent open reduction internal fixation (ORIF) of a displaced fracture dislocation of the acetabulum after a high-speed motor vehicle accident. Remarkably, he achieved full weight-bearing with minimal hip pain and has returned to independent mobility and meaningful work. CONCLUSION: ORIF of an acetabular fracture in a patient with class III obesity presents many challenges. Positioning, surgical approach, fracture manipulation, and postoperative morbidity and mortality can be managed through interdisciplinary collaboration and preoperative communication.

Ankle fractures: High implant cost is not associated with better patient reported outcomes.

INTRODUCTION: Ankle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries. Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture. METHODS: All ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost. RESULTS: There was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [-411.8, -54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [-74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48). CONCLUSIONS: The utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.

Comparisons of Procedures Performed in Training vs in Early Practice by Orthopaedic Trauma Surgeons.

INTRODUCTION: The Orthopaedic Trauma Association (OTA) has maintained an accreditation process of orthopaedic trauma fellowships with various requirements including an annually reviewed list of qualifying trauma cases in the form of American Medical Association Current Procedural Terminology (CPT) codes. The correlation between these established and monitored CPTs and the actual practices of orthopaedic trauma surgeons has not been studied. METHODS: American Board of Orthopaedic Surgery part II case logs (trauma subspecialty) (2012 to 2018) were compared with OTA fellowship case logs (2015 to 2019). Case logs from 447 surgeons and 166 trauma fellowship programs were compared. Four CPT code categories were defined: complex trauma (OTA required CPT codes, excluding Accreditation Council for Graduate Medical Education [ACGME] orthopaedic residency requirements), general trauma (ACGME residency required trauma codes), general orthopaedics (nontrauma ACGME residency requirements), and others (codes not included in residency or trauma fellowship requirements). RESULTS: OTA fellows performed a higher median percentage of complex trauma compared with American Board of Orthopaedic Surgery candidates (34% vs. 21%, P < 0.001): Both cohorts performed a similar percentage of general trauma (23%). OTA fellows performed more general orthopaedics (40% vs. 1%, P < 0.001). Several OTA required codes were performed infrequently (0 to 3 during board collection) by most surgeons, and several procedures are being performed that are not included in current CPT code requirements. DISCUSSION: Early-career traumatologists are performing orthopaedic trauma procedures they were trained on during residency and fellowship, with varying complexity. Trauma fellows perform a higher percentage of complex trauma compared with early-career trauma surgeons. Continued surveillance is necessary such that educational improvements can be made to maximize the quality of trauma fellowship education. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Why do consumers choose private over public health services? Reflective accounts of health providers in Vietnam.

BACKGROUND: In Vietnam and many developing countries, private healthcare is increasingly being leveraged by governments to complement public services and increase health service access and utilisation. Extensive understanding of patterns of utilisation of private over public health services, and the rationale for such consumer decisions, is important to ensure and promote safe, affordable and patient-centred care in the two sectors. Few studies within the Southeast Asian Region have explored how private and public providers interact (via social networks, marketing, and direct contact) with consumers to affect their service choices. This study investigates providers' views on social factors associated with the use of private over public health services in Vietnam. METHOD: A thematic analysis was undertaken of 30 semi-structured interviews with experienced health system stakeholders from the Vietnam national assembly, government ministries, private health associations, health economic association, as well as public and private hospitals and clinics. RESULTS: Multiple social factors were found to influence the choice of private over public services, including word-of-mouth, the patient-doctor relationship and relationships between healthcare providers, healthcare staff attitudes and behaviour, and marketing. While private providers maximise their use of these social factors, most public providers seem to ignore or show only limited interest in using marketing and other forms of social interaction to improve services to meet patients' needs, especially those needs beyond strictly medical intervention. However, private providers faced their own particular challenges related to over-advertisement, over-servicing, excessive focus on patients' demands rather than medical needs, as well as the significant technical requirements for quality and safety. CONCLUSIONS: This study has important implications for policy and practice in Vietnam. First, public providers must embrace social interaction with consumers as an effective strategy to improve their service quality. Second, appropriate regulations of private providers are required to protect patients from unnecessary treatments, costs and potential harm. Finally, the insights from this study have direct relevance to many developing countries facing a similar challenge of appropriately managing the growth of the private health sector.

Contribution of private health services to universal health coverage in low and middle-income countries: Factors affecting the use of private over public health services in Vietnam.

The private sector's contribution to Universal health coverage (UHC) has been increasingly recognised by policymakers in low- and middle-income countries. This study aimed to identify service-provider and consumer-level factors affecting choice of private over public health services in Vietnam. A concurrent mixed-method design was adopted. A quantitative phase explored consumers' health service choice by analysing data from a random national sample of 10,354 individuals aged 16 and over. The qualitative phase investigated how private and public providers organise their services to influence consumer choices by conducting interviews with policymakers, hospital and clinic managers, and health practitioners. The combined results demonstrate that at the individual level, absence of any type of health insurance was the factor most closely associated with the use of private services. Private health services were more likely to be used by people from ethnic majority groups compared to ethnic minorities (odds ratio [OR]: 1.6, 95% CI: 1.4-2.0), and by people living in urban compared to rural areas (OR: 1.1, 95% CI: 1.0-1.3). The service providers suggested that consumers opted for private services that were perceived to have poorer quality in the public sector, such as counselling, physical therapy and rehabilitative care. Additional motivational factors include the private sector's more flexible working hours, shorter waiting times, flexible pricing of services, personalised care and better staff behaviour. The findings can inform national health system planning and coordination activities in Vietnam and other countries that aim to harness the attributes of both the public and private sectors to achieve UHC.

A Case Series of Young Patients with Low-Energy Femoral Neck Fractures.

Background: Fragility femoral neck fractures are traditionally seen in elderly patients after a low-energy fall. In contrast, displaced femoral neck fractures in young patients are usually associated with high-energy mechanisms such as a fall from height or high-speed motor vehicle collisions. However, patients under the age of 45 with fragility femoral neck fractures represent a unique population, and one that is not well-described. This study aims to describe this population and their current workup. Methods: A single institution retrospective chart review of patients who underwent open reduction internal fixation or percutaneous pinning of femoral neck fractures from 2010-2020 was conducted. Inclusion criteria were patients 16-45 years old and femoral neck fractures with a low-energy mechanism of injury (MOI). Exclusion criteria were high-energy fractures, pathologic fractures, and stress fractures. Patient demographics, MOI, past medical history, imaging studies, treatment plan, lab values, DEXA results, and surgical outcomes were recorded. Results: The average age in our cohort was 33 ± 8.5 y/o. 44% (12/27) were male. Vitamin D level was obtained in 78% (21/27) patients and 71% (15/21) those patients were found to be abnormally low. A DEXA scan was obtained in 48% (13/27) of patients and abnormal bone density was found in 90% (9/10) of available results. 41% (11/27) patients received a bone health consultation. Conclusion: A significant portion of femoral neck fractures in young patients were fragility fractures. Many of these patients did not receive bone health workup and their underlying health condition remained untreated. Our study highlighted a missed opportunity of treatment for this unique and poorly understood population. Level of Evidence: III.

How public health insurance expansion affects healthcare utilizations in middle and low-income households: an observational study from national cross-section surveys in Vietnam.

Public health insurance (PHI) has been implemented with different levels of participation in many countries, from voluntary to mandatory. In Vietnam, a law amendment made PHI compulsory nationwide in 2015 with a tolerance phase allowing people a flexible time to enroll. This study aims to examine mechanisms under which the amendment affected the enrollment, healthcare utilization, and out-of-pocket (OOP) expenditures by middle- and low-income households in this transitioning process.Using the biennial Vietnam Household Living Standard Surveys, the study applied the doubly robust difference-in-differences approach to compare outcomes in the post-amendment period from the 2016 survey with those in the pre-amendment period from the 2014 survey. The approach inheriting advantages from its predecessors, i.e., the difference-in-differences and the augmented inverse-probability weighting methods, can mitigate possible biases in policy evaluations due to the changes within the group and between groups over time in the cross-section observational study.The results showed health insurance expansion with extensive subsidies in premiums and medical coverage for persons other than the full-time employed, young children or elderly members in the family, significantly increased enrollments in the middle- and low-income groups by 9% and 8%, respectively. The number of visits for PHI-eligible services also increased, approximately 0.5 more visit per person in the middle-income and 1 more visit per person in the low-income. The amendment, however, so far did not show any significant effect on reducing OOP payments, neither for the low nor the middle-income groups. To further expand PHI coverage and financial protections, policymakers should focus on improving public health facilities, contracting PHI to more accredited private health providers, and motivating the high-income group's enrollments.

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.

Association of Preoperative Opioid Use With Postoperative Opioid Use and Patient-Reported Outcomes in Ankle Fracture Fixation Patients.

Background: Ankle fracture surgery is a common procedure with many patients receiving opioid medications for postoperative pain control. Whether there are factors associated with higher medication quantities or patient-reported outcomes, however, remains largely unknown. Methods: Patients with isolated, rotational ankle fractures who underwent surgical fixation between January 2018 and March 2020 were retrospectively reviewed. Patient demographics, injury characteristics, and preoperative and postoperative opioid prescription information were recorded. Clinical follow-up and Foot and Ankle Ability Measure (FAAM) questionnaires were collected at 6 weeks and 3 months postoperatively. Multiple linear regression was used to examine the influences of age, sex, body mass index (BMI), fracture characteristics, medical comorbidities, and preoperative opioid use (OU) on postoperative opioid morphine milligram equivalent (MME) amount and FAAM scores. Results: A total of 294 patients were included with an average age of 52.11 ± 17.13 years (range, 18-97). Fracture types were proportional to one another. Chronic pain (mean = 145.89, 95% CI = 36.72, 255.05, P = .0009), preoperative OU (mean = 178.22, 95% CI = 47.46, 308.99, P = .0077), psychiatric diagnoses (mean = 143.81, 95% CI = 58.37, 229.26, P = .001), tobacco use (mean = 137.37, 95% CI = 33.35, 229.26, P = .0098), and trimalleolar fractures (mean = 184.83, 95% CI = 86.82, 282.84, P = .0002) were associated with higher postoperative opioid MME amounts. Older age (mean = ‒0.05, 95% CI = ‒0.08, -0.02, P = .0014) and higher BMI (mean = ‒0.06, 95% CI = ‒0.12, 0.00, P = .048) were both independently associated with lower FAAM scores at 6 weeks. At 3 months, higher BMI (mean = ‒0.09, 95% CI = ‒0.13, -0.04, P = .0002), bimalleolar fractures (mean = ‒1.17, 95% CI = ‒2.17, -0.18, P = .021), and higher postoperative MME amounts (mean = ‒0.10, 95% CI = ‒0.19, -0.01, P = .0256) were each independently associated with lower FAAM scores. Conclusion: In this study, we found that patients with chronic pain, preoperative OU, psychiatric diagnoses, tobacco use, and trimalleolar fractures were more likely to have higher amounts of opioid prescribed following ankle fracture surgery. However, only age, BMI, bimalleolar fractures, and postoperative MME amount were associated with lower FAAM scores postoperatively. Level of Evidence: Level III, retrospective cohort study.

Usage of orthopaedic trauma registries among members of the International Orthopaedic Trauma Association: How are we doing?

Introduction: The use of national databases for orthopaedic research has increased significantly in the past decade. The purpose of this study was to report on the current state of orthopaedic trauma registries in 21 countries represented by 20 member societies of the International Orthopaedic Trauma Association (IOTA). Methods: A web-based survey was circulated to all IOTA member societies. The survey consisted of 10 questions (five open-ended and five multiple-choice). Results: Representatives from all 21 countries replied. Five countries (24%) do not currently have or plan to start a registry. One country (5%) had a registry that is now closed. Two countries (10%) are building a registry. Thirteen countries (62%) reported at least one active registry, including four countries with more than one registry. Of the 14 countries that reported the existence of a registry, there were 17 registries noted that included patients with fracture. There were seven registries dedicated to high-energy trauma and four registries that included elderly hip fractures. In addition, 9/17 representatives reported the utilization of a fracture classification and 9/17 noted some level of mandate from medical providers. All responders but one reported that data were manually entered into their registries. Conclusions: Despite the shared vision of quality control and outcome optimization, IOTA society representatives reported significant variability in the depth and format of the orthopaedic trauma registry among IOTA members. These findings represent an opportunity for collaboration across organizations in creating fracture registries. Level of Evidence: Level IV.

Capturing patient-reported outcomes: paper versus electronic survey administration.

Objective: To compare the capture rates and costs of paper patient-reported outcomes (pPRO) administered in-clinic and electronic PROs (ePRO) collected through emails and texts. Design: Retrospective review. Setting: Level 1 trauma center. Patients/Participants: The pPRO program enrolled 2164 patients for postsurgical follow-up in 4 fracture types: ankle, distal radius, proximal humerus, and implant removal from 2012 to 2017. The ePRO program enrolled 3096 patients in 13 fracture types from 2018 to 2020. Among the patients enrolled in the ePRO program, 1296 patients were matched to the 4 original fracture types and time points. Main Outcome Measures: PRO capture rates in 4 fracture types by matched time point and estimated cost of each program per enrolled patient. Results: At first follow-up, pPRO provided a higher capture rate than ePRO for 3 of 4 fracture types except for implant removal (P < 0.05). However, at 6-month and 1-year follow-ups, ePRO demonstrated statistically significant higher capture rates when compared with pPRO for all applicable modules (P < 0.05). The average cost for the pPRO program was $171 per patient versus $56 per patient in the ePRO program. Patients were 1.19 times more likely to complete ePRO compared with pPRO (P = 0.007) after controlling for age, sex, fracture type, and time point. Conclusion: The electronic PRO service has improved long-term capture rates compared with paper PROs, while minimizing cost. A combined program that includes both in-clinic and out of clinic effort may be the ideal model for collection of PROs. Level of Evidence: Level 3.

Comparison of the Neer classification to the 2018 update of the Orthopedic Trauma Association/AO fracture classification for classifying proximal humerus fractures.

Background: The classification of fractures is necessary to ensure a reliable means of communication for clinical interaction, education and research. The Neer classification is the most commonly used classification for proximal humerus fractures. In 2018 the Orthopedic Trauma Association (OTA) and the AO Foundation provided an update to the OTA/AO Fracture Classification Scheme addressing many of the concerns about the previous versions of the classification. The objective of the present study was to evaluate the rater reliability of the 2 classifications and if the classifications subjectively better characterized the fracture patterns. Methods: X-rays and CT scans of 24 proximal humerus fractures were given to 7 independent raters for classification according to the Neer and 2018 OTA/AO classification. Both full-forms and short-forms of the classifications were tested. The Fleiss Kappa statistic was used to assess inter-rater agreement and intra-rater consistency for the 2 classifications. For each case the raters subjectively commented on how well each classification was able to characterize the fracture pattern. Results: All raters graded the 2018 OTA/AO classification as good as or better than the Neer classification for an adequate description of the fracture patterns. The short-form 2018 OTA/AO classification had the most 4 rater and 5 rater agreement cases and the second most 6 rater agreement cases. The short-form Neer classification had the second most 4 rater and 5 rater agreement cases and the most 6 rater agreement cases. The full 2018 OTA/AO had the least 4, 5, or 6 rater agreement cases of all the classification systems. Inter-rater agreement was fair for the full and short form of both the Neer and 2018 OTA/AO classification. The full and short Neer classifications together with the short 2018 OTA/AO classification had moderate intra-rater consistency, while the full 2018 OTA/AO classification only had slight intra-rater consistency. Conclusions: The 2018 OTA/AO classification is equivalent in its short-form to the Neer classification in inter-rater reliability and intra-rater consistency; and is superior in its full form for characterizing specific fracture types. The low inter-rater reliability of the full 2018 OTA/AO classification is a concern that may need to be addressed in the future.