Damage Control Plating in Open Tibial Shaft Fractures: A Cheaper and Equally Effective Alternative to Spanning External Fixation.

The purpose of this study was to evaluate damage control plating (DCP) as an alternative to external fixation (EF) in the provisional stabilization of open tibial shaft fractures. Through retrospective analysis, the study found 445 patients who underwent operative fixation for tibial shaft fractures from 2008 to 2012. Twenty patients received DCP or EF before intramedullary nailing with a minimum follow-up of 3 months. Charts and radiographs were reviewed for postoperative complications. Hospital charges were reviewed for implant costs. Nine patients (45%) with DCP and 11 patients (55%) with EF were analyzed. There was no significant difference in the complication rates. The mean implant cost of DCP was $1028, whereas mean EF construct cost was $4204. Therefore, DCP resulted in significant cost savings with no difference in complication rates, making it a valuable alternative to EF for the provisional stabilization of open tibial shaft fractures.

Does Physician Reimbursement Correlate to Risk in Orthopaedic Trauma?

This study investigated whether current Medicare reimbursements for orthopaedic trauma procedures correlate with complications. A total of 18,510 patients representing 33 orthopaedic trauma procedures from 2005 to 2011 were studied. Adverse events and Medicare payments for each orthopaedic trauma procedure were collected. Linear regressions determined correlations between complications and Medicare payments for orthopaedic trauma procedures. A weak correlation between Medicare payments and complications was found for all procedures (r = .399, p = .021). A 1.0% increase in complications was associated with a payment increase of only $100. There were no correlations between complications and reimbursements for upper extremity (p = .878) and lower extremity (p = .713) procedures. A strong correlation (r = .808, p = .015) existed for hip and pelvic fractures, but a 1.1% increase in hip and pelvic complications correlated with only an increase of $100 in reimbursements. This study is the first to show that Medicare payments are not strongly correlated with complications, therefore demonstrating the potential risks of a bundled payment system for orthopaedic trauma surgeons.

American Society of Anesthesiologists Score as a Predictive Tool to Optimize Blood Ordering for Intraoperative Transfusion in Orthopaedic Trauma Cases.

The objective of this study was to determine the clinical factors that are predictors for intraoperative transfusion in orthopaedic trauma patients. A retrospective chart review of patients admitted to a level I trauma center with isolated fractures was conducted. Variables such as gender, height, weight, body mass index, American Society of Anesthesiologists (ASA) classification, and medical comorbidities were assessed to determine likelihood of blood transfusion. A total of 1819 patients with isolated fractures were identified. ASA class was strongly associated with patients receiving intraoperative blood transfusion. For example, compared with patients with an ASA class I, patients with an ASA class IV were 14.71 times more likely to receive transfusion. Patients' ASA class is correlated with the need for intraoperative blood transfusion in patients undergoing orthopaedic surgery for isolated fractures. Institutional or departmental maximum surgical blood order schedule algorithms could use patients' preoperative ASA class to determine whether blood transfusion will be necessary during procedures.

Student-Driven Approaches to Undergraduate Medical Research: A Peer-Led Symposium.

Exposure to research early in medical school facilitates the development of physician-scientists and competent clinicians. In the last decade, institutions have established programs and policies to address the physician- scientist shortage. However, student-led initiatives to promote medical student engagement in research remain unexplored. This paper presents the design and results of the third iteration of a symposium in which senior medical students provided guidance and advice to preclinical students interested in research. It also reviews the lessons learned from three years of conducting the symposium. [Full article available at http://rimed.org/rimedicaljournal-2016-08.asp, free with no login].

Staged Columnar Fixation of Bicondylar Tibial Plateaus: A Cheaper Alternative to External Fixation.

The objective of this study was to compare complication rates and costs of staged columnar fixation (SCF) to external fixation for bicondylar tibial plateau fractures. Patients who received SCF or temporary external fixation across a 3-year period at a major level I trauma center underwent a retrospective chart review for associated complications. Fisher's exact analysis was used to determine any statistical difference in complication rates between both groups. However, there was no significant difference in complication rates between the SCF and external fixator groups. Average medial plate costs for SCF were $2131 compared with an average external fixator cost of $4070 (p < .0001). Given that all patients with external fixation undergo eventual medial and lateral plating, savings with SCF include $4070 plus operative costs for removing the fixator. As our health care system focuses on cost-cutting efforts, orthopaedic trauma surgeons must explore cheaper and equally effective treatment alternatives.

Locking Versus Nonlocking Implants in Isolated Lower Extremity Fractures: Analysis of Cost and Complications.

The purpose of this study was to investigate operative costs and postoperative complication rates in relation to utilization of locking versus nonlocking implants in isolated, lower limb fractures. Seventy-seven patients underwent plate fixation of isolated bicondylar tibial plateau, bimalleolar ankle, and trimalleolar ankle fractures at a large tertiary care center. Fixation with locking versus nonlocking implants was compared to incidence of postsurgical complications. Costs of these implants were directly compared. No significant correlation was found between locking versus nonlocking implants and incidence of complications. However, the cost of fixation with locking implants was significantly greater than nonlocking for all fractures. Utilization of more costly locking implants was not associated with reduced postoperative complications compared with nonlocking implants. More attention must be dedicated toward maximizing cost efficiency, since uniform usage of nonlocking implants has the potential to reduce surgical costs without compromising patient outcomes in isolated lower extremity fractures.

Pseudotumor cerebri: What We Have Learned from the Idiopathic Intracranial Hypertension Treatment Trial.

Idiopathic intracranial hypertension, also known as pseudotumor cerebri, is an unexplained increase in intracranial pressure associated with permanent severe visual loss in 25% of cases and debilitating headaches. The condition is often associated with obesity. The Idiopathic Intracranial Hypertension Treatment Trial, a large, randomized, collaborative clinical trial, evaluated the efficacy of acetazolamide with weight loss versus placebo with weight loss in participants. Herein, we describe the major components of the clinical trial and discuss its shortcomings. [Full article available at http://rimed.org/rimedicaljournal-2016-05.asp, free with no login].

Emerging Cataract Surgery Practice Patterns in the Veterans Health Administration.

A survey finds low rates for femtosecond laser-assisted cataract surgery, intracameral antibiotics, and immediate sequential bilateral cataract surgery in cataract surgery practice.

Placing Bundled Payments in Perspective: A Survey of the New England Ophthalmological Society.

OBJECTIVE: To determine ophthalmologists' views on the Medicare bundled payment model for specialty physicians in the outpatient setting. DESIGN AND METHODS: The New England Ophthalmology Society (NEOS) was emailed an anonymous survey. Views of bundled payments and demographic characteristics were analyzed. RESULTS: Of responding members, 72% (115/160) strongly opposed bundled payments; 68% (108/160) believed bundled payments will lead to financial losses, and the majority did not support including costs of prescription drugs (69%, 109/159) or preoperative (77%, 123/159) or postoperative complications (59%, 94/159) in the bundle. Respondents who held office in a medical society, were in private practice, solely billed for income, and had mostly conservative political views were significantly more likely to oppose bundling. CONCLUSION: The majority of NEOS ophthalmologists were opposed to bundled payments. Personal beliefs and practice type may influence the level of ophthalmologist support of bundled payments.

Heterotopic ossification after hemiarthroplasty of the hip - A comparison of three common approaches.

OBJECTIVE: Heterotopic ossification (HO) about the hip after total hip arthroplasty and internal fixation of the hip, pelvis, and acetabulum has been linked to surgical approach. However, no study has investigated surgical approach and HO in patients undergoing hemiarthroplasty. We therefore aimed to explore the influence of operative approach in patients undergoing hemiarthroplasty. METHODS: Through a retrospective case series at an Urban level I trauma center, we found 80 patients over the age of 60 undergoing hemiarthroplasty for femoral neck fractures from 2000 to 2009. Patient charts, operative notes, and radiographs were reviewed for demographics, operative approach (anterior: A, anterior-lateral: AL, posterior: P), and any development of HO. Fisher's exact test compared rates of HO among the three approaches. Student's t-tests compared Brooker Classification levels of HO among the approaches. RESULTS: 82 hemiarthroplasties (26 A, 32 AL, 24 P) were included for analysis. 22 patients (27%) had HO. There was no significant difference in the development of HO based upon surgical approach: A: 19% (n = 5); AL: 34% (n = 11); P: 25% (n = 6). There was a significant difference in the grade of HO based on Brooker Classification (BC) with the posterior approach resulting in significantly lower grade of HO: A (BC: 2.60); AL (BC: 2.64); P (BC: 1.50) (p = 0.012). CONCLUSIONS: Our data is the first to evaluate surgical approach and HO in patients with hemiarthroplasty. Patients have a significant risk of developing higher grade HO based on surgical approach (A or AL). Orthopedists should be mindful of these risks when considering A or AL approaches.

Surgical site infection in orthopedic trauma: A case-control study evaluating risk factors and cost.

BACKGROUND: With the shift of our healthcare system toward a value-based system of reimbursement, complications such as surgical site infections (SSI) may not be reimbursed. The purpose of our study was to investigate the costs and risk factors of SSI for orthopedic trauma patients. METHODS: Through retrospective analysis, 1819 patients with isolated fractures were identified. Of those, 78 patients who developed SSIs were compared to 78 uninfected control patients. Patients were matched by fracture location, type of fracture, duration of surgery, and as close as possible to age, year of surgery, and type of procedure. Costs for treatment during primary hospitalization and initial readmission were determined and potential risk factors were collected from patient charts. A Wilcoxon test was used to compare the overall costs of treatment for case and control patients. Costs were further broken down into professional fees and technical charges for analysis. Risk factors for SSIs were analyzed through a chi-squared analysis. RESULTS: Median cost for treatment for patients with SSIs was $108,782 compared to $57,418 for uninfected patients (p < 0.001). Professional fees and technical charges were found to be significantly higher for infected patients. No significant risk factors for SSIs were determined. CONCLUSIONS: Our findings indicate the potential for financial losses in our new healthcare system due to uncompensated care. SSIs nearly double the cost of treatment for orthopedic trauma patients. There is no single driver of these costs. Reducing postoperative stay may be one method for reducing the cost of treating SSIs, whereas quality management programs may decrease risk of infection.

Isolated sacral injuries: Postoperative length of stay, complications, and readmission.

AIM: To investigate inpatient length of stay (LOS), complication rates, and readmission rates for sacral fracture patients based on operative approach. METHODS: All patients who presented to a large tertiary care center with isolated sacral fractures in an 11-year period were included in a retrospective chart review. Operative approach (open reduction internal fixation vs percutaneous) was noted, as well as age, gender, race, and American Society of Anesthesiologists' score. Complications included infection, nonunion and malunion, deep venous thrombosis, and hardware problems; 90-d readmissions were broken down into infection, surgical revision of the sacral fracture, and medical complications. LOS was collected for the initial admission and readmission visits if applicable. Fisher's exact and non-parametric t-tests (Mann-Whitney U tests) were employed to compare LOS, complications, and readmissions between open and percutaneous approaches. RESULTS: Ninety-four patients with isolated sacral fractures were identified: 31 (30.4%) who underwent open reduction and internal fixation (ORIF) vs 63 (67.0%) who underwent percutaneous fixation. There was a significant difference in LOS based on operative approach: 9.1 d for ORIF patients vs 6.1 d for percutaneous patients (P = 0.043), amounting to a difference in cost of $13590. Ten patients in the study developed complications, with no significant difference in complication rates or reasons for complications between the two groups (19.4% for ORIF patients vs 6.3% for percutaneous patients). Eight patients were readmitted, with no significant difference in readmission rates or reasons for readmission between the two groups (9.5% percutaneous vs 6.5% ORIF). CONCLUSION: There is a significant difference in LOS based on operative approach for sacral fracture patients. Given similar complications and readmission rates, we recommend a percutaneous approach.

Gunshot-induced fractures of the extremities: a review of antibiotic and debridement practices.

The use of antibiotic prophylaxis and debridement is controversial when treating low- and high-velocity gunshot-induced fractures, and established treatment guidelines are currently unavailable. The purpose of this review was to evaluate the literature for the prophylactic antibiotic and debridement policies for (1) low-velocity gunshot fractures of the extremities, joints, and pelvis and (2) high-velocity gunshot fractures of the extremities. Low-velocity gunshot fractures of the extremities were subcategorized into operative and non-operative cases, whereas low-velocity gunshot fractures of the joints and pelvis were evaluated based on the presence or absence of concomitant bowel injury. In the absence of surgical necessity for fracture care such as concomitant absence of gross wound contamination, vascular injury, large soft-tissue defect, or associated compartment syndrome, the literature suggests that superficial debridement for low-velocity ballistic fractures with administration of antibiotics is a satisfactory alternative to extensive operative irrigation and debridement. In operative cases or those involving bowel injuries secondary to pelvic fractures, the literature provides support for and against extensive debridement but does suggest the use of intravenous antibiotics. For high-velocity ballistic injuries, the literature points towards the practice of extensive immediate debridement with prophylactic intravenous antibiotics. Our systematic review demonstrates weak evidence for superficial debridement of low-velocity ballistic fractures, extensive debridement for high-velocity ballistic injuries, and antibiotic use for both types of injury. Intra-articular fractures seem to warrant debridement, while pelvic fractures with bowel injury have conflicting evidence for debridement but stronger evidence for antibiotic use. Given a relatively low number of studies on this subject, we recommend that further high-quality research on the debridement and antibiotic use for gunshot-induced fractures of the extremities should be conducted before definitive recommendations and guidelines are developed.

Adverse Events in Orthopaedics: Is Trauma More Risky? An Analysis of the NSQIP Data.

OBJECTIVES: As our healthcare system moves toward bundling payments, orthopaedic trauma surgeons will be increasingly benchmarked on perioperative complications. We therefore sought to determine financial risks under bundled payments by identifying adverse event rates for (1) orthopaedic trauma patients compared with general orthopaedic patients and (2) based on anatomic region and (3) to identify patient factors associated with complications. DESIGN: Prospective. SETTING: Multicenter. PATIENTS/PARTICIPANTS: A total of 146,773 orthopaedic patients (22,361 trauma) from 2005 to 2011 NSQIP data were identified. INTERVENTIONS: Minor and major adverse events, demographics, surgical variables, and patient comorbidities were collected. MAIN OUTCOME MEASUREMENTS: Multivariate regressions determined significant risk factors for the development of complications. RESULTS: The complication rate in the trauma group was 11.4% (2554/22,361) versus 4.1% (5137/124,412) in the general orthopaedic group (P = 0.001). When controlling for all variables, trauma was a risk factor for developing complications [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.57-1.81]. After controlling for several patient factors, hip and pelvis patients were 4 times more likely to develop any perioperative complication than upper extremity patients (OR: 3.79, 95% CI: 3.01-4.79, P = 0.01). Lower extremity patients are 3 times more likely to develop any complication versus upper extremity patients (OR: 2.82, 95% CI: 2.30-3.46, P = 0.01). CONCLUSIONS: Our study is the first to show that orthopaedic trauma patients are 2 times more likely than general orthopaedic patients to sustain complications, despite controlling for identical risk factors. There is also an alarming difference in complication rates among anatomic regions. Orthopaedic trauma surgeons will face increased financial risk with bundled payments. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Operative intervention for geriatric hip fracture: does type of surgery affect hospital length of stay?

Hip fractures are the most costly fall-related fractures. Differences in hospital length of stay (LOS) based on type of surgery could have major financial implications in a potential bundled payment system in which all hip fractures are reimbursed a standard amount. We conducted a study to analyze differences in hospital LOS and costs for total hip arthroplasty (THA), hemiarthroplasty (HA), cephalomedullary nailing, open reduction and internal fixation (ORIF), and closed reduction and percutaneous pinning (CRPP). Through retrospective chart review, 615 patients over age 60 years across a 9-year period at an urban level I trauma center were identified. Mean LOS and costs for hip fracture repair were 6.91 days and $30,011.25, respectively. HA/THA was associated with the longest mean LOS (7.43 days) and highest costs ($33,657.90). After several patient factors were adjusted for, ORIF was associated with 0.84 fewer in-patient days and $3805.20 less in hospitalization costs compared with HA/THA (P=.042). CRPP was associated with 1.63 fewer days and $7383.90 less in costs than HA/THA (P=.0076). Our results provide insight into the financial implications of hip fracture fixation and identify targets for quality improvement initiatives to improve efficiency of resource utilization.

Factors driving readmissions in tibia and femur fractures.

As the American healthcare system shifts towards bundled payments, readmissions will become a measure of healthcare quality. The purpose of this study was to characterize readmission trends and factors influencing readmission in patients with diaphyseal femur and tibia fractures. Through a retrospective chart review, all patients who presented to a level 1 trauma center from 2004 to 2006 were evaluated. By using current procedural terminology codes, 1,040 patients with diaphyseal tibia or femur fractures fixed by IMN were identified. 645 patients were included for analysis. 30-day, 60-day, and 90-day readmission rates were compared with fracture type, reason for readmission, and basic demographic information. The 60-day readmission rate for open tibia fractures (14.8%) was significantly higher than the 60-day readmission rate for closed tibia fractures (8.0%) (p = 0.037). When comparing reasons for 60-day readmissions, 50% of closed fractures were readmitted due to infection, while the other 50% needed additional surgery. 91.7% of open fractures readmitted in 60 days were due to infection. In a bundled payment system, orthopedic trauma must gain insight into drivers of readmission to identify those at risk for readmission and design effective healthcare plans for these patients.

Ankle Fractures and Modality of Hospital Transport at a Single Level 1 Trauma Center: Does Transport by Helicopter or Ground Ambulance Influence the Incidence of Complications?

In an era of concern over the rising cost of health care, cost-effectiveness of auxiliary services merits careful evaluation. We compared costs and benefits of Helicopter Emergency Medical Service (HEMS) with Ground Emergency Medical Service (GEMS) in patients with an isolated ankle fracture. A medical record review was conducted for patients with an isolated ankle fracture who had been transported to a level 1 trauma center by either HEMS or GEMS from January 1, 2000 to December 31, 2010. We abstracted demographic data, fracture grade, complications, and transportation mode. Transportation costs were obtained by examining medical center financial records. A total of 303 patients was included in the analysis. Of 87 (28.71%) HEMS patients, 53 (60.92%) had sustained closed injuries and 34 (39.08%) had open injuries. Of the 216 (71.29%) GEMS patients, 156 (72.22%) had closed injuries and 60 (27.78%) had open injuries. No significant difference was seen between the groups regarding the percentage of patients with open fractures or the grade of the open fracture (p = .07). No significant difference in the rate of complications was found between the 2 groups (p = 18). The mean baseline cost to transport a patient via HEMS was $10,220 + a $108/mile surcharge, whereas the mean transport cost using GEMS was $976 per patient + $16/mile. Because the HEMS mode of emergency transport did not significantly improve patient outcomes, health systems should reconsider the use of HEMS for patients with isolated ankle fractures.

Regional anaesthesia for hip fracture surgery is associated with significantly more peri-operative complications compared with general anaesthesia.

INTRODUCTION: Although several studies have advocated the use of regional versus general anaesthesia as a means of reducing peri-operative complications from hip fracture surgery, the ideal method of anaesthesia remains controversial. Our purpose was to investigate the association between anaesthesia type and peri-operative complications in hip fracture surgery. METHODS: From the 2005-2011 ACS-NSQIP database, all patients with operatively treated hip fractures were identified using CPT codes, and fifteen peri-operative complications were recorded and categorized as either minor or major. Rates of minor, major, and total complications by anaesthesia type were compared using chi-square and Fischer's exact tests. A multivariate model was used to determine odds of minor, major, and total complications between anaesthesia types. Multivariate analysis was then repeated after combining patients who received regional nerve blocks or spinal anaesthesia. RESULTS: A total of 7,764 hip fracture patients were included in our analysis. Spinal anaesthesia had the highest total complication rate (19.6%), followed by general (17.9%) and regional nerve blocks (12.6%). Multivariate analysis demonstrated that spinal anaesthesia was associated with significantly greater odds of minor complications and total complications compared with general anaesthesia. After combining the regional nerve block and spinal anaesthesia groups, multivariate analysis again showed significantly greater odds of minor and total complications with regional versus general anaesthesia. CONCLUSIONS: Using a large multi-centre database, we demonstrate that regional anaesthesia was associated with significantly greater odds of minor and total peri-operative complications compared with general anaesthesia. Our results challenge the notion that regional anaesthesia is the preferred method of anaesthesia for hip fractures in the elderly.

Geographic variations in hospital charges and Medicare payments for major joint arthroplasty.

National data on hospital-level charges and Medicare payments have shown that joint arthroplasty is the most common surgical procedure among the elderly. Yet, no study has investigated micro and macro level geographic variations in hospital charges and payment. We used the Medicare Provider Charge Data to investigate Medicare payments and charges for 2750 hospitals accounting for 427,207 patients who underwent major joint arthroplasty and 932 hospitals for 18,714 patients who had a complication/comorbidity. We found a significant difference in hospital charges and payments based on geographic region (P<0.001). We concluded that hospital charges demonstrate a high variability even when using areas to control for differences in hospital wages and high variation in reimbursements in some areas remains unexplained by Medicare's current method of calculating reimbursement.