Impact of a Dedicated Orthopaedic Trauma Room on Elective Arthroplasty Case Volume.

OBJECTIVE: To examine the effects of implementing a dedicated orthopaedic trauma room (DOTR) on elective arthroplasty volume. DESIGN: Retrospective cohort study. SETTING: Level I academic trauma center. INTERVENTION: A retrospective analysis was performed for two 3-year intervals before and after DOTR introduction on January 20, 2013, at a Level I trauma center. Surgeons were included if they performed elective primary total hip arthroplasty (THA), total knee arthroplasty (TKA), total shoulder arthroplasty (TSA), or reverse total shoulder arthroplasty (RTSA) regularly from 2010 to 2015. MAIN OUTCOME MEASURES: Change in elective arthroplasty volume after the implementation of a DOTR. RESULTS: A total of 2339 cases were performed by surgeons A-E, with an average of 303.3 cases per year pre-DOTR and an average of 476.3 cases per year post-DOTR. On average, within our institution, there were 75.79 per 10,000 cases/year in Michigan pre-DOTR and 104.2 per 10,000 cases/year in Michigan post-DOTR. Surgeons A-E averaged 173.0 more cases per year and increased their average proportion of elective arthroplasty case volume in Michigan. There was a statistically significant market share increase of 9.8 per 10,000 cases/year in Michigan, at our hospital in the post-DOTR periods ( P = 0.039) (CI [0.5442, 19.21], SE = 4.523). This market share increase of 9.8 cases/10,000 cases was the yearly increase in market share that our average surgeons saw after the DOTR implementation, this took into account the observed annual increase in arthroplasty volume statewide during those years. CONCLUSION: Implementation of a DOTR was associated with increases in the total number, annual mean, and annual proportion of elective arthroplasty cases performed in Michigan for both elective surgeons and the institution as a whole. These findings reveal a benefit of DOTR implementation to elective arthroplasty surgeons and health systems on a larger scale, in the form of increased arthroplasty case volume.

Does Hip Fracture Admitting Service Affect Proper Deep Venous Thrombosis Prophylaxis? An Investigation at a Level 1 Trauma Center.

OBJECTIVE: To examine if rates of appropriate thromboprophylaxis prescribing at the time of discharge would be higher in patients admitted to the orthopaedic service. Second, to see if improvements could be made in the rates of these missed events after a structured intervention. DESIGN: Retrospective Cohort Study, Prospective Interventional. SETTING: Level 1 Academic Hospital. PATIENTS: Two hundred forty-six patients undergoing a hip hemiarthroplasty for femoral neck fracture discharged to an extended care facility. INTERVENTION: A letter was sent to the internal quality control committee detailing our preintervention study. MAIN OUTCOME MEASURE: We looked at the differences among admitting services for missed thromboembolic prophylaxis (TPx) at the time of hospital discharge and rates of appropriate TPx after a structured intervention. RESULTS: No statistically significant differences existed in relation to patient age, gender, body mass index, or postoperative discharge day in the preintervention group. Orthopaedic surgery prescribed adequate TPx at discharge for 76 of 77 patients (98.7%), general trauma surgery for 26 of 30 patients (86.7%), and internal medicine for 85 of 96 patients (86.7%) in the preintervention group. There was a statistically significant difference when comparing adequate TPx between orthopaedic surgery and other services (P < 0.013 and <0.021, respectively). Our postintervention data found a significant decrease in the rates of missed TPx on discharge. In our preintervention sample group compared with our postintervention sample group, we saw a decrease in missed TPx of 5/39 versus 0/43 events (P = 0.021). CONCLUSIONS: We found that a letter sent to all members of a hospital internal quality committee decreased incidences of missed TPx. Specifically, this letter explained the details of our study that kept track of rates of missed TPx among different admitting services. We found that after our intervention, which consisted of a letter and a multidisciplinary discussion, the rate of missed thromboembolic prophylaxis events improved from 5/39 (12%) to 0/43 (0%) (P = 0.021). LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Implementation of a Dedicated Orthopaedic Trauma Room in Hip and Femur Fracture Care: A 17-Year Analysis.

OBJECTIVE: To examine the effects of implementing a dedicated orthopaedic trauma room (DOTR) on hip and femur fracture care. DESIGN: A retrospective cohort study. Setting: Level 1 trauma center. Patients: 2928 patients with femoral neck, pertrochanteric, and femoral shaft and distal femur (FSDF) fractures. INTERVENTION: Implementation of a DOTR. MAIN OUTCOME MEASURES: Hospital length of stay (LOS), emergency department (ED) LOS, intensive care unit (ICU) LOS, and time to operating room (TTOR). RESULTS: Implementation of a DOTR resulted in significant improvement in TTOR for all patient groups ( P < 0.05). We found shorter TTOR for pertrochanteric ( P < 0.001), femoral neck ( P = 0.039), and FSDF groups ( P = 0.046). Total hospital LOS was shorter for patients with pertrochanteric ( P < 0.001) and femoral neck fractures ( P = 0.044). Patients with pertrochanteric hip fractures demonstrated shorter ICU LOS ( P < 0.001). No LOS improvements were observed among patients in the FSDF group. ED LOS was significantly longer in all patient groups ( P < 0.001). CONCLUSIONS: Implementation of a DOTR was associated with shorter TTOR, shorter hospital and ICU LOS, and longer ED LOS. There was a greater number of patients transferred into the investigating institution and fewer patients transferred out. These data support the utility of a DOTR as it relates to an improvement in hospital stay-related outcomes in patients with fractures of the hip and femur. Our results suggest that a DOTR in a Level I trauma hospital is associated with improvement in patient care. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does seasonal variation in orthopaedic trauma volume correlate with adverse hospital events and burnout?

INTRODUCTION: Assessing workload and mitigating burnout risk should be a constant goal within training programs. By using work relative value unit (wRVU) data in a non-elective orthopaedic trauma practice, we investigated seasonal variation in workload on an orthopaedic trauma service at a level I trauma centre. We also investigated whether there was a correlation in seasonal preventable adverse patient safety events (PSEs) and resident Epworth Sleepiness Scale (ESS) scores. MATERIALS AND METHODS: Data on wRVUs were collected over an 8-year period for a single orthopaedic trauma surgeon with a non-elective practice. Monthly wRVU totals were tabulated over this 8-year period and compared with total hospital orthopaedic surgical trauma volume. The total number of wRVUs and surgical cases analysed were 80,955 and 9,928 respectively. A total of 1,560 PSEs and four years of resident ESS scores were analysed. Data on seasonal variations was evaluated for significance utilizing the Kruskal-Wallis test. WRVUs were then compared to total case volume, PSEs, and resident ESS scores using Spearman's correlation coefficients. RESULTS: We found that wRVUs significantly differed by month (P-value < 0.001) and season (P-value < 0.001) with the highest volume occurring in the summer months. Seasonal variation in wRVUs demonstrated a positive linear correlation with total surgical volume (P-value <0.001) and resident reported ESS scores (P-value = 0.001). PSEs were highest in the summer (P = 0.026), but were not correlated with our findings of seasonal variations in orthopaedic volume (P-value = 0.741). CONCLUSION: WRVUs of our single surgeon's orthopaedic trauma practice had a seasonal variation with significantly higher volume during the summer. These findings were representative of seasonal variations in total hospital orthopaedic trauma volume and also demonstrated correlation with objective resident sleepiness scores. PSEs were more frequent in the summer but not correlated with seasonal variation in volume. Burnout poses a risk to patient safety and has been shown to be correlated with increased work volume. These topics are important and applicable to various specialties involved in the care of patients with orthopaedic trauma injuries.

Use of a modified retrograde femoral rod as a custom length tibiotalocalcaneal nail.

There has been increasing interest in the use of hindfoot tibiotalocalcaneal (TTC) nails to treat ankle and distal tibia fractures in select patient populations who are at increased risk for soft tissue complications after open reduction and internal fixation with traditional plate and screw constructs. We describe a technique which uses a retrograde femoral nail as a custom length TTC nail. By using a simple modification of the insertion jig, we are able to achieve safe screw trajectories that allow for robust distal interlocking fixation. Review of implantation in multiple cadaveric specimens demonstrates safe placement of distal screw fixation in the calcaneus without risking injury to important neurovascular structures. Because of the 2-cm incremental length options of this particular device, we are able to achieve supraisthmal fixation in the tibia which may lessen the risk for fracture that may be more likely to occur at the tip of a short TTC nail option. Furthermore, a custom length TTC nail is more costly and also requires advanced notice to acquire for the case; retrograde femoral nails are readily stocked and accessible at our level 1 trauma center. This TTC technique offers anatomic restoration while also offering convenience, instrument familiarity, cost savings, and increased patient safety.

THE USE OF POSTURAL RESTORATION FOR TREATMENT OF CHRONIC ROTATOR CUFF PATHOLOGY: A CASE REPORT.

BACKGROUND AND PURPOSE: Postural Restoration Institute® (PRI) theories and rehabilitation techniques focus on restoring balance to anatomical systems. Common postural asymmetries can present in athletes as dysfunctions and limitations. The purpose of this case report was to examine the use of PRI exercises and theories to address pelvic alignment, along with core stabilization, during treatment of shoulder dysfunction in a collegiate volleyball player. CASE DESCRIPTION: A 22-year-old female volleyball athlete reported unresolved right rotator cuff tendinopathy. She presented with bilateral rib cage flare, anterior pelvic tilt, and bilateral ROM differences in hip and shoulder internal and external rotation. PRI® special test findings included a positive left and right Adduction Drop Test (ADT), positive left Extension Drop, and Hruska Adduction Lift test (left=2, right=3) indicating posterior exterior chain (PEC) pattern of dysfunction. The traditional shoulder rehabilitation program from the previous season was eliminated and a PRI based intervention was performed. Intervention exercises included the 90/90 dead bug diaphragmatic breathing, 90/90 hamstring hip lift, and right sidelying respiratory left adductor pull back. Exercises were performed as three sets of ten diaphragmatic breathing repetitions, a minimum of three times weekly prior to activity. OUTCOMES: Likert scale ratings of pain decreased from a six pre-intervention to two. The left hip gained 10° of internal rotation and the right hip gained 14° of external rotation. Right shoulder internal rotation increased 15°. Hruska Adduction Lift improved to a four bilaterally (right by day 24, and left by day 31). Left extension drop test was negative following day 17. DISCUSSION: PRI® exercises focusing on core and pelvic stability translated to improved hip and shoulder ROM, and decreased shoulder pain associated with rotator cuff tendinopathy. By treating pelvic alignment with the PRI® exercises, the ROM imbalance and pain at the shoulder joint were addressed. CONCLUSION: Incorporating PRI exercises and theories into the rehabilitation program of a volleyball player was useful in addressing underlying imbalances throughout the kinetic chain. LEVEL OF EVIDENCE: 3b.

Non-displaced Femoral Neck Stress Fractures in Young Adults: 7-Year Outcomes of Prophylactic Fixation Versus Nonoperative Treatment.

Retrospectively compare outcomes of prophylactic fixation to nonoperative treatment of incomplete or non-displaced femoral neck stress fractures (FNSF) in young adults. Outcomes of 82 patients (mean age 21.7 years) who were diagnosed with incomplete or non-displaced FNSFs from 2002 to 2015 were compared. Forty-one underwent prophylactic fixation; the remaining were treated without surgery. Fracture characteristics and complications were recorded. Pain scores, modified Harris Hip Scores (mHHS), and Hip Outcome Scores (HOS) were obtained and compared. The average fracture line in the operative group was 67% of the femoral neck width versus 18% in the nonoperative group (p < 0.001). There was no difference in outcome scores between the two groups. Prophylactic fixation of high-risk non-displaced FNSFs resulted in similar outcome scores to non-operative management of lower-risk variants at an average of 7.3 years follow up. No patient in either group progressed to a displaced femoral neck stress fracture. (Journal of Surgical Orthopaedic Advances 29(3):173-176, 2020).

Percutaneous Pedicle Screws in the Obese: Should the Skin Incision Be More Lateral?

OBJECTIVE: To determine if the skin incision for lumbar percutaneous pedicle screws should be more lateral in the obese patient. METHODS: This was a retrospective radiographic analysis of 30 obese and non-obese lumbar spine computed tomography (CT) radiographs comparing the depth of soft tissue along the anatomic axis of the pedicle at L4 and L5. RESULTS: The average distance from the pedicle trajectory on the skin to the lateral border of the pedicle at L4 was 1.4 cm and 3.8 cm in the non-obese and obese groups, respectively. The average distance from the pedicle trajectory on the skin to the lateral border of the pedicle at L5 was 2.1 cm and 4.3 cm in the non-obese and obese groups, respectively; both these differences reached statistical significance, p <0.05. CONCLUSIONS: This radiographic study supports a more lateral start point for percutaneous pedicle screws in obese patients to maintain an anatomic trajectory when inserting percutaneous pedicle screws into the lumbar spine at L4 and L5. If a skin incision is made at only 1 cm lateral to the pedicle in the obese patient, the surgeon often has to place significant traction on the skin edge to lateralize their instrumentation to achieve an appropriate angle of insertion. By making a more lateral skin incision, less manipulation of the skin and soft tissues is needed to maintain an anatomic trajectory of the pedicle screw. Decreasing soft tissue manipulation may decrease wound and instrumentation complications in this at-risk population.

Preoperative Management of Antithrombotics in Arthroplasty.

Antithrombotic therapy is common in the arthroplasty patient population; the preoperative management of chronic antithrombotic medications requires coordination among the medical team. It is estimated that approximately 250,000 or 10% of patients on chronic antithrombotic medication undergo treatment interruption for surgical procedures annually in North America. Although the description of postoperative anticoagulation management after arthroplasty is extensive, orthopaedic literature describing the preoperative management of antithrombotic therapy is lacking. The goal of this guideline is to provide practicing orthopaedic surgeons concise recommendations for the preoperative management of common contemporary antithrombotics in the setting of elective arthroplasty using evidence-based guidelines from other medical specialties. All arthroplasty procedures are considered high bleeding risk in accordance with collaborative AAOS and ACC guidelines. Orthopaedic surgeons should collaborate with their colleagues in cardiology, anesthesia, and other specialties when planning perioperative antithrombotic interruption, particularly in the case of medically complex patients such as those with known risk factors for bleeding and clotting disorders. Resumption of antithrombotic therapy after arthroplasty is beyond the scope of this discussion; this should be performed in accordance with cardiology and anesthesia recommendations.

Angiography and Embolization in the Management of Bleeding Pelvic Fractures.

The use, timing, and priority of angioembolization in the management of bleeding pelvic fractures remain ambiguous. The most common vessels for angioembolization are, in decreasing order, the internal iliac artery and its branches, the superior gluteal artery, the obturator artery, and the internal pudendal artery. Technical success rates for this treatment option range from 74% to 100%. The fracture patterns most commonly requiring angioembolization are the Young and Burgess lateral compression and anterior-posterior compression types and Tile type C. Mortality rates after angioembolization of 16% to 50% have been reported, but deaths are usually related to concomitant injuries. The sensitivity and specificity of contrast-enhanced CT in detecting the need for angioembolization range from 60% to 90% and 92% to 100%, respectively. Angioembolization can be effective in the management of bleeding pelvic fractures, but as with any treatment, the risks of complications must be considered. Availability of angioembolization and institutional expertise/preference for the alternative strategy of pelvic packing influence its use.

Unilateral Dislocation of the Posterior Tibialis Tendon (PTT) and Flexor Digitorum Longus Tendon With Contralateral PTT Subluxation in a Patient With Congenitally Shallow Flexor Groove.

INTRODUCTION: Flexor tendon dislocation from the flexor tendon groove posterior of the medial malleolus has been previously described, and may be difficult to diagnose initially, but is amendable to surgical treatment with good outcomes. We present a unique case of unilateral dislocation of the posterior tibialis and flexor digitorum longus tendons with contralateral flexor digitorum longus subluxation that was treated surgically with a good outcome. CASE PRESENTATION: A 37-year-old active duty male sustained a dislocation and subluxation of the flexor tendons bilaterally after a forced dorsiflexion injury. Bilateral ankle magnetic resonance imaging revealed the injuries that this patient sustained and aided in surgical planning. Surgical Treatment. Bilateral flexor tendon groove deepening with periosteal flap elevation and retinacular repair. DISCUSSION/CONCLUSION: This injury has not been previously described in the literature after a forced dorsiflexion mechanism. Advanced imaging is helpful as this injury may be initially misdiagnosed. This case shows that delayed bilateral reconstruction of the flexor tendon grooves and retinacula are reliable methods for pain relief to allow a patient to return to a physically demanding level of function. LEVELS OF EVIDENCE: Level V.