Faculty Bibliography

INTRODUCTION/BACKGROUND:The purpose of this study was to demonstrate a novel technology used to measure improvements in quality and value of care for treatment of hip fracture patients. METHODS:A novel value-based triaging methodology uses a risk prediction (risk M) and inpatient cost prediction (risk C) algorithm and has been demonstrated to accurately predict high-risk:high-cost episodes of care. Two hundred twenty-nine hip fracture patients from 2014 to 2016 were used to establish baseline length of stay (LOS) and total inpatient cost for each (16) risk:cost quadrants. Two hundred sixty-five patients between 2017 and 2019 with hip fractures were input into the algorithm, and historical LOS and cost for each patient were calculated. Historical values were compared with actual values to determine whether the value of the inpatient episode of care differed from the 2014 to 16 cohort. RESULTS:When evaluated without risk or cost stratification, the mean actual LOS and cost of the baseline cohort compared with the 2017 to 2019 cohort were 8.0 vs 7.5 days (P = 0.43) and $25,446 vs $29,849 (P = 0.15), respectively. This analysis demonstrates that there was only a small change in value of care provided to patients based on LOS/cost over the studied period; however, risk:cost analysis using the novel methodology demonstrated that for select risk:cost quadrants, value of care measured by LOS/cost improved, whereas for others it decreased and for others there was no change. CONCLUSION/CONCLUSIONS:Risk-cost-adjusted analysis of inpatient episodes of care rendered by a value-based triaging methodology provides a robust method of assessing improvements and/or decreases in value-based care when compared with a historical cohort. This methodology provides the tools to both track hospital interventions designed to improve quality and decrease cost as well as determine whether these interventions are effective in improving value.

Introduction: The purpose of this study is to assess the effect of radial head/ neck injury in association with proximal ulna fractures. Methods: Between 2006 and 2020, 107 patients presented to our academic medical center for treatment of a proximal ulna fracture and were enrolled into an IRB-approved database. Radiographs, injury details, and surgical interventions were retrospectively reviewed. Patients were classified as having an isolated proximal ulna fracture (PU), a PU fracture with an associated radial head dislocation (M"“D), or a Monteggia fracture with an associated radial head fracture (M"“V). Clinical and functional outcomes were assessed at follow-up to determine what differences exist between fracture patterns. Statistics were generated using Chi-squared tests for categorical variables and one-way ANOVA tests for numerical variables. Results: While all patients ultimately healed, time to radiographic healing in the PU cohort was shorter at 3.57 ± 1.7 months when compared to the M"“V cohort (5.67 ± 3.8 months) (p < 0.05). At follow-up, patients in the M"“V cohort had poorer elbow pronation and supination when compared to the PU and M"“D cohorts (p < 0.05). Patients within the PU cohort had fewer complications than those in the M"“D and M"“V cohorts (p < 0.05). No differences were found between the three cohorts in regard to rates of reoperation, non-union, wound infection, and nerve compression (p > 0.05). Conclusion: The Monteggia fracture with a concomitant radial head/neck fracture is a more disabling injury pattern when compared to an isolated proximal ulna fracture and Monteggia fracture without an associated radial head/neck fracture.

INTRODUCTION/UNASSIGNED:The purpose is to investigate the incidence of wound complications for total knee arthroplasty (TKA) following tibial plateau open reduction and internal fixation (ORIF). MATERIALS AND METHODS/UNASSIGNED:A prospective arthroplasty registry was queried for patients with CPT codes for primary TKA, tibial plateau ORIF, removal of hardware (ROH), and diagnosis of post-traumatic arthritis. Patients were included if they had undergone tibial plateau ORIF and subsequent TKA. Chart review was performed to obtain demographic, clinical and post-operative information. RESULTS/UNASSIGNED:Twenty-one patients were identified, with average age of 56.23 ± 13.2 years at time of tibial plateau ORIF and 62.91 ± 10.8 years at time of TKA. Seven (33.3%) patients had a tibial plateau fracture-related infection (FRI). Eight (38.1%) patients underwent ROH prior to TKA. Seven (33.3%) patients' TKA incision incorporated the prior plateau incisions. Eight (36.4%) patients developed wound complications following TKA and 5 (23.8%) developed an acute periprosthetic joint infection (PJI) following TKA and had the plateau incision incorporated into the TKA incision. FRI history did not increase the rate of wound complications but did increase the rate of ROH prior to TKA. CONCLUSIONS/UNASSIGNED:Previous FRI involving tibial plateau repair surgery doesn't correlate with PJI after conversion TKA for post traumatic OA. Surgeon-controlled factors such as staged ROH and incision placement can help reduce the rate of wound complications following TKA performed after tibial plateau ORIF. LEVEL OF EVIDENCE/UNASSIGNED:Prognostic Level IV. SUPPLEMENTARY INFORMATION/UNASSIGNED:The online version contains supplementary material available at 10.1007/s43465-022-00709-1.

OBJECTIVES/OBJECTIVE:To (1) determine the ability of the Fracture Risk Assessment Tool (FRAX) to identify the probability of contralateral hip fractures within 2 years of index fracture and (2) identify independent risk factors for a subsequent hip fracture. DESIGN/METHODS:Retrospective. SETTING/METHODS:Urban, academic medical center. PATIENTS/METHODS:This study included a consecutive series of patients treated for unilateral hip fractures between September 2015 and July 2019. RESULTS:Eight hundred thirty-two consecutive patients were included in the analysis with a mean age of 81.2 ± 9.9 years. Thirty-one (3.7%) patients sustained a contralateral hip fracture within 2 years with these patients sustaining the second fracture at a mean 294.1 days ± 197.7 days. The average FRAX score for the entire cohort was 11.9 ± 7.4, and the area under receiving operating characteristic curve (AUROC) for FRAX score was 0.682 (95% CI, 0.596-0.767). Patients in the high-risk FRAX group had a >7% risk of contralateral hip fracture within 2 years. Independent risk factors for contralateral hip fracture risk included patient age 80 years or older and decreasing BMI. CONCLUSIONS:This study demonstrates the strong ability of the FRAX score to triage patients at risk of subsequent contralateral hip fracture within 2 years. In this high-risk FRAX group, patients age older than 80 years and who have decreasing BMI after their index fracture have a 12.5% increased risk of fracture within 2 years which is 4× higher than the current World Health Organization 10-year 3% hip fracture risk standard used to initiate pharmacologic treatment. Therefore, high-risk patients identified using this methodology should be targeted more aggressively with preventative measures including social, medical, and potentially surgical interventions. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION/BACKGROUND:The purpose of this study was to assess how quality and volume of common orthopaedic care varies across private, municipal, and federal healthcare delivery systems (HDSs). METHODS:Hip and knee arthroplasty, knee and shoulder arthroscopy, and hip fracture repair were audited over a two-year period. Electronic medical records were reviewed for demographics, diagnosis, lengths of stay (LoSs), surgical wait times, inpatient complication, readmission, and revision surgery rates. Multivariate regression controlled for differences in age, sex, diagnosis, and Charlson Comorbidity Index to determine how HDS correlated with surgical wait time, length of stay, complication rates, readmission, and revision surgery. RESULTS:The 5,696 included patients comprise 87.4% private, 8.6% municipal, and 4.0% federal HDSs. Compared with private HDS for arthroplasty, federal surgical wait times were 18 days shorter (95% CI = 9 to 26 days, P < 0.001); federal LoS was 4 days longer (95% CI = 3.6 to 4.3 days, P < 0.001); municipal LoS was 1 day longer (95% CI = 0.8 to 1.4, P < 0.001); municipal 1-year revision surgery odds were increased (odds ratio [OR] = 2.8, 95% CI = 1.3 to 5.4, P = 0.045); and complication odds increased for municipal (OR = 12.2, 95% CI = 5.2 to 27.4, P < 0.001) and federal (OR = 12.0, 95% CI = 4.5 to 30.8, P < 0.001) HDSs. Compared with private HDS for arthroscopy, municipal wait times were 57 days longer (95% CI = 48 to 66 days, P < 0.001) and federal wait times were 34 days longer (95% CI = 21 to 47 days, P < 0.001). Compared with private HDS for fracture repair, municipal wait times were 0.6 days longer (95% CI = 0.2 to 1.0, P = 0.02); federal LoS was 7 days longer (95% CI = 3.6 to 9.4 days, P < 0.001); and municipal LoS was 4 days longer (95% CI = 2.4 to 4.8, P < 0.001). Only private HDS fracture repair patients received bone health consultations. DISCUSSION/CONCLUSIONS:The private HDS provided care for a markedly larger volume of patients seeking orthopaedic care. In addition, private HDS patients experienced reduced surgical wait times, LoSs, and complication odds for inpatient elective cases, with better referral patterns for nonsurgical orthopaedic care after hip fractures within the private HDS. These results may guide improvements for federal and municipal HDSs.

Background/UNASSIGNED:The purpose of this study was to determine the impact of surgeon volume on outcomes following ankle fracture fixation. Methods/UNASSIGNED:Over 7 years, 362 patients who met inclusion criteria (>18 years with rotational ankle fractures) were identified and treated by orthopaedic surgeons at several hospitals within an academic medical center and were retrospectively reviewed. Surgeons that completed less than 24 ankle fixations per year (<90th percentile) during the study period were classified as low-volume (LV) and surgeons completing 24 or more ankle fixations per year (>90th percentile) were classified as high-volume (HV). Chart review was conducted to gather data regarding perioperative, radiographic, inpatient, and long-term outcome data (average 12-month follow-up). Results/UNASSIGNED:< .05). Conclusion/UNASSIGNED:In this single-center study, we found that patients treated by LV surgeons took 30% longer to heal radiographically and had greater reoperation rates than those treated by HV surgeons. Additionally, patients treated by high-volume surgeons had more anatomic postoperative radiographic ankle mortise reductions and was less cost-effective than when performed by high-volume surgeons. Level of Evidence/UNASSIGNED:Level III, retrospective comparative study.

Introduction/UNASSIGNED:The purpose of this study was to investigate the effect of delayed closures, whether delayed primary closure (DPC) or split-thickness skin grafting (STSG), of operatively treated forearm fractures on short-term soft tissue outcomes. Methods/UNASSIGNED:In this retrospective cohort comparative study of two academic-level one trauma centers from 2010 to 2020, adult patients with diaphyseal forearm fractures who underwent open reduction and internal fixation (ORIF) were either closed primarily at index surgery, or underwent delayed closure, either with DPC or with a STSG. Primary outcome measures were soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture-related infection (FRI) at time of final follow-up. Results/UNASSIGNED:Eighty-one patients with 81 diaphyseal forearm fractures underwent ORIF with a mean follow-up of 14.3 months. Forty-one fractures (50.6%) were open injuries. Thirteen patients (16.0%) were unable to be closed primarily and underwent an average of 2.46 ± 0.7 surgeries including final coverage, with an average of 4.31 ± 2.8 days to final coverage. Four patients (30.8%) underwent DPC and 9 (69.2%) underwent STSG. Five (6.6%) patients in the delayed closure group had pre-operative compartment syndrome and underwent formal two-incision fasciotomies. There were no significant differences between delayed versus primary closure in wound healing complication rates, FRI, or radiographic union. Conclusions/UNASSIGNED:Diaphyseal forearm fractures that undergo ORIF have equivalent short-term soft tissue outcomes when closed primarily at index surgery or when closed in a delayed fashion.

PURPOSE/OBJECTIVE:Chronic use of selective serotonin reuptake inhibitors (SSRIs) for the treatment of depression has been linked to an imbalance in bone metabolism leading to osteoporosis. More recently, the use of SSRIs in murine models has been shown to delay bone healing both in vivo and in vitro by decreasing the osteoblastic differentiation and mineralization. The purpose of this study was to evaluate whether or not chronic use of SSRI's in nonunion patients increases their time to union after surgical intervention. METHODS:We retrospectively analyzed 343 patients in a nonunion database to determine which patients were on SSRI medication. Of these patients, 139 could be contacted and of those 102 were not taking SSRIs and 37 were taking SSRIs. Patient's time to union from nonunion surgical intervention between each cohort at our institution was recorded as the primary outcome. Patient's medical comorbidities that could affect union rates such as diabetes and smoking status were also noted. Baseline Short Musculoskeletal Function Assessment (SMFA) index for bother and function were recorded from the time of nonunion surgery as well as last follow-up. RESULTS:Compared to recent census data, we found significantly more patients in the nonunion cohort using SSRIs (26.6%) than patients in the general population using any type of antidepressant (11%). There was no significant difference in the patients' baseline characteristics other than patients on SSRI treatment had a higher body mass index (BMI) and age (p = 0.048 and p = 0.043, respectively). There was no significant difference noted in the fracture types (p = 0.2063). Patients on SSRIs had a higher SMFA bother index and function index on follow-up (p = 0.0103, p = 0.0147). Patients in the SSRI group had a mean time to union from nonunion surgery of 6.1 months compared to 6.0 in patients without SSRI usage (p = 0.74). These did not reach statistical significance when subcohort analysis for long bone fractures was performed for the femur, tibia, and humerus. CONCLUSION/CONCLUSIONS:To our knowledge, this is the first clinical study to investigate the effects of SSRIs on fracture healing. While in vivo and in vitro murine models have shown that SSRIs can have a deleterious effect on osteoblastic activity, our retrospective analysis did not show a significant difference in time to union between patients with chronic SSRI use and patients who have not been on SSRIs. However, this investigation did show a higher incidence of SSRI use in the nonunion cohort when compared to the general population. In the context of the recent animal model study, this may point to a negative effect of SSRI use on the acute fracture healing process.