Faculty Bibliography

OBJECTIVES/OBJECTIVE:To identify which factors are predictive of surgical site infection in upper extremity fractures, and to assess whether the timing of operative debridement influences infection risk. DESIGN/METHODS:Retrospective database review. SETTING/METHODS:Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. PATIENTS/METHODS:Patients in the NSQIP database with fractures involving the upper extremity. INTERVENTION/METHODS:Surgical management of upper extremity fracture, including operative debridement for open injuries. MAIN OUTCOME MEASUREMENTS/METHODS:Surgical site infection, including both superficial and deep infections. RESULTS:A total of 22,578 patients were identified, including 1298 patients with open injuries (5.7% of total). The overall wound infection rate was 0.79%. Patients with open injuries were found to have a higher incidence of infection compared with those with closed injuries (1.7% vs. 0.7%, P < 0.001). Independent risk factors for 30-day infection included open fracture diagnosis, obesity, smoking, and American Society of Anesthesiolgists class >2 (all P < 0.05). Of patients with open fractures, 79.7% were taken expediently to the operating room. The rate of infection did not differ based on whether surgery was performed expediently or not (1.8% vs. 1.1%, P = 0.431). CONCLUSIONS:Based on an analysis of the NSQIP database, the overall risk of surgical site infection following intervention for open or closed upper extremity fractures remains low. Risk factors for infection include open injury, obesity, and cigarette smoking. There was no difference in the infection rate based on the urgency of operative debridement. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:To determine whether a validated trauma triage tool can identify which middle-aged and geriatric trauma patients with tibial shaft and plateau fractures are at risk for costly admissions and poorer hospital quality measures. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Level 1 trauma center. PATIENTS/PARTICIPANTS/METHODS:64 patients over the age of 55 hospitalized with isolated tibial shaft or plateau fractures. INTERVENTION/METHODS:Patients with either isolated tibial plateau fractures or tibial shaft fractures over a three year period were prospectively enrolled in an orthopedic trauma registry. Demographic information, injury severity, and comorbidities were assessed and incorporated into the STTGMA score, a validated trauma triage score that calculates inpatient mortality risk upon admission. Patients were then grouped into tertiles based on their STTGMA score. MAIN OUTCOME MEASUREMENTS/METHODS:Length of stay, complications, discharge location, and direct variable costs. RESULTS:64 patients met inclusion criteria. 33 (51.6%) patients presented with tibial plateau fractures and 31 (48.4%) with tibial shaft fractures. The mean age was 66.7 ± 10.2 years. Mean length of stay was significantly different between risk groups with a mean of 6.8 ± 4 days (p<0.001). While 19 (90.5%) of minimal risk patients were discharged home, only 7 (33.3%) and 5 (22.7%) of moderate and high-risk patients were discharged home, respectively (p<0.001). Higher risk patients experienced a significantly greater number of complications during hospitalization but had no differences in the need for ICU level care (p=0.027 and p=0.344, respectively). The total cost difference between the lowest and highest risk group was nearly 50% ($14070 ± 8056 vs $25147 ± 14471, mean difference $11077; p=0.022). CONCLUSION/CONCLUSIONS:Application of the STTGMA triage tool allows for prediction of key hospital quality measures and cost of hospitalization that can improve clinical decision-making. LEVEL OF EVIDENCE/METHODS:Prognostic Level III.

The SARS-COV-2 (COVID-19) pandemic has placed unprecedented challenges on the health care system in the United States with New York City at its epicenter. By the end of the 8 week (4/23/2020) since the virus's emergence in New York City, there have been 142,432 confirmed COVID-19 cases and 10,977 deaths attributed to complications from COVID-19-related illnesses. Secondary to policies enacted by the New York State government to limit spread of the virus, Orthopedic Surgery departments at hospitals around the area have witnessed an abrupt change in clinical demands. At a local level one trauma hospital in Queens, New York, Orthopedic Surgery elective cases have been cancelled, trauma consult volume has experienced a sharp decline, and both residents and attendings have been repurposed to meet the new clinical demands of this medical crisis. Our own orthopedic surgery service has adopted care for patients normally admitted to an internal medicine service in a novel Ortho-Medical COVID-19 management team. We prepared this primer to make our experience with caring for COVID-19 patents available as a reference for other surgical subspecialty services preparing to adjust the clinical focus of their hospital teams during this or future pandemics. LEVEL OF EVIDENCE:: Level V.

INTRODUCTION/BACKGROUND:Burnout is an occupational hazard for physicians at all stages of training and medical practice. The purpose of the current study was to determine whether residency factors, with the use of an activity monitor, including the amount of exercise, have any impact on burnout among orthopaedic surgery residents in varying years of training. METHODS:Orthopaedic residents at a single institution were recruited immediately before beginning a new clinical rotation and followed for four weeks. On enrollment, the participants were given a wrist-worn activity monitor (Fitbit Flex) and instructed on its use for tracking physical activity. REDCap was used to collect burnout levels (as assessed by using the Maslach Burnout Inventory and the Patient Health Questionnaire-9), which were completed a total of five times, once at enrollment and weekly during the study period. RESULTS:Twenty-seven residents were enrolled, including 13 junior residents (interns and second years) and 14 senior residents (third, fourth, and fifth years). Seven residents were on fracture rotations, whereas 20 were not. As measured by using the Maslach Burnout Inventory, juniors were more emotionally exhausted (P = 0.01) and depersonalized (P = 0.027). No difference in the objective physical activity data as measured by using the Fitbit Flex and no difference in the self-reported hours of sleep were observed. Residents on orthopaedic trauma rotations also reported significantly higher rates of emotional exhaustion and depersonalization (P < 0.001) than other residents and were more physically active on average (P < 0.030). DISCUSSION/CONCLUSIONS:Although depersonalization and depression are common symptoms seen among orthopaedic surgery residents, this study demonstrated that quality of life improves markedly as they progress through their residency training. Residents on orthopedic trauma rotations have greater levels of emotional exhaustion and depersonalization. This pilot study suggests that burnout prevention programs should begin at the start of training to provide residents with strategies to combat and then reinforced while on orthopaedic trauma rotations. LEVEL OF EVIDENCE/METHODS:Level III Diagnostic Study.

Introduction/UNASSIGNED:Rising costs of post-acute care facilities for both the patient and payers make discharge home after hospital stay, with or without home help, a favorable alternative for all parties. Our objectives were to assess the effect of marital status, a large source of social support for many, on disposition following hospital stay. Methods/UNASSIGNED:Patients were prospectively entered into an institutional review board-approved, trauma database at a large, academic medical center. Patients aged 55 years or older with any fracture injury between 2014 and 2017 were included. Retrospectively, their relationship status was recorded through review of patient records. A status of "married" was separated from those with a status self-reported as "single," "divorced," or "widowed." Multinomial logistic regression was used to assess whether discharge location differs by marital status while controlling for demographics and injury characteristics. Results/UNASSIGNED:Of 1931 patients, 8.3% were divorced, 29.9% were single, 20.0% were widowed, and 41.8% were married. There was a significant correlation between discharge disposition and marital status. Single patients had 1.71 times, and widowed patients had 1.80 times, the odds of being discharged to a nursing home, long-term care facility, or skilled nursing facility compared to married patients after controlling for age, gender, Score for Trauma Triage in the Geriatric and Middle-Aged score, and insurance type. Additionally, single and widowed patients experienced 1.36 and 1.30 times longer length of hospital stay than their married counterparts, respectively. Discussion/UNASSIGNED:Patients who are identified as "single" or "widowed" should have early social work intervention to establish clear discharge expectations. Early intervention in this way would allow time for contact with close, living relatives or friends who may be able to provide sufficient support so that patients can return home. Increasing home discharge rates for these patients would reduce lengths of hospital stay and reduce post-acute care costs for both patient and payers without materially altering unplanned readmission rates.

PURPOSE/OBJECTIVE:The purpose of this study is to determine if the radiographic humerus union measurement (RHUM) is predictive of union in humeral shaft fractures treated nonoperatively. METHODS:All patients with long bone fracture nonunion presenting to a single surgeon were enrolled in a prospective registry. This registry was queried to identify patients with humeral shaft fractures treated nonoperatively and developed nonunion. The nonunion cohort was matched to a three to one gender- and age-matched control group that were treated nonoperatively for a humeral shaft fracture and achieved union. Two fellowship-trained orthopedic traumatologists blinded to eventual union scored radiographs obtained 12 weeks after injury using the RHUM. A binomial logistic regression determined the effect of the RHUM on the likelihood of developing union. RESULTS:Nine patients with humeral shaft fractures treated nonoperatively with radiographs 12 weeks after injury that developed nonunion were identified. These patients were matched to 27 controls. Logistic regression demonstrated the RHUM was a significant predictor of healing 12 weeks after humeral shaft fracture treated nonoperatively (p = 0.014, odds ratio 9.434, 95% CI for OR 1.586-56.098). All patients with RHUM below 7 went on to nonunion. All patients with RHUM above 8 healed. Three of seven patients (43%) with RHUM of 7 or 8 healed. CONCLUSION/CONCLUSIONS:The RHUM demonstrated an increased likelihood of achieving union 12 weeks after injury. Orthopedic surgeons can counsel patients that fractures with RHUM scores of 6 or below are in danger of developing nonunion and can target interventions appropriately.

BACKGROUND:The purpose of this study was to compare narcotic use in the 90-day postoperative period across orthopaedic trauma, spine, and adult reconstruction patients and examine whether patient-reported pain scores at discharge correlate with narcotic use during the 90-day postoperative period. METHODS:Electronic medical record query was done between 2012 and 2015 using diagnosis-related groups for spine, adult reconstruction, and trauma procedures. Demographics, length of stay (LOS), visual analog scale pain scores during hospitalization, and narcotics prescribed in the 90-day postoperative period were collected. Multivariate analysis and linear regression were done. RESULTS:Five thousand thirty patients were analyzed. Spine patients had the longest LOS, highest mean pain during LOS, and were prescribed the most morphine in the 90-day postoperative period. Linear regression revealed that pain scores at discharge markedly influence the quantity of narcotics prescribed in the 90-day postoperative period. DISCUSSION/CONCLUSIONS:Patient-reported pain at hospital discharge was associated with increased narcotic use in the 90-day postoperative period.

OBJECTIVES/OBJECTIVE:To evaluate the causes of 30-day readmissions following orthopedic trauma surgery and classify them based on their relation to the index admission. DESIGN/METHODS:Retrospective chart review. SETTING/METHODS:One large, academic medical center. PARTICIPANTS/METHODS:Patients admitted to a large, academic medical center for a traumatic fracture injury over a nine-year period. INTERVENTION/METHODS:Assignment of readmission classification. MAIN OUTCOME MEASUREMENTS/METHODS:Readmissions within 30 days of discharge were identified and classified into: orthopedic complications; medical complications; and non-complications. A chi-square test was performed to assess any difference in the proportion of readmissions between the hospital-reported readmission rate and the orthopedic complication readmission rate. RESULTS:1,955 patients who were admitted between 2011-2018 for an acute orthopedic trauma fracture injury were identified. Eighty-nine patients were readmitted within 30 days of discharge with an overall readmission rate of 4.55%. Within the 30-day readmission cohort, 30 (33.7%) were the direct result of orthopedic treatment complications, 36 (40.4%) were unrelated medical conditions, and 23 (25.8%) were non-complications. Thus, the readmission rate directly due to orthopedic treatment complications was 1.53%. A chi-square test of homogeneity revealed a statistically significant difference between the hospital-reported readmission rate and the orthopedic-treatment complication readmission rate, p < .0005. CONCLUSION/CONCLUSIONS:The use of 30-day readmissions as a measure of hospital quality of care overreports the number of preventable readmissions and penalizes surgeons and hospitals for caring for patients with less optimal health. LEVEL OF EVIDENCE/METHODS:Diagnostic Level III.