Faculty Bibliography

OBJECTIVES/OBJECTIVE:Analyze the effectiveness of a BPCI (Bundle Payments for Care Improvement) initiative at a large urban medical center for hip fracture patients included in the bundle payment program with respect to improving patient outcomes and reducing cost DESIGN:: Retrospective cohort SETTING:: Single Academic Institution PATIENTS/PARTICIPANTS:: Patients discharged with the DRG codes 469-470 performed for hip fractures between July 2011 and September 2014 were evaluated. A BPCI initiative focused on optimizing care coordination, patient education, expectations, and minimizing post-acute facility and resource utilization was initiated in October 2013. Patient outcomes prior to the introduction of the BPCI initiative were compared to those who participated in the initiative. INTERVENTION/METHODS:Application of BPCI principles MAIN OUTCOME MEASURES:: length of stay, location of discharge, readmission within 90 days, and 90-day episode of care costs RESULTS:: Sixty-one patients received care prior to the initiative, and forty-four patients were treated with the initiative. The mean length of stay decreased from 6.8 to 5.3 days and the percentage of patients discharged home increased by nearly 10% with the introduction of the BPCI initiative (6.6% vs. 15.9%). There was a 13.1% reduction in total 90-day episode of care cost ($57,546 vs. $49,993, p=0.210) upon introduction of the initiative. There was no significant difference in readmission rate between the two cohorts. CONCLUSION/CONCLUSIONS:This study demonstrates the success of one such program for hip fracture arthroplasty patients aimed at care coordination and minimizing post-acute hospitalization facility care both with respect to improved patient outcomes and substantial cost reduction. LEVEL OF EVIDENCE/METHODS:Therapeutic Level IV.

BACKGROUND:Socioeconomic disparities are an inherent and currently unavoidable aspect of medicine. Knowledge of these disparities is an essential component towards medical decision making, particularly among an increasingly diverse population. While healthcare disparities have been elucidated in a wide variety of orthopaedic conditions and management options, they have not been established among patients who present for treatment of an ununited fracture. The purpose of this study is to answer the following questions: 1) Following surgical management of (fracture) non-unions, are there differences in outcomes between differing ethnic groups? 2) Following surgical management of (fracture) non-unions, are there differences in outcomes between patients with differing education levels? 3) Following surgical management of (fracture) non-unions, are there differences in outcome between patients with differing incomes? METHODS:Between September 2004 and December 2017, operatively treated patients who presented with a long bone fracture non-union were prospectively followed. These patients presented with a variety of fracture non-unions that underwent surgical intervention. Sociodemographic factors were recorded at presentation. Long-term outcomes were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, post-operative complications and physical exam at latest follow up. The SMFA is a 46-item questionnaire, assessing patient functional and emotional response to musculoskeletal ailments. RESULTS:Three-hundred-twenty-nine patients met inclusion criteria. Patients with a lower education had worse long-term functional outcomes (P < 0.001) and increased pain scores (P = 0.002) at latest follow-up. Patients who made less than $50,000 annually had worse long-term functional outcomes (P = 0.002) and reported higher pain scores (P = 0.003) following surgical management of (fracture) non-unions. Multiple linear regression demonstrated education level to be an independent predictor of long-term functional outcomes following surgical management of (fracture) non-unions (B= -0.154, 95% Confidence Interval [CI]=-10.96 to -1.26, P = 0.014). No differences existed in outcomes or pain scores between those of different ethnic groups. No differences existed regarding post-operative complications and time to union between patients of different ethnic groups, educational levels and income status. CONCLUSION/CONCLUSIONS:Patients with lower education levels and individuals who make less than $50,000 annually have worse functional outcomes following surgical management of (fracture) non-unions. Orthopaedic trauma surgeons should therefore be aware of these disparities, and consider early interventions aimed at optimizing patient recovery in these subsets.

The purpose of this study was to analyze the perioperative complication rate and inpatient hospitalization costs associated with hip fractures in patients older than 90 years compared with patients younger than 90 years. Patients 60 years and older with hip fractures treated operatively at 1 academic medical center between October 2014 and September 2016 were analyzed. Patient demographics, comorbidities, length of stay, procedure performed, and inpatient complications were analyzed. Total cost of admission was obtained from the hospital finance department. Outcomes were compared between patients older than 90 years and patients younger than 90 years. A total of 500 patients with hip fractures were included in this study. There were 109 (21.8%) patients 90 years and older and 391 (78.2%) patients 60 to 89 years. There was no difference in fracture pattern, operation performed, Charlson Comorbidity Index, or length of stay between the 2 groups. The mean length of stay for patients 90 years and older with hip fractures was 7.8±4.3 days vs 7.6±4.2 days for the younger cohort (P=.552). There was no observed difference in perioperative complications. Finally, there was no difference in the total mean cost of admission. Patients 90 years and older are at no greater risk for perioperative complications based on age alone. They are also no more likely to require longer or more costly hospitalizations than patients younger than 90 years. [Orthopedics. 201x; xx(x):xx-xx.].

Introduction/UNASSIGNED:Non-traumatic stress fractures of the humerus are often related to a throwing motion. This type of humeral fracture is often due to uncoordinated muscular activity on the humeral shaft. These forces over time may contribute to mid-shaft humeral stress fractures, an injury often referred to as a "throwers fracture." The ultimate strength of bone is decreased when a screw hole is created, as in open reduction and internal fixation repairs (ORIF). Case Report/UNASSIGNED:This case study discusses a patient who underwent plate and screw fixation of a previous stress fracture of the humerus. He continued to remain active and competitive in collegiate baseball, playing the catcher position which leads to a recurrent stress fracture. A combination of low Vitamin D and stress-shielded bone likely resulted in the reinjury. Physicians treating patients with these injuries should be aware of the possibility of refracture if inciting factors are not modified. This case of a non-traumatic humeral shaft stress refracture, following ORIF, has not been described in the literature. Conclusion/UNASSIGNED:The unusual case of a humeral stress refracture following ORIF is presented. A combination of low Vitamin D and stress-shielded bone likely resulted in the reinjury. Physicians treating patients with these injuries should be aware of the possibility of refracture if inciting factors are not modified.

Introduction/UNASSIGNED:Lateral compression type 1 (LC1) pelvic ring fractures make up 63% of all pelvic ring injuries. This fracture pattern is typically seen in older patients. The purpose of this study is to assess the ambulatory status of individuals sustaining LC1 fractures at long-term follow-up and what specific characteristics, if any, effect this status or functional outcomes. Methods/UNASSIGNED:Over a 2-year period, all pelvic ring injury at 2 hospitals within one academic institution was queried. One hundred sixty-one low-energy LC1 pelvic fractures were identified. Results/UNASSIGNED:= .010). Forty-three (86%) patients didn't use an assistive ambulatory device prior to sustaining the LC1 fracture. Seven (14%) patients utilized assistive devices both before and after the LC1 injury. Thirteen (26%) patients, who did not utilize assistive ambulatory devices prior to their injury, necessitated them at long-term follow-up. Discussion/UNASSIGNED:Surgeons should be aware of these associations, as they can implement early interventions aimed at patients at risk, for assistive device use, following LC1 pelvic fractures. Conclusion/UNASSIGNED:More than a quarter of the patients sustaining an LC1 pelvic fracture continue to use an aid for ambulation at long-term follow-up. Older age, complications, and falls within 30 days of this injury are associated with the utilization of an assistive ambulatory device.

Both hemiarthroplasty and total hip arthroplasty have been well described as effective methods of management for displaced femoral neck fractures in the elderly. Acetabular erosion is a common long-term complication of hemiarthroplasty. We present a case in which rapid acetabular erosion occurs within weeks of hemiarthroplasty, ultimately leading to an acetabular fracture and need for revision to total hip arthroplasty. Early and rapid acetabular erosion following hip hemiarthroplasty has not been well documented in current literature. It may lead to acetabular fracture and may be secondary to infectious causes. If encountered, an infection workup should be initiated.

BACKGROUND:The complication rate of locked plating for proximal humerus fractures remains stubbornly high. The purpose of this study was to determine if a learning curve exists with the operative treatment of proximal humerus fractures. METHODS:We prospectively followed 161 consecutive patients with proximal humerus fractures treated by a single surgeon with locked plates from 2005 to 2016. Radiographic data, functional outcomes, and complications from the surgeon's first 81 patients were compared to the subsequent 80 patients. RESULTS:There was no statistical difference in the rates of complications (p = 0.29) or screw penetration (p = 0.19). There were no differences in DASH scores (p = 0.64 to 0.79) or tip-apex distance (p = 0.40). Head shaft angles were slightly smaller in patients treated earlier in the surgeon's career (p = 0.02). DISCUSSION/CONCLUSIONS:While surgeon experience is certainly a favorable quality, there does not appear to be a significant "learning curve" in the treatment of proximal humerus fractures.

OBJECTIVE:To compare the incidence of venous thromboembolism (VTE) amongst patients with pelvic and/or lower extremity fractures directly admitted to our institution versus those transferred from an outside hospital for definitive management. DESIGN/METHODS:Retrospective cohort SETTING:: Tertiary care orthopedic hospital PATIENTS:: 690 patients who received definitive care for a lower extremity fracture at our institution between 2010 and 2017. INTERVENTION/METHODS:Inter-facility transfer for definitive management of pelvic or lower extremity fracture. MAIN OUTCOME MEASUREMENTS/METHODS:VTE incidence, time to surgery RESULTS:: The interfacility transfer (TR) group was comprised of 126 patients and the direct admission (DA) group was comprised of 564 patients. TR patients had a significantly higher incidence of VTE compared to the DA group: 9.5% vs 0.7%, respectively (p < 0.001). Time to surgery was also longer in the TR group compared to the DA group: 3.05 +/- 3.00 days vs. 2.16 +/- 2.42 days, respectively (p = 0.005). Demographics for TR and DA did not significantly differ with regards to age, gender, length of stay, or ASA score. In the TR group, no complete and explicit documentation regarding thromboprophylaxis administration while at the outside facility was found. CONCLUSIONS:Patients undergoing interfacility transfer for definitive management of pelvic and lower extremity fractures are at significantly increased risk for the development of VTE. LEVEL OF EVIDENCE/METHODS:Level III retrospective cohort.

BACKGROUND:The incidence and risk factors of wound-healing complications following rotational ankle fracture surgery are well documented in the literature. However, there is a paucity regarding management options following these complications. The goal of this study was to provide a descriptive analysis of one surgeon's experience managing wound complications in patients who have undergone ankle fracture surgery. METHODS:A total of 215 patients who were operatively treated for an unstable ankle were retrospectively identified. Patient demographics, medical histories, initial injury characteristics, surgical interventions, and clinical follow-up were collected. Twenty-five of these patients developed postoperative wound problems. RESULTS:Of the original cohort of 215 patients, 25 (11.6%) developed wound-healing complications. Their average age was 53.6 ± 18.0 years; there were 12 males (48.0%). Connective tissue/inflammatory disease (odds ratio [OR] 3.9), cardiovascular disease (OR 3.6), and active smoking (OR 3.3) were associated with an increased likelihood of developing postoperative wound complications. With regard to injuries, open fractures (OR 17.9) had the highest likelihood of developing postoperative complications, followed by type 44-C (OR 2.8) and trimalleolar fractures (OR 2.0). CONCLUSION/CONCLUSIONS:Wound complications following open treatment of ankle fractures occurred with an incidence of 11.6% in this series, of which only about half required operative intervention. A third of wounds were managed by orthopaedics in conjunction with plastic surgery. LEVELS OF EVIDENCE/METHODS:Level III: Retrospective comparative study.