Faculty Bibliography

OBJECTIVES:To evaluate monetary trends in government (Medicare) reimbursement rates for 20 commonly used orthopedic trauma surgical procedures over a 20-year period. METHODS:The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for the 20 common Current Procedural Terminology (CPT) codes in orthopaedic trauma, and reimbursement data were extracted. All monetary data were adjusted for inflation to 2020 US dollars (USD) using changes to the US Consumer Price Index. Both the average annual and the total percentage change in reimbursement and in Relative Value Units were calculated for all included procedures. RESULTS:After adjusting for inflation, the average reimbursement for all procedures decreased by 30.0% from 2000 to 2020. Total Relative Value Units during this time increased by 4.4% on average. Procedures about the foot and ankle demonstrated the greatest decrease in the mean adjusted reimbursement at -42.6%, whereas procedures about the shoulder and upper extremity demonstrated the smallest mean decrease at 23.7% during the study period. From 2000 to 2020, the adjusted reimbursement rate for all included procedures decreased by an average of 1.5% each year. CONCLUSION:To the best of our knowledge, this is the first study to comprehensively evaluate trends in procedural Medicare reimbursement for orthopaedic trauma. When adjusted for inflation, Medicare reimbursement for included procedures has steadily decreased from 2000 to 2020. Increased awareness and consideration of these trends will be important for policy makers, hospitals, and surgeons to assure continued access to meaningful surgical orthopaedic trauma care in the United States.

BACKGROUND:Nonunion of fractures about the proximal humerus represents a rare and complex problem. The purpose of this study was to evaluate the clinical and functional outcomes following proximal humerus fracture (PHF) nonunion repair using a plate and screw construct with a direct comparison to those experienced following operative fixation of acute PHF using a plate and screw construct. METHODS:Two separate patient cohorts were included in this study. The first consisted of 16 patients diagnosed with a non-united PHF who underwent operative nonunion repair treated with a standard algorithmic approach. The comparison group consisted of 173 patients who achieved union following initial open reduction and internal fixation of an acute PHF treated with a proximal humerus locking plate construct. All patients had at least 12 months of postoperative follow-up. Outcomes were assessed for both groups using American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale (VAS) pain scores, and postoperative shoulder range of motion (ROM). Statistical analyses were used to compare these outcome measures between the two cohorts. RESULTS:The nonunion repair cohort consisted of eleven surgical neck nonunions and five nonunions of both the surgical neck and greater tuberosity. Ten patients had undergone surgical treatment for their original fracture, while six were initially treated non-operatively. All patients had Boileau type 3 sequelae of their proximal humerus fracture. Union was achieved in all patients at a mean of 5.4 months following nonunion repair. Complications included hardware failure requiring revision in two patients (12.5%) and avascular necrosis requiring conversion to anatomic total shoulder arthroplasty following union in one patient (6.3%). The nonunion repair and acute fracture cohorts did not differ with respect to mean ASES scores, VAS pain scores, or active shoulder ROM at any postoperative time point. CONCLUSION/CONCLUSIONS:Surgical repair of PHF nonunion is a viable treatment strategy that can lead to consistent bony healing with outcomes comparable to those of patients who achieve fracture union following initial surgical repair of an acute proximal humerus fracture. Surgeons should be cognizant of mechanical considerations that may lead to early failure.

BACKGROUND:The number of reverse total shoulder arthroplasties (RTSAs) performed annually has increased, and the indications for RTSA have expanded beyond rotator cuff arthropathy to include treatment of complex proximal humeral fractures. No studies exist comparing clinical, functional, and radiographic outcomes in patients receiving RTSA for the treatment of acute fracture vs. those undergoing the procedure for degenerative conditions. This study was designed to fill the void in this knowledge gap. We hypothesized that patients undergoing RTSA for fracture treatment would experience worse clinical outcomes than those undergoing elective RTSA. METHODS:A prospectively collected database was queried for patients undergoing RTSA between 2007 and 2016. Patients were sorted based on the indication for RTSA: treatment of acute proximal humeral fracture vs. "elective" treatment of degenerative conditions of the shoulder. Baseline demographic characteristics, intraoperative and perioperative complications, and clinical, functional, and radiographic outcomes were collected. Only patients with ≥2 years' follow-up were included. Final outcomes were compared between the fracture and elective groups. RESULTS:In total, 1984 patients met the inclusion criteria, with 1876 in the elective group and 108 in the fracture group. Compared with the elective RTSA group, the group undergoing RTSA for fracture treatment was older, was female dominant, and was less likely to have undergone a previous operation on the ipsilateral shoulder. RTSA for fracture was associated with a longer hospital length of stay and greater intraoperative blood loss. The incidence of postoperative adverse events was 7.1% in the elective group vs. 4.6% in the fracture group. Functional outcomes did not differ beyond 1 year or at mean final follow-up > 40 months. CONCLUSION/CONCLUSIONS:Despite differences in patient demographic characteristics, the outcome and complication profiles are similar between patients undergoing RTSA for acute fracture and those indicated for the treatment of degenerative conditions of the shoulder.

OBJECTIVES/OBJECTIVE:To evaluate the outcomes of patients who underwent soft tissue flap coverage during treatment of a tibia fracture nonunion. DESIGN/METHODS:Retrospective analysis on prospectively collected data. SETTING/METHODS:Academic medical center. PATIENTS/PARTICIPANTS/METHODS:157 patients were treated for a fracture nonunion following a tibia fracture over a 15-year period. Sixty-six had sustained an open tibial fracture initially and 25 of these patients underwent soft tissue flaps for their open tibia fracture nonunion. INTERVENTION/METHODS:Manipulation of soft tissue flaps, either placement or elevation for graft placement in ununited previously open tibial fractures. MAIN OUTCOME MEASUREMENTS/METHODS:Bony healing, time to union, ultimate soft tissue status, postoperative complications, and functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA). This group was compared to a group of open tibial fracture nonunions that did not undergo soft tissue transfer. RESULTS:Bony healing was achieved in 24/25 patients (96.0%) who received flaps at a mean time to union of 8.7 ± 3.3 months compared to 39/41 patients (95.1%) at a mean 7.5 ± 3.2 months (p > 0.05) in the non-coverage group. Healing rate and time to union did not differ between groups. At latest follow-up, the flap coverage group reported a mean SMFA index of 17.1 compared to an SMFA index of 27.7 for the non-coverage group (p = 0.037). CONCLUSIONS:Utilization of soft tissue flaps in the setting of open tibia shaft nonunion repair surgery are associated with a high union rate (>90%). Coverage with or manipulation of soft tissue flaps did not result in improved bony healing rate or time to union compared to those who did not require flaps. However, soft tissue flap coverage was associated with higher functional scores at long-term follow-up. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Historically, clavicle fracture repairs have been performed under general anesthesia. However, in the last few years, the combination of an interscalene brachial plexus block and a modified superficial cervical plexus block has been described to provide adequate anesthesia for clavicle fracture surgery, with the added benefit of postoperative analgesia. Members of our anesthesiology department began utilizing this block with sedation for a subset of patients undergoing clavicle fracture fixation in March, 2013. METHODS:This study is a retrospective review of patients who underwent clavicle fracture repair at a single institution between June, 2014 and November, 2017. The decision for type of anesthesia (regional vs. general) was made jointly by the patient, anesthesiologist, and surgeon. Demographic data, relevant perioperative times, and intraoperative pain medication consumption were recorded, and comparisons were made in these variables between the regional and general groups. RESULTS:A total of 110 patients with 110 fractures were included. Fifty-two patients received regional anesthesia only with the combined block, while 58 patients received general anesthesia with an interscalene brachial plexus block. There were no major anesthetic-related complications noted in any patients, and there were no cases in which regional anesthesia had to be converted to general anesthesia because of block failure. Anesthesia start time was significantly longer in the general anesthesia group (29 vs. 20 minutes, p=0.022), as was total case time (164 vs. 131 minutes, p<0.001). Patients in the general group required significantly more intraoperative fentanyl administration (207 vs. 141 mcg, p=0.002). CONCLUSION/CONCLUSIONS:Regional anesthesia using a combined brachial plexus and modified superficial cervical plexus is a reliable, efficacious technique. The combined block appears to be a reasonable alternative to general anesthesia with interscalene brachial plexus block, and may have benefits with regards to anesthesia start time and total case time. LEVEL OF EVIDENCE/METHODS:Level III; Retrospective Cohort Comparison; Treatment Study.

INTRODUCTION:Urinary tract infection (UTI) complications are often attributed to the inappropriate use of urinary catheters. PURPOSE:We sought to examine the effectiveness of a hospital-wide policy aimed at reducing the use of indwelling Foley catheters. METHODS:We completed a retrospective review of prospectively collected data on 577 hip and femur fracture patients aged 55 years and older who were operatively treated at a Level 1 trauma center between October 2014 and March 2019. New standard-of-care guidelines restricting the use of indwelling Foley catheters were implemented starting January 2018, and we compared perioperative outcomes between cohorts. RESULTS:Over a 50% absolute reduction in indwelling Foley catheter use and a near 30% relative reduction in hospital-acquired UTI were achieved. Postpolicy cohort patients without indwelling Foley catheters experienced lower odds of hospital-acquired UTI, higher odds of home discharge, as well as decreased time to surgery, shorter length of stay, and lower total inpatient cost compared with those with indwelling Foley catheters. CONCLUSIONS:The policy of restricting indwelling Foley catheter placement was safe and effective. A decrease in indwelling Foley catheter use led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes.

The purpose of this study was to compare the functional outcomes of diabetic patients who were treated for a fracture nonunion against matched controls. Sixty-one diabetic patients (type 1 or type 2) were identified from a prospective database. This cohort was paired with matched controls and univariate analysis was performed to evaluate for differences in complication rates, time to bony union and functional outcomes at 3, 6, 12, and greater than 24 months post-operatively.The diabetic group was composed of 29 females and 32 males, with an average age of 58 years, and 17 upper extremity nonunions and 43 lower extremity nonunions. Time to bony union, complication rate or functional outcomes at any follow-up time point did not significantly differ between groups. The comorbidity of diabetes mellitus does not lead to worse functional outcomes or increased complications following surgical treatment for a fracture nonunion.

Background/UNASSIGNED:Orthopedic surgeons use radiographs to determine degrees of fracture healing, guide progression of clinical care, and assist in determining weight bearing and removal of immobilization. However, no gold standard exists to determine the progression of healing of humeral shaft fractures treated non-operatively. Purpose/UNASSIGNED:The purpose of this study was to determine whether a scale comparable to the modified Radiographic Union Score for Tibial (RUST) fractures applied to non-operatively treated humeral shaft fractures can increase interobserver reliability in determining fracture healing. Methods/UNASSIGNED:A retrospective review was undertaken by three orthopedic traumatologists and one musculoskeletal radiologist, who evaluated 50 sets of anteroposterior and lateral radiographs, presented at random, of non-operatively treated humeral shaft fractures at various stages of healing from 17 patients. The radiographs were scored using a modified RUST scale called the Radiographic Humerus Union Measurement (RHUM). Observers were blinded to the time from injury. After a 4-week washout period, observers again scored the same radiographs. Observers classified each fracture as either healed or not healed based on the combination of radiographs. Inter- and intraobserver reliability of the RHUM were determined using an intraclass correlation coefficient (ICC). Interobserver reliability of determining a healed fracture was calculated using Cohen's kappa (κ) statistics. A receiver operator characteristic curve was conducted to determine the RHUM score predictive of a fracture being considered healed. Results/UNASSIGNED:ICC demonstrated almost perfect interobserver reliability (ICC, 0.838; ICC 95% CI, 0.765 to 0.896) and intraobserver reliability (ICC range, 0.822 to 0.948) of the RHUM. κ demonstrated substantial agreement between observers in considering a fracture healed (κ = 0.647). Receiver operating characteristic (ROC) curve demonstrated that a RHUM of 10 or higher is an excellent predictor of the observer considering the fracture healed (area under the ROC curve = 0.946, specificity = 0.957, 95% CI specificity, 0.916 to 0.979). Conclusions/UNASSIGNED:This cortical scoring system has excellent interobserver reliability in humeral shaft fractures treated non-operatively. Consistent with previous cortical scoring systems, a RHUM score of 10 or above can be considered radiographically healed.

BACKGROUND:The purpose of this study was to compare the long-term functional status of patients treated surgically for a clavicular nonunion using patients treated either op-eratively or non-operatively for an acute clavicle fracture as a comparison group. METHODS:Twenty consecutive patients treated by a single surgeon for a clavicle fracture nonunion were identified. For comparison of outcomes, acute clavicle fractures were identified from an electronic medical record (EMR) query of the same orthopedic surgeon. Ninety acute clavicle fracture patients were identified and 27 (30%) patients were available for long-term follow-up. Clavicular nonunions were compared to acute clavicle fracture patients in a univariate analysis then a multivariate analysis to analyze clavicle nonunion patients against operative and non-operative acute clavicle fracture patients. The main outcome measures were time to bony union, postoperative complications, visual analog scale (VAS) pain scores, and Short Musculoskeletal Functional Assessment (SMFA) scores at long-term follow-up. RESULTS:There was no difference in time to healing or functional outcomes as assessed by SMFA and VAS pain scores between clavicle nonunion and acute fracture patients. Postoperative complications also did not differ between the groups. CONCLUSIONS:Patients who are treated surgically for clavicular nonunions ultimately regain a similar functional status as patients who are treated either operatively or non-operatively for an acute clavicle fracture and heal acutely.

Olecranon osteotomy allows for improved visualization of the distal humeral articular surface. This study compared the clinical outcomes of 2 methods of olecranon repair following olecranon osteotomy as part of distal humerus fracture repair. This was a retrospective review of distal humerus fractures treated via a transolecranon approach during a 9-year period. In each case, the olecranon osteotomy was fixed with either tension band wiring (TBW) or plate fixation (PF). Patient demographics, injury information, and surgical management were recorded. Measured outcomes included elbow motion, time to osteotomy union, and postoperative complications. Mayo Elbow Performance Index (MEPI) scores were obtained for all patients. Forty-eight patients were included. All patients had intra-articular AO type 13-C2 or 13-C3 distal humerus fractures and underwent open reduction and internal fixation (ORIF) with olecranon osteotomy. Mean documented follow-up was 20.5 months. Twenty-seven patients had fixation of the olecranon osteotomy with TBW, and 21 with PF. Clinically, there were no differences in osteotomy time to union, elbow motion, or MEPI score at final follow-up. However, patients fixed with TBW had greater elbow extension at both 6-month and final follow-up. Complication rates did not differ. Patients undergoing TBW or PF for repair of an olecranon osteotomy following ORIF of intra-articular distal humerus fractures have similar outcomes. Patients undergoing osteotomy PF may experience less terminal elbow extension when compared with those fixed with TBW. Given their similar clinical outcomes, either modality may be considered when selecting a construct for olecranon osteotomy repair as part of comminuted distal humerus fracture repair. [Orthopedics. 2021;44(x):xx-xx.].