Faculty Bibliography

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.

INTRODUCTION/BACKGROUND:The purpose of this study was to combine a validated middle-age and geriatric trauma risk assessment tool (STTGMA) with a novel cost-prediction tool to create an objective triage tool for elderly hip fractures that would guide value-based care initiatives. METHODS:From October 2014 to January 2018, all patients aged ≥55 years who were admitted with a primary diagnosis of hip fracture to a single level 1 trauma center were enrolled. Upon evaluation in the emergency department, demographics, injury severity, and functional status were recorded to calculate the trauma triage score (STTGMARisk). A model to predict high-cost hip fracture patients was created using similar variables (STTGMACost). RESULTS:Three hundred sixty-one consecutive operative hip fracture patients were enrolled. Inpatient mortalities were skewed toward STTGMARisk3 with 21.4% of patients in this high-risk group ultimately expiring during their hospitalization. High-cost patients were correctly skewed to the STTGMACost2 and STTGMACost3 groups with 88.9% of all high-cost operatively treated hip fracture correctly triaged to these cohorts. Statistically significant variations were found in cost within each STTGMARisk group. CONCLUSIONS:A simple risk score calculated upon admission (STTGMARisk and STTGMACost) was able to be used as a triage tool not only to differentiate increased mortality risk but also to predict high-cost patients based on resource utilization in hip fracture patients. LEVEL OF EVIDENCE/METHODS:Prognostic, level II.

Fracture-related infection (FRI) remains a challenging complication that imposes a heavy burden on orthopaedic trauma patients. The surgical management eradicates the local infectious focus and if necessary facilitates bone healing. Treatment success is associated with debridement of all dead and poorly vascularized tissue. Debridement is, however, often associated with formation of a dead space, which provides an ideal environment for bacteria and is a potential site for recurrent infection. Dead space management is therefore of critical importance. For this reason, the use of locally delivered antimicrobials has gained attention, not only for local antimicrobial activity, but also for dead space management. Local antimicrobial therapy has been widely studied in periprosthetic joint infection, without addressing the specific problems of FRI. Furthermore, the literature presents a wide array of methods and guidelines with respect to the use of local antimicrobials. The present review describes the scientific evidence related to dead space management with a focus on the currently available local antimicrobial strategies in the management of FRI. LEVEL OF EVIDENCE:: Level V.

The purpose of this study is to determine when functional outcome no longer improves following tibial plateau fracture. A patient series of operatively treated tibial plateau fractures was reviewed. Patients were evaluated using the short musculoskeletal function assessment (SMFA), range of motion (ROM) assessment, and pain levels at visual analog scale (VAS) at 3, 6, and 12 months postoperatively. Fractures were classified by the Schatzker's classification using preoperative imaging. The case series was divided into two groups based on fracture patterns. Friedman's tests were conducted to determine if there were differences in SMFA, ROM, or VAS throughout the postoperative course. A total of 117 patients with tibial plateau fractures treated operatively, with complete follow-up and without complication, were identified. Seventy-seven patients (65.8%) sustained lateral tibial plateau fractures (Schatzker's I-III). Friedman's test demonstrated significant differences in SMFA (p < 0.0005) and ROM (p < 0.0005) at the three time points. Post hoc analysis demonstrated a significant difference in SMFA (p < 0.0005) and ROM (p = 0.003) between 3 and 6 months postoperatively but no significant difference in either metric between 6 and 12 months postoperatively. Friedman's test demonstrated no significant difference in VAS postoperatively (p = 0.210). Forty patients (34.2%) sustained medial or bicondylar tibial plateau fractures (Schatzker's IV-VI). Friedman's test demonstrated significant differences in SMFA (p < 0.0005) and ROM (p < 0.0005) at the three time points. Post hoc analysis demonstrated a strong trend toward significance in SMFA between 3 and 6 months postoperatively (p = 0.088), and demonstrated a significant difference between 6 and 12 months postoperatively (p = 0.013). ROM was found to be significantly different between 3 and 6 months postoperatively (p = 0.010), but no difference was found between 6 and 12 months postoperatively (p = 0.929). Friedman's test demonstrated no significant difference in VAS postoperatively (p = 0.941). In this cohort, no significant difference in function, ROM, or pain level exists between 6 and 12 months after treatment of lateral tibial plateau fractures. However, there are significant improvements in function for at least 1 year following medial or bicondylar tibial plateau fractures.

Tibial plateau fracture is an injury commonly seen by those who treat trauma around the knee and/or sports-related injuries. In this video article, we present our protocol for surgical treatment of a tibial plateau fracture, which includes definitive fixation with use of a plate-and-screw construct, addressing of all associated soft-tissue injuries at the time of the surgical procedure, filling of any residual voids with bone cement, and early rehabilitation with weight-bearing beginning at 10 to 12 weeks postoperatively. The major steps of the procedure are (1) preoperative planning with digitally templated plates and screws, (2) patient positioning and setup, (3) anterolateral approach toward the proximal aspect of the tibia, (4) submeniscal arthrotomy, (5) booking open of the proximal aspect of the tibia at the fracture site, (6) tagging of the meniscus, (7) fracture reduction and placement of the Kirschner wire, (8) confirmation of reduction with C-arm image intensification, (9) internal fixation with a plate-and-screw construct, and (10) closure.

BACKGROUND:Supracondylar humerus fractures account for two thirds of all hospitalizations for elbow injuries in children. A prevailing assumption exists regarding whether treatment quality varies by surgeon training background. This study compares radiographic outcomes of pediatric supracondylar humerus fractures treated by fellowship trained pediatric orthopedists (PO) and non-pediatric orthopedists (adult traumatologists, AT) with regard specifically to ability to obtain and maintain an operative closed reduction. METHODS:We retrospectively reviewed all pediatric patients between 2007 and 2013 operatively treated for closed extension-type supracondylar humerus fractures. Inclusion criteria included skeletally immature patients with Gartland classification type II and III fractures. Eighty-five cases were included with 37 fractures treated by four fellowship trained adult traumatologists at a level I trauma center and 48 fractures treated by five fellowship trained pediatric orthopedists at a tertiary referral center. Radiographs were analyzed for Baumann's angle and shaft-condylar angle, then statistical comparisons were performed to compare preoperative and postoperative measurements. RESULTS:There was no difference in age, gender, laterality, fracture classification, use of medial pins, or neurovascular injuries between PO and AT (p > 0.05). Change in Baumann's angle (p = 0.61) or shaft-condylar angle (p = 0.87) did not differ between PO and AT. There was no significant difference in operative and postoperative Baumann's angle (p = 0.18 and p = 0.59, respectively) and shaft-condylar angle measurements (p = 0.05 and p = 0.09, respectively) between PO and AT. There was no difference in loss of reduction between the two groups (p = 0.64). CONCLUSIONS:Radiographic analysis of supracondylar humerus fractures showed no significant difference in alignment or loss of reduction when treated by pediatric orthopedists compared to non-pediatric orthopedists. Though it seems that the trend is to send pediatric fracture care to tertiary referral centers it may not be necessary for simple fracture management.

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.

BACKGROUND:Resident burnout-the state of exhaustion, maladaptive detachment, and low sense of accomplishment-is a widely documented phenomenon that affects between 27% and 75% of residents in the United States. To our knowledge, no previous study has examined the relationship between resident burnout and performance on the Orthopaedic In-Training Examination (OITE). The current investigation sought to evaluate whether an association exists between indices of orthopaedic surgery resident burnout as assessed by the Maslach Burnout Inventory (MBI) and performance on the OITE. METHODS:In a cross-sectional study of the orthopaedic surgery residents at a single large academic institution, the MBI was completed by all trainees in May 2016. The results of the 2016 OITE were documented for each resident, including the percentage of correctly answered questions and OITE percentile ranking. To control for individual test-taking skills, United States Medical Licensing Examination (USMLE) Step-1 and Step-2 scores also were documented for each resident. The relationship between the MBI subscale scores and OITE performance was evaluated. RESULTS:The analysis included 100% of the 62 orthopaedic surgery residents in training at our institution. Sixteen (25.8%) of the residents experienced at least moderate emotional exhaustion, while 32 (51.6%) of the residents experienced at least moderate depersonalization and 8 (12.9%) of the residents experienced a moderate sense of impaired personal accomplishment. Postgraduate year (PGY)-2 residents had the highest emotional exhaustion and depersonalization scores compared with residents in other years of training. Each of the 3 MBI indices of burnout was associated with worse OITE performance when controlling for general test-taking ability. CONCLUSIONS:In this study of orthopaedic surgery residents at a large academic training program, burnout was present among residents in all PGYs of training; it was most prevalent during the second year of training. Increased levels of the 3 components of burnout were associated with worse performance on the OITE. While there is a lack of consensus in the existing literature, this study provides additional evidence that burnout is negatively associated with 1 aspect of overall resident performance. CLINICAL RELEVANCE/CONCLUSIONS:Orthopaedic surgery residency training is challenging; residents are tasked to acquire a considerable amount of knowledge, develop complex surgical skills, and hone critical clinical thinking in a relatively short period of time. Identifying modifiable contributors to resident burnout and the development of strategies to promote resident wellness during training are important as we strive toward developing the next generation of capable, competent, and well-balanced orthopaedic surgeons.