Faculty Bibliography

Patterns of discharge location may be evident based on the "sickness" profile of the patient. This study sought to evaluate the ability of the STTGMA tool, a validated mortality risk index for middle-aged and geriatric trauma patients, to predict discharge location in a cohort of low-energy elderly hip fracture patients, with successful discharge planning measured by readmission rates. Low-energy hip fracture patients aged 55 years and older were prospectively followed throughout their hospitalization. On initial evaluation in the Emergency Department, each patient's age, comorbidities, injury severity, and functional status were utilized to calculate a STTGMA score. Discharge location was recorded with the primary outcome measure of an unsuccessful discharge being readmission within 30 days. Patients were risk stratified into minimal-, low-, moderate-, and high-risk STTGMA cohorts. A p-value of <0.05 was considered significant for all statistical tests. 408 low-energy hip fractures were enrolled in the study with a mean age of 81.3±10.6 years. There were 214 (52.5%) intertrochanteric fractures, 167 (40.9%) femoral neck fractures, and 27 (6.6%) subtrochanteric femur fractures. There was no difference in readmission rates within STTGMA risk cohorts with respect to discharge location; however, among individual discharge locations there was significant variation in readmission rates when patients were risk stratified. Overall, STTGMA risk cohorts appeared to adequately risk-stratify readmission with 3.5% of minimal-risk patients experiencing readmission compared to 24.5% of moderate-risk patients. Specific cohorts deemed high-risk for readmission were adequately identified. The STTGMA tool allows for prediction of unfavorable discharge location in hip fracture patients. Based on observations made via the STTGMA tool, improvements in discharge planning can be undertaken to increase home discharge and to more closely track "high-risk" discharges to help prevent readmissions.

Introduction/UNASSIGNED:The purpose of this study was to analyze the effect of the admitting service on cost of care for hip fracture patients by comparing the cost difference between patients admitted to the medicine service versus those admitted to a surgical service. Methods/UNASSIGNED:value of <.05 as significant. Results/UNASSIGNED:= .034) compared to patients admitted to the medicine service. Discussions/UNASSIGNED:In our urban safety net hospital, hip fracture patients admitted to medicine service had longer lengths of stay and higher total hospitalization costs than patients who were admitted to surgery service. Conclusions/UNASSIGNED:This study highlights that the admitting service should be an area of focus for hospitals when developing programs to provide effective and cost-conscious care to hip fracture patients.

The purpose of this study is to evaluate incidence, preoperative laboratory markers, and outcomes of patients who positively cultured pathogens (PCP) at time of surgery for long bone fracture nonunion. Two-hundred and eighty-eight patients were enrolled in a trauma study on long bone nonunion. Two-hundred and sixteen of those 288 patients were cultured at the time of fracture nonunion surgery. Laboratory data were collected prior to intervention and infectious laboratory markers ordered on patients suspected for infection. Patients were followed for one year. Wound complications, antibiotic use, healing, function, and re-admission for further surgery were assessed. Cultures returned positive on 59 patients (representing 20.5% of the 288 patient cohort or 27.3% of the 216 patients cultured in the operative suite). More PCP's (47.5%; 28 of 59) developed wound complications, with greater mean antibiotic duration and more frequent returns to the OR averaging 1.3 procedures per patient. Twelve-month follow-up was obtained on 249 of the 288 (86.5%) and PCPs reported globally worse function. Patients who PCP at the time of operative management for long bone nonunion was a prognostic indicator of poorer long-term functional outcomes.

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.

OBJECTIVES/OBJECTIVE:What patient characteristics and injury factors predict decreased knee range of motion (ROM) following operative management of tibial plateau fractures? DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Academic medical center. PATIENTS/METHODS:Over 11 years, tibial plateau fractures at a single academic institution were prospectively followed. A total of 266 patients were included in this study. INTERVENTION/METHODS:Surgical repair of tibial plateau fractures and secondary interventions due to arthrofibrosis. MAIN OUTCOME MEASURE/METHODS:Clinical outcomes were evaluated using the Short Musculoskeletal Function Assessment (SMFA) and range of motion (ROM) at 3-month, 6-month and long-term follow-up. Secondary outcomes were considered as the need for a subsequent procedure due to arthrofibrosis. RESULTS:At 3-month follow-up, the mean ROM was 113°. By long-term follow-up (mean=17 months), the mean ROM improved to 125°. Independent predictors of decreased knee ROM were the following: At 3-month follow-up, open fractures (P=0.047), application of a knee spanning external fixator (P=0.026), orthopaedic poly trauma (P=0.003), and tibial spine involvement (P=0.043). At long-term follow-up, non-Caucasian ethnicity (P=0.003), increasing age (P=0.003), and a deep infection (P=0.002). Ten patients (3.7%required a secondary procedure for arthrofibrosis. There was a significant improvement in the knee ROM (P<0.001) and functional outcomes (P=0.004) following the intervention. CONCLUSIONS:At long-term follow-up, independent predictors of decreased knee ROM were non-Caucasian ethnicity, increasing age, and sustaining a post-operative complication of a deep infection. Secondary interventions were reliable treatments for arthrofibrosis. LEVEL OF EVIDENCE/METHODS:Prognostic level III.

Introduction/UNASSIGNED:In response to increasing health-care costs, Centers for Medicare & Medicaid Services has initiated several programs to transition from a fee-for-service model to a value-based care model. One such voluntary program is Bundled Payments for Care Improvement Advanced (BPCI Advanced) which includes all hip and femur fractures that undergo operative fixation. The purpose of this study was to analyze the current cost and resource utilization of operatively fixed (nonarthroplasty) hip and femur fracture procedure bundle patients at a single level 1 trauma center within the framework of a risk stratification tool (Score for Trauma Triage in the Geriatric and Middle-Aged [STTGMA]) to identify areas of high utilization before our hospitals transition to bundle period. Materials and Methods/UNASSIGNED:A cohort of Medicare-eligible patients discharged with the Diagnosis-Related Group (DRG) codes 480 to 482 (hip and femur fractures requiring surgical fixation) from a level 1 trauma center between October 2014 and September 2016 was evaluated and assigned a trauma triage risk score (STTGMA score). Patients were stratified into groups based on these scores to create a minimal-, low-, moderate-, and high-risk cohort. Length of stay (LOS), discharge location, need for Intensive Care Unit (ICU)/Step Down Unit (SDU) care, inpatient complications, readmission within 90 days, and inpatient admission costs were recorded. Results/UNASSIGNED:= .029). The mean total cost of admission for the entire cohort of patients was US$25,446 (US$9725), with a nearly US$9000 greater cost for high-risk patients compared to the low-risk patients. High-cost areas of care included room/board, procedure, and radiology. Discussion/UNASSIGNED:High-risk patients were more likely to have longer and more costly admissions with average index admission costs nearly US$9000 more than the lower risk patient cohorts. These high-risk patients were also more likely to develop inpatient complications and require higher levels of care. Conclusion/UNASSIGNED:This analysis of a 2-year cohort of patients who would qualify for the BPCI Advanced hip and femur procedure bundle demonstrates that the STTGMA tool can be used to identify high-risk patients who fall outside the bundle.

OBJECTIVES/OBJECTIVE:To determine the effect of osteonecrosis (ON) on the clinical and functional outcome after open reduction and internal fixation of proximal humerus fractures. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Academic medical center. PATIENTS/METHODS:Over a 12-year period, patients were screened and identified on presentation to the emergency department or in the clinical office for inclusion in an institutional review board-approved registry. One hundred sixty-five patients with 166 proximal humerus fractures met inclusion criteria. Eight patients developed radiographic evidence of ON (4.8%). INTERVENTION/METHODS:Surgical repair of proximal humerus fractures. MAIN OUTCOME MEASURE/METHODS:Patients were divided into 2 cohorts; 1 cohort being those diagnosed with ON and the other cohort being those who were not. All patients were prospectively followed and assessed for clinical and functional outcomes at the latest follow-up visit (mean = 22.9 months) using the Disabilities of Arm, Shoulder and Hand survey along with ranges of motion of the injured extremity. RESULTS:Average postoperative forward elevation for patients with ON was worse than those without ON (P = 0.002). Additionally, there was a significant difference in Disabilities of Arm, Shoulder and Hand scores at the latest follow-up between the 2 groups (P = 0.026). There was no difference in external rotation or mean length of follow-up between the 2 groups (P > 0.05). CONCLUSIONS:This study demonstrates the negative effects of ON after open reduction and internal fixation of proximal humerus fractures. Those who develop ON have poorer functional and clinical outcomes as compared with patients without ON. Consequently, the development of ON can be used as a predictor of poor outcomes. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.