Faculty Bibliography

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.

Objectives/UNASSIGNED:To quantify radiographic changes observed in humeral shaft frctures throughout course of treatment with functional bracing. Design/UNASSIGNED:Retrospective cohort study. Setting/UNASSIGNED:Level 1 Trauma Center and affiliated Tertiary Care Center. Patients/UNASSIGNED:72 retrospectively identified patients with fracture of the humeral diaphysis. Intervention/UNASSIGNED:Application of functional brace with radiographs obtained immediately after brace application and at 1 week, 2 weeks, 3 weeks, 6 weeks, 3 months, 6 months and 12 month follow-up.Main Outcome Measure: Fracture angulation, measured in the coronal and sagittal planes. Results/UNASSIGNED:522 radiographs from 72 patients were critically reviewed. All fractures were followed to healing. Sixty-six patients (92%) successfully healed their fractures with non-operative treatment. The average angulation on immediate post-brace X-ray was 12 degrees varus ad 7 degrees procurvatum. At final follow-up, average coronal angulation was 14 degrees and 4 degrees procurvatum. Fracture angulation changed a mean 2 degrees in the AP plane and 3 degrees in the sagittal plane over the course of care. Linear regression determined fracture angulation proceeds toward both varus and recurvatum at 0.01 degrees per day. Conclusion/UNASSIGNED:Humeral shaft fractures treated non-operatively heal with minimal change in angulation after brace application. If angulation on the post-brace radiograph is acceptable and there is no history of repeat trauma and no cosmetic deformity, radiographs may be utilized less frequently. Patients should be evaluated via history and physical exam at follow-up prior to the 6-week point, at which time regular radiographs (6 week, 3 month, 6 month, 12 month) should commence.

OBJECTIVES/OBJECTIVE:Analyze the effectiveness of a BPCI (Bundle Payments for Care Improvement) initiative for patients who would be included in a future potential Surgical Hip and Femur Fracture Treatment (SHFFT) bundle. DESIGN/METHODS:Retrospective cohort SETTING:: Single Academic Institution PATIENTS/PARTICIPANTS:: Patients discharged with operative fixation of a hip or femur fracture (DRG codes 480-482) between 1/2015-10/2016 were included. A BPCI initiative based upon an established program for BPCI Total Joint Arthroplasty (TJA) was initiated for patients with hip and femur fractures in January 2016. Patients were divided into non-bundle (care before initiative) and bundle (care with initiative) cohorts. INTERVENTION/METHODS:Application of BPCI principles MAIN OUTCOME MEASURES:: Length of stay, location of discharge, readmissions RESULTS:: 116 patients participated in the "institutional bundle," and 126 received care prior to the initiative. There was a trend towards decreased mean length of stay, (7.3 ± 6.3 days vs. 6.8 ± 4.0 days, p=0.457) and decreased readmission within 90 days (22.2% vs. 18.1%, p=0.426). The number of patients discharged home doubled (30.2% vs. 14.3%, p=0.008). There was no difference in readmission rates in bundle vs. non-bundle patients based on discharged home status; however, bundle patients discharged to SNF trended towards less readmissions than non-bundle patients discharged to SNF (37.3% vs. 50.6%, p=0.402). Mean episode cost reduction due to initiative was estimated to be $6,450 using Medicare reimbursement data. CONCLUSION/CONCLUSIONS:This study demonstrates the potential success of a BPCI initiative at one institution in decreasing post-acute care facility utilization and cost of care when used for a hip and femur fracture population. LEVEL OF EVIDENCE/METHODS:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:Determine if a novel inpatient mortality risk assessment tool designed to be calculated in the emergency department (ED) setting can risk stratify patient reported functional outcomes and mortality at one year. DESIGN/METHODS:Prospective cohort SETTING:: Academic level one trauma center PATIENTS:: 685 patients >55 years old who were orthopaedic surgery consults or trauma surgery consults in the ED between 10/1/2014 and 9/30/2015. INTERVENTION/METHODS:Calculation of validated trauma triage score (STTGMA) using each patient's demographics, injury severity, and functional status MAIN OUTCOME MEASUREMENTS:: mortality, EQ-5D questionnaire, and percent return to baseline function since their hospitalization at one-year post hospitalization. RESULTS:45 (6.6%) patients died within the year following hospitalization. Of remaining 639 patients available for follow-up, 247 (38.7%) were successfully contacted. There was no observed difference between patients who were successfully contacted and those who were not. The mean STTGMA score was 2.1 ± 3.6%. Patients reported on average a 76.4 ± 27.5% return to baseline function. When comparing patients between risk groups, there was a significant difference in EQ-5D scores and percent return to baseline. Kaplan-Meier survival curve shows that high risk patients had pronounced decreased survival within the initial days after discharge compared to other cohorts. CONCLUSION/CONCLUSIONS:This study demonstrates that patients identified with the STTGMA tool as having an increased risk of inpatient mortality following trauma correlate with poorer functional outcomes at one year. The STTGMA risk score is also a valuable tool to stratify risk of mortality up to one year following discharge. LEVEL OF EVIDENCE/METHODS:Level IV, Prognostic.

Sharps-related injuries represent a significant occupational hazard to orthopedic surgeons. Despite increased attention and targeted interventions, evidence suggests that the majority of incidents continue to go unreported. The purpose of this study was to examine the incidence, attitudes, and factors that affect the reporting of sharps injuries among orthopedic surgery residents at a large academic teaching hospital in an effort to increase reporting rates and design effective interventions. This study administered an anonymous cross-sectional survey regarding intraoperative sharps exposures to current orthopedic house staff, with an 87% (54/62) response rate. Overall, 76% of surveyed residents (41/54) had at least one sharps exposure during residency. The majority of these incidents (55%) were never reported. The most common reason cited for not reporting was a "perception of low risk." Residents whose exposures were witnessed by others on the surgical team were more likely to report the incident (57% vs. 23%, p = 0.043), suggesting that peer pressure acts to improve reporting rates. While the implementation of a "needlestick hotline" and increased education has led to improved reporting rates at our institution, further improvements aimed at reducing unwitnessed incidents, and therefore unreported incidents, could comprise an increased emphasis on surgical team vigilance, positive peer pressure, the incorporation of sharps-specific surgical debriefing statements and anonymous tip lines.