Faculty Bibliography

Previous studies have demonstrated no significant difference in overall functional outcomes of patients discharged to a sub acute setting versus home with health services after total joint arthroplasty. These findings coupled with pressure to reduce health care costs and the implementation of a prospective payment system under Medicare have supported the use of home rehabilitation services and the trend towards earlier discharge after hospitalization. While the overall functional outcome of patients discharged to various settings has been studied, there is a relative dearth of investigation comparing postoperative complications and readmission rates between various discharge dispositions. Our study demonstrated patients discharged home with health services had a significantly lower 30day readmission rate compared to those discharged to inpatient rehab facilities. Patients discharged to rehab facilities have a higher incidence of comorbidity and this association could be responsible for their higher rate of readmission.

INTRODUCTION: The purpose of this study was to determine whether development of a hospital-acquired condition (HAC) affected responses to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions. HCAHPS is a national, standardized satisfaction survey. Patient responses form, in part, the basis for Medicare reimbursement to hospitals via the value-based purchasing system established by the Patient Protection and Affordable Care Act of 2010. We hypothesized that patients who developed an HAC would be less satisfied with their care. METHODS: We randomly distributed the HCAHPS survey, a validated, standardized measure of patient satisfaction, to 6,056 patients discharged from our institution for any orthopedic admission over a 2-year period. All patients who develop HACs are logged by our hospital quality assurance monitoring system. We reviewed the HCAHPS database, identified completed surveys associated with patients who had developed an HAC, and compared satisfaction scores between patients with HACs and patients without HACs. Survey scores were normalized to a 100-point scale. Univariate analysis was performed for two global ratings, and six specific satisfaction categories. Subgroup analysis was performed for surgical site infections (SSIs) and venous thromboembolic disease (VTE). RESULTS: A total of 2,876 controls and 159 HAC cases were identified from completed surveys. The cases and controls were similar in terms of race, however, the HAC group contained significantly more women (p < .001). Patients in the HAC group also were, on average, significantly older, with a mean age of 66.84 versus 58.65 (p < .001). There was no difference in satisfaction scores in patients' mean rating of communication by nurses (p = .81), communication by doctors (p = .31), communication about medications (p = .69), pain control (p = .66), the cleanliness of the hospital environment (p = .54), and the quietness of the hospital (p = .589). The mean normalized score for overall satisfaction was 93.99 (out of 100) for controls and 94.84 for HAC cases (p = .61). The mean normalized score for overall willingness to recommend the hospital to others was 90.22 for controls and 90.65 for HAC cases (p = .77). There was no statistically significant difference in satisfaction for patients with SSI versus VTE versus all other HACs (p > .05). DISCUSSION: Performance on HCAHPS is an area that demands hospital attention both to provide patient-centered care and to maximize revenue. Development of an HAC was not associated with decreased satisfaction scores in a population of orthopedic surgery patients at a private, university-affiliated specialty center. The lack of any statistically significant difference in patient satisfaction may be attributable to patient satisfaction with care in response to complications, the decreased sensitivity inherent to using a general satisfaction survey, or a homogeneity among orthopedic surgery patients and their expectations of care.

OBJECTIVES: The purpose of this study was to determine what patient and injury factors are associated with the presence of a meniscus tear in tibial plateau fractures. We also sought to compare functional outcome, pain scores, and range of motion between patient groups with and without meniscal injury. MATERIALS AND METHODS: A total of 99 patients with 101 acute tibial plateau fractures were included in the study cohort. Patients were divided into two groups: those with and without meniscus tears at the time of initial injury. Statistical analysis with Student's t-test for continuous variables and chi square test for categorical variables was performed to compare those with and without a meniscal tear. Logistic regression was performed to identify the variables that predicted the presence of a meniscus tear and repeated ANOVA measures were used to assess functional outcome scores. RESULTS: Fifty-four patients with 56 tibial plateau fractures (55%) were found to have an associated meniscal tear. The average amount of joint depression in this group was 12.3 mm (range: 2.0 to 29.5 mm). The remaining 45 patients with 45 fractures (45%) had an average depression of 5.4 mm (range: 0.0 to 12.8 mm). Degree of tibial plateau depression was the only significant predictor of meniscal injury. CONCLUSIONS: Our findings suggest that amount of depression in tibial plateau fractures is a significant predictor of the occurrence of a meniscus tear with an odds ratio of 1.36. We also found no significant difference in the functional outcome, pain scores, and knee range of motion between the group with and without meniscus tears at the longest follow-up interval. These findings suggest that acute repair of meniscal injury following traumatic fracture of the tibial plateau could produce functional results similar to those patients that did not sustain a meniscus tear.

BACKGROUND CONTEXT: Previous studies have shown improved outcomes associated with higher volume surgeons and hospitals. Revision adult spinal deformity surgery (RASDS) is a particularly high-risk intervention. We aimed to assess complication rates in RASDS by surgeon and hospital operative volume for this entity. PURPOSE: We aimed to assess complication rates in RASDS by surgeon and hospital operative volume for this entity. STUDY DESIGN/SETTING: Analysis of National Inpatient Sample. PATIENT SAMPLE: Adult spinal deformity revision surgery patients, age>50, with in-hospital stays including a spine arthrodesis for a diagnosis of scoliosis from 2003-2009. OUTCOME MEASURES: Complications, mortality, length of stay and hospital charges. METHODS: The 2003-2009 National Inpatient Sample was queried using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for patients age>50 with in-hospital stays including a spine arthrodesis for a diagnosis of scoliosis. Annual surgeon and hospital identifiers were used to allocate records into volume quartiles by number of surgeries performed in that year. Hospitals and surgeons were assigned to a quartile based on the annual volume of ASDS cases. In 2003, hospitals with <=5 procedures and surgeons with<2 were assigned to the first quartile (low-volume), whereas hospitals with >=30 and surgeons with >=11 procedures were assigned to the fourth quartile (high-volume). In 2009, the first quartile included hospitals <=10, and surgeons <=3, and the fourth quartile included hospitals >=44 and surgeons >=18. The primary endpoint was morbidity during the hospital stay. One-way analysis of variance was used to assess continuous measures, chi-square for categorical measures. RESULTS: A total of 9,321 (8774 primaries and 247 revisions) patients in the NIS database met our inclusion criteria. High volume hospitals had a greater mean number of cases annually (58/yr high volume vs 4.7/yr low volume, p<0.001). Mean hospital charges at!

BACKGROUND: The quality of reduction of the syndesmosis is an important factor in the outcome of ankle fractures associated with a syndesmotic injury. The purpose of this study was to directly compare the accuracy of syndesmotic reductions obtained using intraoperative standard fluoroscopic techniques against reductions obtained using three-dimensional imaging of the Iso-C3D fluoroscope. METHODS: We prospectively reviewed imaging studies of patients who were diagnosed as having preoperative or intraoperative evidence of syndesmotic diastasis (on the basis of the fluoroscopic Cotton test and/or a manual external rotation stress test) who underwent syndesmotic fixation at one of two level-I trauma centers. Center A used intraoperative computed tomography (CT) imaging to assess reduction (