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Streamlining orthopaedic trauma surgical care: do all patients need medical clearance?

Cieremans, David A; Gao, John; Choi, Sammy; Lyon, Thomas R; Bosco, Joseph A; Rozell, Joshua C
INTRODUCTION/BACKGROUND:Preoperative medical optimization is necessary for safe and efficient care of the orthopaedic trauma patient. To improve care quality and value, a preoperative matrix was created to more appropriately utilize subspecialty consultation and avoid unnecessary consults, testing, and operating room delays. Our study compares surgical variables before and after implementation of the matrix to assess its utility. METHODS:A retrospective review of all orthopaedic trauma cases 6 months before and after the use of the matrix (2/2021-8/2021) was conducted an urban, level one trauma centre in collaboration with internal medicine, cardiology, anaesthesia, and orthopaedics. Patients were separated into two cohorts based on use of the matrix during the initial orthopaedic consultation. Logistic regressions were performed to limit significant differences in comorbidities. Independent samples t-tests and Chi-squared tests were used to compare means and proportions, respectively, between the two cohorts. RESULTS:In total, 576 patients were included in this study (281 pre- and 295 post-matrix implementation). Use of the matrix resulted in no significant difference in time to OR, LOS, readmissions, or ER visits; however, it resulted in 18% fewer overall preoperative consults for general trauma, and 25% fewer pre-operative consults for hip fractures. Older patients were more likely to require a consult regardless of matrix use. When controlling for comorbidities, patients with renal disease were at higher risk for increased LOS. CONCLUSION/CONCLUSIONS:Use of an orthopaedic surgical matrix to predict preoperative subspecialty consultation is easy to implement and allows for better care utilization without a corresponding increase in complications and readmissions. Follow-up studies are needed to reassess the relationships between matrix use and a potential decrease in ER to OR time, and validate its use.
PMID: 36593366
ISSN: 1434-3916
CID: 5409862

A review of open pelvic fractures with concurrent genitourinary injuries

Tischler, Eric H; Wolfert, Adam J; Lyon, Thomas; Suneja, Nishant
INTRODUCTION/BACKGROUND:Open pelvic fractures (OPFs) are uncommon but potentially lethal traumatic injuries. Often caused by high energy blunt trauma, they can cause severe injury to abdominal and pelvic structures. We sought to conduct a review of the literature in order to ascertain the rates of genitourinary injury and vaginal laceration after OPF and the rates of resulting infection and mortality. METHODS:A review of PubMed was conducted to identify studies reporting the rates of genitourinary injury from OPF. Study characteristics, patient characteristics, and outcomes were collected. The data were pooled, and descriptive statistics were obtained. RESULTS:Eight studies encompassing 343 patients were included. Average age was 35.1 years (10-85.9), 28% were female, and the average Injury Severity Score was 26.5 (4-75). 95.5% of patients had a blunt mechanism of injury. Motor vehicle collision (23.9%), motorcycle accident (19.7%), and pedestrian struck (19.3%) were the most common etiologies. Overall mortality and infection rates were 31.2% and 18.7%, respectively. 19.7% of patients suffered an injury to the genitourinary system, and 32.4% of females sustained a vaginal laceration. DISCUSSION/CONCLUSIONS:OPFs have the potential for extremely high morbidity and mortality. While much research has been done to prevent early mortality from hemorrhage, there is comparatively little research into late mortality stemming from infection and sepsis. Intravenous antibiotics are the mainstay of treatment, and local antibiotics usage has been encouraged. In patients with a vaginal laceration, it is important to provide antibiotic coverage for vaginal flora.
PMID: 36209481
ISSN: 1432-1068
CID: 5351842

Decreasing Post-Operative Opioid Prescriptions Following Orthopedic Trauma Surgery: The "Lopioid" Protocol

Landes, Emma K; Leucht, Philipp; Tejwani, Nirmal C; Ganta, Abhishek; McLaurin, Toni M; Lyon, Thomas R; Konda, Sanjit R; Egol, Kenneth A
OBJECTIVE:To assess the effectiveness of a multimodal analgesic regimen containing "safer" opioid and non-narcotic pain medications in decreasing opioid prescriptions following surgical fixation in orthopedic trauma. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:One urban, academic medical center. SUBJECTS/METHODS:Traumatic fracture patients from 2018 (848) and 2019 (931). METHODS:In 2019 our orthopedic trauma division began a standardized protocol of post-operative pain medications that included: 50 mg of tramadol four times daily, 15 mg of meloxicam once daily, 200 mg gabapentin twice daily, and 1 g of acetaminophen every 6 hours as needed. This multimodal regimen was dubbed the "Lopioid" protocol. We compared this protocol to all patients from the prior year who followed a standard protocol that included Schedule II narcotics. RESULTS:Greater mean MME were prescribed at discharge from fracture surgery under the standard protocol compared to the Lopioid protocol (252.3 vs 150.0; p < 0.001) and there was a difference in the type of opioid medication prescribed (p < 0.001). There was a difference in the number of refills filled for patients discharged with opioids after surgical treatment between standard and Lopioid cohorts (0.31 vs 0.21; p = 0.002). There was no difference in the types of medication-related complications (p = 0.710) or the need for formal pain management consults (p = 0.199), but patients in the Lopioid cohort had lower pain scores at discharge (2.2 vs 2.7; p = 0.001). CONCLUSIONS:The Lopioid protocol was effective in decreasing the amount of Schedule II narcotics prescribed at discharge and the number of opioid refills following orthopedic surgery for fractures.
PMID: 34999901
ISSN: 1526-4637
CID: 5112942

Vaginal Laceration in an Open Pelvic Fracture Case Report: A Novel, Prophylactic Antibiotic Delivery Mechanism [Case Report]

Suneja, Nishant; Tischler, Eric H; Lockwood, Skye; Wolfert, Adam J; Martingano, Daniel; Praditpan, Piyapa; Lyon, Thomas
Introduction/UNASSIGNED:. This case presents a 65-year-old female status post-pedestrian-vehicle struck diagnosed with an open pelvic fracture with extension into the outer one-third of the vaginal wall. The patient was successfully treated with emergent surgical debridement, pelvic stabilization, and internal placement of a novel combination of metronidazole antibiotic gel and vancomycin/tobramycin Polymethyl methacrylate beads. Conclusion/UNASSIGNED:No evidence of infection was observed with the use of topical metronidazole-coated vancomycin/tobramycin Polymethyl methacrylate beads for contaminated open pelvic fracture injury involving the vaginal wall. Further research on antibiotic gels for use in high-risk open fractures is required.
PMID: 34055438
ISSN: 2090-6749
CID: 4890882

Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post-COVID-19 World

Konda, Sanjit R; Ranson, Rachel A; Solasz, Sara J; Dedhia, Nicket; Lott, Ariana; Bird, Mackenzie L; Landes, Emma K; Aggarwal, Vinay K; Bosco, Joseph A; Furgiuele, David L; Gould, Jason; Lyon, Thomas R; McLaurin, Toni M; Tejwani, Nirmal C; Zuckerman, Joseph D; Leucht, Philipp; Ganta, Abhishek; Egol, Kenneth A
OBJECTIVES:(1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING:One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS:One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION:The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS:Inpatient and 30-day mortality, major, and minor complications. RESULTS:Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION:The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
PMID: 32815845
ISSN: 1531-2291
CID: 4574902

Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective

Egol, Kenneth A; Konda, Sanjit R; Bird, Mackenzie L; Dedhia, Nicket; Landes, Emma K; Ranson, Rachel A; Solasz, Sara J; Aggarwal, Vinay K; Bosco, Joseph A; Furgiuele, David L; Ganta, Abhishek; Gould, Jason; Lyon, Thomas R; McLaurin, Toni M; Tejwani, Nirmal C; Zuckerman, Joseph D; Leucht, Philipp
OBJECTIVES/OBJECTIVE:To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN/METHODS:Prospective cohort study SETTING:: Seven musculoskeletal care centers with New York City and Long Island. PATIENTS/PARTICIPANTS/METHODS:138 recent and 115 historical hip fracture patients. INTERVENTION/METHODS:Patients with hip fractures occurring between February 1, 2020 and April 15, 2020 or between February 1, 2019 and April 15, 2019 were prospectively enrolled in an orthopedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs) or COVID negative (C-). MAIN OUTCOME MEASUREMENTS/METHODS:Hospital quality measures, inpatient complications and mortality rates. RESULTS:Seventeen (12.2%) patients were confirmed C+ by testing and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared to Cs and C- cohorts, had: an increased mortality rate (35.3% vs 7.1% vs 0.9%), increased length of hospital stay, a greater major complication rate and a greater incidence of ventilator need postoperatively. CONCLUSIONS:COVID-19 had a devastating effect on the care of hip fracture patients during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in hip fracture patients complicated by COVID-19. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
PMID: 32482976
ISSN: 1531-2291
CID: 4468782

Can We Accurately Predict Which Geriatric and Middle-Aged Hip Fracture Patients Will Experience a Delay to Surgery?

Konda, Sanjit R; Johnson, Joseph R; Kelly, Erin A; Chan, Jeffrey; Lyon, Thomas; Egol, Kenneth A
Introduction/UNASSIGNED:This study sought to investigate whether a validated trauma triage risk assessment tool can predict time to surgery and delay to surgery. Materials and Methods/UNASSIGNED:Patients aged 55 and older who were admitted for operative repair or arthroplasty of a hip fracture over a 3-year period at a single academic institution were included. Risk quartiles were constructed using Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) calculations. Negative binomial and multivariable logistic regression were used to evaluate time to surgery and delay to surgery, respectively. Pairwise comparisons were performed to evaluate 30-day mortality rates and demonstrate the effectiveness of the STTGMA tool in triaging mortality risk. Results/UNASSIGNED:= .046). Discussion/UNASSIGNED:Patients in higher STTGMA quartiles encountered longer time to surgery, greater operative delays, and higher 30-day mortality. Conclusion/UNASSIGNED:Score for Trauma Triage in the Geriatric and Middle-Aged can quickly identify hip fracture patients at risk for a delay to surgery and may allow treatment teams to optimize surgical timing by proactively targeting these patients. Level of Evidence/UNASSIGNED:Prognostic Level III.
PMID: 32821470
ISSN: 2151-4585
CID: 4565592

Who Is the Geriatric Trauma Patient? An Analysis of Patient Characteristics, Hospital Quality Measures, and Inpatient Cost

Konda, Sanjit R; Lott, Ariana; Mandel, Jessica; Lyon, Thomas R; Robitsek, Jonathan; Ganta, Abhishek; Egol, Kenneth A
Purpose/UNASSIGNED:The purpose of this study was 2-fold: 1) to investigate the age-related frequency, demographics and distribution of the middle-aged and geriatric orthopedic trauma population and 2) to describe the age-related frequency and distribution of hospital quality measure outcomes and inpatient cost. Methods/UNASSIGNED:All patients > 55 years of age who required orthopedic, trauma, or neurosurgery consults at 3 hospitals within an academic medical center from 2014 to 2017 were prospectively followed. On initial evaluation, each patient's demographics, injury severity, and functional status were collected. Patients were grouped into low and high-energy mechanism cohorts and divided into 5 groups based on age. Hospital quality measures including length of stay, complications, discharge location, and cost of care was compared between age groups. Data were analyzed using ANOVA and Chi-square tests. Results/UNASSIGNED:A total of 3965 patients were included in this study of which 3268 (82%) sustained low-energy trauma and 697 (18%) sustained high-energy trauma. With increasing age, more patients had more comorbidities, were less likely to be community ambulators, and more likely to use assistive devices (p < 0.05). Patients in older age groups had longer lengths of stay, more complications, were more likely to need ICU level care, and were less likely to be discharged home (p < 0.05). Rates of mortality were also greater in patients of more advanced age in both low and high-energy cohorts, and the calculated risk triage tool (STTGMA) score increased with each age bracket (p < 0.05). Total cost of care differed between age groups in the low-energy cohort (p = 0.003). Conclusion/UNASSIGNED:This epidemiological study provides a clear picture of the frequency and distribution of demographic, physiologic characteristics, outcomes, and cost of care in a middle-aged and geriatric orthopedic trauma population as evaluated by the STTGMA risk tool. Risk profiling of geriatric trauma patients allows for the establishment of baseline norms.
PMID: 32974077
ISSN: 2151-4585
CID: 4606002

Using Trauma Triage Score to Risk Stratify Inpatient Triage, Hospital Quality Measures, and Cost in Middle-Aged and Geriatric Orthopaedic Trauma Patients

Konda, Sanjit R; Lott, Ariana; Saleh, Hesham; Lyon, Thomas; Egol, Kenneth A
OBJECTIVES/OBJECTIVE:Investigate the efficacy of a novel geriatric trauma risk assessment tool (STTGMA) designed to predict inpatient mortality to risk stratify measures of hospital quality and cost of care in middle-aged and geriatric orthopaedic trauma patients. DESIGN/METHODS:Prospective cohort study SETTING:: Academic medical center PATIENTS:: 1592 patients aged 55 and older who were evaluated by orthopaedic surgery in the emergency department between 10/1/2014-9/30/2016. INTERVENTION/METHODS:Calculation of inpatient mortality risk score (STTGMA) using each patient's demographics, injury severity, and functional status. Patients were stratified into minimal, low, moderate, and high-risk cohort groups based on risk of <0.9%, 0.9-1.9%, 1.9-5%, and >5%. MAIN OUTCOME MEASUREMENTS/METHODS:length of stay, complications, disposition, readmission, and cost RESULTS:: 1278 patients (80.3%) sustained low-energy injuries and 314 patients (19.7%) sustained high-energy injuries. The average age was 73.8 ± 11.8 years. The mean length of hospital stay was 5.2 days with a significant difference between the STTGMA risk groups. This risk stratification between groups was also seen in complication rate, need for ICU/SDU care, percentage of patients discharged home, and readmission within 30-days. The mean total cost of admission for the minimal risk group was less than one-third that of the high-risk cohort. CONCLUSIONS:the STTGMA tool is able to risk stratify hospital quality outcome measures and cost. Thus, it is a valuable clinical tool for health care providers in identifying high-risk patients in efforts to continue to provide high-quality resource conscious care to orthopaedic trauma patients. LEVEL OF EVIDENCE/METHODS:Prognostic Level II.
PMID: 31188798
ISSN: 1531-2291
CID: 3930082

Ability of a Risk Prediction Tool to Stratify Quality and Cost of Older Patients with Operative Ankle Fractures

Lott, Ariana; Egol, Kenneth A; Lyon, Thomas; Konda, Sanjit R
OBJECTIVES/OBJECTIVE:To investigate the ability of a validated geriatric trauma risk prediction tool to stratify hospital quality metrics and inpatient cost for middle-aged and geriatric patients admitted from the ED for operative treatment of an ankle fracture. DESIGN/METHODS:Prospective cohort study SETTING:: Single Academic Medical Center PATIENTS:: Patients aged 55 and older who sustained a rotational ankle fracture and were treated operatively during their index hospitalization INTERVENTION:: Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), using patient's demographic, injury severity, and functional status. Patients were stratified into groups based on scores to create a minimal-, low-, moderate-, and high-risk cohort. MAIN OUTCOME MEASUREMENTS/METHODS:length of stay, complications, need for ICU/SDU level care, discharge location, and index admission costs RESULTS:: Fifty ankle fracture patients met inclusion criteria. Mean length of stay was 7.8 ± 5.2 days with a significant difference among the four risk groups (4.6 day difference between low and high risk). 73.1% of minimal risk patients were discharged home compared to 0% of high-risk patients. There was no difference in complication rate or in need for ICU level care between groups. However, high-risk patients had a mean total inpatient cost two times greater than that of minimal risk patients. CONCLUSION/CONCLUSIONS:The STTGMA tool is able to meaningfully stratify older ankle fracture patients requiring operative fixation with regards to hospital quality metrics and cost. This information may allow for efficient targeted reductions in costs while optimizing outcomes. LEVEL OF EVIDENCE/METHODS:Prognostic, Level III.
PMID: 30664055
ISSN: 1531-2291
CID: 3610392