Racial Disparities Exist in 90-Day Unplanned Return to the Emergency Department Following Orthopaedic Trauma Surgery.

OBJECTIVES: Racial disparities in healthcare outcomes exist, including in orthopaedic trauma care. The aim of this study was to determine the impact of race, social deprivation, and payor status on 90-day emergency department (ED) revisits among orthopaedic trauma surgery patients at a Level 1 trauma academic medical center. DESIGN: Retrospective chart review analysis. SETTING: Level 1 trauma academic center in Durham, NC. PATIENT SELECTION CRITERIA: Adult patients undergoing orthopaedic trauma surgery between 2017 and 2021. OUTCOME MEASURES AND COMPARISONS: The primary outcome of this retrospective cohort study was 90-day return to the ED. Logistic regression analysis was performed for variables of interest [race, social deprivation (measured by the Area Deprivation Index), and payor status] separately and combined, with each model adjusting for distance to the hospital. Results were interpreted as odds ratios (ORs) of 90-day ED revisits comparing levels of the respective variables. Statistical significance was assessed at α = 0.05. RESULTS: A total of 3120 adult patients who underwent orthopaedic trauma surgery between 2017 and 2021 were included in the analysis. Black race (OR = 1.47; 95% confidence interval [CI]: 1.17-1.84, P < 0.001) and Medicaid coverage (OR = 1.63, 95% CI: 1.20-2.21, P = 0.002) were significantly associated with higher odds of return to ED compared with non-Black or non-Medicaid-covered patients. While ethnic minority (Hispanic/Latino or non-White) was statistically significant while adjusting only for distance to the hospital (OR = 1.23, 95% CI: 1.00-1.50, P = 0.047), it was no longer significant after adjusting for the other sociodemographic variables (OR = 1.13, 95% CI: 0.91-1.39, P = 0.27). The weighted Area Deprivation Index was not associated with a difference in odds of return to ED in any adjusted models. CONCLUSIONS: The results highlight the presence of racial and socioeconomic disparities in ED utilization, with Black race and Medicaid coverage significantly associated with higher odds of return to the ED. Future research should delve deeper into comprehending the root causes contributing to these racial and socioeconomic utilization disparities and evaluate the effectiveness of targeted interventions to reduce them. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evaluating the risk of return to the operating room across all elective orthopaedic procedures.

BACKGROUND: Although elective procedures have life-changing potential, all surgeries come with an inherent risk of reoperation. There is a gap in knowledge investigating the risk of reoperation across orthopaedics. We aimed to identify the elective orthopaedic procedures with the highest rate of unplanned reoperation and the reasons for these procedures having such high reoperation rates. METHODS: Patients in the NSQIP database were identified using CPT and ICD-10 codes. We isolated 612,815 orthopaedics procedures from 2018 to 2020 and identified the 10 CPT codes with the greatest rate of unplanned return to the operating room. For each index procedure, we identified the ICD-10 codes for the reoperation procedure and categorized them into infection, mechanical failure, fracture, wound disruption, hematoma or seroma, nerve pathology, other, and unspecified. RESULTS: Below knee amputation (BKA) (CPT 27880) had the highest reoperation rate of 6.92% (37 of 535 patients). Posterior-approach thoracic (5.86%) or cervical (4.14%) arthrodesis and cervical laminectomy (3.85%), revision total hip arthroplasty (5.23%), conversion to total hip arthroplasty (4.33%), and revision shoulder arthroplasty (4.22%) were among the remaining highest reoperation rates. The overall leading causes of reoperation were infection (30.1%), mechanical failure (21.1%), and hematoma or seroma (9.4%) for the 10 procedures with the highest reoperation rates. CONCLUSIONS: This study successfully identified the elective orthopaedic procedures with the highest 30-day return to OR rates. These include BKA, posterior thoracic and cervical spinal arthrodesis, revision hip arthroplasty, revision total shoulder arthroplasty, and cervical laminectomy. With this data, we can identify areas across orthopaedics in which revising protocols may improve patient outcomes and limit the burden of reoperations on patients and the healthcare system. Future studies should focus on the long-term physical and financial impact that these reoperations may have on patients and hospital systems. LEVEL OF CLINICAL EVIDENCE: IV.

Major Metropolitan Area COVID-19 - Positive Patients Undergoing Emergency and Elective Orthopaedic Surgeries: A Case-matched Control Study.

The SARS-CoV-2 pandemic affected surgical management in Orthopaedics. This study explores the effect of COVID-19-positive patients on time to surgery from admission, total time spent in preoperative preparation, costs of orthopaedic care, and inpatient days in COVID-19-positive patients. The authors' case-matched study was based on the surgeon, procedure type, and patient demographics. The authors reviewed 58 cases, 23 males and 35 females. The results for the COVID-19-positive and -negative groups are time to admission (362.9; 388.4), time in preparation (127.8; 122.3), inpatient days to surgery (0.2; 0.2), and orthopaedic cost ($81,938; $86,352). With available numbers, no significant difference could be detected for inpatient days until surgery, any associated time to surgery, or orthopaedic costs for operating on COVID-19-positive patients during the pandemic. Perceived increased time and cost of care of COVID-19-positive patients were not proven in this study. (Journal of Surgical Orthopaedic Advances 33(1):014-016, 2024).

Automating Patient-reported Data Collection: Does it Work?

OBJECTIVE: There are several electronic patient-reported outcomes (ePROs) vendors that are being used at institutions to automate data collection. However, there is little known about their success in collecting patient-reported outcomes (PROs) and it is unknown which patients are more likely to complete these surveys. In this study, we assessed rates of PRO completion, as well as determined factors that contributed to the completion of baseline and follow-up surveys. METHODS: We queried our ePRO platform to assess rates of completion for baseline and follow-up surveys for patients from October 2019 to June 2022. All baseline surveys were administered before pediatric orthopaedic procedures, and follow-up surveys were sent at 3 months, 6 months, 1 year, and 2 years after surgery to patients with baseline data. Descriptive statistics were used to summarize the data. Univariate and multivariate analyses were performed to assess differences in patients who did and did not complete surveys. RESULTS: This study included 1313 patients during the study period. Baseline surveys were completed by 66% of the cohort (n = 873 patients). There was a significant difference in race/ethnicity and language spoken in the patients who did and did not complete baseline surveys ( P < 0.01) with lower rates of completion in African American, Hispanic, and Spanish-speaking patients. At least one follow-up was obtained for 68% of patients with baseline surveys (n = 597 patients). There were significant differences in completion rates based on race/ethnicity ( P = 0.03) and language spoken ( P = 0.01). There were lower rates of baseline completion for patients with government insurance in our multivariate analysis (odds ratio: 0.6, P < 0.01). CONCLUSION: Baseline and follow-up PRO data can be obtained from the majority of patients using automated ePRO platforms. However, additional focus is needed on collecting data from traditionally underrepresented patient groups to better understand outcomes in these patient populations. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Reducing post-operative length of stay, is it worth the effort?

BACKGROUND: Studies show that reducing the length of hospital stay (LOS) for surgical patients leads to cost savings. We hypothesize that LOS has a nonlinear relationship to cost of care and reduction may not have a meaningful impact on it. We have attempted to define the relationship of LOS to cost of care. We utilized the itemized bill, generated in real time, for hospital services. MATERIALS: Adult patients admitted under General, Neuro, and Orthopedic surgery over a 3-month period, with an LOS between 4 and 14 days, were the study population. Itemized bill details were analyzed. Charges in Pakistani rupees were converted to US dollar. Ethical exemption for study was obtained. RESULTS: Of the 853 patients, 38% were admitted to General Surgery, 27% to Neurosurgery, and 35% to Orthopedics. A total of 64% of the patients had an LOS between 4 and 6 days; 36% had an LOS between 7 and 14 days. Operated and conservatively managed constituted 82% and 18%, respectively. Mean total charge for operated patients was higher $3387 versus $1347 for non-operated ones. LOS was seen to have a nonlinear relationship to in-hospital cost of care. The bulk of cost was centered on the day of surgery. This was consistent across all services. The last day of stay contributed 2.4%-3.2% of total charge. CONCLUSIONS: For surgical patients, the cost implications rapidly taper in the postoperative period. The contribution of the last day of stay cost to total cost is small. For meaningful cost containment, focus needs to be on the immediate perioperative period.

Are orthopedic clinical trials representative? An analysis of race and ethnicity reported in clinical trials between 2007 and 2022 : Running title: representation of clinical trials in orthopedic surgery.

INTRODUCTION: Prior studies investigating the racial and ethnic representation of orthopedic trial participants have found low rates of reporting, but these studies are dated due to the passing of the National Institutes of Health Final Rule in 2017 requiring the reporting of racial and ethnic data among clinical trials. Therefore, we evaluated the representativeness of orthopedic clinical trials before and after the Final Rule. METHODS: A cross-sectional survey of orthopaedic clinical trials registered at ClinicalTrials.gov between October 1, 2007 and May 20, 2023 was conducted. After identifying and screening 23,752 clinical trials, 1564 trials were included in the analysis. Trials started before the implementation of the Final Rule on January 18, 2017 were grouped and compared to trials that began after. Odds ratios (OR) were utilized to identify trial characteristics associated with reporting race/ethnicity data. One-proportion z tests compared the representation of each racial and ethnic category to the 2020 United States Census. RESULTS: In total, 34% (544 of 1564) of orthopedic clinical trials evaluated reported the race of participants, while 28% (438 of 1564) reported ethnicity. Trials registered after the Final Rule were more likely to report racial (OR: 5.15, 95%CI: 3.72-7.13, p < 0.001) and ethnic (OR: 3.23, 95%CI: 2.41-4.33, p < 0.001) representation of participants. Compared with the distribution of race and ethnicity reported by the United States 2020 Census, orthopedic trials had 16.6% more White participants (95% CI 16.4%, 16.8%; p < 0.001), 3.2% fewer Black participants (95%CI 3.1%, 3.3%; p < 0.001), and 5.7% fewer Hispanic/Latino participants (95%CI 5.2%, 6.2%; p < 0.001). Trials with enrollment sizes over 100 participants were also more likely to report race and ethnicity, with odds increasing with increased sample size. CONCLUSIONS: The Final Rule marginally improved the reporting of race and ethnicity in orthopedic clinical trials, and underrepresentation of Black or African American, Multiracial, and Hispanic populations persists. LEVEL OF EVIDENCE: III.

National Trends in Orthopaedic Pain Management from 2016 to 2020.

INTRODUCTION: Effective pain management is vital in orthopaedic care, impacting postoperative recovery and patient well-being. This study aimed to discern national and regional pain prescription trends among orthopaedic surgeons through Medicare claims data, using geospatial analysis to ascertain opioid and nonopioid usage patterns across the United States. METHODS: Physician-level Medicare prescription databases from 2016 to 2020 were filtered to orthopaedic surgeons, and medications were categorized into opioids, muscle relaxants, anticonvulsants, and NSAIDs. Patient demographics were extracted from a Medicare provider demographic data set, while county-level socioeconomic metrics were obtained primarily from the American Community Survey. Geospatial analysis was conducted using Geoda software, using Moran I statistic for cluster analysis of pain medication metrics. Statistical trends were analyzed using linear regression, Mann-Whitney U test, and multivariate logistic regression, focusing on prescribing rates and hotspot/coldspot identification. RESULTS: Analysis encompassed 16,505 orthopaedic surgeons, documenting more than 396 million days of pain medication prescriptions: 57.42% NSAIDs, 28.57% opioids, 9.84% anticonvulsants, and 4.17% muscle relaxants. Annually, opioid prescriptions declined by 4.43% ( P < 0.01), while NSAIDs rose by 3.29% ( P < 0.01). Opioid prescriptions dropped by 210.73 days yearly per surgeon ( P < 0.005), whereas NSAIDs increased by 148.86 days ( P < 0.005). Opioid prescriptions were most prevalent in the West Coast and Northern Midwest regions, and NSAID prescriptions were most prevalent in the Northeast and South regions. Regression pinpointed spine as the highest and hand as the lowest predictor for pain prescriptions. DISCUSSION: On average, orthopaedic surgeons markedly decreased both the percentage of patients receiving opioids and the duration of prescription. Simultaneously, the fraction of patients receiving NSAIDs dramatically increased, without change in the average duration of prescription. Opioid hotspots were located in the West Coast, Utah, Colorado, Arizona, Idaho, the Northern Midwest, Vermont, New Hampshire, and Maine. Future directions could include similar examinations using non-Medicare databases.

An Inclusive Analysis of Racial and Ethnic Disparities in Orthopedic Surgery Outcomes.

BACKGROUND: Despite increasing attention, disparities in outcomes for Black and Hispanic patients undergoing orthopedic surgery are widening. In other racial-ethnic minority groups, outcomes often go unreported. We sought to quantify disparities in surgical outcomes among Asian, American Indian or Alaskan Native, and Native Hawaiian or Pacific Islander patients across multiple orthopedic subspecialties. MATERIALS AND METHODS: The National Surgical Quality Improvement Program was queried to identify all surgical procedures performed by an orthopedic surgeon from 2014 to 2020. Multivariable logistic regression models were used to investigate the impact of race and ethnicity on 30-day medical complications, readmission, reoperation, and mortality, while adjusting for orthopedic subspecialty and patient characteristics. RESULTS: Across 1,512,480 orthopedic procedures, all patients who were not White were less likely to have arthroplasty-related procedures (P<.001), and Hispanic, Asian, and American Indian or Alaskan Native patients were more likely to have trauma-related procedures (P<.001). American Indian or Alaskan Native (adjusted odds ratio [AOR], 1.005; 95% CI, 1.001-1.009; P=.011) and Native Hawaiian or Pacific Islander (AOR, 1.009; 95% CI, 1.005-1.014; P<.001) patients had higher odds of major medical complications compared with White patients. American Indian or Alaskan Native patients had higher risk of reoperation (AOR, 1.005; 95% CI, 1.002-1.008; P=.002) and Native Hawaiian or Pacific Islander patients had higher odds of mortality (AOR, 1.003; 95% CI, 1.000-1.005; P=.019) compared with White patients. CONCLUSION: Disparities regarding surgical outcome and utilization rates persist across orthopedic surgery. American Indian or Alaskan Native and Native Hawaiian or Pacific Islander patients, who are under-represented in research, have lower rates of arthroplasty but higher odds of medical complication, reoperation, and mortality. This study highlights the importance of including these patients in orthopedic research to affect policy-related discussions. [Orthopedics. 2024;47(3):e131-e138.].

Incidence, etiology and time course of delays to adult spinal deformity surgery: a single-center experience.

PURPOSE: We sought to determine the incidence, origin, and timeframe of delays to adult spinal deformity surgery so that institutions using preoperative multidisciplinary patient assessment teams might better anticipate and address these potential delays. METHODS: Complex spine procedures for treatment of adult spinal deformity from 1/1/18 to 8/31/21 were identified. Procedures for infection, tumor, and urgent/emergent cases were excluded. Operations delayed due to COVID or those that were performed outside of our established perioperative care pathway were also excluded. The electronic health record was used to identify the etiology and timeline of all pre- and peri-operative delays. RESULTS: Of 235 patients scheduled for complex spine surgery, 193 met criteria for inclusion. Of these patients, 35 patients experienced a surgical delay (18.1%) with a total of 41 delays recorded. Reasons for delay include medically unoptimized (25.6%), intraoperative complication (17.9%), patient directed delay (17.9%), patient illness/injury (15.4%), scheduling complication (10.3%), insurance delay/denial (5.1%), and unknown (2.6%). Twenty-four delays experienced by 22 individuals occurred within 7 days of their scheduled surgery date. CONCLUSION: At a single multidisciplinary center, most delays to adult spinal deformity surgery occur before a patient is admitted to the hospital, and for recommendations of additional medical workup/clearance. We suspect that the preoperative protocol might increase pre-admission delays for unoptimized patients, as the protocol is intended to ensure patients receive surgery only when they are medically ready. Further research is needed to determine the economic and system impact of delays related to a preoperative optimization protocol weighed against the reduction in adverse events these protocols can provide.

Representation of Women in Academic Orthopaedic Leadership: Where Are We Now?

BACKGROUND: Women have long been underrepresented in orthopaedic surgery; however, there is a lack of quantitative data on the representation of women in orthopaedic academic program leadership. QUESTIONS/PURPOSES: (1) What is the proportion of women in leadership roles in orthopaedic surgery departments and residency programs in the United States (specifically, chairs, vice chairs, program directors, assistant program directors, and subspecialty division chiefs)? (2) How do women and men leaders compare in terms of years in position in those roles, years in practice, academic rank, research productivity as represented by publications, and subspecialty breakdown? (3) Is there a difference between men and women in the chair or program director role in terms of whether they are working in that role at institutions where they attended medical school or completed their residency or fellowship? METHODS: We identified 161 academic orthopaedic residency programs from the Accreditation Council for Graduate Medical Education (ACGME) website. Data (gender, length of time in position, length of time in practice, professorship appointment, research productivity as indirectly measured via PubMed publications, and subspecialty) were collected for chairs, vice chairs, program directors, assistant program directors, and subspecialty division chiefs in July 2020 to control for changes in leadership. Information not provided by the ACGME and PubMed was found using orthopaedic program websites and the specific leader's curriculum vitae. Complete data were obtained for chairs and program directors, but there were missing data points for vice chairs, assistant program directors, and division chiefs. All statistical analysis was performed using SPSS using independent t-tests for continuous variables and the Pearson chi-square test for categorical variables, with p < 0.05 considered significant. RESULTS: Three percent (4 of 153) of chairs, 8% (5 of 61) of vice chairs, 11% (18 of 161) of program directors, 27% (20 of 75) of assistant program directors, and 9% (45 of 514) of division chiefs were women. There were varying degrees of missing data points for vice chairs, assistant program directors, and division chiefs as not all programs reported or have those positions. Women chairs had fewer years in their position than men (2 ± 1 versus 9 ± 7 [95% confidence interval -9.3 to -5.9]; p < 0.001). Women vice chairs more commonly specialized in hand or tumor compared with men (40% [2 of 5] and 40% [2 of 5] versus 11% [6 of 56] and 4% [2 of 56], respectively; X2(9) = 16; p = 0.04). Women program directors more commonly specialized in tumor or hand compared with men (33% [6 of 18] and 17% [3 of 18] versus 6% [9 of 143] and 11% [16 of 143], respectively; X2(9) = 20; p = 0.02). Women assistant program directors had fewer years in practice (9 ± 4 years versus 14 ± 11 years [95% CI -10.5 to 1.6]; p = 0.045) and fewer publications (11 ± 7 versus 30 ± 48 [95% CI -32.9 to -5.8]; p = 0.01) than men. Women division chiefs had fewer years in practice and publications than men and were most prevalent in tumor and pediatrics (21% [10 of 48] and 16% [9 of 55], respectively) and least prevalent in spine and adult reconstruction (2% [1 of 60] and 1% [1 of 70], respectively) (X2(9) = 26; p = 0.001). Women program directors were more likely than men to stay at the same institution they studied at for medical school (39% [7 of 18] versus 14% [20 of 143]; odds ratio 3.9 [95% CI 1.4 to 11.3]; p = 0.02) and trained at for residency (61% [11 of 18] versus 42% [60 of 143]; OR 2.2 [95% CI 0.8 to 5.9]; p = 0.01). CONCLUSION: The higher percentage of women in junior leadership positions in orthopaedic surgery, with the data available, is a promising finding. Hand, tumor, and pediatrics appear to be orthopaedic subspecialties with a higher percentage of women. However, more improvement is needed to achieve gender parity in orthopaedics overall, and more information is needed in terms of publicly available information on gender representation in orthopaedic leadership. CLINICAL RELEVANCE: Proportional representation of women in orthopaedics is essential for quality musculoskeletal care, and proportional representation in leadership may help encourage women to apply to the specialty. Our findings suggest movement in an improving direction in this regard, though more progress is needed.

Opioid Reduction Through Postoperative Pain Management in Pediatric Orthopedic Surgery.

OBJECTIVES: Our goal with this initiative was to reduce discharge opioid prescriptions while maintaining optimal pain management through the use of standardized pain prescribing guidelines for pediatric patients after orthopedic surgical procedures. METHODS: Through analysis of established yet inconsistent prescribing practices, we created a 4-tiered guideline for pediatric orthopedic postoperative pain management prescription ordering. Following the Model for Improvement methodology including iterative plan-do-study-act cycles, the team created an electronic medical record order set to be used at discharge from the hospital. The provider compliance with this order set was monitored and analyzed over time by using provider-level and aggregate control charts. A secondary measure of opioid prescriptions (morphine milligram Eq [MME] dosage per patient) was tracked over time. The balancing measure was the analysis of unanticipated opioid prescription refills. RESULTS: Greater than 90% compliance with the guidelines was achieved and sustained for 20 months. This resulted in a 54% reduction in opioids prescribed during the improvement period (baseline = 71 MME per patient; postintervention = 33 MME per patient) and has been sustained for 12 months. The percentage of unanticipated opioid prescription refills did not significantly change from the period before the institution of the guidelines and after institution of the guidelines (2017 = 3%; 2019 = 3%). CONCLUSIONS: The creation of these guidelines has led to a significant reduction in the number of opioids prescribed while maintaining effective postoperative pain management.

Direct medical costs after surgical or nonsurgical treatment for degenerative lumbar spinal disease: A nationwide matched cohort study with a 10-year follow-up.

OBJECTIVE: The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease. METHODS: The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years. RESULTS: The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p<0.01). Initially, surgery treatment led to more charge to NHIS ($2,762) than nonsurgical treatment ($180.4) (p<0.01). Compared with the non-surgical cohort, the surgery cohort charged $33/month more for the first 3 months, charged less at 12 months, and charged approximately the same over the course of 10 years. CONCLUSION: Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.

Three months in a high-volume tertiary orthopaedic trauma unit: What is a registrar worth?

BACKGROUND: South Africa has a high burden of traumatic injuries that is predominantly managed in the public healthcare system, despite the relative disparity in human resources between the public and private sectors. Because of budget and theatre time constraints, the trauma waiting list often exceeds 50 - 60 patients who need urgent and emergent surgery in high-volume orthopaedic trauma centres. This situation is exacerbated by other surgical disciplines using orthopaedic theatre time for life-threatening injuries because of lack of own theatre availability. One of the proposed solutions to this problem is outsourcing of some of the cases to private medical facilities. OBJECTIVES: To establish the volume of work done by an orthopaedic registrar during a 3-month trauma rotation, and to calculate the implant and theatre costs, as well as compare the salary of a registrar with the theoretical private surgeon fees for procedures performed by the registrar in the 3-month period. METHODS: In a retrospective study, the surgical logbook of a single registrar during a 3-month rotation, from 14 January to 14 April 2019, was reviewed. Surgeon fees were calculated for these procedures, according to current medical aid rates, without additional modifier codes being added. RESULTS: During the 3-month study period, a total of 157 surgical procedures was performed, ranging from total hip arthroplasty to debridement of septic hands. Surgeon fees amounted to ZAR186 565.10 per month ‒ double the gross salary of a registrar. Total implant costs amounted to ZAR1 272 667. Theatre costs were ZAR1 301 976 for the 3-month period. CONCLUSIONS: Although this analysis was conducted over a short period, it highlights the significant amount of trauma work done by a single individual at a high-volume tertiary orthopaedic trauma unit. With increasing budget constraints, pressure on theatre time and a growing population, cost-effective expansion of resources is needed. From this study, it appears that increasing capacity in the state sector could be cheaper than private outsourcing, although a more in-depth analysis needs to be conducted.

Longitudinal survival trends of patients with cancer with surgically managed appendicular metastatic bone disease: systematic review.

BACKGROUND: Advances in systemic cancer therapies have improved survival for patients with metastatic carcinoma; however, it is unknown whether these advances have translated to improved survival for patients with appendicular metastatic bone disease (A-MBD) after orthopedic interventions. We conducted a study to evaluate the trend in overall survival for patients who underwent orthopedic surgery for A-MBD between 1968 and 2018. METHODS: A systematic search of Embase and Medline to identify studies published since 1968 evaluating patients treated with orthopedic surgery for A-MBD was conducted for a previously published scoping review. We used a meta-regression model to assess the longitudinal trends in 1-, 2- and 5-year overall survival between 1968 and 2018. The midpoint year of patient inclusion for each study was used for analysis. We categorized primary tumour types into a tumour severity score according to prognosis for a further meta-regression analysis. RESULTS: Of the 5747 studies identified, 103 were retained for analysis. Meta-regression analysis showed no significant effect of midpoint study year on survival across all time points. There was no effect of the weighted average of tumour severity scores for each study on 1-year survival over time. CONCLUSION: There was no significant improvement in overall survival between 1968 and 2018 for patients with A-MBD who underwent orthopedic surgery. Orthopedic intervention remains a poor prognostic variable for patients with MBD. This finding highlights the need for improved collection of prospective data in this population to identify patients with favourable survival outcomes who may benefit from personalized oncologic surgical interventions.

Analysis of Tertiary Hospital Utilization in Pediatric Orthopaedics: a Study Using Nationwide Sample Data from Korea.

BACKGROUND: In the Korean medical system, the severity classification for a specific disease depends primarily on its nationwide admission rate in tertiary hospitals. Inversely, one of the important designation criteria for a tertiary hospital is the hospital's treatment ratio of patients classified as having a specific severe disease. Most diseases requiring pediatric orthopaedic surgery (POS) are not currently classified as high severity in terms of disease severity. We investigated the admission rates for the representative POS diseases in tertiary hospitals and compared these rates with those for adult orthopaedic surgery (AOS) diseases. METHODS: Seven POS diagnoses and three AOS diagnoses were selected based on frequency of admission. Nationwide sample data were used to investigate the admission rates for these representative diagnoses from 2008 to 2017. RESULTS: Six of the seven frequent POS diagnoses presented high admission rates in tertiary hospitals (62.5-92.3%). In contrast, all frequent AOS diagnoses presented low admission rates in tertiary hospitals. CONCLUSION: The admission rates of frequent POS diagnoses in tertiary hospitals are high. Considering that these rates are the most important factors for the classification of disease severity, POS diseases seem to be underestimated in terms of severity. This may lead to a tendency for tertiary hospitals to intentionally reduce the admission of children with POS diseases. As a result, these children may not receive appropriate professional care. Therefore, for the disease severity, POS diseases should be classified differently from general AOS diseases by using different criteria reflecting the patient's age.

Cervical lymphatic malformations amenable to transhairline robotic surgical excision in children: A case series.

ABSTRACT: Lymphatic malformations are rare benign malformations that predominantly occur in the head and neck region. The advent of surgical robots in head and neck surgery may provide beneficial outcomes for pediatric patients. Here, we describe our experiences with transhairline incisions for robot-assisted surgical resection of cervical lymphatic malformations in pediatric patients.In this prospective longitudinal cohort study, we recruited consecutive patients under 18 years of age who were diagnosed with congenital cervical lymphatic malformations and scheduled for transhairline approach robotic surgery at a single medical center. We documented the docking times, console times, surgical results, complications, and postoperative follow-up outcomes.The studied patients included 2 with mixed-type lymphatic malformations and 2 with macrocystic-type lymphatic malformations. In all 4 patients, the incision was hidden in the hairline; the incision length was <5 cm in 3 patients but was extended to 6 cm in 1 patient. Elevating the skin flap and securely positioning it with Yang retractor took <1 hour in all cases. The mean docking time was 5.5 minutes, and the mean console time was 1 hour and 46 minutes. All 4 surgeries were completed endoscopically with the robot. The average total drainage volume in the postoperative period was 21.75 mL. No patients required tracheotomy or nasogastric feeding tubes. Neither were adverse surgery-associated neurovascular sequelae observed. All 4 patients were successfully treated for their lymphatic malformations, primarily with robotic surgical excisions.Cervical lymphatic malformations in pediatric patients could be accessed, properly visualized, and safely resected with transhairline-approach robotic surgery. Transhairline-approach robotic surgery is an innovative method for meeting clinical needs and addressing esthetic concerns.

Management of patients with hip fracture receiving anticoagulation: What are we doing in Canada?

BACKGROUND: Direct oral anticoagulants (DOACs) are rapidly replacing warfarin for therapeutic anticoagulation; however, many DOACs are irreversible and may complicate bleeding in emergent situations such as hip fracture. In this setting, there is a lack of clear guidelines for the timing of surgery. The purpose of this study was to evaluate the current practices of Canadian orthopedic surgeons who manage patients with hip fracture receiving anticoagulation. METHODS: In January-March 2018, we administered a purpose-specific cross-sectional survey to all currently practising orthopedic surgeons in Canada who had performed hip fracture surgery in 2017. The survey evaluated approaches to decision-making and timing of surgery in patients with hip fracture receiving anticoagulation. RESULTS: A total of 280 surgeons representing a mix of academic and community practice, seniority and fellowship training responded. Nearly one-quarter of respondents (66 [23.4%]) were members of the Canadian Orthopaedic Trauma Society (COTS). Almost three-quarters (206 [73.6%]) felt that adequate clinical guidelines for patients with hip fracture receiving anticoagulation did not exist, and 177 (61.9%) indicated that anesthesiology or internal medicine had a greater influence on the timing of surgery than the attending surgeon. A total of 117/273 respondents (42.9%) indicated that patients taking warfarin should have immediate surgery (with or without reversal), compared to 63/270 (23.3%) for patients taking a DOAC (p < 0.001). Members of COTS were more likely than nonmembers to advocate for immediate surgery in all patients (p < 0.05). CONCLUSION: There is wide variability in Canada in the management of patients with hip fracture receiving anticoagulation. Improved multidisciplinary communication, prospectively evaluated treatment guidelines and focus on knowledge translation may add clarity to this issue. LEVEL OF EVIDENCE: IV.