The effect of pre-operative shoulder injections on post-operative opioid use, infection and revision following shoulder arthroplasty.

Background: Treatment of glenohumeral osteoarthritis (GHOA) may include conservative management with use of intraarticular injections, prior to considering total shoulder arthroplasty (TSA). The purpose of this study was to assess trends in the use of preoperative cortisone (CO) and hyaluronic acid (HA) injections, as well as investigate the relationship between injection use and infection or revision arthroplasty following TSA. Methods: Pearl Driver was used to identify all patients undergoing TSA for GHOA between 2010 and 2018. Patients were categorized based on the type and number of injections they received. Outcomes of interest included post-operative opioid use, post-operative infection, and risk of revision surgery within 1 year of the index procedure. Results: The incidence of patients receiving a CO or HA injections within 1 year of their TSA decreased by 83% and 54%, respectively. Patients who had received 1 or more steroid injections had higher odds of prolonged opiate use following surgery. Patients that received 1 or 2 CO injection prior to TSA had an increased risk of needing revision surgery. Discussion: Use of intraarticular injections for the management of GHOA has declined. Patients receiving preoperative injections had increased odds of prolonged opiate use and the need for revision surgery.

Robotic Simulation in Urologic Surgery.

Robotic surgery continues to revolutionize the field of urologic surgery, and thus it is crucial that graduating urologic surgery residents demonstrate proficiency with this technology. The large learning curve of utilizing robotic technology limits resident immediate participation in real-life robotic surgery, and skill acquisition is further challenged by variable case volume. Robotic simulation offers an invaluable opportunity for urologic trainees to cultivate strong foundational skills in a non-clinical setting, ultimately leading to both competence and operative confidence. Several different simulation technologies and robotic assessment protocols have been developed and demonstrate validity in several domains. However, despite their demonstrable utility, there is no formal robotic curricula within US urologic surgery residencies. In this article, we will review the current state of robotic simulation training in urologic surgery and highlight the importance of its widespread utilization in urologic surgery residency training programs.

Arthroscopic Simulation in Orthopaedic Surgery Training.

Surgical simulation has become a commonly utilized and well-researched training adjunct in nearly all surgical specialties. Balancing high-quality orthopaedic surgical training in the face of work hour restrictions and efficiency pressures has become a challenge to educators and trainees alike. Surgical simulation is an opportunity to enhance such training and potentially permit trainees to be better equipped for the operating room. In orthopaedics, various low-fidelity, high-fidelity, and virtual reality simulation platforms are readily available to almost all trainees and permit simulation of a wide array of arthroscopic surgeries. In this review, we seek to highlight the potential utility of simulation-based training in orthopaedic surgery, the various types of available simulators, and review the evidence for simulator use.

Supplementary Fixation Improves Stability of Intra-Articular Distal Radius Fractures Managed With a Spanning Plate.

PURPOSE: Previous studies evaluating weight bearing of distal radius fractures treated through dorsal spanning bridge plates used extra-articular fracture models, and have not evaluated the role of supplementary fixation. We hypothesized that supplementary fixation with a spanning dorsal bridge plate for an intra-articular wrist fracture would decrease the displacement of individual articular pieces with cyclic axial loading and allow for walker or crutch weight bearing. METHODS: Thirty cadaveric forearms were matched into 3 cohorts, controlling for age, sex, and bone mineral density. An intra-articular fracture model was fixed with the following 3 techniques: (1) cohort A with a dorsal bridge plate, (2) cohort B with a dorsal bridge plate and two 1.6-mm k-wires, and (3) cohort C with a dorsal bridge plate and a radial pin plate. Specimens were axially loaded cyclically with escalating weights consistent with walker and crutch weight-bearing with failure defined as 2-mm displacement. RESULTS: No specimens failed at 2- or 5-kg weights, but cohort A had significantly more displacement at these weights compared with cohort B. Cohort A had significantly more failure than cohort C. Both cohort A and cohort B had significantly more displacement at crutch weight bearing compared with cohort C. The supplementary fixation group had significantly lower displacement at crutch weight-bearing compared with cohort A in all gaps. Survival curves demonstrated the fixation cohort to survive higher loads than the nonfixation group. CONCLUSION: There was significantly less displacement and less failure of intra-articular distal radius fractures treated with a spanning dorsal bridge plate and supplementary fixation. Our model showed that either type of fixation was superior to the nonfixation group. CLINICAL SIGNIFICANCE: When considering early weight-bearing for intra-articular distal radius fractures treated with a spanning dorsal bridge plate, supplementary fixation may be considered as an augmentation to prevent fracture displacement.

Do Patient Demographic and Socioeconomic Factors Influence Surgical Treatment Rates After ACL Injury?

INTRODUCTION: Anterior cruciate ligament (ACL) injuries may be managed nonoperatively in certain patients and injury patterns; however, complete ACL ruptures are commonly reconstructed to restore anterior and lateral rotatory stability of the knee. While ACL reconstruction is well-studied, the literature is sparse with regard to which socioeconomic patient factors are associated with patients undergoing ACL reconstruction rather than nonoperative management after diagnosis of an ACL injury. The current study seeks to evaluate this relationship between patient demographics as well as socioeconomic factors and the rate of surgery following ACL injuries. METHODS: Patients ≤65 years of age with a primary ACL injury between 2011 and 2018 were retrospectively identified in the New York Statewide Planning and Research Cooperative System database. International Classification of Disease 9/10 and Current Procedural Terminology codes were used to identify these patients and their subsequent ACL reconstructions. Logistic regression was performed to determine the effect of patient factors on the likelihood of having surgery after the diagnosis of an ACL injury. RESULTS: Compared to White patients, African American patients were significantly less likely to undergo ACL reconstruction following an ACL injury (OR=0.65, 95% CI, 0.573-0.726). Patients older than 35 had decreased odds of undergoing ACL reconstruction compared to younger patients, with patients 55-64 having the lowest odds (OR=0.166, 95% CI, 0.136-0.203). Patients with Medicaid (OR=0.84, 95% CI, 0.757-0.933) or self-pay insurance (OR=0.67, 95% CI, 0.565-0.793), and those with worker's compensation (OR=0.715, 95% CI, 0.621-0.823) had decreased odds of undergoing ACL reconstruction relative to patients with private insurance. Patients with higher Social Deprivation Index (SDI) were significantly more likely to be treated nonoperatively after ACL injuries compared to those with lower SDI (mean nonoperative SDI score, 61, operative SDI, 56, P<0.0001). DISCUSSION: In patients with ACL injuries, there are socioeconomic and patient-related factors that are associated with increased odds of undergoing ACL reconstruction. These factors are important to recognize as they represent a source of potential inequality in access to care and an area with potential for improvement.

A Review of Abductor Tendon Tears: The Hidden Lesion of the Hip.

¼: Greater trochanteric pain syndrome consists of a group of associated conditions involving the lateral hip that can be debilitating to patients, mostly women between ages 40 and 60 years. ¼: Abductor tendon tears are becoming a more recognized cause of lateral hip pain in patients without hip osteoarthritis. ¼: Diagnosis of this condition is critical to patient care because misdiagnosis often leads to unnecessary prolonged pain and even unnecessary procedures that address different pathologies. ¼: Treatment strategies consists of nonoperative modalities such as nonsteroidal anti-inflammatory medications, corticosteroid injections, and physical therapy, but for refractory cases, surgical techniques including repair, augmentation, and reconstruction have been well-described in the literature providing patients with acceptable outcomes.

Trends and Reported Complications in Ankle Arthroplasty and Ankle Arthrodesis in the State of New York, 2009-2018.

Background: Ankle arthroplasty has emerged as a viable alternative to ankle arthrodesis due in large part to recent advancements in both surgical technique and implant design. This study seeks to document trends of arthroplasty and arthrodesis for ankle osteoarthritis in New York State from 2009-2018 in order to determine if patient demographics play a role in procedure selection and to ascertain the utilization of each procedure and rates of complications. Methods: Patients 40 years and older from 2009-2018 were identified using International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10), Clinical Modification (CM) diagnosis and procedure codes for ankle osteoarthritis, ankle arthrodesis, and ankle arthroplasty in the New York statewide planning and research cooperative system database. A trend analysis for both inpatient and outpatient procedures was performed to evaluate the changing trends in utilization of ankle arthrodesis and ankle arthroplasty over time. A multivariable logistic regression was used to assess the odds of receiving ankle arthrodesis relative to ankle arthroplasty. Complications were compared between inpatient ankle arthrodesis and arthroplasty using multivariable Cox proportional hazards regression. Results: A total of 3735 cases were included. Ankle arthrodesis increased by 25%, whereas arthroplasty increased by 757%. African American race, federal insurance, workers compensation, presence of comorbidities, and higher social deprivation were associated with increased odds of having an ankle arthrodesis vs an ankle arthroplasty. Compared with ankle arthroplasty, ankle arthrodesis was associated with increased rates of readmission, surgical site infection, acute renal failure, cellulitis, urinary tract infection, and deep vein thrombosis. Conclusion: Ankle arthroplasty volume has grown substantially without a decrease in ankle arthrodesis volume, suggesting that ankle arthroplasty may be selectively used for a different population of patients than ankle arthrodesis patients. Despite the increased growth of ankle arthroplasty, certain patient demographics including patients from minority populations, federal insurance, and from areas of high social deprivation have higher odds of receiving arthrodesis. Level of Evidence: Level III, retrospective cohort.

Social Disparities in Outpatient and Inpatient Management of Pediatric Supracondylar Humerus Fractures.

Socioeconomic status, race, and insurance status are known factors affecting adult orthopaedic surgery care, but little is known about the influence of socioeconomic factors on pediatric orthopaedic care. The purpose of this study was to determine if demographic and socioeconomic related factors were associated with surgical management of pediatric supracondylar humerus fractures (SCHFs) in the inpatient versus outpatient setting. Pediatric patients (<13 years) who underwent surgery for SCHFs were identified in the New York Statewide Planning and Research Cooperative System database from 2009−2017. Inpatient and outpatient claims were identified by International Classification of Diseases-9-Clinical Modification (CM) and ICD-10-CM SCHF diagnosis codes. Claims were then filtered by ICD-9-CM, ICD-10-Procedural Classification System, or Current Procedural Terminology codes to isolate SCHF patients who underwent surgical intervention. Multivariable logistic regression analysis was performed to determine the effect of patient factors on the likelihood of having inpatient management versus outpatient management. A total of 7079 patients were included in the analysis with 4595 (64.9%) receiving inpatient treatment and 2484 (35.1%) receiving outpatient treatment. The logistic regression showed Hispanic (OR: 2.386, p < 0.0001), Asian (OR: 2.159, p < 0.0001) and African American (OR: 2.095, p < 0.0001) patients to have increased odds of inpatient treatment relative to White patients. Injury diagnosis on a weekend had increased odds of inpatient management (OR: 1.863, p = 0.0002). Higher social deprivation was also associated with increased odds of inpatient treatment (OR: 1.004, p < 0.0001). There are disparities among race and socioeconomic status in the surgical setting of SCHF management. Physicians and facilities should be aware of these disparities to optimize patient experience and to allow for equal access to care.

What's New in Pediatric Orthopaedic Health Care Disparities?

BACKGROUND: Health care disparities are prevalent within pediatric orthopaedics in the United States. Social determinants of health, such as income, race, social deprivation, place of residence, and parental involvement, all play a role in unequal access to care and disparate outcomes. Although there has been some effort to promote health equity both within pediatric orthopaedics and the US health care system altogether, disparities persist. In this review, we aim to identify major sources of inequality and propose solutions to achieve equitable care in the future. METHODS: We searched the PubMed database for papers addressing disparities in pediatric orthopaedics published between 2016 and 2021, yielding 283 papers. RESULTS: A total of 36 papers were selected for review based upon new findings. Insurance status, race, and social deprivation are directly linked to poorer access to care, often resulting in a delay in presentation, time to diagnostic imaging, and surgery. Although these disparities pervade various conditions within pediatric orthopaedics, they have most frequently been described in anterior cruciate ligament/meniscal repairs, tibial spine fractures, adolescent idiopathic scoliosis, and upper extremity conditions. Treatment outcomes also differ based on insurance status and socioeconomic status. Several studies demonstrated longer hospital stays and higher complication rates in Black patients versus White patients. Patients with public insurance were also found to have worse pain and function scores, longer recoveries, and lower post-treatment follow-up rates. These disparate outcomes are, in part, a response to delayed access to care. CONCLUSIONS: Greater attention paid to health care disparities over the past several years has enabled progress toward achieving equitable pediatric orthopaedic care. However, delays in access to pediatric orthopaedic care among uninsured/publicly insured, and/or socially deprived individuals remain and consequently, so do differences in post-treatment outcomes. Reducing barriers to care, such as insurance status, transportation and health literacy, and promoting education among patients and parents, could help health care access become more equitable. LEVEL OF EVIDENCE: Level IV-narrative review.

The Effects of Social and Demographic Factors on High-Volume Hospital and Surgeon Care in Shoulder Arthroplasty.

INTRODUCTION: This study seeks to evaluate (1) the relationship between hospital and surgeon volumes of shoulder arthroplasty and complication rates and (2) patient demographics/socioeconomic factors that may affect access to high-volume shoulder arthroplasty care. METHODS: Adults older than 40 years who underwent shoulder arthroplasty between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database using International Classification of Disease 9/10 and Current Procedural Terminology codes. Medical/surgical complications were compared across surgeon and facility volumes. The effects of demographic factors were analyzed to determine the relationship between such factors and surgeon/facility volume in shoulder arthroplasty. RESULTS: Seven thousand seven hundred eighty-five patients were included. Older, Hispanic/African American, socially deprived, nonprivately insured patients were more likely to be treated by low-volume facilities. Low-volume facilities had higher rates of readmission, urinary tract infection, renal failure, pneumonia, and cellulitis than high-volume facilities. Low-volume surgeons had patients with longer hospital lengths of stay. DISCUSSION: Important differences in patient socioeconomic factors exist in access to high-volume surgical care in shoulder arthroplasty, with older, minority, and underinsured patients markedly more likely to receive care by low-volume surgeons and facilities. This may highlight an area of potential focus to improve access to high-volume care.

Social and Demographic Factors Impact Shoulder Stabilization Surgery in Anterior Glenohumeral Instability.

Purpose: To assess independent predictors of surgery after an emergency department visit for shoulder instability, including patient-related and socioeconomic factors. Methods: Patients presenting to the emergency department were identified in the New York Statewide Planning and Research Cooperative System database from 2015 to 2018 by International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for anterior shoulder dislocation or subluxation. All shoulder stabilization procedures in the outpatient setting were identified using Current Procedural Terminology codes (23455, 23460, 23462, 23466, and 29806). A multivariable logistic regression was performed to assess the impact of patient factors on the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation, Charlson Comorbidity Index, recurrent dislocation, and primary insurance type. Results: In total, 16,721 patients with a shoulder instability diagnosis were included in the analysis and 1,028 (6.1%) went on to have surgery. Patients <18 years old (odds ratio [OR] 8.607, P < .0001), those with recurrent dislocations (OR 2.606, P < .0001), or worker's compensation relative to private insurance (OR 1.318, P = .0492) had increased odds of receiving surgery. Hispanic (OR 0.711, P = .003) and African American (OR 0.63, P < .0001) patients had decreased odds of surgery compared with White patients. Patients with Medicaid (OR 0.582, P < .0001) or self-pay (OR 0.352, P < .0001) insurance had decreased odds of undergoing surgery relative to privately insured patients. Patients with greater levels of social deprivation (OR 0.993, P < .0001) also were associated with decreased odds of surgery. Conclusions: Anterior glenohumeral instability and subsequent stabilization surgery is associated with disparities among patient race, primary insurance, and social deprivation. Clinical Relevance: Considering the relationship between differential care and health disparities, it is critical to define and increase physician awareness of these disparities to help ensure equitable care.

Surgeon and Facility Volume are Associated With Postoperative Complications After Total Knee Arthroplasty.

Background: Surgeon and hospital volumes may affect outcomes of various orthopedic procedures. The purpose of this study is to characterize the volume dependence of both facilities and surgeons on morbidity and mortality after total knee arthroplasty. Methods: Adults who underwent total knee arthroplasty for osteoarthritis from 2011 to 2015 were identified using International Classification of Diseases-9 Clinical Modification diagnostic and procedural codes in the New York Statewide Planning and Research Cooperative System database. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, while controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20%. Results: Of 113,784 identified patients, 71,827 were treated at a high- or low-volume facility or by low- or high-volume surgeon. Low-volume facilities had higher 1-month, 3-month, and 12-month rates of readmission, urinary tract infection, cardiorespiratory arrest, surgical site infection, and wound complications; higher 3- and 12-month rates of pneumonia, cellulitis, and in-facility mortality; and higher 12-month rates of acute renal failure and revision. Low-volume surgeons had higher 1-, 3-, and 12-month rates of readmission, urinary tract infection, acute renal failure, pneumonia, surgical site infection, deep vein thrombosis, pulmonary embolism, cellulitis, and wound complications; higher 3- and 12-month rates of cardiorespiratory arrest; and higher 12-month rate of in-facility mortality. Conclusions: These results suggest volume shifting toward higher volume facilities and/or surgeons could improve patient outcomes and have potential cost savings. Furthermore, these results can inform healthcare policy, for example, designating institutions as centers of excellence.

Pre-Operative Medications as a Predictor for Post-Operative Complications Following Geriatric Hip Fracture Surgery.

Background: Fragility hip fractures are a common orthopedic injury seen in Emergency Departments, with variable outcomes that can range from average to devastating. Currently, few reliable metrics to predict which patients will suffer post-operative complications exist. The aim of this study was to determine if the number and type of pre-operative medications can help predict post-operative complications. Methods: A prospectively collected database of hip fracture patients was retrospectively reviewed. Patients with isolated greater trochanteric fractures, periprosthetic fractures, or re-fractures were excluded. Pre-operative baseline characteristics as well as number and type of post-operative complications were reviewed. Any complication within 6 months of surgery and complications that could be directly attributable to the surgical procedure within 2 years of surgery were examined. Major complications (return to the operating room, deep infection, pulmonary, cardiac, and hematologic) and minor medical complications were assessed. A multivariate regression model was performed to identify independent risk factors. Results: Three-hundred ninety-one patients were included. A majority were aged 80-90 and female, and lived at home prior to presentation. Overall, 33.7% of patients suffered a complication within a 2-year follow-up period. Mortality rates were 5.4%, 10.0%, and 14.9% over 30 days, 1 year, and 2 years, respectively. After assessing this relationship while controlling for age, sex, injury type, pre-operative residence, ambulatory status, ASA score, and CCI score, the relationship remained significant for both an increased number of complications (P = .048) and a higher likelihood of having a complication (P = .008). Cardiovascular (P = .003), pulmonary (P = .001), gout (P = .002), or diabetes (P = .042) medications were associated with a higher likelihood for experiencing a complication. Conclusions: Our study suggests that there is a strong and linear relationship between the number and type of pre-operative medications taken and risk of post-operative complications. This exists for up to 8 medications, at which point further increase does not contribute to an increased risk of complication. This relationship exists even after controlling for confounding variables and can be used by surgeons to better counsel patients and families regarding their specific risk for suffering perioperative complications.

Epidemiology and Revision Rates of Pediatric ACL Reconstruction in New York State.

BACKGROUND: There are limited epidemiologic data examining the incidence of pediatric anterior cruciate ligament reconstruction (ACLR) over the past decade. PURPOSE: To examine statewide population trends in the incidence of ACLR in a pediatric population. STUDY DESIGN: Descriptive epidemiology study. METHODS: Inpatient and outpatient claims for pediatric patients who underwent ACLR between 2009 and 2017 were identified in the New York Statewide Planning and Research Cooperative System database via International Classification of Diseases (ICD), Revision 9, Clinical Modification; ICD, Revision 10, Clinical Modification and Procedural Classification System; or Current Procedural Terminology codes. New York population data for each year between 2009 and 2017 were used from the New York State Department of Health to calculate the rates of ACLR per 100,000 people aged 3 to 19 years and determine the 95% confidence limits. The rates were then stratified by age, sex, and insurance. Two-year rates of revision and contralateral ACLR were also analyzed by sex. RESULTS: Between 2009 and 2017, 20,170 pediatric ACLRs were identified. The rates of pediatric ACLR increased steadily from 49.3 per 100,000 in 2009 (95% CI, 47.2-51.4) to a peak of 61.0 (95% CI, 58.6-63.4) in 2014 and decreased to 51.8 (95% CI, 49.6-54.1) by 2017. The age group 15 to 17 years had the highest rates of ACLR of all age groups, peaking at 198.5 (95% CI, 188.3-208.7) per 100,000. Analysis by sex showed that ACLR rates between males and females were not different. Males had a 2-year ipsilateral revision rate of 4.3%, while females had a rate of 3.3% (P = .0001). Females had a contralateral ACLR rate of 4.0%, while males had a rate of 2.6% (P = .0002). CONCLUSION: Pediatric ACLR rates continued to rise until 2014, but there was a demonstrable decrease in rates after 2014. This decline in pediatric ACLR may point to the efficacy of injury prevention programs or changes in practice management. The high revision rate in males and high contralateral surgery rate in females can help guide patient counseling for return to play and complication risk. CLINICAL RELEVANCE: This study showed that ACLR in pediatric patients may be decreasing in recent years. There were differences in revision and contralateral ACLR by sex.

Successful Fracture Healing for Femoral Neck Nonunion with Bone Marrow Aspirate Concentrate.

INTRODUCTION: Femoral neck fractures in the young patient require prompt anatomic reduction and stabilization to preserve the vascular supply to the femoral head and minimize future need for arthroplasty. Secondary to unique biomechanical and vascular considerations, these injuries are prone to nonunion. CASE REPORT: A 29-year-old male with a chronic femoral neck fracture nonunion who experienced successful fracture healing and symptom resolution following Bone Marrow Aspirate Concentrate (BMAC) administration. DISCUSSION: Femoral neck nonunion in young patients is a challenging problem with treatment strategies aimed at improving the biological and biomechanical fracture environment. While the use of both vascularized and nonvascularized bone grafting has shown promising results, they have high complication rates and substantial donor site morbidity. BMAC has demonstrated multiple uses throughout orthopedic surgery and may result in an improved fracture healing environment with minimal patient morbidity. CONCLUSION: The success of the BMAC procedure for this patient is promising and may be considered in similar patients, with or without revision internal fixation methods.

Implant Charge Differences Between Distal Radius Fixation Constructs (CPT 25607, 25608, and 25609).

BACKGROUND: Implants are a significant contributor to health care costs. We hypothesized that extra-articular fracture patterns would have a lower implant charge than intra-articular fractures and aimed to determine risk factors for increased cost. METHODS: In total, 163 patients undergoing outpatient distal radius fracture fixation at 2 hospitals were retrospectively reviewed stratified by Current Procedural Terminology codes. Implants and associated charges were noted, as were sex, age, insurance status, surgeon specialty, and location. Bivariate and multivariable regression were used to determine associations. RESULTS: Total implant charges were significantly lower for 25607 (extraarticular, $3,348) than 25608 (2-part intraarticular, $3,859) and 25609 (3+ part intraarticular, $3,991). In addition, intra-articular fractures had higher charges for distal screws/pegs and bone graft. Charge was lower when surgery was performed at a trauma center. There was no charge difference associated with insurance status, age, sex, hand surgery specialty, or fellow status. Substantial intersurgeon variation existed in all fracture types. CONCLUSION: Distal radius fractures may represent a good model for examining implant costs. Extra-articular fractures had lower implant charges than intra-articular fractures. These data may be used to help construct pricing for distal radius fracture bundles and potential cost savings.

The Effect of Hospital and Surgeon Volumes on Complication Rates After Fixation of Peritrochanteric Hip Fractures.

OBJECTIVE: This study evaluates the relationship between hospital and surgeon volumes of peritrochanteric hip fracture fixation and complication rates. METHODS: Adults (60 years of age or older) who underwent surgical fixation for closed peritrochanteric fractures from 2009 to 2015 were identified using International Classification of Diseases 9 and 10 Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Readmission, reoperations, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes. Statistical significance was set at P < 0.05. RESULTS: A total of 29,656 patients were included in the study. Low-volume (LV) facilities had higher rates of readmission [hazard ratio (HR) 1.07, 95% confidence interval (CI), 1.05-1.17], pneumonia (HR 1.36, 95% CI, 1.22-1.51), wound complications (HR 1.24, 95% CI, 1.03-1.49), and mortality (HR 1.15, 95% CI, 1.04-1.27) but lower rates of acute renal failure (HR 0.90, 95% CI, 0.83-0.98), deep vein thrombosis (HR 0.66, 95% CI, 0.55-0.78), and acute respiratory failure (HR 0.77, 95% CI, 0.62-0.95) than high-volume (HV) facilities. Patients treated by LV surgeons had lower rates of readmission (HR 0.92, 95% CI, 0.87-0.97) and deep vein thrombosis (HR 0.78, 95% CI, 0.66-0.94) but higher rates of acute renal failure (HR 1.13, 95% CI, 1.04-1.22) than those treated by HV surgeons. CONCLUSIONS: There are increased rates of mortality, readmission, and certain complications when peritrochanteric femur fractures are surgically managed at LV hospitals compared with those managed at HV hospitals. Thus, the benefit of a high-volume surgical facility is apparent in mortality and readmissions but not all complications. There was no significant decrease in complications if fixation was performed by HV surgeons relative to LV surgeons. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outpatient Operative Management of Pediatric Supracondylar Humerus Fractures: An Analysis of Frequency, Complications, and Cost From 2009 to 2018.

BACKGROUND: In an effort to increase the value of health care in the United States, there has been increased focus on shifting certain procedures to an outpatient setting. While pediatric supracondylar humerus fractures (SCHFs) have traditionally been treated in an inpatient setting, recent studies have investigated the safety and efficiency of outpatient surgery for these injuries. This retrospective study aims to examine ongoing trends of outpatient surgical care for SCHFs, examine the safety and complication rates of these procedures, and investigate the potential cost-savings from this shift in care. METHODS: Pediatric patients less than 13 years old who underwent surgery for closed SCHF from 2009 to 2018 were identified using International Classification of Diseases-9/10 Clinical Modification and Procedural Classification System codes in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear regression was used to assess the shift in proportion of outpatient surgical management of these injuries over time. Multivariable Cox proportional hazards regression was used to compare return to emergency department (ED) visit, readmission, reoperation, and other adverse events. A 2-sample t test was performed on the average charge amount per claim for inpatient versus outpatient surgery. RESULTS: A total of 8488 patients were included in the analysis showing there was a statistically significant shift towards outpatient management between 2009 (23% outpatient) and 2018 (59% outpatient) (P<0.0001). Relative to inpatient surgical management, outpatient surgical management had lower rates of return ED visits at 1 month (hazard ratio: 0.744, P=0.048). All other adverse events compared across inpatient and outpatient surgical management were not significantly different. The median amount billed per claim for inpatient surgeries was significantly higher than for outpatient surgeries ($16,097 vs. $9,752, P<0.0001). White race, female sex, and weekday ED visit were associated with increased rate of outpatient management. CONCLUSIONS: This study demonstrates the trend of increasing outpatient surgical management of pediatric SCHF from 2009 to 2018. The increased rate of outpatient management has not been associated with elevated complication rates but is associated with significantly reduced health care charges. LEVEL OF EVIDENCE: Level III-retrospective cohort.

A Simple Initiative to Decrease Time to Antibiotic Prophylaxis for Open Fractures Is Durable After 2 Years.

INTRODUCTION: A simple antibiotic prophylaxis initiative can effectively decrease the time to antibiotic administration for patients with open fractures. We aim to determine whether adherence to the protocol decreased over time without active input from the orthopaedic trauma team. PATIENTS AND METHODS: This retrospective cohort study included adult patients with open fractures (excluding hand) presenting directly to the emergency department at one Level I trauma center. Three separate 50-patient groups were included: a preimplementation cohort, immediately postimplementation cohort, and a retention cohort 2 years later. The primary outcome was time from emergency department presentation to antibiotic administration, and secondary outcomes were the percentage of patients receiving antibiotics within 60 minutes and incidence of infection requiring revision surgery within 90 days. The χ2 and Student t-tests evaluated between-group differences, and multivariable linear or logistic regression evaluated risk factors. RESULTS: After implementation, the time from presentation to antibiotic administration decreased markedly from 123.1 to 35.7 minutes and remained durable (50.0 minutes) at retention. The proportion of patients receiving antibiotics within 60 minutes increased markedly from 46% preimplementation to 82% postintervention and remained similar at retention (80%). The postintervention and retention groups were markedly more likely to receive antibiotics within 60 minutes than the preintervention group (odds ratio [OR], 8.4 and 4.7, respectively), as were patients with a higher Gustilo-Anderson type (OR, 2.4/unit increase), lower extremity injury (OR, 2.8), and male sex (OR, 3.1); mechanism, age, and Injury Severity Score were not associated. No difference was observed in infection. CONCLUSIONS: Our educational initiative showed durable results in reducing the time from presentation to antibiotic administration after 2 years. LEVEL OF EVIDENCE: Therapeutic Level III.