Impact of novel psychosocial programming on readmission and recidivism rates among patients with violence-related trauma.

INTRODUCTION: The Victims of Crime Advocacy and Recovery Program (VOCARP) provides advocacy, mental health resources, and educational materials. This study will report complications, readmissions, and recidivism among crime victims, and who used or did not use victim services. MATERIALS AND METHODS: Patients engaged with programming from 3/1/17 until 12/31/18 were included. Control groups were patients injured by violent trauma without VOCARP use (N = 212) and patients injured by unintentional injuries (N = 201). Readmissions, complications, reoperations, and trauma recidivism were reported. RESULTS: 1019 patients (83%) used VOCARP. VOCARP users were less often male (56% vs. 71%), less commonly married (12% vs. 41%), and had fewer gunshot wounds (GSWs, 26% vs. 37%) and sexual assaults (4.1% vs. 8%), all p < 0.05. Of all 1,423 patients, 6.6% had a readmission and 7.4% developed a complication. VOCARP patients had fewer complications (4.5% vs. 13.7%), infections (2% vs. 9%), wound healing problems (1% vs. 3.3%), and deep vein thromboses (0.3% vs. 1.9%), all p < 0.05, but no differences in unplanned operations (4.5%). GSW victims had the most complications, readmissions, and unplanned surgeries. Prior trauma recidivism was frequent among all groups, with crime victim patients having 40% prior violence-related injury (vs 9.0% control, p < 0.0001). Trauma recidivism following VOCARP use occurred in 8.5% (vs 5.7% for non-users, p = 0.16). CONCLUSION: Crime victims differ from other trauma patients, more often with younger age, single marital status, and unemployment at baseline. Complications were lower for VOCARP patients. GSW patients had the most complications, readmissions, and unplanned secondary procedures, representing a population for future attention.

Virtual visits among gynecologic oncology patients during the COVID-19 pandemic are accessible across the social vulnerability spectrum.

OBJECTIVE: The COVID-19 pandemic has quickly transformed healthcare systems with expansion of telemedicine. The past year has highlighted risks to immunosuppressed cancer patients and shown the need for health equity among vulnerable groups. In this study, we describe the utilization of virtual visits by patients with gynecologic malignancies and assess their social vulnerability. METHODS: Virtual visit data of 270 gynecology oncology patients at a single institution from March 1, 2020 to August 31, 2020 was obtained by querying a cohort discovery tool. Through geocoding, the CDC Social Vulnerability Index (SVI) was utilized to assign social vulnerability indices to each patient and the results were analyzed for trends and statistical significance. RESULTS: African American patients were the most vulnerable with a median SVI of 0.71, Asian 0.60, Hispanic 0.41, and Caucasian 0.21. Eighty-seven percent of patients in this study were Caucasian, 8.9% African American, 3.3% Hispanic, and 1.1% Asian, which is comparable to the baseline institutional gynecologic cancer population. The mean census tract SVI variable when comparing patients to all census tracts in the United States was 0.31 (range 0.00 least vulnerable to 0.98 most vulnerable). CONCLUSIONS: Virtual visits were utilized by patients of all ages and gynecologic cancer types. African Americans were the most socially vulnerable patients of the cohort. Telemedicine is a useful platform for cancer care across the social vulnerability spectrum during the pandemic and beyond. To ensure continued access, further research and outreach efforts are needed.

Frequent Sural Nerve Injury with Posterior Approach for Ankle Fracture Fixation.

INTRODUCTION: The purpose of this study was to report the incidence of iatrogenic sural nerve injury in a large, consecutive sample of surgically managed ankle fractures and to identify factors associated with sural nerve injury and subsequent recovery. We hypothesize that a direct posterior approach may be associated with higher risk of iatrogenic sural nerve injury. METHODS: A retrospective cohort study of 265 skeletally mature patients who sustained ankle fractures over a 2-year period was done. All were treated with open reduction and internal fixation of fractured malleoli. Patient, injury, and treatment features were documented. The presence (n = 26, 9.8%) of sural nerve injury and recovery of sural nerve function were noted. RESULTS: All 26 sural nerve injuries were iatrogenic, occurring postoperatively after open reduction and internal fixation. Patients who sustained sural nerve injuries had more ankle fractures secondary to motor vehicle collisions (23.1% versus 9.2%), more associated trimalleolar fractures (69.2% versus 33.9%), and more Orthopaedic Trauma Association/AO 44B3 fractures (57.7% versus 25.1%), all P < 0.05. A posterior approach to the posterior malleolus through the prone position was used in 20.4% of patients. All 26 of the sural nerve injuries (100%) occurred when the patient was placed prone for a posterior approach, P < 0.001. Therefore, 26 of the 54 patients (48%) treated with a posterior approach sustained an iatrogenic sural nerve injury. 62% of patients had full recovery of sural nerve function with no residual numbness, and patients with nerve recovery had fewer associated fracture-dislocations (23.1% versus 100%, P = 0.003). CONCLUSIONS: A posterior approach for posterior malleolus fixation was associated with a 48% iatrogenic sural nerve injury rate, with 62% recovering full function within 6 months of injury. Morbidity of this approach should be considered, and surgeons should be cautious with nerve handling. LEVEL OF EVIDENCE: Level III, Therapeutic.

Trauma recidivism is reduced with engagement in psychosocial programming following orthopaedic trauma.

INTRODUCTION: Recidivism is common following injury. Interventions to enhance patient engagement may reduce trauma recidivism. Education, counseling, peer mentorship, and other resources are known as Trauma Recovery Services (TRS). The authors hypothesized that TRS use would reduce trauma recidivism. METHODS: Over five years at a level 1 trauma center, 954 adults treated operatively for pelvic, spine, and femoral fractures were reviewed. Recidivism was defined as return to trauma center for new injury within 30-months. All patients were offered TRS. Multivariate logistic regression statistical analysis was used to identify predictors of recidivism. RESULTS: Three hundred and ninety-seven of all patients (42 %) utilized TRS, including educational materials (n = 293), peer visits (n = 360), coaching (n = 284), posttraumatic stress disorder (PTSD) screening (n = 74), and other services. Within the entire sample, 136 patients (14 %) returned to the emergency department for an unrelated trauma event after mean 21 months. 13 % of TRS users became recidivists. Overall, 49 % of recidivists had history of pre-existing mental illness. High rates of TRS engagement between recidivists and non-recidivists were seen (75 %); however, non-recidivists were more likely to use multiple types of recovery services (49 % vs 34 %, p = 0.002), and were more likely to engage with trauma peer mentors (former trauma survivors) more than once (91 % vs 81 %, p = 0.03). After multivariable analysis, patients using multiple different recovery services had a lower risk of recidivism (p = 0.04, OR 0.42, 95 % CI [0.19-0.96]). CONCLUSIONS: Multifaceted engagement with recovery programming is associated with less recidivism following trauma. Future study of resultant reductions in healthcare costs are warranted. LEVEL OF EVIDENCE: Level II; Prognostic.

Mortality Rates After Nonoperative Geriatric Hip Fracture Treatment: A Matched Cohort Analysis.

OBJECTIVE: To compare the mortality rate between geriatric patients with hip fracture treated nonoperatively and a matched cohort treated operatively. DESIGN: Retrospective Observational Matched Cohort Study. SETTING: Academic Level 1 Trauma Center. PATIENTS: Geriatric patients who sustained femoral neck and intertrochanteric/peritrochanteric fractures, excluding isolated greater trochanteric fractures. All patients older than 65 years with hip fractures over a 10-year period were identified. Operative patients were matched at a 2:1 ratio, when possible, to nonoperative patients based on Charlson Comorbidity Index and American Society of Anesthesiologists score. INTERVENTION: Nonoperative treatment or operative treatment (femoral neck fractures: cannulated screw fixation or hemiarthroplasty; intertrochanteric/peritrochanteric fractures: sliding hip screw or cephalomedullary nail fixation; or proximal femoral locking plate). MAIN OUTCOMES: Mortality calculated at 30 and 90 days, and 1-year after injury. Mortality was compared between groups using logistic regression while controlling for age, CVA/TIA, and dementia. RESULTS: Seven hundred seventy-two patients (171 nonoperative and 601 operative) were initially identified. After applying the matching algorithm, 128 nonoperative and 239 operative patients were included in the analysis. There were no significant differences in age, sex, Charlson Comorbidity Index, or American Society of Anesthesiologists score between the cohorts. Nonoperative patients had a significantly higher 1-year mortality rate than operative patients [46.1% vs. 18.0%, Odds Ratio (95% confidence interval): 3.85 (2.34-6.41), P < 0.001]. CONCLUSIONS: Geriatric patients with hip fracture treated nonoperatively had a 1-year mortality rate of 46.1%, more than double the rate among operative patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The economic impact of gunshot wounds on an urban level 1 trauma center.

INTRODUCTION: Firearm-related injuries impact the healthcare system, taxpayers, and injured patients due to lost productivity and reduced quality of life. The goal was to quantify the economic costs related to hospitalization for gunshot wounds (GSWs) at a single urban level 1 trauma center. MATERIALS AND METHODS: 941 patients over 27 months were treated for GSW. Elements related to hospitalization including length of stay, surgical procedures, medications and therapies, and subsequent readmission were identified, and costs were determined, inclusive of fixed and variable direct and indirect costs of facility care. Costs were classified based on body region: abdominal, chest, soft tissue, extremity or pelvic girdle, and head/neck/face. RESULTS: Mean age was 30 years, with 94% male. Most patients (81%) were admitted, and 8% sustained fatal injuries. Overall, 12% were seen previously or subsequently for additional, unrelated GSWs. Mean costs per patient were: $66,780 for abdominal GSWs; $3,986 for chest; $3,509 for soft tissue; $19,875 for extremities; $64,533 for head or neck, and means of $25,249 for two regions and $26,638 for three regions. Over the prospective period, 941 individuals sustained GSWs (approximately 35 per month). 37% were to the extremities, 23% were within the skin/subcutaneous tissue, 7% to the abdomen, 7% to the chest, 6% to the head or neck, and 20% to two or more body regions. Total facility costs for these 941 GSWs was $18.9 million, or $698,960 per month. 55% of the patients had Medicaid, and 33% were uninsured, resulting in substantial uncompensated expenses for the trauma center. CONCLUSION: Firearm-related injuries generate considerable expense. Our data underestimated cost, as professional services and indirect costs associated with lost economic productivity of patients and caregivers were excluded. No objective assessment of the disastrous personal and social impact was projected. Moving forward, interventions to prevent initial injury and recidivism in this high-risk population are crucial. LEVEL OF EVIDENCE: Level III.

Surgical Versus Nonsurgical Management of Acetabular Fractures With Associated Patterns in Elderly Patients: Factors Affecting Outcomes.

INTRODUCTION: Among elderly patients, anterior column posterior hemitransverse (ACPHT) and associated both column (ABC) are common acetabular fracture patterns after low-energy mechanisms. Given the paucity of outcomes data in this cohort, the goal of this study was to determine the favorability of results with surgical versus nonsurgical management. Secondarily, factors linked with poor functional outcomes were assessed. METHODS: Over a 16-year period, 81 patients aged ≥60 years with 82 ACPHT and ABC acetabular fractures were evaluated. Retrospectively, patient demographics, injury details, and early and late complications were collected. Functional outcomes were assessed with the Musculoskeletal Function Assessment (MFA) after a minimum of 12 months of follow-up. RESULTS: During the study period, 81 patients sustained 82 ACPHT (n = 35, 43%) or ABC (n = 47) fractures, most secondary to low-energy falls (71%). Patients managed surgically were younger, had higher-energy mechanisms, and more often had an associated hip dislocation or marginal impaction (all P < 0.05). Of note, 42.3% and 18.5% of patients had early and late complications, respectively, with no differences between surgical and nonsurgical groups. Posttraumatic arthrosis (PTA) was noted in 27% overall (36% surgical versus 16% nonsurgical, P = 0.10). The mean MFA score was 25.2 after 59 months. Better outcomes were associated with high-energy mechanisms, multiple injuries, and surgical management (all P < 0.05). The worst MFA outcomes were among patients with PTA (40.2) and those requiring a secondary procedure (45.7), both P < 0.05. DISCUSSION: Nonsurgical management had a low rate of PTA. Mitigating PTA and decreasing the rate of secondary surgeries seem crucial achieving satisfactory outcomes. Higher-energy injuries benefit from open reduction and internal fixation, as indicated by better MFA scores.

Factors Considered in Ranking Pediatric Orthopedic Fellowship Applicants: A Survey of Program Directors.

The field of orthopedic surgery continues to grow rapidly in popularity. Ninety percent of orthopedic residents pursue fellowship training after residency, representing the highest rate of subspecialty training among surgical specialties. The goal of this study was to determine the factors considered most important by pediatric orthopedic fellowship program directors (PDs) in evaluating applicants and determining a rank list. A web-based survey was sent to all 42 US pediatric orthopedic fellowship programs. The PDs were contacted through publicly accessible email addresses found on program websites or the Pediatric Orthopaedic Society of North America website. Respondents were asked to indicate the fellowship program size and the number of applicants interviewed and ranked each year. The PDs were then asked to rank a list of 12 factors to reflect the relative importance of these criteria in evaluating fellowship applicants. Three emails were sent: 1 at the initial survey release and 2 reminder emails at 2 and 4 weeks. Surveys were anonymous. The overall response rate was 69% (29 of 42). Of the responding PDs, 48% (14 of 29) indicated that the interview was the most important factor in ranking fellowship applicants, whereas 31% (9 of 29) considered the applicant's letters of recommendation most important. Personal connections to the applicant or letter writer and research experience were each considered most important by 10% of responding PDs. Nearly half (48%) of responding PDs considered in-person interviews the most important factor in ranking fellowship applicants. Our results provide useful information for medical students and orthopedic residents planning to pursue fellowship training in pediatric orthopedics. [Orthopedics. 2022;45(4):e207-210.].

"Did You Think You Would Die?": Fear of Death and Its Relationship to the Development of Posttraumatic Stress Disorder After Traumatic Injury.

INTRODUCTION: Patient-specific factors may influence posttraumatic stress disorder (PTSD) development and warrant further examination. This study investigates potential association between patient-reported fear of death at the time of injury and development of PTSD. METHODS: Over 35 months, 250 patients were screened for PTSD at their first posthospitalization clinic visit and were asked "Did you think you were going to die from this injury?" (yes or no). PTSD screening was conducted using the PTSD checklist for DSM-5 questionnaire. A score ≥33 was considered positive for PTSD, and patients were offered ancillary psychiatric services. Retrospectively, medical records were reviewed for baseline demographics and injury information. RESULTS: Forty-three patients (17%) indicated a fear of death. The mean age was 46 years, with patients who feared death being younger (36 versus 48, P < 0.001), and 62% were male. The most common mechanisms of injury were motor vehicle or motorcycle collisions (30%) and ground-level falls (21%). Gunshot wounds were more common among patients who feared death from trauma (44% versus 7%, P < 0.001). PTSD questionnaires were completed a median of 26 days after injury, with an average score of 12.6. PTSD scores were higher for patients with fear of death (32.7 versus 8.5), and these patients required more acute interventions (47% versus 7%), both P < 0.001. After multivariable logistic regression, patients who thought that they would die from their trauma had >13 times higher odds of developing PTSD (odds ratios: 13.42, P < 0.0001). Apart from positive psychiatric history (OR: 5.46, P = 0.001), no factors (ie, age, sex, mechanism, or any injury or treatment characteristic) were predictive of positive PTSD scores on regression. DICUSSION: Patients who reported fear of death at the time of injury were 13 times more likely to develop PTSD. Simply asking patients whether they thought that they would die at the time of injury may prospectively identify PTSD risk. LEVEL OF EVIDENCE: Prognostic Level II.

Single dose IV Antibiotic for Low-Energy Extremity Gunshot Wounds: A Prospective Protocol.

Objective: To prospectively determine infection rate following low-energy extremity GSWs with a single dose IV antibiotic protocol. Summary Background Data: Previous work suggests that a single IV antibiotic dose, without formal surgical debridement, mitigates infection risk. Methods: Over 35 months 530 adults with low-energy GSWs to the extremities were included. Three hundred fifty-two patients (66%) had ≥30 days follow-up. Patients were administered a single dose of first-generation IV cephalosporin antibiotics, and those with operative fractures received 24-hour perioperative antibiotics. Injury characteristics, treatment, protocol adherence, and outcomes (infection) were assessed between the protocol group (single-dose antibiotics) and the non-protocol group (no antibiotics or extra doses of antibiotics). Results: Compliance with the single-dose protocol occurred in 66.8%, while 33.2% received additional antibiotics or no antibiotics. The deep infection rate requiring surgical debridement was 0.8%, while the combined rate of all infections was 11.1%. Age, sex, injury location, multiple injuries, fracture presence, and type of surgery did not affect infection rate. Adherence to the antibiotic protocol was associated with a reduction in infection risk (odds ratio = 0.39, 95% confidence interval 0.19-0.83, P = 0.01). Receipt of additional antibiotics outside of our single-dose protocol did not predict further reduction in rate of infection (P = 0.64). Conclusions: A standardized protocol of single-dose IV antibiotic appears effective in minimizing infection after low-energy GSW to the extremities. Level of Evidence: Therapeutic Level II.

Using the STTGMA Risk Stratification Tool to Predict Complications, Additional Operations, and Functional Outcomes After Ankle Fracture.

OBJECTIVES: To determine the usefulness of a validated trauma triage score to stratify postdischarge complications, secondary procedures, and functional outcomes after ankle fracture. DESIGN: Retrospective cohort. SETTING: Level 1 trauma center. PATIENTS: Four hundred fifteen patients 55 years of age and older with 431 ankle fractures. INTERVENTION: Closed or open reduction. MAIN OUTCOME MEASUREMENTS: Score for Trauma Triage in Geriatric and Middle-Aged Patients (STTGMA), postdischarge complications, secondary operations, Foot Function Index (FFI, n = 167), and Short Musculoskeletal Function Assessment (SMFA, n = 165). RESULTS: Mean age was 66 years, 38% were men, and 68% of fractures were secondary to ground-level falls. Forty patients (9.6%) required an additional procedure, with implant removal most common (n = 21, 5.1%), and 102 (25%) experienced a postdischarge complication. On multiple linear regression, STTGMA was not a significant independent predictor of complications or secondary procedures. Patients completed FFI and SMFA surveys a median of 62 months (5.2 years) after injury. On the FFI, low-risk STTGMA stratification was an independent predictor of worse functional outcomes. Similarly, low-risk stratification was a predictor of worse scores on the SMFA dysfunction and daily activity subcategories (both B > 10, P < 0.05). CONCLUSIONS: Low-risk STTGMA stratification predicted worse long-term function. The STTGMA tool was not able to meaningfully stratify risk of postdischarge complications and secondary procedures after ankle fracture. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of Psychosocial and Economic Factors on Functional Outcomes After Operative Calcaneus Fractures.

OBJECTIVES: To report functional outcome scores after operative intraarticular calcaneus fracture and to determine risk factors associated with worse outcomes. DESIGN: Retrospective study. SETTING: Urban Level 1 trauma center. PATIENTS AND PARTICIPANTS: Ninety-six patients with 114 calcaneus fractures treated by a single surgeon over a 14-year period. INTERVENTION: Surgical treatment with open reduction and internal fixation with lateral extensile approach or percutaneous reduction and fixation. MAIN OUTCOME MEASUREMENTS: Functional outcome scores as assessed by the Musculoskeletal Function Assessment (MFA) and the Foot Function Index (FFI) after mean 56 months follow-up. RESULTS: Seventy-two patients (75%) completed functional outcome questionnaires. Patients with functional outcome data were more often employed (86% vs. 67%, P = 0.07), but were no different in terms of age, sex, medical history, mechanism of injury, or injury characteristics. The mean FFI score was 30 (range: 2-89), and the mean MFA score was 28 (range: 2-80). One-third of patients reported scores >30 on the FFI, MFA, or both. Age, sex, tobacco use, mechanism of injury, fracture pattern, open injury, and postoperative infection were not associated with outcome scores. Alcohol abuse and failure to return to work were associated with worse (higher) FFI scores. Alcohol abuse, psychiatric illness, unemployment (before and after injury), polytrauma, and posttraumatic osteoarthrosis were associated with worse (higher) MFA scores. CONCLUSIONS: Polytrauma, alcohol abuse, psychiatric illness, work status, and posttraumatic osteoarthrosis were predictors of poor functional outcomes. The findings of this study add to previous literature that has demonstrated the importance of social, behavioral, and environmental factors on recovery after orthopaedic injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Supination Adduction Ankle Fractures Are Associated With Arthritis and Poor Outcomes.

OBJECTIVE: To compare complications and functional outcomes between supination adduction type II (SAD) injuries and torsional ankle injuries (TAI). DESIGN: Retrospective cohort. SETTING: Level 1 trauma center. PATIENTS AND METHODS: Patients (n = 1531) treated for ankle fractures (OTA/AO 43B or 44) over 16 years were identified. The most recent 200 consecutive adult patients treated for TAI (OTA/AO 44, not SAD) served as controls. MAIN OUTCOME MEASURES: Complications, unplanned secondary procedures, and patient-reported functional outcome scores, as measured by the Foot Function Index and Short Musculoskeletal Function Assessment. RESULTS: Sixty-five patients with SAD injuries (4.2%) were included. They were younger (43.2 vs. 47.7 years, P = 0.08) and more commonly involved in a motorized collision, (58.5% vs. 29.0%) and more often multiply injured: other orthopaedic injuries (66.2% vs. 31.0%) and other nonorthopaedic injuries (40.0% vs. 7.5%, all P < 0.001 vs. TAI). Overall complication and unplanned secondary procedure rates were not different between groups. Those with a SAD injury had more posttraumatic arthrosis (80.0% vs. 40.9%, P = 0.004), but no differences were noted in infection, wound healing, malunion, or nonunion. The mean functional outcome scores were worse for SAD patients over 6 years after injury among all the Foot Function Index and Short Musculoskeletal Function Assessment categories; however, these differences were not significant. CONCLUSIONS: SAD injuries represented 4.2% of all ankle fractures, occurring in younger patients through higher-energy mechanisms and more often associated with polytrauma. Despite 80% of SAD patients developing posttraumatic arthrosis, secondary procedures were not more common, and functional outcomes after a SAD injury were not different from TAI. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Implementation of programming for survivors of violence-related trauma at a level 1 trauma center.

BACKGROUND: Prior investigation of violence intervention programs has been limited. This study will describe resources offered by Victims of Crime Advocacy and Recovery Program (VOCARP), their utilization, and effect on recidivism. METHODS: VOCARP was established in 2017 at our center, and all patients who engaged with programming (n=1019) were prospectively recorded. Patients are offered services in the emergency department, on inpatient floors and at outpatient clinic visits. Two control groups (patients sustaining violent injuries without VOCARP use (n=212) and patients with non-violent trauma (n=201)) were similarly aggregated. RESULTS: During 22 months, 96% of patients accepted education materials, 31% received financial compensation, 27% requested referrals, and 22% had crisis interventions. All other resources were used by <20% of patients. Patients who used VOCARP resources were substantially different from those who declined services; they were less often male (56% vs. 71%), more often single (79% vs. 51%), had greater unemployment (63% vs. 51%) and were less frequently shot (gunshot wound: 26% vs. 37%), all p<0.05. Overall recidivism rate was 9.4%, with no difference between groups. Use of mental health services was linked to lower recidivism rates (4.4% vs. 11.7%, p=0.016). While sexual assault survivors who used VOCARP resources had lower associated recidivism (2.4% vs. 12%, p=0.14), this was not statistically significant. DISCUSSION: This represents the largest violence intervention cohort reported to date to our knowledge. Despite substantial engagement, efficacy in terms of lower recidivism appears limited to specific subgroups or resource utilization. LEVEL OF EVIDENCE: Level II. Therapeutic.

Diagnosing Fractures of the Distal Tibial Articular Surface in Tibia Shaft Fractures: Is Computed Tomography Always Necessary?

OBJECTIVES: To identify the incidence of distal articular fractures in a series of distal third tibia shaft fractures and to report the utility of both computed tomography (CT) scans and Radiographic Investigation of the Distal Extension of Fractures into the Articular Surface of the Tibia (RIDEFAST) ratios for identification of articular involvement. DESIGN: Retrospective cohort. SETTING: Level 1 trauma center. PATIENTS: Four hundred seventeen patients with distal third tibia shaft fractures were included in the study. INTERVENTION: Intramedullary nail or plate fixation. MAIN OUTCOME MEASURES: Type of articular fracture, time of diagnosis, and RIDEFAST ratios. RESULTS: One hundred one of the 417 distal third fractures (24%) had a fracture of the distal tibia articular surface. Of these 101 fractures, 41 (41%) represented an extension of the primary fracture line and 60 (59%) were separate malleolar fractures. Of the 101 articular fractures, 95 (94%) were identified preoperatively and 6 (6%) were identified intraoperatively. Of the 95 fractures identified preoperatively, 87 (92%) were identified on plain radiographs and 8 (8%) by CT scan. Thirty-five preoperative CT scans were performed on distal third tibia shaft fractures in search of an intra-articular fracture. In 27 patients (77%), no articular fracture was present, representing an overall yield of 23% among CT scans performed to rule out an articular fracture in distal third tibia shaft fractures. RIDEFAST ratios for all 101 distal tibia shaft fractures with articular involvement and 100 fractures with no articular involvement were not significantly different (P > 0.05) using both coronal and sagittal plane measurements. CONCLUSIONS: CT scans performed on distal third tibia shaft fractures in search of articular fractures had a low yield (23%). Widespread use of CT scan to diagnose fractures of the distal tibia articular surface in the setting of distal tibia shaft fractures does not seem warranted. No statistically significant differences in RIDEFAST ratios were found between fractures with and without articular involvement, indicating that more work is necessary before RIDEFAST can be used to reliably rule out articular involvement in this setting. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reduction techniques for intramedullary nailing of tibial shaft fractures: a comparative study.

OBJECTIVES: To assess the impact of various reduction techniques on postoperative alignment following intramedullary nail (IMN) fixation of tibial shaft fractures. DESIGN: Retrospective comparative study. SETTING: Level I trauma center. PATIENTS: Four hundred twenty-eight adult patients who underwent IMN fixation of a tibial shaft fracture between 2008 and 2017. INTERVENTION: IMN fixation with use of one or more of the following reduction techniques: manual reduction, traveling traction, percutaneous clamps, provisional plating, or blocking screws. MAIN OUTCOME MEASURES: Immediate postoperative coronal and sagittal plane alignment, measured as deviation from anatomic axis (DFAA); coronal and sagittal plane malalignment (defined as DFAA >5° in either plane). RESULTS: Four hundred twenty-eight patients met inclusion criteria. Manual reduction (MR) alone was used in 11% of fractures, and adjunctive reduction aids were used for the remaining 89%. After controlling for age, BMI, and fracture location, the use of traveling traction (TT) with or without percutaneous clamping (PC) resulted in significantly improved coronal plane alignment compared to MR alone (TT: 3.4°, TT+PC: 3.2°, MR: 4.5°, P = .007 and P = .01, respectively). Using TT+PC resulted in the lowest rate of coronal plane malalignment (13% vs 39% with MR alone, P = .01), and using any adjunctive reduction technique resulted in decreased malalignment rates compared to MR (24% vs 39%, P = .02). No difference was observed in sagittal plane alignment between reduction techniques. Intraclass correlation coefficient (ICC) results indicated excellent intraobserver reliability on both planes (both ICC>0.85), good inter-observer reliability in the coronal plane (ICC = 0.7), and poor inter-observer reliability in the sagittal plane (ICC = 0.05). CONCLUSIONS: The use of adjunctive reduction techniques during IMN fixation of tibia fractures is associated with a lower incidence of coronal plane malalignment when compared to manual reduction alone. LEVEL OF EVIDENCE: Therapeutic Level III.

Fracture fixation in the polytrauma patient: Markers that matter.

Timing and type of fracture fixation in the multiply-injured trauma patient have been important and controversial topics. Ideal care for these patients come from providers who communicate well with one another in a team fashion and view the whole person, rather than focusing on injury to individual systems. This group encompasses a wide range of musculoskeletal and other injuries, further complicated by the broad spectrum of patients, with variability in age, medical and social comorbidities, all of which may have profound impact upon outcomes. The concept of Early Total Care arose from the realization that early definitive fixation of femur fractures provided pulmonary and systemic benefits to most patients. However, insufficient assessment and understanding of the physiological status of polytraumatized patients at the time of major orthopaedic procedures, potentially with inclusion of multiple other procedures in the same setting resulted in more morbidity, swinging the pendulum of care toward initial Damage Control Orthopaedics to minimize surgical insult. More recently, iterative assessment of response to resuscitation using Early Appropriate Care guidelines, suggests definitive fixation of most axial and femoral injuries within 36 h after injury appears safe in resuscitated patients, as measured by improvement of acidosis.

Improvement in Outpatient Follow-up With a Postdischarge Phone Call Intervention.

INTRODUCTION: Attending clinic appointments after injury is crucial for orthopaedic trauma patients to evaluate healing and to update recommendations. However, attendance at these appointments is inconsistent. The purpose of this study was to assess the effect of a personalized phone call placed 3 to 5 days after hospital discharge on attendance at the first postdischarge outpatient clinic visit. METHODS: This prospective study was done at an urban level 1 trauma center. One hundred fifty-nine patients were exposed to a reminder phone call, with 33% of patients being reached for a conversation and 28% receiving a voicemail reminder. Phone calls were made by a trained trauma recovery coach, and the main outcome measure was attendance at the first postdischarge clinic visit. RESULTS: Eighty-six patients (54%) attended their scheduled appointments. Appointment adherence was more common among the group reached for a conversation (70% versus 51% for voicemail cohort and 34% for no contact group). Patients exposed to the Trauma Recovery Services (TRS) during their hospital stay attended appointments more often (91% versus 61%, P = 0.026). Age, sex, mechanism of injury, and distance from the hospital were not associated with specific follow-up appointment adherence. Insured status was associated with higher attendance rates (71% versus 46%, P = 0.0036). Other economic factors such as employment were also indicative of attendance (64% versus 48%, P = 0.05). Current tobacco use was associated with poor appointment attendance (30%) versus 56% for nonsmokers (P = 0.001). DISCUSSION: Patients reached by telephone after discharge had better rates of subsequent clinic attendance. Economic factors and substance use appear vital to postoperative clinic visit compliance. Patients with met psychosocial needs, as identified by individuals with satisfactory emotional support, and exposure to TRS had the highest rates of postdischarge appointment attendance.

Predicting Length of Stay and Readmissions After an Ankle Fracture Using a Risk Stratification Tool (STTGMA).

OBJECTIVES: To determine the usefulness of a validated trauma triage score to stratify short-term outcomes including hospital length of stay (LOS), in-hospital complications, discharge location, and rate of readmission after an ankle fracture. DESIGN: Retrospective cohort. SETTING: Level 1 trauma center. PATIENTS: Four hundred fifteen patients, age ≥55 with 431 ankle fractures. INTERVENTION: Closed or open reduction. MAIN OUTCOME MEASUREMENTS: Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA). RESULTS: Of the 415 patients, 38% were male, 72% were white, and the mean age was 66 years. The mean LOS was 4.4 days, and this increased from 2.6 days in the minimal-risk group to 11.8 days in the high-risk group (P < 0.001). Similarly, 74% of minimal-risk patients were discharged home versus 13% of high-risk patients (P < 0.001). There were 19 readmissions (4.6%) within 30 days, ranging from 1.5% to 10% depending on the risk cohort (P = 0.006). Seventy-three patients (18%) experienced an in-hospital complication. On multiple linear regression, moderate- and high-risk STTGMA stratification was predictive of a longer hospital LOS, and moderate-risk STTGMA stratification was predictive of subsequent readmission after injury. CONCLUSIONS: Calculation of the STTGMA score is helpful for stratifying patients according to hospital LOS and readmission rates, which have substantial bearing on resource utilization and cost of care. The STTGMA tool may allow for effective identification of patients to potentially ameliorate these common issues and to inform payers and policymakers regarding patients at risk for greater costs of care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Are we missing the mark? Relationships of psychosocial issues to outcomes after injury: A review of OTA annual meeting presentations.

OBJECTIVES: To observe the availability of information about social, emotional, and psychological factors in abstracts presented at the Orthopaedic Trauma Association (OTA) annual meeting. DATA SOURCE: OTA website (https://ota.org/education/meetings-and-courses/meeting-archive/). STUDY SELECTION: All abstracts selected for paper or poster presentation at the 2016 through 2018 OTA annual meetings, as published in the final program. Studies were included if they sought to measure mental illness, substance use or abuse, pain, or other psychosocial issues. If studies utilized 1 or more patient-reported outcome measures (PROMs), they were also included. DATA EXTRACTION: For each abstract meeting inclusion criterion, studies were assessed for interventions intended to improve outcomes in any of the listed psychosocial domains. DATA SYNTHESIS/RESULTS: Nine hundred forty-two abstracts were evaluated over a 3-year period. Of these, 294 (31.2%) met inclusion criteria. Twenty-five abstracts (8.5% of 294) reported mental illness, with depression (n = 14), anxiety (n = 9), and posttraumatic stress disorder (n = 5) being the most common. Eighty-eight abstracts (29.9% of 294) reported substance-use of tobacco, alcohol, narcotics, and/or recreational drugs. Tobacco-use was most prevalent (n = 59), followed by opioid-use (n = 31). Ten abstracts reported substance abuse. Pain was measured in 95 abstracts, and 203 abstracts utilized PROMs. Thirty-five abstracts found that these psychosocial elements significantly impacted outcomes or complications. Many abstracts did not assess the influence of these factors on clinical outcomes (n = 99). Sixteen studies described an intervention aimed at mitigating these features. CONCLUSIONS: This study illustrates limited attention to the impact of psychological, social, and environmental factors on outcomes after orthopaedic trauma. Substance-abuse problems and mental health concerns are not only predictors of poor clinical and PROMs of pain and quality of life after injury, but have also been implicated in subsequent recidivism. Only 3% of 942 abstracts observed mental health and 1% reported substance-abuse. Moving forward, greater understanding of psychosocial issues may enhance interventions to impact long-term outcomes.