ON Path: outpatient nonunion pathway for lower-extremity nonunions.

Objectives: The purpose of this study was to assess the safety and efficacy of outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol. Design: Retrospective case series. Setting: Tertiary referral hospital and hospital outpatient department. Patients: All consecutive nonunion surgeries performed by 1 surgeon between 2014 and 2019 were identified. Outpatient and short-stay surgeries for patients with nonunion of the tibia and femur were eligible (n = 50). Intervention: Outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol. Main Outcome Measurements: Length of stay, postoperative emergency department visits, all complications, reoperations, and time to union. Results: Fifty patients were eligible, with 32 male patients (64%) and an average age of 46.5 years. The patient cohort consisted of 28 femur (56%) and 22 tibia (44%) nonunions. The average length of stay was 0.36 days. Seven patients (14%) required reoperation, 6 patients because of deep infection and 1 patient because of painful implant removal. Four patients (8%) presented to the emergency department within 1 week of surgery. One patient requiring amputation and patients lost to follow-up were excluded from the union rate calculation. For the remaining patients (46/50), 100% (46/46) united their nonunion. The average time to radiographic union was 7.82 months. Conclusions: An outpatient pathway is safe and effective for medically appropriate patients undergoing nonunion surgery. Outpatient nonunion surgery is a reasonable alternative that achieves similar outcomes compared with inpatient nonunion studies in the published literature. Level of Evidence: IV.

Balancing Safety, Comfort, and Fall Risk: An Intervention to Limit Opioid and Benzodiazepine Prescriptions for Geriatric Patients.

Introduction: This study reports on the impact of a clinical decision support tool embedded in the electronic medical record and characterizes the demographics, prescribing patterns, and risk factors associated with opioid and benzodiazepine misuse in the older adult population. Significance: This study reports on prescribing patterns for patients ≥65 years-old who presented to Emergency Departments (ED) or Urgent Care (UC) facilities across a large healthcare system following a fall (n = 34,334 encounters; n = 25,469 patients). This system implemented a clinical decision support intervention which provides an alert when the patient has an evidence-based risk factor for prescription drug misuse; prescribers can continue, amend or cancel the prescription. Results: Of older adults presenting with a fall, 31.4% (N = 7986) received an opioid or benzodiazepine prescription. Women and younger patients (65-74) had a higher likelihood of receiving a prescription (P < .0001). 11% had ≥1 risk factor. Women were more likely to receive an early refill (P = .0002) and younger (65-74) men were more likely to have a past positive toxicology (P < .0001). A prescription was initiated in 8,591 encounters, and 946 (9.0%) triggered an alert. In 58 cases, the alert resulted in a prescription modification, and in 80 the prescription was canceled. Conclusions: Documented risk for opioid misuse in the elderly was 10% among patients presenting to the ED/UC after a fall. The dangers associated with opioid/benzodiazepine use increase with age as does fall risk. Awareness of risk factors is an important first step; more work is needed to address potentially hazardous prescriptions in this population.

Preventing Fragility Fractures: A 3-Month Critical Window of Opportunity.

INTRODUCTION: Low-energy falls are the leading cause of injury-related morbidity and mortality in the elderly. In the past, physicians focused on treating fractures resulting from falls rather than preventing them. The purpose of this study is to identify patients with a hospital encounter for fall prior to a fracture as an opportunity for pre-injury intervention when patients might be motivated to engage in falls prevention. MATERIALS & METHODS: A retrospective analysis of all emergency room and inpatient encounters in 2016 with an ICD10 diagnosis code including "fall" across a tri-state health system was performed. Subsequent encounters with diagnosis of fracture within 2 years were then identified. Data was collected for time to subsequent fracture, fracture type and location, and length of stay of initial encounter. RESULTS: There were 12,382 encounters for falls among 10,589 patients. Of those patients, 1,040 (9.8%) sustained a subsequent fracture. Fractures were most commonly lower extremity fractures (661 fractures; 63.5%), including hip fractures (447 fractures; 45.87%). Median time from fall to fracture was 105 days (IQR 16-359 days). DISCUSSION: Falls are an important, modifiable risk factor for fragility fracture. This study demonstrates that patients are presenting to the hospital with one of the main modifiable risk factors for fracture within a time window that allows for intervention. CONCLUSIONS: Presentation to the hospital for a fall is a vital opportunity to intervene and prevent subsequent fracture in a high-risk population.

Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center.

OBJECTIVES: Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic. DESIGN: Retrospective chart review. SETTING: Outpatient visits (in-person, telephone, virtual-Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic. INTERVENTION: Virtual visits utilizing the Doxy.me platform. MAIN OUTCOME MEASURES: Accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). METHODS: All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). RESULTS: Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028). CONCLUSION: A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.