Orthopaedic surgery residents report little subjective or objective familiarity with healthcare costs.

PURPOSE: Residents have limited education regarding the cost of orthopaedic interventions. Orthopaedic residents' knowledge was surveyed in three scenarios involving an intertrochanteric femur fracture: 1) uncomplicated course with 2-day hospital stay; 2) complicated course necessitating ICU admission; and 3) readmission for pulmonary embolism management. METHODS: From 2018 to 2020, 69 orthopaedic surgery residents were surveyed. Respondents estimated hospital charges and collections; professional charges and collections; implant cost; and level of knowledge depending on the scenario. RESULTS: Most residents (83.6%) reported feeling "not knowledgeable". Respondents reporting "somewhat knowledgeable" did not perform better than those who reported "not knowledgeable". In the uncomplicated scenario, residents underestimated hospital charges and collections (p < 0.01; p = 0.87), and overestimated hospital charges and collections and professional collections (all p < 0.01) with an average percent error of 57.2%. Most residents (88.4%) were aware the sliding hip screw construct costs less than a cephalomedullary nail. In the complex scenario, while residents underestimated the hospital charges (p < 0.01), the estimated collections were closer to the actual figure (p = 0.16). In the third scenario, residents overestimated the charges and collections (p = 0.04; p = 0.04). CONCLUSIONS: Orthopaedic surgery residents receive little education regarding healthcare economics and feel unknowledgeable therefore a role for formal economic education during orthopaedic residency may exist.

Union and displacement characteristics following percutaneous screw fixation of superior pubic rami fractures.

PURPOSE: To determine union and displacement metrics following percutaneous screw fixation (antegrade or retrograde) of superior pubic rami fractures. METHODS: This is a retrospective cohort study from a single level 1 trauma center. Skeletally mature patients with at least one superior pubic ramus fracture present as part of a lateral compression-type pelvic ring injury were included. RESULTS: Eighty-five (85) patients with 95 superior pubic rami fractures met the study's inclusion criteria. LC1, LC2, and LC3 injuries occurred in 76.5%, 15.3%, and 8.2% of patients, respectively. The majority of patients underwent concurrent posterior pelvic ring fixation (94.1%). Superior ramus screw placement occurred predominantly via retrograde technique (81.1%) with cannulated screws of size 6.5 mm or larger (93.7%). Of the 95 eligible fractures, 90 (94.7%) achieved union at a mean of 14.0 weeks (7-40 weeks). Of these united fractures, 69 (76.7%) healed with no measurable displacement, while the remaining 23.3% healed with residual mean displacement of 3.9 mm (range: 0.5-9.0 mm). Multivariable analysis demonstrated a positive association between age (p = 0.04) and initial displacement (p = 0.04) on the final degree of residual displacement at union. A Kaplan-Meier survival analysis identified increased age to be significantly related to increased time to union (X2 (2) = 21.034, p < 0.001). CONCLUSIONS: Union rates following percutaneous screw fixation of superior pubic rami fractures associated with lateral compression-type pelvic ring injuries approach 95%. Though minimal in an absolute sense, increasing age and a greater degree of initial displacement may influence the final degree of residual displacement at union. LEVEL OF EVIDENCE: IV.

Altered cortical GABAA receptor composition, physiology, and endocytosis in a mouse model of a human genetic absence epilepsy syndrome.

Patients with generalized epilepsy exhibit cerebral cortical disinhibition. Likewise, mutations in the inhibitory ligand-gated ion channels, GABAA receptors (GABAARs), cause generalized epilepsy syndromes in humans. Recently, we demonstrated that heterozygous knock-out (Hetα1KO) of the human epilepsy gene, the GABAAR α1 subunit, produced absence epilepsy in mice. Here, we determined the effects of Hetα1KO on the expression and physiology of GABAARs in the mouse cortex. We found that Hetα1KO caused modest reductions in the total and surface expression of the ß2 subunit but did not alter ß1 or ß3 subunit expression, results consistent with a small reduction of GABAARs. Cortices partially compensated for Hetα1KO by increasing the fraction of residual α1 subunit on the cell surface and by increasing total and surface expression of α3, but not α2, subunits. Co-immunoprecipitation experiments revealed that Hetα1KO increased the fraction of α1 subunits, and decreased the fraction of α3 subunits, that associated in hybrid α1α3ßγ receptors. Patch clamp electrophysiology studies showed that Hetα1KO layer VI cortical neurons exhibited reduced inhibitory postsynaptic current peak amplitudes, prolonged current rise and decay times, and altered responses to benzodiazepine agonists. Finally, application of inhibitors of dynamin-mediated endocytosis revealed that Hetα1KO reduced base-line GABAAR endocytosis, an effect that probably contributes to the observed changes in GABAAR expression. These findings demonstrate that Hetα1KO exerts two principle disinhibitory effects on cortical GABAAR-mediated inhibitory neurotransmission: 1) a modest reduction of GABAAR number and 2) a partial compensation with GABAAR isoforms that possess physiological properties different from those of the otherwise predominant α1ßγ GABAARs.

The Association Between Orthopaedic Surgeon Academic Productivity Metrics and Compensation from Medical Industry.

INTRODUCTION: Academic research has value well beyond personal financial gain. However, these endeavors do require a notable amount of time and opportunity cost. Academic productivity may raise a researcher's profile within the field, increasing the likelihood for interactions with the medical industry and possibly cultivating relationships with future monetary significance. METHODS: Queries of the Centers for Medicaid and Medicare Services publicly available Open Payments System allowed for extraction of industry compensation data for orthopaedic surgeons. Aggregate data produce three compensation groups (mean annual income) for individual physicians: none; 1 to $100,000; and >$100,000. Physicians in the highest income category were matched 1:1 with physicians in each of the other two compensation groups. Selected physicians then underwent an academic productivity assessment. Queries of Web of Science, Scopus, and Google Scholar User Profile databases provided the h-index and m-index for each surgeon. Bivariate and multivariate analyses produced statistical results. In addition to the analysis of the tiered income groups, analysis of compensation as a continuous variable also occurred. RESULTS: From 2016 to 2020, 636, 7,617, and 22,091 US orthopaedic surgeons earned mean annual industry compensation >$100,000; between $1 and $100,000; and $0, respectively. Royalties (80.8%) predominated in the top earning group, compared with Consulting Fees (46.5%) in the second-tier group. The highest income group had higher h-index ($0 versus $1 to 100,000 versus >$100,000 = 3.6 versus 7.5 versus 20.0, P < 0.001) and m-index ($0 versus $1 to 100,000 versus >$100,000 = 0.26 versus 0.44 versus 0.80, P < 0.001) scores than either the intermediate or no compensation groups. In addition, h-index and m-index correlated positively with total compensation (h-index: r = 0.32, P < 0.001; m-index: r = 0.20, P < 0.001). Multivariable analysis of factors associated with increased industry compensation identified h-index (B = 0.034, P < 0.001) and years active (B = 0.042, P < 0.001) as having significant associations with physician compensation. Physician subspecialty also correlated with industry compensation. DISCUSSION: Academic research can provide invaluable contributions to the improvement of patient care. These efforts often require notable personal sacrifice with minimal direct remuneration. However, academic productivity metrics correlate positively with industry compensation, highlighting a possible supplementary benefit to scholarly efforts. LEVEL OF EVIDENCE: Level III.

Academic Productivity in Orthopaedic Traumatology Correlates Positively With Industry Compensation.

OBJECTIVE: To determine the association between academic productivity and industry compensation among Orthopaedic Traumatologists. DESIGN: Retrospective cohort study. SETTING: Review of the Centers for Medicaid and Medicare Services Open Payments program from 2016 to 2020. PARTICIPANTS: 1120 Orthopaedic Traumatologists. MAIN OUTCOME MEASUREMENTS: To determine if an Orthopaedic Traumatologist's h-index and m-index, as generated from Web of Science, Scopus, and Google Scholar User Profile databases, correlate with total payments from medical industry in 7 categories, including Royalties and Licensing Fees, Consulting Fees, Gifts, Honoraria, and 3 unique Speaking Fee delineations. RESULTS: Of 30,343 Orthopaedic Surgeons in the Open Payments program, 1120 self-identified with the Orthopaedic Trauma taxonomy. From 2016 to 2020, 499 surgeons (44.6%) received compensation in one of the eligible categories, most commonly from Consulting Fees (67.3%), though payments from Royalties provided the greatest gross income (70.4%). Overall, for all 1120 surgeons, h-index (r = 0.253, P < 0.001) and m-index (r = 0.136, P < 0.01) correlated positively with mean annual total industry compensation. The highest annual compensation group had higher h-index ($0 vs. $1-$1k vs. $1k-$10k vs. >$10k: 5.0 vs. 6.6 vs. 9.6 vs. 16.8, P < 0.001) and m-index ($0 vs. $1-$1k vs. $1k-$10k vs. >$10k: 0.48 vs. 0.60 vs. 0.65 vs. 0.89, P < 0.001) scores than either the intermediate or the no compensation groups. Multivariable analysis of factors associated with increased industry compensation, including H-index and years active, identified both as having significant associations with physician payments [H-index (B = 0.073, P < 0.001); years active (B = 0.059, P < 0.001)]. Subgroup analysis of the highest annual earner group (>$250k/year) also demonstrated the highest overall h-index (27.6, P < 0.001) and m-index (1.23, P = 0.047) scores, even when compared with other high-earners ($10k-$50k, $50k-$250k). Overall, each increase in h-index above an h-index of 3 was associated with an additional $1722 (95% CI: $1298-2146) of annual industry compensation. CONCLUSIONS: Academic productivity metrics have a positive association with industry compensation for Orthopaedic Traumatologists. This may highlight a potential ancillary benefit to scholarly efforts.

Academic productivity metrics correlate positively with industry funding amongst orthopedic shoulder and elbow surgeons.

Background: Research efforts can produce practice-changing results with widespread implications for patient care. While critical to the advancement of the field, such efforts do not often provide direct compensation. However, a researcher's academic productivity may facilitate industry relationships, either as the impetus for the affiliation or a result of collaboration. Methods: Queries of the Centers for Medicaid and Medicare Services publicly available Open Payments System allowed for extraction of industry compensation data for orthopedic surgeons in 7 categories, including royalties and licensing fees, consulting fees, gifts, honoria, and 3 unique speaking fees delineations. This system identifies physicians by taxonomy identifications; however, Centers for Medicaid and Medicare Services does not have a unique code for shoulder and elbow surgeons. Therefore, identification of shoulder and elbow surgeons proceeded utilizing the American Shoulder and Elbow Surgeons (ASES) society 2019 membership directory. Cross-referencing this membership list with extracted Open Payments data provided industry funding information for all ASES members. Physicians then underwent an academic productivity assessment. Queries of Web of Science, Scopus, and Google Scholar User Profile databases provided the Hirsch index (h-index) and m-index for each surgeon. Bivariate and multivariate analyses produced statistical results. Results: From 2016 to 2020, 631,130, 158, and 72 ASES members earned mean annual industry compensation <$1000, between $1001 and $10,000, between $10,001 and $100,000, and >$100,000, respectively. Royalties (91.5%) predominated in the top earning group, compared with consulting fees (58.0%, 55.0%) in the 2 middle-tier groups. H-index and m-index correlated positively with total compensation (h-index: r = 0.18, P < .001; m-index: r = 0.10, P < .001). The highest income group (>$100,000) had higher h-index and m-index scores than either intermediate ($1001-$10,000, $10,001-$100,000) or lowest (<$1000) compensation groups (From lowest to highest income bracket-h-index: 14.8 vs. 16.4 vs. 19.4 vs. 32, P < .001; m-index: 0.79 vs. 0.85 vs. 0.91 vs. 1.18, P = .003). Multivariable analysis of factors associated with increased industry compensation identified only h-index (B = 8046, P < .001) as having a significant association with physician compensation, with each single unit increase in h-index associated with an 18% increase in industry funding. Conclusion: Among a group of academic shoulder and elbow surgeons, industry compensation correlates positively with academic productivity metrics, with an associated $8046/yr increase in industry funding for each single-unit increase in h-index over 9. Future studies may focus on more clearly defining the causal directionality of these results.

Outcomes After Acute Versus Staged Fixation of Complete Articular Tibial Plafond Fractures.

OBJECTIVE: To determine the outcomes after acute versus staged fixation of complete articular tibial plafond fractures. DESIGN: Retrospective cohort study. SETTING: Single Level 1 Trauma center. PARTICIPANTS: 98 skeletally mature patients with OTA/AO 43C type fractures who underwent definitive fixation with plate and screw constructs and had a minimum 6 months of follow-up. INTERVENTION: Acute open reduction internal fixation (aORIF) versus staged (sORIF) definitive fixation. MAIN OUTCOME MEASUREMENT: Rates of wound dehiscence/necrosis and deep infection. RESULTS: Acute (N = 40) versus staged (N = 58) ORIF groups had comparable rates of vascular disease, renal disease, and substance/nicotine use, but aORIF patients had higher rates of diabetes mellitus (10% vs. 0%, P < 0.001), which correlated with higher American Society of Anaesthesiologist scores (>American Society of Anaesthesiologist 3: 37.5% vs. 13.8%, P = 0.02). Both groups achieved anatomic/good reductions, as determined by postoperative CT scans, at rates greater than 90%; however, the sORIF group required modestly longer operative times to achieve this outcome (aORIF vs. sORIF: 121 vs. 146 minutes, P = 0.02). Postoperatively, both groups had similar rates of wound dehiscence (2.5% vs. 6.9%, P = 0.65), superficial infections (10% vs. 17.2%, P = 0.39), and deep infections (10% vs. 8.6%, P = 0.99). While the injury pattern itself required free flap coverage in 1 patient in each group, unplanned free flap coverage occurred in 10.0% and 10.3% of aORIF and sORIF groups, respectively. Overall, rates of unplanned reoperations, excluding ankle arthrodesis, did not differ between groups (aORIF vs. sORIF:12.5% vs. 25.9%, P = 0.13). CONCLUSIONS: In select patients managed by fellowship-trained orthopaedic traumatologists, acute definitive pilon fixation can produce acceptable outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

High- Versus Low-Energy Intertrochanteric Hip Fractures in Young Patients: Injury Characteristics and Factors Associated With Complications.

OBJECTIVE: To compare fracture patterns and associated injuries for young patients with high- versus low-energy intertrochanteric hip fractures and to report on factors associated with complications after surgical fixation of high-energy fractures. DESIGN: Retrospective comparative study. SETTING: Academic Level 1 Trauma Center. PATIENTS: A total of 103 patients 50 years of age or younger were included: 80 high-energy fractures and 23 low-energy fractures. INTERVENTION: Cephalomedullary nailing (N = 92) or a sliding hip screw (N = 11). MAIN OUTCOME MEASURES: Radiographic characteristics of fracture morphology, implant position, and reduction quality and postoperative complications were the main outcome measures. RESULTS: Compared with young patients with low-energy fractures, those with high-energy fractures had more fracture comminution ( P = 0.013) and higher ISS scores ( P < 0.003) and were more likely to require open reduction ( P < 0.001). Patients with low-energy fractures from a ground-level fall had higher rates of alcohol abuse (0.032), cirrhosis (0.010), and chronic steroid use (0.048). Overall reoperation rate for high-energy fractures was 7%, including 2 IT fracture nonunions (5%) and 1 deep infection (2%). For high-energy fractures, ASA class ( P = 0.026), anterior lag screw position ( P = 0.001), and varus malreduction ( P < 0.001) were associated with malunion. Four-part fracture (OTA/AO 31A2.3/Jensen 5) ( P = 0.028) and residual calcar gap >3 mm ( P = 0.03) were associated with reoperation. CONCLUSIONS: Surgical treatment of high-energy IT fractures in young patients is technically demanding with potential untoward outcomes. Injury characteristics and severity are significantly different for young patients with high-energy IT fractures compared with low-energy fractures. For young patients with a high-energy IT fracture, surgeons can anticipate a high rate of associated injuries and complex fracture patterns requiring open reduction. For young patients with a low-energy IT fracture, comanagement with a hospitalist or a geriatrician should be considered because they may be physiologically older. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does a Reduced Secondary Operation Rate Offset Higher Implant Charges when Utilizing Suture Button Fixation for Syndesmotic Injuries?

OBJECTIVE: To determine whether a reduced secondary operation rate offsets higher implant charges when using suture button fixation for syndesmotic injuries. DESIGN: Retrospective cohort study. SETTING: Single, urban, Level 1 trauma center. PARTICIPANTS: Three-hundred twenty-seven (N = 327) skeletally mature patients with rotational ankle fractures (OTA/AO type 44) necessitating concurrent syndesmotic fixation. INTERVENTION: Suture button or solid 3.5-mm screw syndesmotic fixation. MAIN OUTCOME MEASUREMENTS: To compare implant charges with secondary operation charges based on differential implant removal rates between screws and suture buttons. RESULTS: Patients undergoing screw fixation were older (48.8 vs. 39.6 years, P < 0.01), had more ground-level fall mechanisms (59.3% vs. 51.1%, P = 0.026), and sustained fewer 44C type injuries (34.7% vs. 56.8%, P = 0.01). Implant removal occurred at a higher rate in the screw fixation group (17.6% vs. 5.7%, P = 0.005). Binomial logistic regression identified nonsmoker status (B = 1.03, P = 0.04) and implant type (B = 1.41, P = 0.008) as factors associated with implant removal. Adjusting for age, the NNT with a suture button construct to prevent one implant removal operation was 9, with mean resulting additional implant charges of $9747 ($1083/case). Backward calculations using data from previous large studies estimated secondary operation charges at approximately $14220, suggesting a potential 31.5% cost savings for suture buttons when considering reduced secondary operation rates. CONCLUSIONS: A reduced secondary operation rate may offset increased implant charges for suture button syndesmotic fixation when considering institutional implant removal rates for operations occurring in tertiary care settings. Given these offsetting charges, surgeons should use the syndesmotic fixation strategy they deem most appropriate in their practice setting. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Results of a Nationwide Practice Survey of Orthopaedic Traumatologists.

OBJECTIVE: To describe the current practice setting, clinical metrics, and reimbursements for orthopaedic traumatologists in the United States. DESIGN AND SETTING: Nationwide survey of orthopaedic traumatologists. PARTICIPANTS: Orthopaedic traumatologists with an active clinical practice. RESULTS: Five-hundred three orthopaedic traumatologists responded to the survey request. A plurality of respondents practiced in an academic setting (48%), with a majority in practice 10 years or less (54%), and having achieved the untenured (89%) rank of assistant professor (37%). For those within private groups, 62% had achieved "partner" status, generally within 1-3 years (53%) of employment. Most surgeons (85%) reported access to a dedicated orthopaedic trauma room, providing nearly all surgeons (97%) with a first start case on weekdays, but only 55% with a first start on weekends. The greatest degree of ancillary support came from physician assistants (80%). Orthopaedic traumatologists most often reported working between 51 and 70 hours per week (66%), with 4-6 nights of call/month (43%), 1 clinic day/week (42%), and with the majority of clinical volume (>75%) related to managing traumatic injury. More than half (53%) of respondents received compensation for call. Annual case volumes and wRVU varied widely. Commonly, respondents had 100% of their salary guaranteed (48%), and most reported eligibility for additional revenue through production bonuses (70%). Three subgroup analyses by years in practice, practice setting, and physician sex provider further insight into clinical characteristics. CONCLUSIONS: The results of this nationwide survey provide insight into the current clinical status of orthopaedic traumatology. Providers may find this information useful in job searches and contract negotiations.

An Anatomical Evaluation of the Trapezium and Its Relationship to Basilar Joint Osteophytic Change.

BACKGROUND: To perform a comprehensive osteologic investigation into trapezium anatomy and investigate the relationship between anatomical factors and osteophyte formation, focusing on sex-specific differences. METHODS: This was a cadaveric study involving 1233 trapezia and first metacarpals. Two subgroups ("Control" and "Main Study") were established. The "Control" cohort was used to identify features of the trapezium in specimens devoid of osteophytic change. The prevalence and severity of osteophytic change were investigated in the "Main Study" cohort. Sex differences were specifically assessed. Regression analyses were used to identify factors associated with osteophyte formation. RESULTS: Three discrete surface morphologies exist at the trapezium trapeziometacarpal (TM) facet: heart, quadrilateral, and bean. Controlling for height, men have a larger trapezium TM facet surface area. However, the trapezium assumes the same off-center saddle shape in both sexes. The presence of osteophytes at the basilar joint is a common finding; no differences in osteologic prevalence exist between sexes. The progression of osteophytic change complements the radiographic Eaton-Littler classification system. The trapezium TM facet increases the surface area with incremental osteophyte involvement, with the degree of surface area expansion correlated with increases in the severity of osteophytic change. Increased age, increased surface area, bean morphology, and decreased volar joint depth are associated with more severe osteophyte formation. CONCLUSIONS: Anatomical features of the trapezium may contribute to osteophyte development. Although the prevalence of osteophytic disease appears equal between sexes, sex differences exist in some anatomical parameters. These differences may help explain the increased prevalence of symptomatic basilar joint disease in women.

Weight-bearing status may influence rates of radiographic healing following reamed, intramedullary fixation of diaphyseal femur fractures.

OBJECTIVE: To investigate the effect of weight-bearing status on radiographic healing of diaphyseal femur fractures. DESIGN: Retrospective 1:1 matched cohort study. SETTING: Single-level 1 trauma center. PARTICIPANTS: One-hundred forty-four (N = 154) patients matched 1:1 in non-weight bearing (NWB) and weight-bearing as tolerated (WBAT) groups. INTERVENTION: Non-weight bearing following reamed, statically locked intramedullary fixation of diaphyseal femur fracture, generally due to concurrent lower extremity fracture. MAIN OUTCOME MEASUREMENT: Postoperative radiographic healing using modified Radiographic Union Scale for Tibia fractures (mRUST) scores. RESULTS: Groups were well matched on age, sex, race, prevalence of tobacco and alcohol use, diabetes mellitus status, Injury Severity Score, fracture pattern and shaft location, vascular injury, open fracture prevalence, and operative characteristics. Radiographic follow-up was similar between groups (231 vs 228 days, P = .914). At 6 to 8 weeks status post intramedullary fixation, the median mRUST score in the NWB group (9) was lower than that of the WBAT group (10) (mean: 8.4 vs 9.7, P = .004). At 12 to 16 weeks, the median mRUST in the NWB group (10) was again lower than the WBAT group (12) (mean: 9.9 vs 11.7, P = .003). The median number of days to 3 cortices of bridging callous was 85 in the WBAT group, compared with 122 in the NWB group (P = .029). Median time to mRUST scores of 12 (111 vs 162 days, P = .008), 13 (218 vs 278 days, P = .023), and 14 (255 vs 320 days, P = .028) were all longer in the NWB group compared with the WBAT group. CONCLUSIONS: Non-weight bearing after intramedullary fixation of diaphyseal femur fractures delays radiographic healing, with median time to 3 cortices of bridging callous increased from 85 days in WBAT groups to 122 days in NWB groups. These results provide clinicians with an understanding of the expected postoperative course, as well as further support the need to expeditiously advance weight-bearing status.Level of Evidence: IV.

Risk Factors for Posttraumatic Stress Disorder in Acute Trauma Patients.

OBJECTIVE: To identify risk factors for posttraumatic stress disorder (PTSD) after traumatic injury. SETTING: Single urban Level I trauma center. DESIGN: Prospective. PATIENTS/PARTICIPANTS: Three hundred men (66%) and 152 women treated for traumatic injuries were administered the PTSD checklist for a Diagnostic and Statistical Manual of Mental Disorders fifth edition (PCL-5) survey during their first post-hospital visit over a 15-month period. INTERVENTION: Screening for PTSD in trauma patients. MAIN OUTCOME MEASUREMENT: The prevalence of disease and risk factors for the development of PTSD based on demographic, medical, injury, and treatment variables. RESULTS: One hundred three patients screened positive for PTSD (26%) after a mean of 86 days after injury. Age less than 45 years was an independent risk factor for the development of PTSD [odds ratio (OR) 2.64, 95% confidence interval (CI) (1.40-4.99)]. Mechanisms of injury associated with the development of PTSD included pedestrians struck by motor vehicles [OR 7.35, 95% CI (1.58-34.19)], motorcycle/all terrain vehicle crash [OR 3.17, 95% CI (1.04-9.65)], and victims of crime [OR 3.49, 95% CI (0.99-9.20)]. Patients sustaining high-energy mechanism injuries and those who were victims of crime scored higher on the PCL-5 [OR 2.39, 95% CI (1.35-4.22); OR 4.50, 95% CI (2.52-8.05), respectively]. CONCLUSIONS: One quarter of trauma patients screened positive for PTSD at 3 months after their injury. A mechanism of injury is a risk factor for PTSD, and younger adults, victims of crime, and pedestrians struck by motor vehicles are at higher risk. These findings offer the potential to more effectively target and refer vulnerable patient populations to appropriate treatment. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a compete description of levels of evidence.

Factors influencing functional outcomes following open reduction internal fixation of acetabular fractures.

INTRODUCTION: Recent large series of patient-reported outcomes after acetabulum fracture are limited, and potentially modifiable risk factors may be unidentified. The goal of this study was to describe patient and injury factors which negatively influence functional outcomes following operative management of acetabular fractures. METHODS: 699 patients with acetabular fractures were treated with open reduction and internal fixation (ORIF). Musculoskeletal Function Assessment (MFA) questionnaire was completed after a minimum 12 months post-injury by 283 adults. MFA scores range from 1 to 100 and higher scores represent greater dysfunction. Factors were assessed for potential association with MFA scores, and univariate and multiple linear regression analyses were performed. RESULTS: Survey respondents were more severely injured than non-respondents, with more chest injury (38% vs 22%, p<0.001) and higher Injury Severity Score (19.3 vs 16.8, p=0.003). Patients were 69% male with mean age 44.0 years. Approximately one-third were smokers (31%), while 14% had comorbid diabetes mellitus type II. The majority of injuries occurred during a motor vehicle collision (65%); low-energy mechanisms were rare (4.2%). The most common fracture pattern was isolated posterior wall (23%), followed by transverse/posterior wall (21%). Heterotopic ossification (HO) was noted in 22%: Brooker 1: 29.5%, 2: 23.0%, 3: 32.8%, and 4: 14.8%. Tobacco use (ß = 18.4, p<0.001), obesity (ß = 0.39, p=0.009), diabetes (ß = 8.2, p=0.029), post-traumatic arthrosis (PTA) (ß = 5.94 p=0.035), and increasing HO severity (ß = 8.93, p<0.001) were independently associated with worse MFA scores. Tobacco use had the strongest association, followed by the severity of HO. CONCLUSION: In a large series of patient-reported functional outcomes following fixation of acetabular fractures, tobacco use, obesity, comorbid diabetes, PTA, and HO were associated with worse MFA scores. Further study to mitigate HO should be considered. LEVEL OF EVIDENCE: III.

Variations in Revenue Generation for the Care of Orthopaedic Trauma Patients.

BACKGROUND: In the background of increasing competition between trauma centers, this study investigated the relative reimbursement of trauma care provided in an urban trauma setting, comparing patients previously unknown (new) to the system, representing potential sources of new revenue, and those who were known (established), having received medical care previously in the same system. METHODS: A retrospective review of 440 patients with high-energy fractures at a single level 1 trauma center was conducted. Payment to charge (P/C) ratios for professional and facilities services within 6 months of injury were calculated. RESULTS: Mean professional charges per patient were $35,522 and $30,639 (P = 0.11), between new and established patients, respectively, whereas mean professional payments were statistically different, $7,894 and $4,365 (P < 0.001). Mean differences in P/C for facilities payments for new and established patients were not statistically significant, but professional P/C was higher in new patients (P < 0.001), consistent with better insured patients. DISCUSSION: Insurance companies reimburse for professional or facilities services with statistically different P/C ratios. Treating new patients at our institution likely benefits our institution by offering exposure to a more favorable payer mix and more complex patients. LEVEL OF EVIDENCE: Retrospective level III.

Five-year Trends in Opioid Prescribing Following Orthopaedic Trauma.

INTRODUCTION: Legislatures across the country are passing new opioid prescribing laws. To understand the effects of this legislation, baseline autonomous shifts in physician opioid prescribing must be evaluated. METHODS: The purpose of this retrospective dual cohort comparison study was to evaluate 5-year opioid prescribing trends in orthopaedic trauma patients. Demographic and injury information were collected on adult trauma patients with surgically managed orthopaedic fractures from 2012 (N = 190) and 2017 (N = 160). The amount of opioid medication prescribed from discharge to 1 year after the injury was collected. Opioid prescriptions were converted to morphine milligram equivalents (MMEs). The main outcome measure was opioid medication prescribed in 2017 versus 2012. RESULTS: The cohorts were well-matched on sex, race, medical comorbidities, substance use, fracture location, Injury Severity Score, hospital length of stay, and intensive care unit admission metrics. However, the 2012 cohort was older than the 2017 cohort (51.9 versus 43.3 years, P < 0.001). When controlling for age, total opioid medication prescribed was greater in 2012 than in 2017 (1,680 versus 1,110 MME, P = 0.001). Patients in 2017 received both lower discharge prescriptions (523 versus 407 MME, P < 0.001) and lower total opioid prescription refill amounts (1,140 versus 766 MME, P = 0.037). The number of refills prescribed was equal, but patients received lower amounts of opioid medications per refill in 2017 (333 versus 243 MME, P < 0.001). Despite these differences, the percentage of patients ceasing prescription opioid use 1 year after injury was unchanged (90.6% versus 92.1%, P = 0.675). DISCUSSION: Over 5 years, providers have successfully reduced the amount of opioid medication prescribed to surgically managed orthopaedic trauma patients through self-directed measures. The effects of opioid prescribing legislation should be viewed from this baseline.

Acute compartment syndrome of the deltoid: a case report and systematic review of the literature.

BACKGROUND: Deltoid compartment syndrome is a rare entity. The purpose of this study was to report a recent case and perform a systematic literature review. METHODS: Patient data were gathered from chart review and clinical encounters. For the review, the MEDLINE, Embase, and Ovid databases were queried for deltoid compartment syndrome cases. Seventeen articles reporting on 18 patients with deltoid compartment syndrome were included. RESULTS: Including our patient, 9 of 19 patients (47.4%) presented with compartment syndrome limited to the deltoid. Most patients presented with additional affected compartments, most commonly in the ipsilateral arm (7 of 19, 37%). Isolated deltoid involvement often resulted from iatrogenic injury; of 10 iatrogenic reports, 8 involved only the deltoid. Of 19 cases, 5 (26%) occurred in powerlifters, climbers, or anabolic steroid or testosterone injectors. In 13 of 19 cases (68%), the patients were men aged 18-36 years, and only 1 female case (5%) was reported. Prolonged recumbence owing to substance abuse was documented in 6 of 19 cases (32%). CONCLUSION: Deltoid compartment syndrome is rare, with only 19 reported cases, including our patient. Men are more commonly affected, and isolated deltoid compartment syndrome occurs in about 50% of reported cases. More than half of cases are iatrogenic, secondary to prolonged lateral decubitus positioning, injections, and surgical interventions about the shoulder. Prolonged recumbence from intoxication is also a common etiology. Providers should be aware of and recognize deltoid compartment syndrome to facilitate urgent surgical management.

Prevalence of posttraumatic stress disorder in acute trauma patients.

OBJECTIVE: To determine the prevalence of positive screening for posttraumatic stress disorder (PTSD) amongst trauma patients. DESIGN: Prospective, longitudinal study. SETTING: Single urban US level 1 trauma center. PATIENTS AND METHODS: Four hundred fifty-two adult trauma patients were administered the PTSD checklist for DSM-V (PCL-5) survey upon posthospital outpatient clinic visit. This included 300 men (66%) and 152 women with mean age 43.8 years and mean Injury Severity Score (ISS) 11.3, with 83% having fractures of the pelvis and/or extremities. Medical and injury related variables were recorded. Multivariate logistic regression analysis was performed to identify factors predictive of screening positive for PTSD. MAIN OUTCOME MEASUREMENT: Prevalence and risk factors for screening positive for PTSD amongst the trauma patient population. RESULTS: Twenty-six percent of trauma patients screened positive for PTSD after mean 86 days following injury. These patients were younger (35 vs 46 years old, P < 0.001) and more commonly African American (56% vs 43% Caucasian, P < 0.001). Pedestrians struck by motor vehicles (OR 4.70, P = 0.040) and victims of crime (OR 4.12, P = 0.013) were more likely to screen positive. Psychiatric history, injury severity (ISS), and injury type did not predict positive screening. CONCLUSION: One-in-four patients suffering traumatic injuries screened positive for PTSD suggesting the prevalence of PTSD among trauma patients far exceeds that of the general population. Predictive factors included victims of crime and pedestrians struck by motor vehicles. Screening measures are needed in orthopaedic trauma surgery clinics to refer these at-risk patients for proper evaluation and treatment. LEVEL OF EVIDENCE: Prognostic; Level II.

Appropriate Use Criteria for the Nonarthroplasty Treatment of Knee Osteoarthritis in Veterans.

While patients without knee instability use more nonarthroplasty treatments over a longer period prior to total knee arthroplasty, patients with less severe knee osteoarthritis are at risk of receiving interventions judged to be rarely appropriate.

The Trauma Service Line: Revenue From Subsequent Injury- and Noninjury-Related Care.

OBJECTIVE: To calculate the revenue generated for injury- and noninjury-related services after the initial injury event in an orthopaedic trauma population. DESIGN: Retrospective cohort study. SETTING: Single Level 1 trauma center. PARTICIPANTS: Four hundred forty adult trauma patients treated operatively for spine, pelvis, and/or upper or lower extremity fractures with ≥1 night stay. INTERVENTION: Operative fracture management. MAIN OUTCOME MEASUREMENT: Revenue for follow-up care and for noninjury-related indications for 24 months. RESULTS: Most patients returned for follow-up (92.3%), generating 6704 visits with professional and technical collections of $8,135,022 and $37,292,722, respectively, per 1000 unique patients. The greatest revenue was from rehabilitation services. Patients were less likely to return if they resided outside adjacent counties [odds ratio (OR) = 0.16], experienced a complication (OR = 0.38), or were older (OR per 10-year increase: 0.66) (all P < 0.0001). More than 70% of trauma patients were new to our system, accounting for 33% of all subsequent noninjury-related visits, most for primary care (25.6%). Male patients [OR = 3.28, 95% confidence interval (CI), 1.08-9.93], nonwhites (OR = 3.41; 95% CI, 1.41-8.28), and patients residing near the trauma center (OR = 16.1, 95% CI, 2.13-121) were more likely to return (P < 0.0001). Realized noninjury-related professional and technical revenue was $506 per operative orthopaedic trauma case. CONCLUSIONS: Demographics and outcomes predict likelihood of follow-up. Rehabilitation services account for the greatest revenue per patient. The greatest number of return visits was for primary care services; awareness of such services, especially in men and in those residing near the hospital system, could improve retention.