The Effect of Forearm Shortening on Forearm Range of Motion.

PURPOSE: Osseous shortening of the forearm is performed during forearm replantation; however, no large clinical reviews have discussed its effects on patient outcomes. A recent cadaver study demonstrated the progressive loss of forearm pronation/supination ranges of motion with increased shortening lengths using external fixation. Our study aimed to quantify the effects of shortening on passive forearm motion using internal fixation after 2, 4, and 6 cm of mid-forearm shortening. METHODS: A volar Henry approach and direct approach to the ulna were used on 8 cadaveric specimens. The forearms were sequentially shortened by 2, 4, and 6 cm. Fixation was performed on the volar surfaces of the radius and ulna. Pronation and supination of the forearms were tested by applying 1 Nm of torque at baseline and after the fixation of both the radius and ulna using osteotomy. Radiographs and measurements were obtained at each phase to determine the maximum radial bow and radioulnar gap. Data were analyzed using a linear mixed-effects model. RESULTS: Greater shortening of the radius and ulna led to progressively greater reductions in both pronation and supination range of motion. Larger differences were seen in supination at 2-4 cm of shortening and in pronation at 4-6 cm of shortening. Changes in supination were found to be associated with the radial bow and radioulnar gap; changes in pronation were found to be associated with the radial bow and radial bow's location. CONCLUSIONS: This study demonstrates that quantifiable effects on passive forearm motion occur after osseous shortening of the forearm. CLINICAL RELEVANCE: This information may improve surgeons' and patients' understanding of the changes in forearm motion expected after shortening in the setting of replantation or tumor resection or in the setting of limb salvage of a mangled extremity.

Using a Comanagement Model to Develop a Hip Fracture Integrated Care Pathway.

EXECUTIVE SUMMARY: Hip fracture care represents a service line that profoundly affects patients' quality of life. As hospitals and physicians are motivated to improve quality, reduce costs, and maximize efficiency of care, several alignment models have been proposed under new healthcare legislation. Evaluation of such models as they pertain to hip fracture care warrants further investigation. In this article, we identify the current model of operations present in large healthcare organizations, examine the reasoning behind hospital-physician alignment, and describe specific comanagement principles that are common in healthcare settings. Furthermore, the effects of a comanagement model on a hip fracture integrated care pathway will be demonstrated through a case study. A comanagement team was formed at a Level I academic trauma center to create an integrated care pathway for the hip fracture service line. An internal data review of hip fracture cases before and after implementation of the pathway was undertaken to assess the impact of this model in terms of postoperative outcomes and resource utilization. The postimplementation group displayed more observant care while consuming fewer resources. Thus, the comanagement model described in this article serves as a powerful tool, allowing hospitals and physicians to improve the quality of care. This study provides recommendations based on our success in the hip fracture setting that may be extrapolated to improve service lines and healthcare efficiency nationally.

Novel Surgical Approach to Segmental Bone Transport Using a Magnetic Intramedullary Limb Lengthening System.

Posttraumatic bone defects (BDs) remain a difficult complication for orthopaedic surgeons. Surgical goals in these reconstructive cases are to create stable limb fixation, maintain limb length, and provide adequate soft-tissue coverage. Historically, surgical approaches in these cases have required the use of an external fixator, which is associated with several postoperative complications. A plate-assisted bone segment transport (PABST) technique using a magnetic limb lengthening system eliminates the need for an external fixator and is effective for these reconstructive cases. A 51-year-old male patient presented as a category I trauma after a motorcycle collision. Osseous injury was defined as Gustilo-Anderson type IIIB distal tibia and fibula fracture (AO 42-C2). After fixation failure, the PABST technique was performed using a magnetic intramedullary limb lengthening system. Radiographic union was achieved 18 months postoperatively. This innovative surgical technique is effective in treating posttraumatic BDs without the need for limb shortening or the use of an external fixator. PABST has the potential to decrease postoperative complications in BD reconstructive cases using all-internal technology designed for limb lengthening. PABST, in this instance, uses a magnetic intramedullary nail that is controlled with a hand-held external remote to allow for precise, adjustable, and bidirectional bone segment transport.

Implementation of a Hip Fracture Care Pathway Using Lean Six Sigma Methodology in a Level I Trauma Center.

INTRODUCTION: The application of Lean Six Sigma (LSS) methodology with regard to hip fracture care remains unexamined. The aim of this study is to illustrate the application of LSS principles in the implementation of a hip fracture integrated care pathway (ICP). METHODS: A multidisciplinary team at a level I trauma center formed a hip fracture ICP using LSS principles. An ICP aimed toward decreasing time to surgery to <48 hours was implemented in April 2012. RESULTS: A total of 505 hip fracture patients met inclusion criteria. A total of 221 patients entered the preimplementation cohort, and 284 were incorporated in the postimplementation cohort. The percentage of patients who received surgical fixation beyond 48 hours significantly decreased (9.50% versus 4.23%; P = 0.01). Significantly more complications were detected in the postimplementation cohort (62.44% versus 80.10%; P < 0.01). The postimplementation cohort showed a significantly shorter length of stay (P = 0.02) and decreased hospital cost (P = 0.016). CONCLUSION: Our findings suggest that using LSS methods in an ICP at our institution resulted in markedly greater percentage of patients receiving surgical care within 48 hours, greater detection of complication, and reduced resource consumption.

Thrower's Fracture of the Humerus: An Investigation of Risk Factors Following an Unlikely Scenario: A Case Report.

CASE: A 26-year-old amateur baseball player without prodromal arm pain sustained a thrower's fracture of the humerus on a warm-up throw performed with submaximal effort. The fracture occurred during the first throwing session following a 6-week layoff. The patient was treated nonoperatively and made a full recovery, but he elected to not return to throwing sports. CONCLUSION: Because of the lack of risk factors in this case, we suggest that time off or irregularity in throwing may play a greater role in a thrower's fracture than previously established. Recreational throwers should undergo appropriate preseason training before returning to throwing.

Effect of Time of Operation on Hip Fracture Outcomes: A Retrospective Analysis.

INTRODUCTION: Hip fractures are a common source of morbidity, mortality, and cost burden for elderly patients. We conducted a retrospective analysis of patients with hip fracture treated during the day or night at a rural level I academic trauma center and compared the postoperative outcomes and resource utilization for both groups. METHODS: Patients aged ≥55 years with hip fractures treated with definitive surgical fixation from April 2011 to April 2013 were included in this study. Patients who underwent surgery between 7 AM and 5 PM were included in the day cohort, while those who underwent surgery between 5 PM and 7 AM were included in the night cohort. A total of 441 patients met the study inclusion criteria. RESULTS: Comparison of the baseline characteristics of the two cohorts did not demonstrate significant variance. Although postoperative outcomes and resource utilization trends varied between the day and night cohort, only in-hospital cost was significantly higher in the day cohort (P = 0.04). Postoperative variables, including blood loss, [INCREMENT]hematocrit level, length of surgery, length of stay, time to surgery, in-hospital mortality, and 30-day readmission, did not vary significantly. CONCLUSION: Our study demonstrates a significantly higher cost associated with hip fracture procedures performed between 7 AM and 5 PM. In addition, perioperative blood loss and length of surgery were used as markers of physician fatigue; however, no statistically significant difference among these variables was found between hip fracture intervention performed during the day versus at night. LEVEL OF EVIDENCE: III, retrospective observational study.

Affordable Care Organizations and Bundled Pricing: A New Philosophy of Care.

Under the Patient Protection and Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services' Innovation was chartered to develop new models of health care delivery. The changes meant a drastic need to restructure the health care system. To minimize costs and optimize quality, new laws encourage continuity in health care delivery within an integrated system. Affordable care organizations provided a model of high-quality care while reducing costs. Bundled payments can have a substantial effect on the national expenditures. This article examines new developments in bundle payments, affordable care organizations, and gainsharing agreements as they pertain to arthroplasty.