Risk factors for the development of heterotopic ossification after acetabular fracture fixation.

BACKGROUND: Heterotopic ossification (HO) is a common complication of the operative treatment of acetabular fractures. Although the surgical approach has been shown to correlate with the development of ectopic bone, specific risk factors have not been elucidated. QUESTIONS/PURPOSES: The purposes of this study were to determine specific risk factors associated with the development of severe HO and the frequency with which patients develop severe HO after acetabular fracture fixation through an isolated Kocher-Langenbeck approach. METHODS: Using an institutional orthopaedic trauma database at a regional Level I trauma center, patients undergoing open treatment of acetabular fractures during the study period (January 2000 to January 2010) were identified. A review of medical records and imaging studies was performed on 508 patients who were treated by the senior author (MR) through an isolated Kocher-Langenbeck approach. During the study period, the senior author used indomethacin for HO prophylaxis in patients who had ipsilateral femur fracture treated with antegrade reamed medullary nailing or severe local soft tissue injury; 49 (10%) of the patients he treated with the Kocher-Langenbeck approach received prophylaxis, and they were excluded from this study, leaving a total of 459 patients who met inclusion criteria. Of those, 147 (29%) were lost to followup or did not have radiographs both before and at a minimum of 6 weeks (median, 1 week; range, 0-3 weeks), leaving 312 (61% of the patients treated with the Kocher-Langenbeck approach during this time) available for this analysis. Demographic data as well as information related to cause of injury, associated periacetabular findings, other system injuries, and treatment were gathered. Final followup radiographs were assessed for the presence of ectopic bone by two of the authors (TJO, AS) using the modified Brooker classification. Logistic regression was performed to identify possible predictors of development of severe ectopic bone. RESULTS: The only predictor we identified for the development of severe HO was the need for prolonged mechanical ventilation (odds ratio, 7.1; 95% confidence interval, 2.9-17.3; p=0.001). Injury Severity Score, sex, presence of comminution, femoral head impaction, dislocation, degloving injury, debris in the joint, number of other fractures, and head and chest Abbreviated Injury Score>2 did not correlate with severe HO. Severe HO (Brooker Class III or IV) developed in 38 of 312 patients (12%). CONCLUSIONS: Patients with prolonged mechanical ventilation might benefit from HO prophylaxis given the increased risk of developing severe HO in this patient population. However, future prospective studies need to be performed to verify this finding given the fact that a considerable number of patients were prophylactically treated in this study. LEVEL OF EVIDENCE: Level IV, prognosticstudy. See Guidelines for Authors for a complete description of levels of evidence.

Clinical and financial comparison of operative and nonoperative treatment of displaced clavicle fractures.

HYPOTHESIS: Surgical stabilization of displaced clavicle fractures was once considered to have rare indications. Our purpose was to present the clinical and economic effects of surgical management using data collected from operative and nonoperative patients. METHODS: Our fracture database was queried from January 1, 2005, to January 1, 2010, identifying 204 patients with displaced midclavicular fractures. Radiographs and charts were reviewed, and questionnaires were distributed. RESULTS: Operative patients had less chronic pain (6.1% vs 25.3%), less cosmetic deformity (18.2% vs 32.5%), less weakness (10.6% vs 33.7%), less loss of motion (15.2% vs 31.3%), and fewer nonunions (0% vs 4.8%). Operative patients missed fewer days of work (8.4 days vs 35.2 days) and required less assistance (3 days vs 7 days) for care at home. Mean income lost was $321.69 versus $10,506.25. Operative patients had a mean emergency department bill of $2,060.51 versus $1,871.92 and had a mean hospital bill of $8,520.30 versus $3,692.65, and anesthesia charges averaged $946.11. Operative patients required less physical therapy, and the mean physical therapy cost was $971.76 versus $1,820. Nonoperative patients required more pain medication ($43.22 vs $45.98). Overall, the cost was $12,976.94 for operative patients and $18,068.27 for nonoperative patients. CONCLUSIONS: Patients with displaced clavicle fractures benefit clinically and financially from stabilization. They have less chronic pain, less deformity, less weakness, and better range of motion. They return to work sooner, take less pain medication, and require less physical therapy. Their initial hospital bill is higher because of surgical charges but is balanced by less income loss, resulting in a cost savings of $5,091.33 in operative patients.

Screw Apophysiodesis for Chronic Ischial Apophysitis Refractory to Apophyseal Drilling in a Teenage Athlete: A Case Report.

CASE: A 17-year-old elite male soccer player, initially treated for chronic ischial apophysitis with transapophyseal drilling 18 months before, presented with persistent apophysitis symptoms and unfused apophysis on imaging. An open screw apophysiodesis was performed. The patient was able to gradually return to play and, within 8 months, was competing symptom-free at a high-level soccer academy. At 1 year postoperatively, the patient was still playing soccer and continued to be asymptomatic. CONCLUSION: In refractory cases not responding to conservative management or transapophyseal drilling, screw apophysiodesis may be used to obtain apophyseal closure with symptom resolution.

Scedosporium prolificans osteomyelitis in an immunocompetent child treated with a novel agent, hexadecylphospocholine (miltefosine), in combination with terbinafine and voriconazole: a case report.

We describe an 8-year-old girl who sustained multiple compound fractures in an accident involving agricultural equipment. She developed Scedosporium prolificans osteomyelitis of the pelvis, septic arthritis of the hip, and myositis of adjacent muscles. The infection progressed, despite extensive surgical debridement and joint washouts with 0.2% polyhexamethylene biguanide; antifungal therapy with caspofungin, terbinafine, and voriconazole; and adjunctive therapy with interferon-gamma. Gradual resolution was achieved after the addition of a novel agent, hexadecylphospocholine (miltefosine), and the continuation of terbinafine and voriconazole. This is the first report of the use of miltefosine as an antifungal agent in the management of severe infection with S. prolificans.

Frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns.

OBJECTIVES: Bicondylar tibial plateau fracture management remains therapeutically challenging, partly because of multiplanar articular comminution. This study was performed to evaluate the frequency and morphologic characteristics of the posteromedial fragment in this injury pattern. DESIGN: Retrospective chart and radiographic review. SETTING: Urban Level 1 university trauma center. PATIENTS: Fifty-seven patients sustaining 57 Orthopedic Trauma Association (OTA) C-Type bicondylar tibial plateau fractures formed the study group. MAIN OUTCOME MEASURE: Between May 2000 and March 2003, 170 OTA C-Type bicondylar tibial plateau fractures were identified using an orthopaedic database. One hundred and forty-six fractures had computed tomographic (CT) scans performed prior to definitive fixation and were reviewed using the Picture Archiving and Communication System (PACS). Sixty-six (45.2%) injuries had fractures that involved the medial articular surface. Nine with suboptimal CTs were excluded, leaving 57 injuries for review. Forty-two patients demonstrated coronal plane posteromedial fragments. Morphologic evaluation of the posteromedial fragment included articular surface area, maximum posterior cortical height (PCH), and sagittal fracture angle (SFA). RESULTS: Forty-two of 57 injuries (74%) demonstrated a posteromedial fragment that comprised a mean of 58% of the articular surface of the medial tibial plateau (range, 19%-98%) and a mean of 23% of the entire tibial plateau articular surface (range, 8%-47%). Mean posteromedial fragment height was 42 mm (range, 16-59 mm), and mean sagittal fracture angle was 81 degrees (range, 33 degrees to 112 degrees). Six patients demonstrated fracture patterns not accurately identified by the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) fracture classification system. CONCLUSIONS: A posteromedial fragment was observed in nearly one third of the bicondylar plateau fractures evaluated. The morphologic features of this fragment may have clinical implications when using currently available laterally applied fixed-angle screw/plate implants to stabilize these injuries. Alternate or supplementary fixation methods may be required when managing this injury pattern.

Operating Room Efficiency: Benefits of an Orthopaedic Traumatologist at a Level II Trauma Center.

OBJECTIVES: Fellowship-trained orthopaedic traumatologists are presumably taught skill sets leading to "best practice" outcomes and more efficient use of hospital resources. This should result in more favorable economic opportunities when compared with general orthopaedic surgeons (GOSs) providing similar clinical services. The purpose of our study was to compare the operating room utilization and financial data of traumatologists versus GOSs at a level II trauma center. DESIGN: Retrospective review. SETTING: Level II community-based trauma hospital. PATIENTS/PARTICIPANTS: Patients who presented to the emergency room at our institution with fractures and orthopaedic conditions requiring surgical intervention from January 1, 2010, to December 31, 2011. INTERVENTION: Operative fracture fixation by members of our orthopaedic trauma panel, including fellowship and nontrauma fellowship-trained orthopaedic surgeons. MAIN OUTCOME MEASUREMENTS: Our institutional database was queried to determine operative times, surgical supply and implant costs, and surgery labor expenses. Patients were stratified according to those treated by our trauma panel's 3 traumatologists and those treated by the 15 GOSs on our trauma panel. These 2 groups were then compared using standard statistical methods. RESULTS: A total of 6449 orthopedic cases were identified and 2076 of these involved fracture care. One thousand one hundred ninety-nine patients were treated by traumatologists and 877 by GOSs. There was no statistical difference detected in American Society of Anesthesiologists score between trauma and nontrauma groups. Overall, the traumatologist group demonstrated significantly decreased procedure times when compared with the GOS group (55.6 vs. 75.8 minutes, P , 0.0001). In 16 of 18 most common procedure types, traumatologists were more efficient. This led to significantly decreased surgical labor costs ($381.4 vs. $484.8; P < 0.0001) and surgical supply and implant costs ($2567 vs. $3003; P < 0.0001). CONCLUSIONS: This study demonstrates that in our communitybased trauma system, fracture care provided by traumatologists results in improved utilization of hospital-based resources when compared with equivalent services provided by GOSs. Significantly decreased operative times, surgical labor expenses, and supply and implant costs by the fellowship-trained group represent enhanced control of the design, plan, execution, and monitoring of orthopaedic trauma care. Traumatologists can provide leadership recommendations for operating room efficiency in community-based orthopaedic trauma care models. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Impact of Hospital-Employed Physician Assistants on a Level II Community-Based Orthopaedic Trauma System.

OBJECTIVES: The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospitalbased PAs on orthopaedic trauma care at a level II community hospital. DESIGN: Retrospective case series. SETTING: Level II trauma center. PATIENTS/PARTICIPANTS: One thousand one hundred four trauma patients with orthopaedic injuries. INTERVENTION: PA involvement. MAIN OUTCOME MEASUREMENTS: Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients. RESULTS: At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P . 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27). CONCLUSIONS: Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Operating room efficiency: benefits of an orthopaedic traumatologist at a level II trauma center.

OBJECTIVES: Fellowship-trained orthopaedic traumatologists are presumably taught skill sets leading to "best practice" outcomes and more efficient use of hospital resources. This should result in more favorable economic opportunities when compared with general orthopaedic surgeons (GOSs) providing similar clinical services. The purpose of our study was to compare the operating room utilization and financial data of traumatologists versus GOSs at a level II trauma center. DESIGN: Retrospective review. SETTING: Level II community-based trauma hospital. PATIENTS/PARTICIPANTS: Patients who presented to the emergency room at our institution with fractures and orthopaedic conditions requiring surgical intervention from January 1, 2010, to December 31, 2011. INTERVENTION: Operative fracture fixation by members of our orthopaedic trauma panel, including fellowship and nontrauma fellowship-trained orthopaedic surgeons. MAIN OUTCOME MEASUREMENTS: Our institutional database was queried to determine operative times, surgical supply and implant costs, and surgery labor expenses. Patients were stratified according to those treated by our trauma panel's 3 traumatologists and those treated by the 15 GOSs on our trauma panel. These 2 groups were then compared using standard statistical methods. RESULTS: A total of 6449 orthopedic cases were identified and 2076 of these involved fracture care. One thousand one hundred ninety-nine patients were treated by traumatologists and 877 by GOSs. There was no statistical difference detected in American Society of Anesthesiologists score between trauma and nontrauma groups. Overall, the traumatologist group demonstrated significantly decreased procedure times when compared with the GOS group (55.6 vs. 75.8 minutes, P < 0.0001). In 16 of 18 most common procedure types, traumatologists were more efficient. This led to significantly decreased surgical labor costs ($381.4 vs. $484.8; P < 0.0001) and surgical supply and implant costs ($2567 vs. $3003; P < 0.0001). CONCLUSIONS: This study demonstrates that in our community-based trauma system, fracture care provided by traumatologists results in improved utilization of hospital-based resources when compared with equivalent services provided by GOSs. Significantly decreased operative times, surgical labor expenses, and supply and implant costs by the fellowship-trained group represent enhanced control of the design, plan, execution, and monitoring of orthopaedic trauma care. Traumatologists can provide leadership recommendations for operating room efficiency in community-based orthopaedic trauma care models. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Why veteran orthopaedic trauma surgeons are being fired and what we can do about it?

The financial realities of providing trauma care to injured patients can make it difficult to produce an accurate assessment of the cumulative value orthopaedic trauma surgeons provide to healthcare and university institutions. As with many political battles in the field of medicine, physicians who have been diligently focused on providing patient care were completely unaware of the impending upheaval around them. Whether orthopaedic trauma surgeons are employed or in some type of partnership with hospitals, too often surgeons find the relationship one-sided. In order to effectively negotiate with hospitals, surgeons must demonstrate the comprehensive value they provide to their respective healthcare institutions and universities. Orthopaedic trauma surgeons make direct and indirect financial contributions to the hospital in addition to educational and community services. The sum total of these valued contributions helps fund non-revenue generating programs, provides marketing opportunities, and improves the regional and national reputation of the healthcare institution. This paper provides a comprehensive review of the value contributed to healthcare institutions by orthopaedic trauma surgeons and will serve as a blueprint for all surgeons to accurately account for and demonstrate their value to hospitals while providing efficient and compassionate care to our patients.

Early surgical stabilization of flail chest with locked plate fixation.

OBJECTIVES: To compare the results of surgical stabilization with locked plating to nonoperative care of flail chest injuries. DESIGN: Retrospective case-control study. SETTING: Level II trauma center. PATIENTS/PARTICIPANTS: From January 2005 to January 2010, 22 patients with flail chest treated with locked plate fixation were compared with a matched cohort of 28 nonoperatively managed patients at our institution. INTERVENTION: Open reduction internal fixation of rib fractures with 2.7-mm locking reconstruction plates. MAIN OUTCOME MEASUREMENTS: Demographic data, such as age, sex, injury severity score, number of fractures, and lung contusion severity, were recorded. Intensive care unit data concerning length of stay (LOS), tracheostomy, and ventilator days were noted. Operative data, such as time to OR, operative time, and estimated blood loss, were recorded. Hospital data, including total hospital LOS, need for reintubation, and home oxygen requirements, were documented. RESULTS: Average follow-up period of operatively managed patients was 17.84 ± 4.51 months, with a range of 13-22 months. No case of hardware failure, hardware prominence, wound infection, or nonunion was reported. Operatively treated patients had shorter intensive care unit stays (7.59 vs. 9.68 days, P = 0.018), decreased ventilator requirements (4.14 vs. 9.68 days, P = 0.007), shorter hospital LOS (11.9 vs. 19.0 days, P = 0.006), fewer tracheostomies (4.55% vs. 39.29%, P = 0.042), less pneumonia (4.55% vs. 25%, P = 0.047), less need for reintubation (4.55% vs. 17.86%, P = 0.34), and decreased home oxygen requirements (4.55% vs. 17.86%, P = 0.034). CONCLUSIONS: This study demonstrates the potential benefits of surgical stabilization of flail chest with locked plate fixation. When compared with case-matched controls, operatively managed patients demonstrated improved clinical outcomes. Locked plate fixation seems to be safe as no complications associated with hardware failure, plate prominence, wound infection, or nonunion were noted.

Financial impact of a dedicated orthopaedic traumatologist on a private group practice.

OBJECTIVE: The purpose of the study was to demonstrate the financial impact of the addition of a dedicated orthopaedic traumatologist to a private group practice at a Level II community-based trauma system. DESIGN: Retrospective review of financial records. SETTING: Level II trauma center and large group practice. METHODS: Office billing and financial data were evaluated for the 12 months before the addition of a dedicated, hospital-based, orthopaedic traumatologist and for a 2-year period after the hiring. Outcomes such as payor mix, collection rates, time to breakeven, days off, call days, evenings worked, durable medical equipment, and x-ray and casting reimbursement were analyzed. RESULTS: The addition of a dedicated traumatologist was financially beneficial for the partnership. Existing practices increased 23% in charges and 32% in collections despite partners taking more vacation days and 14% less call. This was partially the result of increased nontrauma referrals, full clinic templates, and uninterrupted elective operating room schedules. Over a 2-year period, elective arthroplasty cases increased 13.1%, elective arthroscopy cases increased 35.4%, and total patient office visits increased 18.8%. The payor mix for trauma patients was poorer than the group average; however, this was offset by decreased overhead requirements. Collections rate for the trauma partner in evaluation and management, surgery, casting, durable medical equipment, and radiology improved dramatically after the first year to become just slightly less than other clinic-specialized practices. The cost of bringing on a new trauma partner is substantial but regained after 6 months. CONCLUSIONS: A dedicated orthopaedic traumatologist can be extremely beneficial to a group practice and to the traumatologist given the appropriate case volume, payor mix, and a relative value unit-based payment system.