Comparable Outcomes Between Native and Periprosthetic Fractures of the Distal Femur.

Despite the rising prevalence of arthroplasty and aging population, limited data exist regarding differences in periprosthetic fracture clinical outcomes compared with native counterparts. This study compares differences in hospital treatment, morbidity, and mortality associated with periprosthetic distal femur fractures at an urban level 1 trauma center. We retrospectively reviewed all adult AO/OTA type 33 fractures (526) that presented to our institution between 2009 and 2018. In total, 54 native and 54 periprosthetic fractures were matched by age and gender. We recorded demographics, operative measures, length of stay (LOS), discharge disposition, and mortality. We used McNemar's and paired t-tests for analysis where appropriate (p < 0.05) (IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY; IBM Corp.). The average age at injury was 74 years ± 12 (native) compared with 73 years ± 12 (periprosthetic). After 1:1 matching, the groups had similar body mass index (31.01 vs. 32.98, p = 0.966 for native and periprosthetic, respectively) and mechanisms of injury with 38 native and 44 periprosthetic (p = 0.198) fractures from low-energy falls. Both groups had 51/54 fractures managed with open reduction internal fixation with a locking plate. The remaining were managed via amputation or intramedullary nail fixation. Mean operative time (144 minutes (±64) vs. 132 minutes (±62), p = 0.96) and estimated blood loss (319 mL (±362) vs. 289 mL (±231), p = 0.44) were comparable between the native and periprosthetic groups, respectively. LOS: 9 days ± 7 (native) versus 7 days ± 5 (periprosthetic, p = 0.31); discharge disposition (to skilled nursing facility/rehab): n = 47 (native) versus n = 43 (periprosthetic, p = 0.61); and mortality: n = 6 (native) versus n = 8 (periprosthetic, p = 0.55). No significant differences were observed. We found no statistical differences in morbidity and mortality in periprosthetic distal femur fractures treated over 10 years at a level 1 trauma center. Native and periprosthetic AO/OTA type 33 distal femur fractures are serious injuries with similar outcomes at a level 1 trauma center.

Which Application Factors Are Associated With Outstanding Performance in Orthopaedic Surgery Residency?

BACKGROUND: Identifying ideal candidates for orthopaedic surgery residency is difficult. Data available for applicant selection are evolving; preclinical grades and the Alpha Omega Alpha (AOA) honors society are being phased out at some medical schools. Similarly, three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have been eliminated. There is renewed interest in improving resident selection to provide a diverse, comprehensive educational opportunity that produces orthopaedic surgeons who are prepared for practice. QUESTIONS/PURPOSES: We sought to identify whether (1) academic achievements, (2) letters of recommendation, (3) research activity, and (4) miscellaneous factors available on Electronic Residency Application Service (ERAS) applications were associated with outstanding residency performance. METHODS: Ten faculty members (22% of all full-time faculty) with extensive educational involvement for at least 7 years, whose expertise covered all subspecialty departments at an urban, academic orthopaedic surgery residency program, were given an anonymous survey on the performance of the four most recent classes of residency graduates (24 residents). This survey was developed due to the lack of a validated residency outcomes tool or objective metrics for residency performance. The evaluated criteria were decided upon after discussion by a relatively large group of academic orthopaedic surgeons considering the factors most important for graduating orthopaedic residents. The faculty were selected based on their long-term knowledge of the residency, along with their diversity of specialty and backgrounds; there were no nonresponders. Faculty graded each resident on a scale from 1 to 10 (higher is better) on six criteria: surgical technical skills, research productivity, clinical knowledge, professionalism, personality, and fellowship match. The mean of the faculty ratings made by all faculty for all six criteria was calculated, producing the overall residency performance score. Factors available on each resident's ERAS application were then correlated with their overall residency performance score. Categorical ERAS factors, including AOA status, five or more honors in core clerkships, at least three exceptional letters of recommendation, collegiate athletics participation, expertise with a musical instrument, and research (6-year) track residents, were correlated with overall residency performance score via point biserial analysis. Continuous ERAS factors including USMLE Step 1 and Step 2 scores, number of publications before residency, number of research years before residency, medical school ranking, and number of volunteer experiences were correlated with overall residency performance score via Pearson correlation. USMLE Step 1 three-digit scores were evaluated despite their recent elimination because of their historic importance as a screening tool for residency interviews and for comparison to USMLE Step 2, which retains a three-digit score. Application factors with a p < 0.2 on univariate analysis (five or more honors in core clerkships, at least three exceptional letters of recommendation, research track residents) were included in a stepwise linear regression model with "overall residency performance score" as the outcome variable. All p values < 0.05 were considered significant. RESULTS: The mean overall residency performance score was 7.9 ± 1.2. Applicants with at least five honors grades in core clerkships had overall residency performance scores 1.2 points greater than those of their peers (95% confidence interval (CI) 0.3 to 2.0; p = 0.01, Cohen ƒ 2 = 0.2, representing a small effect size). ERAS applications including at least three exceptional letters of recommendation were associated with a 0.9-point increase in residency performance (95% CI 0.02 to 1.7; p = 0.046, Cohen ƒ 2 = 0.1, representing a small effect size). Participation in the residency research (6-year) track was associated with a 1-point improvement in residency performance (95% CI 0.1 to 1.9; p = 0.03, Cohen ƒ 2 = 0.2, again, representing a small effect size). Together, these three factors accounted for 53% of the variance in overall residency performance score observed in this study. CONCLUSION: Past clinical excellence, measured by core clerkship grades and exceptional letters of recommendation, is associated with slightly improved overall orthopaedic residency performance scores. Applicants meeting both criteria who also complete a research track residency may perform substantially better in residency than their counterparts, as these three factors accounted for half of all the variance observed in the current study. Although minimum requirements are necessary, traditionally used screening factors (such as USMLE scores, AOA status, medical school rank, and number of publications) may be of less utility in identifying successful future residents than previously thought. LEVEL OF EVIDENCE: Level III, therapeutic study.

Validation of the Artificial Floor Technique in First Metatarsophalangeal Joint Arthrodesis.

BACKGROUND: Patient function after arthrodesis of the first metatarsophalangeal joint (MTPJ) relies on proper positioning of the first MTPJ. To maximize the likelihood of good postoperative function, the dorsiflexion angle, referred to as the fusion sagittal angle, should range between 20° and 30°, corresponding to 10° to 15° of dorsiflexion off the weightbearing axis. However, achieving appropriate sagittal alignment intraoperatively is challenging. The artificial floor technique (AFT) uses a rigid, flat surface to simulate the weightbearing position of the foot intraoperatively to accurately position the first MTPJ without fluoroscopy. This technique has been previously described and is commonly used but, to our knowledge, it has never been validated. QUESTIONS/PURPOSES: (1) Is the AFT a valid and repeatable technique for positioning the fusion sagittal angle between 20° and 30° of dorsiflexion from the first metatarsal? (2) Does the fusion sagittal angle obtained using the AFT vary with foot size? METHODS: In this retrospective study, a search was performed using Current Procedural Terminology codes for patients undergoing first MTPJ arthrodesis by one surgeon between June 2012 and June 2020. The surgical technique used during this time did not vary and consisted of the use of a rigid, flat, sterile surface. The entire foot was placed flat on the surface, simulating the weightbearing position and allowing for an evaluation of the fusion sagittal angle of the first MTPJ. The target sagittal alignment was achieved when the soft tissue of the plantar surface at the distal-most aspect of the proximal phalanx was measured (using a sterile ruler) as 1 cm off the artificial floor. The recommended fusion sagittal angle falls within a range of 20° to 30°, which allows for 1-mm to 2-mm variations in measuring the elevation of the proximal phalanx off the artificial floor. Fixation was achieved with two 2.8-mm threaded, double-pointed Steinmann pins placed through the intramedullary canal of the proximal and distal phalanges and into the first metatarsal. Once fixation was achieved, the fusion sagittal angle was confirmed with the AFT without using fluoroscopy. Postoperatively, patients were allowed to bear weight fully on their heels in a postoperative, rigid-soled shoe. During the study period, 117 patients (135 feet) underwent first MTPJ arthrodesis utilizing the AFT for either first MTPJ arthritis/hallux rigidus, hallux valgus, or inflammatory arthropathy. Of those, we considered patients with preoperative AP and lateral weightbearing radiographs and patients with AP and lateral weightbearing radiographs at 3 months postoperatively after the removal of the internal fixation construct as eligible for analysis. Based on these criteria, 84% (113 of 135) of feet were included in the final radiographic analysis. Sixteen percent (22 of 135) of the feet were excluded because postoperative radiographs demonstrating the removal of the internal fixation construct were absent from the Picture Archiving and Communication System (PACS) in these cases. The length of the whole foot, first metatarsal, and proximal phalanx were measured on preoperative weightbearing radiographs. In addition, fusion sagittal angles were measured on weightbearing radiographs after removal of internal fixation construct at a minimum of 3 months postoperatively (mean 3.5 ± 2.2 months). No patients were lost to follow-up before obtaining those radiographs. Two qualified reviewers independently evaluated each radiograph. We ascertained inter- and intraobserver reliability using intraclass correlation coefficients (ICCs). We determined whether the fusion sagittal angle obtained using the AFT varied with foot size by using a multiple linear regression model. RESULTS: In the entire study group, the mean fusion sagittal angle using the AFT was 27° ± 4°. The interobserver ICC of the fusion sagittal angle measurements was 0.92 (95% confidence interval [CI] 0.56 to 0.97; p < 0.001). The intraobserver ICC for reviewer 1 was 0.95 (95% CI 0.92 to 0.97; p < 0.001) and the intraobserver ICC for reviewer 2 was 0.97 (95% CI 0.88 to 0.98; p < 0.001). Ninety-one percent (103 of 113) of the study group fell within the acceptable range of 20° to 30° ± 2°. The multiple linear regression analyses demonstrated that the preoperative lengths of the whole foot (ß =-0.05 [95% CI -0.12 to 0.02]; p = 0.16), proximal phalanx (ß =-0.13 [95% CI -0.46 to 0.20]; p = 0.44), and first metatarsal (ß = 0.13 [95% CI -0.10 to 0.35]; p = 0.27) were not independently associated with the postoperative fusion sagittal angle. CONCLUSION: The AFT allows for accurate and reproducible positioning of the first MTPJ within the appropriate functional range of dorsiflexion, regardless of foot size. Additionally, this technique can be performed without fluoroscopy and so avoids radiation exposure to the patient and the surgical team. LEVEL OF EVIDENCE: Level III, therapeutic study.

Patient Satisfaction Is Improved With Exposure to Trauma Recovery Services.

INTRODUCTION: The purpose of this study is to assess the impact of Trauma Recovery Services (TRS), a program facilitating engagement and recovery on satisfaction after orthopaedic trauma. METHODS: Two hundred ninety-four patients with surgically managed extremity fractures were prospectively surveyed. Satisfaction was assessed after 12 months using a 13-question telephone survey, rated on a Likert scale from 1 to 5 (with five being excellent). TRS resource utilization during and after hospitalization was recorded. Eighty-eight patients (30%) used TRS. RESULTS: Overall satisfaction was high with a mean score of 4.32. Although no differences were observed between the control group and patients with TRS utilization in age, sex, race, insurance, smoking history, or employment status, TRS patients sustained more high-energy mechanisms (81% versus 56%) and had more associated psychiatric illness (33% versus 17%), both P < 0.01. Multivariable regression indicated general exposure to TRS to be an independent predictor of higher overall care ratings (B = 1.31; P = 0.03). DISCUSSION: Utilization of TRS was the greatest predictor of better overall care ratings. This study builds on existing evidence demonstrating the positive impact of Trauma Survivor Network programming. We conclude that a hospital-wide program supporting patient education and engagement can effectively increase patient satisfaction after traumatic injury. LEVEL OF EVIDENCE: Prognostic Level II.

Factors associating with surgical site infection following operative management of malleolar fractures at an urban level 1 trauma center.

OBJECTIVES: To identify comorbidities and injury characteristics associated with surgical site infection (SSI) following internal fixation of malleolar fractures in an urban level 1 trauma setting. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seven-hundred seventy-six consecutive patients with operatively managed malleolar fractures from 2006 to 2016. INTERVENTION: Open reduction internal fixation. MAIN OUTCOME MEASUREMENTS: Superficial SSI (erythema and drainage treated with oral antibiotics and wound care) or deep SSI (treated with surgical debridement and antibiotics). RESULTS: Fifty-six (7.2%) patients developed SSI, with 17 (30%) of these being deep infections. An a-priori power analysis of n = 325 (α=0.05, ß=0.2) was tabulated for differences in univariate analysis. Univariate analysis identified categorical associations (P < .05) between SSI and diabetes mellitus, drug abuse, open fracture, and renal disease but not tobacco abuse, body mass index, or neuropathy. Multivariate logistic regression identified categorical associations between diabetes (OR = 2.2, 95% CI: 1.1-4.3), drug abuse (OR = 3.9, 95% CI: 1.2-12.7), open fracture (OR = 4.1, 95% CI: 1.3-12.8), and renal disease (OR = 2.7, 95% CI: 1.4-5.0) and any (superficial or deep) SSI. A separate multivariate logistic regression analysis found categorical associations between deep SSI requiring reoperation and diabetes (OR = 4.4, 95% CI: 1.6-12.2) and open fracture (OR = 4.1, 95% CI: 1.3-12.8). Furthermore, American society of anesthesiologists classification (ASA) Class 4 patients were (OR = 9.2, 95% CI: 2.0-41.79) more likely to experience an SSI than ASA Class 1 patients. CONCLUSIONS: Factors associated with SSI following malleolar fracture surgery in a single urban level 1 trauma center included diabetes, drug abuse, renal disease, and open fracture. The presence of diabetes or open type fractures were associated with deep SSI requiring reoperation. LEVEL OF EVIDENCE: Level 3 prognostic: retrospective cohort study.

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.

Self-Reported Recovery Likelihood Predicts Higher Physician Ratings: A Survey of Patients After Orthopaedic Surgery.

OBJECTIVES: What are the differences between elective and trauma patient satisfaction and do patient and diagnosis factors predict physician scores? DESIGN: Prospective cohort study. SETTING: Urban Level 1 Trauma center. PATIENTS/PARTICIPANTS: Three hundred twenty-three trauma patients and 433 elective orthopaedic patients treated at our center by the same surgeons. INTERVENTION: Trauma patients treated surgery for one or more fractures; elective patients treated with hip, knee, or shoulder arthroplasty, or rotator cuff repair. MAIN OUTCOME MEASUREMENTS: Telephone survey regarding patient experience and satisfaction with their care. The survey included questions from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, and responses were rated on a 1-5 point Likert scale (5 best). RESULTS: Elective surgery patients had mean age of 56.4 years, and trauma patients were mean 50.3 years of age. Trauma patients rated their likelihood to make a full recovery lower than elective patients (median, interquartile range), 5.0 (1.0) versus 4.0 (2.0) (P < 0.001). After multivariate binary logistic regression, patients who rated the hospital higher (≥4 vs. ≤3) were more likely (odds ratio = 10.0, 95% confidence interval, 6.4-15.8) to score physicians better. Similarly, patients who scored their overall likelihood of recovering ≥4 compared with ≤3 were more likely (odds ratio = 3.6, 95% confidence interval, 2.9-5.6) to rate their physicians more positively. CONCLUSIONS: Patient perceptions including their likelihood to make a full recovery and their overall impression of the hospital predicted higher physician scores. We conclude that these physician scores are subject to patient perception biases and are not independent of the overall care experience. We recommend HCAHPS and physician ratings' web sites include internal controls, such as the patient perception of overall likelihood to recover, to aid in interpreting survey results.