Assessing the Accuracy of Estimated Lipoprotein(a) Cholesterol and Lipoprotein(a)-Free Low-Density Lipoprotein Cholesterol.

Background Accurate measurement of the cholesterol within lipoprotein(a) (Lp[a]-C) and its contribution to low-density lipoprotein cholesterol (LDL-C) has important implications for risk assessment, diagnosis, and treatment of atherosclerotic cardiovascular disease, as well as in familial hypercholesterolemia. A method for estimating Lp(a)-C from particle number using fixed conversion factors has been proposed (Lp[a]-C from particle number divided by 2.4 for Lp(a) mass, multiplied by 30% for Lp[a]-C). The accuracy of this method, which theoretically can isolate "Lp(a)-free LDL-C," has not been validated. Methods and Results In 177 875 patients from the VLDbL (Very Large Database of Lipids), we compared estimated Lp(a)-C and Lp(a)-free LDL-C with measured values and quantified absolute and percent error. We compared findings with an analogous data set from the Mayo Clinic Laboratory. Error in estimated Lp(a)-C and Lp(a)-free LDL-C increased with higher Lp(a)-C values. Median error for estimated Lp(a)-C <10 mg/dL was -1.9 mg/dL (interquartile range, -4.0 to 0.2); this error increased linearly, overestimating by +30.8 mg/dL (interquartile range, 26.1-36.5) for estimated Lp(a)-C ≥50 mg/dL. This error relationship persisted after stratification by overall high-density lipoprotein cholesterol and high-density lipoprotein cholesterol subtypes. Similar findings were observed in the Mayo cohort. Absolute error for Lp(a)-free LDL-C was +2.4 (interquartile range, -0.6 to 5.3) for Lp(a)-C<10 mg/dL and -31.8 (interquartile range, -37.8 to -26.5) mg/dL for Lp(a)-C≥50 mg/dL. Conclusions Lp(a)-C estimations using fixed conversion factors overestimated Lp(a)-C and subsequently underestimated Lp(a)-free LDL-C, especially at clinically relevant Lp(a) values. Application of inaccurate Lp(a)-C estimations to correct LDL-C may lead to undertreatment of high-risk patients.

Does Physician Reimbursement Correlate to Risk in Orthopaedic Trauma?

This study investigated whether current Medicare reimbursements for orthopaedic trauma procedures correlate with complications. A total of 18,510 patients representing 33 orthopaedic trauma procedures from 2005 to 2011 were studied. Adverse events and Medicare payments for each orthopaedic trauma procedure were collected. Linear regressions determined correlations between complications and Medicare payments for orthopaedic trauma procedures. A weak correlation between Medicare payments and complications was found for all procedures (r = .399, p = .021). A 1.0% increase in complications was associated with a payment increase of only $100. There were no correlations between complications and reimbursements for upper extremity (p = .878) and lower extremity (p = .713) procedures. A strong correlation (r = .808, p = .015) existed for hip and pelvic fractures, but a 1.1% increase in hip and pelvic complications correlated with only an increase of $100 in reimbursements. This study is the first to show that Medicare payments are not strongly correlated with complications, therefore demonstrating the potential risks of a bundled payment system for orthopaedic trauma surgeons.

Incidence and predictive risk factors of postoperative sepsis in orthopedic trauma patients.

BACKGROUND: Postoperative sepsis is associated with high mortality and the national costs of septicemia exceed those of any other diagnosis. While numerous studies in the basic orthopedic science literature suggest that traumatic injuries facilitate the development of sepsis, it is currently unclear whether orthopedic trauma patients are at increased risk. The purpose of this study was thus to assess the incidence of sepsis and determine the risk factors that significantly predicted septicemia following orthopedic trauma surgery. MATERIALS AND METHODS: 56,336 orthopedic trauma patients treated between 2006 and 2013 were identified in the ACS-NSQIP database. Documentation of postoperative sepsis/septic shock, demographics, surgical variables, and preoperative comorbidities was collected. Chi-squared analyses were used to assess differences in the rates of sepsis between trauma and nontrauma groups. Binary multivariable regressions identified risk factors that significantly predicted the development of postoperative septicemia in orthopedic trauma patients. RESULTS: There was a significant difference in the overall rates of both sepsis and septic shock between orthopedic trauma (1.6%) and nontrauma (0.5%) patients (p < 0.001). For orthopedic trauma patients, ventilator use (OR = 15.1, p = 0.002), history of pain at rest (OR = 2.8, p = 0.036), and prior sepsis (OR = 2.6, p < 0.001) were significantly associated with septicemia. Statistically predictive, modifiable comorbidities included hypertension (OR = 2.1, p = 0.003) and the use of corticosteroids (OR = 2.1, p = 0.016). CONCLUSIONS: There is a significantly greater incidence of postoperative sepsis in the trauma cohort. Clinicians should be aware of these predictive characteristics, may seek to counsel at-risk patients, and should consider addressing modifiable risk factors such as hypertension and corticosteroid use preoperatively. Level of evidence Level III.

American Society of Anesthesiologists Score as a Predictive Tool to Optimize Blood Ordering for Intraoperative Transfusion in Orthopaedic Trauma Cases.

The objective of this study was to determine the clinical factors that are predictors for intraoperative transfusion in orthopaedic trauma patients. A retrospective chart review of patients admitted to a level I trauma center with isolated fractures was conducted. Variables such as gender, height, weight, body mass index, American Society of Anesthesiologists (ASA) classification, and medical comorbidities were assessed to determine likelihood of blood transfusion. A total of 1819 patients with isolated fractures were identified. ASA class was strongly associated with patients receiving intraoperative blood transfusion. For example, compared with patients with an ASA class I, patients with an ASA class IV were 14.71 times more likely to receive transfusion. Patients' ASA class is correlated with the need for intraoperative blood transfusion in patients undergoing orthopaedic surgery for isolated fractures. Institutional or departmental maximum surgical blood order schedule algorithms could use patients' preoperative ASA class to determine whether blood transfusion will be necessary during procedures.

Pre-operative labs: Wasted dollars or predictors of post-operative cardiac and septic events in orthopaedic trauma patients?

PURPOSE: As US healthcare expenditures continue to rise, there is significant pressure to reduce the cost of inpatient medical services. Studies have estimated that over 70% of routine labs may not yield clinical benefits while adding over $300 in costs per day for every inpatient. Although orthopaedic trauma patients tend to have longer inpatient stays and hip fractures have been associated with significant morbidity, there is a dearth of data examining pre-operative labs in predicting post-operative adverse events in these populations. The purpose of this study was to assess whether pre-operative labs significantly predict post-operative cardiac and septic complications in orthopaedic trauma and hip fracture patients. METHODS: Between 2006 and 2013, 56,336 (15.6%) orthopaedic trauma patients were identified and 27,441 patients (7.6%) were diagnosed with hip fractures. Pre-operative labs included sodium, BUN, creatinine, albumin, bilirubin, SGOT, alkaline phosphatase, white count, hematocrit, platelet count, prothrombin time, INR, and partial thromboplastin time. For each of these labs, patients were deemed to have normal or abnormal values. Patients were noted to have developed cardiac or septic complications if they sustained (1) myocardial infarction (MI), (2) cardiac arrest, or (3) septic shock within 30 days after surgery. Separate regressions incorporating over 40 patient characteristics including age, gender, pre-operative comorbidities, and labs were performed for orthopaedic trauma patients in order to determine whether pre-operative labs predicted adverse cardiac or septic outcomes. RESULTS: 749 (1.3%) orthopaedic trauma patients developed cardiac complications and 311 (0.6%) developed septic shock. Multivariate regression demonstrated that abnormal pre-operative platelet values were significantly predictive of post-operative cardiac arrest (OR: 11.107, p=0.036), and abnormal bilirubin levels were predictive (OR: 8.487, p=0.008) of the development of septic shock in trauma patients. In the hip fracture cohort, abnormal partial thromboplastin time was significantly associated with post-operative myocardial infarction (OR: 15.083, p=0.046), and abnormal bilirubin (OR: 58.674, p=0.002) significantly predicted the onset of septic shock. CONCLUSIONS: This is the first study to demonstrate the utility of pre-operative labs in predicting perioperative cardiac and septic adverse events in orthopaedic trauma and hip fracture patients. Particular attention should be paid to haematologic/coagulation labs (platelets, PTT) and bilirubin values. LEVEL OF EVIDENCE: Prognostic Level II.

Risk factors for adverse cardiac events in hip fracture patients: an analysis of NSQIP data.

PURPOSE: Cardiovascular complications constitute morbidity and mortality for hip fracture patients. Relatively little data exist exploring risk factors for post-operative complications. Using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database, we identified significant risk factors associated with adverse cardiac events in hip fracture patients and provide recommendations for practising orthopaedists. METHODS: A cohort of 27,441 patients with hip fractures from 2006 to 2013 was identified using Current Procedural Terminology codes. Cardiac complications were defined as cardiac arrests or myocardial infarctions occurring within 30 days after surgery. Bivariate analysis was run on over 30 patient and surgical factors to determine significant associations with cardiac events. Multivariate logistical analysis was then performed to determine risk factors most predictive for cardiac events. RESULTS: Of the 27,441 hip fracture patients, 594 (2.2%) had cardiac complications within 30 days post-operatively. There was no significant association with respect to type of hip fracture surgery and adverse cardiac event rates (p = 0.545). After multivariate analysis, dialysis use (OR: 2.22, p = 0.026), and histories of peripheral vascular disease (OR: 2.11, p = 0.016), stroke (OR: 1.83, p = 0.009), COPD (OR: 1.69, p = 0.014), and cardiac disease (OR: 1.55, p = 0.017) were significantly predictive of post-operative cardiac events in all hip fracture patients. CONCLUSION: Orthopaedic trauma surgeons should be aware of cardiac disease history and atherosclerotic conditions (PVD, stroke) in risk stratifying patients to prevent cardiac complications. Our recommendations to reduce cardiac events include simple pre-operative lab-work to full-fledged cardiac work-up and referrals to specific medicine disciplines based on the specific risk factors present.

Risk factors for discharge to rehabilitation among hip fracture patients.

Length of stay (LOS) drives costs for hip fracture patients. One factor that affects LOS is delayed transfer of patients to rehabilitation centers. It is therefore imperative that orthopedists have a mechanism for identifying which patients require rehabilitation services after surgery. We conducted a study to identify patient risk factors that are significantly associated with discharge to rehabilitation. Using 2011 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) data, we prospectively analyzed the cases of 4815 patients who underwent hip fracture surgery and had discharge information available. Discharge location, surgery type, patient demographics, 32 patient comorbidities, and 7 operative factors were identified in these patients. Fisher exact tests were used to determine which patient factors were significantly associated with discharge to rehabilitation. Of the 4815 patients, 80.3% were discharged to rehabilitation and 19.7% to home. After multivariable analysis, age over 65 years, female sex, dialysis, prior percutaneous coronary intervention, hypertension, general anesthesia, and ASA (American Society of Anesthesiologists) class higher than 2 had higher odds of discharge to rehabilitation, and DNR (do not resuscitate) status had higher odds of discharge to home. This study was the first to determine which factors predicted discharge to rehabilitation in hip fracture patients. Knowing these risk factors provides orthopedists with a mechanism that can be used to identify which patients require rehabilitation after surgery, thereby facilitating transfer and potentially decreasing LOS and associated costs.

Impact of type of surgery on deep venous thrombi and pulmonary emboli: a look at twenty seven thousand hip fracture patients.

PURPOSE: Deep venous thrombi (DVT) and pulmonary emboli (PE) are common complications in hip fracture patients. It is imperative that orthopaedists know the patient risk factors for DVT and PE, including if type of surgery plays a role. To this end, we used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify significant risk factors. METHODS: From the 2006-2011 ACS NSQIP database, 27,441 patients with hip fractures were identified using a Current Procedural Terminology (CPT) code search. DVT and PE complications, type of surgery based on CPT code, patient demographics, medical comorbidities and operative factors were identified for each patient. Fisher's exact tests were used to (1) determine if rates of DVT and PE significantly differed based on type of surgery and (2) identify significant associations between patient factors and development of DVT/PE. These significant factors were then used as covariates in multivariable analysis to determine which risk factors predicted postoperative DVT/PE. RESULTS: Of the 27,441 hip fracture patients, 449 (1.6 %) developed DVT/PE. There was a significant difference in rates of DVT/PE based on surgery (p = 0.015): patients undergoing intramedullary nailing of inter-/peri-/subtrochanteric femoral fractures had the highest rates of DVT/PE (2.06 %). After multivariate analysis, renal failure and recent surgery were significant risk factors for DVT/PE. CONCLUSIONS: This study was the first to show through large, multicentre, prospective data that type of hip fracture surgery impacts rates of DVT/PE. We further identified two additional risk factors orthopaedists should be aware of. Knowing these risk factors will help in peri-operative planning to reduce complications.

Adverse Events in Orthopaedics: Is Trauma More Risky? An Analysis of the NSQIP Data.

OBJECTIVES: As our healthcare system moves toward bundling payments, orthopaedic trauma surgeons will be increasingly benchmarked on perioperative complications. We therefore sought to determine financial risks under bundled payments by identifying adverse event rates for (1) orthopaedic trauma patients compared with general orthopaedic patients and (2) based on anatomic region and (3) to identify patient factors associated with complications. DESIGN: Prospective. SETTING: Multicenter. PATIENTS/PARTICIPANTS: A total of 146,773 orthopaedic patients (22,361 trauma) from 2005 to 2011 NSQIP data were identified. INTERVENTIONS: Minor and major adverse events, demographics, surgical variables, and patient comorbidities were collected. MAIN OUTCOME MEASUREMENTS: Multivariate regressions determined significant risk factors for the development of complications. RESULTS: The complication rate in the trauma group was 11.4% (2554/22,361) versus 4.1% (5137/124,412) in the general orthopaedic group (P = 0.001). When controlling for all variables, trauma was a risk factor for developing complications [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.57-1.81]. After controlling for several patient factors, hip and pelvis patients were 4 times more likely to develop any perioperative complication than upper extremity patients (OR: 3.79, 95% CI: 3.01-4.79, P = 0.01). Lower extremity patients are 3 times more likely to develop any complication versus upper extremity patients (OR: 2.82, 95% CI: 2.30-3.46, P = 0.01). CONCLUSIONS: Our study is the first to show that orthopaedic trauma patients are 2 times more likely than general orthopaedic patients to sustain complications, despite controlling for identical risk factors. There is also an alarming difference in complication rates among anatomic regions. Orthopaedic trauma surgeons will face increased financial risk with bundled payments. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Operative intervention for geriatric hip fracture: does type of surgery affect hospital length of stay?

Hip fractures are the most costly fall-related fractures. Differences in hospital length of stay (LOS) based on type of surgery could have major financial implications in a potential bundled payment system in which all hip fractures are reimbursed a standard amount. We conducted a study to analyze differences in hospital LOS and costs for total hip arthroplasty (THA), hemiarthroplasty (HA), cephalomedullary nailing, open reduction and internal fixation (ORIF), and closed reduction and percutaneous pinning (CRPP). Through retrospective chart review, 615 patients over age 60 years across a 9-year period at an urban level I trauma center were identified. Mean LOS and costs for hip fracture repair were 6.91 days and $30,011.25, respectively. HA/THA was associated with the longest mean LOS (7.43 days) and highest costs ($33,657.90). After several patient factors were adjusted for, ORIF was associated with 0.84 fewer in-patient days and $3805.20 less in hospitalization costs compared with HA/THA (P=.042). CRPP was associated with 1.63 fewer days and $7383.90 less in costs than HA/THA (P=.0076). Our results provide insight into the financial implications of hip fracture fixation and identify targets for quality improvement initiatives to improve efficiency of resource utilization.

Factors driving readmissions in tibia and femur fractures.

As the American healthcare system shifts towards bundled payments, readmissions will become a measure of healthcare quality. The purpose of this study was to characterize readmission trends and factors influencing readmission in patients with diaphyseal femur and tibia fractures. Through a retrospective chart review, all patients who presented to a level 1 trauma center from 2004 to 2006 were evaluated. By using current procedural terminology codes, 1,040 patients with diaphyseal tibia or femur fractures fixed by IMN were identified. 645 patients were included for analysis. 30-day, 60-day, and 90-day readmission rates were compared with fracture type, reason for readmission, and basic demographic information. The 60-day readmission rate for open tibia fractures (14.8%) was significantly higher than the 60-day readmission rate for closed tibia fractures (8.0%) (p = 0.037). When comparing reasons for 60-day readmissions, 50% of closed fractures were readmitted due to infection, while the other 50% needed additional surgery. 91.7% of open fractures readmitted in 60 days were due to infection. In a bundled payment system, orthopedic trauma must gain insight into drivers of readmission to identify those at risk for readmission and design effective healthcare plans for these patients.

Ankle Fractures and Modality of Hospital Transport at a Single Level 1 Trauma Center: Does Transport by Helicopter or Ground Ambulance Influence the Incidence of Complications?

In an era of concern over the rising cost of health care, cost-effectiveness of auxiliary services merits careful evaluation. We compared costs and benefits of Helicopter Emergency Medical Service (HEMS) with Ground Emergency Medical Service (GEMS) in patients with an isolated ankle fracture. A medical record review was conducted for patients with an isolated ankle fracture who had been transported to a level 1 trauma center by either HEMS or GEMS from January 1, 2000 to December 31, 2010. We abstracted demographic data, fracture grade, complications, and transportation mode. Transportation costs were obtained by examining medical center financial records. A total of 303 patients was included in the analysis. Of 87 (28.71%) HEMS patients, 53 (60.92%) had sustained closed injuries and 34 (39.08%) had open injuries. Of the 216 (71.29%) GEMS patients, 156 (72.22%) had closed injuries and 60 (27.78%) had open injuries. No significant difference was seen between the groups regarding the percentage of patients with open fractures or the grade of the open fracture (p = .07). No significant difference in the rate of complications was found between the 2 groups (p = 18). The mean baseline cost to transport a patient via HEMS was $10,220 + a $108/mile surcharge, whereas the mean transport cost using GEMS was $976 per patient + $16/mile. Because the HEMS mode of emergency transport did not significantly improve patient outcomes, health systems should reconsider the use of HEMS for patients with isolated ankle fractures.

Hip fractures are risky business: an analysis of the NSQIP data.

INTRODUCTION: Hip fractures are one of the most common types of orthopaedic injury with high rates of morbidity. Currently, no study has compared risk factors and adverse events following the different types of hip fracture surgeries. The purpose of this paper is to investigate the major and minor adverse events and risk factors for complication development associated with five common surgeries for the treatment of hip fractures using the NSQIP database. METHODS: Using the ACS-NSQIP database, complications for five forms of hip surgeries were selected and categorized into major and minor adverse events. Demographics and clinical variables were collected and an unadjusted bivariate logistic regression analyses was performed to determine significant risk factors for adverse events. Five multivariate regressions were run for each surgery as well as a combined regression analysis. RESULTS: A total of 9640 patients undergoing surgery for hip fracture were identified with an adverse events rate of 25.2% (n=2433). Open reduction and internal fixation of a femoral neck fracture had the greatest percentage of all major events (16.6%) and total adverse events (27.4%), whereas partial hip hemiarthroplasty had the greatest percentage of all minor events (11.6%). Mortality was the most common major adverse event (44.9-50.6%). For minor complications, urinary tract infections were the most common minor adverse event (52.7-62.6%). Significant risk factors for development of any adverse event included age, BMI, gender, race, active smoking status, history of COPD, history of CHF, ASA score, dyspnoea, and functional status, with various combinations of these factors significantly affecting complication development for the individual surgeries. CONCLUSIONS: Hip fractures are associated with significantly high numbers of adverse events. The type of surgery affects the type of complications developed and also has an effect on what risk factors significantly predict the development of a complication. Concerted efforts from orthopaedists should be made to identify higher risk patients and prevent the most common adverse events that occur postoperatively.

Asking for the 22-modifier in isolated ankle fractures: does the operative note make the case?

We evaluated the operative notes for justification on the use of the 22-modifier in ankle fracture cases and compared the differences in physician billing and reimbursement. A total of 265 patients who had undergone operative management of isolated ankle fractures across a 10-year period were identified at a level I trauma center through a retrospective chart review. Of the 265 patients, 61 (23.0%) had been billed with the 22-modifier. The radiographs were reviewed by 3 surgeons to determine the complexity of the case. The amount of the professional fees and payments was obtained from the financial services department. Operative reports were reviewed for inclusion of eight 22-modifier criteria and word count. Mann-Whitney U tests of means were used to compare cases with and without the 22-modifier. From our analysis of preoperative radiographs, 37 (60%) showed evidence of a significantly complex fracture that justified the use of the 22-modifier. A review of the operative reports showed that 42 (68%) did not identify 2 or more reasons for requesting the 22-modifier in the report. Overall, the 22-modifier cases were not always reimbursed significantly greater amounts than the nonmodifier cases. No significant difference in the average word count of the operative notes was found. We have concluded that orthopedic trauma surgeons do not appropriately justify the use of the 22-modifier within their operative report. Further education on modifiers and the use of the operative report as billing documentation is required to ensure surgeons are adequately reimbursed for difficult trauma cases.

An assessment of the inter-rater reliability of the ASA physical status score in the orthopaedic trauma population.

OBJECTIVES: Although recent literature has demonstrated the utility of the ASA score in predicting postoperative length of stay, complication risk and potential utilization of other hospital resources, the ASA score has been inconsistently assigned by anaesthesia providers. This study tested the reliability of assignment of the ASA score classification by both attending anaesthesiologists and anaesthesia residents specifically among the orthopaedic trauma patient population. METHODS: Nine case-based scenarios were created involving preoperative patients with isolated operative orthopaedic trauma injuries. The cases were created and assigned a reference score by both an attending anaesthesiologist and orthopaedic trauma surgeon. Attending and resident anaesthesiologists were asked to assign an ASA score for each case. Rater versus reference and inter-rater agreement amongst respondents was then analyzed utilizing Fleiss's Kappa and weighted and unweighted Cohen's Kappa. RESULTS: Thirty three individuals provided ASA scores for each of the scenarios. The average rater versus reference reliability was substantial (Kw=0.78, SD=0.131, 95% CI=0.73-0.83). The average rater versus reference Kuw was also substantial (Kuw=0.64, SD=0.21, 95% CI=0.56-0.71). The inter-rater reliability as evaluated by Fleiss's Kappa was moderate (K=0.51, p<.001). An inter-rater comparison within the group of attendings (K=0.50, p<.001) and within the group of residents were both moderate (K=0.55, p<.001). There was a significant increase in the level of inter-rater reliability from the self-reported 'very uncomfortable' participants to the 'very comfortable' participants (uncomfortable K=0.43, comfortable K=0.59, p<.001). CONCLUSIONS: This study shows substantial agreement strength for reliability of the ASA score among anaesthesiologists when evaluating orthopaedic trauma patients. The significant increase in inter-rater reliability based on anaesthesiologists' comfort with the ASA scoring method implies a need for further evaluation of ASA assessment training and routine use on the ground. These findings support the use of the ASA score as a statistically reliable tool in orthopaedic trauma.

Healthcare reimbursement models and orthopaedic trauma: will there be change in patient management? A survey of orthopaedic surgeons.

OBJECTIVES: Healthcare reimbursement models are changing. Fee-for-service may be replaced by pay-for-performance or capitated care. The purpose of this study was to examine the potential changes in orthopaedic trauma surgery patient management based on potential shifts in policy surrounding readmission and reimbursement. METHODS: An e-mail survey consisting of 3 case-based scenarios was delivered to 375 orthopaedic surgeons. Five options for management of each case were provided. Each of the 3 cases was presented in 3 different healthcare settings: scenario A, our current healthcare setting; scenario B, in which 90-day reoperation or readmission would not be reimbursed; and scenario C, in which a capitated healthcare structure paid a fixed amount per patient. RESULTS: The response rate was 40.3% with 151 surgeons completing the survey. A 71.1% of the respondents were in private practice settings, whereas 28.3% were in academic centers. In each case, there was significant increase in the respondents' choice to transfer patients to tertiary care centers under both the capitated and penalization systems as compared with the current fee-for-service model. CONCLUSIONS: This survey is the first of its kind to demonstrate through case-based scenarios that a healthcare system with readmission penalties and capitated reimbursement models may lead to a significant increase in transfer of complex orthopaedic trauma patients to tertiary care centers. Physicians should be encouraged to continue evidence-based medicine instead of making decisions due to finances, and other avenues of healthcare savings should be explored to decrease patient transfer rates with healthcare changes.

The costs of operative complications for ankle fractures: a case control study.

As our healthcare system moves towards bundling payments, it is vital to understand the potential financial implications associated with treatment of surgical complications. Considering that surgical treatment of ankle fractures is common, there remains minimal data relating costs to postsurgical intervention. We aimed to identify costs associated with ankle fracture complications through case-control analysis. Using retrospective analysis at a level I trauma center, 28 patients with isolated ankle fractures who developed complications (cases) were matched with 28 isolated ankle fracture patients without complications (controls) based on ASA score, age, surgery type, and fracture type. Patient charts were reviewed for demographics and complications leading to readmission/reoperation and costs were obtained from the financial department. Wilcoxon tests measured differences in the costs between the cases and controls. 28 out of 439 patients (6.4%) developed complications. Length of stay and median costs were significantly higher for cases than controls. Specifically, differences in total costs existed for infection and hardware-related pain. This is the first study to highlight the considerable costs associated with the treatment of complications due to isolated ankle fractures. Physicians must therefore emphasize methods to control surgical and nonsurgical factors that may impact postoperative complications, especially under a global payment system.

Do practice settings influence defensive medicine in orthopedic surgery?

Defensive medicine is often practiced out of fear of legal liability. We conducted a study to compare the costs of defensive medicine among US orthopedic surgeons by practice type and American Medical Association (AMA) state medical liability classification. Two thousand surgeons registered with the American Academy of Orthopaedic Surgeons were sent a survey on defensive medicine. Costs were analyzed using 2011 Centers for Medicare and Medicaid Services data. Of the 2000 surgeons, 1214 (61%) completed the survey. Results showed that defensive tests were ordered by a higher proportion of nonacademic physicians than academic physicians in all 8 categories of orthopedic care, with a mean difference of $2348 in monthly defensive expenditures between groups. A higher rate of defensive testing by orthopedists in AMA crisis states versus safe states was also observed in 6 of the 8 areas of care studied, with mean monthly defensive expenditures ranging from $9208 in crisis states to $6596 in safe states. Defensive orthopedics contributes significantly to health care costs, with marginal benefit to patients-especially in nonacademic and crisis-state orthopedics practices.

Distal tibia fractures and medial plating: factors influencing re-operation.

PURPOSE: We compared types of complications leading to re-operations in open and closed distal tibia fractures treated by locking or nonlocking medial plates. METHODS: Ninety-three patients from 2002 to 2012 who underwent open reduction and internal fixation (ORIF) and medial plating for distal extra-articular or partial articular tibia fractures were identified. Charts were retrospectively reviewed to determine the incidence of re-operation based on the type of complication that developed. Fisher's exact and chi-square tests were performed to analyze the incidence of complications based on injury and type of plate used. RESULTS: Thirty-three (35.5 %) patients required re-operations: 28.6 % (n = 16) with closed injuries had complications leading to re-operations compared with 45.9 % (n = 17) of patients with open injuries (p = 0.12). Patients with closed injuries were more likely to require re-operation due to hardware pain/prominence (p = 0.03), whereas patients with open injuries were more likely to require re-operation due to nonunion (p = 0.04). There were no significant differences in infection (p = 0.66) or malunion (p = 0.99) between groups. Locking plates showed higher costs but were not associated with decreased risk of re-operation. CONCLUSIONS: There was a high re-operation rate associated with distal tibia medial plating, with significant differences in the reason for re-operation between open versus closed groups. Complication rates were not influenced by the use of locking plates. Results of this study suggest that methods be considered to reduce re-operation based on type of fracture, such as early bone grafting or the use of alternate implants for open fractures.