Improving Patient Recall Following Operative Orthopaedic Trauma.

BACKGROUND: Orthopaedic trauma patients may experience poor recall regarding their injury and treatment, impairing postoperative outcomes. We sought to evaluate the impact of a standardized postoperative educational protocol on patient recall, adherence to the treatment plan, and satisfaction. METHODS: Two hundred and twenty adult, English-speaking patients with surgically treated lower-extremity fractures were prospectively included. One hundred and ten patients in the educational intervention cohort met with a non-physician study member after surgery but before hospital discharge. They were given a written questionnaire evaluating knowledge of key aspects of their injury and treatment plan. For incorrectly answered questions, the study team member told the patient the correct answer (e.g., "No, you broke your tibia."). Immediately after, the patient was verbally asked the question again (e.g., "Which bone did you break?"), repeating the process until the answer was correct. The 110 patients in the control cohort did not receive this "teach-back" protocol. During their first postoperative appointment, all 220 patients completed a follow-up questionnaire assessing recall, adherence to the treatment plan, and satisfaction. RESULTS: The control cohort correctly answered 64% of recall-oriented questions versus 89% in the intervention cohort (p < 0.001). Eighty-two percent of control patients versus 89% patients in the intervention cohort adhered to postoperative weight-bearing restrictions (p = 0.09). Eighty-four percent of controls adhered to their deep venous thrombosis prophylaxis regimen versus 99% of the intervention cohort (p < 0.001). On a 5-point Likert scale, controls were less satisfied with their overall orthopaedic care compared with patients in the intervention cohort (mean of 4.38 ± 0.84 versus 4.54 ± 0.63 points; p = 0.02), although this difference was less than the minimal clinically relevant difference of 10% that was defined at study onset. On propensity score-weighted multivariable analysis, receipt of the postoperative educational intervention was the only modifiable factor associated with improvement in patient recall (26% improvement [95% confidence interval, 20% to 31%]; p < 0.001). CONCLUSIONS: Some orthopaedic trauma patients' nonadherence to surgeon recommendations and dissatisfaction with care may be mitigated by postoperative education. This standardized postoperative educational protocol improves orthopaedic trauma patients' recall, adherence to their treatment plan, and satisfaction in a manner requiring minimal time. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for infection in severe open tibial shaft fractures.

OBJECTIVE: To evaluate risk factors for infection in severe open tibial shaft fractures. METHODS: A secondary analysis of a multicenter prospective study investigated internal versus external fixation of severe open tibia fractures at 20 US Level I trauma centers. Adult patients, aged <65 years, with a Gustilo-Anderson Type IIIB or severe IIIA metaphyseal or diaphyseal tibia fracture were included. All fractures underwent definitive fixation with either a modern ring external fixator, intramedullary device, and/or plate. Fourteen variables previously identified as risk factors for infection were included in the analysis. Deep surgical site infection was defined as an infection treated with surgical debridement within 1 year of index surgery. RESULTS: The study cohort included 430 patients. Deep surgical site infection requiring reoperation occurred in 108 (25 %) patients. The final model identified four risk factors for infection: age >40 years (OR, 2.00; 95 % CI, 1.3-3.1), Gustilo-Anderson Type IIIB (OR, 1.80; 95 % CI, 1.1-3.0), embedded wound contamination (OR, 1.69; 95 % CI, 1.1-2.7), and wound length (OR, 1.02/cm; 95 % CI, 1.0-1.05). The model performed poorly at distinguishing infected from uninfected patients (Area Under the Curve=0.57; 95 % CI, 0.51-0.63). CONCLUSIONS: Surgeons can now counsel patients with these risk factors that they are at a markedly higher risk of infection. The identification of these risk factors may direct future research aimed at mitigating the risk of deep surgical site infection in this patient population.

Early major fracture care in polytrauma-priorities in the context of concomitant injuries: A Delphi consensus process and systematic review.

BACKGROUND: The timing of major fracture care in polytrauma patients has a relevant impact on outcomes. Yet, standardized treatment strategies with respect to concomitant injuries are rare. This study aims to provide expert recommendations regarding the timing of major fracture care in the presence of concomitant injuries to the brain, thorax, abdomen, spine/spinal cord, and vasculature, as well as multiple fractures. METHODS: This study used the Delphi method supported by a systematic review. The review was conducted in the Medline and EMBASE databases to identify relevant literature on the timing of fracture care for patients with the aforementioned injury patterns. Then, consensus statements were developed by 17 international multidisciplinary experts based on the available evidence. The statements underwent repeated adjustments in online- and in-person meetings and were finally voted on. An agreement of ≥75% was set as the threshold for consensus. The level of evidence of the identified publications was rated using the GRADE approach. RESULTS: A total of 12,476 publications were identified, and 73 were included. The majority of publications recommended early surgery (47/73). The threshold for early surgery was set within 24 hours in 45 publications. The expert panel developed 20 consensus statements and consensus >90% was achieved for all, with 15 reaching 100%. These statements define conditions and exceptions for early definitive fracture care in the presence of traumatic brain injury (n = 5), abdominal trauma (n = 4), thoracic trauma (n = 3), multiple extremity fractures (n = 3), spinal (cord) injuries (n = 3), and vascular injuries (n = 2). CONCLUSION: A total of 20 statements were developed on the timing of fracture fixation in patients with associated injuries. All statements agree that major fracture care should be initiated within 24 hours of admission and completed within that timeframe unless the clinical status or severe associated issues prevent the patient from going to the operating room. LEVEL OF EVIDENCE: Delphi-Consensus/Systematic Review; Level IV.

Minimal Clinically Important Difference (MCID) for the Short Musculoskeletal Function Assessment (SMFA) in Severe Lower Extremity Trauma: Pooled Data from 7 Multicenter, Prospective Clinical Trials.

BACKGROUND: The Short Musculoskeletal Function Assessment (SMFA) is a well validated, widely used patient-reported outcome (PRO) measure for orthopaedic patients. Despite its widespread use and acceptance, this measure does not have an agreed upon minimal clinically important difference (MCID). The purpose of the present study was to create distributional MCIDs with use of a large cohort of research participants with severe lower extremity fractures. METHODS: Three distributional approaches were used to calculate MCIDs for the Dysfunction and Bother Indices of the SMFA as well as all its domains: (1) half of the standard deviation (one-half SD), (2) twice the standard error of measurement (2SEM), and (3) minimal detectable change (MDC). In addition to evaluating by patient characteristics and the timing of assessment, we reviewed these calculations across several injury groups likely to affect functional outcomes. RESULTS: A total of 4,298 SMFA assessments were collected from 3,185 patients who had undergone surgical treatment of traumatic injuries of the lower extremity at 60 Level-I trauma centers across 7 multicenter, prospective clinical studies. Depending on the statistical approach used, the MCID associated with the overall sample ranged from 7.7 to 10.7 for the SMFA Dysfunction Index and from 11.0 to 16.8 for the SMFA Bother Index. For the Dysfunction Index, the variability across the scores was small (<5%) within the sex and age subgroups but was modest (12% to 18%) across subgroups related to assessment timing. CONCLUSIONS: A defensible MCID can be found between 7 and 11 points for the Dysfunction Index and between 11 and 17 points for the Bother Index. The precise choice of MCID may depend on the preferred statistical approach and the population under study. While differences exist between MCID values based on the calculation method, values were consistent across the categories of the various subgroups presented. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Complications and Outcomes After Fixation of Lisfranc Injuries at an Urban Level 1 Trauma Center.

OBJECTIVES: To evaluate patients with tarsometatarsal fractures and dislocations and describe complications and secondary operations. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Consecutive adults treated acutely for Lisfranc injuries with reduction and fixation using standard techniques of rigid medial fixation and flexible lateral fixation. OUTCOME MEASURES AND COMPARISONS: Complications include infections, wound healing problems, nonunion, malunion, and posttraumatic arthrosis (PTA), and secondary unplanned procedures after a minimum of 2-year radiographic follow-up. RESULTS: Mean age of the included 118 patients was 40 years (range, 18-73 years) and 96 (74%) were male. Comorbidities included obesity (n = 32; 40%), diabetes mellitus (n = 12; 9%), and tobacco use (n = 67; 52%). Thirty (23%) were open injuries, and concomitant forefoot injuries were present in 47% and hindfoot injuries in 12%. Unplanned secondary procedures, including implant removals, were performed on 39 patients (33%), most often for removal of painful implants (26%) or infectious debridement (9%). Sixty-seven complications occurred, with PTA most frequent (37%). Deep infections occurred in 8%. On multivariate analysis, open injury ( P = 0.028, CI = 1.22-30.63, OR = 6.12) and concomitant forefoot injury ( P = 0.03, CI = 1.12-9.76, OR = 3.31) were independent risk factors for complication. CONCLUSIONS: Open Lisfranc injuries were associated with complications, with deep infections occurring in 9%. Secondary procedures were most often performed for pain relief; the most common late complication was PTA, warranting counseling of patients about potential long-term sequelae of injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Identifying Risk Factors for Osteonecrosis After Talar Fracture.

OBJECTIVE: To identify patient, injury, and treatment factors associated with the development of avascular necrosis (AVN) after talar fractures, with particular interest in modifiable factors. DESIGN: Retrospective chart review. SETTING: 21 US trauma centers and 1 UK trauma center. PATIENT SELECTION CRITERIA: Patients with talar neck and/or body fractures from 2008 through 2018 were retrospectively reviewed. Only patients who were at least 18 years of age with fractures of the talar neck or body and minimum 12 months follow-up or earlier diagnosis of AVN were included. Further exclusion criteria included non-operatively treated fractures, pathologic fractures, pantalar dislocations, and fractures treated with primary arthrodesis or primary amputation. OUTCOME MEASUREMENTS AND COMPARISONS: The primary outcome measure was development of AVN. Infection, nonunion, and arthritis were secondary outcomes. RESULTS: In total, 798 patients (409 men; 389 women; age 18-81 years, average 38.6 years) with 798 (532 right; 264 left) fractures were included and were classified as Hawkins I (51), IIA (71), IIB (113), III (158), IV (40), neck plus body (177), and body (188). In total, 336 of 798 developed AVN (42%), more commonly after any neck fracture (47.0%) versus isolated body fracture (26.1%, P < 0.001). More severe Hawkins classification, combined neck and body fractures, body mass index, tobacco smoking, right-sided fractures, open fracture, dual anteromedial and anterolateral surgical approaches, and associated medial malleolus fracture were associated with AVN ( P < 0.05). After multivariate regression, fracture type, tobacco smoking, open fractures, dual approaches, age, and body mass index remained significant ( P < 0.05). Excluding late cases (>7 days), time to joint reduction for Hawkins type IIB-IV neck injuries was no different for those who developed AVN or not. AVN rates for reduction of dislocations within 6 hours of injury versus >6 hours were 48.8% and 57.5%, respectively. Complications included 60 (7.5%) infections and 70 (8.8%) nonunions. CONCLUSIONS: Forty-two percent of all talar fracture patients developed AVN, with talar neck fractures, more displaced fractures, and open injuries having higher rates. Injury-related factors are most prognostic of AVN risk. Surgical technique to emphasize anatomic reduction, without iatrogenic damage to remaining blood supply appears to be prudent. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acetabular fractures in elderly patients are associated with high rates of complications during the initial admission.

Background: Acetabular fractures among the elderly are common. Identification of risk factors predisposing elderly patients to in-hospital complications is critical to mitigating morbidity and mortality. Methods: A retrospective cohort study was performed including 195 patients ≥60 years old who sustained acetabulum fractures treated at a single level 1 trauma center. Operative (n=110, 56.4%) or non-operative management was undertaken, and complications during the index hospitalization were defined. Results: Seventy-three patients (37%) developed a complication during their hospitalization. Most common complications were acute respiratory failure: 13.3%, pneumonia: 10.3%, urinary tract infection: 10.3%, cardiac dysrhythmia: 9.7%, and acute kidney injury: 6.2%. On multivariable analysis, factors associated with in-hospital complications were increased age (adjusted OR (AOR): 1.06, 95% CI: 1.01 to 1.11, p=0.013), more comorbidities (AOR: 1.69, 95% CI: 1.07 to 2.65, p=0.024), operative management (AOR: 0.3, 95% CI: 0.12 to 0.76, p=0.011), and increased length of stay (AOR: 1.34, 95% CI: 1.2 to 1.51, p<0.001). Conclusions: Acetabular fractures in the elderly are associated with high rates of in-hospital complications. Advanced age, more medical comorbidities and longer lengths of stay predicted higher risk of developing complications. Whereas operative management was associated with lower risk of developing complications during the initial admission, it is important to note the selection bias in which healthier patients with improved baseline functionality may be more likely to undergo operative management. Level of evidence: Level III therapeutic.

Appointment wait times for surgical care in the Veterans Health Administration and Community Care Program.

BACKGROUND: The Veterans Health Administration has been criticized for long wait times; however, studies indicate that Veterans Health Administration wait times are shorter than those for the Veterans Health Administration's Community Care Program. Previous studies have analyzed primary care wait times, but few have compared surgical specialties. METHODS: Using a publicly available data set of veteran appointments compiled from the Veterans Health Administration's Corporate Data Warehouse, a nationally representative database containing 623,868 surgical consults from January 1 to June 30, 2021, mean differences in wait times between the Veterans Health Administration and the Community Care Program were calculated across surgical specialties. RESULTS: In total, 49.6% of the surgical consults placed during the study period were for the Community Care Program. Across all surgical specialties, wait times were shorter in the Veterans Health Administration. Cardiothoracic surgery had the shortest mean wait times (23.1 days Veterans Health Administration; 30.0 days Community Care Program). The greatest difference in wait times was observed in plastic surgery, with Community Care Program appointments occurring 15.8 days later than Veterans Health Administration appointments on average. CONCLUSION: Across all surgical specialties, the Veterans Health Administration had shorter wait times than the Community Care Program during the study period.

Impact of novel psychosocial programming on readmission and recidivism rates among patients with violence-related trauma.

INTRODUCTION: The Victims of Crime Advocacy and Recovery Program (VOCARP) provides advocacy, mental health resources, and educational materials. This study will report complications, readmissions, and recidivism among crime victims, and who used or did not use victim services. MATERIALS AND METHODS: Patients engaged with programming from 3/1/17 until 12/31/18 were included. Control groups were patients injured by violent trauma without VOCARP use (N = 212) and patients injured by unintentional injuries (N = 201). Readmissions, complications, reoperations, and trauma recidivism were reported. RESULTS: 1019 patients (83%) used VOCARP. VOCARP users were less often male (56% vs. 71%), less commonly married (12% vs. 41%), and had fewer gunshot wounds (GSWs, 26% vs. 37%) and sexual assaults (4.1% vs. 8%), all p < 0.05. Of all 1,423 patients, 6.6% had a readmission and 7.4% developed a complication. VOCARP patients had fewer complications (4.5% vs. 13.7%), infections (2% vs. 9%), wound healing problems (1% vs. 3.3%), and deep vein thromboses (0.3% vs. 1.9%), all p < 0.05, but no differences in unplanned operations (4.5%). GSW victims had the most complications, readmissions, and unplanned surgeries. Prior trauma recidivism was frequent among all groups, with crime victim patients having 40% prior violence-related injury (vs 9.0% control, p < 0.0001). Trauma recidivism following VOCARP use occurred in 8.5% (vs 5.7% for non-users, p = 0.16). CONCLUSION: Crime victims differ from other trauma patients, more often with younger age, single marital status, and unemployment at baseline. Complications were lower for VOCARP patients. GSW patients had the most complications, readmissions, and unplanned secondary procedures, representing a population for future attention.

Comparisons of Procedures Performed in Training vs in Early Practice by Orthopaedic Trauma Surgeons.

INTRODUCTION: The Orthopaedic Trauma Association (OTA) has maintained an accreditation process of orthopaedic trauma fellowships with various requirements including an annually reviewed list of qualifying trauma cases in the form of American Medical Association Current Procedural Terminology (CPT) codes. The correlation between these established and monitored CPTs and the actual practices of orthopaedic trauma surgeons has not been studied. METHODS: American Board of Orthopaedic Surgery part II case logs (trauma subspecialty) (2012 to 2018) were compared with OTA fellowship case logs (2015 to 2019). Case logs from 447 surgeons and 166 trauma fellowship programs were compared. Four CPT code categories were defined: complex trauma (OTA required CPT codes, excluding Accreditation Council for Graduate Medical Education [ACGME] orthopaedic residency requirements), general trauma (ACGME residency required trauma codes), general orthopaedics (nontrauma ACGME residency requirements), and others (codes not included in residency or trauma fellowship requirements). RESULTS: OTA fellows performed a higher median percentage of complex trauma compared with American Board of Orthopaedic Surgery candidates (34% vs. 21%, P < 0.001): Both cohorts performed a similar percentage of general trauma (23%). OTA fellows performed more general orthopaedics (40% vs. 1%, P < 0.001). Several OTA required codes were performed infrequently (0 to 3 during board collection) by most surgeons, and several procedures are being performed that are not included in current CPT code requirements. DISCUSSION: Early-career traumatologists are performing orthopaedic trauma procedures they were trained on during residency and fellowship, with varying complexity. Trauma fellows perform a higher percentage of complex trauma compared with early-career trauma surgeons. Continued surveillance is necessary such that educational improvements can be made to maximize the quality of trauma fellowship education. LEVEL OF EVIDENCE: Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Functional Outcomes After High-Energy Lisfranc Injuries.

BACKGROUND: Midfoot fractures and dislocations are infrequent and functional outcomes following Lisfranc injuries have not been well described. The purpose of this project was to explore functional outcomes following operative treatment of high-energy Lisfranc injury. METHODS: A retrospective cohort of 46 adults with tarsometatarsal fractures and dislocations treated at a single Level 1 trauma center were reviewed. Demographic, medical, social, and injury features of these patients and their injuries were recorded. Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA) surveys were collected after mean 8.7 years' follow-up. Multiple linear regression was performed to identify independent predictors of outcome. RESULTS: Forty-six patients with mean age 39.7 years completed functional outcome surveys. Mean SMFA scores were 29.3 (dysfunction) and 32.6 (bothersome). Mean FFI scores were 43.1 (pain), 43.0 (disability), and 21.7 (activity), with a mean total score of 35.9. FFI pain scores were worse than published values for fractures of the plafond (33, P = .04), distal tibia (33, P = .04), and talus (25.3, P = .001). Lisfranc injury patients reported worse disability (43.0 vs 29, P = .008) and total FFI scores (35.9 vs 26, P = .02) compared with distal tibia fractures. Tobacco smoking was an independent predictor of worse FFI (P < .05) and SMFA emotion and bothersome scores (P < .04). Chronic renal disease was a predictor of worse FFI disability (P = .04) and SMFA subcategory scores (P < .04). Male sex was associated with better scores in all SMFA categories (P < .04). Age, obesity, or open injury did not affect functional outcomes. CONCLUSION: Patients reported worse pain by FFI after Lisfranc injury compared to other injuries about the foot and ankle. Tobacco smoking, female sex, and preexisting chronic renal disease are predictive of worse functional outcome scores, warranting further study in a larger sample, as well as counseling of long-term consequences of this injury. LEVEL OF EVIDENCE: Level IV, retrospective, prognostic.

Recidivism after orthopaedic trauma has diminished over time.

PURPOSE: The purpose was to analyze our trauma population during two periods to assess for predictors of recidivism. METHODS: Prior (2007-2011, n = 879) and recent (2014-2019, n = 954) orthopaedic trauma patients were reviewed. Recidivists were those returning with an unrelated injury. Recidivism rates were compared, and factors associated with recidivism were identified. RESULTS: Recidivism decreased: 18.7% to 14.3% (p = 0.01). Mean age and sex of the two cohorts were not different. Recent recidivists were more likely to sustain gunshot wound (GSW) injuries (22.1% vs 18.9%, p = 0.09), and mental illness was more common (56.6% vs 28.1%, p < 0.0001). The recent recidivist population was less often married (12.9% vs 23.8%, p = 0.03), and both recidivist groups were often underinsured (Medicaid or uninsured: (60.6% vs 67.0%)). CONCLUSION: Recidivism diminished, although more GSW and mental illness were seen. Recidivists are likely to be underinsured. The changing profile of recidivists may be attributed to socioeconomic trends and new programs to improve outcomes after trauma.

Factors associated with surgeon recognition of mental health care opportunities and inclination to attend to mental health.

PURPOSE: A notable percentage of people that die by suicide have had a medical visit within a few months of their death. In a survey-based experiment, we evaluated: 1) whether there are any surgeon, setting, or patient factors associated with surgeon rating of mental health care opportunities, and 2) if there are any surgeon, setting, or patient factors associated with likelihood of mental health referrals. METHODS: One hundred and twenty-four upper extremity surgeons of the Science of Variation Group viewed five scenarios of a person with one orthopedic condition. The following aspects of the scenarios were independently randomized: Social worker or psychologist available, office workload, socioeconomic status, gender, age, mental health factors, mental health clues, and diagnosis. RESULTS: Accounting for potential confounders, surgeon likelihood of discussing mental health was associated with cancer, disadvantaged socioeconomic status, mental health factors other than being shy, prior suicide attempt, history of physical or emotional abuse, isolation, and when the office is not busy. Factors independently associated with higher likelihood of referring a patient for mental health care included cancer, disadvantaged socioeconomic status, mental health cues, mental health risk factors, and a social worker or psychologist available in the office. CONCLUSION: Using random elements in fictitious scenarios we documented that specialist surgeons are aware of and attuned to mental health care opportunities, are motivated to discuss notable cues, and will make mental health referrals, in part influenced by convenience.

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.

Value Challenge: A Bottoms-Up Approach to Minimizing Cost and Waste in Orthopaedic Surgery.

Astronomical increases in medical expenses and waste produce widespread financial and environmental impacts. Minor changes to minimize costs within orthopaedics, the most used surgical subspecialty, could result in substantial savings. However, few orthopaedic surgeons are educated or experienced to implement cost containment strategies. This study aims to investigate cost containment opportunities and provide a framework for educating and incorporating residents into cost-saving initiatives. Methods: Orthopaedic surgical residents from an academic program with a Level I trauma center were queried during 2019 to 2022 regarding suggestions for cost containment opportunities. Based on feasibility and the estimated impact, 7 responses were selected to undergo cost-saving analyses. Results: The proposed initiatives fell into 2 categories: minimizing waste and optimizing patient care. Eliminating nonessential physical therapy/occupational therapy consults led to the greatest estimated savings ($8.6M charges/year), followed by conserving reusable drill bits ($2.2M/year) and reducing computed tomography scans on lower extremity injuries ($446K/year). Conclusion: Current medical training provides limited formal education on cost-effective care. Efforts to mitigate the growing financial and environmental costs of health care should include encouraging and incorporating resident feedback into cost reduction strategies. This tactic will likely have a positive impact on the behavior of such resident surgeons as they enter practice and have more awareness of costs and value. Level of Evidence: V (cost-minimization study).

Outcomes of Geriatric Periprosthetic Distal Femur Fractures: Comparison of Fixation Versus Reconstruction.

OBJECTIVE: Comparing outcomes of periprosthetic distal femur fractures treated with open reduction and internal fixation (ORIF) versus distal femoral replacement (DFR). SETTING: Three major academic hospitals within one metropolitan area. DESIGN: Retrospective. PATIENTS/PARTICIPANTS: Three hundred seventy patients >64 years old with periprosthetic distal femur fractures were identified and 115 were included (65 ORIF vs. 50 DFR). INTERVENTION: ORIF with locked plating versus DFR. MAIN OUTCOME MEASUREMENT: One-year mortality, ambulatory status at 1 year, reoperations, and hospital readmissions. RESULTS: No differences were observed between ORIF and DFR cohorts regarding demographics or medical history, including Charleston Comorbidity Index. DFR was associated with longer hospital stay (6.09 days ORIF vs. 9.08 days DFR, P < 0.001) and more frequent blood transfusion (12.3% ORIF vs. 44.0% DFR, P < 0.001). Logistic regression analysis using propensity score matching (PSM) demonstrated no statistically significant difference in reoperation, hospital readmission, ambulatory status at 1 year, or 1-year mortality between the 2 cohorts. Finally, applying Bayesian model averaging using PSM to identify risk factors for 1-year mortality demonstrated that increasing age, length of index hospital stay, and 90-day hospital readmission were significantly associated with 1-year mortality, regardless of type of surgical treatment. CONCLUSION: Rehospitalization, reoperation, ambulatory status, and 1-year mortality are no different between ORIF and DFR in the treatment of geriatric periprosthetic distal femur fractures when PSM is applied to mitigate selection bias. Further study is warranted to elucidate functional outcomes, long-term sequelae, and costs of care related to these treatment options to better guide treatment planning. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fixation of displaced intra-articular calcaneus fractures is safe using either sinus tarsi or extensile lateral approach.

INTRODUCTION: Management of displaced intra-articular calcaneus fractures continues to challenge surgeons. Use of the extensile lateral surgical approach (ELA) had been standard practice however wound necrosis and infection have become deterrents. The sinus tarsi approach (STA) has gained popularity as a less invasive technique to optimize articular reduction while minimizing soft tissue injury. Our aim was to compare wound complications and infections following calcaneus fractures treated using ELA versus STA. METHODS: Retrospective review of 139 displaced intra-articular calcaneus fractures (AO/OTA 82C; Sanders II-IV injuries) treated operatively at 2 level-I trauma centers using STA (n = 84) or ELA (n = 55) over a 3-year period with minimum 1-year follow up was performed. Demographic, injury, and treatment-related characteristics were collected. Primary outcomes of interest included wound complications, infection, reoperation, and American Orthopaedic Foot and Ankle Society ankle and hindfoot scores. Univariate comparisons between groups were conducted using Chi-Square, Mann-Whitney, and independent sample t-tests at the p < 0.05 significance level, where appropriate. Multivariable regression analysis was performed to identify risk factors for poor outcomes. RESULTS: Demographic characteristics were homogenous between cohorts. Most sustained falls from height (77%). Sanders III fractures were most common (42%). Patients treated with STA went to surgery earlier (6.0 days STA vs 13.2 ELA, p < 0.001). No differences were seen in restoration of Bohler's angle, varus/valgus angle, or calcaneal height, yet the ELA significantly improved calcaneal width (-2 mm STA vs -13.3 mm ELA, p < 0.001). There were no significant differences in wound necrosis or deep infection based on surgical approach (12% STA vs 22% ELA, p = 0.15). Seven patients underwent subtalar arthrodesis for arthrosis (4% STA vs 7% ELA). No differences in AOFAS scores were seen. Risk factors for reoperation included Sanders type IV patterns (OR = 6.6, p = 0.001), increasing BMI (OR = 1.2, p = 0.021), and advanced age (OR = 1.1, p = 0.005), not surgical approach. CONCLUSION: Despite prior concerns, use of ELA versus STA for fixation of displaced intra-articular calcaneus fractures was not associated with more complication risk, illustrating both are safe when indicated and executed appropriately.

Do Patients Reporting Fractures Experience Food Insecurity More Frequently Than the General Population?

BACKGROUND: The economic burden of traumatic injuries forces families into difficult tradeoffs between healthcare and nutrition, particularly among those with a low income. However, the epidemiology of food insecurity among individuals reporting having experienced fractures is not well understood. QUESTIONS/PURPOSES: (1) Do individuals in the National Health Interview Survey reporting having experienced fractures also report food insecurity more frequently than individuals in the general population? (2) Are specific factors associated with a higher risk of food insecurity in patients with fractures? METHODS: This retrospective, cross-sectional analysis of the National Health Interview Survey was conducted to identify patients who reported a fracture within 3 months before survey completion. The National Health Interview Survey is an annual serial, cross-sectional survey administered by the United States Centers for Disease Control, involving approximately 90,000 individuals across 35,000 American households. The survey is designed to be generalizable to the civilian, noninstitutionalized United States population and is therefore well suited to evaluate longitudinal trends in physical, economic, and psychosocial health factors nationwide. We analyzed data from 2011 to 2017 and identified 1399 individuals who reported sustaining a fracture during the 3 months preceding their survey response. Among these patients, 27% (384 of 1399) were older than 65 years, 77% (1074) were White, 57% (796) were women, and 14% (191) were uninsured. A raw score compiled from 10 food security questions developed by the United States Department of Agriculture was used to determine the odds of 30-day food insecurity for each patient. A multivariate logistic regression analysis was performed to determine factors associated with food insecurity among patients reporting fractures . In the overall sample of National Health Interview Survey respondents, approximately 0.6% (1399 of 239,168) reported a fracture. RESULTS: Overall, 17% (241 of 1399) of individuals reporting broken bones or fractures in the National Health Interview Survey also reported food insecurity. Individuals reporting fractures were more likely to report food insecurity if they also were aged between 45 and 64 years (adjusted odds ratio 4.0 [95% confidence interval 2.1 to 7.6]; p < 0.001), had a household income below USD 49,716 (200% of the federal poverty level) per year (adjusted OR 3.1 [95% CI 1.9 to 5.1]; p < 0.001), were current tobacco smokers (adjusted OR 2.8 [95% CI 1.6 to 5.1]; p < 0.001), and were of Black race (adjusted OR 1.9 [95% CI 1.1 to 3.4]; p = 0.02). CONCLUSION: Among patients with fractures, food insecurity screening and routine nutritional assessments may help to direct financially vulnerable patients toward available community resources. Such screening programs may improve adherence to nutritional recommendations in the trauma recovery period and improve the physiologic environment for adequate soft tissue and bone healing. Future research may benefit from the inclusion of clinical nutritional data, a broader representation of high-energy injuries, and a prospective study design to evaluate cost-efficient avenues for food insecurity interventions in the context of locally available social services networks. LEVEL OF EVIDENCE: Level III, prognostic study.

Trauma recidivism is pervasive and is associated with mental and social health opportunities.

INTRODUCTION: Recidivism after orthopedic trauma results in greater morbidity and costs. Prior studies explored the effects of social and medical factors affecting the frequency of return to the hospital with new, unrelated injury. Identification of mental, social and other risk factors for trauma recidivism may provide opportunities for mitigation. The purposes of this study are to determine the rates of subsequent, unrelated injury noted among orthopedic trauma patients at a large urban trauma center and to evaluate what patient and injury features are associated with greater rates of trauma recidivism. We hypothesize higher rates of new injuries will be related to ballistic trauma and other forms of assault, alcohol and recreational drug use, unemployment, and unmarried status among our trauma patients. METHODS: A series of 954 skeletally mature patients at a level 1 trauma center over a 5 year period were included in the study. All were treated operatively for thoracolumbar, pelvic ring, acetabulum, and/or proximal or shaft femoral fractures from a high energy mechanism. Retrospective review of demographic, injury, medical, and social factors, and subsequent care was performed. Trauma recidivism was defined as returning to the emergency department for treatment of any new injury. A backward stepwise logistic regression statistical analysis was used to identify independent predictors of recidivism. RESULTS: Mean age of all patients was 41.2 years, and 73.2% were male. 136 patients (14.3%) returned with a new injury within a mean of 21 months. These trauma recidivists were more likely to sustain a GSW (22.1% vs 11.4%, p = 0.001). They had higher rates of substance use, including tobacco (57.4% vs 41.8%, p = 0.001) and recreational drugs (50.7% vs 34.4%, p = 0.001), and were less likely to be married (10% vs 25.9%, p<0.001). Mental illness was pervasive, noted in 56.6% of patients with new injury (vs 32.8%, p<0.001). Medicaid insurance was most common in the trauma recidivist population (58.1% vs 35.0%, p = 0.001), and 12.5% were uninsured. Completing high school or more education was protective (93% non-recidivist (vs 79%, p = 0.001). Sixty-nine patients (50.7%) were repeat trauma recidivists within the study period. Independent predictors of new injury included recreational drug use (OR 1.64, p = 0.05) and history of assault due to GSW or other means (OR 1.67, p = 0.05). History of pre-existing mental illness represented the greatest risk factor for trauma recidivism (OR 2.55, p<0.001). DISCUSSION: New injuries resulting in emergency department presentation after prior orthopedic trauma occurred in 14.3% and were associated with history of assault, lower education, Medicaid insurance, tobacco smoking and recreational drug use. Mental illness was the greatest risk factor. Over half of patients with these additional injuries were repeat trauma recidivists, returning for another new injury within less than 2 years. Awareness of risk factors may promote focused education and other interventions to mitigate this burden. LEVEL OF EVIDENCE: Level 3 retrospective, prognostic.