Routine 2-Week Postoperative Radiographs After Geriatric Hip Fracture Fixation: Low Utility and High Cost.

BACKGROUND: Geriatric hip fractures are associated with a large financial burden on both patients and payors, yet minimal data exist regarding postoperative cost optimization and guidelines for delivering high-value care. We assessed the utility and cost of routine radiographs at the first postoperative visit (FPOV) after fixation of geriatric hip fractures. METHODS: We retrospectively evaluated patients with isolated geriatric hip fractures treated with internal fixation between January 2018 and September 2020. Medical records were reviewed to assess whether radiographs at the FPOV changed management. Direct costs of radiographs at the FPOV were estimated using Medicare Fee Schedule data. Indirect costs were estimated by assessing transportation costs. National costs were estimated by extrapolating institutional and Medicare data to the estimated 300,000 to 500,000 annual hip fractures in the United States. RESULTS: Two hundred forty-one patients were included. A majority had intertrochanteric fractures (80%), were injured because of a ground-level fall (94%), and received long intramedullary nails (73%). One patient (1/241, 0.41%) had their postoperative management changed by FPOV radiographs, and that patient had an acute reinjury before their FPOV. Patients discharged home (50/241, 21%) traveled mean 51.3 miles each way, and those discharged to another facility (191/241, 79%) traveled mean 24.1 miles each way. The national estimated direct cost of routine radiographs at the FPOV totaled $10.9 to $18.2 m annually. The national indirect costs are estimated to be $1.2 to $1.9 m annually for patients discharged home and $63.4 to $105.7 m annually for patients discharged to a facility. CONCLUSIONS: Routine radiographs at the FPOV after internal fixation of geriatric hip fractures may not change management and should only be obtained when specifically indicated. Elimination of routine radiographs and conduction of the FPOV virtually by telemedicine could result in national cost savings of estimated $75.5 to $125.8 m annually without compromising quality of care.

The Association between Race and Extended Length of Stay in Low-energy Proximal Humerus Fractures in Elderly Patients.

INTRODUCTION: Proximal humerus fractures (PHFs) are one of the most common fractures among patients aged 65 years and older, commonly due to low-energy mechanisms. It is essential to identify drivers of increased healthcare utilization in geriatric PHF patients and bring awareness to any disparities in care. Here, we identify factors associated with the likelihood of inpatient admission and prolonged hospital stay among patients aged 65 years and older who sustain PHF due to falls. METHODS: A national database was used to identify patients aged 65 years and older who suffered proximal humeral fractures due to a fall. Patient factors were analyzed for association with the likelihood of admission and odds of prolonged stay (≥5 days). RESULTS: In the study period, 75,385 PHF patients who met our inclusion criteria presented to the emergency department and 14,118 (18.7%) were admitted. Black race was significantly associated with decreased odds of admission ( P < 0.001) and increased likelihood of prolonged stay ( P = 0.007) compared with White patients. Patients aged 75 to 84 and 85+ were both more likely to be admitted ( P < 0.001) and experienced a prolonged hospital stay ( P = 0.015). Patients undergoing surgical intervention with reverse total shoulder arthroplasty were associated with admission and prolonged length of stay ( P < 0.001). Hospitals in Midwestern ( P < 0.001) and Western ( P < 0.001) regions exhibited lower rates of admission and Northeastern hospitals were associated with prolonged stays ( P = 0.001). Finally, trauma and nonmetropolitan ( P < 0.001) centers were associated with admission. CONCLUSION: Our study highlights the notable influence of age and race on the likelihood of hospital admission and prolonged hospital stay. Specifically, Black patients exhibited prolonged hospital stay, which has been associated with lower-quality care, warranting additional exploration. Understanding these demographic and hospital-related factors is essential for optimizing resource allocation and reducing healthcare disparities in the care of PHF patients, especially as the population ages and the incidence of PHF continues to rise.

Pre-injury depression and anxiety in patients with orthopedic trauma and their treatment.

PURPOSE: Depressive symptoms have a known negative impact on outcomes following musculoskeletal injury. This study determined the pre-injury prevalence of psychiatric diagnoses of depression and anxiety, medication lapses and psychiatric consult services among patients admitted for orthopaedic trauma. METHODS: This is a retrospective study of data from our Level-1 trauma center. Patients admitted to the orthopaedic trauma service during 2010-2015 were included (N = 4053). Demographics, Injury Severity Scores (ISS), mental health diagnoses, psychotropic medications, medication type and delay, psychiatric consultation use, intensive care unit (ICU) stay and total hospital length of stay (LOS) were abstracted from medical records and the institutional trauma registry. RESULTS: The 12-month prevalence of a major depressive episode is 6.6%-8.6% in adults in the United States. In our database, only 152/4053 (3.8%) of the patients had documented medical history of depression (80%) or anxiety (30%), and these patients had a 32% longer LOS (p < 0.016). Nearly two-thirds of patients who used psychotropic medications prior to injury experienced a delay in receiving these medications in the hospital (median = 1.0 day, range 0-14 days). Sixteen percent of patients also received a new psychotropic medication while hospitalized: an antipsychotic (8/16 patients, to treat delirium), an anxiolytic (3/16 patients for acute anxiety), or an antidepressant (1/16). Among patients with depression or anxiety, 16.7% received a psychiatric consult. Patients with psychiatric consults had higher ISS, were more likely to have longer ICU LOS and had longer hospital LOS than those without consults (all p < 0.05). CONCLUSION: The prevalence of depression and anxiety is grossly under-reported in our registry compared to national prevalence data. Patients with pre-existing disease had longer LOS and a higher rate of extended ICU care. Further studies are needed to characterize the true prevalence of disease in this patient population and its effect on patient outcomes after traumatic orthopaedic injury.

Assessment of ankle and hindfoot stability and joint pressures using a human cadaveric model of a large lateral talar process excision: a biomechanical study.

Lateral talar process fragment excision may be followed by hindfoot instability and altered biomechanics. There is controversy regarding the ideal fragment size for internal fixation versus excision and a concern that excision of a large fragment may lead to significant instability. The aim of this study was to assess the effect of a simulated large lateral talar process excision on ankle and subtalar joint stability.A custom-made seesaw rig was designed to apply inversion/eversion stress loading on 7 fresh-frozen human cadaveric lower legs and investigate them in pre-excision, 5 cm and 10 cm lateral talar process fragment excision states. Anteroposterior radiographs were taken to assess ankle and subtalar joint tilt and calculate angular change from neutral hindfoot alignment to 10-kg forced inversion/eversion. Ankle joint pressures and contact areas were measured under 30-kg axial load in neutral hindfoot alignment.In comparison to the pre-excision state, no significantly different mediolateral angular change was observed in the subtalar joint after 5 and 10 cm lateral talar process fragment excision in inversion and eversion. With respect to the ankle joint, 10-cm fragment excision produced significantly bigger inversion tibiotalar tilt compared with the pre-excision state, P = .04. No significant change of the ankle joint pressure and contact area was detected after 5 and 10-cm excision in comparison with the pre-excison state.An excision of up to 10 cm of the lateral talar process does not cause a significant instability at the level of the subtalar joint but might be a destabilizing factor at the ankle joint under inversion stress. The latter could be related to extensive soft tissue dissection required for resection.