Orthopaedic trauma surgeons and direct anterior total hip arthroplasty: evaluation of learning curve at a level I academic institution.

BACKGROUND: Interest in the direct anterior approach for total hip arthroplasty has increased over recent years; however, the potential for substantial complications exists, especially during the surgeon's learning curve. We evaluated the change in various metrics to help identify a single surgeon's learning curve. Additionally, we examined whether the learning curve was different for primarily arthroplasty versus trauma-trained surgeons. METHODS: We reported outcomes from the first 50 total hip arthroplasties performed through a direct anterior approach by a trauma fellowship-trained orthopaedic surgeon. Intraoperative and post-operative clinical outcomes were evaluated, including length of procedure, estimated blood loss, length of hospitalization, disposition to home versus care facility, need for blood transfusion, and complications. Previous reported learning curve outcomes were analysed with a comparison between those who are primarily arthroplasty specialists versus those who include hip arthroplasty as only a portion of their practice. RESULTS: A significant difference in surgical time from 135 to 113 min was observed between the first 25 cases and the last 25. Estimated blood loss (EBL) and lateral femoral cutaneous nerve injury rates decreased but not to a significant degree. Among reported learning curves, surgical time was significantly lower among fellowship-trained arthroplasty specialists when compared with other surgeons. CONCLUSION: Our data support that surgeons who perform primarily joint arthroplasty will likely have a decreased surgical time, but similar EBL compared to those who include arthroplasty as only a portion of their practice, however, a number of confounding variables do exist, and additional investigation is warranted.

Delayed union and nonunions: epidemiology, clinical issues, and financial aspects.

Fracture healing is a critically important clinical event for fracture patients and for clinicians who take care of them. The clinical evaluation of fracture healing is based on both radiographic findings and clinical findings. Risk factors for delayed union and nonunion include patient dependent factors such as advanced age, medical comorbidities, smoking, non-steroidal anti-inflammatory use, various genetic disorders, metabolic disease and nutritional deficiency. Patient independent factors include fracture pattern, location, and displacement, severity of soft tissue injury, degree of bone loss, quality of surgical treatment and presence of infection. Established nonunions can be characterised in terms of biologic capacity, deformity, presence or absence of infection, and host status. Hypertrophic, oligotrophic and atrophic radiographic appearances allow the clinician to make inferences about the degree of fracture stability and the biologic viability of the fracture fragments while developing a treatment plan. Non-unions are difficult to treat and have a high financial impact. Indirect costs, such as productivity losses, are the key driver for the overall costs in fracture and non-union patients. Therefore, all strategies that help to reduce healing time with faster resumption of work and activities not only improve medical outcome for the patient, they also help reduce the financial burden in fracture and non-union patients.

Analysis of usage and associated cost of external fixators at an urban level 1 trauma centre.

OBJECTIVE: To determine the usage, indication, duration, and cost associated with external fixation usage. Additionally, to show the significant cost associated with external fixator use and reinvigorate discussions on external fixator reuse. DESIGN, SETTING, AND PATIENTS: A retrospective review of a prospectively gathered trauma database was undertaken to identify all patients treated with external fixation frames for pelvic and lower extremity injuries between September 2007 and July 2010. MAIN OUTCOME AND MEASURES: We noted the indications for frame use, and we determined the average duration of external fixation for each indication. The cost of each frame was calculated from implant records. RESULTS: 341 lower extremity and pelvic fractures were treated with external fixation frames during the study period. Of these, 92% were used as temporary external fixation. The average duration of temporary external fixation was 10.5 days. The cost of external fixation frame components was $670,805 per year. The average cost per external fixation frame was $5900. CONCLUSIONS: The majority of external fixators are intended as temporary frames, in place for a limited period of time prior to definitive fixation of skeletal injuries. As such, most frames are not intended to withstand physiologic loads, nor are they expected provide a precise maintenance of reduction. Given the considerable expense associated with external fixation frame components, the practice of purchasing external fixation frame components as disposable "single-use" items appears to be somewhat wasteful. LEVEL OF EVIDENCE: Level II.