The high-risk hip fracture patient and the palliative care consult : A retrospective study to investigate risks of complications and the utility of a palliative care consult in hip fracture patients undergoing surgical fixation.

We evaluated the utility of a palliative care consult (PCC) in high-risk hip fracture patients. The main result was that a PCC reflects certain risk factors for post-surgical complications and is associated with a delay to surgery in the high-risk patient population that it served. PURPOSE: The objective of this study was to identify risks of complications in surgically managed hip fractures and determine the utility of a PCC in this population, particularly regarding time to the operating room (OR). METHODS: Retrospective cohort at a Level I academic trauma center. RESULTS: Four hundred sixty-two patients were treated surgically for hip fracture. Decreased pre-injury ambulatory status (OR 2.18, 95% CI 1.13-4.20, p = .02), time to OR > 48 h (OR 4.76, 95% CI 1.43-15.87, p = .011), and obtaining a pre-operative PCC (OR 3.03, 95% CI 1.34-6.85, p = .008) were independent risk factors for post-surgical complications. Multivariate risk factors for obtaining a PCC included older age (OR 1.1, CI 1.0-1.1, p = .007), pre-injury ambulatory status (OR 2.2, CI 1.3-3.9, p = .005), renal failure (OR 3.1, CI 1.1-9.0, p = 0.032), and higher ASA category (OR 2.6, CI 1.2-5.5, p = .014). A delay of more than 48 h was associated with being male ( OR 4.6, CI 1.4-15.0, p = .013) or having obtained a PCC (OR 5.5, CI 1.4-22.7, p = .017). CONCLUSIONS: Obtaining a PCC can reflect risks of complications and mortality. It is a valuable resource for use in high-risk patients who are inherently at risk for delays to surgery and should be used judiciously.

Defining Haglund's deformity radiographically by incorporating the biomechanics of ankle motion.

BACKGROUND: Haglund's deformity is clinically defined by the presence of retrocalcaneal tenderness, with previous radiographic parameters relying on calcaneal anatomic parameters that did not considering the influence of ankle motion on posterior calcaneal-Achilles impingement METHODS: Standing foot radiographs from 55 patients with clinically defined Haglund's deformity were compared to 50 control patients using previously described measurements and 2 new angular measurements based on the linkage between ankle rotation and posterior calcaneal-Achilles impingement. The ability of each measure to distinguish between Haglund's and control patients was assessed. RESULTS: The combination of the angles to account for both increased calcaneal tubercle height and increased posterior calcaneal prominence could distinguish between the two patient groups (p = .018, Area under the curve = 63.2%). None of the previously published radiographic criteria were different between the two patient groups. CONCLUSIONS: The proposed radiographic criteria were more predictive than previous criteria that did not address the role of ankle motion.

Surgical versus nonsurgical treatment of acute Achilles ruptures in the high demand patient: Using decision analysis to help clinical decisions.

BACKGROUND: Recent literature suggests that functional treatment of acute non-insertional Achilles tendon ruptures yields outcomes (re-rupture and function) similar to those of surgery, but does not address the unique issues in treating high performance athletes or other high demand patients. METHODS: Decision analysis was used to develop an estimate of outcome utility for both types of treatment using published Costs and Quality-Adjusted Life Years (QALYs) values. The expected value for either treatment was then calculated for high, intermediate, and normal demand patients, using the specific functional needs of the patients. RESULTS: Nonoperative treatment is the preferred management for normal demand patients, while high and intermediate demand patients are more likely to experience better expected functional outcomes from surgery. CONCLUSION: The combination of a decision analysis and expected value analysis provides evidence-based support for the existing intuitive recommendations that favor surgical treatment in elite athletes and other high demand patients. LEVEL OF EVIDENCE: III.

Rebooting the Electronic Health Record.

Justifications for the widespread adoption and integration of an electronic health record (EHR) have long leaned on the purported benefits of the technology. However, the performance of the EHR has been underwhelming relative to the promises of immediate access to relevant patient information, clinical decision supports, computerized ordering, and transferable patient data. In this narrative review, we provide an overview of the historical problems and limitations of the EHR, detail the core principles that define agile processes that may overcome the barriers faced by the current EHR, and re-imagine what an integrated, seamless EHR that serves its users and patients might look like. Moving forward, the EHR should be redesigned using a middle-out framework and empowering dual-type champions to maintain the sustainable diffusion of future innovations.

What Is the Efficacy of a Nonoperative Program Including a Specific Stretching Protocol for Flexor Hallucis Longus Tendonitis?

BACKGROUND: Diagnosis and treatment of tendonitis/entrapment of the flexor hallucis longus (FHL) has been sporadically described in the evidence, primarily in the context of dancers and other athletes. Although various nonspecific nonoperative treatments have been described, it is not clear how often they achieve a satisfactory amount of symptom improvement. QUESTIONS/PURPOSES: The present study was designed to address the following questions regarding the nonoperative treatment of FHL tendonitis: (1) In a population of patients where the default management option for FHL tendonitis is a comprehensive nonsurgical approach, what proportion of patients thus treated opted not to have surgery? (2) What factors were associated with a patient's decision to undergo surgery after a period of nonsurgical management? METHODS: The 656 patients included were all those diagnosed with FHL tendonitis who were initially treated nonoperatively in the foot and ankle division between January 2009 and December 2018. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and final outcome were obtained from the electronic medical record. The primary outcome was the decision to have surgery due to unsatisfactory symptom improvement. We compared patients who opted for surgery with those who did not after nonoperative treatment with univariable and multivariable statistics using demographics, comorbidities, and clinical findings as potential risk factors, with p < 0.05. RESULTS: Forty-four percent (180 of 409) of patients decided to forgo surgery after the institution of a specific FHL stretching program. Surgery was more likely in patients with clinical hallux rigidus (OR 2.4 [95% CI 1.16 to 4.97]; p = 0.02) or posteromedial ankle pain (OR 1.78 [95% CI 1.12 to 2.83]; p = 0.01) and less likely in those who completed an FHL stretching program (OR 0.15 [95% CI 0.08 to 0.27]; p < 0.001). CONCLUSION: FHL tendonitis is more common than the previous evidence suggests and frequently occurs in nonathletes. Once it was diagnosed by detection of tenderness anywhere along the tendon, most frequently at the fibroosseous tunnel, nonoperative treatment focused on specific FHL stretching and immobilization in more severe cases reduced the symptoms to the extent that 44% of patients decided that surgery was unnecessary. The key to its diagnosis is awareness that this injury is possible because most patients treated in this study had been previously seen by orthopaedic providers who had not appreciated the presence of the condition, leading to a delay in diagnosis and treatment of more than a year in many patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

The Effect of Dexamethasone on Postoperative Blood Glucose in Patients With Type 2 Diabetes Mellitus Undergoing Total Joint Arthroplasty.

BACKGROUND: Perioperative glucocorticoids are routinely administered to patients undergoing total joint arthroplasty (TJA) to decrease postoperative pain and nausea. However, there is concern regarding the effects of glucocorticoids on perioperative glucose control in diabetes. The goal of this study is to determine if administration of preoperative dexamethasone to diabetic patients is significantly associated with hyperglycemia and increased insulin requirements in the immediate postoperative period after TJA and to identify risk factors for postoperative hyperglycemia immediately after TJA. METHODS: A retrospective review of type 2 diabetic patients undergoing TJA from 2010 to 2015 (n = 285) was undertaken to evaluate the effect of dexamethasone on postoperative glucose control. Preoperative baseline characteristics were compared between patients who did and did not receive 8 mg of intravenous dexamethasone preoperatively. Postoperative glucose and insulin requirements were evaluated with respect to dexamethasone dosing. Statistical analysis was performed using logistic regression models. RESULTS: Dexamethasone administration did not correlate with the maximum postoperative blood glucose (P = .78). There was a significantly higher initial postoperative blood glucose after intravenous dexamethasone administration (P < .01). Dexamethasone administration was associated with increased aspart insulin requirements on postoperative day 0 (P = .04). However, preoperative hemoglobin A1c was most strongly associated with postoperative glucose control. CONCLUSION: Preoperative dexamethasone administration to diabetic patients was associated with an initial increase in blood glucose and increased insulin requirement on postoperative day 0. Yet the observed effect on glucose control in diabetic patients may not outweigh the known clinical benefits of perioperative glucocorticoids.

Posterior tibial tendon dysfunction: Imperfect specificity of magnetic resonance imaging.

MRI is frequently used in the evaluationand treatment of tibialis posterior tendon (PTT) dysfunction. MRI is reported to have sensitivity up to 95%, with 100% specificity, in the detection of rupture of the PTT. We present three cases where MRI demonstrated complete or partial rupture of the PTT, where subsequent surgery showed an intact PTT with tenosynovitis. In all cases, there was a source of inflammation external to the tendon. It is hypothesized that this exogenous origin of inflammation caused changes in the MRI signal in the PTT that resemble that seen in ruptures. These cases show that in the presence of inflammation near the tibialis posterior tendon, the MRI may falsely indicate a high-grade rupture of the tendon. Recommendations for treatment of suspected PTT rupture in the presence of significant other sources of inflammation are proposed.

Quantitative relationship of first metatarsophalangeal head morphology to hallux rigidus and hallux valgus.

BACKGROUND: Previous qualitative studies have linked first metatarsal head morphology with hallux valgus (HV) and hallux rigidus (HR). This study used a quantitative measurement of 1st MT radius of curvature to assess if HR MT heads were flatter than HV heads. METHODS: Weight bearing foot films were used in HV, HR, and normal patients (no forefoot complaints) to measure the metatarsal head radius of curvature (normalized by dividing the radius of curvature by the first metatarsal length to adjust for magnification and foot size). RESULTS: Radiographs from 299 feet were analyzed (105 normal, 57 HR, and 137 HV). The mean normalized radius of curvature was smaller in HV than HR, with normal feet in between (p<.05 for all comparisons). Metatarsal head curvature did not vary with age, weight, or BMI. CONCLUSION: These quantitative measurements are consistent with qualitative observations, validating the use of subjective metatarsal head morphology assessments.

Work-hour restrictions and orthopaedic resident education: a systematic review.

PURPOSE: The ACGME (US) and The European Working Time Directive (UK) placed work-hour restrictions on medical trainees with the goal of improved patient safety. However, there has been concern over a potential decrease in medical education. Orthopaedic training is the focus of this study. We examined previously published subjective and objective data regarding education and work-hour restrictions and developed the questions: Do specific perceptions emerge within the subjective studies examined? Are there objective differences in educational measures before and after work-hour restrictions? Is there a difference between the subjective and objective data? METHODS: A systematic review was conducted via MedLine, regarding orthopaedic studies in the USA and UK, with reference to work-hour restrictions and education. RESULTS: Subjective survey studies demonstrate that residents and attending physicians have a negative response to work-hour restrictions because of the perceived impact on their overall education and operating room experience. Conversely, limited objective studies demonstrated no change in operative volume before or after implementation of restrictions. CONCLUSIONS: This review highlights the need for more objective studies on the educational implications of work-hour restrictions. Studies to date have not demonstrated a measurable difference based on case logs or training scores. Opinion-based surveys demonstrate an overall negative perception by both residents and attending physicians, on the impact of work-hour restrictions on orthopaedic education. Current published data is limited and stronger evidence-based data are needed before definitive conclusions can be reached.

Considerations Regarding Vitamin D in Foot and Ankle Treatment and Surgery.

Although the impact that vitamin D has on bone healing is uncertain in foot and ankle (F&A) surgery, there is support for vitamin D supplementation (2000 IU/day) with calcium (1 g/day) to promote bone healing. Although orthopedic F&A surgeons are frequently the first provider to detect the harbingers of osteoporosis by the occurrence of fragility fractures, this should trigger referral to the appropriate specialist for assessment and treatment. There is circumstantial evidence suggesting a role of hypovitaminosis D in bone marrow edema syndrome and possibly osteochondritis dissecans. There should be a low threshold for assessing vitamin D levels in such patients.

Analysis of the Costs and Complications of First Metatarsophalangeal Joint Arthrodesis Comparing Locked and Non-locked Plate Fixation Constructs.

BACKGROUND: The ideal fixation method for the first metatarsophalangeal joint (first MTP) remains uncertain. This study compares nonunion and revision surgery rates of first MTP arthrodesis between nonlocking semitubular plates and precontoured locking plates. METHODS: Demographics, fixation technique, and complications of all patients who underwent primary first MTP arthrodesis between 2013 and 2018 were determined from radiographs and clinical records. Cost data were from a 1-year subset of isolated first MTP fusion surgeries. The primary outcome measures of this study were the nonunion and complication rates, with associated costs of patients undergoing first metatarsophalangeal arthrodesis with either a noncontoured semitubular plate or a precontoured locking plate. RESULTS: The study included 189 patients, with a mean follow-up of 18.7 months. The overall nonunion rate was 10.1%, with no difference between the locking and nonlocking plates. The prevalence of a painful implant was also similar. Surgeries using locking plates cost an average of $1,500 more than those using nonlocked plates. CONCLUSIONS: Because there was no difference in revision between locking and nonlocking plate fixation for primary first MTP arthrodesis, routine use of the more expensive locking plates may not be justified. LEVEL OF EVIDENCE: Level III (Retrospective cohort study).

Donning Gloves Before Surgical Gown Cross-contaminates the Assistant.

Background: Maintaining a sterile surgical environment is of the upmost importance in total joint arthroplasty. The surgical gown-glove interface is a frequent and known cause of bacterial contamination. A variation of the traditional staff-assisted open-gloving technique has been developed in an attempt to address this. In this method, the surgeon dons their undergloves before their gown. Although this has demonstrated improved sterility for the surgeon, no studies have considered the effects of this technique on the person assisting the surgeon. The present study was designed to investigate this. We hypothesize that the process of donning undergloves before the surgical gown leads to higher rates of contamination for the assistant. Methods: We performed a comparative study between the traditional and a gloves-first scrubbing technique. We assessed the differences in gown and glove contamination of the surgical assistant following each scrubbing event. Two surgeons applied ultraviolet light-disclosing lotion to their upper extremities and then performed each method in a randomized order with 40 surgical technologists/nurses. Blinded evaluators then quantified the amount of contamination on the surgical assistant's gown and gloves. Results: The gloves-first technique resulted in increased contamination of the surgical assistant's gloves (P = .002). There was no difference in contamination of the surgical gown (P =.982). Conclusions: Although the staff-assisted open-gloving technique may improve the sterility of the surgeon, it does so at the expense of the surgical assistant. Surgeons adopting this technique should consider donning their own undergloves or having the assistant rescrub before any further contact with the sterile environment.

A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.

BACKGROUND: Since the Institute of Medicine's report, To Err is Human, was published, numerous interventions have been designed and implemented to correct the defects that lead to medical errors and adverse events; however, most efforts were largely reactive. Safety, communication, team performance, and efficiency are areas of care that attract a great deal of attention, especially regarding the introduction of new technologies, techniques, and procedures. We describe a multidisciplinary process that was implemented at our hospital to identify and mitigate hazards before the introduction of a new technique: high-dose-rate intraoperative radiation therapy, (HDR-IORT). METHODS: A multidisciplinary team of surgeons, anesthesiologists, radiation oncologists, physicists, nurses, hospital risk managers, and equipment specialists used a structured process that included in situ clinical simulation to uncover concerns among care providers and to prospectively identify and mitigate defects for patients who would undergo surgery using the HDR-IORT technique. RESULTS: We identified and corrected 20 defects in the simulated patient care process before application to actual patients. Subsequently, eight patients underwent surgery using the HDR-IORT technique with no recurrence of simulation-identified or unanticipated defects. CONCLUSION: Multiple benefits were derived from the use of this systematic process to introduce the HDR-IORT technique; namely, the safety and efficiency of care for this select patient population was optimized, and this process mitigated harmful or adverse events before the inclusion of actual patients. Further work is needed, but the process outlined in this paper can be universally applied to the introduction of any new technologies, treatments, or procedures.

Ankle Fracture Stability-Based Classification: A Study of Reproducibility and Clinical Prognostic Ability.

OBJECTIVE: To compare the reproducibility and prognostic capacity of 2 commonly used ankle fracture classifications to the stability-based classification. METHODS: One hundred ninety-three consecutive rotational-type ankle fractures treated during a year at our institution in patients older than 18 years were retrospectively analyzed. Pilon and pathologic fractures were excluded. The fractures were treated by attending physicians who were unaware of the stability-based classification system. Three observers classified injury radiographs using the Lauge-Hansen, Weber/AO, and stability-based classifications systems. Reproducibility (interobserver variation) of each classification system was calculated using kappa statistics. Prognostic values were evaluated by calculating the area under the curve for the receiver-operating characteristic curves (using surgery as the positive outcome). RESULTS: The stability-based and Weber/AO classifications showed better reproducibility [kappa 0.938 (95% confidence interval 0.921-0.952), kappa 0.97 (0.961-0.976)], respectively, than the Lauge-Hansen [kappa 0.74 (0.664-0.795); P < 0.05]. The stability-based classification was more accurate (P < 0.001) in predicting surgical treatment [area under the curve 0.883 (95% confidence interval 0.852-0.914)] compared with the other 2 classifications [0.626 (0.576-0.675) and 0.698 (0.641-0.755)], respectively. CONCLUSIONS: The stability-based classification was both highly reproducible (kappa 0.938) and had superior prognostic capacity to identify patients who needed surgical intervention compared with both the Lauge-Hansen and AO/Weber classification systems. Importantly, there were no patients who were classified as stable who failed nonoperative treatment. This extends earlier studies by directly demonstrating its prognostic advantage to other classification systems.

Business Modeling of Orthopaedic Trauma in the Emergency Department: An Untapped Revenue Stream.

INTRODUCTION: Emergency departments (EDs) and emergency medicine and orthopaedic residencies can be faced with financial challenges while caring for patients. Procedures performed by residents are a potentially viable source of revenue that may make orthopaedic coverage of the ED a financially viable service line. METHODS: A custom text-mining program was created and validated, which allowed evaluation of all orthopaedic resident notes. Procedures performed in the ED were quantified, allowing for the calculation of professional fee billing data. The patients with distal radius fractures were followed after fracture reduction through final outpatient clinic follow-up to identify additional professional fee billing. RESULTS: Over a 1-year period, more than $445,000 in uncaptured professional fees charged was identified in the 12 most common Current Procedural Terminology codes for splint application and fracture reduction in the ED. More than $395,000 of outpatient professional revenue was received for patients who had reduction of distal radius fractures in the ED. CONCLUSION: A notable, previously unrecognized and uncaptured source of revenue was identified and quantified. Professional fee billing for distal radius fracture reduction in the ED did not have a negative effect on outpatient professional fee revenue received for these patients.

Contribution of the flexor hallucis longus to loading of the first metatarsal and first metatarsophalangeal joint.

BACKGROUND: A recent clinical study suggested that restrictive tenosynovitis of the flexor hallucis longus (FHL) may play an important causative role in hallux rigidus. The goals of this research were to assess normal function of the FHL and the effect of restricted FHL gliding on the loading of the hallux metatarsophalangeal joint (MTPJ). We hypothesized that proximal displacement of the FHL would increase the forces carried by the FHL tendon, causing increased loading of the first metatarsal and MTPJ. MATERIALS AND METHODS: Dynamic simulations of the stance phase of walking were created by loading 5 non-embalmed, non-paired cadaver lower extremities (2 male, 3 female; mean age, 69; range, 56 to 75) in the Robotic Dynamic Activity Simulator (RDAS). The RDAS recreates lower leg motion and muscle activity based on kinematic and electromyographic data of healthy subjects. FHL tendon forces and excursions were measured for the entire stance phase of gait. Bone strains in the mid-shaft of the first metatarsal were recorded and used to derive the in situ forces and moments imposed on the metatarsal and the hallux MTPJ. RESULTS: Under force-feedback control, FHL excursion averaged 6.57 (+/-3.13) mm during gait. When the FHL was held 2-, 4-, and 6-mm proximal to the mid-point of normal excursion to simulate progressive stenosis, the forces in the FHL tendon, first metatarsal and first MTP joint were progressively, and significantly, increased (p < 0.05). CONCLUSION: These findings support the hypothesis that progressive fibrosis at the FHL myotendinous junction can cause increased loading of the hallux MTPJ, thereby leading to hallux rigidus.