Are Orthopaedic Trauma Surgeons Appropriately Compensated for Treating Acetabular Fractures? An Analysis of Operative Times and Relative Value Units.

OBJECTIVES: To evaluate the work relative value units (RVUs) attributed per minute of operative time (wRVU/min) in fixation of acetabular fractures, evaluate surgical factors that influence wRVU/min, and compare wRVU/min with other procedures. DESIGN: Retrospective. SETTING: Level 1 academic center. PATIENT SELECTION CRITERIA: Two hundred fifty-one operative acetabular fractures (62 A, B, C) from 2015 to 2021. OUTCOME MEASURES AND COMPARISONS: Work relative value unit per minute of operative time for each acetabular current procedural terminology (CPT) code. Surgical approach, patient positioning, total room time, and surgeon experience were collected. Comparison wRVU/min were collected from the literature. RESULTS: The mean wRVU per surgical minute for each CPT code was (1) CPT 27226 (isolated wall fracture): 0.091 wRVU/min, (2) CPT 27227 (isolated column or transverse fracture): 0.120 wRVU/min, and (3) CPT 27228 (associated fracture types): 0.120 wRVU/min. Of fractures with single approaches, anterior approaches generated the least wRVU/min (0.091 wRVU/min, P = 0.0001). Average nonsurgical room time was 82.1 minutes. Surgeon experience ranged from 3 to 26 years with operative time decreasing as surgeon experience increased ( P = 0.03). As a comparison, the wRVU/min for primary and revision hip arthroplasty have been reported as 0.26 and 0.249 wRVU/min, respectively. CONCLUSIONS: The wRVUs allocated per minute of operative time for acetabular fractures is less than half of other reported hip procedures and lowest for isolated wall fractures. There was a significant amount of nonsurgical room time that should be accounted for in compensation models. This information should be used to ensure that orthopaedic trauma surgeons are being appropriately supported for managing these fractures. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The use of xenogenic dermal matrices in the context of open extremity wounds: where and when to consider?

Optimal treatment of orthopaedic extremity trauma includes meticulous care of both bony and soft tissue injuries. Historically, clinical scenarios involving soft tissue defects necessitated the assistance of a plastic surgeon. While their expertise in coverage options and microvascular repair is invaluable, barriers preventing collaboration are common. Acellular dermal matrices represent a promising and versatile tool for orthopaedic trauma surgeons to keep in their toolbox. These biological scaffolds are each unique in how they are used and promote healing. This review explores some commercial products and offers guidance for selection in different clinical scenarios involving traumatic wounds.

Liposomal Bupivacaine Associated with Cost Savings during Postoperative Pain Management in Fragility Intertrochanteric Hip Fractures.

Background: Intertrochanteric hip fractures are among the most common and most expensive diagnoses in the Medicare population. Liposomal bupivacaine is a novel preparation of a commonly used analgesic agent that, when used intraoperatively, decreases narcotic requirements and hospital length of stay and increases the likelihood of discharge to home. The purpose of this investigation was to determine whether there was an economic benefit to utilizing intraoperative liposomal bupivacaine in patients with fragility intertrochanteric hip fractures in comparison to a group of patients who did not receive liposomal bupivacaine. Methods: This is a retrospective observational study performed at two academic medical centers. Fifty-six patients with intertrochanteric hip fractures treated with cephalomedullary nail implant who received standard hip fracture pain management protocol were compared to a cohort of 46 patients with intertrochanteric hip fractures who received additional intraoperative injections of liposomal bupivacaine. All other standards of care were identical. A cost analysis was completed including the cost of liposomal bupivacaine, operating room costs, and discharge destination. Statistical significance was set at p < 0.05. Results: Although the length of hospital stay was similar between the two groups (3.2 days vs. 3.8 days, p = 0.08), patients receiving intraoperative liposomal bupivacaine had a lower likelihood of discharge to a skilled nursing facility (84.8% vs. 96.4%, p = 0.002) and a longer operative time (73.4 minutes vs 67.2 minutes, p = 0.004). The cost-benefit analysis indicated that for an investment of $334.18 in the administration of 266 mg of liposomal bupivacaine, there was a relative saving of $1,323.21 compared to the control group. The benefit-cost ratio was 3.95, indicating a $3.95 benefit for each $1 spent in liposomal bupivacaine. Conclusions: Despite the increased initial cost, intraoperative use of liposomal bupivacaine was found to be a cost-effective intervention due to the higher likelihood of discharge to home during the postoperative management of patients with intertrochanteric hip fractures.

The minimal clinically important difference for the nonarthritic hip score at 2-years following hip arthroscopy.

PURPOSE: The purpose of this study was to determine and establish the MCID for the NAHS at 2 years in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). METHODS: Patients that underwent primary hip arthroscopy for FAIS between 2010 and 2016 were analyzed for eligibility. Data were collected from a single surgeon's hip arthroscopy database. MCID was calculated for the NAHS utilizing a distribution-based method. RESULTS: The study included 298 patients (184 females) with an average age of 40.4 ± 13.0 years and average body mass index (BMI) of 25.7 ± 4.2 kg/m2. At baseline, the cohort's average NAHS score was 48.7 ± 13.6 and demonstrated an improvement of 36.5 ± 17.0 for NAHS at follow-up. This resulted in MCID values of + 8.5 for NAHS. CONCLUSION: This is the first study to report the MCID (+ 8.5) for NAHS following primary hip arthroscopy, and as such, is a valuable contribution to future hip arthroscopy research. LEVEL OF EVIDENCE: IV.

Radiographic Factors Associated With Failure of Revision Hip Arthroscopy.

PURPOSE: To identify clinical and radiographic factors associated with failure of revision hip arthroscopy (RHA). METHODS: A database was used to identify patients who underwent primary hip arthroscopy and revision hip arthroscopy (RHA) from January 2007 to December 2017 for the indication of femoroacetabular impingement and failure of the index procedure, respectively. The primary outcome was defined as the change, or difference, in the preoperative to postoperative alpha angle between patients with successful RHA and those with failed RHA. Failure was defined as reoperation on the operative hip for any indication or a modified Harris Hip Score (mHHS) of less than 70 at the 1-year postoperative time point. All patients had a minimum of 2 years' follow-up from the date of revision hip surgery. Patients with a history of revision were divided into those with failed revisions and those with successful revisions. The inclusion criteria for failed revision included a history of subsequent revision surgery (or arthroplasty) or an mHHS of less than 70 at final follow-up. RESULTS: The study included 26 patients, comprising 8 (31%) with failed RHA and 18 (69%) with successful revision. The failure group showed a significantly smaller decrease in the alpha angle with surgery, measured on the Dunn view, compared with the success group. When the preoperative alpha angle was held constant, each 1° increase in the difference between the preoperative and postoperative alpha angles achieved during surgery was associated with a 17% decrease in the odds of failure. Patients included in the success group had both a higher preoperative mHHS (44.2 ± 8.6 vs 34.7 ± 9.6) and a higher postoperative mHHS (83.2 ± 8.3 vs 62.3 ± 14.2) than patients with failed RHA. There was a statistically significant difference in the frequency of patients who achieved the patient acceptable symptomatic state of +74.0 between the failure (25%) and success (83%) groups; 88% of patients in the failure group met the minimal clinically important difference, whereas 100% of patients in the success group (n = 18) met it. CONCLUSIONS: Complete resection of cam lesions as determined by changes in the alpha angle, anterior offset, and head-neck ratio when measured on the Dunn 45° view correlates with positive clinical outcomes after RHA. LEVEL OF EVIDENCE: III, Retrospective Comparative Study.

Age-Associated Pathology and Functional Outcomes After Hip Arthroscopy in Female Patients: Analysis With 2-Year Follow-up.

BACKGROUND: Previous research has demonstrated a statistically significant relationship between hip arthroscopy outcomes and age. PURPOSE: To investigate the link, if any, between hip arthroscopy outcomes and intraoperative pathology as well as with patient age and sex. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Of 272 female patients aged ≥14 years undergoing primary hip arthroscopy for femoroacetabular impingement between August 2010 and September 2017, and with 2-year patient-reported outcome scores, a total of 194 (71.3%) were included for final analysis. These patients were separated into 3 age-based cohorts: <30 years (n = 44), 30 to 45 years (n = 74), and >45 years (n = 76). Their data were then analyzed and compared with respect to patient characteristic information, intraoperative pathology, and functional outcome scores for statistical significance, which was set at P < .05. RESULTS: When an analysis of variance was conducted for the 3 age groups at 2-year follow-up, there was a statistically significant difference for modified Hip Harris Score (P = .0003; <30 years, 88.26 ± 13.1 [mean ± SD]; 30-45 years, 82.68 ± 18.0; >45 years, 75.03 ± 19.5). The results of an analysis of variance comparing 2-year Non-arthritic Hip Score were also statistically significant (P = .0002; <30 years, 89.9 ± 13.7; 30-45 years, 85.8 ± 15.8; >45 years, 78.1 ± 17.2). Results of logistic regression demonstrated that the odds of a cam-type lesion decreased by 0.971 for every additional year in age among female patients. The odds of achieving the patient-acceptable symptomatic state decreased by a factor of 0.96 for each additional year in age (P < .0004). CONCLUSION: Surgical treatment of femoroacetabular impingement in females led to improved functional outcomes at 2 years of follow-up, although older female patients did worse after hip arthroscopy as compared with their younger counterparts. There may be an age-dependent decrease in incidence of cam-type lesions in female patients.

Infant and Young Child Feeding Decision Making and Practices: Malawian Mothers' and Fathers' Roles in the Context of HIV.

BACKGROUND: Few studies in low- and middle-income countries have examined the roles of couples in infant and young child feeding decision making and practices, and there is no corresponding data in the context of human immunodeficiency virus (HIV). Research aim: This study aimed to explore mothers' and fathers' perceptions of their roles in feeding decision making and practices. METHODS: The authors conducted in-depth interviews with 15 mothers and their male partners, recruited from the catchment areas of two urban and two rural government clinics in Lilongwe District, Malawi. The mothers were ≥ 18 years of age, were HIV positive, and had a child < 24 months of age. Twelve of the 15 fathers were also HIV positive. The interviews were analyzed using content analysis. RESULTS: Mothers were responsible for child care, including breastfeeding and complementary feeding. Fathers provided monetary support for purchasing food and offered verbal support to encourage mothers to implement recommended feeding practices. Many fathers found it difficult to support adequate complementary feeding because of household food insecurity. Mothers were advised on child feeding during prevention of mother-to-child transmission clinic visits. No fathers in this study accompanied women to clinic appointments, so they were less well-informed about feeding than mothers. Fathers usually deferred to mothers in feeding decision making. One-third of mothers wanted fathers to be more involved in child feeding. CONCLUSION: Malawian mothers' and fathers' roles in feeding decision making in the context of HIV align with local gender norms. Strategies are needed to improve fathers' knowledge of and involvement in child feeding, as desired by mothers.