Background: The impact of non-steroidal anti-inflammatory drugs (NSAIDs) on rotator cuff repair is an ongoing area of study within orthopedics, with conflicting results in current literature. Despite concerns over the deleterious effects of NSAIDs on rotator cuff healing, they are becoming an integral part of a multimodal post-operative pain control regiment. The purpose of this study was to compare post-operative patient-reported outcomes (PROs), complications rates, and retear rates of arthroscopic rotator cuff repairs in patients using ibuprofen post-operatively to those who abstained from NSAIDs for six weeks after surgery. It was hypothesized that a short course of ibuprofen post-operatively would not lead to inferior PRO scores, increased retear rates, nor increased complication rates after arthroscopic rotator cuff repair. Methods: Patients of the primary surgeon who underwent arthroscopic rotator cuff repair between 2012 and 2022 were evaluated by retrospective chart review. In May 2017 the primary surgeon changed his protocol from avoiding NSAIDs for six weeks after surgery to routinely prescribing two weeks of Ibuprofen 800 mg TID post-operatively. Patients who avoided NSAIDs for six weeks were compared to patients who were prescribed NSAIDs post-operatively. Patient demographic data, pre-operative MRI results, pre-operative and post-operative PROs were collected from the EMR. Additionally, post-operative complications and repair failures requiring reoperation within one year were evaluated. Results: 125 patients met inclusion criteria for this study with 36 patients in the NSAID group and 89 in the no NSAID group. When comparing improvement in PROs, the NSAID group reached MCID at one year in 83.8 % of patients and the no NSAID group reached MCID at one year in 73.9 % of patients. There was no significant difference between the groups in reaching MCID improvement at one year (p = 0.471). Five post-operative complications were reported in the no NSAID group and two in the NSAID group (5.7 % vs 5.4 %, respectively, p = 0.827). Finally, there was no significant difference in the percentage of post-operative rotator cuff repair failures requiring revision in the first year between the groups (2.3 % vs 2.7 %, p = 1.000). Conclusion: There was no difference in percent of patients improving their PRO by the MCID between the groups that used ibuprofen and the group that did not. There was also no difference in post-operative complication rates and rates of symptomatic retear requiring reoperation between the groups. This supports that a short course of NSAIDs post-operatively, specifically ibuprofen, after rotator cuff repair does not increase reoperation rates nor lead to a clinically significant decrease in PROs at one year.
INTRODUCTION: The treatment of closed humeral shaft fractures tends to be successful with functional bracing. Treatment failure due to iatrogenic conversion to an open fracture has not been described in the literature. We present a case series of patients that experienced open humeral shaft fractures after initially being treated with functional bracing for closed humeral shaft fractures and describe what factors are associated with this complication. MATERIALS AND METHODS: This was a retrospective case series performed at three level 1 trauma centers across North America. All nonoperatively treated humeral shaft fractures were reviewed from 2001 to 2023. Patients were included if they sustained a humeral shaft fracture, > 18 years old, were initially treated non-operatively with functional bracing which subsequently converted to an open fracture. Eight patients met inclusion criteria. All included patients were eventually treated with irrigation, debridement, and open reduction and internal fixation. Outcomes assessed included mortality rate, time until the fracture converted from closed to open, need for further surgery, and bony union. Descriptive statistics were used in analysis. RESULTS: The eight included patients on average were 65 ± 21.4 years old and had a body mass index (BMI) of 25.6 ± 5.2. Six patients were initially injured due to a fall. Time until the fractures became open on average was 5.2 ± 3.6 weeks. Three patients (37.5%) died within 1.8 ± 0.6 years after initial injury. The average Charlson Comorbidity Index (CCI) score was 4.5 ± 3.4. Three patients (37.5%) had dementia. Common characteristics among this cohort included a history of visual disturbances (50.0%), cerebrovascular accident (50.0%), smoking (50.0%), and alcohol abuse (50.0%). CONCLUSION: Conversion from a closed to open humeral shaft fracture after functional bracing is a potentially devastating complication. Physicians should be especially cognizant of patients with a low BMI, history of falling or visual disturbance, dementia, age ≥ 65, decreased sensorimotor protection, and significant smoking or alcohol history when choosing to use functional bracing as the final treatment modality. LEVEL OF EVIDENCE: IV.
Background: Minimum clinically important difference (MCID) values are commonly used to measure treatment success for total knee arthroplasty (TKA). MCID values vary according to calculation methodology, and prior studies have shown that patient factors are associated with failure to achieve MCID thresholds. The purpose of this study was to determine if anchor-based 1-year Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS-JR) MCID values varied among patients undergoing TKA based on patient-specific factors. Methods: This was a retrospective review of patients undergoing TKA from 2017-2018. Patients without baseline or 1-year KOOS-JR or Patient-Reported Outcome Measurement Information System Global Health data or that underwent procedures other than primary TKA were excluded. MCIDs were calculated and compared between patient groups according to preoperative characteristics. Results: Among the included 976 patients, 1-year KOOS-JR MCIDs were 26.6 for men, 28.2 for women, 30.7 for patients with a diagnosis of anxiety and/or depression, and 26.7 for patients without a diagnosis. One-year MCID values did not differ significantly according to gender (P = .379) or mental health diagnosis (P = .066), nor did they correlate with body mass index (ß = -0.034, P = .822). Preoperative KOOS-JR decile demonstrated an inverse relationship with 1-year MCID values and attainment of MCID. Conclusions: The proportion of patients attaining KOOS-JR MCID values demonstrated an inverse relationship with preoperative baseline function. Future investigation may identify patient factors that allow surgeons to better capture patient satisfaction with their procedure despite failure to attain a 1-year MCID.
BACKGROUND: The purpose of this retrospective analysis of a prospective quality control project was to determine whether the use of intrawound vancomycin powder (IVP) decreases the rate of periprosthetic joint infection (PJI) within 90 days following primary total hip arthroplasty (THA). METHODS: From October 2021 to September 2022, a prospective quality control project was undertaken in which 10 high-volume THA surgeons alternated between using and not using IVP each month while keeping other perioperative protocols unchanged. A retrospective analysis of the project was performed to compare the group of patients who received IVP to the group of patients who did not. The primary outcome was a culture positive infection within 90 days following primary THA. Secondary outcomes included gram-positive culture, overall reoperation rate, wound complications, readmission, and wound complications within 90 days post-operatively. A total of 1,193 primary THA patients were identified for analysis. There were 523 (43.8%) patients who received IVP and were included in the IVP group, while 670 (56.2%) did not and were included in the non-IVP group. Age, body mass index, and sex were similar between the 2 groups (P > .25). RESULTS: The IVP group had a higher rate of culture positive joint infections (1.7 [0.8, 3.2] versus 0.3% [0.04, 1.1], P = .01) than the non-IVP group. All PJI's were found to have gram positive bacteria in both groups. The IVP group had a higher overall reoperation rate than the non-IVP group (6.1 [4.2, 8.5] versus 2.4% [1.4, 3.9], P < .01). The IVP group had a higher reoperation rate for any wound complication compared to non-IVP patients (2.7 [1.5, 4.5] versus 0.7% [0.2, 1.7], P < .01). The overall readmission rate (6.1 [4.2, 8.5] versus 2.8% [1.7, 4.4], P < .01), as well as readmission for suspected infection (2.1 [1.1, 3.7] versus 0.6% [0.02, 1.5], P = .03), were higher in the IVP group. CONCLUSIONS: The use of IVP in primary THA was associated with a higher rate of PJI, overall reoperation, reoperation for wound complications, and readmission in a prospective quality control project. Until future prospective randomized studies determine the safety and efficacy of IVP in THA conclusively, we advocate against its utilization.
BACKGROUND: Insertion of a skeletal traction pin in the distal femur or proximal tibia can be a painful and unpleasant experience for patients with a lower-extremity fracture. The purpose of this study was to determine whether providing patients with audio distraction (AD) during traction pin insertion can help to improve the patient-reported and the physician-reported experience and decrease pain and/or anxiety during the procedure. METHODS: A prospective randomized controlled trial was conducted at 2 level-I trauma centers. Patients ≥18 years of age who were conscious and oriented and had a medical need for skeletal traction were included. Patients were randomized to receive AD or not receive AD during the procedure. All other procedure protocols were standardized and were the same for both groups. Surveys were completed by the patient and the physician immediately following the procedure. Patients rated their overall experience, pain, and anxiety during the procedure, and physicians rated the difficulty of the procedure, both on a 1-to-10 Likert scale. RESULTS: A total of 54 patients met the inclusion criteria. Twenty-eight received AD and 26 did not. Femoral fractures were the most common injury (33 of 55, 60.0%). Baseline demographic characteristics did not differ between the 2 groups. The overall patient-reported procedure experience was similar between the AD and no-AD groups (3.9 ± 2.9 [95% confidence interval (CI), 3.1 to 4.7] versus 3.5 ± 2.2 [95% CI, 2.9 to 4.1], respectively; p = 0.55), as was pain (5.3 ± 3.2 [95% CI, 4.4 to 6.2] versus 6.1 ± 2.4 [95% CI, 5.4 to 6.8]; p = 0.28). However, anxiety levels were lower in the AD group (4.8 ± 3.3 [95% CI, 3.9 to 5.7] versus 7.1 ± 2.8 [95% CI, 6.3 to 7.9]; p = 0.007). Physician-reported procedure difficulty was similar between the groups (2.6 ± 2.0 [95% CI, 2.1 to 3.1] versus 2.8 ± 1.7 [95% CI, 2.3 to 3.3]; p = 0.69). CONCLUSIONS: AD is a practical, low-cost intervention that may reduce patient anxiety during lower-extremity skeletal traction pin insertion. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
OBJECTIVES: To evaluate the timing of definitive fixation of tibial plateau fractures relative to fasciotomy closure with regard to alignment and articular reduction. DESIGN: Retrospective case series. SETTING: Four Level I trauma centers. PATIENT SELECTION CRITERIA: Patients with tibial plateau fractures (TPF) with ipsilateral compartment syndrome treated with fasciotomy between 2006 and 2018 met inclusion criteria. Open fractures, patients younger than 18 years, patients with missed or delayed treatment of compartment syndrome, patients with a diagnosis of compartment syndrome after surgical fixation, and patients whose plateau fracture was not treated with open reduction and internal fixation were excluded. Patients were divided into 2 groups depending on the relative timing of fixation to fasciotomy closure: early fixation (EF) was defined as fixation before or at the time of fasciotomy closure, and delayed fixation (DF) was defined as fixation after fasciotomy closure. OUTCOME MEASURES AND COMPARISONS: Radiographic limb alignment (categorized as anatomic alignment (no varus/valgus), ≤5 degrees varus/valgus, or >5 degrees varus/valgus) and articular reduction (categorized as anatomic alignment with no residual gap or step-off, <2 mm, 2-5 mm, and >5 mm of articular surface step-off) were compared between early and delayed fixation groups. In addition, superficial and deep infection rates were compared between those in the EF and DF cohorts. Subgroup analysis within the EF cohort was performed to compare baseline characteristics and outcomes between those that received fixation before closure and those that underwent concurrent fixation and closure within one operative episode. RESULTS: A total of 131 patients met inclusion criteria for this study. Sixty-four patients (48.9%) were stratified into the delayed fixation group, and 67 patients (51.1%) were stratified into the early fixation group. In the EF cohort, 57 (85.1%) were male patients with an average age of 45.3 ± 13.6 years and an average body mass index of 31.0 ± 5.9. The DF cohort comprised primarily male patients (44, 68.8%), with an average age of 46.6 ± 13.9 years and an average body mass index of 28.4 ± 7.9. Fracture pattern distribution did not differ significantly between the early and delayed fixation cohorts ( P = 0.754 for Schatzker classification and P = 0.569 for OTA/AO classification). The relative risk of infection for the DF cohort was 2.17 (95% confidence interval, 1.04-4.54) compared with the EF cohort. Patients in the early fixation cohort were significantly more likely to have anatomic articular reduction compared with their delayed fixation counterparts (37.5% vs. 52.2%; P < 0.001). CONCLUSIONS: This study demonstrated higher rates of anatomic articular reduction in patients who underwent fixation of tibial plateau fractures before or at the time of fasciotomy closure for acute compartment syndrome compared with their counterparts who underwent definitive fixation for tibial plateau fracture after fasciotomy closure. The relative risk of overall infection for those who underwent fasciotomy closure after definitive fixation for tibial plateau fracture was 2.17 compared with the cohort that underwent closure before or concomitantly with definitive fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Compartment Syndromes , Fasciotomy , Fracture Fixation, Internal , Tibial Fractures , Humans , Tibial Fractures/surgery , Fasciotomy/methods , Male , Retrospective Studies , Female , Compartment Syndromes/surgery , Compartment Syndromes/etiology , Fracture Fixation, Internal/methods , Middle Aged , Adult , Treatment Outcome , Time-to-Treatment , Time Factors , Tibial Plateau Fractures
This study aims to compare 90-day and 6-month outcomes and implant costs of intertrochanteric and subtrochanteric fracture fixation using cephalomedullary nails (CMNs) from a single name-brand company to fixation using generic CMNs. This was a retrospective matched cohort study. All CMN procedures for a single surgeon in a single US metropolitan institution from 2021 to 2022 were identified using current procedural terminology codes. Nearest neighbor 1:1 matching was conducted between the name-brand and generic cohorts controlling for (1) age, (2) American Society of Anesthesiologists score, and (3) Charlson Comorbidity Index. A total of 50 patients were successfully matched (25 namebrand versus 25 generic). The average implant cost per case for the name-brand group was $3,587 versus $1,615 for the generic group. Cost of disposables averaged $109 for the generic implant sets versus $916 for the name-brand (P < 0.001). Overall, a cost savings of 61% could be generated per case with the use of generic implants and disposables. Fixation of intertrochanteric and subtrochanteric fractures using generic CMNs produces similar outcomes compared with using name-brand CMNs for approximately half the implant cost.
Hip Fractures , Surgeons , Humans , Cohort Studies , Nails , Retrospective Studies , Drugs, Generic , Hip Fractures/surgery
BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) in adolescent patients, particularly those aged 16 and under, are increasingly common procedure that lacks robust clinical and patient-reported outcome (PRO) data. The purpose of this study was to report 2-year PROs of patients receiving ACLR aged 16 or younger using the single assessment numerical evaluation (SANE) and knee injury and osteoarthritis outcome score (KOOS). Secondary aims included characterizing treatment characteristics, return to sport (RTS), and clinical outcomes. METHODS: The institutional PRO database was queried for patients receiving ACLR from 2009 to 2020. Patients aged older than 16, revision procedures, concomitant ligament repairs/reconstructions, and patients without full outcome data at 2 years were excluded. Outcomes over 2 years after ACLR included SANE, KOOS, reinjuries, reoperations, and time to RTS. RESULTS: A total of 98 patients were included with an average age of 15.0 years. Most patients were females (77.6%). Bone-tendon-bone autograft (69.4%) was the most used. Average RTS was 8.7 months (range: 4.8 to 24.0 mo), with 90% of patients eventually returning to sport. A total of 23 patients (23.5%) experienced a reinjury and 24.5% (n = 24) underwent reoperation. Timing to RTS was not associated with reinjury, but patients who returned between 9.5 and 13.7 months did not sustain reinjuries. Mean KOOS and SANE scores at 2 years were 87.1 and 89.1, respectively, with an average improvement of +18.4 and +22.9, respectively. Change in KOOS was negatively impacted by reinjury to the anterior cruciate ligament graft and reoperation (anterior cruciate ligament failure: +10.0 vs 19.3, P = 0.081, respectively; reoperation: +13.2 vs +20.1, P = 0.051, respectively), though these did not reach statistical significance. CONCLUSION: Patients experienced improved SANE and KOOS scores after ACLR. Rates of reinjury and reoperation were relatively high and negatively impacted PRO scores but were not associated with the timing of RTS. Adolescent patients should be counseled regarding the risk of subsequent ipsilateral and contralateral knee injury after ACLR. LEVEL OF EVIDENCE: Level IV-case series.
Anterior Cruciate Ligament Injuries , Anterior Cruciate Ligament Reconstruction , Knee Injuries , Reinjuries , Female , Adolescent , Humans , Male , Reoperation , Anterior Cruciate Ligament Injuries/surgery , Anterior Cruciate Ligament Reconstruction/methods , Knee Injuries/surgery , Patient Reported Outcome Measures , Knee Joint/surgery
A 52-year-old man presented with a bicondylar tibial plateau fracture and acute compartment syndrome. Continuous compartment pressure monitoring was used while the patient was treated with fasciotomies and application of an external fixator. The intraoperative pressure reading in the anterior compartment decreased from 105 mm Hg to 50 mm Hg after skin and subcutaneous tissue incision. Pressure continued to decrease to 10 mm Hg after all 4 compartments were released. The patient underwent staged open reduction and internal fixation and healed both fracture and fasciotomy incisions without complication. To our knowledge, this is the first report of continuous pressure changes during the different stages of a compartment release. Future studies could expand on use of this technology to gain information on compartment pressures during release and how single release affects pressures in other compartments. [Orthopedics. 2024;47(2):e98-e101.].
Compartment Syndromes , Tibial Fractures , Male , Humans , Middle Aged , Fasciotomy/adverse effects , Compartment Syndromes/diagnosis , Compartment Syndromes/etiology , Compartment Syndromes/surgery , Fracture Fixation, Internal/adverse effects , External Fixators/adverse effects , Tibial Fractures/surgery , Tibial Fractures/complications
Background: Anterior cruciate ligament reconstruction (ACLR) is a common procedure that has been shown to have relatively good outcomes amongst various graft types. Operative time in ACLR has been found to influence outcomes and cost. The purpose of this study was to evaluate the association of operative time in primary arthroscopically performed anterior cruciate ligament reconstruction (ACLR) and graft type while controlling for confounders that influence time. Methods: All patients who received ACLR between 2018 and 2022 were included in this retrospective cohort study. Exclusion criteria consisted of age (≤16 years), revisions, concomitant ligament reconstruction or tendon repairs, or other simultaneously performed procedures that could potentially add substantial variation in operative time. The primary outcome was operative time. Graft types included allograft, bone-tendon-bone (BTB) autograft, hamstring tendon (HS) autograft and quadriceps tendon (QT) autograft. Results: A total of 1813 primary ACLRs were included. The average operative time was 98.9 ± 33.0 min. Graft utilization varies considerably among surgeons. The most used graft type was BTB autograft (42.6%) followed by HS autograft (32.3%) and allograft (21.4%). Only 68 cases (3.8%) used a QT autograft. Seven of the 15 included surgeons primarily used BTB autograft. One surgeon predominately used QT autograft. No difference in operative time was observed among the autograft types (p = 0.342). Allograft ACLR was significantly faster by 27-33 min compared to using BTB autograft, HS autograft, or QT autograft (p < 0.001). Conclusion: Operative time did not vary by type of autograft selected. Allograft ACLR was performed approximately 30 min faster than autograft ACLR. Further studies examining the effect on patient outcomes of reduced operative time and minimizing graft harvest morbidity in ACLR is important to more accurately determine the cost-effectiveness of allograft ACLR.
INTRODUCTION: Ankle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries. Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture. METHODS: All ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost. RESULTS: There was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [-411.8, -54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [-74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48). CONCLUSIONS: The utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.
Ankle Fractures , Ankle Injuries , Humans , Ankle Fractures/surgery , Ankle Fractures/diagnosis , Activities of Daily Living , Retrospective Studies , Fracture Fixation, Internal/methods , Ankle Injuries/surgery , Treatment Outcome
BACKGROUND: Distal radius fractures (DRFs) are common orthopaedic injuries. They can be treated in many ways, but the volar locking plate (VLP) is more frequent. Currently, there is limited information regarding the minimum clinically important difference (MCID) in surgically treated DRFs. The purpose of this study was to calculate MCID values for the Patient-Reported Wrist Evaluation (PRWE) in the setting of VLP-treated DRFs. METHODS: A retrospective review was conducted for patients with isolated, surgically-treated DRFs with a VLP. Exclusions included any concomitant procedure other than a carpal tunnel release, skeletal immaturity, polytrauma, open fracture, or missing PRWE data. MCID was calculated using PRWE, an overall health question, and the anchor-based method. RESULTS: A total of 131 patients were identified. Approximately 54.2% injured their dominant hand. AO/OTA classification 23C was the most common (n=89, 67.9%). Average baseline, 6-week, and 12-week PRWE were 71.8 ± 19.6, 34.3 ± 20.1, and 21.2 ± 18.0 respectively. This corresponds to an average change from baseline PRWE at 6 weeks and 12 weeks of -37.5 ± 23.4 and -50.6 ± 22.3, respectively. Average MCID values for 6 weeks and 12 weeks were 43.1 ± 18 and 56.0 ± 20.0, respectively (p<0.001). Hand dominance did not correlate with MCID value (rs = 0.084 at six weeks, rs = 0.099 at 12 weeks). MCID value additionally did not correlate with sex, AO/OTA classification, smoking status, ASA score, or BMI. Treatment at a level 1 trauma center and diagnosis of anxiety and/or depression correlated with a higher 6-week MCID value (rs = 0.308 and rs = 0.410, respectively). Increasing age weakly correlated with higher 12-week MCID value (rs = 0.352). CONCLUSIONS: This study demonstrated an MCID calculation using an overall health anchor. MCID value varied with follow-up time and correlated weakly with age, diagnosis of anxiety and/or depression, and treatment facility, but it did not correlate with injury of the dominant hand. Future research should analyze how to apply MCID and identify successful treatment in the setting of DRF care.
Radius Fractures , Wrist Fractures , Humans , Infant , Wrist , Radius Fractures/surgery , Treatment Outcome , Wrist Joint , Fracture Fixation, Internal/methods , Bone Plates , Range of Motion, Articular
INTRODUCTION: Distal radius fractures (DRFs) are common injuries, warranting a need to analyze the cost of treatment. The purpose of this study was to analyze the effect of implant costs on patient-reported outcomes in DRFs. METHODS: A PRO registry was retrospectively reviewed for isolated, surgically treated DRF patients. A total of 140 patients met criteria to be included in this study. Implant cost was obtained from the chargemaster database. RESULTS: The average total implant cost was $1,289.67 ± 215.32. The average Patient-rated Wrist Evaluation scores preoperatively, at 6 weeks, and at 12 weeks were 70.8 ± 20.1, 36.6 ± 21.1, and 22.8 ± 18.0, respectively. No statistically significant relationships were observed between cost and Patient-rated Wrist Evaluation scores at 6 weeks or 12 weeks (r = -0.05, P = 0.59; r = -0.04, P = 0.64, respectively). Implant costs were shown to not be affected by fracture complexity (AO/OTA classification: 23A = $1,335.50, 23B = $1,246.86, and 23C = $1,293.14). DISCUSSION: The total cost of implants did not influence patient outcomes indicating that patients receive no additional benefit from more costly constructs.
Radius Fractures , Wrist Fractures , Wrist Injuries , Humans , Retrospective Studies , Radius Fractures/surgery , Wrist Injuries/surgery , Fracture Fixation, Internal
Aims & objectives: The purpose of this study was to evaluate for cost variation in distal radius fractures (DRFs) treated with a volar locking plate (VLP) and to identify key factors that affect the total construct cost. Materials & methods: A retrospective case series was conducted for a single healthcare system. A total of 140 patients with a DRF treated with a VLP from May 2014 to December 2021 were identified. Patients were excluded for polytrauma, open fractures, and skeletal immaturity. Results: Most patients were female (n = 120, 85.7%) and were on average 59 ± 13.7 years old. Patients most often injured their dominant hand (n = 75, 53.6%) and presented with an AO/OTA 23C fracture (n = 93, 66.4%). Twenty-two surgeons were included with fellowship training in hand or trauma and orthopaedic or plastic surgery residency. Orthopaedic hand-trained surgeons treated the highest proportion of 23C fractures (69.8%). Ninety patients (64.3%) were treated at a surgery center. The average cost was $1289.67 ± $215.32 (range: $857.83-$2156.95). The most expensive fixation constructs used a variable angle locking screw ($1316.75 ± $264.99) or a multidirectional threaded peg ($1321.67 ± $192.94). Multivariable regression analysis revealed none of the study variables to be significant contributors to construct cost (all p-values >0.27). Conclusions: Surgically treated DRFs with a VLP demonstrated similar total implant costs regardless of fracture pattern, surgeon specialty, or treatment facility. Contrary to previous literature, VLPs showed minimal cost variation, although some surgeons were able to decrease the overall cost by reducing the number of screws used.
Objectives: The purpose of this study was to obtain information on Canadian orthopaedic trauma surgeon practices and salary demographics. It was hypothesized that most of the practicing surgeons recognize specific practice aspects (compensation, call schedule, operating room availability, and provided support staff) as key factors in employment opportunity evaluation. Design: Cross-sectional survey study. Setting: Orthopaedic Trauma Association (OTA) practice surveys. Participants: All active Canadian members of the OTA were eligible to participate. Main Outcome Measurement: A 50-question survey was sent through email to OTA members assessing physician, practice, and compensation metrics of Canadian orthopaedic traumatologists. Results: Fifty-two of 113 Canadian OTA members participated giving a response rate of 46%. All surgeons worked in an academic practice, either for a university (83%) or community hospital (17%). Only 2% of surgeons have changed jobs in the last 5 years, and over 73% of surgeons maintain the same place of employment during their careers. Most had an available dedicated orthopaedic trauma operating room (73%). The majority indicated having residents (71%) and fellows (63%) as support staff. Many reported completing 300-500 cases per year (42%), which decreased during COVID-19 for 50% of surgeons. The most common reported compensation was between $400,000 and $600,000 US dollars (25%) with many working 4-6 call shifts a month (48%) and 51-70 hours a week (48%). Conclusion: This study demonstrated the varying practice and physician economic variables currently in Canada. The identification and continued surveillance of these employment variables will allow for transparency in job market evaluation by applicants. Level of Evidence: Level V.
Objective: To compare the capture rates and costs of paper patient-reported outcomes (pPRO) administered in-clinic and electronic PROs (ePRO) collected through emails and texts. Design: Retrospective review. Setting: Level 1 trauma center. Patients/Participants: The pPRO program enrolled 2164 patients for postsurgical follow-up in 4 fracture types: ankle, distal radius, proximal humerus, and implant removal from 2012 to 2017. The ePRO program enrolled 3096 patients in 13 fracture types from 2018 to 2020. Among the patients enrolled in the ePRO program, 1296 patients were matched to the 4 original fracture types and time points. Main Outcome Measures: PRO capture rates in 4 fracture types by matched time point and estimated cost of each program per enrolled patient. Results: At first follow-up, pPRO provided a higher capture rate than ePRO for 3 of 4 fracture types except for implant removal (P < 0.05). However, at 6-month and 1-year follow-ups, ePRO demonstrated statistically significant higher capture rates when compared with pPRO for all applicable modules (P < 0.05). The average cost for the pPRO program was $171 per patient versus $56 per patient in the ePRO program. Patients were 1.19 times more likely to complete ePRO compared with pPRO (P = 0.007) after controlling for age, sex, fracture type, and time point. Conclusion: The electronic PRO service has improved long-term capture rates compared with paper PROs, while minimizing cost. A combined program that includes both in-clinic and out of clinic effort may be the ideal model for collection of PROs. Level of Evidence: Level 3.
Introduction: Intertrochanteric (IT) fractures that fail fixation are traditionally treated with arthroplasty, introducing significant risk of morbidity and mortality in frail older adult patients. Revision fixation with cement augmentation is a relatively novel technique that has been reported in several small scale international studies. Here we report a clinical series of 22 patients that underwent revision fixation with cement augmentation for IT fracture fixation failure. Methods: This retrospective case series identified all patients that underwent revision intramedullary nailing from 2018 to 2021 at two institutions within a large metropolitan healthcare system. Demographics, injury characteristics, Charlson Comorbidity Index score, and surgical characteristics were extracted from the electronic medical record. Outcomes were extracted from the electronic medical record and included radiographic findings, pain, functional outcomes, complications, and mortality. Results: Average follow-up after revision surgery was 15.2 ± 10.6 months. Twenty patients (90.9%) reported improved pain and achieved union or progressive healing after surgery. Most of these patients regained some degree of independent ambulation (19 patients, 86.4%), with only 5 patients (22.7%) requiring increased assistance for their activities of daily living (ADLs). One-year mortality was 13.6% (3 patients). Of the 5 patients (22.7%) that experienced complications, 2 patients (9.1%) required revision hemiarthroplasty for subsequent fixation failure. The other 3 patients did well when complications resolved. Conclusions: Revision fixation with cement augmentation can be an effective, safe, cost-effective alternative to arthroplasty for the management of cases involving non-infected failed IT fracture fixation with implant cut-out or cut-through limited to the femoral head in older adult patients that have appropriate acetabular bone stock.
INTRODUCTION: External fixator costs have been shown to be highly variable. Current information on external fixator costs and cost drivers is limited. The aim of this study was to examine the cost variation as well as the patient-, injury-, and surgeon-related cost drivers associated with temporizing external fixation constructs in tibial plateau and pilon fracture management. MATERIALS AND METHODS: A retrospective review was conducted to identify isolated tibial plateau and pilon fractures treated with temporizing external fixation from 2006-2018 at a level 1 trauma center. Inclusion criteria were based on fractures managed with primary external fixation, skeletal maturity, and isolated ipsilateral fracture fixation. Fracture patterns were identified radiographically using Schatzker, Weber, and OTA classification systems. Implant costs were determined using direct purchase price from the institution. The primary outcome was the external fixator total construct cost. Clinical covariates and secondary outcomes, namely unplanned reoperations, were extracted. Factors associated with cost (i.e. cost drivers) were identified via multivariable regression analysis. RESULTS: A total of 319 patients were included in this study (121 tibial plateau and 198 pilon fractures). Mean plateau construct cost was $5,372.12 and mean pilon construct cost was $3,938.97. Implant cost correlated poorly with demographic (r2=0.01 & r2=0.01), injury-independent (r2<0.01 & r2=0.03), and fracture pattern classifications (r2=0.03 & r2=0.02). Traumatologists produced significantly cheaper implants for pilon fractures (p=0.05) but not for plateau fractures (p=0.85). There was no difference in construct cost or components between patients that underwent unplanned reoperation and those that did not for both tibial plateau (p>0.19) and pilon (p>0.06). Clamps contributed to 69.9% and 77.3% of construct costs for tibial plateau and pilon, respectively. The most cost-efficient fixation constructs for tibial plateau and pilon fractures were the following respectively: of 5 clamps, 2 bars, and 4 pins; and of 4 clamps, 2 bars, and 3 pins. CONCLUSIONS: There is large cost variation in temporizing external fixation management. Cost drivers included surgeon bias and implant preference as well as use of external fixator clamps. Introducing construct standardization will contain healthcare spending without sacrificing patient outcomes. LEVEL OF EVIDENCE: Level III. Retrospective Cohort.
Ankle Fractures , Tibial Fractures , Bone Nails , External Fixators , Fracture Fixation , Fracture Fixation, Internal , Humans , Retrospective Studies , Tibial Fractures/diagnostic imaging , Tibial Fractures/surgery , Treatment Outcome
OBJECTIVE: To determine the level of interest in standardization of design for fracture fixation implants within the orthopaedic trauma community. METHODS: A survey regarding implant removal concerns and implant design preferences was electronically distributed to members of Orthopaedic Trauma Association (OTA). RESULTS: Three hundred thirty respondents participated in the survey (response rate of 19%) Only 2.4% of respondents indicated a consistent ability to identify the implant vendor and/or manufacturer of retained implants in the preoperative planning phase of care; >75% of respondents reported investing a minimum of an additional 30 minutes to their operative times to remove screw(s) to successfully extract a plate. More than 80% of respondents reported multiple occurrences requiring modification of their surgical plans because of implants that could not be removed, preventing the completion of the planned procedure. The majority of respondents expressed interest in the adoption of standardized locking head screws for mini, small, and large screw sizes sets (63.5%); 84.8% of respondents desire standardization of screw head and driver sizes across the industry. Also, 83.6% of respondents expressed interest in the adoption of a standardized locking screw head for each cannulated screw, regardless of manufacturer. CONCLUSIONS: Members of the orthopaedic community, as represented in the membership of the OTA, are interested in the adoption of universal standards in implant design. Establishing standard screw heads and drivers will optimize the delivery of operative care.
Orthopedics , Bone Plates , Bone Screws , Device Removal/methods , Fracture Fixation, Internal , Humans , Surveys and Questionnaires
As the Coronavirus 2019 (COVID-19) pandemic evolves, it is critical to understand how patients' feelings and perceptions have changed. The aim of this study was to understand current feelings and concerns about seeking and receiving orthopaedic care 9 mo into the global pandemic. METHODS: Utilizing a survey developed to evaluate the attitudes and beliefs from healthcare respondents about receiving care during the COVID-19 pandemic, an updated and revised version, evaluating changes in perception of respondents 9 mo into the pandemic, was distributed to a group of panelists by email. RESULTS: Out of 1200 individuals, 197 (16%) completed the survey. A majority of respondents reported high level of comfort in the immediate or near-term receiving care in an orthopaedic clinic, urgent care clinic specifically for orthopaedics, or in an emergency room. Six percent of respondents reported a delay in seeking orthopaedic care despite COVID-19 concerns that occurred between studies. Respondents reported their primary reason for delaying care was because of concerns for risk of COVID-19 exposure from other patients (83%). More than 75% of respondents stated they are "extremely" or "very" likely to get the COVID-19 vaccine when it becomes available to the public. Respondents had a generally negative outlook on pandemic efforts locally to globally. CONCLUSIONS: Despite dismal overall perceptions regarding the outlook of the pandemic; consumers are becoming increasingly comfortable obtaining orthopaedic care. The ability of healthcare providers and practices to adherence to safety protocols will remain essential to maintaining consumer trust and confidence. LEVEL OF EVIDENCE: Level IV.
