Analyzing risk factors for treatment failure in fracture-related infection.

INTRODUCTION: Fracture-related infection (FRI) represents a challenging clinical scenario. Limited evidence exists regarding treatment failure after initial management of FRI. The objective of our investigation was to determine incidence and risk factors for treatment failure in FRI. MATERIALS AND METHODS: We conducted a retrospective review of patients treated for FRI between 2011 and 2015 at three level 1 trauma centers. One hundred and thirty-four patients treated for FRI were identified. Demographic and clinical variables were extracted from the medical record. Treatment failure was defined as the need for repeat debridement or surgical revision seven or more days after the presumed final procedure for infection treatment. Univariate comparisons were conducted between patients who experienced treatment failure and those who did not. Multivariable logistic regression was conducted to identify independent associations with treatment failure. RESULTS: Of the 134 FRI patients, 51 (38.1%) experienced treatment failure. Patients who failed were more likely to have had an open injury (31% versus 17%; p = 0.05), to have undergone implant removal (p = 0.03), and additional index I&D procedures (3.3 versus 1.6; p < 0.001). Most culture results identified a single organism (62%), while 15% were culture negative. Treatment failure was more common in culture-negative infections (p = 0.08). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common organism associated with treatment failure (29%; p = 0.08). Multivariate regression demonstrated a statistically significant association between treatment failure and two or more irrigation and debridement (I&D) procedures (OR 13.22, 95% CI 4.77-36.62, p < 0.001) and culture-negative infection (OR 4.74, 95% CI 1.26-17.83, p = 0.02). CONCLUSIONS: The rate of treatment failure following FRI continues to be high. Important risk factors associated with treatment failure include open fracture, implant removal, and multiple I&D procedures. While MRSA remains common, culture-negative infection represents a novel risk factor for failure, suggesting aggressive treatment of clinically diagnosed cases remains critical even without positive culture data. LEVEL OF EVIDENCE: Retrospective cohort study; Level III.

Current and Future Applications of Fluorescence Guidance in Orthopaedic Surgery.

Fluorescence-guided surgery (FGS) is an evolving field that seeks to identify important anatomic structures or physiologic phenomena with helpful relevance to the execution of surgical procedures. Fluorescence labeling occurs generally via the administration of fluorescent reporters that may be molecularly targeted, enzyme-activated, or untargeted, vascular probes. Fluorescence guidance has substantially changed care strategies in numerous surgical fields; however, investigation and adoption in orthopaedic surgery have lagged. FGS shows the potential for improving patient care in orthopaedics via several applications including disease diagnosis, perfusion-based tissue healing capacity assessment, infection/tumor eradication, and anatomic structure identification. This review highlights current and future applications of fluorescence guidance in orthopaedics and identifies key challenges to translation and potential solutions.

Trajectory of Recovery in PROMIS Global Physical Health After Surgical Fracture Fixation.

INTRODUCTION: Patient-reported outcomes (PROs) provide data on the effect of conditions and treatments on patients' lives without third party interpretation. Mounting evidence suggests that PROs may be useful in elective procedure decision making, but its utility in trauma remains unclear. Longitudinally collected PROs may prove effective in identifying patients recovering below the norm. We sought to document recovery trajectory in patients with and without complication and to evaluate the sources of variability in functional recovery after injury. METHODS: This retrospective study included 831 patients with trauma, identified via Current Procedural Terminology (CPT) codes for surgical extremity and/or pelvic/acetabular fracture management between 2014 and 2018. Global Physical Health (GPH) scores collected via the PROMIS Global Health in a 14-month window after injury were analyzed using mixed-effects modeling. RESULTS: A curvilinear GPH recovery trajectory was observed where patients demonstrated an initial positive recovery trajectory (B = 1.28, P < 0.001) gradually decelerating over time (B = -0.07, P < 0.001). Patients who experienced complications requiring revision surgery demonstrated markedly lower GPH scores. Several notable predictors of postoperative physical health recovery were identified, including both between-person (B = 0.52, 95% CI, 0.48 to 0.56) and within-person (B = 0.41, 95% CI, 0.36 to 0.46) Global Mental Health (GMH) score, Body Mass Index (BMI) (B = -0.07, 95% CI, -0.12 to -0.02), two or more psychiatric diagnoses (B = -0.97, 95% CI, -1.84 to 0.09), Injury Severity Score 10 to 15 and 16+ (B = -2.62, 95% CI, -4.81 to 0.42 and B = -2.17, 95% CI, -3.60 to 0.74, respectively), readmission for complication (B = -2.64, 95% CI, -3.60 to 1.68), and lower extremity or multiextremity fracture (relative to upper extremity) (B = -3.61, 95% CI, 4.45 to 2.78, B = -4.11, 95% CI, -5.77 to 2.44, respectively). Additional analysis suggests that GMH scores are related to the presence of psychiatric diagnoses. DISCUSSION: This study establishes a normal course of recovery as reflected by PROMIS GPH score to serve as an index for monitoring individual postoperative course. Patients who experienced a complication demonstrated markedly lower GPH across all time points, potentially allowing earlier identification of at-risk patients. Furthermore, GMH may represent a modifiable risk factor that could profoundly affect physical recovery. LEVEL OF EVIDENCE: Level III (Prognostic Study = Retrospective Cohort).

Creating a Value Dashboard for Orthopaedic Surgical Procedures.

BACKGROUND: Value-based health-care delivery is a framework for restructuring our health-care systems with the goal of providing better outcomes for patients at lower cost. Value is determined by patient health outcomes per dollar spent on health services. We sought to develop a value dashboard that could be used to easily track and improve the value of total hip and knee arthroplasty (THA and TKA). METHODS: We created a value dashboard for TKAs and THAs at our institution. Value was defined as quality of outcomes per dollar spent. The dashboard for each procedure displayed the average value by surgeon, compared with institutional averages for physical function scores and cost. Quality metrics were determined by weighted surgeon ranking using a modified Delphi process and included both clinical and patient-reported outcomes, as measured by the mean change in the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) physical function score, mean change in the Hip disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR) or the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR), mean change in the modified Single Assessment Numeric Evaluation (SANE) score, complication rate, periprosthetic joint infection (PJI) rate, and 30-day readmission rate. Average direct costs per surgeon were used. Data from January 2017 through April 2018 were included to ensure 1-year follow-up. RESULTS: Six surgeons were included in the value dashboard for TKA, and 5 were included in the THA dashboard. The value for TKA by surgeon ranged from 7% below to 12% above the institutional benchmark. The value for THA by surgeon ranged from 12% below to 7% above the institutional benchmark. CONCLUSIONS: The proposed dashboard utilizes value in a health-care framework and could be used for comparing and improving value for THA and TKA. This dashboard successfully combined patient outcome metrics and direct costs of surgical procedures. Future studies should focus on involving patients in this process and using national data to create benchmarks, which could provide a more accurate representation of value than using institutional averages.

Selecting Residents for Predetermined Factors Identified and Thought to be Important for Work Performance and Satisfaction: A Methodology.

OBJECTIVE: The medical profession seeks to hire and train individuals who consistently meet and/or exceed both job and cultural expectations. Resident selection is often not structured to meet this goal. The objective of this quality improvement project was to evaluate a classic unscripted interview process (OI) in conjunction with a structured, scripted interview process (SI) developed using an established hiring methodology from industry not yet utilized in health care. Qualitative questions we sought to answer: (1) Can SI be practically applied to the selection of residents? (2) Is there a significant difference in the relative position of applicants between the OI and SI rank lists? (3) Qualitatively, does SI help the evaluation/discussion of the affective domain? METHODS: Design: Prospective qualitative comparison of OI versus SI. SETTING: Dartmouth Hitchcock Medical Center, Lebanon, NH. PARTICIPANTS: Applicants were assessed by OI and SI. SI factors were selected based on a job profile. Interview scripts were created from validated behavioral and attitudinal questions. Online assessments assessed 2 important attributes - adaptability and values. Rank lists were compared for relative rank position of applicants. Feedback from faculty was obtained. RESULTS: Fifty-two applicants. Critical attributes were self-management, integrator-synthesizer, versatility, communication, and achievement. Absolute mean difference in rank/applicant was 9.8 (standard deviation 8.9, Range 0-36) positions. Comparing the top 20 candidates of each rank list, 40% of those applicants were only on one list. Faculty felt that applicants were given a greater opportunity to show "who they are." CONCLUSIONS: In conjunction with OI, an industry proven methodology was practically applied to define and select for high performance for the authors' specific institution. Comparing OI and SI resulted in substantial differences in rank lists. This initiative seemed to provide a structure to evaluate values and motivations that are inherently difficult to assess. Faculty felt SI in conjunction with OI gave a greater chance for applicants to show "who they are."

Short term patient outcomes after total knee arthroplasty: Does the implant matter?

BACKGROUND: Newer implants for total knee arthroplasty (TKA) often gain market share at higher cost with little patient-reported and long-term clinical data. We compared outcomes after TKA using two different implants: DePuy PFC Sigma and Attune. METHODS: Using a prospective data repository from an academic tertiary medical center, we analyzed 2116 TKAs (1603 Sigma and 513 Attune) from April 2011 through July 2016. Outcomes included length of surgery, length of stay, facility discharge, 90-day reoperation, range of motion (ROM) change, and patient-reported physical function (PCS). RESULTS: There was no difference in length of surgery (Attune -2.87 min, P = 0.143). Implant type was not associated with extended LOS (>3 days) (OR 0.80, P = 0.439). There was no difference in facility discharge (OR 0.65, P = 0.103). Unadjusted 90-day reoperations were 0.3% for Sigma and 1.0% for Attune cohorts (P = 0.158). Sigma implants were associated with more ROM improvement in unadjusted analyses (+2.1 degree improvement P = 0.031). Fifty nine percent of the Sigma cohort and 49% of the Attune cohort achieved the minimal clinically important (MCID) change for PCS improvement, although there was no adjusted difference in achieving MCID (Attune OR 0.84, P = 0.435). There was no adjusted difference in absolute PCS improvement (Attune +0.12 score, P = 0.864). CONCLUSIONS: Our data show no difference in physical function and most outcomes between Sigma and Attune. Attune implants had shorter absolute LOS, but there were no differences in extended LOS.

Do Aggregate Socioeconomic Status Factors Predict Outcomes for Total Knee Arthroplasty in a Rural Population?

BACKGROUND: We sought to determine whether several preoperative socioeconomic status (SES) variables meaningfully improve predictive models for primary total knee arthroplasty (TKA) length of stay (LOS), facility discharge, and clinically significant Veterans RAND-12 physical component score (PCS) improvement. METHODS: We prospectively collected clinical data on 2198 TKAs at a high-volume rural tertiary academic hospital from April 2011 through March 2016. SES variables included race and/or ethnicity, living alone, education, employment, and household income, along with numerous adjusting variables. We determined individual SES predictors and whether the inclusion of all SES variables contributed to each 10-fold cross-validated area under the model's area under the receiver operating characteristic (AUC). We also used 1000-fold bootstrapping methods to determine whether the SES and non-SES models were statistically different from each other. RESULTS: At least 1 SES predicted each outcome. Ethnic minority patients and those with incomes <$35,000 predicted longer LOS. Ethnic minority patients, the unemployed, and those living alone predicted facility discharge. Unemployed patients were less likely to achieve PCS improvement. Without the 5 SES variables, the AUC values of the LOS, discharge, and PCS models were 0.74 (95% confidence interval [CI] 0.72-0.77, "acceptable"); 0.86 (CI 0.84-0.87, "excellent"); and 0.80 (CI 0.78-0.82, "excellent"), respectively. Including the 5 SES variables, the 10-fold cross-validated and bootstrapped AUC values were 0.76 (CI 0.74-0.79); 0.87 (CI 0.85-0.88); and 0.81 (0.79-0.83), respectively. CONCLUSION: We developed validated predictive models for outcomes after TKA. Although inclusion of multiple SES variables provided statistical predictive value in our models, the amount of improvement may not be clinically meaningful.

Report of ganglion cyst in the anterior cruciate ligament of a 6-year-old child.

BACKGROUND: Intra-articular ganglion cysts of the knee are extremely rare within the pediatric population. To our knowledge, only seven case reports have been published in the medical literature identifying pediatric patients with intra-articular cysts of the anterior cruciate ligament (ACL). Intra-articular cysts of the knee are a rare cause of knee discomfort and mechanical symptoms such as locking of the knee. To our knowledge, up until now the youngest patient reported in the medical literature with an intra-articular ganglion cyst of the ACL was a 7-year-old boy. CASE REPORT: We describe a 6-year-old boy who presented with a unilateral intra-articular ganglion cyst of the ACL in the right knee. In addition to the diagnostic work-up of radiographs and MRI, the cyst was successfully treated with arthroscopic resection and debridement to decompress the cyst. CLINICAL RELEVANCE: We provide a review of the proposed pathogenesis, diagnostic modalities, differential diagnosis, treatment options, and complications of treatment for intra-articular cysts of the ACL. LEVEL OF EVIDENCE: Level V, case report.

Ankle fractures in the elderly: what you get depends on where you live and who you see.

OBJECTIVES: This study was performed to determine 1) the rate of ankle fractures in the elderly in the United States stratified by hospital referral region, and 2) whether the percentage of ankle fractures treated surgically is affected by factors, such as fracture location, hospital referral region, concentration of orthopaedists, presence of a teaching hospital in that region, patient age, race, gender, or the number and type of specific medical comorbidities. DESIGN: A 20% sample of Medicare Part B claims from the years 1998 to 2000 was analyzed. PATIENTS/INTERVENTION: The CPT codes for operative and nonoperative treatment of isolated medial malleolar, isolated lateral malleolar, bimalleolar, and trimalleolar fractures were identified. These codes were used to determine the overall rate of ankle fractures and individual fracture types. MAIN OUTCOME MEASUREMENT: : The rate of ankle fractures was evaluated by hospital referral region, patient age (groups of 5 years, aged 65 years or older), gender, and race. The percentage of surgical treatment was determined for each fracture type as the number of surgically treated fractures over the total number of ankle fractures within each subtype and analyzed by fracture type, hospital referral region, and concentration of orthopaedists in that region, presence of a teaching hospital within the hospital service area, patient age, gender, race, and number and type of specific medical comorbidities. Regression was performed by using the above variables. RESULTS: We identified 33,704 ankle fractures: 7.6% were isolated medial malleolar, 50.8% were isolated lateral malleolar, 27.4% were bimalleolar, and 14.2% were trimalleolar fractures. The overall United States average was 4.2 ankle fractures per 1000 Medicare enrollees. The rate of ankle fractures varied by a factor of 8, from 1 per 1000 Medicare enrollees in San Francisco, CA, to 8.3 in Hickory, NC. The rate of ankle fractures was highest in white women at 5.8 and lowest in nonwhite men at 1.5 per 1000 Medicare enrollees. The overall rate of ankle fractures that underwent surgical stabilization was 33%, ranging from 14% in Binghampton, NY, to 72% in Napa, CA. The rate of surgical intervention was 22% for isolated medial malleolar fractures, 11% for isolated lateral malleolar fractures, 58% for bimalleolar fractures, and 74% for trimalleolar fractures. In regression analysis, the factors associated with nonoperative care after ankle fracture were: older age, female gender, increasing number of comorbidities as measured by the Charlson index, presence of diabetes or peripheral vascular disease, and living in a hospital service area that had a designated teaching hospital. Beneficiaries living in areas in which a hospital was a member of the Council of Teaching Hospitals were less likely to receive surgical treatment of their ankle fracture. Increasingly older age was strongly associated with decreased likelihood of having surgical intervention, with each 5 year age grouping progressively less likely to have surgical treatment. The concentration of orthopaedists in the region was not associated with the likelihood of having surgical treatment. CONCLUSIONS: The term ankle fracture involves a wide spectrum of injuries. We found a large variation through the United States in both the rate of ankle fractures and the percentage of those that undergo surgical intervention.

A single injection ultrasound-assisted femoral nerve block provides side effect-sparing analgesia when compared with intrathecal morphine in patients undergoing total knee arthroplasty.

Postoperative pain after total knee arthroplasty (TKA) is severe, and achieving adequate analgesia remains a clinical challenge. We tested the hypothesis that, in patients having unilateral TKA under intrathecal (IT) anesthesia, the addition of a femoral nerve block would provide superior analgesia when compared with IT morphine and demonstrate fewer adverse side effects. In a single-blinded and controlled trial, 41 ASA I-III patients undergoing unilateral TKA were randomized into 2 groups. Both groups received 15 mg of IT hyperbaric bupivacaine for the surgical anesthetic. Group ITM received 250 microg of IT morphine and group FNB received an ultrasound-assisted femoral nerve block with 40 mL of 0.5% ropivacaine, 5 microg/mL of epinephrine, and 75 microg of clonidine. At 1, 2, 4, 6, 12, and 24 h postoperatively, we measured visual analog scales for pain, cumulative IV morphine consumption, hemodynamics, and side effects. There were no statistically significant differences in morphine consumption, pain at rest, or pain with movement. However, group FNB had fewer perioperative side effects including nausea, vomiting, and pruritus (P < 0.05 for each event). This corresponded to a decrease in patient satisfaction in group ITM, in which 20% of the patients rated their experience as "unsatisfactory" (P < 0.05). We conclude that, in comparison with IT morphine, a single injection femoral nerve block provides equivalent analgesia but with a significant reduction in side effects for patients having TKA under bupivacaine intrathecal anesthesia.