Barriers to care for musculoskeletal sarcoma patients: a public health perspective.

Introduction: This study seeks to investigate the barriers to care that exist for patients presenting with sarcomas of musculoskeletal origin. Understanding the roots of delays in care for patients with musculoskeletal sarcoma is particularly important given the necessity of prompt treatment for oncologic diagnoses. Investigators reviewed relevant studies of publications reporting barriers to care in patients undergoing diagnosis and treatment of musculoskeletal tumors. Methods: A comprehensive literature search was conducted using Scopus, Embase, Web of Science, and PubMed-MEDLINE. Twenty publications were analyzed, including a total of 114,056 patients. Results: Four barrier subtypes were identified: Socioeconomic Status, Geographic Location, Healthcare Quality, Sociocultural Factors. Socioeconomic status included access to health insurance and income level. Geographic location included distance traveled by patients, access to referral centers, type of hospital system and resource-challenged environments. Healthcare quality included substandard imaging, access to healthcare resources, and healthcare utilization prior to diagnosis. Sociocultural factors included psychological states, nutrition, education and social support. Conclusion: After identifying the most significant barriers in this study, we can target specific public health issues within our community that may reduce delays in care. The assessment of barriers to care is an important first step for improving the delivery of oncologic patient care to this patient population.

Early Post-operative Pain Course Following Primary and Secondary Targeted Muscle Reinnervation - a Temporal Description of Pain Outcomes.

INTRODUCTION: Targeted muscle reinnervation (TMR) is an effective surgical treatment of neuropathic pain for amputees. However, limited data exists regarding the early post-operative pain course for patients who undergo either Primary (<14 days since amputation) or Secondary (≥14 days) TMR. This study aims to outline the post-operative pain course for Primary and Secondary TMR during the first six post-operative months, to aid in patient education and expectation management. METHODS: Patients were eligible if they underwent TMR surgery between 2017 and 2023. Prospectively collected patient-reported outcome measures of pain scores, Pain Interference, and Pain Intensity were analyzed. Multilevel mixed-effect models were utilized to visualize and compare pain courses between Primary and Secondary TMR patients. RESULTS: A total of 203 amputees were included, with 40.9% being Primary and 59.1% being Secondary TMR patients. Primary TMR patients reported significantly lower pain scores over the full 6-month post-operative trajectory (p<0.001) compared to Secondary TMR patients, with a difference of Δ-1.0 at day of TMR (Primary=4.5, Secondary=5.5), and a difference of Δ-1.4 at the 6-month mark (Primary=3.6, Secondary=5.0). Primary TMR patients also reported significantly lower Pain Interference (p<0.001) and Pain Intensity scores (p<0.001) over the complete trajectory of their care. CONCLUSION: Primary TMR patients report lower pain during the first six months post-operatively compared to secondary TMR patients. This may reflect how pre-existing neuropathic pain is more challenging to mitigate through peripheral nerve surgery. The current trends may assist in both understanding the post-operative pain course and in managing patient expectations following TMR.

The Role of Risk Tolerance in a Patient's Decision to Undergo Total Knee and Hip Arthroplasty.

BACKGROUND: A patient's decision-making process to undergo surgery is crucial for surgeons to understand for patient-counseling purposes. Total knee and hip arthroplasty, like any other major surgery, is associated with serious, sometimes life-threatening, complications. Using the results of discrete choice experiments (DCEs), we aimed to understand the relationship between a patient's risk tolerance and choosing to undergo surgery in real life. METHODS: This is a retrospective study of prospectively collected DCE results for 142 potential knee or hip arthroplasty clinic patients from October 2021 to March 2022. The DCE presented the patient with 2 scenarios, each of which was made up of different combinations of attributes and levels. A hierarchal Bayesian model was used to obtain a risk score that reflected the risk attributes chosen by each patient. Logistic regressions were then used to evaluate the association between a patient's willingness to incur risk and their decision to undergo a total joint arthroplasty. RESULTS: Of the 142 patients enrolled in the DCE, 89 (62.3%) underwent a total joint arthroplasty. Risk score (odds ratio [OR] = 2.6, 95% confidence interval [CI] 1.1 to 6.6, P = 0.04), men (OR = 2.5, 95% CI 1.1 to 5.9, P = 0.028), and patients who have hip osteoarthritis (OR = 2.4, 95% CI 1.1 to 5.5, P = 0.036) increased the odds of undergoing arthroplasty, whereas physical function of at least 75% at the initial visit (OR = 0.3, 95% CI 0.1 to 0.7, P = 0.004) decreased these odds. CONCLUSIONS: We found that a patient's willingness to incur risk, lower baseline physical function, and men were all independently associated with undergoing total knee arthroplasty. We believe that these findings prompt much-needed future studies that focus solely on the relationship between patients' inherent risk behavior and surgical and patient-reported outcomes.

Principles of Minimally Invasive Reduction and Nail Fixation for Subtrochanteric Femur Fractures.

Subtrochanteric femur fractures have a reputation as difficult orthopaedic injuries to treat. Strong deforming forces, including the hip musculature and high physiologic forces, must be counteracted to obtain and maintain reduction. Adding to the complexity is a wide variety of fracture morphologies that must be recognized to execute an appropriate surgical plan. The challenging nature of this injury is demonstrated by nonunion rates of 4% to 5%, but some series have reports of up to 15% and malunion rates of 10% to 15%. Improved outcomes have been shown to be dependent on appropriate reduction and stable fixation, which can be achieved with less surgical insult. The treating surgeon must have a thorough understanding of the injury characteristics and reduction techniques to appropriately execute minimally invasive techniques for these difficult fractures.

Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

How Are Age, Gender, and Country Differences Associated With PROMIS Physical Function, Upper Extremity, and Pain Interference Scores?

BACKGROUND: The interpretation of patient-reported outcomes requires appropriate comparison data. Currently, no patient-specific reference data exist for the Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF), Upper Extremity (UE), and Pain Interference (PI) scales for individuals 50 years and older. QUESTIONS/PURPOSES: (1) Can all PROMIS PF, UE, and PI items be used for valid cross-country comparisons in these domains among the United States, the United Kingdom, and Germany? (2) How are age, gender, and country related to PROMIS PF, PROMIS UE, and PROMIS PI scores? (3) What is the relationship of age, gender, and country across individuals with PROMIS PF, PROMIS UE, and PROMIS PI scores ranging from very low to very high? METHODS: We conducted telephone interviews to collect custom PROMIS PF (22 items), UE (eight items), and PI (eight items) short forms, as well as sociodemographic data (age, gender, work status, and education level), with participants randomly selected from the general population older than 50 years in the United States (n = 900), United Kingdom (n = 905), and Germany (n = 921). We focused on these individuals because of their higher prevalence of surgeries and lower physical functioning. Although response rates varied across countries (14% for the United Kingdom, 22% for Germany, and 12% for the United States), we used existing normative data to ensure demographic alignment with the overall populations of these countries. This helped mitigate potential nonresponder bias and enhance the representativeness and validity of our findings. We investigated differential item functioning to determine whether all items can be used for valid crosscultural comparisons. To answer our second research question, we compared age groups, gender, and countries using median regressions. Using imputation of plausible values and quantile regression, we modeled age-, gender-, and country-specific distributions of PROMIS scores to obtain patient-specific reference values and answer our third research question. RESULTS: All items from the PROMIS PF, UE, and PI measures were valid for across-country comparisons. We found clinically meaningful associations of age, gender, and country with PROMIS PF, UE, and PI scores. With age, PROMIS PF scores decreased (age ß Median = -0.35 [95% CI -0.40 to -0.31]), and PROMIS UE scores followed a similar trend (age ß Median = -0.38 [95% CI -0.45 to -0.32]). This means that a 10-year increase in age corresponded to a decline in approximately 3.5 points for the PROMIS PF score-a value that is approximately the minimum clinically important difference (MCID). Concurrently, we observed a modest increase in PROMIS PI scores with age, reaching half the MCID after 20 years. Women in all countries scored higher than men on the PROMIS PI and 1 MCID lower on the PROMIS PF and UE. Additionally, there were higher T-scores for the United States than for the United Kingdom across all domains. The difference in scores ranged from 1.21 points for the PROMIS PF to a more pronounced 3.83 points for the PROMIS UE. Participants from the United States exhibited up to half an MCID lower T-scores than their German counterparts for the PROMIS PF and PROMIS PI. In individuals with high levels of physical function, with each 10-year increase in age, there could be a decrease of up to 4 points in PROMIS PF scores. Across all levels of upper extremity function, women reported lower PROMIS UE scores than men by an average of 5 points. CONCLUSION: Our study provides age-, gender-, and country-specific reference values for PROMIS PF, UE, and PI scores, which can be used by clinicians, researchers, and healthcare policymakers to better interpret patient-reported outcomes and provide more personalized care. These findings are particularly relevant for those collecting patient-reported outcomes in their clinical routine and researchers conducting multinational studies. We provide an internet application ( www.common-metrics.org/PROMIS_PF_and_PI_Reference_scores.php ) for user-friendly accessibility in order to perform age, gender, and country conversions of PROMIS scores. Population reference values can also serve as comparators to data collected with other PROMIS short forms or computerized adaptive tests. LEVEL OF EVIDENCE: Level II, diagnostic study.

The Use of Blocking Wires in Fibular Intramedullary Nailing of an Ankle Fracture with Hardware Failure: A Case Report.

A 24-year-old male, with a body mass index (BMI) of 31.7 and a previous open reduction and internal fixation (ORIF) of the left ankle seven years ago, presented to the emergency department with a peri-implant, comminuted fibula fracture with broken hardware and syndesmotic injury. The nature of the revision surgery made proper guidewire placement during fibular nailing difficult. Blocking wires assisted in ensuring proper guidewire placement. The patient was successfully managed with revision ORIF, fibular nailing, and syndesmotic fixation. Blocking wires are a helpful tool for achieving proper fracture alignment and stability during intramedullary nailing procedures and may be considered in fibular nailing situations.

Patient-Reported Outcome Measurement in Orthopaedic Trauma.

Patient-reported outcome (PRO) measurements are validated tools developed to quantify self-reported aspects of capability, mindset, and circumstances in a standardized fashion. While PRO measurements have primarily been used in the research realm, a growing body of work now underscores substantial opportunities in applying the data generated by these tools to advance patient-centered musculoskeletal care. Specifically, the insights into a patient's health status derived from these measures can augment the standard biomedical approach to the management of patients with orthopaedic trauma. For instance, PRO measures have demonstrated the high prevalence of psychological distress and social concerns within trauma populations and shown that mindsets and circumstances account for a substantial amount of the variation in levels of symptom intensity and capability in these patients. Such findings support the need for a more integrated, biopsychosocial, and multidisciplinary team-based approach to orthopaedic trauma care that include both technical and nontechnical skillsets. In this chapter, we explore the range of available fixed-scale and computer adaptive PRO measures that can quantify aspects of capability, mindsets, and circumstances of the patient with orthopaedic trauma during their experience of injury, recovery, and rehabilitation. Furthermore, we define human, technical, and system-level challenges within the often complex, dynamic, and clinically intense trauma setting. Finally, we highlight potential opportunities through successfully implementing PRO measurements for clinical decision support, shared decision making, predicting health outcomes, and developing advanced care pathways for patients and populations with orthopaedic trauma.

Discharge prescribing and subsequent opioid use after traumatic musculoskeletal injury.

OBJECTIVE: To investigate the effects of discharge opioid supply after surgery for musculoskeletal injury on subsequent opioid use. STUDY DESIGN: Instrumental variables analysis of retrospective administrative data. METHODS: Data were acquired on 1039 patients treated operatively for a musculoskeletal injury between 2011 and 2015 at 2 level I trauma centers. State registry data were used to track all postoperative opioid prescription fills. Discharge surgical resident was identified for each patient. We categorized residents in the top one-third of opioid prescribing as high-supply residents and others as low-supply residents, with adjustment for service attending physician and month. The primary outcome was subsequent opioid use, defined as new opioid prescriptions and cumulative prescribed opioid supply 7 to 8 months after injury. RESULTS: On average, patients of high-supply residents received an additional 96 morphine milligram equivalents (MME) at discharge (95% CI, 29-163 MME; P < .01), or 16% more, compared with patients of low-supply residents, which is equivalent to an additional 2-day supply at a typical dosage. In the seventh or eighth month after surgery, patients of high-supply residents received a greater total MME volume than patients of low-supply residents (difference, 13.0 MME; 95% CI, 3.1-22.9 MME; P < .01) despite receiving a greater cumulative supply of opioid medications through the sixth month after surgery. CONCLUSIONS: After surgery for musculoskeletal injury, patients discharged by residents who prescribe greater supplies of opioid pain medications received higher supplies of opioids 7 to 8 months after surgery than patients discharged by residents who tend to prescribe less. Thus, limiting postoperative supplies of opioid pain medication may help reduce chronic opioid use.

Psychiatric comorbidity and trauma: impact on inpatient outcomes and implications for future management.

PURPOSE: This study aimed to quantify the impact of pre-existing psychiatric illness on inpatient outcomes after major trauma and to assess acuity of psychiatric presentation as a predictor of outcomes. METHODS: A retrospective single-center cohort study identified adult trauma patients with an Injury Severity Score (ISS) ≥ 16 between January 2018 and December 2019. Bivariate analysis assessed patient characteristics, injury characteristics, and injury outcomes between patients with and without psychiatric comorbidity. A sub-group analysis explored further effects of psychiatric history and need for inpatient psychiatric consultation on outcomes. RESULTS: Of 640 patients meeting inclusion criteria, 99 patients (15.4%) had at least one psychiatric comorbidity. Patients with psychiatric comorbidity sustained distinct mechanisms of injury and higher in-hospital morbidity (44% vs. 26%, OR 1.97, 95% CI 1.17-3.3, p = 0.01), including pulmonary morbidity (31% vs. 21%, p < 0.01), neurologic morbidity (18% vs 7%, p < 0.01), and deep wound infection (8% vs. 2%, p < 0.01) than the control cohort. Psychiatric patients also had significantly greater median intensive care unit (ICU), length of stay (LOS) (1 day vs. 0 days, p = 0.04), median inpatient ward LOS (10 days vs. 7 days, p = 0.02), and median overall hospital LOS (16 days vs. 11 days, p < 0.01). In sub-group analysis, patients with a history of psychiatric illness alone had comparable outcomes to the control group. CONCLUSIONS: Psychiatric comorbidity negatively impacts inpatient morbidity and inpatient LOS. This effect is most pronounced among acute psychiatric episodes with or without a history of mental illness.

Assessment of the added value of intravenous gadolinium for knee osteosarcoma resection planning in pediatric and young adult patients.

BACKGROUND AND OBJECTIVES: To assess the impact of Gadolinium-enhanced magnetic resonance imaging (MRI) sequences on Preoperative imaging evaluation and surgical planning parameters for osteosarcoma (OS) of the knee in pediatric and young adult patients. METHODS: Thirty MRI scans of patients with OS about the knee were reviewed by five orthopedic oncologists. Key preoperative parameters (neurovascular bundle involvement, intra-articular tumor extension, extent of intramedullary extension) and surgical plans were evaluated based on non-contrast versus Gd contrast enhanced sequences. Assessment agreement, inter-rater agreement, and intrarater agreement between pre and postcontrast images were evaluated via Kappa statistics. RESULTS: Moderate agreement was seen between non and contrast-enhanced assessment of neurovascular involvement and intra-articular tumor extension. Intrarater reproducibility was substantial for neurovascular bundle involvement (precontrast Kappa: 0.63, postcontrast Kappa: 0.69). Intrarater reproducibility was also substantial for precontrast (Kappa: 0.70) and moderate for postcontrast (Kappa: 0.50) assessment of intra-articular tumor extension. Planned resection length and choice of surgical approach were similar between sequences. The addition of Gd-enhanced sequences improved the inter-rater agreement across collected parameters. CONCLUSIONS: While some findings suggest that contrast enhanced sequences may not significantly alter the assessment of key preoperative planning parameters by orthopedic oncologists, they may help reduce variability among providers with differing experience levels.

"Pain Sketches Demonstrate Patterns of Pain Distribution and Pain Progression following Primary Targeted Muscle Reinnervation in Amputees."

BACKGROUND: Numerical scales are validated methods to report pain outcomes after Targeted Muscle Reinnervation (TMR) but do not include the assessment of qualitative pain components. This study evaluates the application of pain sketches within a cohort of patients undergoing primary TMR and describes differences in pain progression according to early postoperative sketches. METHODS: This study included 30 patients with major limb amputation and primary TMR. Patients' drawings were categorized into four categories of pain distribution (focal (FP), radiating (RP), diffuse (DP) and no pain (NP)) and inter-rater reliability was calculated. Secondly, pain outcomes were analyzed for each category. Pain scores were the primary and Patient-Reported Outcomes Measurement Information System (PROMIS) instruments were the secondary outcomes. RESULTS: The inter-rater reliability for the sketch categories was good (overall Kappa coefficient of 0.8). The NP category reported a mean decrease in pain of 4.8 points, followed by the DP (2.5 points) and FP categories (2.0 points). The RP category reported a mean increase in pain of 0.5 points. For PROMIS Pain Interference and Pain Intensity, the DP category reported a mean decrease of 7.2 and 6.5 points respectively, followed by the FP category (5.3 and 3.6 points). The RP category reported a mean increase of 2.0 points in PROMIS Pain Interference and a mean decrease of 1.4 points in PROMIS Pain Intensity. Secondary outcomes for the NP category were not reported. CONCLUSIONS: Pain sketches demonstrated reliability in pain morphology assessment and might be an adjunctive tool for pain interpretation in this setting.

Using bookmarking methods with orthopedic clinicians and patients with fractures produces score interpretation labels for patient-reported outcome measures.

OBJECTIVE: The objective of this study was to determine the patient-reported outcome measure (PROM) score ranges associated with descriptive labels (i.e., within normal limits, mild, moderate, severe) by using bookmarking methods with orthopedic clinicians and patients who have experienced a bone fracture. STUDY DESIGN AND SETTING: We created vignettes comprised of six items and responses from the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Function, Physical Function, and Pain Interference item banks reflecting different levels of severity. Two groups of patients with fractures (n = 11) and two groups of orthopedic clinicians (n = 16) reviewed the vignettes and assigned descriptive labels independently and then discussed as a group until reaching consensus via a videoconference platform. RESULTS: PROMIS Physical Function and Pain Interference thresholds (T = 50, 40, 25/30 and T = 50/55, 60, 65/70, respectively) for patients with bone fractures were consistent with the results from other patient populations. Upper Extremity thresholds were about 10 points (1 SD) more severe (T = 40, 30, 25/20) compared to the other measures. Patient and clinician perspectives were similar. CONCLUSION: Bookmarking methods generated meaningful score thresholds for PROMIS measures. These thresholds between severity categories varied by domain. Threshold values for severity represent important supplemental information to interpret PROMIS scores clinically.

Clockwise torque results in higher reoperation rates in left-sided femur fractures.

PURPOSE: Effects of clockwise torque rotation onto proximal femoral fracture fixation have been subject of ongoing debate: fixated right-sided trochanteric fractures seem more rotationally stable than left-sided fractures in the biomechanical setting, but this theoretical advantage has not been demonstrated in the clinical setting to date. The purpose of this study was to identify a difference in early reoperation rate between patients undergoing surgery for left- versus right-sided proximal femur fractures using cephalomedullary nailing (CMN). MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried from 2016-2019 to identify patients aged 50 years and older undergoing CMN for a proximal femoral fracture. The primary outcome was any unplanned reoperation within 30 days following surgery. The difference was calculated using a Chi-square test, and observed power calculated using post-hoc power analysis. RESULTS: In total, of 20,122 patients undergoing CMN for proximal femoral fracture management, 1.8% (n=371) had to undergo an unplanned reoperation within 30 days after surgery. Overall, 208 (2.0%) were left-sided and 163 (1.7%) right-sided fractures (p=0.052, risk ratio [RR] 1.22, 95% confidence interval [CI] 1.00-1.50), odds ratio [OR] 1.23 (95%CI 1.00-1.51), power 49.2% (α=0.05). CONCLUSION: This study shows a higher risk of reoperation for left-sided compared to right-sided proximal femur fractures after CMN in a large sample size. Although results may be underpowered and statistically insignificant, this finding might substantiate the hypothesis that clockwise rotation during implant insertion and (postoperative) weightbearing may lead to higher reoperation rates. LEVEL OF EVIDENCE: Therapeutic level II.

BRASD trial: biomechanical reposition techniques in anterior shoulder dislocation-a randomized multicenter clinical trial.

BACKGROUND: Biomechanical reduction techniques for shoulder dislocations have demonstrated high reduction success rates with a limited pain experience for the patient. We postulated that the combination of biomechanical reduction techniques with the shortest length of stay would also have the lowest pain experience and the highest first reduction success rate. METHODS: A randomized multicenter clinical trial was performed to compare different biomechanical reduction techniques in treating anterior shoulder dislocations without the use of invasive pain relief. Patients who were able to perform adduction of the arm were randomly assigned to Cunningham, the modified Milch, and the scapular manipulation technique. Those who were not able to do so were randomly assigned to modified Milch and the scapular manipulation technique. Primary outcomes were emergency department length of stay and pain experienced during the reduction process, measured by the numeric pain rating scale. Secondary outcomes were reduction time, reduction success, use of analgesics or sedatives, and complications. RESULTS: Three hundred eight patients were included, of whom 134 were in the adduction group. In both groups, no differences in emergency department length of stay and experienced pain were observed between the treatment arms. In the adduction group, the modified Milch technique had the highest first reduction success rates 52% (p = 0.016), within protocol 61% (p = 0.94), and with sedation in the ED 100% ( -). In the no-adduction group, the modified Milch was also the most successful primary reduction technique with 51% success (p = 0.040), within protocol 66% (p = 0.90), and with sedation in the ED 98% (p = 0.93). No complications were recorded in any of the techniques. CONCLUSION: A combination of biomechanical techniques resulted in a similar length of stay in the emergency department and showed similar pain scores with an overall high success rate of reduction. In both groups, the modified Milch had the highest first-reduction success rate. TRIAL REGISTRATION: Netherlands Trial Register NTR5839-1 April 2016. Ethical committee Noord-Holland with the CCMO-number NL54173.094.15.

Intercontinental validation of a clinical prediction model for predicting 90-day and 2-year mortality in an Israeli cohort of 2033 patients with a femoral neck fracture aged 65 or above.

PURPOSE: Mortality prediction in elderly femoral neck fracture patients is valuable in treatment decision-making. A previously developed and internally validated clinical prediction model shows promise in identifying patients at risk of 90-day and 2-year mortality. Validation in an independent cohort is required to assess the generalizability; especially in geographically distinct regions. Therefore we questioned, is the SORG Orthopaedic Research Group (SORG) femoral neck fracture mortality algorithm externally valid in an Israeli cohort to predict 90-day and 2-year mortality? METHODS: We previously developed a prediction model in 2022 for estimating the risk of mortality in femoral neck fracture patients using a multicenter institutional cohort of 2,478 patients from the USA. The model included the following input variables that are available on clinical admission: age, male gender, creatinine level, absolute neutrophil, hemoglobin level, international normalized ratio (INR), congestive heart failure (CHF), displaced fracture, hemiplegia, chronic obstructive pulmonary disease (COPD), history of cerebrovascular accident (CVA) and beta-blocker use. To assess the generalizability, we used an intercontinental institutional cohort from the Sheba Medical Center in Israel (level I trauma center), queried between June 2008 and February 2022. Generalizability of the model was assessed using discrimination, calibration, Brier score, and decision curve analysis. RESULTS: The validation cohort included 2,033 patients, aged 65 years or above, that underwent femoral neck fracture surgery. Most patients were female 64.8% (n = 1317), the median age was 81 years (interquartile range = 75-86), and 80.4% (n = 1635) patients sustained a displaced fracture (Garden III/IV). The 90-day mortality was 9.4% (n = 190) and 2-year mortality was 30.0% (n = 610). Despite numerous baseline differences, the model performed acceptably to the validation cohort on discrimination (c-statistic 0.67 for 90-day, 0.67 for 2-year), calibration, Brier score, and decision curve analysis. CONCLUSIONS: The previously developed SORG femoral neck fracture mortality algorithm demonstrated good performance in an independent intercontinental population. Current iteration should not be relied on for patient care, though suggesting potential utility in assessing patients at low risk for 90-day or 2-year mortality. Further studies should evaluate this tool in a prospective setting and evaluate its feasibility and efficacy in clinical practice. The algorithm can be freely accessed: https://sorg-apps.shinyapps.io/hipfracturemortality/ . LEVEL OF EVIDENCE: Level III, Prognostic study.

What Are the Functional and Surgical Outcomes of Tibial Turnup-plasty for Salvage in Patients With Chronic Lower Extremity Infection?

BACKGROUND: Tibial turnup-plasty is a rarely performed surgical option for large bone defects of the distal or entire femur and can serve as an alternative to hip disarticulation or high above-knee amputation. It entails pedicled transport of the ipsilateral tibia with or without the proximal hindfoot for use as a vascularized autograft. It is rotated 180° in the coronal or sagittal plane to the remaining proximal femur or pelvis, augmenting the functional length of the thigh. Prior reports consist of small case series with heterogeneous surgical techniques. Patient-reported outcome measures after the procedure have not been reported, and ambulatory status after the procedure is also unknown. QUESTIONS/PURPOSES: (1) What proportion of patients underwent reoperation after tibial turnup-plasty? (2) What is the ambulatory status and what proportion of patients used a prosthesis after tibial turnup-plasty? (3) What are the Patient-Reported Outcome Measurement Information System (PROMIS) Global-10 mental and physical function scores after tibial turnup-plasty? METHODS: A retrospective analysis was performed of 11 patients who underwent tibial turnup-plasty between 2003 and 2021 by a single orthopaedic oncology division in collaboration with a reconstructive plastic surgery team. Nine patients were men, with a median age of 55 years (range 34 to 75 years). All had chronic infections after arthroplasty or oncologic reconstructions, with a median number of 13 surgeries before turnup-plasty. All were considered to have no other surgical options other than hip disarticulation or high transfemoral amputation. All patients who were offered this possibility accepted it. Data of interest included patient demographics and comorbidities, surgical history that led to limb compromise, medical and surgical perioperative complications, date of prosthesis fitting, and functional capacity at the most recent follow-up interval based on ambulatory status and PROMIS Global-10 mental and physical function scores. The statistical analysis was descriptive. RESULTS: The median number of reoperations after turnup-plasty was one (range 0 to 11). Of the six patients who underwent at least one reoperation, indications for surgery included wound infection (four patients), nonunion of the osteosynthesis site (two), heterotopic ossification (one), tumor recurrence (one), and flap hypoperfusion treated with local tissue revision (one). One patient underwent conversion to external hemipelvectomy for tumor recurrence. Ten of the 11 patients were ambulatory at the final follow-up interval with standard above-knee amputation prostheses. Two ambulated unassisted, four used a single crutch or cane, and four used two crutches or a walker. Of the nine patients for whom scores were available, the median PROMIS Global-10 physical and mental health scores were 48 (range 30 to 68) and 53 (range 41 to 68), both within the standard deviation of the population mean of 50. CONCLUSION: The tibial turnup-plasty is a complex surgical option for patients with large bone defects of the femur for whom there are no alternative surgeries capable of producing residual extremities with acceptable functional length. This should be viewed as a procedure of last resort to avoid a hip disarticulation or a high transfemoral amputation in patients who have typically undergone numerous prior operations. Although ambulation with a prosthesis within 1 year can be expected, almost all patients will require an assistive device to do so, and reoperations are frequent. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Rib fractures in the elderly population: a systematic review.

BACKGROUND: Multiple rib fractures are associated with significant morbidity and mortality, especially in elderly patients. There is growing interest in surgical stabilization in this subgroup of patients. This systematic review compares conservative treatment to surgical fixation in elderly patients (older than 60 years) with multiple rib fractures. The primary outcome is mortality. Secondary outcomes include hospital and intensive care length of stay (HLOS and ILOS), duration of mechanical ventilation (DMV) and pneumonia rates. METHODS: Multiple databases were searched for comparative studies reporting on conservative versus operative treatment for rib fractures in patients older than 60 years. Both observational studies and randomised clinical trials were considered. RESULTS: Five observational studies (n = 2583) were included. Mortality was lower in operatively treated patients compared to conservative treatment (4% vs. 8%). Pneumonia rate and DMV were similar (5/6% and 5.8/6.5 days) for either treatment modality. Overall ILOS and HLOS of stay were longer in operatively treated patients (6.5 ILOS and 12.7 HLOS vs. 2.7 ILOS and 6.5 ILOS). There were only minimal reports on perioperative complications. Notably, the median number of rib fractures (8.4 vs. 5) and the percentage of flail chest were higher in operatively treated patients (47% vs. 39%). CONCLUSION: It remains unknown to what extent conservative and operative treatment contribute individually to reducing morbidity and mortality in the elderly with multiple rib fractures. To date, the quality of evidence is rather low, thus well-performed comparative observational studies or randomised controlled trials considering all confounders are needed to determine whether operative treatment can improve a patient's outcome.

Are Detailed, Patient-level Social Determinant of Health Factors Associated With Physical Function and Mental Health at Presentation Among New Patients With Orthopaedic Conditions?

BACKGROUND: It is well documented that routinely collected patient sociodemographic characteristics (such as race and insurance type) and geography-based social determinants of health (SDoH) measures (for example, the Area Deprivation Index) are associated with health disparities, including symptom severity at presentation. However, the association of patient-level SDoH factors (such as housing status) on musculoskeletal health disparities is not as well documented. Such insight might help with the development of more-targeted interventions to help address health disparities in orthopaedic surgery. QUESTIONS/PURPOSES: (1) What percentage of patients presenting for new patient visits in an orthopaedic surgery clinic who were unemployed but seeking work reported transportation issues that could limit their ability to attend a medical appointment or acquire medications, reported trouble paying for medications, and/or had no current housing? (2) Accounting for traditional sociodemographic factors and patient-level SDoH measures, what factors are associated with poorer patient-reported outcome physical health scores at presentation? (3) Accounting for traditional sociodemographic factor patient-level SDoH measures, what factors are associated with poorer patient-reported outcome mental health scores at presentation? METHODS: New patient encounters at one Level 1 trauma center clinic visit from March 2018 to December 2020 were identified. Included patients had to meet two criteria: they had completed the Patient-Reported Outcome Measure Information System (PROMIS) Global-10 at their new orthopaedic surgery clinic encounter as part of routine clinical care, and they had visited their primary care physician and completed a series of specific SDoH questions. The SDoH questionnaire was developed in our institution to improve data that drive interventions to address health disparities as part of our accountable care organization work. Over the study period, the SDoH questionnaire was only distributed at primary care provider visits. The SDoH questions focused on transportation, housing, employment, and ability to pay for medications. Because we do not have a way to determine how many patients had both primary care provider office visits and new orthopaedic surgery clinic visits over the study period, we were unable to determine how many patients could have been included; however, 9057 patients were evaluated in this cross-sectional study. The mean age was 61 ± 15 years, and most patients self-reported being of White race (83% [7561 of 9057]). Approximately half the patient sample had commercial insurance (46% [4167 of 9057]). To get a better sense of how this study cohort compared with the overall patient population seen at the participating center during the time in question, we reviewed all new patient clinic encounters (n = 135,223). The demographic information between the full patient sample and our study subgroup appeared similar. Using our study cohort, two multivariable linear regression models were created to determine which traditional metrics (for example, self-reported race or insurance type) and patient-specific SDoH factors (for example, lack of reliable transportation) were associated with worse physical and mental health symptoms (that is, lower PROMIS scores) at new patient encounters. The variance inflation factor was used to assess for multicollinearity. For all analyses, p values < 0.05 designated statistical significance. The concept of minimum clinically important difference (MCID) was used to assess clinical importance. Regression coefficients represent the projected change in PROMIS physical or mental health symptom scores (that is, the dependent variable in our regression analyses) accounting for the other included variables. Thus, a regression coefficient for a given variable at or above a known MCID value suggests a clinical difference between those patients with and without the presence of that given characteristic. In this manuscript, regression coefficients at or above 4.2 (or at and below -4.2) for PROMIS Global Physical Health and at or above 5.1 (or at and below -5.1) for PROMIS Global Mental Health were considered clinically relevant. RESULTS: Among the included patients, 8% (685 of 9057) were unemployed but seeking work, 4% (399 of 9057) reported transportation issues that could limit their ability to attend a medical appointment or acquire medications, 4% (328 of 9057) reported trouble paying for medications, and 2% (181 of 9057) had no current housing. Lack of reliable transportation to attend doctor visits or pick up medications (ß = -4.52 [95% CI -5.45 to -3.59]; p < 0.001), trouble paying for medications (ß = -4.55 [95% CI -5.55 to -3.54]; p < 0.001), Medicaid insurance (ß = -5.81 [95% CI -6.41 to -5.20]; p < 0.001), and workers compensation insurance (ß = -5.99 [95% CI -7.65 to -4.34]; p < 0.001) were associated with clinically worse function at presentation. Trouble paying for medications (ß = -6.01 [95% CI -7.10 to -4.92]; p < 0.001), Medicaid insurance (ß = -5.35 [95% CI -6.00 to -4.69]; p < 0.001), and workers compensation (ß = -6.07 [95% CI -7.86 to -4.28]; p < 0.001) were associated with clinically worse mental health at presentation. CONCLUSION: Although transportation issues and financial hardship were found to be associated with worse presenting physical function and mental health, Medicaid and workers compensation insurance remained associated with worse presenting physical function and mental health as well even after controlling for these more detailed, patient-level SDoH factors. Because of that, interventions to decrease health disparities should focus on not only sociodemographic variables (for example, insurance type) but also tangible patient-specific SDoH characteristics. For example, this may include giving patients taxi vouchers or ride-sharing credits to attend clinic visits for patients demonstrating such a need, initiating financial assistance programs for necessary medications, and/or identifying and connecting certain patient groups with social support services early on in the care cycle. LEVEL OF EVIDENCE: Level III, prognostic study.