Multicenter, Prospective, Observational Study of Nonoperative Versus Operative Treatment for High-Energy Midshaft Clavicle Fractures.

OBJECTIVES: Evaluate if nonoperative or operative treatment of displaced clavicle fractures delivers reduced rates of nonunion and improved Disability of the Arm, Shoulder, and Hand (DASH) scores. DESIGN: Multicenter, prospective, observational. SETTING: Seven Level 1 Trauma Centers in the United States. PATIENT SELECTION CRITERIA: Adults with closed, displaced (100% displacement/shortened >1.5 cm) midshaft clavicle fractures (Orthopaedic Trauma Association 15.2) were treated nonoperatively, with plates and screw fixation, or with intramedullary fixation from 2003 to 2018. OUTCOME MEASURES AND COMPARISONS: DASH scores (2, 6 weeks, 3, 6, 12, and 24 months), reoperation, and nonunion were compared between the nonoperative, plate fixation, and intramedullary fixation groups. RESULTS: Four hundred twelve patients were enrolled, with 203 undergoing plate fixation, 26 receiving intramedullary fixation, and 183 treated nonoperatively. The average age of the nonoperative group was 40.1 (range 18-79) years versus 35.8 (range 18-74) in the plate group and 39.3 (range 19-56) in the intramedullary fixation group (P = 0.06). One hundred forty (76.5%) patients in the nonoperative group were male compared with 154 (75.9%) in the plate group and 18 (69.2%) in the intramedullary fixation group (P = 0.69). All groups showed similar DASH scores at 2 weeks, 12 months, and 24 months (P > 0.05). Plate fixation demonstrated better DASH scores (median = 20.8) than nonoperative (median = 28.3) at 6 weeks (P = 0.04). Intramedullary fixation had poorer DASH scores at 6 weeks, 3 months, and 6 months than plate fixation and worse DASH scores than nonoperative at 6 months (P < 0.05). The nonunion rate for nonoperative treatment (14.6%) was significantly higher than the plate group (0%) (P < 0.001). CONCLUSIONS: Operative treatment of displaced clavicle fractures provided lower rates of nonunion than nonoperative treatment. Except at 6 weeks, no difference was observed in DASH scores between plate fixation and nonoperative treatment. Intramedullary fixation resulted in worse DASH scores than plate fixation at 6 weeks, 3 months, and 6 months and worse DASH scores than nonoperative at 6 months. Implant removal was the leading reason for reoperation in the plate and intramedullary fixation groups, whereas surgery for nonunion was the primary reason for surgery in the nonoperative group. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

An introduction to orthopaedic coding and billing.

Coding is the process of identifying descriptive terms and codes for diagnoses and medical services, which result from patient interactions with physicians and other healthcare providers. This information is organized in alpha and/or numeric fashion and may be used for charge submission, performance measurement, and data collection for emerging technology, services, and procedures. Under the Health Insurance Portability and Accountability Act, The Department of Health and Human Services designated the International classification of Diseases and Current Procedural Terminology as the national standard code sets for healthcare professional services and procedures. The purpose of this article is to summarize the most important aspects of the billing and coding process.

Use of Continuous Passive Motion in the Postoperative Treatment of Intra-Articular Knee Fractures.

BACKGROUND: The use of continuous passive motion in the postoperative treatment of intra-articular fractures around the knee is increasing. The purpose of this study was to determine the effects of a continuous passive motion device on knee range of motion after operative treatment of intra-articular fractures around the knee. METHODS: Forty patients with intra-articular fractures of either the proximal part of the tibia or the distal end of the femur were prospectively randomized to the use of continuous passive motion or standardized physical therapy in the immediate postoperative period for forty-eight hours. The primary outcome was knee range of motion. Secondary outcome measures included pain scores, Lower Limb Outcomes Questionnaire scores, and Short Musculoskeletal Function Assessment scores. Evaluations were conducted at forty-eight hours, two weeks, six weeks, three months, and six months postoperatively. RESULTS: There was no significant difference in knee extension between the groups at any time point measured. Knee flexion was significantly greater at forty-eight hours in the group managed with the continuous passive motion device than in the group managed without the continuous passive motion device (p < 0.005). However, there was no significant difference in knee flexion at any other time point. There was no significant difference in knee pain at forty-eight hours between groups. Six (30%) of twenty patients were unable to tolerate the use of the continuous passive motion device. There were no significant differences in overall complications. CONCLUSIONS: The results of this study suggest that the use of continuous passive motion in the immediate postoperative period following the treatment of intra-articular fractures offers no benefit with regard to knee motion at six months and is not tolerated by all patients. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee.

The purpose of this new classification compendium is to republish the Orthopaedic Trauma Association's (OTA) classification. The OTA classification was originally published in a compendium of the Journal of Orthopaedic Trauma in 1996. It adopted The Comprehensive Classification of the Long Bones developed by Müller and colleagues and classified the remaining bones. In this compendium, the introductory chapter reviews new scientific information about classifying fractures that has been published in the last 11 years. The classification is presented in a revised format that is easier to follow. The OTA and AO classification will now have a unified alpha-numeric code eliminating the differences that have existed between the 2 codes. The code was significantly revised for the clavicle and scapula, foot and hand, and patella. Dislocations have been expanded on an anatomic basis and for most joints will be coded separately. This publication should stimulate new developments and interest in a unified language to code and classify fractures. Further improvements in classification will result in better patient care and clinical research.

Continuous infusion of local anesthetic at iliac crest bone-graft sites for postoperative pain relief. A randomized, double-blind study.

BACKGROUND: Autologous bone graft is the so-called gold standard for reconstruction of bone defects and nonunions. The most frequent complication is donor site pain. The iliac crest is a common source for autologous bone graft. The purpose of this study was to determine whether a continuous infusion of 0.5% bupivacaine into the iliac crest harvest site provides pain relief that is superior to the relief provided by systemic narcotic pain medication alone in patients undergoing reconstructive orthopaedic trauma procedures. METHODS: A prospective, double-blind randomized study of patients over eighteen years of age who were undergoing harvesting of iliac crest bone graft was conducted. The patients were randomized to the treatment arm (bupivacaine infusion pump) or the placebo arm. Postoperatively, all study patients received morphine sulfate with use of a patient-controlled analgesia pump. The patients recorded the pain at the donor and recipient sites with use of a scale ranging from 0 to 10. The use of systemic narcotic medication was recorded. Independent-samples t tests were used to assess differences in perceived pain relief between the treatment and control groups at zero, eight, sixteen, twenty-four, thirty-two, forty, and forty-eight hours after surgery. Pain was also assessed at two and six weeks postoperatively. RESULTS: Sixty patients were enrolled. Across all data points, except pain at the recipient site at twenty-four hours, no significant differences in the perception of pain were found between the bupivacaine group and the placebo group. On the average, patients in the treatment group reported more pain than those in the control group. No significant difference was found between the two groups with regard to the amount of narcotic medication used. CONCLUSIONS: No difference in perceived pain was found between the groups. The results of this small, unstratified study indicate that continuous infusion of bupivacaine at iliac crest bone-graft sites during the postoperative period is not an effective pain-control measure in hospitalized patients receiving systemic narcotic medication.