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.

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).

Recommendations on the use of virtual interviews in the orthopaedic trauma fellowship match: A survey of applicant and fellowship director perspectives.

OBJECTIVE: The aim of this study was to assess applicant and fellowship director (FD) perspectives on virtual interviewing based on the 2019 to 2020 orthopaedic trauma fellowship interview experience and to develop recommendations for future application cycles. METHODS: Web-based surveys were distributed to all matched applicants and orthopaedic trauma FDs after the 2019 and 2020 orthopaedic trauma fellowship match. Thirty-one applicants and 23 FDs completed the survey-response rates of 34% and 38%, respectively. RESULTS: Virtual interviews were completed by 68% of applicants and 17% of FDs. Twenty-nine percent of applicants felt they were able to familiarize themselves with the culture of programs, and 38% of applicants were satisfied with their ability to present themselves. Most (62%) were comfortable ranking programs based on the virtual interview, but 38% reported the format influenced them to rank a program lower. Among all applicants, 77% preferred the in-person interview. Most FDs (75%) reported virtual interviews limited their ability to familiarize themselves with an applicant, and only 50% were comfortable ranking an applicant afterward. Still, 78% of FDs believe there is a role for virtual interviews in the fellowship match. Choosing a virtual interview may negatively affect applicants as 97% of applicants worry the choice conveys less interest to programs, while 43% of FDs would interpret it as less interest. CONCLUSIONS: Virtual interviews have multiple shortcomings but are technically feasible and provide reasonable information to applicants and FDs to complete the match process. Our recommendations, based on the perspectives of applicants and FDs, can guide their implementation.

Perspective on optical imaging for functional assessment in musculoskeletal extremity trauma surgery.

SIGNIFICANCE: Extremity injury represents the leading cause of trauma hospitalizations among adults under the age of 65 years, and long-term impairments are often substantial. Restoring function depends, in large part, on bone and soft tissue healing. Thus, decisions around treatment strategy are based on assessment of the healing potential of injured bone and/or soft tissue. However, at the present, this assessment is based on subjective clinical clues and/or cadaveric studies without any objective measure. Optical imaging is an ideal method to solve several of these issues. AIM: The aim is to highlight the current challenges in assessing bone and tissue perfusion/viability and the potentially high impact applications for optical imaging in orthopaedic surgery. APPROACH: The prospective will review the current challenges faced by the orthopaedic surgeon and briefly discuss optical imaging tools that have been published. With this in mind, it will suggest key research areas that could be evolved to help make surgical assessments more objective and quantitative. RESULTS: Orthopaedic surgical procedures should benefit from incorporation of methods to measure functional blood perfusion or tissue metabolism. The types of measurements though can vary in the depth of tissue sampled, with some being quite superficial and others sensing several millimeters into the tissue. Most of these intrasurgical imaging tools represent an ideal way to improve surgical treatment of orthopaedic injuries due to their inherent point-of-care use and their compatibility with real-time management. CONCLUSION: While there are several optical measurements to directly measure bone function, the choice of tools can determine also the signal strength and depth of sampling. For orthopaedic surgery, real-time data regarding bone and tissue perfusion should lead to more effective patient-specific management of common orthopaedic conditions, requiring deeper penetrance commonly seen with indocyanine green imaging. This will lower morbidity and result in decreased variability associated with how these conditions are managed.

Screw Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures in the Elderly: A Cost-Effectiveness Analysis.

OBJECTIVE: To evaluate the cost-effectiveness of screw fixation versus hemiarthroplasty for nondisplaced femoral neck fractures in low-demand elderly patients. METHODS: We constructed a Markov decision model using a low-demand, 80-year-old patient as the base case. Costs, health-state utilities, mortality rates, and transition probabilities were obtained from published literature. The simulation model was cycled until all patients were deceased to estimate lifetime costs and quality-adjusted life years (QALYs). The primary outcome was the incremental cost-effectiveness ratio with a willingness-to-pay threshold set at $100,000 per QALY. We performed sensitivity analyses to assess our parameter assumptions. RESULTS: For the base case, hemiarthroplasty was associated with greater quality of life (2.96 QALYs) compared with screw fixation (2.73 QALYs) with lower cost ($23,467 vs. $25,356). Cost per QALY for hemiarthroplasty was $7925 compared with $9303 in screw fixation. Hemiarthroplasty provided better outcomes at lower cost, indicating dominance over screw fixation. CONCLUSIONS: Hemiarthroplasty is a cost-effective option compared with screw fixation for the treatment of nondisplaced femoral neck fractures in the low-demand elderly. Medical comorbidities and other factors that impact perioperative mortality should also be considered in the treatment decision. LEVEL OF EVIDENCE: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Variability in Discharge Disposition Across US Trauma Centers After Treatment for High-Energy Lower Extremity Injuries.

OBJECTIVE: To evaluate the association between patient- and center-level characteristics and discharge to an inpatient facility versus home after treatment for lower extremity trauma, as well as examine the variability in discharge disposition across clinical centers after controlling for these factors. DESIGN: This is an analysis of data collected prospectively across 5 multicenter studies of extremity trauma. SETTING: US Trauma Centers. PARTICIPANTS: Patients 18-80 years with lower extremity trauma treated at 1 of 55 participating centers. MAIN OUTCOME MEASURE: Discharge disposition. RESULTS: Among 2365 patients treated at 1 of 55 centers across 13 states, 673 (28.5%) were discharged to an inpatient facility, and 1692 (71.5%) were discharged home. Individuals who were older, female, unmarried, insured, higher body mass index, history of severe alcohol abuse, Gustilo type IIIB or IIIC open injuries, bilateral, spine and upper extremity injuries, higher injury severity score scores, or intensive care unit stay were more likely to be discharged to an inpatient facility. Even after accounting for patient- and center-level characteristics, there was substantial variation in discharge disposition across centers (likelihood ratio test: P < 0.001). CONCLUSION: Variation in discharge disposition may represent a potential for improvement in resource utilization and cost savings. Further studies are needed to examine the relationship between utilization of postdischarge inpatient facility after trauma and outcomes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bone-specific kinetic model to quantify periosteal and endosteal blood flow using indocyanine green in fluorescence guided orthopedic surgery.

This letter describes a hybrid plug/compartment (HyPC) kinetic model to fit dynamic indocyanine green fluorescence data acquired in a porcine model of long bone traumatic fracture. Parametric images of periosteal blood flow, endosteal blood flow, total bone blood flow and fraction of endosteal-to-periosteal flow were obtained by applying the HyPC model on a pixel-by-pixel basis. Intraoperative discrimination between healthy and damaged bone could facilitate debridement reducing post-operative complications from non-union and infection. The ability to quantify periosteal and endosteal blood flow could inform nail vs. plate-and-screw decisions to avoid further compromising cortical blood supply.

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."

Psychiatric Illness Is Common in Elderly Fracture Patients.

OBJECTIVES: To (1) describe the prevalence of psychiatric illness in fracture patients ≥70 years of age and (2) investigate the association between psychiatric illness and complications requiring unplanned readmission in elderly patients. DESIGN: Retrospective cohort study. PATIENTS/PARTICIPANTS: One thousand one hundred eighty-six patients ≥70 years of age with surgically treated fractures and ≥1-month follow-up treated from 2012 to 2017. INTERVENTION: None. MAIN OUTCOME MEASURE: Complication requiring unplanned readmission. RESULTS: Forty-four percent of patients ≥70 years of age have psychiatric comorbidities, and of those, 34% had >1 diagnosis. There was a higher rate of readmission among patients with psychiatric diagnosis compared with those without psychiatric diagnosis (35% vs. 21%, P < 0.001). There was a higher prevalence of psychiatric illness among patients 70 years of age or older compared with patients less than 70 years of age (44% vs. 39%, P = 0.007). Multivariate regression analysis controlling for age, sex, Charlson Comorbidity Index, dementia, delirium during admission, tobacco use, substance abuse, Injury Severity Score, fracture location, number of procedures, and number of fractures demonstrated an independent association between psychiatric illness and unplanned readmission (adjusted OR 1.54, 95% confidence interval, 1.15-2.07, P = 0.003). CONCLUSIONS: Almost half of the elderly patients in the present cohort have psychiatric comorbidities. Furthermore, psychiatric illness is an independent predictor of unplanned readmission, which may have substantial consequences for recovery and cost of care. This emphasizes the need for more attention to these issues in geriatric patient populations and the need to identify means to influence the downstream consequences of these comorbidities. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Survivorship After High-Energy Geriatric Trauma.

OBJECTIVES: To evaluate in-hospital, 1-year, and 5-year survivorship of geriatric patients after high-energy trauma, to compare survivorship of geriatric patients who sustained high-energy trauma with that of those who sustained low-energy trauma, and to identify predictors for mortality. DESIGN: Retrospective. SETTING: Urban Level I trauma center. PATIENTS: Study group of 1849 patients with high-energy trauma and comparison group of 761 patients with low-energy trauma. INTERVENTION: Each patient was observed from the time of index admission through the end of the study period or until death or readmission. MAIN OUTCOME MEASUREMENT: Long-term survivorship based on the Social Security Death Index. RESULTS: Survivorship between patients with high-energy and low-energy injuries was statistically significant. Among patients who sustained high-energy injuries, in-hospital mortality was 8%, 1-year mortality was 15%, and 5-year mortality was 25%. Among patients who sustained low-energy injuries, in-hospital mortality was 3%, 1-year mortality was 23%, and 5-year mortality was 40%. Low-energy mechanism of injury was an independent predictor for 1-year and 5-year mortality, even when controlling for Charlson Comorbidity Index (CCI), Injury Severity Score (ISS), age, sex, body mass index (BMI), and admission Glasgow Coma Scale (GCS) score. CONCLUSIONS: Geriatric patients with high-energy injuries and those with low-energy injuries seem to represent different patient populations, and low-energy mechanism seems to be a marker for frailty. High-energy mechanism was associated with lower long-term mortality rates, even when controlling for CCI, ISS, age, sex, BMI and admission GCS score. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Culture-Negative Infection After Operative Fixation of Fractures.

OBJECTIVES: (1) Compare the outcomes of patients with orthopaedic trauma with culture-negative infection with those with pathogens identified; (2) identify the incidence of culture-negative infection and describe the common characteristics. DESIGN: Retrospective study. SETTING: Two level 1 trauma centers. PATIENTS: A total of 391 patients 16 years of age or older who underwent irrigation and debridement for surgical site infection after having undergone fracture fixation were included. INTERVENTION: Patients underwent irrigation and debridement with cultures, and antibiotic therapy was initiated. MAIN OUTCOME MEASUREMENT: Treatment failure due to unsuccessful eradication of infection and time to union. RESULTS: We found 9% incidence of culture-negative infection. Approximately one-third of patients in both groups went on to have treatment failure (25% of pathogen-specific infections, 38% of culture-negative infections, P = 0.15), and there was no difference between the 2 groups with regard to time to union (22 vs. 24 weeks, P = 0.55). More than one-third of patients required subsequent reconstructive procedure and 5% of patients in each group required amputation to control their infection. There was no difference between the groups with respect to the use of antibiotics before intervention and culture. CONCLUSION: This study confirms the devastating effect that postoperative infections can have and suggests that, with clinical sign of infection, negative cultures do not portend a better prognosis. These entities should be treated in a similar manner to infections with positive cultures. Furthermore, we believe that future studies should not strictly rely on the presence of positive intraoperative cultures. Consensus as to what constitutes a clinical infection, in the absence of positive cultures, is needed. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.