PROMIS Physical Function and Pain Interference Scores are Correlated with Tibial Shaft Fracture Nonunion Following Intramedullary Nailing.

OBJECTIVE: To assess trends in PROMIS Physical Function (PF) and Pain Interference (PI) in surgically treated tibial shaft fracture patients progressing to union versus nonunion. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients with operatively treated tibial shaft fractures (AO/OTA 42-A,B,C) using an intramedullary nail. OUTCOME MEASURES AND COMPARISONS: PROMIS physical function and pain interference were compared between patients progressing to union and patients requiring nonunion repair. RESULTS: A total of 234 patients (196 union, 38 nonunion) were included consisting 144 males and 90 females. The mean age of included patients was 40.8 years. A significant difference in mean PROMIS PF between union and nonunion patients was observed at 1-3 months (p=0.005), 3-6 months (p<0.001), 6-9 months (p=0.003), and 6-12 months (p=0.018). The odds of developing nonunion for every unit decrease in PROMIS PF was significant at 3-6 months (OR 1.07, p=0.028) and 6-9 months (OR 1.17, p=0.015). A significant difference in mean PROMIS PI between union and nonunion patients was observed at 1-3 months (p=0.001), 3-6 months (p=0.005), and 6-9 months (p=0.005). The odds of developing nonunion for every unit increase in PROMIS PI was significant at 1-3 months (OR 1.11, p=0.005), 3-6 months (OR 1.10, p=0.011), and 6-9 months (OR 1.23, p=0.011). CONCLUSION: Poorly trending PROMIS PF and PI in the clinical setting is a factor that can be used to evaluate progression to nonunion following tibial shaft repair where imaging studies may lag behind. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Associations between Present-on-Admission Do-Not-Resuscitate Orders and Short-Term Outcomes in Patients with Pneumonia.

OBJECTIVES: Do-not-resuscitate (DNR) orders are used to express patient preferences for cardiopulmonary resuscitation. This study examined whether early DNR orders are associated with differences in treatments and outcomes among patients hospitalized with pneumonia. METHODS: This is a retrospective cohort study of 768,015 adult patients hospitalized with pneumonia from 2010 to 2015 in 646 US hospitals. The exposure was DNR orders present on admission. Secondary analyses stratified patients by predicted in-hospital mortality. Main outcomes included in-hospital mortality, length of stay, cost, intensive care admission, invasive mechanical ventilation, noninvasive ventilation, vasopressors, and dialysis initiation. RESULTS: Of 768,015 patients, 94,155 (12.3%) had an early DNR order. Compared with those without, patients with DNR orders were older (mean age 80.1 ± 10.6 years vs 67.8 ± 16.4 years), with higher comorbidity burden, intensive care use (31.6% vs 30.6%), and in-hospital mortality (28.2% vs 8.5%). After adjustment via propensity score weighting, these patients had higher mortality (odds ratio [OR] 2.39, 95% confidence interval [CI] 2.33-2.45) and lower use of intensive therapies such as vasopressors (OR 0.83, 95% CI 0.81-0.85) and invasive mechanical ventilation (OR 0.68, 95% CI 0.66-0.70). Although there was little relationship between predicted mortality and DNR orders, among those with highest predicted mortality, DNR orders were associated with lower intensive care use compared with those without (66.7% vs 80.8%). CONCLUSIONS: Patients with early DNR orders have higher in-hospital mortality rates than those without, but often receive intensive care. These orders have the most impact on the care of patients with the highest mortality risk.

Multi-Institutional Analysis of Insurance Denial Patterns Within Rhinology.

BACKGROUND: Obtaining insurance approval is a necessary component of healthcare in the United States and denials of these claims have been estimated to result in a loss of 3% to 5% of revenue. OBJECTIVE: Examine the trends in insurance denials for rhinological procedures. METHODS: A retrospective review of deidentified financial data of patients who were treated by participating physicians across 3 institutions from January 1, 2021, to June 30, 2023. The data was queried for rhinological and non-rhinological procedures via CPT codes. Cumulative insurance denials were calculated and stratified by procedure and insurance type. Write-offs were dollar amounts associated with final denials. RESULTS: A sample of 102,984 procedures and visits revealed a final denial rate between 2.2% and 2.9% across institutions (p = .72). The top three rhinological procedures for final write-offs were: nasal endoscopy (16.24%, $111,836.87), nasal debridement or polypectomy (6.48%, $79,457.51), and destruction of intranasal lesion (2.11%, $56,932.20). The write-off percentage for each procedure was highest among commercial insurance payers as opposed to Medicare or Medicaid. CONCLUSION: Final denial rates of rhinology procedures ranged between 2% and 3%. Common procedures such as nasal endoscopy and nasal debridement are among the highest written-off procedures. Insurance denials can lead to notable revenue loss. Rhinology practices must continue to remain knowledgeable of the changes and effects of insurance reimbursement on their practice.

Impact of screening participation on modelled mortality benefits of a multi-cancer early detection test by socioeconomic group in England.

BACKGROUND: Cancer burden is higher and cancer screening participation is lower among individuals living in more socioeconomically deprived areas of England, contributing to worse health outcomes and shorter life expectancy. Owing to higher multi-cancer early detection (MCED) test sensitivity for poor-prognosis cancers and greater cancer burden in groups experiencing greater deprivation, MCED screening programmes may have greater relative benefits in these groups. We modelled potential differential benefits of MCED screening between deprivation groups in England at different levels of screening participation. METHODS: We applied the interception multi-cancer screening model to cancer incidence and survival data made available by the National Cancer Registration and Analysis Service in England to estimate reductions in late-stage diagnoses and cancer mortality from an MCED screening programme by deprivation group across 24 cancer types. We assessed the impact of varying the proportion of people who participated in annual screening in each deprivation group on these estimates. RESULTS: The modelled benefits of an MCED screening programme were substantial: reductions in late-stage diagnoses were 160 and 274 per 100 000 persons in the least and most deprived groups, respectively. Reductions in cancer mortality were 60 and 99 per 100 000 persons in the least and most deprived groups, respectively. Benefits were greatest in the most deprived group at every participation level and were attenuated with lower screening participation. CONCLUSIONS: For the greatest possible population benefit and to decrease health inequalities, an MCED implementation strategy should focus on enhancing equitable, informed participation, enabling equal participation across all socioeconomic deprivation groups. TRIAL REGISTRATION NUMBER: NCT05611632.

Recovery Curves for Lisfranc ORIF Using PROMIS Physical Function and Pain Interference.

OBJECTIVES: To determine the postoperative trajectory and recovery of patients who undergo Lisfranc open reduction and internal fixation using Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI). DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENT SELECTION CRITERIA: Patients who underwent Lisfranc open reduction and internal fixation between January 2002 and December 2022 with documented PROMIS PF and/or PI scores after surgery. OUTCOME MEASURES AND COMPARISONS: PROMIS PF and PI were mapped over time up to 1 year after surgery. A subanalysis was performed to compare recovery trajectories between high-energy and low-energy injuries. RESULTS: A total of 182 patients were included with average age of 38.7 (SD 15.9) years (59 high-energy and 122 low-energy injuries). PROMIS PF scores at 0, 6, 12, 24, and 48 weeks were 30.2, 31.4, 39.2, 43.9, and 46.7, respectively. There was significant improvement in PROMIS PF between 6 and 12 weeks ( P < 0.001), 12-24 weeks ( P < 0.001), and 24-48 weeks ( P = 0.022). A significant difference in PROMIS PF between high and low-energy injuries was seen at 0 week (28.4 vs. 31.4, P = 0.010). PROMIS PI scores at 0, 6, 12, 24, and 48 weeks were 62.2, 58.5, 56.6, 55.7, and 55.6, respectively. There was significant improvement in PROMIS PI 0-6 weeks ( P = 0.016). A significant difference in PROMIS PI between high-energy and low-energy injuries was seen at 48 weeks with scores of (58.6 vs. 54.2, P = 0.044). CONCLUSIONS: After Lisfranc open reduction and internal fixation, patients can expect improvement in PF up to 1 year after surgery, with the biggest improvement in PROMIS PF scores between 6 and 12 weeks and PROMIS PI scores between 0 and 6 weeks after surgery. Regardless the energy type, Lisfranc injuries seem to regain comparable PF by 6-12 months after surgery. However, patients with higher energy Lisfranc injuries should be counseled that these injuries may lead to worse PI at 1 year after surgery as compared with lower energy injuries. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Development of the 12-Item Facial Complaints Evaluation Scale (FaCES-12).

OBJECTIVES: Chronic rhinosinusitis and related rhinologic disorders are common in routine otolaryngologic practice. Common presenting symptoms include nasal obstruction, facial pain, facial pressure, headache, and a subjective feeling of the face feeling "swollen," a perceptual distortion. No validated scale exists to assess facial pain in addition to perceptual distortion or headache. The objective was to develop a novel scale for assessment of facial symptoms experienced by patients presenting for rhinologic evaluation. METHODS: This was a prospective validation cross-sectional study. A patient questionnaire, the 12-item Facial Complaints Evaluation Scale (FaCES-12), was created to evaluate facial symptoms based on clinical experience and the literature, including severity and timing of facial pain, facial pressure, facial perceptual swelling, and headache. Each item was assessed utilizing an 11-point Likert scale ranging from 0 to 10 in severity. Data was collected prospectively from 210 patients in 1 private and 2 academic otolaryngologic practices from August to December 2019 along with the PROMIS Pain Intensity Scale 3a and 22-Item Sino-nasal Outcome Test. Construct validity was determined using Pearson correlation and exploratory factor analysis. Internal consistency and test-retest reliability were assessed by calculating Cronbach's alpha and assessing test-retest scores. RESULTS: A new 12-item scale named FaCES-12 was developed. FaCES-12 demonstrated high reliability with a Cronbach's alpha of .94 and high test-retest reliability (r = .90). The scale revealed very strong correlation with the PROMIS Pain Intensity Scale 3a (r = .81) and moderate correlation with the Sino-nasal Outcome Test (r = .48). Exploratory factor analysis demonstrated the scale contained interrelated variables that measured unique components of facial sensations. CONCLUSION: The FaCES-12 is a valid and reliable instrument for use in the evaluation of facial symptoms. Further research into the application of this scale is warranted.

Sinonasal Symptom Correlation With the Postoperative Polyp Scale (POPS).

BACKGROUND: Commonly used endoscopic nasal polyp grading scales have been shown to correlate poorly with symptom scores and quality of life metrics. The recently described Postoperative Polyp Scale (POPS) is a grading system that more accurately characterizes polyp recurrence in postoperative sinus cavities by describing incremental recurrence in relation to the surgically opened sinus cavities. OBJECTIVE: The objective of this study was to determine if the POPS correlated with sinonasal symptoms. METHODS: CRSwNP patients were prospectively administered SNOT-22 questionnaires and graded according to the POPS starting at their 1-month postoperative appointments. Total POPS scores (sum of each side) and Max POPS score (larger value of left and right) were correlated with SNOT-22 total scores and subdomains using Kendall correlation testing. RESULTS: A total of 127 patients were enrolled in the study. Both Total POPS or Max POPS were significantly correlated to the SNOT-22 total score (P < .001, P < .001), Rhinologic (P < .001, P < .001), Extra-Nasal Rhinologic (P < .001, P < .001), Ear/Facial (P < .001, P < .001), and Psychologic (P = .028, P = .017) subdomains. Kendall's tau indicated strong correlation (≥0.3) with Rhinologic subdomain, moderate correlation (.21-.29) with Extra-Nasal Rhinologic and Ear/Facial subdomains, and weak correlation (.1-.19) with Psychologic subdomain. CONCLUSION: Previous endoscopic nasal polyp grading scales poorly correlate with symptoms and patient reported outcome measures. The new POPS moderately correlates with the total SNOT-22 score and strongly correlates with the Rhinologic subdomain, indicating that it may have good potential as a tool to evaluate postoperative CRSwNP patients.

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.).

The MCID of the PROMIS physical function instrument for operatively treated tibial plateau fractures.

INTRODUCTION: Understanding minimal clinically important differences (MCID) in patient reported outcome measurement are important in improving patient care. The purpose of this study was to determine the MCID of Patient-Reported Outcome Measurement System (PROMIS) Physical Function (PF) domain for patients who underwent operative fixation of a tibial plateau fracture. METHODS: All patients with tibial plateau fractures that underwent operative fixation at a single level 1 trauma center were identified by Current Procedural Terminology codes. Patients without PROMIS PF scores or an anchor question at two-time points postoperatively were excluded. Anchor-based and distribution-based MCIDs were calculated. RESULTS: The MCID for PROMIS PF scores was 4.85 in the distribution-based method and 3.93 (SD 14.01) in the anchor-based method. There was significantly more improvement in the score from the first postoperative score (<7 weeks) to the second postoperative time (<78 weeks) in the improvement group 10.95 (SD 9.95) compared to the no improvement group 7.02 (SD 9.87) in the anchor-based method (P < 0.001). The percentage of patients achieving MCID at 7 weeks, 3 months, 6 months, and 1 year were 37-42 %, 57-62 %, 80-84 %, and 95-87 %, respectively. DISCUSSION: This study identified MCID values for PROMIS PF scores in the tibial plateau fracture population. Both MCID scores were similar, resulting in a reliable value for future studies and clinical decision-making. An MCID of 3.93 to 4.85 can be used as a clinical and investigative standard for patients with operative tibial plateau fractures.

Meniscus Tear Requiring Intraoperative Repair Does Not Influence Midterm Patient-Reported Outcomes in Operatively Treated Tibial Plateau Fractures.

OBJECTIVES: Evaluate whether intraoperatively repaired lateral meniscus injuries impact midterm patient-reported outcomes in those undergoing operative fixation of tibial plateau fracture. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENT SELECTION CRITERIA: All patients (n = 207) who underwent operative fixation of a tibial plateau fracture from 2016 to 2021 with a minimum of 10-month follow-up. OUTCOME MEASURES AND COMPARISONS: The Patient-Reported Outcomes Measurement Information System Physical Function, Knee Injury and Osteoarthritis Outcome Score, and the PROMIS-Preference health utility score. RESULTS: Overall, 207 patients were included with average follow-up of 2.9 years. Seventy-three patients (35%) underwent intraoperative lateral meniscus repair. Gender, age, body mass index, Charlson comorbidity index, days to surgery, ligamentous knee injury, open fracture, vascular injury, polytraumatic injuries, Schatzker classification, and Orthopaedic Trauma Association classification were not associated with meniscal repair ( P > 0.05). Rates of reoperation (42% vs. 31%, P = 0.11), infection (8% vs. 10%, P = 0.60), return to work (78% vs. 75%, P = 0.73), and subsequent total knee arthroplasty (8% vs. 5%, P = 0.39) were also similar between those who had a meniscal repair and those without a meniscal injury, respectively. There was no difference in Patient-Reported Outcomes Measurement Information System Physical Function (46.3 vs. 45.8, P = 0.707), PROMIS-Preference (0.51 vs. 0.50, P = 0.729), and all Knee Injury and Osteoarthritis Outcome Score domain scores at the final follow-up between those who had a meniscal repair and those without a meniscal injury, respectively. CONCLUSIONS: In patients with an operatively treated tibial plateau fracture, the presence of a concomitant intraoperatively identified and repaired lateral meniscal tear results in similar midterm PROMs and complication rates when compared with patients without meniscal injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prevalence of neural tube defects in England prior to the mandatory fortification of non-wholemeal wheat flour with folic acid: a population-based cohort study.

OBJECTIVES: To determine the baseline trends in the total birth prevalence of neural tube defects (NTDs) in England (2000-2019) to enable the impact of folic acid fortification of non-wholemeal wheat flour to be monitored. DESIGN: Population-based, observational study using congenital anomaly (CA) registration data for England curated by the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS). SETTING: Regions of England with active registration in the time period. PARTICIPANTS: Babies that were liveborn or stillborn and pregnancies that resulted in a termination of pregnancy or a late miscarriage (20-23 weeks' gestation) with an NTD. MAIN OUTCOME MEASURES: Total birth prevalence of anencephaly, spina bifida and all NTDs in England. Poisson regression analysis was used to evaluate time trends with regional register as a random effect. The progress of national registration across England was assessed. RESULTS: There were 4541 NTD pregnancies out of 3 637 842 births in England; 1982 anencephaly and 2127 spina bifida. NTD prevalence was 12.5 (95% CI 12.1 to 12.9) per 10 000 total births. NTD prevalence per 10 000 total births was significantly higher in 2015-2019 (13.6, 95% CI 12.9 to 14.4) compared with 2010-2014 (12.1, 95% CI 11.7 to 12.5). An increasing trend in NTDs overall was detected (incidence rate ratio (IRR) 1.01, 1.00 to 1.02), although further analysis determined this effect was confined to 2015-2019 (compared against 2000-2004, IRR 1.14, 1.04 to 1.24). The birth prevalence of anencephaly reflected this pattern. The prevalence of spina bifida remained relatively stable over time. CONCLUSIONS: Baseline NTD prevalence for England has been established. National and standardised CA registration is in place, facilitating the systematic and consistent monitoring of pre-fortification and post-fortification NTD trends and evaluating the impact of fortification on NTD prevalence.

Surgical management and weight-bearing recommendations for geriatric distal femur fractures.

Objective: To investigate current practices among orthopaedic trauma surgeons in treating geriatric distal femur fractures and evaluate current postoperative weight-bearing recommendations. Methods: A 26-question survey was emailed to Major Extremity Trauma Research Consortium surgeon members to characterize current practice with different fixation methods for distal femur fractures and the surgeon-directed postoperative weight-bearing recommendations for each approach. Results: Surveys were completed by 123 orthopaedic trauma surgeons with a response rate of 37% (123/332). Retrograde intramedullary nailing (IMN) was commonly performed by 88% of surgeons, and lateral locked plate was commonly performed by 74% of surgeons. Retrograde IMN with a lateral plate was commonly performed by 51% of surgeons. Dual femoral plating was commonly performed by 18% of surgeons and sometimes performed by 39% of surgeons. Surgeons were significantly more likely to allow immediate postoperative weight-bearing for retrograde IMN (P < 0.001), retrograde IMN with lateral plate (P < 0.001), and dual plate (P < 0.001) as compared with locked lateral plate. Most surgeons (79%) would be interested in participating in a randomized controlled trial (RCT) investigating single implant versus dual implant for distal femur fractures and believe that a trial incorporating immediate weight-bearing is important. Conclusion: A variety of implants are commonly used to treat geriatric distal femur fractures. Patients with distal femur fracture commonly have weight-bearing restrictions in the immediate postoperative period. A large proportion of orthopaedic trauma surgeons have clinical equipoise for an RCT to investigate the impact of surgical construct and weight-bearing on geriatric distal femur fracture patient recovery.

Worse Quality of Life Associated With Hyperextension Varus Tibial Plateau Fracture Pattern.

OBJECTIVES: Compare patient-reported outcome measures between hyperextension varus tibial plateau (HEVTP) fracture patterns to non-HEVTP fracture patterns. DESIGN: Retrospective study. SETTING: Single academic Level 1 Trauma Center. PATIENT SELECTION CRITERIA: All patients who underwent fixation of a tibial plateau fracture from 2016 to 2021 were collected. Exclusion criteria included inaccurate Current Procedural Terminology code, ipsilateral compartment syndrome, bilateral fractures, incomplete medical records, or follow-up <10 months. OUTCOME MEASURES AND COMPARISONS: In patients who underwent fixation of a tibial plateau fracture, compare Patient-Reported Outcomes Measurement Information System-Physical Function, PROMIS Preference, and Knee Injury and Osteoarthritis Outcome Score (KOOS) between patients with a HEVTP pattern with those without. RESULTS: Two-hundred and seven patients were included, of which 17 (8%) had HEVTP fractures. Compared with non-HEVTP fracture patterns, patients with HEVTP injuries were younger (42.6 vs. 51.0, P = 0.025), more commonly male (71% vs. 44%, P = 0.033), and had higher body mass index (32.8 vs. 28.0, P = 0.05). HEVTP fractures had significantly more ligamentous knee (29% vs. 6%, P = 0.007) and vascular (12% vs. 1%, P = 0.035) injuries. Patient-Reported Outcomes Measurement Information System-Physical Function scores were similar between groups; however, PROMIS-Preference (0.37 vs. 0.51, P = 0.017) was significantly lower in HEVTP fractures. KOOS pain, activities of daily living, and quality-of-life scores were statistically lower in HEVTP fractures, but only KOOS quality-of-life was clinically relevant (41.7 vs. 59.3, P = 0.004). CONCLUSIONS: The HEVTP fracture pattern, whether unicondylar or bicondylar, was associated with a higher rate of ligamentous and vascular injuries compared with non-HEVTP fracture patterns. They were also associated with worse health-related quality of life at midterm follow-up. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Return to Skiing After Tibial Plateau Fracture.

Background: Tibial plateau fractures in skiers are devastating injuries with increasing incidence. Few studies have evaluated patient-reported outcomes and return to skiing after operative fixation of a tibial plateau fracture. Purpose: To (1) identify demographic factors, fracture characteristics, and patient-reported outcome measures that are associated with return to skiing and (2) characterize changes in skiing performance after operative fixation of a tibial plateau fracture. Study Design: Case series; Level of evidence, 4. Methods: We reviewed all operative tibial plateau fractures performed between 2016 and 2021 at a single level-1 trauma center. Patients with a minimum of 10-month follow-up data were included. Patients who self-identified as skiers or were injured skiing were divided into those who returned to skiing and those who did not postoperatively. Patients were contacted to complete the Patient-Reported Outcomes Measurement Information System-Physical Function domain (PROMIS-PF), the Knee injury and Osteoarthritis Outcome Score-Activities of Living (KOOS-ADL), and a custom return-to-skiing questionnaire. Multivariate logistic regression was performed with sex, injury while skiing, PROMIS-PF, and KOOS-ADL as covariates to evaluate factors predictive of return to skiing. Results: A total of 90 skiers with a mean follow-up of 3.4 ± 1.5 years were included in the analysis. The rate of return to skiing was 45.6% (n = 41). The return cohort was significantly more likely to be men (66% vs 41%; P = .018) and injured while skiing (63% vs 39%; P = .020). In the return cohort, 51.2% returned to skiing 12 months postoperatively. The percentage of patients who self-reported skiing on expert terrain dropped by half from pre- to postinjury (61% vs 29.3%, respectively). Only 78% of return skiers had regained comfort with skiing at the final follow-up. Most patients (65%) felt the hardest aspect of returning to skiing was psychological. In the multivariate regression, the male sex and KOOS-ADL independently predicted return to skiing (P = .006 and P = .028, respectively). Conclusion: Fewer than half of skiers who underwent operative fixation of a tibial plateau fracture could return to skiing at a mean 3-year follow-up. The knee-specific KOOS-ADL outperformed the global PROMIS-PF in predicting a return to skiing.

Geriatric Distal Femur Fractures Treated With Distal Femoral Replacement Are Associated With Higher Rates of Readmissions and Complications.

OBJECTIVE: Compare mortality and complications of distal femur fracture repair among elderly patients who receive operative fixation versus distal femur replacement (DFR). DESIGN: Retrospective comparison. SETTING: Medicare beneficiaries. PATIENTS/PARTICIPANTS: Patients 65 years of age and older with distal femur fracture identified using Center for Medicare & Medicaid Services data from 2016 to 2019. INTERVENTION: Operative fixation (open reduction with plating or intramedullary nail) or DFR. MAIN OUTCOME MEASUREMENTS: Mortality, readmissions, perioperative complications, and 90-day cost were compared between groups using Mahalanobis nearest-neighbor matching to account for differences in age, sex, race, and the Charlson Comorbidity Index. RESULTS: Most patients (90%, 28,251/31,380) received operative fixation. Patients in the fixation group were significantly older (81.1 vs. 80.4 years, P < 0.001), and there were more an open fractures (1.6% vs. 0.5%, P < 0.001). There were no differences in 90-day (difference: 1.2% [-0.5% to 3%], P = 0.16), 6-month (difference: 0.6% [-1.5% to 2.7%], P = 0.59), and 1-year mortality (difference: -3.3% [-2.9 to 2.3], P = 0.80). DFR had greater 90-day (difference: 5.4% [2.8%-8.1%], P < 0.001), 6-month (difference: 6.5% [3.1%-9.9%], P < 0.001), and 1-year readmission (difference: 5.5% [2.2-8.7], P = 0.001). DFR had significantly greater rates of infection, pulmonary embolism, deep vein thrombosis, and device-related complication within 1 year from surgery. DFR ($57,894) was significantly more expensive than operative fixation ($46,016; P < 0.001) during the total 90-day episode. CONCLUSIONS: Elderly patients with distal femur fracture have a 22.5% 1-year mortality rate. DFR was associated with significantly greater infection, device-related complication, pulmonary embolism, deep vein thrombosis, cost, and readmission within 90 days, 6 months, and 1 year of surgery. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Transfusion after harvesting bone graft with RIA: Practice changes reduced transfusion rate by more than half.

INTRODUCTION: The Reamer Irrigator Aspirator (RIA) is frequently used as a tool for bone graft harvesting procedures. The initial use of this instrument for bone grafting was met with significant blood loss and high transfusion rates. However, the RIA remains an excellent tool to obtain large volumes of viable autologous graft. The aim of this study was to investigate how changes in the technical use of the RIA may affect blood loss. MATERIALS AND METHODS: We conducted a retrospective chart review of all patients who underwent RIA bone graft harvest over a 12-year study period. The patients were divided into two cohorts based upon changes in the technique used to obtain autograft harvest with the RIA. The traditional cohort (2008-2012) connected the RIA to dilation and curettage suction and selected reamer size based on radiographic parameters. The modified cohort (2012-2020) connected the RIA to wall suction, used improved techniques for reamer head sizing, and more diligence was paid toward the time the RIA was suctioning in the canal. Demographic information, surgical details, pre- and post-operative hematocrit (HCT), transfusion rate, intra-operative blood loss, reported volume of graft harvested, and iatrogenic fracture were recorded. RESULTS: 201 patients were included in the study with 61 patients in the traditional and 140 patients in the modified cohorts respectively. The average age was 51 years (range: 18-97) with 107 (53%) males. There was no difference in the demographic data between the two cohorts. No difference was noted between the traditional and modified cohorts in terms of the amount of average graft harvested (54cc vs 51cc; p = 0.34) or major complications (1 vs 2; p = 0.91). However, when comparing the traditional versus modified cohorts the traditional group demonstrated a larger average blood loss (675cc vs 500cc; p=<0.01) and HCT drop (13.7 vs 9.5; p=<0.01) with a higher transfusion rate (44% vs 19%; p = 0.001). CONCLUSION: This series demonstrated a significant improvement in blood loss and transfusion with modified techniques used to obtain autologous bone graft with the RIA. Importantly, these techniques do not appear to limit bone graft harvest yield and can therefore be efficiently implemented without limiting the utility of the RIA.

Ostial Patency Measurements After Endoscopic Sphenoidotomies and Frontal Sinusotomies.

BACKGROUND: Sphenoid and frontal sinuses have narrow ostia and are prone to stenosis. However, their relative rates of patency are not well established, and descriptive rates of sphenoid stenosis have never been reported. The objective is to measure the patency of the sphenoid and frontal sinus ostia postoperatively. METHODS: A prospective multi-institutional cohort study was performed. Ostial patency was measured at surgery and 3 and 6 months postoperatively. Pertinent clinical history such as the presence of nasal polyps and prior history of ESS as well as the use of steroid eluting stents were recorded. Overall stenosis rates were calculated for both the sphenoid and frontal sinuses, and Wilcoxon-Signed Rank Test was used to compare intraoperative and postoperative ostial areas. Factorial Analysis of Variance (ANOVA) was performed to determine effects of 5 clinical factors. RESULTS: Fifty patients were included. The mean sphenoid sinus ostial area decreased 42.2% in size from baseline to 3 months postoperatively (T0 55.2 ± 28.7 mm vs T3 m 31.8 ± 25.5 mm, P < .001). The mean frontal sinus ostial area decreased 39.8% in size from baseline to 3 months postoperatively (T0 33.7 ± 17.2 mm vs T3 m 19.9 ± 15.1 mm, P < .001). Neither the sphenoid nor the frontal sinus ostial patency demonstrated statistically significant change from 3 to 6 months postoperatively. CONCLUSION: Both sphenoid and frontal sinus ostia routinely narrow postoperatively, predominately from baseline to 3 months. These findings can serve as a reference for both clinical outcomes and future studies of these surgeries.

Intravenous to Oral Antibiotic Switch Therapy Among Patients Hospitalized With Community-Acquired Pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is a leading cause of hospital admissions and antimicrobial use. Clinical practice guidelines recommend switching from intravenous (IV) to oral antibiotics once patients are clinically stable. METHODS: We conducted a retrospective cohort study of adults admitted with CAP and initially treated with IV antibiotics at 642 US hospitals from 2010 through 2015. Switching was defined as discontinuation of IV and initiation of oral antibiotics without interrupting therapy. Patients switched by hospital day 3 were considered early switchers. We compared length of stay (LOS), in-hospital 14-day mortality, late deterioration (intensive care unit [ICU] transfer), and hospital costs between early switchers and others, controlling for hospital characteristics, patient demographics, comorbidities, initial treatments, and predicted mortality. RESULTS: Of 378 041 CAP patients, 21 784 (6%) were switched early, most frequently to fluoroquinolones. Patients switched early had fewer days on IV antibiotics, shorter duration of inpatient antibiotic treatment, shorter LOS, and lower hospitalization costs, but no significant excesses in 14-day in-hospital mortality or late ICU admission. Patients at a higher mortality risk were less likely to be switched. However, even in hospitals with relatively high switch rates, <15% of very low-risk patients were switched early. CONCLUSIONS: Although early switching was not associated with worse outcomes and was associated with shorter LOS and fewer days on antibiotics, it occurred infrequently. Even in hospitals with high switch rates, <15% of very low-risk patients were switched early. Our findings suggest that many more patients could be switched early without compromising outcomes.

Postoperative Polyp Scale (POPS): Development of a New Sinonasal Polyp Grading Scale.

OBJECTIVE: Commonly used endoscopic grading scales, such as the nasal polyp scale, inadequately describe the degree of polyposis found postoperatively in the paranasal sinus cavities. The purpose of this study was to create a novel grading system that more accurately characterizes polyp recurrence in postoperative sinus cavities, the Postoperative Polyp Scale (POPS). METHODS: A modified Delphi method was utilized to establish the POPS using consensus opinion among 13 general otolaryngologists, rhinologists, and allergists. Postoperative endoscopy videos from 50 patients with chronic rhinosinusitis with nasal polyps were reviewed by 7 fellowship-trained rhinologists and scored according to the POPS. Videos were rated again 1 month later by the same reviewers, and scores were assessed for test-retest and inter-rater reliability. RESULTS: Overall inter-rater reliability for the first and second reviews of the 52 videos was Kf = 0.49 (95% CI 0.42-0.57) and Kf = 0.50 (95% CI 0.42-0.57) for the POPS. Intra-rater reliability showed near-perfect test-retest reliability for the POPS with Kf = 0.80 (95% CI 0.76-0.84). CONCLUSION: The POPS is an easy-to-use, reliable, and novel objective endoscopic grading scale that more accurately describes polyp recurrence in the postoperative state which will be useful in the future for measuring the efficacy of various medical and surgical interventions. LEVEL OF EVIDENCE: 5 Laryngoscope, 133:2885-2890, 2023.