Persistently elevated joint contact stress after periacetabular osteotomy is associated with joint failure at minimum 10-year follow-up.

Periacetabular osteotomy (PAO) is a common treatment for prearthritic hip dysplasia. The goal of this investigation was to determine if computationally assessed hip contact mechanics are associated with joint failure at minimum 10-year follow-up. One hundred patients with hip dysplasia (125 hips) completed patient-reported outcomes an average of 13.8 years (range 10.0-18.0 years) after PAO. 63/125 hips were classified as having failed: 26 converted to total hip arthroplasty (THA) and 37 with significant disability indicated by modified Harris Hip Score (mHHS) ≤ 70. Differences in discrete element analysis-computed contact mechanics were compared between (1) preserved and failed hips, (2) preserved hips and hips that failed by THA, and (3) preserved hips and hips that failed by mHHS ≤ 70. Failed hips had significantly higher preoperative contact stress and exposure metrics (p < 0.001-0.009) than preserved hips. Failed hips also had significantly higher postoperative peak contact stress (p = 0.018), higher mean contact stress (p < 0.001), and smaller contact area (p = 0.044). When assessed based on type of failure, hips that failed by THA had significantly higher postoperative contact stress and exposure metrics than preserved hips (p < 0.001-0.020). In hips that failed by mHHS ≤ 70, mean postoperative contact stress exposure was significantly higher compared to preserved hips (p = 0.043). Despite improved radiographic measures of dysplasia after PAO, pathologic joint contact mechanics can persist and predict treatment failure at minimum 10 years after surgery. Operative and nonoperative techniques specifically intended to reduce harmful contact mechanics in dysplastic hips may have the potential to further improve clinical outcomes after PAO.

Providing a computationally derived, mechanically optimised target correction during preoperative planning can improve joint contact mechanics of hip dysplasia treated with periacetabular osteotomy.

AIM: Preoperative identification of acetabular corrections that optimally improve joint stability and reduce elevated contact stresses could further reduce osteoarthritis progression in patients with hip dysplasia who are treated with periacetabular osteotomy (PAO). The purpose of this study was to investigate how providing patient-specific, mechanically optimal acetabular reorientations to the surgeon during preoperative planning affected the surgically achieved correction. METHODS: Preoperative CT scans were used to create patient-specific hip models for 6 patients scheduled for PAO. A simulated acetabular fragment was extracted from the preoperative pelvis model and computationally rotated to simulate candidate acetabular reorientations. For each candidate, discrete element analysis was used to compute contact stresses during walking, which were summed over the gait cycle and scaled by patient age to obtain chronic contact stress-time exposure. The ideal patient-specific reorientation was identified using a cost function that balances minimising chronic stress exposures and achieving surgically acceptable acetabular coverage angles. The optimal reorientation angles and associated contact mechanics were provided to the surgeon preoperatively. After PAO was performed, a model of the surgically achieved correction was created from a postoperative CT scan. Radiographic coverage and contact mechanics were compared between preoperative, optimal, and surgically achieved orientations. RESULTS: While surgically achieved reorientations were not significantly different from optimal reorientations in radiographically measured lateral (p = 0.094) or anterior (p = 0.063) coverage, surgically achieved reorientations had significantly (p = 0.031) reduced total contact area compared to optimal reorientations. The difference in lateral coverage and peak chronic exposure between surgically achieved and optimal reorientations decreased with increasing surgeon experience using the models (R² = 0.758, R2 = 0.630, respectively). CONCLUSIONS: Providing hip surgeons with a patient-specific, computationally optimal reorientation during preoperative planning may improve contact mechanics after PAO, which may help reduce osteoarthritis progression in patients with hip dysplasia.

Incidence and risk factors for non-union of the superior ramus osteotomy when hip dysplasia is treated with periacetabular osteotomy.

Periacetabular osteotomy (PAO) is a well-established surgical treatment for hip dysplasia. Few studies report risk factors for the development of superior ramus osteotomy non-union. The purpose of this investigation was to document the incidence and risk factors for this complication. We identified 316 consecutive hips that underwent PAO for symptomatic acetabular dysplasia with a minimum 1-year radiographic follow-up. We developed and validated a technique to measure the superior ramus osteotomy location on anterior-posterior (AP) pelvis radiographs and computed tomography. Logistic regression with generalized estimating equations was used to evaluate the relationships between odds of non-union and potential demographic and radiographic predictor variables in univariate and multivariate analyses. Twenty-nine (9.2%) hips developed superior ramus non-union. Age {median [interquartile range (IQR)] 23 years (18-35) healed versus 35 years (26-40) non-united, P = 0.001}, pre-operative lateral center-edge angle (LCEA) [16° (11-20) healed versus 10° (6-13) non-united, P < 0.001] and the distance from the superior ramus osteotomy to the ilioishial line [15.8 mm (13.2-18.7) healed versus 18.1 mm (16.2-20.5) non-united, P < 0.001] varied significantly between groups. Using multivariate analysis, moderate-to-severe dysplasia [LCEA < 15°, odds ratio (OR) 5.95, standard error (SE) 3.32, 95% confidence interval (CI) 1.99-17.79, P = 0.001], increased age (5-year increase, OR 1.29, SE 3.32, 95% CI 1.105-1.60, P-value = 0.018) and distance from the ilioishial line (3-mm increase, OR 1.67, SE 0.22, 95% CI 1.29-2.18, P < 0.001) were at increased risk of developing non-union. Superior ramus osteotomy non-union is common after PAO. Older age, moderate-to-severe dysplasia, and more medial osteotomy location were independent risk factors for non-union. Consideration should be made in high-risk patients for a more lateral superior ramus osteotomy and adjuvant medical and surgical interventions.

Substantial Loss of Skeletal Muscle Mass Occurs After Femoral Fragility Fracture.

BACKGROUND: Femoral fragility fractures in older adults can result in devastating loss of physical function and independence. Skeletal muscle atrophy likely contributes to disability. The purpose of this study was to characterize the change in skeletal muscle mass, investigate the relationship with malnutrition and physical function, and identify risk factors for skeletal muscle loss. METHODS: Adults ≥65 years of age who were treated with operative fixation of an isolated femoral fragility fracture were enrolled in this multicenter, prospective observational study. Skeletal muscle mass was assessed within 72 hours of admission using multifrequency bioelectrical impedance analysis, which was repeated at 6 weeks, 3 months, and 6 months. Sarcopenia was defined by sex-specific cutoffs for the appendicular skeletal muscle mass index. The Mini Nutritional Assessment was used to measure nutritional status at the time of injury. Physical function was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function domain. Linear mixed models were used to evaluate changes in skeletal muscle mass and PROMIS Physical Function scores over time and to evaluate factors associated with skeletal muscle mass changes. RESULTS: Ninety participants (74% female) with a mean age of 77.6 ± 9.0 years were enrolled. At the time of injury, 30 (33%) were sarcopenic and 44 (49%) were at risk for malnutrition or had malnutrition. Older age was associated with lower skeletal muscle mass (age of ≥75 versus <75 years: least squares mean [and standard error], -3.3 ± 1.6 kg; p = 0.042). From the time of injury to 6 weeks, participants lost an average of 2.4 kg (9%) of skeletal muscle mass (95% confidence interval [CI] = ‒3.0 to ‒1.8 kg; p < 0.001). This early loss did not recover by 6 months (1.8 kg persistent loss compared with baseline [95% CI = ‒2.5 to ‒1.1 kg]; p < 0.001). Participants with normal nutritional status lost more skeletal muscle mass from baseline to 6 weeks after injury compared with those with malnutrition (1.3 kg more loss [standard error, 0.6 kg]; p = 0.036). A 1-kg decrease in skeletal muscle mass was associated with an 8-point decrease in the PROMIS Physical Function (model parameter estimate, 0.12 [standard error, 0.04]; p = 0.002). CONCLUSIONS: We found that older adults with femoral fragility fractures lost substantial skeletal muscle mass and physical function. Participants with adequate baseline nutrition actually lost more muscle mass than those who were malnourished, indicating that future investigations of interventions to prevent muscle loss should focus on older adults regardless of nutritional status. LEVEL OF EVIDENCE: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Food Insecurity Is Common in the Orthopedic Trauma Population at a Rural Academic Trauma Center.

Background: Food insecurity is an increasingly recognized public health issue. Identifying risk factors for food insecurity would support public health initiatives to provide targeted nutrition interventions to high-risk individuals. Food insecurity has not been investigated in the orthopedic trauma population. Methods: From April 27, 2021 to June 23, 2021, we surveyed patients within six months of operative pelvic and/or extremity fracture fixation at a single institution. Food insecurity was assessed using the validated United States Department of Agriculture Household Food Insecurity questionnaire generating a food security score of 0 to 10. Patients with a food security score ≥ 3 were classified as Food Insecure (FI) and patients with a food security score < 3 were classified as Food Secure (FS). Patients also completed surveys for demographic information and food consumption. Differences between FI and FS for continuous and categorical variables were evaluated using the Wilcoxon sum rank test and Fisher's exact test, respectively. Spearman's correlation was used to describe the relationship between food security score and participant characteristics. Logistic regression was used to determine the relationship between patient demographics and odds of FI. Results: We enrolled 158 patients (48% female) with a mean age of 45.5 ± 20.3 years. Twenty-one patients (13.3%) screened positive for food insecurity (High security: n=124, 78.5%; Marginal security: n=13, 8.2%; Low security: n=12, 7.6%; Very Low security: n=9, 5.7%). Those with a household income level of ≤ $15,000 were 5.7 times more likely to be FI (95% CI 1.8-18.1). Widowed/single/divorced patients were 10.2 times more likely to be FI (95% CI 2.3-45.6). Median time to the nearest full-service grocery store was significantly longer for FI patients (t=10 minutes) than for FS patients (t=7 minutes, p=0.0202). Age (r= -0.08, p=0.327) and hours working (r= -0.10, p=0.429) demonstrated weak to no correlation with food security score. Conclusion: Food insecurity is common in the orthopedic trauma population at our rural academic trauma center. Those with lower household income and those living alone are more likely to be FI. Multicenter studies are warranted to evaluate the incidence and risk factors for food insecurity in a more diverse trauma population and to better understand its impact on patient outcomes. Level of Evidence: III.

Radiographically successful periacetabular osteotomy does not achieve optimal contact mechanics in dysplastic hips.

BACKGROUND: Optimal correction of hip dysplasia via periacetabular osteotomy may reduce osteoarthritis development by reducing damaging contact stress. The objective of this study was to computationally determine if patient-specific acetabular corrections that optimize contact mechanics can improve upon contact mechanics resulting from clinically successful, surgically achieved corrections. METHODS: Preoperative and postoperative hip models were retrospectively created from CT scans of 20 dysplasia patients treated with periacetabular osteotomy. A digitally extracted acetabular fragment was computationally rotated in 2-degree increments around anteroposterior and oblique axes to simulate candidate acetabular reorientations. From discrete element analysis of each patient's set of candidate reorientation models, a mechanically optimal reorientation that minimized chronic contact stress exposure and a clinically optimal reorientation that balanced improving mechanics with surgically acceptable acetabular coverage angles was selected. Radiographic coverage, contact area, peak/mean contact stress, and peak/mean chronic exposure were compared between mechanically optimal, clinically optimal, and surgically achieved orientations. FINDINGS: Compared to actual surgical corrections, computationally derived mechanically/clinically optimal reorientations had a median[IQR] 13[4-16]/8[3-12] degrees and 16[6-26]/10[3-16] degrees more lateral and anterior coverage, respectively. Mechanically/clinically optimal reorientations had 212[143-353]/217[111-280] mm2 more contact area and 8.2[5.8-11.1]/6.4[4.5-9.3] MPa lower peak contact stresses than surgical corrections. Chronic metrics demonstrated similar findings (p ≤ 0.003 for all comparisons). INTERPRETATION: Computationally selected orientations achieved a greater mechanical improvement than surgically achieved corrections; however, many predicted corrections would be considered acetabular over-coverage. Identifying patient-specific corrections that balance optimizing mechanics with clinical constraints will be necessary to reduce the risk of osteoarthritis progression after periacetabular osteotomy.

Syndesmosis Malposition Assessed on Weight-Bearing CT Is Common After Operative Fixation of Intra-articular Distal Tibia Plafond Fracture.

OBJECTIVES: To evaluate reliability of measurement techniques for syndesmosis position after operative fixation of distal tibia plafond fracture on weight-bearing computed tomography (WBCT), identify risk factors for syndesmosis malposition, and determine if syndesmosis malposition is associated with higher pain and lower physical function. DESIGN: Prospective cohort study. SETTING: Three Level 1 trauma centers. PARTICIPANTS: Twenty-six subjects who underwent open reduction and internal fixation of distal tibia plafond fractures with bilateral ankle WBCT 1 year or greater after injury were included in the study. INTERVENTION: Operative fixation of distal tibia plafond fracture. MAIN OUTCOME MEASUREMENT: Fibula position in the tibia incisura, injury characteristics, and patient-reported outcomes were the main outcome measurements. RESULTS: Interrater reliability for syndesmosis position measurements were excellent for the Phisitkul technique on both injured and healthy ankles (intraclass correlation coefficients [ICCs]: 0.93-0.98). The Nault technique demonstrated moderate-to-excellent interrater reliability (ICCs: 0.67-0.98), apart from the angle of rotation measurement (ICCs: 0.18-0.67). Sixteen of 26 subjects (62%) had syndesmosis malposition defined as >2 mm difference comparing the tibial-fibular relationship in injured and uninjured ankles using these 2 methods. Patients with syndesmosis malposition reported lower Foot and Ankle Ability Measure: Activities of Daily Living scores; other recorded patient-reported outcomes were not significantly different. CONCLUSIONS: Measurement techniques for syndesmosis position on WBCT were reliable after operative fixation of distal tibia plafond fracture. Syndesmosis malposition is common after these injuries and predicted impaired physical function. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Malnutrition is Common and Increases the Risk of Adverse Medical Events in Older Adults With Femoral Fragility Fractures.

Background: Femoral fragility fractures are one of the most common injuries managed by orthopedic surgeons. Malnutrition influences the poor outcomes observed in this population. Our purpose was to assess the annual trends of malnutrition diagnosis and determine risk factors for malnutrition and complications in patients 65 years and older presenting with femoral fragility fractures. We hypothesized that malnutrition would increase the risk of postoperative wound infection, wound dehiscence, non-union, and mortality. Methods: The PearlDiver database was reviewed from 2010 to 2020. Patients ≥ 65-years-old with femur fractures treated with operative fixation were identified by CPT code. A preoperative diagnosis of malnourished state was defined by ICD-9 and ICD-10 codes and patients were divided into malnourished and non-malnourished cohorts. Patients were tracked for one year following operative fixation of a femoral fragility fracture for the occurrence of infection, wound dehiscence, nonunion and mortality. The rates of these complications were compared between malnourished and nonmalnourished cohorts. Results: There were 178,283 total femoral fragility fractures identified in patients aged 65-years or older. The overall prevalence of malnutrition diagnosis in this geriatric population was 12.8%. Documented malnutrition in femoral fragility fractures increased from 1.6% to 32.9% from 2010-2020 (P<0.0001). Compared to patients without malnutrition, patients with malnutrition are at increased risk of mortality (OR 1.31, 95% CI 1.2558 - 1.3752, p < 0.0001), are more likely to develop a wound infection (OR 1.49; 95% CI 1.252 - 1.7626; p < 0.0001), more likely to have a wound dehiscence (OR 1.55; 95% CI 1.3416 - 1.7949; p < 0.0001), and more likely to develop non-union (1.89; 95% CI 1.6946 - 2.1095; p < 0.0001). Multiple demographic variables were associated with malnutrition diagnosis including higher age, higher Charlson Comorbidity Index, female sex, dementia, and institutionalization. Parkinson's disease, feeding difficulty and institutionalization demographic variables had the highest risk of malnutrition. Conclusion: The current study found that malnutrition diagnosis significantly increases the risk of adverse medical events in elderly adults with femoral fragility fractures. The rates of malnutrition increased steadily from 2010-2020. This trend is likely a result of increased awareness and testing for malnutrition, not reflecting an actual increased prevalence of malnutrition. Multiple expected demographic variables are associated with diagnosis of malnutrition. Level of Evidence: III.

Reliability of Multifrequency Bioelectrical Impedance Analysis to Quantify Body Composition in Patients After Musculoskeletal Trauma.

Background: Changes in body composition, especially loss of lean mass, commonly occur in the orthopedic trauma population due to physical inactivity and inadequate nutrition. The purpose of this study was to assess inter-rater and intra-rater reliability of a portable bioelectrical impedance analysis (BIA) device to measure body composition in an orthopedic trauma population after operative fracture fixation. BIA uses a weak electric current to measure impedance (resistance) in the body and uses this to calculate the components of body composition using extensively studied formulas. Methods: Twenty subjects were enrolled, up to 72 hours after operative fixation of musculoskeletal injuries and underwent body composition measurements by two independent raters. One measurement was obtained by each rater at the time of enrollment and again between 1-4 hours after the initial measurement. Reliability was assessed using intraclass correlation coefficients (ICC) and minimum detectable change (MDC) values were calculated from these results. Results: Inter-rater reliability was excellent with ICC values for body fat mass (BFM), lean body mass (LBM), skeletal muscle mass (SMM), dry lean mass (DLM), and percent body fat (PBF) of 0.993, 0.984, 0.984, 0.979, and 0.986 respectively. Intra-rater reliability was also high for BFM, LBM, SMM, DLM, and PBF, at 0.994, 0.989, 0.990, 0.983, 0.987 (rater 1) and 0.994, 0.988, 0.989, 0.985, 0.989 (rater 2). MDC values were calculated to be 4.05 kg for BFM, 4.10 kg for LBM, 2.45 kg for SMM, 1.21 kg for DLM, and 4.83% for PBF. Conclusion: Portable BIA devices are a versatile and attractive option that can reliably be used to assess body composition and changes in lean body mass in the orthopedic trauma population for both research and clinical endeavors. Level of Evidence: III.

Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting After Fracture Fixation: A Randomized Controlled Trial.

BACKGROUND: Postoperative complications and substantial loss of physical function are common after musculoskeletal trauma. We conducted a prospective randomized controlled trial to assess the impact of conditionally essential amino acid (CEAA) supplementation on complications and skeletal muscle mass in adults after operative fixation of acute fractures. METHODS: Adults who sustained pelvic and extremity fractures that were indicated for operative fixation at a level-I trauma center were enrolled. The subjects were stratified based on injury characteristics (open fractures and/or polytrauma, fragility fractures, isolated injuries) and randomized to standard nutrition (control group) or oral CEAA supplementation twice daily for 2 weeks. Body composition (fat-free mass [FFM]) was measured at baseline and at 6 and 12 weeks postoperatively. Complications were prospectively collected. An intention-to-treat analysis was performed. The relative risk (RR) of complications for the control group relative to the CEAA group was determined, and linear mixed-effects models were used to model the relationship between CEAA supplementation and changes in FFM. RESULTS: Four hundred subjects (control group: 200; CEAA group: 200) were enrolled. The CEAA group had significantly lower overall complications than the control group (30.5% vs. 43.8%; adjusted RR = 0.71; 95% confidence interval [CI] = 0.55 to 0.92; p = 0.008). The FFM decreased significantly at 6 weeks in the control subjects (-0.9 kg, p = 0.0205), whereas the FFM was maintained at 6 weeks in the CEAA subjects (-0.33 kg, p = 0.3606). This difference in FFM was not seen at subsequent time points. CONCLUSIONS: Our results indicate that CEAA supplementation has a protective effect against common complications and early skeletal muscle wasting after operative fixation of extremity and pelvic fractures. Given the potential benefits of this inexpensive, low-risk intervention, multicenter prospective studies in focused trauma populations are warranted. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Composite Failure of Hip Dysplasia Treated With Periacetabular Osteotomy: A Minimum 10-Year Follow-up.

INTRODUCTION: Periacetabular osteotomy (PAO) is a common surgical treatment of prearthritic hip dysplasia in young adults, but there are few long-term studies of clinical outcomes. The purpose of this investigation was to report a minimum 10-year clinical follow-up of hip dysplasia treated with PAO and identify risk factors for composite failure. METHODS: We identified 151 patients (198 hips) who underwent PAO to treat hip dysplasia at a single institution. Enrolled subjects completed a series of six patient-reported outcome instruments and provided information about subsequent surgeries. We defined composite failure as conversion to total hip arthroplasty or modified Harris Hip Score ≤70. Logistic regression with generalized estimating equations was used to evaluate the relationships between odds of failure and potential predictor variables in univariate and multivariate analyses. RESULTS: A total of 124 subjects (167 hips) with a minimum 10-year follow-up were enrolled. The median time from PAO to the final follow-up was 13 years (range 10-18 years). There were 71 hips that met criteria for failure: 32 with total hip arthroplasty and 39 with modified Harris Hip Score ≤70. Univariate logistic regression analyses revealed multiple preoperative factors that predicted composite failure: increased age and body mass index, osteoarthritis (OA), and more severe acetabular dysplasia. Postoperative factors that predicted failure included lateral undercoverage and formation of heterotopic ossification (HO). The final multivariate model identified body mass index ≥30 kg/m2 (odds ratio [OR], 3.84 [95% confidence interval (CI), 1.68-8.78], P = 0.001), higher preoperative Tönnis grade OA (OR, 2.65 [95% CI, 1.50-4.66], P < 0.001), and HO formation (OR, 16.52 [95% CI, 2.08-135.96], P = 0.009) as independent predictors of failure. CONCLUSIONS: This study corroborates current hip dysplasia literature, identifying increasing age and presence of preoperative OA as risk factors for composite failure in univariate analyses. In addition, we found that obesity and HO formation were independent predictors of persistent hip dysfunction. LEVEL OF EVIDENCE: Therapeutic Level IV.

Emergency department telemedicine consults decrease time to interpret computed tomography of the head in a multi-network cohort.

INTRODUCTION: Telemedicine can improve access to emergency stroke care in rural areas, but the benefit of telemedicine across different types and models of telemedicine networks is unknown. The objectives of this study were to (a) identify the impact of telemedicine on emergency department (ED) stroke care, (b) identify if telemedicine impact varied by network and (c) describe the variation in process outcomes by telemedicine across EDs. METHODS: A prospective cohort study identified stroke patients in four telemedicine networks between November 2015 and December 2017. Primary exposure was telemedicine consultation during ED evaluation. Outcomes included: (a) interpretation of computed tomography (CT) of the head within 45 minutes and (b) time to administer tissue plasminogen activator (tPA). An interaction term tested for differences in telemedicine effect on stroke care by network and hospital. RESULTS: Of the 932 stroke subjects, 36% received telemedicine consults. For subjects with a last known well time within two hours of ED arrival (27.9%), recommended CT interpretation within 45 minutes was met for 66.8%. Telemedicine was associated with higher odds of timely head CT interpretation (adjusted odds ratio = 3.03; 95% confidence interval (CI) 1.69-5.46). The magnitude of the association between telemedicine and time to interpret a CT of the head differed between telemedicine networks (interaction term p = 0.033). Among eligible patients, telemedicine was associated with faster time to administer tPA (adjusted hazard ratio = 1.81; 95% CI 1.31-2.50). DISCUSSION: Telemedicine consultation during the ED encounter decreased the time to interpret at CT of the head among stroke patients, with differing magnitudes of benefit across telemedicine networks. The effect of heterogeneity of telestroke affects across different networks should be explored in future analyses.

Emergency Department Telemedicine Consults are Associated with Faster Time-to-Electrocardiogram and Time-to-Fibrinolysis for Myocardial Infarction Patients.

Introduction: Acute myocardial infarction (AMI) is a time-sensitive condition. Meeting guideline-recommended time metrics for these patients can be challenging in rural emergency departments (EDs). Telemedicine has been shown to improve the quality and timeliness of emergency care in rural areas. The objective of this study was to evaluate the impact of telemedicine on the timeliness of emergency AMI care for patients presenting to rural EDs with chest pain. Methods: A prospective cohort study, conducted in six telemedicine networks, identified ED patients presenting with chest pain from November 2015 through December 2017. Primary exposure was telemedicine consultation during the ED visit. The primary outcome was time-to-electrocardiogram (ECG). For eligible AMI patients, secondary outcomes included: (1) fibrinolysis administered and (2) time-to-fibrinolysis. Analyses for multivariable models were conducted by using logistic regression, clustered at the hospital level. Results: Overall, 1,220 patients presenting with chest pain were included in the study cohort (27.1% received telemedicine). Time-to-ECG was, on average, 0.39 times (95% confidence interval [CI] -0.26 to -0.52) faster for telemedicine cases. Among eligible patients, telemedicine was associated with higher odds of fibrinolysis administration (adjusted odds ratio 7.17, 95% CI 2.48-20.49). In a sensitivity analysis excluding patients with cardiac arrest, time-to-fibrinolysis administration did not differ when telemedicine was used. Discussion: In telemedicine networks, telemedicine consultation during the ED visit was associated with improved timeliness of ECG evaluation and increased use of fibrinolytic reperfusion therapy for rural AMI patients. Future work should focus on the impact of telemedicine consultation on patient-centered outcomes.