Fractures in Patients With Diabetes Mellitus: Findings From a 20-year Registry at a Single Level 1 Trauma Center.

INTRODUCTION: Diabetes mellitus (DM) is a risk factor of infection. Although DM has been associated with worse functional outcomes after acetabular fracture, literature regarding the effect of DM on surgical site infection and other early complications is lacking. METHODS: A 20-year registry from a level 1 trauma center was queried to identify 134 patients with DM and 345 nondiabetic patients with acetabular fractures. RESULTS: The diabetic patient population was older (57.2 versus 43.2; P < 0.001) and had higher average body mass index (33.6 versus 29.5; P < 0.001). Eighty-three patients with DM and 270 nondiabetics were treated surgically (62% versus 78%; P < 0.001). Diabetic patients who were younger (54.6 versus 61.4; P = 0.01) with fewer comorbidities (1.7 versus 2.2; P = 0.04) were more frequently managed surgically. On univariate analysis, patients with DM more commonly developed any early infection (28.4% versus 21%; P = 0.049) but were no more likely to develop surgical site infection, or other postoperative complications. Older patient age, length of stay, baseline pulmonary disease, and concurrent abdominal injury were independent predictors of postoperative infection other than surgical site infection. Diabetics that developed infection had more comorbidities (2.4 versus 1.5; P < 0.001) and higher Injury Severity Score (24.1 versus 15.8; P = 0.003), and were more frequently insulin-dependent (72.7% versus 41%; P = 0.01). DISCUSSION: Independent of management strategy, diabetic patients were more likely to develop an infection after acetabular fracture. Insulin dependence was associated with postoperative infection on univariate analysis. Optimal selection of surgical candidates among patients with DM may limit postoperative infections.

What Are the Differences in Hospital Cost Associated With the Use of Cemented Versus Cementless Femoral Stems in Hemiarthroplasty and Total Hip Arthroplasty for the Treatment of Femoral Neck Fracture?

BACKGROUND: The purpose of this study was to determine if there is a difference in hospital costs associated with the use of cemented versus cementless femoral stems in hemiarthroplasty (HA) and total hip arthroplasty (THA) for the treatment of femoral neck fracture (FNF). METHODS: This retrospective cohort study utilizes the 2019 Medicare Provider Analysis and Review Limited Data Set. Patients undergoing arthroplasty for the treatment of FNF were identified. Patients were grouped by cemented or cementless femoral stem fixation. There were 16,148 patients who underwent arthroplasty for FNF available: 4,913 THAs (3,705 patients who had cementless femoral stems and 1,208 patients who had cemented femoral stems) and 11,235 HAs (6,099 patients who had cementless femoral stems and 5,136 who had cemented femoral stems). Index hospital costs were estimated by multiplying total charges by cost-to-charge ratios. Costs were analyzed using univariable and multivariable generalized linear models. RESULTS: Cemented femoral stem THA generated 1.080 times (95% confidence interval, 1.06 to 1.10; P < .001), or 8.0%, greater index hospital costs than cementless femoral stem THA, and cemented femoral stem HA generated 1.042 times (95% confidence interval, 1.03 to 1.05; P < .001), or 4.2%, greater index hospital costs than cementless femoral stem HA. CONCLUSIONS: Cemented femoral stems for FNF treated with either THA or HA are associated with only a small portion of increased cost compared to cementless femoral stems. Providers may choose the method of arthroplasty stem fixation for the treatment of FNF based on what they deem most appropriate for the specific patient.

Recovery Services for Interpersonal Violence Victims on Healthcare Use at a Trauma Center.

INTRODUCTION: Treatment of interpersonal violence (IPV) patients is often complicated by social and mental health comorbidities. New American College of Surgeons (ACS) requirements include provision of psychosocial support services for recovery after injury. We aim to describe utilization and patient outcomes after provision of Trauma Recovery Services (TRS) at our institution for the IPV population. These services include assistance with food, housing, criminal justice, and advocacy. METHODS: IPV patients were identified between September 6, 2018 and December 20, 2020. Demographic information was collected. TRS utilization and specific services rendered were identified. Primary outcome measures included initial length of stay (LOS), number of subsequent emergency department (ED) visits, and outpatient visits within 1 y after the initial injury. Statistical analyses included t-tests, Chi-squared tests, and multivariate regression analyses. RESULTS: A total of 502 patients were included in the final cohort, and 394 patients (78.5%) accepted the utilization of TRS services after initial interaction. Patients were on average 33.4 y old, and 59.4% were females. Patients who were older (P < 0.001) and homeless (P = 0.004) were more likely to use TRS, while victims of sexual assault (P < 0.001) and single patients (P = 0.041) were less likely. Patients who utilized TRS had longer initial LOS (P < 0.001), more ED visits (P < 0.001), and more outpatient visits (P = 0.01) related to the initial complaint, independent of potential confounders on multivariate linear regression. Food and housing service utilization associated with LOS (P = 0.01), ED visits (P < 0.001), and outpatient visits (P < 0.001). Additionally, transportation services were associated with longer LOS (P = 0.01) while patient advocacy services were associated with more ED visits (P = 0.03). CONCLUSIONS: TRS was extensively utilized by IPV patients, and associated with more follow-up appointments, ED visits, and longer LOS. Emphasis on injury mechanisms, baseline demographics, and social features may further characterize patients in need who tend toward utilization.

Radiographic parameters associated with fracture-related infection in high energy bicondylar tibial plateau fractures managed with two-stage treatment: Identifying the bad actors.

INTRODUCTION: High energy tibial plateau fractures are fraught with complications, particularly fracture-related infection (FRI). Previous studies have evaluated patient demographics, fracture classification, and injury characteristics as risk factors for FRI in patients with these injuries. This study evaluated the relationship between radiographic parameters (fracture length relative to femoral condyle width (FLF ratio), initial femoral displacement (FD ratio), and tibial widening (TW ratio)) and fracture-related infection following internal fixation in high energy bicondylar tibial plateau fractures. METHODS: 225 patients treated for bicondylar tibial plateau fractures at two level I trauma centers were retrospectively reviewed. Patient characteristics, fracture classification, and radiographic measurements were analyzed to determine association with FRI. RESULTS: The rate of FRI was 13.8%. Increased fracture length, FLF ratio, FD ratio, TW ratio, and fibula fracture were each associated with FRI on regression analysis, independent of clinical variables. Cutoff values were identified for each parameter and patients were risk stratified based on these radiographic parameters. High-risk patients had a 2.68- and 12.36-times risk of FRI compared to medium and low-risk patients, respectively. DISCUSSION: This study is the first to examine the relationship between radiographic parameters and FRI in high energy bicondylar tibial plateau fractures. Fracture length, FLF ratio, FD ratio, TW ratio, and fibula fracture were identified as radiographic parameters associated with FRI. More importantly, risk stratifying patients based on these parameters accurately identified patients at increased risk of FRI. Not all bicondylar tibial plateau fractures are created equal and radiographic parameters can be utilized to help identify the bad actors.

Perioperative allogenic blood transfusions are associated with increased fracture related infection rates, but not nonunion in operatively treated distal femur fractures.

INTRODUCTION: Distal femur fractures are common injuries that remain difficult for orthopedic surgeons to treat. High complication rates, including nonunion rates as high as 24% and infection rates of 8%, can lead to increased morbidity for these patients. Allogenic blood transfusions have previously been identified as risk factors for infection in total joint arthroplasty and spinal fusion surgeries. No studies have explored the relationship between blood transfusions and fracture related infection (FRI) or nonunion in distal femur fractures. METHODS: 418 patients with operatively treated distal femur fractures at two level I trauma centers were retrospectively reviewed. Patient demographics were collected including age, gender, BMI, medical comorbidities, and smoking. Injury and treatment information was also collected including open fracture, polytrauma status, implant, perioperative transfusions, FRI, and nonunion. Patients with less than three months of follow up were excluded. RESULTS: 366 patients were included in final analysis. One hundred thirty-nine (38%) patients received a perioperative blood transfusion. Forty-seven (13%) nonunions and 30 (8%) FRI were identified. Allogenic blood transfusion was not associated with nonunion (13% vs 12%, P = 0.87), but was associated with FRI (15% vs 4%, P<0.001). Binary logistic regression analysis identified a dose dependent relationship between number of perioperative blood transfusions and FRI: total transfusion ≥2 U PRBC RR= 3.47(1.29, 8.10, P = 0.02), ≥3 RR= 6.99 (3.01, 12.40, P<0.001), and ≥4 RR= 8.94 (4.03, 14.42, P<0.001). DISCUSSION: In patients undergoing operative treatment of distal femur fractures, perioperative blood transfusions are associated with increased risk of fracture related infection, but not the development of a nonunion. This risk association increases in a dose-dependent relationship with increasing total blood transfusions received.

Emphysematous Osteomyelitis of the Pubis Associated With Necrotizing Soft Tissue Infection of the Thigh.

Emphysematous osteomyelitis (EO) is a rare condition identified through the presence of intraosseous gas. It is frequently fatal even with prompt recognition and management. We report a case of EO presenting with a necrotizing soft tissue infection of the thigh in the setting of prior pelvic radiation. The purpose of this study was to highlight the unusual association between EO and necrotizing soft tissue infection.

Patients who have undergone total shoulder arthroplasty prefer greater surgeon involvement in shared decision making.

BACKGROUND: There has been a shift in medical decision making from a paternalist model to a shared decision-making (SDM) approach, described as a patient-physician relationship where both parties collaborate to arrive on an evidence-based treatment regimen that best suits the patient's needs and values. However, there is a scarcity in evidence regarding SDM in shoulder arthroplasty. The purpose of this study was to evaluate overall patient preference for SDM and determine demographic and socioeconomic factors related to SDM preference in those undergoing shoulder arthroplasty. METHODS: Patients aged 40-89 years who had undergone a total shoulder arthroplasty were enrolled. Two-part questionnaires were administered collecting patient demographic information and SDM subscale scores postoperatively. Bivariate and multivariate regression models were used to determine factors associated with SDM Total and subscale scores. RESULTS: A total of 125 patients (53 male; mean age, 69.5 ± 10.4 years) who had undergone primary total shoulder arthroplasty were included. The mean Total SDM score was -2.24 ± 1.9 and the Preoperative, Operative, and Postoperative SDM subscale scores were -1.54 ± 2.0, -2.59 ± 2.2, and -2.48 ± 2.1, respectively, indicating a preference for SDM in the Preoperative subscale and surgeon-driven decision making in the total score and other 2 subscales. Multivariate regression models demonstrated a preference for surgeon decision making at both the 4-12-week postoperative period for the Preoperative subscale (odds ratio [OR] -1.03, 95% CI -2.0, -0.1, P = .039) and the 2-4-week postoperative period for the Operative subscale (OR -1.74, 95% CI -3.4, -0.1, P = .038) when compared to patients at the 2-week postoperative period. No other variables were significantly associated with any of the SDM subscale scores or Total SDM score. CONCLUSION: Patients reported a more passive role in the decision-making process with an overall preference for a surgeon-led approach in primary total shoulder arthroplasty. Patients preferred a shared decision-making approach in regard to preoperative considerations but indicated a significant preference for surgeon-led decision making regarding day of surgery decisions. There were no correlations between SDM scores and age, sex, race, income, education level, insurance type, or treating surgeon. Overall, patients demonstrated a predilection for an SDM approach for preoperative considerations, contrary to those decisions associated with the day of surgery and postoperative care.

High-volume Arthroplasty Centers Are Associated With Lower Hospital Costs When Performing Primary THA and TKA: A Database Study of 288,909 Medicare Claims for Procedures Performed in 2019.

BACKGROUND: With bundled payments and alternative reimbursement models expanding in scope and scale, reimbursements to hospitals are declining in value. As a result, cost reduction at the hospital level is paramount for the sustainability of profitable inpatient arthroplasty practices. Although multiple prior studies have investigated cost variation in arthroplasty surgery, it is unknown whether contemporary inpatient arthroplasty practices benefit from economies of scale after accounting for hospital characteristics and patient selection factors. Quantifying the independent effects of volume-based cost variation may be important for guiding future value-based health reform. QUESTIONS/PURPOSES: We performed this study to (1) determine whether the cost incurred by hospitals for performing primary inpatient THA and TKA is independently associated with hospital volume and (2) establish whether length of stay and discharge to home are associated with hospital volume. METHODS: The primary data source for this study was the Medicare Provider Analysis and Review Limited Data Set, which includes claims data for 100% of inpatient Medicare hospitalizations. We included patients undergoing primary elective inpatient THA and TKA in 2019. Exclusion criteria included non-Inpatient Prospective Payment System hospitalizations, nonelective admissions, bilateral procedures, and patients with cancer of the pelvis or lower extremities. A total of 500,658 arthroplasties were performed across 2762 hospitals for 492,262 Medicare beneficiaries during the study period; 59% (288,909 of 492,262) of procedures were analyzed after the exclusion criteria were applied. Most exclusions (37% [182,733 of 492,262]) were because of non-Inpatient Prospective Payment System hospitalizations. Among the study group, 87% (251,996 of 288,909) of procedures were in patients who were 65 to 84 years old, 88% (255,415 of 288,909) were performed in patients who were White, and 63% (180,688 of 288,909) were in patients who were women. Elixhauser comorbidities and van Walraven indices were calculated as measures of patient health status. Hospital costs were estimated by multiplying cost-to-charge ratios obtained from the 2019 Impact File by total hospital charges. This methodology enabled us to use the large Medicare Provider Analysis and Review database, which helped decrease the influence of random cost variation through the law of large numbers. Hospital volumes were calculated by stratifying claims by national provider identification number and counting the number of claims per national provider identification number. The data were then grouped into bins of increasing hospital volume to more easily compare larger-volume and smaller-volume centers. The relationship between hospital costs and volume was analyzed using univariable and multivariable generalized linear models. Results are reported as exponential coefficients, which can be interpreted as relative differences in cost. The impact of surgical volume on length of stay and discharge to home was assessed using binary logistic regression, considering the nested structure of the data, and results are reported as odds ratios (OR). RESULTS: Hospital cost and mean length of stay decreased, while rates of discharge to home increased with increasing hospital volume. After controlling for potential confounding variables such as patient demographics, health status, and geographic location, we found that inpatient arthroplasty costs at hospitals with 10 or fewer, 11 to 100, and 101 to 200 procedures annually were 1.32 (95% confidence interval [CI] 1.30 to 1.34; p < 0.001), 1.17 (95% CI 1.17 to 1.17; p < 0.001), and 1.10 (95% CI 1.10 to 1.10; p < 0.001) times greater than those of hospitals with 201 or more inpatient procedures annually. In addition, patients treated at smaller-volume hospitals had increased odds of experiencing a length of stay longer than 2 days (OR 1.25 to 3.44 [95% CI 1.10 to 4.03]; p < 0.001) and decreased odds of being discharged to home (OR 0.34 to 0.78 [95% CI 0.29 to 0.86]; p < 0.001). CONCLUSION: Higher-volume hospitals incur lower costs, shorter lengths of stay, and higher rates of discharge to home than lower-volume hospitals when performing inpatient THA and TKA. These findings suggest that small and medium-sized regional hospitals are disproportionately impacted by declining reimbursement and may necessitate special treatment to remain viable as bundled payment models continue to erode hospital payments. Further research is also warranted to identify the key drivers of this volume-based cost variation, which may facilitate quality improvement initiatives at the hospital and policy levels.

External fixator pin placement during initial management of tibial plateau fractures: are there parameters to minimize pin-plate overlap?

PURPOSE: External fixator pin site overlap with definitive fixation implants (pin-plate overlap) has been identified as a risk factor for surgical site infection in tibial plateau fractures. Despite this, pin-plate overlap occurs in 24-38% of patients. This study sought to identify radiographic characteristics associated with pin-plate overlap to help minimize occurrences. METHODS: 283 patients at two Level I trauma centers were retrospectively reviewed. Radiographic measurements were recorded including fracture length, distance from fracture to proximal tibial pin site, and pin site distance-to-fracture (PSF) ratio. RESULTS: 70 (24.7%) cases of pin-plate overlap were identified. Pin-plate overlap was associated with increased fracture length (81.5 ± 32.1 mm vs 56.9 ± 26.1 mm, p < 0.001) and decreased distance from fracture to proximal tibial pin site (84.5 ± 37.1 mm vs 126.9 ± 35.8 mm). Pins placed greater than 100 mm and 150 mm from the fracture eliminated 36/70 (51%) and 67/70 (96%) pin-plate overlaps, respectively. Pins placed with a PSF ratio greater than 1.5 and 2.0 eliminated 47/70 (67%), and 57/70 (81%) of pin-plate overlaps, respectively. CONCLUSIONS: Longer fractures, pins closer to the fracture, and decreased PSF ratio were associated with overlap. Placing proximal tibial pins more than 100 mm from the fracture eliminated most pin-plate overlaps.

Do Patients With Chronic Diabetes Have Worse Motor Outcomes After Cervical ASIA C Traumatic Spinal Cord Injury?

STUDY DESIGN: This was a level IV retrospective prognostic study. OBJECTIVE: The objective of this study was to determine if patients with chronic diabetes have worse functional outcomes and motor recovery after cervical traumatic spinal cord injury (TSCI). SUMMARY OF BACKGROUND DATA: Diabetes mellitus has multiple deleterious neurological effects and has been shown to worsen elective cervical spine surgery outcomes. Prior literature has scarcely characterized the impact of chronic diabetes on motor and functional outcomes after TSCI. METHODS: The National Spinal Cord Injury Statistical Center (NSCISC) database was utilized to retrospectively collect data on cervical American Spinal Injury Association (ASIA) C TSCI between 2011 and 2016. Patients were divided into diabetes and nondiabetes groups. Primary outcomes included wheelchair requirement and ambulatory status 1 year after injury. Secondary outcomes were motor score collected at the time of rehab admission, rehab discharge, and 1-year follow-up. All outcome variables were analyzed using univariate and multivariate regression to assess for differences between diabetes and nondiabetes groups and possible confounders. RESULTS: A total of 219 patients met the inclusion criteria for the study: 193 without diabetes and 26 with diabetes (12.0%). After controlling for confounders, patients with diabetes had had significantly increased wheelchair requirement (83.3% vs. 51.8%, relative risk=1.63, 95% confidence interval: 1.20-1.83, P =0.009 multivariate) and decreased ambulatory rates (50% vs. 67.9%, relative risk=0.55, 95% confidence interval: 0.25-0.98, P =0.042 multivariate) at 1 year. They also had no difference in average total motor scores at rehab admission but significantly worse total motor scores at rehab discharge (50.6±23.3 vs. 60.3±21.4, P =0.033 univariate, P =0.002 multivariate). CONCLUSIONS: Patients with diabetes have increased wheelchair requirement and decreased ambulatory ability at 1 year after the injury as well as diminished recovery in motor scores after motor-incomplete cervical TSCI. These patients may be targets for aggressive diabetic screening and intervention to minimize negative outcomes.

Depression Is Transiently Increased in Patients Undergoing Two-Stage Revision Arthroplasty.

BACKGROUND: The implications of two-stage revision on mental health are poorly understood. The purpose of this study is to determine (1) whether patients undergoing two-stage revision total hip and knee arthroplasty for prosthetic joint infection were more likely to get Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scores consistent with major depressive disorder (MDD) than those undergoing aseptic revision and (2) whether these symptoms resolved after the procedure. METHODS: Records of all 366 patients that underwent revision total hip or knee arthroplasty from January 1, 2015, - June 20, 2019, were reviewed. Forty-two patients were excluded for missing PROMIS Depression scores or incomplete treatment. Preoperative (<3 months), early postoperative (2-8 weeks), and final postoperative (6-18 months) Depression scores were collected. Patients crossing the PROMIS Depression threshold equivalent to a Patient Health Questionnaire-9 score ≥10, indicative of MDD, were evaluated. RESULTS: More two-stage revision patients developed Depression scores indicative of MDD perioperatively than the aseptic cohort (20.0% vs 6.5%, P = .01). Two-stage revision patients had higher (worse) median Depression scores preoperatively (54.8 vs 51.3, P = .04) and at early follow-up (54.3 vs 49.9, P = .01), but not at final follow-up (50.4 vs 49.1, P = .39). Across all patients, Depression scores improved by 2.4 points at early follow-up (95% confidence interval:1.1-3.7; P < .001) and 3 points at final follow-up (95% confidence interval:1.5-4.5; P < .001; minimal clinically important difference 3.0). CONCLUSIONS: Twenty percent of two-stage revision arthroplasty patients, compared to <7% of aseptic revision patients, developed PROMIS Depression scores consistent with MDD during treatment. At final follow-up, a clinically significant improvement in Depression scores from baseline was evident in both cohorts.

Is pin-plate overlap in tibial plateau fractures associated with increased infection rates?

INTRODUCTION: Despite advances in the treatment of high energy proximal tibia fractures, including the utilization of staged management with external fixation, the infection rate remains high. Overlap between external fixator pin sites and definitive internal fixation has been proposed as a risk factor for infection. METHODS: This retrospective study reviews 244 patients with staged knee-spanning external fixation followed by delayed definitive internal fixation at two separate level one trauma centers. Presence of pin-plate overlap as well as several other known risk factors for infection were recorded and measured to include open fractures, compartment syndrome, operative time and number of incisions. Development of deep infection was the primary outcome. Both univariate and multivariate statistics were applied to determine differences in rates of infection. RESULTS: 65 (26.6%) patients had presence of pin-plate overlap while 179 (73.4%) patients had no overlap. There were no differences between overlapping and non-overlapping groups with respect to other infectious risk factors. Deep infection occurred in 34 (13.9%) total patients, 18 (27.7%) were in patients with pin-plate overlap and 16 (8.9%) in those without overlap. (P = 0.003; RR 3.01, 95% CI 1.51-4.76). DISCUSSION: This large, multicenter study demonstrated a statistically significant association between pin-plate overlap and the development of deep infection in tibial plateau fractures. On multivariate analysis, pin-plate overlap was identified as an independent risk factor for infection. When treating these complex injuries, surgeons should consider the definitive fixation construct when placing external fixation pins.

Concussion-Reporting Behavior in Rugby: A National Survey of Rugby Union Players in the United States.

BACKGROUND: Rugby is the fastest growing team sport in the United States for male and female athletes. It is a contact/collision sport with an injury risk profile that includes concussions. PURPOSE: To examine the prevalence of concussions in male and female rugby players in the United States and to characterize behaviors around reporting concussions that could be a target for prevention and treatment efforts. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: An online survey distributed to active members on the USA Rugby membership list was used to examine self-reported concussions in male and female athletes. Concussion-reporting behaviors and return to play after a concussion were also explored. Statistical analysis was used to compare male with female athletes and report differences, with years of experience as a dependent variable. RESULTS: The proportion of athletes with a history of at least 1 concussion was 61.9% in all respondents. Of those who reported a concussion, 50.8% reported the concussion during the game or practice in which it occurred, and 57.6% reported at least 1 concussion to a qualified medical provider. Overall, 27.7% of participants who reported ≥1 rugby-related concussion in our survey noted that at least 1 of these concussions was not formally reported. The most commonly cited reasons for not reporting a concussion included not thinking that it was a serious injury, not knowing that it was a concussion at the time, and not wanting to be pulled out of the game or practice. Additionally, 61.0% of athletes did not engage in recommended return-to-play protocols after their most recent rugby-related concussion. CONCLUSION: US rugby union athletes may not report concussions to medical personnel or follow return-to-play protocols guided by medical advice. This could result from a lack of education on concussion recognition and the risks associated with continued play after a concussion as well as limited access to health care. Further education efforts focusing on the identification of concussions, removal from play, and return-to-play protocols are necessary in the US rugby union population.

Design of a dual slot antenna for small animal microwave ablation studies.

This study presents the development of a dual-slot antenna for small animal tumor ablation. By using a dual-slot design at 8 GHz, it was hypothesized that smaller and more spherical ablations can be produced. After computer-aided design optimization, antennas were fabricated and ablations performed at 5-20 W for 15-120 s with the objective of creating ablations with a diameter/length aspect ratio of at least 0.9. The new dual-slot design at 8 GHz created significantly more spherical ablations than a commercial antenna at 2.45 GHz in ex vivo liver tissue (Average Aspect Ratio 0.8081 vs. 0.4532, p <;<; 0.05). In vivo studies confirmed the highly spherical results ex vivo. Initial testing shows that the dual-slot antenna and 8 GHz generator can be used to ablate tumors in mice.