Evaluation of a tiered operating room strategy at an academic centre: comparing high-efficiency and conventional operating rooms.

BACKGROUND: Wait times for many elective orthopedic surgical procedures in Ontario have become unacceptably long and substantially exceed the recommended guidelines. As a consequence, many patients experience chronic pain, disability and other poor health outcomes. The purpose of this study was to test a novel, resource-saving redesign of outpatient operating room (OR) services, based on tiered grouping of surgical cases, to maximize health benefits for patients while improving efficiency and decreasing wait times. METHODS: This prospective cohort study enrolled adult patients scheduled to undergo unilateral lower limb procedures that had a low requirement for surgical resources and did not require admission to the hospital (ambulatory surgical services) at an academic hospital. Patients were randomly assigned to a conventional OR group or a high-efficiency (tiered) OR group, in which the intensity of surgical, anesthesia and nursing resources was matched to the procedure and the patient's health status. The tiered OR made use of local anesthesia and a block room rather than general anesthesia. Primary outcomes were costs of surgical services provided and patient health outcomes; secondary outcomes were patient and staff satisfaction with each OR setup. RESULTS: The costs associated with the high-efficiency OR were 60% lower than those associated with the conventional OR (this was primarily due to the streamlining of OR care and elimination of the need to use a postanesthetic care unit), with the same or equivalent patient health outcomes. No differences in patient and staff satisfaction were found between the 2 setups. CONCLUSION: The use of tiered, ambulatory services for elective orthopedic surgery does not compromise health outcomes and patient satisfaction, and it is associated with substantial cost savings.

Anatomic Repair vs Closed Reduction of the Syndesmosis.

BACKGROUND: The goal of the study was to compare radiographic and functional outcomes between conventional closed syndesmotic reduction and screw fixation with open reduction, direct repair of the anterior inferior tibiofibular ligament (AiTFL) and screw fixation. We hypothesized that open reduction with restoration of the AiTFL would provide an improved reduction with better radiographic and functional outcomes. METHODS: Fifty consecutive patients with OTA 44-C ankle fractures were enrolled. Treatment was nonrandomized and based on surgeon preference. Patients were treated with either open reduction, suture-anchor AiTFL repair, and screw fixation (ART group), or conventional closed reduction of the syndesmosis followed by screw fixation (CR group). The primary outcome measure was anteroposterior (AP) displacement of the fibula on CT scan at 3 months postoperatively. Secondary outcome measures included the Maryland Foot Score, the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle Hindfoot Score, and the Foot and Ankle Outcome Score (FAOS). RESULTS: Mean AP difference between injured and noninjured ankles was decreased in the ART group compared with the CR group (0.7 ± 0.3 mm vs 1.5 ± 0.3 mm, P = .008). No differences were observed between groups in overall scores for secondary outcome measures. The ART group displayed a significant difference in Maryland Foot Shoe subscore at 12 months (ART = 9.5 vs CR = 8.3, P = .03) and FAOS Quality of Life subscore at 12 months (64.1 compared to 38.3, P = .04). CONCLUSION: Open anatomic syndesmotic repair resulted in improved radiographic outcomes compared with closed reduction. Cosmesis was worse at 6 weeks compared to the CR group; however, quality of life and shoewear were improved in the ART group at 1 year postoperatively. LEVEL OF EVIDENCE: Level II, prospective comparative study.

What is the Real Rate of Radial Nerve Injury After Humeral Nonunion Surgery?

OBJECTIVES: To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample. DESIGN: Consecutive retrospective cohort review. SETTING: Eighteen academic orthopedic trauma centers. PATIENTS/PARTICIPANTS: Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery. INTERVENTION: Humeral shaft nonunion repair and assessment of postoperative radial nerve function. MAIN OUTCOME: Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery. RESULTS: Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18-93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P = 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved. CONCLUSION: In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Improved Reduction of the Tibiofibular Syndesmosis With TightRope Compared With Screw Fixation: Results of a Randomized Controlled Study.

OBJECTIVE: To compare the rate of malreduction after high fibular fractures associated with syndesmosis injury treated with open reduction and internal fixation, with either 2 screws or 1 knotless TightRope device. DESIGN: Prospective randomized controlled multicenter trial. SETTING: Eleven academic and community hospitals including Level 1 and Level 2 trauma centers across Canada. PATIENTS/PARTICIPANTS: One hundred three patients with OTA/AO 44-C injuries with demonstrated radiographic syndesmosis diastasis or instability after malleolar bony fixation were followed for 12 months after treatment. METHODS: Open reduction of the syndesmosis was performed in all cases. Fixation was randomized to either TightRope (1 knotless TightRope, group T) or screw fixation (two 3.5-mm cortical positional screws placed across 3 cortices, group S). Surgical techniques and rehabilitation were standardized. All surgeons were trained or experienced in the use of the TightRope device. Follow-up was performed at 2 and 6 weeks, 3, 6, and 12 months. MAIN OUTCOME MEASURE: Rate of malreduction based on bilateral ankle computed tomography scan results at 3 months after fixation. Secondary outcome measures included adverse events, reoperation, and validated functional outcomes including the EQ-5D, the Olerud-Molander Ankle Score, the Foot and Ankle Disability Index, and the Work Productivity Activity Impairment Questionnaire. The estimated sample size required to detect a difference in reduction rate was 72 patients, but the estimated sample size required to detect a difference in functional outcome scores was 240 patients, suggesting the study was adequately powered for radiographic results only. RESULTS: Overall, the rate of malreduction using screw fixation was 39% compared with 15% using TightRope fixation (P = 0.028, χ). Analysis of computed tomography results was performed using a 2-mm translation or 10-degree rotation threshold for malreduction and included fibular translation (anterior, posterior); syndesmosis distance (anterior, posterior, and mid); medial compression; and rotation (fibular and articular). Patients in group T had greater anterior translation (5.4 ± 1.8 mm) compared with the contralateral limb (4.3 ± 1.3 mm, P < 0.01) or group S (4.6 ± 1.5 mm, P = 0.05). Group T syndesmoses also had greater diastasis compared with control limb (4.1 ± 1.3 vs. 3.3 ± 1.4 mm, P < 0.01) and less fibular medialization compared with group S (1.04 ± 1.8 vs. 0.3 ± 1.8 mm, P = 0.05). Functional outcome measures demonstrated significant improvements over time, but no differences between fixation groups. Foot and Ankle Disability Index scores at each time interval were 44 ± 22 (T) versus 45 ± 24 (S) (6 weeks), 76 ± 14 versus 73 ± 17 (3 months), 89 ± 10 versus 86 ± 13 (6 months), and 93 ± 9 versus 90 ± 14 (12 months) (all P > 0.2). The reoperation rate was higher in the screw group compared with TightRope (30% vs. 4%, P = 0.02) with the difference driven by the rate of implant removal. CONCLUSIONS: Based on our results, the TightRope device seems to compare favorably with two, 3.5-mm, 3-cortex screw fixation for syndesmosis injuries. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Short Versus Long InterTAN Fixation for Geriatric Intertrochanteric Hip Fractures: A Multicentre Head-to-Head Comparison.

OBJECTIVE: To determine if geriatric intertrochanteric hip fracture patients achieve equivalent postoperative functional status after management with either a short (180-200 mm) or a long (260-460 mm) InterTAN intramedullary device. DESIGN: Retrospective review of a prospective randomized control trial. SETTING: Four Level I Trauma Centers. PATIENTS/PARTICIPANTS: One hundred eight patients with OTA/AO classification 31A-1 and 31A-2 intertrochanteric hip fractures were included in the study. INTERVENTION: Internal fixation using an IT device. MAIN OUTCOMES MEASURES: Primary outcomes included Functional Independence Measure and Timed Up and Go. Secondary outcomes included blood loss, surgical time, length of stay, adverse events, and mortality. RESULTS: Seventy-one short and 37 long IT patients met study inclusion criteria. Demographics were similar between groups. There was no difference in Functional Independence Measure or Timed Up and Go scores between the 2 IT groups at any of the time points collected. Mean operative time was lower in the short IT group than in the long IT group (60 vs. 73 minutes; P = 0.021). A higher proportion of long IT patients had reamed constructs (95% vs. 48% short IT, P < 0.001). Postoperative blood loss was significantly higher in the long IT group without a significant influence on the number of patients requiring transfusion (P = 0.582) or average units transfused (P = 0.982). There was no significant difference in the proportion of postoperative adverse events between the 2 cohorts despite a higher number of peri-implant femur fractures in the short IT group than in the long IT group (5 vs. 1, P = 0.350). CONCLUSIONS: Postoperative functional status was not influenced by the length of IT device in the management of geriatric intertrochanteric hip fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Multicenter Randomized Control Trial Comparing a Novel Intramedullary Device (InterTAN) Versus Conventional Treatment (Sliding Hip Screw) of Geriatric Hip Fractures.

OBJECTIVES: To compare outcomes in elderly patients with intertrochanteric hip fractures treated with either the sliding hip screw (SHS) or InterTAN intramedullary device (IT). DESIGN: Prospective, randomized, multicenter clinical trial. SETTING: Five level 1 trauma centers. PATIENTS: Two hundred forty-nine patients 55 years of age or older with AO/OTA 31A1 (43) and OA/OTA 31A2 (206) fractures were prospectively enrolled and followed for 12 months. INTERVENTION: Computer generated randomization to either IT (n = 123) or SHS (n = 126). MAIN OUTCOME MEASUREMENTS: The Functional Independence Measure (FIM) and the Timed Up and Go test (TUG) were used to measure function and motor performance. Secondary outcome measures included femoral shortening, complications, and mortality. RESULTS: Demographics, comorbidities, preinjury FIM scores and TUG scores were similar between groups. Patients (17.2%) who received an IT had limb shortening greater than 2 cm compared with 42.9% who received an SHS (P < 0.001). To determine the importance of preinjury function and fracture stability, we analyzed the subgroup of patients with the ability to walk 150 m independently preinjury and an OA/OTA 31A-2 fracture (n = 70). In this subgroup, patients treated with SHS had greater shortening and demonstrated poorer FIM and TUG scores compared with patients treated with an IT. CONCLUSIONS: Overall, most patients with intertrochanteric femur fractures can expect similar functional results whether treated with an intramedullary or extramedullary device. However, active, functional patients have an improved outcome when the InterTAN is used to treat their unstable intertrochanteric fracture. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Role of patient information handouts following operative treatment of ankle fractures: a prospective randomized study.

BACKGROUND: Widespread evidence exists for directed patient information interventions (eg, pamphlets) in the setting of several orthopaedic conditions and interventions. Up until now, no study had assessed the role of these interventions in the management of patients following ankle fractures. METHODS: Between 2005 and 2007, 40 patients who suffered an operative ankle fracture were randomized to either a standard treatment group for an ankle fracture or an enhanced information group who received an American Academy of Orthopaedic Surgeons ankle fracture information pamphlet that explained postoperative routine at our institution and a physiotherapy handout depicting a standard protocol. Study participants were followed for 3 months clinically and radiographically. At the 6-week and 3-month intervals, study participants completed the Olerud-Molander Questionnaire and 2 questions regarding their level of satisfaction. The primary outcome measure was the Likert-scale-based survey question determining the level of satisfaction with the treating staff. RESULTS: Participants in the enhanced information group were more satisfied with treatment at 3 months (9.2 vs 6.3; P < .001). There were significant improvements in work/activity ability at 6 weeks (P = .01), but this advantage disappeared at 3 months (P = .24). No differences in postoperative complication rates were noted. CONCLUSIONS: Information enhancement in the form of pamphlets can be helpful in providing patients with accessible information in the postoperative period. While they do not seem to have a sustained impact on postoperative outcomes, handouts may enhance the interaction between staff and patient at postoperative visits, improving patient satisfaction. LEVEL OF EVIDENCE: Level I, appropriately powered randomized prospective cohort study.

Operative versus nonoperative treatment of unstable lateral malleolar fractures: a randomized multicenter trial.

OBJECTIVES: To compare clinical and functional outcomes after operative and nonoperative treatment of undisplaced, unstable, isolated fibula fractures. DESIGN: Randomized multicenter clinical trial. SETTING: Six level 1 trauma centers. PATIENTS/PARTICIPANTS: Eighty-one patients with undisplaced, unstable, isolated fibula fractures as confirmed by an external rotation stress examination demonstrating an increase in medial clear space to 5 mm or greater were followed for 12 months after treatment. INTERVENTION: Forty-one patients were treated operatively by open reduction and internal fixation of the fibula. Forty patients underwent nonoperative treatment, which included the use of a short leg cast or brace and protected weight bearing for 6 weeks. MAIN OUTCOME MEASUREMENTS: Functional outcomes determined using the Olerud-Molander Ankle Score and the Short Form 36. Radiographic outcomes included measurement of union and displacement at each visit. RESULTS: There were no statistically significant differences in functional outcome scores or pace of recovery between the operative and nonoperative groups at any time interval (ß = -0.28, 3.49; P = 0.936). Complications in the nonoperative group included 8 patients with a medial clear space ≥5 mm and 8 patients with delayed union or nonunion. In the operative group, 5 patients had a surgical site infection and 5 patients required hardware removal. CONCLUSIONS: Patients managed operatively had equivalent functional outcomes compared with nonoperative treatment; however, the risk of displacement and problems with union was substantially lower in patients managed with surgery.

Functional and radiographic results of patients with syndesmotic screw fixation: implications for screw removal.

OBJECTIVE: Screw fixation of the injured syndesmosis restores stability but may reduce motion. The purpose of this study is to determine whether functional outcomes and radiographic results after ankle fracture are affected by the status of the syndesmosis screw. DESIGN: Retrospective review of a consecutive clinical series. SETTING: Level 1 academic trauma center. PATIENTS: One hundred six adults were reviewed radiographically; mean follow up was 15 months (range, 4-30 months). Seventy-six of the 106 patients completed formal functional testing; mean follow up was 23 +/- 13 months (range, 12-32 months). INTERVENTION: Open reduction and internal fixation, including fixation of the tibiofibular syndesmosis. MAIN OUTCOME MEASUREMENTS: Patients with intact, broken or loose, or removed syndesmosis screws were compared. Functional outcomes were measured using the Lower Extremity Measure and the Olerud Molander ankle score. Radiologic review included tibiofibular clear space, tibiofibular overlap, and medial clear space. RESULTS: Functional outcomes were improved in patients with fractured, loosened, or removed screws compared with those with intact screws. The Lower Extremity Measure score for patients with intact screws was 70 +/- 6 compared with 85 +/- 3 for fractured, loosened, or removed screws (P = 0.01). The Olerud Molander ankle score for patients with intact screws was 47 +/- 8.0 compared with 64 +/- 4 for fractured, loosened, or removed screws (P = 0.04). There was no difference in outcome comparing fractured, loosened, and removed screws. The tibiofibular clear space was narrowed in patients with intact screws compared with removed, fractured, or loose screws. The tibiofibular clear space for intact screws was 3.1 +/- 0.2 compared with 4.1 +/- 0.2 for removed, fractured, or loosened screws (P = 0.005). There was no difference in outcome comparing large and small fragment screws. CONCLUSIONS: An intact syndesmosis screw was associated with a worse functional outcome compared with loose, fractured, or removed screws. However, there were no differences in functional outcomes comparing loose or fractured screws with removed screws. Screw removal is unlikely to benefit patients with loose or fractured screws but may be indicated in patients with intact syndesmosis screws.

Functional outcome and persistent disability after isolated fracture of the femur.

BACKGROUND: The purpose of this study was to assess the functional outcome and causes of persistent disability in patients with isolated femoral shaft fractures treated at an academic level-1 trauma centre. METHODS: We prospectively enrolled 40 consecutive skeletally mature patients with isolated, nonpathologic diaphyseal femur fractures. All patients underwent fracture reduction and fixation using an antegrade locked intramedullary nail. We measured functional outcome using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index and the Short Musculoskeletal Functional Assessment (SMFA). We obtained visual analog scores for pain in the groin, buttock, thigh and knee 6 months after the injury. RESULTS: Joint-related and musculoskeletal outcome scores improved gradually from the baseline assessment to the 6-month review. Mean scores (and standard deviations [SDs]) on the WOMAC index improved gradually from 57 (23) to 24 (22) for pain, from 57 (25) to 30 (20) for stiffness and from 70 (21) to 21 (23) for function (p < 0.001). The mean SMFA score (and SD) improved from 64 (13) to 25 (20) (p = 0.024). We noted no further improvements in functional outcome measures from the 6-month to the 12-month assessment (p > 0.21). Patients reported more pain in the knee than in other anatomic locations; the mean pain scores (and SDs) were 3.7 (3.1) in the knee, 2.5 (2.7) in the thigh, 1.7 (2.7) in the buttock and 1.0 (1.7) in the groin (p = 0.003). We noted correlations between knee pain and WOMAC pain (rho = 0.748, p < 0.001), function (rho = 0.701, p < 0.001) and SMFA (rho = 0.733, p < 0.001). We noted weaker correlations between thigh, groin and buttock pain and functional outcomes, with rho scores ranging from 0.2 to 0.55. CONCLUSION: Recovery from femur fractures occurs most rapidly in the first 6 months after injury. Residual deficits in functional outcome were still measurable 12 months after injury. Knee pain was the most common and most severe source of patient discomfort 12 months after isolated femur fractures, and demonstrated moderate to good correlation with general and joint-specific functional outcome measures.