Rapid Recovery Total Joint Arthroplasty is Safe, Efficient, and Cost-Effective in the Veterans Administration Setting.

BACKGROUND: Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting. METHODS: In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively. RESULTS: After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07). CONCLUSION: In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty.

Maximizing safety in screw placement for posterior facet fixation in calcaneus fractures: a cadaveric radio-anatomical study.

BACKGROUND: Successful screw fixation of reduced posterior facet fragments to the unexposed, nondisplaced sustentaculum tali avoids breaching the subtalar joint or disrupting surrounding soft tissue structures. Safe passage for screw fixation through this narrow bony corridor has not been rigorously defined. METHODS: Computed tomography scans of 8 cadaveric feet were digitally reconstructed in 3-D; 3.5-mm-diameter screws were simulated, aiming at the center of the sustentaculum tali from 5 locations (0%, 25%, 50%, 75%, and 100%) along the posterolateral facet joint. The range of entry points, screw paths trajectories, and screw lengths that did not breach the subtalar joint or the medial calcaneal cortex were evaluated. RESULTS: To prevent violation of the subtalar joint or the medial calcaneal cortex while reaching the center of the sustentaculum tali, screws must be inserted at least 5 mm below the joint line. Screw placement 15 ± 1 mm below the posterior facet measured perpendicular to the joint line provided the widest safe corridor with the trajectory of the ranges from 6 to 36 degrees parallel to the joint depending on the location along the posterior facet and 20 ± 2 degrees perpendicular to the joint at all locations. The average maximal length of screws placed at the ideal entry points ranged from 44 to 46 mm, longest at the 100% location and shortest at the 25% location. CONCLUSIONS: Operative guidelines facilitating instrumentation into the sustentaculum tali have been defined applying to most calcanei, assuming the fractures are well reduced: screws, approximately 40 mm in length, should be started 15 mm below the posterior facet measured perpendicular to the joint line and aimed 20 degrees perpendicular to the joint line toward the joint and 6 to 36 degrees anteversion parallel to the joint line increasing at each position from anterior to posterior. CLINICAL RELEVANCE: The operative guidelines described in this study may assist surgeons in the placement of screws for the fixation of posterior facet fragments to the sustentaculum tali.

2010 mid-America Orthopaedic Association Physician in Training Award: healing complications are common after locked plating for distal femur fractures.

BACKGROUND: Several mechanical studies suggest locking plate constructs may inhibit callus necessary for healing of distal femur fractures. However, the rate of nonunion and factors associated with nonunion are not well established. QUESTIONS/PURPOSES: We (1) determined the healing rate of distal femur fractures treated with locking plates, (2) assessed the effect of patient injury and treatment variables on fracture healing, and (3) compared callus formation in fractures that healed with those that did not heal. PATIENTS AND METHODS: We retrospectively reviewed 82 patients treated with 86 distal femur fractures using lateral locking plates. We reviewed all charts and radiographs to determine patient and treatment variables and then determined the effects of these variables on healing. We quantitatively measured callus at 6, 12, and 24 weeks. The minimum time for telephone interviews and SF-36v2(TM) scores was 1 year (mean, 4.2 years; range, 1-7.2 years). RESULTS: Fourteen fractures (20%) failed to unite. Demographics and comorbidities were similar in patients who achieved healing compared with those who had nonunions. There were more empty holes in the plate adjacent to fractures that healed; comminuted fractures failed to heal more frequently than less comminuted fractures. Less callus formed in fractures with nonunions and in patients treated with stainless steel plates compared with titanium plates. Complications occurred in 28 of 70 fractures (40%), 19 of which had additional surgery. CONCLUSIONS: We found a high rate of nonunion in distal femur fractures treated with locking plates. Nonunion presented late without hardware failure and with limited callus formation suggesting callus inhibition rather than hardware failure is the primary problem. Mechanical factors may play a role in the high rate of nonunion.

Efficacy and Validation of a Simulation-Based Compartment Syndrome Instructional Course.

Background: This study reports the validity and effectiveness of a simulation-based compartment syndrome instructional course. Methods: Six post-graduation year one (PGY1) orthopaedic residents and six PGY5 residents participated in the study. All PGY1 residents participated in a four-hour compartment syndrome training simulation. An anatomic compartment model was used to test needle placement accuracy in four leg muscle compartments. Pre-training, immediate post-training, and one-month post-training performance data were collected from all PGY1 residents, as well as data from a onetime assessment of all PGY5 residents. These assessments included a paper test for lower leg anatomy (anatomy module), a procedural test of needle placement accuracy using an anatomic compartment syndrome simulation module (needle placement module), and an assessment of ability to measure compartment pressure via low cost simulation (pressure measurement module). Face validity of the needle placement module and pressure measurement module were assessed using a structured questionnaire given to all 12 study participants and three orthopaedic faculty. Results: The PGY1 residents demonstrated significant improvement at immediate post-training in all three assessments compared to their pre-training performances (anatomy p=0.019, needle placement p=0.026, pressure measurement p=0.033 and Objective Structured Assessment of Technical Skill (OSATS) score for pressure measurement p <0.0001). This performance was maintained at the one-month post-training assessment. Immediate post-training and one-month post-training PGY1 resident performances were comparable with PGY5 resident performance in all tests.Fifteen participants rated the face validity of the needle placement and pressure measurement modules. For the needle placement module, 73.3% of participants highly rated (4 out of 5 or greater) for realism, 86.7% highly rated for being an effective tool for teaching, and 80% highly rated for needing the model to be available throughout their training. The pressure measurement module did not receive high face validity ratings. Conclusions: With minimal, inexpensive training, the performance of junior residents in a compartment syndrome simulation was improved to a level comparable with senior residents. In addition, this performance was maintained at one-month post-training. The compartment syndrome anatomic module had highly-rated face validity. Clinical Relevance: Training junior residents to accurately diagnose compartment syndrome using a realistic simulation may allow for greater diagnostic accuracy in the clinical setting.

Complications of locking plate fixation in complex proximal tibia injuries.

OBJECTIVES: To report the complications and pitfalls in the treatment of complex injuries of the proximal tibia when locking plates are used. DESIGN, SETTING, AND PATIENTS: This was a retrospective case series conducted at a university Level I trauma center. Thirty-seven patients with complex proximal tibia fractures (41C1, 41C2, 41C3, 41A2, 42A2) were treated with locking plates. INTERVENTION: All fractures were treated with locking plates (Less Invasive Stabilization System (LISS); Synthes, Paoli, PA). MAIN OUTCOME MEASUREMENTS: Healing, alignment, infection, and other complications. RESULTS: Twelve fractures (32%) healed without any complications. Eight patients (22%) developed deep infections that required operative debridements, and 5 of them had a hardware removal; 1 eventually required an above-knee amputation. Eight cases (22%) had postoperative malalignment, with hyperextension as the most common deformity. Three cases (8%) had loss of alignment into varus during healing. Other complications were 1 superficial wound dehiscence, 1 delayed soft-tissue breakdown, 4 hardware irritations, 1 peroneal nerve injury at the distal part of a 9-hole plate, 1 tibial tubercle nonunion, and 1 postoperative compartment syndrome. CONCLUSION: The complication rate, particularly infection, was higher than in previous reports. Other complications such as hardware prominence, malalignment, and loss of alignment were similar to those of historical controls. Some of the complications may reflect the techniques that were used and should decrease with more experience; however, some may be inherent in the treatment of high-energy fractures using locking plates.

Percutaneous Reduction and Screw Fixation of Displaced Intra-articular Fractures of the Calcaneus.

BACKGROUND: Extensile open approaches to reduce and fix intra-articular calcaneal fractures are associated with high levels of wound complications. To avoid these complications, a technique of percutaneous reduction and fixation with screws alone was developed. This study assessed the clinical outcomes, radiographs, and postoperative CT scans after operative treatment with this technique. METHODS: 153 consecutive patients with 182 intra-articular calcaneal fractures were reviewed. All patients were assessed for early postoperative complications at 3 months from the injury. The clinical results were assessed for patients seen at a minimum of 1 year after surgery (mean follow-up of 2.6 years; 90 patients, 106 feet). In patients who had both preoperative and postoperative CT scans (50 patients, 60 feet), the articular reduction was quantitatively analyzed. RESULTS: At the 3-month follow-up, there were 1% superficial infections and 1% rate of screw irritation. The complications at a minimum of 1 year after injury included screw irritation 9.3%, subtalar osteoarthritis requiring subtalar fusion 5.5%, malunion 1.8%, and deep infection 0.9%. Bohler angle, calcaneal facet height, and width were significantly improved postoperatively ( P < .01). Bohler angle increased on average +24.1 degrees postoperatively with a loss of angle of 4.9 degrees at the 3-month follow-up. There was significant improvement ( P < .01) in posterior talocalcaneal joint reduction on postoperative CT scan but residual displacement remained. At the final follow-up, 54.5% of the patients reported a residual pain level of 3 or lower. CONCLUSION: This study suggests that reasonable early results could be achieved from the percutaneous treatment of intra-articular calcaneal fractures using screws alone based on articular reduction and level of residual pain. LEVEL OF EVIDENCE: Level IV, retrospective case series.

A Hybrid Reality Radiation-Free Simulator for Teaching Wire Navigation Skills.

OBJECTIVES: Surgical simulation is an increasingly important method to facilitate the acquiring of surgical skills. Simulation can be helpful in developing hip fracture fixation skills because it is a common procedure for which performance can be objectively assessed [ie, the tip-apex distance (TAD)]. The procedure requires fluoroscopic guidance to drill a wire along an osseous trajectory to a precise position within bone. The objective of this study was to assess the construct validity for a novel radiation-free simulator designed to teach wire navigation skills in hip fracture fixation. METHODS: Novices (n = 30) with limited to no surgical experience in hip fracture fixation and experienced surgeons (n = 10) participated. Participants drilled a guide wire in the center-center position of a synthetic femoral head in a hip fracture simulator, using electromagnetic sensors to track the guide-wire position. Sensor data were gathered to generate fluoroscopic-like images of the hip and guide wire. Simulator performance of novice and experienced participants was compared to measure construct validity. RESULTS: The simulator was able to discriminate the accuracy in guide-wire position between novices and experienced surgeons. Experienced surgeons achieved a more accurate TAD than novices (13 vs. 23 mm, respectively, P = 0.009). The magnitude of improvement on successive simulator attempts was dependent on the level of expertise; TAD improved significantly in the novice group, whereas it was unchanged in the experienced group. CONCLUSIONS: This hybrid reality, radiation-free hip fracture simulator, which combines real-world objects with computer-generated imagery, demonstrates construct validity by distinguishing the performance of novices and experienced surgeons. There is a differential effect depending on the level of experience, and it could be used as an effective training tool in novice surgeons.