RESUMO
The current relative value units (RVU)-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs bi-malleolar vs tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation for uni-malleolar versus bi-malleolar versus tri-malleolar ankle fractures. The 2012 to 2017 American College of Surgeons - National Surgical Quality Improvement Program files were queried using current Procedural Terminology (CPT) codes for patients undergoing open reduction internal fixation for uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814), and tri-malleolar (CPT-27822,CPT-27823) ankle fractures. A total of 7830 (37.2%) uni-malleolar, 7826 (37.2%) bi-malleolar and 5391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs, Mean RVU/minute and Reimbursement rate ($/min) and Mean Reimbursement/case for each fracture type were calculated and compared using Kruskal-Wallis tests. The mean total RVU for each fracture type was as follows: (1) Uni-malleolar: 9.99, (2) Bi-malleolar = 11.71 and 3) Tri-malleolar = 12.87 (p < .001). A statistically significant difference was noted in mean operative time (uni-malleolar = 63.2 vs bi-malleolar = 78.6 vs tri-malleolar = 95.5; p < .001) between the 3 groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar = $7.21/min vs bi-malleolar = $6.75/min vs tri-malleolar = $6.10; p < .001). The average reimbursement/case was $358, $420, and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Foot & ankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.
Assuntos
Fraturas do Tornozelo , Cirurgiões , Humanos , Fraturas do Tornozelo/diagnóstico por imagem , Fraturas do Tornozelo/cirurgia , Tornozelo , Articulação do Tornozelo , Extremidade Inferior , Estudos Retrospectivos , Fixação Interna de FraturasRESUMO
BACKGROUND: Critical access hospitals (CAHs) play an important role in providing access to care for many patients in rural communities. Prior studies have shown that these facilities are able to provide timely and quality care for patients who undergo various elective and emergency general surgical procedures. However, little is known about the quality and reimbursement of surgical care for patients undergoing surgery for hip fractures at CAHs compared with non-CAH facilities. QUESTIONS/PURPOSES: Are there any differences in 90-day complications, readmissions, mortality, and Medicare payments between patients undergoing surgery for hip fractures at CAHs and those undergoing surgery at non-CAHs? METHODS: The 2005 to 2014 Medicare 100% Standard Analytical Files were queried using ICD-9 procedure codes to identify Medicare-eligible beneficiaries undergoing open reduction and internal fixation (79.15, 79.35, and 78.55), hemiarthroplasty (81.52), and THA (81.51) for isolated closed hip fractures. This database was selected because the claims capture inpatient diagnoses, procedures, charged amounts and paid claims, as well as hospital-level information of the care, of Medicare patients across the nation. Patients with concurrent fixation of an upper extremity, lower extremity, and/or polytrauma were excluded from the study to ensure an isolated cohort of hip fractures was captured. The study cohort was divided into two groups based on where the surgery took place: CAHs and non-CAHs. A 1:1 propensity score match, adjusting for baseline demographics (age, gender, Census Bureau-designated region, and Elixhauser comorbidity index), clinical characteristics (fixation type and time to surgery), and hospital characteristics (whether the hospital was located in a rural ZIP code, the average annual procedure volume of the operating facility, hospital bed size, hospital ownership and teaching status), was used to control for the presence of baseline differences in patients presenting at CAHs and those presenting at non-CAHs. A total of 1,467,482 patients with hip fractures were included, 29,058 of whom underwent surgery in a CAH. After propensity score matching, each cohort (CAH and non-CAH) contained 29,058 patients. Multivariate logistic regression analyses were used to assess for differences in 90-day complications, readmissions, and mortality between the two matched cohorts. As funding policies of CAHs are regulated by Medicare, an evaluation of costs-of-care (by using Medicare payments as a proxy) was conducted. Generalized linear regression modeling was used to assess the 90-day Medicare payments among patients undergoing surgery in a CAH, while controlling for differences in baseline demographics and clinical characteristics. RESULTS: Patients undergoing surgery for hip fractures were less likely to experience many serious complications at a critical access hospital (CAH) than at a non-CAH. In particular, after controlling for patient demographics, hospital-level factors and procedural characteristics, patients treated at a CAH were less likely to experience: myocardial infarction (3% (916 of 29,058) versus 4% (1126 of 29,058); OR 0.80 [95% CI 0.74 to 0.88]; p < 0.001), sepsis (3% (765 of 29,058) versus 4% (1084 of 29,058); OR 0.69 [95% CI 0.63 to 0.78]; p < 0.001), acute renal failure (6% (1605 of 29,058) versus 8% (2353 of 29,058); OR 0.65 [95% CI 0.61 to 0.69]; p < 0.001), and Clostridium difficile infections (1% (367 of 29,058) versus 2% (473 of 29,058); OR 0.77 [95% CI 0.67 to 0.88]; p < 0.001) than undergoing surgery in a non-CAH. CAHs also had lower rates of all-cause 90-day readmissions (18% (5133 of 29,058) versus 20% (5931 of 29,058); OR 0.83 [95% CI 0.79 to 0.86]; p < 0.001) and 90-day mortality (4% (1273 of 29,058) versus 5% (1437 of 29,058); OR 0.88 [95% CI 0.82 to 0.95]; p = 0.001) than non-CAHs. Further, CAHs also had risk-adjusted lower 90-day Medicare payments than non-CAHs (USD 800, standard error 89; p < 0.001). CONCLUSION: Patients who received hip fracture surgical care at CAHs had a lower risk of major medical and surgical complications than those who had surgery at non-CAHs, even though Medicare reimbursements were lower as well. Although there may be some degree of patient selection at CAHs, these facilities appear to provide high-value care to rural communities. These findings provide evidence for policymakers evaluating the impact of the CAH program and allocating funding resources, as well as for community members seeking emergent care at local CAH facilities. LEVEL OF EVIDENCE: Level III, therapeutic study.
Assuntos
Fixação de Fratura/normas , Acessibilidade aos Serviços de Saúde/normas , Fraturas do Quadril/cirurgia , Hospitais/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Serviços de Saúde Rural/normas , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Fixação de Fratura/efeitos adversos , Fixação de Fratura/economia , Fixação de Fratura/mortalidade , Custos de Cuidados de Saúde/normas , Acessibilidade aos Serviços de Saúde/economia , Fraturas do Quadril/diagnóstico por imagem , Fraturas do Quadril/economia , Fraturas do Quadril/mortalidade , Humanos , Reembolso de Seguro de Saúde/normas , Masculino , Medicare/economia , Medicare/normas , Pessoa de Meia-Idade , Readmissão do Paciente , Complicações Pós-Operatórias/mortalidade , Indicadores de Qualidade em Assistência à Saúde/economia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Serviços de Saúde Rural/economia , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
As the current healthcare model transitions from fee-for-service to value-based payments, identifying cost-drivers of 90-day payments following surgical procedures will be a key factor in risk-adjusting prospective bundled payments and ensuring success of these alternative payment models. The 5% Medicare Standard Analytical Files data set for 2005-2014 was used to identify patients undergoing open reduction and internal fixation (ORIF) for isolated unimalleolar, bimalleolar, and trimalleolar ankle fractures. All acute care and post-acute care payments starting from day 0 of surgery to day 90 postoperatively were used to calculate 90-day costs. Patients with missing data were excluded. Multivariate linear regression modeling was used to derive marginal cost impact of patient-level (age, sex, and comorbidities), procedure-level (fracture type, morphology, location of surgery, concurrent ankle arthroscopy, and syndesmotic fixation), and state-level factors on 90-day costs after surgery. A total of 6499 patients were included in the study. The risk-adjusted 90-day cost for a female patient, aged 65 to 69 years, undergoing outpatient ORIF for a closed unimalleolar ankle fracture in Michigan was $6949 ± $1060. Individuals aged <65 or ≥70 years had significantly higher costs. Procedure-level factors associated with significant marginal cost increases were inpatient surgery (+$5577), trimalleolar fracture (+$1082), and syndesmotic fixation (+$2822). The top 5 comorbidities with the largest marginal cost increases were chronic kidney disease (+$8897), malnutrition (+$7908), obesity (+$5362), cerebrovascular disease/stroke (+$4159), and anemia (+$3087). Higher costs were seen in Nevada (+$6371), Massachusetts (+$4497), Oklahoma (+$4002), New Jersey (+$3802), and Maryland (+$3043) compared with Michigan. With the use of a national administrative claims database, the study identifies numerous patient-level, procedure-level, and state-level factors that significantly contribute to the cost variation seen in 90-day payments after ORIF for ankle fracture. Risk adjustment of 90-day costs will become a necessity as bundled-payment models begin to take over the current fee-for-service model in patients with fractures.
Assuntos
Fraturas do Tornozelo/economia , Fraturas do Tornozelo/cirurgia , Fixação Interna de Fraturas/economia , Custos de Cuidados de Saúde , Redução Aberta/economia , Risco Ajustado , Idoso , Idoso de 80 Anos ou mais , Cuidado Periódico , Feminino , Humanos , Masculino , Medicare , Pessoa de Meia-Idade , Fatores de Tempo , Estados UnidosRESUMO
Despite increasing interest toward managing isolated ankle fractures in an outpatient setting, evidence of its safety remains largely limited. The 2007 to 2014 Humana Administrative Claims database was queried to identify patients undergoing open reduction internal fixation for unimalleolar, bimalleolar, or trimalleolar isolated closed ankle fractures. Two cohorts (outpatient versus inpatient) were then matched on the basis of age, sex, race, region, fracture type (uni-/bi-/trimalleolar) and Elixhauser Comorbidity Index to control for selection bias. Multivariate regression analyses were performed to report independent impact of outpatient-treated ankle fracture surgery on 90-day complications, readmission, and emergency department visit rates. Independent-samples t test was used to compare global 90-day costs between cohorts. A total of 5317 inpatient-treated and 6941 outpatient-treated closed ankle fractures were included in the final cohort. After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia (2.3% versus 4.0%; p < .001), myocardial infarction (0.9% versus 1.8%; pâ¯=â¯.005), acute renal failure (2.2% versus 5.3%; p < .001), urinary tract infections (7.4% versus 12.3%; p < .001), and pressure ulcers (0.9% versus 2.0%; pâ¯=â¯.001). Outpatient ankle fractures also had lower rates of 90-day readmissions (9.7% versus 14.1%; p < .001) and emergency department visits (13.8% versus 16.2%; pâ¯=â¯.028). Last, overall 90-day costs for outpatient ankle fractures were nearly $9000 lower than costs for inpatient ankle fractures ($12,923 versus $21,866; p < .001). Based on our findings, it appears that outpatient treatment of ankle fractures can be deemed safe and feasible in a select cohort of patients.
Assuntos
Procedimentos Cirúrgicos Ambulatórios/economia , Fraturas do Tornozelo/cirurgia , Fixação de Fratura/economia , Custos de Cuidados de Saúde , Hospitalização/economia , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Feminino , Fixação de Fratura/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
OBJECTIVE: Delirium is one of the most common acute psychiatric disturbances taking place in patients, particularly elderly, following hip fractures. Using a validated national surgical database, we sought to define the incidence, risk factors and clinical impact associated with the occurrence of delirium following open reduction and internal fixation (ORIF) for hip fracture. METHODS: The 2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Hip Fracture Targeted Procedure file-was retrieved and merged with the ACS-NSQIP 2016 file. A total of 7859 patients were finally included in the study. RESULTS: A total of 2177 (27.7%) patients experienced an episode of delirium following the procedure. Adjusted analysis showed an increasing age ≥ 65 years (p < 0.001), partially dependent functional health status prior to surgery (p = 0.001), bleeding disorder (p = 0.012), preoperative dementia (p < 0.001), preoperative delirium (p < 0.001), being bed-ridden postoperatively (p < 0.001), no weight bearing as tolerated on first postoperative day (p < 0.001), an ASA grade > II (p < 0.001), non-emergency case (p = 0.010) and a prolonged length of stay > 3 days (p < 0.001). In addition, Black or African-American ethnicity had a lower odds of developing postoperative delirium (p = 0.020) as compared to Whites. Moreover, postoperative delirium was significantly associated with non-home discharge disposition (p < 0.001), higher odds of 30-day readmissions (p < 0.001) and 30-day mortality (p < 0.001). CONCLUSION: This study identifies several risk factors associated with the occurrence of postoperative delirium in patients undergoing ORIF for hip fracture. Surgeons can utilize these data to risk stratify and consequently tailor an appropriate preoperative and postoperative care protocol to prevent the occurrence of delirium.
Assuntos
Demência/epidemiologia , Delírio do Despertar/epidemiologia , Fixação Interna de Fraturas/psicologia , Fraturas do Quadril/cirurgia , Redução Aberta/psicologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Pessoas Acamadas/psicologia , Transtornos da Coagulação Sanguínea/epidemiologia , Bases de Dados Factuais , Demência/etnologia , Feminino , Nível de Saúde , Fraturas do Quadril/mortalidade , Humanos , Incidência , Tempo de Internação , Masculino , Readmissão do Paciente/estatística & dados numéricos , Fatores de Risco , Estados Unidos/epidemiologia , Suporte de CargaRESUMO
PURPOSE: Past literature has reported metabolic syndrome (MetS) to complicate postoperative care in patients undergoing various surgical procedures. We sought to analyze the impact of MetS on 30-day outcomes following hip fracture surgeries in the geriatric population. MATERIALS AND METHODS: The 2015-2016 ACS-NSQIP database was queried for patients undergoing hip fracture repair using CPT codes for total hip arthroplasty (27130), hemiarthroplasty (27125) and open reduction internal fixation (27236, 27244, 27245). Only patients ≥ 65 years of age undergoing surgery due to a traumatic hip fracture were included in the study. MetS was defined using preset criteria used by other NSQIP studies as the presence of-(1) diabetes mellitus AND (2) hypertension requiring medication AND (3) BMI ≥ 30 kg/m2. RESULTS: Out of 31,621 patients, a total of 1388 (4.4%) geriatric patients with MetS underwent hip fracture surgery. Following adjusted analysis, the presence of MetS was associated with higher odds of a prolonged length of stay > 5 days (OR 1.14 [95% CI 1.01-1.29]; p = 0.031), deep SSI (OR 2.48 [95% CI 1.20-5.14]; p = 0.014), progressive renal insufficiency (OR 3.27 [95% CI 1.98-5.42]; p < 0.001), acute renal failure (OR 2.08 [95% CI 1.04-4.15]; p = 0.038), urinary tract infection (OR 1.43 [95% CI 1.12-1.81]; p = 0.004), 30-day readmissions (OR 1.28 [95% CI 1.08-1.52]; p = 0.005) and a non-home discharge (OR 1.42 [95% CI 1.18-1.71]; p < 0.001). CONCLUSION: MetS is associated with a significantly increased risk of several postoperative complications, readmissions and non-home discharge dispositions. Providers can utilize these data to promote the need for better perioperative care in these high-risk patients.
Assuntos
Fraturas do Quadril/epidemiologia , Fraturas do Quadril/cirurgia , Síndrome Metabólica/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Injúria Renal Aguda/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/efeitos adversos , Comorbidade , Progressão da Doença , Feminino , Fixação Interna de Fraturas/efeitos adversos , Hemiartroplastia/efeitos adversos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Redução Aberta/efeitos adversos , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Insuficiência Renal Crônica/epidemiologia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Infecções Urinárias/epidemiologiaRESUMO
Trimalleolar ankle fractures are unstable injuries with possible syndesmotic disruption. Recent data have described inherent morbidity associated with screw fixation of the syndesmosis, including the potential for malreduction, hardware irritation, and post-traumatic arthritis. The posterior malleolus is an important soft tissue attachment for the posterior inferior syndesmosis ligament. We hypothesized that fixation of a sizable posterior malleolar (PM) fracture in supination external rotation type IV (SER IV) ankle fractures would act to stabilize the syndesmosis and minimize or eliminate the need for trans-syndesmotic fixation. A retrospective review of trimalleolar ankle fractures surgically treated from October 2006 to April of 2011 was performed. A total of 143 trimalleolar ankle fractures were identified, and 97 were classified as SER IV. Of the 97 patients, 74 (76.3%) had a sizable PM fragment. Syndesmotic fixation was required in 7 of 34 (20%) and 27 of 40 (68%), respectively, when the PM was fixed versus not fixed (p = .0002). When the PM was indirectly reduced using an anterior to posterior screw, 7 of 15 patients (46.7%) required syndesmotic fixation compared with none of 19 patients when the PM fragment was fixated with direct posterior lateral plate fixation (p = .0012). Fixation of the PM fracture in SER IV ankle fractures can restore syndesmotic stability and, thus, lower the rate of syndesmotic fixation. We found that fixation of a sizable PM fragment in SER IV or equivalent injuries through posterolateral plating can eliminate the need for syndesmotic screw fixation.
Assuntos
Fraturas do Tornozelo/fisiopatologia , Fraturas do Tornozelo/cirurgia , Parafusos Ósseos , Fixação Interna de Fraturas/métodos , Amplitude de Movimento Articular/fisiologia , Supinação/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fraturas do Tornozelo/diagnóstico por imagem , Feminino , Fixação Interna de Fraturas/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Ongoing lower extremity long-bone nonunion is a devastating condition and associated with substantial patient morbidity. There is limited evidence regarding physical and mental function after surgical management of lower extremity nonunions. The purpose of this study was to assess general physical and mental health and lower extremity specific physical function of patients that underwent surgery for a lower extremity long-bone nonunion. METHODS: One-hundred and twenty-four adult patients who underwent successful surgical management for a lower extremity long-bone nonunion between June 2002 and December 2021 were evaluated at an average follow-up of 8.6 years (interquartile range [IQR]: 4 - 12). General physical and mental health was assessed with the Short-Form 12 (SF-12) physical (PCS) and mental (MCS) component summaries, and lower extremity specific physical function with the Lower Extremity Functional Scale (LEFS). Multivariable linear regression was performed to identify variables that were independently associated with outcomes. RESULTS: The median LEFS was 50 (IQR: 37 - 63) and the median SF-12 PCS was 43 (IQR: 33 - 52), which are both lower than normative population scores (LEFS: 77 and PCS: 51, p < 0.0001). The median SF-12 MCS was 50, which was comparable to the normative population score of 51 (p < 0.0001). The number of previous surgeries before the index nonunion treatment (p = 0.018 and p = 0.041) and the number of revision surgeries after the index nonunion treatment (p = 0.022 and p = 0.041) were associated with lower LEFS and SF-12 PCS scores. CONCLUSION: At an average of 8.6 years after lower extremity nonunion surgery that led to bone healing, patients continue to report lower general and lower extremity specific physical functioning compared to the normative population. The number of surgical attempts to obtain definitive healing was associated with compromised physical function scores. Mental health scores may return close to normative population scores. These results can be used to inform patients and guide treatment strategies and healthcare policies.
RESUMO
OBJECTIVES: Acute orthopedic traumatic musculoskeletal injuries are prevalent, costly, and often lead to persistent pain and functional limitations. Psychological risk factors (eg, pain catastrophizing and anxiety) exacerbate these outcomes but are often overlooked in acute orthopedic care. Addressing gaps in current treatment approaches, this mixed-methods pilot study explored the use of a therapeutic virtual reality (VR; RelieVRx ), integrating principles of mindfulness and cognitive-behavioral therapy, for pain self-management at home following orthopedic injury. METHODS: We enrolled 10 adults with acute orthopedic injuries and elevated pain catastrophizing or pain anxiety from Level 1 Trauma Clinics within the Mass General Brigham health care system. Participants completed daily RelieVRx sessions at home for 8 weeks, which included pain education, relaxation, mindfulness, games, and dynamic breathing biofeedback. Primary outcomes were a priori feasibility, appropriateness, acceptability, satisfaction, and safety. Secondary outcomes were pre-post measures of pain, physical function, sleep, depression, and hypothesized mechanisms (pain self-efficacy, mindfulness, and coping). RESULTS: The VR and study procedures met or exceeded all benchmarks. We observed preliminary improvements in pain, physical functioning, sleep, depression, and mechanisms. Qualitative exit interviews confirmed high satisfaction with RelieVRx and yielded recommendations for promoting VR-based trials with orthopedic patients. DISCUSSION: The results support a larger randomized clinical trial of RelieVRx versus a sham placebo control to replicate the findings and explore mechanisms. There is potential for self-guided VR to promote evidence-based pain management strategies and address the critical mental health care gap for patients following acute orthopedic injuries.
Assuntos
Atenção Plena , Realidade Virtual , Humanos , Projetos Piloto , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Catastrofização/psicologia , Terapia Cognitivo-Comportamental/métodos , Manejo da Dor/métodos , Terapia de Exposição à Realidade Virtual/métodos , Dor Musculoesquelética/terapia , Dor Musculoesquelética/etiologia , Dor Musculoesquelética/psicologia , Ansiedade/etiologia , Ansiedade/terapia , Autogestão , Medição da DorRESUMO
OBJECTIVES: To report on adverse events during magnetic resonance imaging (MRI) in patients with external fixators. METHODS: . DESIGN: Retrospective case series. SETTING: Two Level 1 trauma centers. PATIENT SELECTION CRITERIA: Patients with external fixators on the appendicular skeleton or pelvis undergoing MRI between January 2005 and September 2023. OUTCOME MEASURES AND COMPARISONS: Adverse events, defined as any undesirable event associated with the external fixator being inside or outside the MRI bore during imaging, including (subjective) heating, displacement or pullout of the external fixator, or early MRI termination for any reason. RESULTS: A total of 97 patients with 110 external fixators underwent at least one MRI scan with an external fixator inside or outside of the MRI bore. The median age was 51 years (interquartile range: 39-63) and 56 (58%) were male. The most common external fixator locations were the ankle (24%), knee (21%), femur (21%), and pelvis (19%). The median duration of the MRI was 40 minutes (interquartile range: 26-58), 86% was performed using 1.5-Tesla MRI, and 14% was performed using 3.0-Tesla MRI. Ninety-five percent of MRI was performed for the cervical spine/head. Two MRI scans (1.6%), one of the shoulder and one of the head and cervical spine, with the external fixator outside of the bore were terminated early because of patient discomfort. There were no documented events of displacement or pullout of the external fixator. CONCLUSIONS: These findings suggest that MRI scans of the (cervical) spine and head can be safely obtained in patients with external fixators on the appendicular skeleton or pelvis. Given the low numbers of MRI scans performed with the external fixator inside the bore, additional studies are necessitated to determine the safety of this procedure. The results from this study can aid orthopaedic surgeons, radiologists, and other stakeholders in developing local institutional guidelines on MRI scanning with external fixators in situ. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Fixadores Externos , Fraturas Ósseas , Imageamento por Ressonância Magnética , Segurança do Paciente , Humanos , Masculino , Pessoa de Meia-Idade , Imageamento por Ressonância Magnética/métodos , Feminino , Estudos Retrospectivos , Adulto , Fraturas Ósseas/cirurgia , Fraturas Ósseas/diagnóstico por imagem , Fixação de Fratura/métodos , Centros de TraumatologiaRESUMO
Inpatient zoledronic acid (IP-ZA) administered during the initial fracture hospitalization significantly improves the osteoporosis treatment rate. Clinical outcomes of IP-ZA after hip fracture remain uncertain. Here we report a cohort study that emulated a randomized controlled trial using real-world data and evaluated the risk of all-cause-mortality and radiologically confirmed subsequent new fractures among patients hospitalized for a hip fracture who had received IP-ZA as compared with propensity-matched controls. A total of 654 patients who had received IP-ZA and 6877 controls (for whom anti-osteoporosis treatment was indicated but no IP-ZA started during index hospitalization) were included in the study. The primary cohort comprised 652 IP-ZA patients (IP-ZA group) and 1926 matched controls (untreated group), with 71.7% female 92.1% White participants, with a mean age of 80.9 years. Cumulative all-cause mortality over the 24-month follow-up for the IP-ZA group was 12.3% and 20.7% for the untreated group (hazard ratio [HR], 0.62; 95% CI, 0.49-0.78, p < .001). A total of 585 (89.7%) patients in IP-ZA group received only a single dose of ZA during the 24 months, and the death rate of this single dose group was 13.3%, which was significantly lower than that of the untreated group (HR, 0.70; 95% CI, 0.55-0.89, p = .003). Rates of radiologically confirmed cumulative subsequent new vertebral fractures were 2.0% in the IP-ZA group and 5.4% in the untreated group (HR, 0.40; 95% CI, 0.22-0.71, p = .001). A similarly lower rate of new vertebral fractures was seen in the single dose subgroup (1.9% vs 5.4%; HR, 0.44; 95% 0.24-0.82, p = .008). IP-ZA, administered during the initial hospitalization for hip fracture, was associated with lower all-cause-mortality and risk of radiologically confirmed subsequent new vertebral fractures, and thus offers a mechanism to narrow the treatment gap in patients having sustained a hip fragility fracture.
Hip fracture is a serious complication of osteoporosis affecting approximately 300 000 Americans per year and is associated with a 20%-30% 1-year mortality rate. Most patients with hip fracture are elderly (average age, 80-81 years), with multiple underlying medical conditions and are often unable to timely attend post-hospitalization outpatient follow-up to initiate anti-osteoporosis treatment. As a result, only ~10% of posthip fracture patients receive treatment for underlying osteoporosis. We have previously reported that zoledronic acid (ZA) administered during initial fracture hospitalization (IP-ZA) is safe and can effectively improve the osteoporosis treatment rate to 70%. The present study analyzed the clinical outcomes of 652 patients who had sustained hip fractures and were treated with IP-ZA and 1926 matched controls and revealed significantly reduced rates of all-cause mortality and vertebral compression fracture (VCF) during a 2-year follow-up period. Of note, nearly 90% of the treated patients received only a single dose of ZA (namely, IP-ZA), suggesting that, for most patients, the only opportunity to receive anti-osteoporosis treatment was during the index fracture hospitalization. Importantly, reduced mortality and VCF rates were readily seen in this single-dose group of patients. Our data suggest that IP-ZA is beneficial for osteoporotic hip fracture.
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Difosfonatos , Fraturas do Quadril , Hospitalização , Imidazóis , Ácido Zoledrônico , Humanos , Fraturas do Quadril/tratamento farmacológico , Ácido Zoledrônico/uso terapêutico , Feminino , Masculino , Idoso de 80 Anos ou mais , Difosfonatos/uso terapêutico , Imidazóis/uso terapêutico , Imidazóis/farmacologia , Idoso , Conservadores da Densidade Óssea/uso terapêuticoRESUMO
Context: Addressing vitamin D deficiency (VDD) is important for fracture secondary prevention. Objectives: To explore the function of a fracture liaison service (FLS) to address VDD. Design Setting and Patients: An observational study of patients admitted to the Massachusetts General Hospital with fractures between January 1, 2016, and October 31, 2023, cared for by the FLS. Intervention: Ergocalciferol 50 000 international units (50ku-D2) oral daily for 3 to 7 days. Main Outcomes Measures: VDD prevalence. Efficacy of inpatient daily 50ku-D2 in raising serum 25-hydroxyvitamin D (25OHD) levels. Results: Of the 2951 consecutive patients, 724 (24.53%) had VDD (defined by 25OHD ≤ 19â ng/mL). Men (252/897, or 28.09%) were more likely than women (472/2054, or 22.98%) to have VDD (P = .003). VDD was seen in 41.79% (117/280), 24.41% (332/1360), and 20.98% (275/1311) of patients of aged ≤59, 60 to 79, and ≥80 years, respectively (P < .00001). Of the 1303 patients with hip fractures, 327 (25.09%) had VDD, which was associated with a longer length of stay (8.37 ± 7.35 vs 7.23 ± 4.78 days, P = .009) and higher trend of 30-day-readmission rate (13.63% vs 18.35%, P = .037). In a cohort of 32 patients with complete data, each dose of 50ku-D2 increased serum 25OHD by 3.62 ± 2.35â ng/mL without affecting serum calcium or creatinine levels. Conclusion: VDD was seen in nearly 25% of Massachusetts General Hospital FLS patients and more prevalent in male and younger patients. VDD was associated with longer length of stay and higher 30-day-readmission risk in patients with hip fracture. Daily 50ku-D2 appeared to be a practical way to quickly replete vitamin D in the inpatient setting.
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OBJECTIVE: The objective of this study was to compare the quality of syndesmotic reduction with the ankle in maximal dorsiflexion versus neutral plantarflexion (normal resting position). METHODS: Baseline computed tomography (CT) imaging of 10 cadaveric ankle specimens from 5 donors was obtained with the ankles placed in normal resting position. Two fellowship-trained orthopaedic surgeons disrupted the syndesmosis of each ankle specimen. All ankles were then placed in neutral plantarflexion and were subsequently reduced with thumb pressure under direct visualization through an anterolateral approach and stabilized with one 0.062-inch K-wire placed from lateral to medial in a quadricortical fashion across the syndesmosis. Postreduction CT scans were then obtained with the ankle in normal resting position. This process was repeated with the ankles placed in maximal dorsiflexion during reduction and stabilization. Postreduction CT scans were then obtained with the ankles placed in normal resting position. All postreduction CT scans were compared with baseline CT imaging using mixed-effects linear regression with significance set at P < 0.05. RESULTS: Syndesmotic reduction and stabilization in maximal dorsiflexion led to increased external rotation of the fibula compared with baseline scans [13.0 ± 5.4 degrees (mean ± SD) vs. 7.5 ± 2.4 degrees, P = 0.002]. There was a tendency toward lateral translation of the fibula with the ankle reduced in maximal dorsiflexion (3.3 ± 1.0 vs. 2.7 ± 0.7 mm, P = 0.096). No other statistically significant differences between measurements of reduction with the ankle placed in neutral plantarflexion or maximal dorsiflexion compared with baseline were present (P > 0.05). CONCLUSIONS: Reducing the syndesmosis with the ankle in maximal dorsiflexion may lead to malreduction with external rotation of the fibula. There was no statistically significant difference in reduction quality with the ankle placed in neutral plantarflexion compared with baseline. Future studies should assess the clinical implications of ankle positioning during syndesmotic fixation.
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Articulação do Tornozelo , Cadáver , Humanos , Articulação do Tornozelo/diagnóstico por imagem , Articulação do Tornozelo/cirurgia , Articulação do Tornozelo/anatomia & histologia , Articulação do Tornozelo/fisiologia , Traumatismos do Tornozelo/cirurgia , Traumatismos do Tornozelo/diagnóstico por imagem , Masculino , Posicionamento do Paciente , Feminino , Fraturas do Tornozelo/cirurgia , Fraturas do Tornozelo/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Idoso , Pessoa de Meia-Idade , Fixação Interna de Fraturas/métodos , Amplitude de Movimento Articular/fisiologiaRESUMO
PURPOSE: For polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 h) versus delayed (>24 h) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. METHODS: The 2017-2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 h, delayed definitive fixation (DDF) as fixation of both fractures after 24 h, and early staged fixation (ESF) as fixation of one femur within 24 h and the other femur after 24 h. Propensity score matching and multilevel mixed effects regression models were used to compare groups. RESULTS: 1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p = 0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p = 0.012), a shorter ICU LOS (5 vs 7 days, p < 0.001) and a shorter hospital LOS (10 vs 15 days, p < 0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p = 0.007), but a longer ICU LOS (8 vs 6 days, p = 0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 h and total hospital LOS by 27 h. CONCLUSION: Early definitive fixation (≤ 24 h) is preferred over delayed definitive fixation (>24 h) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.
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Fraturas do Fêmur , Tempo de Internação , Humanos , Fraturas do Fêmur/cirurgia , Feminino , Masculino , Adulto , Pessoa de Meia-Idade , Tempo de Internação/estatística & dados numéricos , Traumatismo Múltiplo/cirurgia , Estudos Retrospectivos , Tempo para o Tratamento/estatística & dados numéricos , Fixação de Fratura/métodos , Complicações Pós-Operatórias/epidemiologia , Fixação Interna de Fraturas/métodos , Resultado do Tratamento , Melhoria de Qualidade , Pontuação de Propensão , Fatores de TempoRESUMO
OBJECTIVE: To compare the adverse event profile and patient comorbidity profile of lower extremity orthopaedic trauma patients admitted via interfacility transfer (IT) to direct admission (DA) patients from home. METHODS: A total of 39,497 patients from 2012 to 2019 were identified in the American College of Surgeon National Surgical Quality Improvement Program database. DA patients were compared with IT patients for differences in preoperative comorbidities, adverse events, length of stay, and readmissions in the 30-day postoperative period. Student t tests were used to assess continuous variables. Pearson χ 2 test and odds ratios (ORs) were used for categorical variables. RESULTS: The IT group comprised 7167 patients, and the DA group comprised 32,330 patients. IT patients were on average older (65.5 vs. 58.8 years, P < 0.01), more likely to be American Society of Anesthesiologists Status >2 ( P < 0.01), and had a worse comorbidity profile for numerous preoperative risk factors. IT patients had significantly higher rates of mortality [3.3% vs. 1.4%; odds ratio (OR) 2.29; 95% confidence interval (CI), 1.96-2.77], major complications (10.2% vs. 6.1%; OR 1.74; 95% CI, 1.60-1.91), significantly higher readmission rates (5.8% vs. 4.8%, P < 0.01, OR 1.22 95% CI, 1.09-1.36), and more infectious complications (7% vs. 4.7%; OR 1.54; 95% CI, 1.38-1.71) than DA patients. Transfer remained a significant factor predicting major adverse events in regression analysis controlling for patient characteristics and fracture type ( P < 0.01; B 1.197; 95% CI, 1.09-1.32). CONCLUSIONS: This study revealed that IT patients undergoing operative management of pelvic, acetabular, and lower extremity fractures are at a significantly increased risk of major complications, readmission, and have a higher morbidity burden than DA patients. As healthcare transitions to value-based care and bundled payments, hospitals that accept a high volume of ITs will face exposure to added risk and financial penalties without adequate policy protections. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fraturas Ósseas , Traumatismos da Perna , Transição para Assistência do Adulto , Humanos , Estados Unidos/epidemiologia , Readmissão do Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Fraturas Ósseas/epidemiologia , Fraturas Ósseas/cirurgia , Fraturas Ósseas/complicações , Traumatismos da Perna/complicações , Fatores de Risco , Extremidade Inferior/cirurgia , Estudos RetrospectivosRESUMO
CONTEXT: Zoledronic acid (ZA) administered during the initial hospitalization for a fragility fracture improves the osteoporosis pharmacotherapy rate. Distinguishing the safety profile of inpatient ZA (IP-ZA) in this context is crucial if this approach is to be widely adopted. OBJECTIVE: To study the acute safety profile of IP-ZA. METHODS: An observational study of patients admitted to the Massachusetts General Hospital with fragility fractures who were eligible to receive IP-ZA. Patients were treated with or without IP-ZA. Acetaminophen, either as a single pre-ZA dose or standing multiple-doses-per-day regimen for 48 hours or longer after ZA infusion, was also administered along with protocolized vitamin D and calcium supplementation. Changes in body temperature, serum creatinine, and serum calcium were measured. RESULTS: A total of 285 consecutive patients, meeting inclusion and exclusion criteria, are included in this analysis; 204 patients received IP-ZA. IP-ZA treatment was associated with a transient mean rise of body temperature of 0.31 °C on the day following its administration. Temperatures above 38 °C were seen in 15% of patients in the IP-ZA group and 4% in the nontreated group. Standing multiple-doses-per-day but not a single pre-ZA dose of acetaminophen effectively prevented this temperature increase. IP-ZA did not affect serum creatinine levels. Mean levels of serum total calcium and albumin-corrected calcium decreased by 0.54 mg/dL and 0.40 mg/dL, respectively, at their nadirs (Day 5). No patient experienced symptomatic hypocalcemia. CONCLUSION: IP-ZA along with standing multiple-doses-per-day acetaminophen, administered to patients in the immediate postfracture period, is not associated with significant acute adverse effects.
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Conservadores da Densidade Óssea , Fraturas Ósseas , Humanos , Acetaminofen , Conservadores da Densidade Óssea/efeitos adversos , Cálcio , Creatinina , Difosfonatos/efeitos adversos , Fraturas Ósseas/prevenção & controle , Fraturas Ósseas/induzido quimicamente , Imidazóis/efeitos adversos , Pacientes Internados , Ácido ZoledrônicoRESUMO
ABSTRACT: Most of the current orthopaedic residents are considered Millennials (born between 1981 and 1996) and are often trained by attending surgeons who are from Generation X (born between 1965 and 1980) or the Baby Boomer generation (born between 1946 and 1964). The Generation X orthopaedic surgeons were largely trained by Baby Boomers who were very demanding of their trainees and expected excellence. The Baby Boomers had been inspired, mentored, and trained by the Greatest Generation (born between 1901 and 1927). Baby Boomers took nothing for granted and nothing was given to them on a silver platter. Generation X was trained under these premises and was expected to abide by similar values. Regarding the next generation of residents, current faculty hope to instill the same qualities that had been instilled in them during their training. This value transference sometimes presents a challenge because of the differences in attitudes and perspectives that may exist between Millennial residents and their predecessors regarding work-life balance, teaching styles, the regulation of duty hours, and feedback assessments. These differences require an evolution in the methods of surgical education to optimize the educational benefit and ensure good will and rapport between the generations. Trainees and faculty alike have a responsibility to understand each other's differences and come together to ensure that knowledge, experience, values, and skill sets are effectively passed on to a new generation of orthopaedic surgeons.
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Internato e Residência , Cirurgiões Ortopédicos/educação , Ortopedia/educação , Recursos Humanos , Escolaridade , HumanosRESUMO
BACKGROUND: Discharge to an inpatient care facility (skilled-care or rehabilitation) has been shown to be associated with adverse outcomes following elective total joint arthroplasties. Current evidence with regard to hip fracture surgeries remains limited. METHODS: The 2015-2016 ACS-NSQIP database was used to query for patients undergoing total hip arthroplasty, hemiarthroplasty and open reduction internal fixation for hip fractures. A total of 15,655 patients undergoing hip fracture surgery were retrieved from the database. Inpatient facility discharge included discharges to skilled-care facilities and inpatient rehabilitation units. Multi-variate regression analysis was used to assess for differences in 30-day post-discharge outcomes between home-discharge versus inpatient care facility discharge, while adjusting for baseline differences between the 2 study populations. RESULTS: A total of 12,568 (80.3%) patients were discharged to an inpatient care facility. Discharge to an inpatient care facility was associated with higher odds of any complication (OR 2.03 [95% CI, 1.61-2.55]; p < 0.001), wound complications (OR 1.79 [95% CI, 1.10-2.91]; p = 0.019), cardiac complications (OR 4.49 [95% CI, 1.40-14.40]; p = 0.012), respiratory complication (OR 2.29 [95% CI, 1.39-3.77]; p = 0.001), stroke (OR 7.67 [95% CI, 1.05-56.29]; p = 0.045, urinary tract infections (OR 2.30 [95% CI, 1.52-3.48]; p < 0.001), unplanned re-operations (OR 1.37 [95% CI, 1.03-1.82]; p = 0.029) and readmissions (OR 1.38 [95% CI, 1.16-1.63]; p < 0.001) following discharge. CONCLUSION: Discharge to inpatient care facilities versus home following hip fracture surgery is associated with higher odds of post-discharge complications, re-operations and readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimise the risk of complications.
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Artroplastia de Quadril , Fraturas do Quadril , Assistência ao Convalescente , Artroplastia de Quadril/efeitos adversos , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/cirurgia , Humanos , Incidência , Pacientes Internados , Alta do Paciente , Readmissão do Paciente , Complicações Pós-Operatórias/epidemiologia , Fatores de RiscoRESUMO
BACKGROUND: The Letournel and Judet classification system is commonly used for classifying acetabular fractures. However, for orthopaedic surgeons with less experience with these fractures, correct classification can be more difficult. A stepwise approach has been suggested to enhance the inexperienced observer's ability to properly classify acetabular fractures, but it is unclear whether this actually improves one's ability. QUESTIONS/PURPOSES: We asked (1) whether the use of a step-by-step algorithm improves residents' ability to classify acetabular fractures, (2) whether resident experience influenced ability to correctly classify acetabular fractures, and (3) which acetabular fractures were the most difficult to classify? METHODS: Forty-six residents reviewed 15 sets of plain radiographs of 10 acetabular fracture patterns. Residents used the Letournel and Judet classification with only a diagram for reference. Three weeks later they were asked to classify the fractures a second time with the use of the algorithm. We then compared the number of correct responses from the two sessions and determined whether resident experience and use of the algorithm influenced correct classification. RESULTS: We found an improvement in the number of correctly classified fractures between the first (348/690 [50%]) and second (409/690 [59%]) sessions. Thirty-two of 46 participants improved their score with the use of the algorithm. There was a tendency for participants with more residency training to correctly classify the fractures. CONCLUSIONS: The algorithm provided modest improvement to the residents' ability to classify acetabular fractures. This or other such algorithms could provide residents with a basic tool to better evaluate standard radiographs and classify acetabular fractures.
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Acetábulo/lesões , Competência Clínica , Fraturas Ósseas/classificação , Fraturas Ósseas/cirurgia , Internato e Residência , Ortopedia/educação , Acetábulo/diagnóstico por imagem , Algoritmos , Fraturas Ósseas/diagnóstico por imagem , Humanos , RadiografiaRESUMO
INTRODUCTION: Despite an increasing number of elderly individuals undergoing surgical fixation for ankle fractures, few studies have investigated peri-operative outcomes and safety of surgery in an octogenarian and nonagenarian population (age >80 years). MATERIALS AND METHODS: The 2012-2017 American College of Surgeons database was queried for patients undergoing open reduction internal fixation for isolated uni-malleolar, bi-malleolar and tri-malleolar ankle fractures. The study cohort was divided into 3 comparison groups (age <65 years, 65-75 and >80). Multi-variate regression analyzes were used to compare the independent effect of varying age groups on 30-day post-operative outcomes while controlling for baseline clinical characteristics and co-morbidity burdens. RESULTS: A total of 19,585 patients were included: 5.3% were >80 years, 18.1% were 65-79 years, and 76.6% were <65 years. When compared to the non-geriatric population, individuals >80 years were at a significantly Abstract: higher risk of 30-day wound complications (OR 1.84; p = 0.019), pulmonary complications (OR 3.88; p < 0.001), renal complications (OR 1.96; p = 0.015), septic complications (OR 3.72; p = 0.002), urinary tract infections (OR 2.24; p < 0.001), bleeding requiring transfusion (OR 1.90; p = 0.025), mortality (or 7.44; p < 0.001), readmissions (OR 1.65; p = 0.004) and non-home discharge (OR 13.91; p < 0.001). DISCUSSION: Octogenarians undergoing ankle fracture fixation are a high-risk population in need of significant pre-operative surgical and medical optimization. With the majority of patients undergoing non-elective ORIF procedures, it is critical to anticipate potential complications and incorporate experienced geriatric providers early in the surgical management of these patients. CONCLUSIONS: Octogenarians and nonagenarians are fundamentally distinct and vulnerable age groups with a high risk of complications, readmissions, mortality and non-home discharges compared to other geriatric (65-79 years) and non-geriatric (<65 years) patients. Pre-operative counseling and risk-stratification are essential in this vulnerable patient population.