Incidence and reasons for hardware removal following operative fixation of distal radius fractures.

PURPOSE: To determine the incidence and reasons for hardware removal after operative fixation of distal radius fractures. METHODS: We retrospectively reviewed 33 patients who underwent removal of a volar distal radius plate from 2007 to 2013. We recorded the primary reason for plate removal, patient sex, body mass index, AO fracture type, and plate manufacturer. The total number of both distal radius plating procedures and implant removals was analyzed. RESULTS: Of the 33 patients who underwent implant removal, the most common reasons for removal were pain (30%), tenosynovitis (27%), malunion (24%), infection (12%), nonunion (6%), and tendon rupture (3%). The most common AO fracture types requiring plate removal were A2, C2, and C3 (7 each). A total of 517 distal radius fractures received plate fixation at our institution from 2007 to 2009, a number that rose to 610 from 2010 to 2012. The number of distal radius plate removals over that same time was relatively constant at 17 and 16, respectively. CONCLUSIONS: We advise continued review of reasons for implant removal to limit future hardware complications related to volar plating of distal radius fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A Quality Improvement Approach to Improving Discharge Documentation.

Introduction: Accurate discharge documentation is critical to ensuring a safe and effective transition of care following hospitalization, yet many discharge summaries do not meet consensus standards for content. A local needs assessment demonstrated gaps in documentation of 3 essential elements: discharge diagnosis, discharge medications, and follow-up appointments. This study aimed to increase the completion of three discharge elements from a baseline of 45% by 20 percentage points over 16 months for patients discharged from the general pediatrics service. Methods: Ten discharge summaries were randomly selected and analyzed during each successive 2-week time period. Plan-Do-Study-Act cycles aimed to improve provider knowledge of essential discharge summary content, clarify communication during rounds, and create electronic health record shortcuts and quick-reference tools. Results: The percentage of discharge summaries containing all 3 required elements increased from 45% to 73%. Specifically, documentation increased for discharge diagnosis (65%-87%), discharge medications (71%-90%), and follow-up appointments (88%-93%). There was no significant delay in discharge summary completion. Conclusions: Discharge summaries are meaningfully and sustainably improved through provider education, workflows for clear communication, and electronic health record optimization.

Intramedullary Nailing Compared with Spica Casts for Isolated Femoral Fractures in Four and Five-Year-Old Children.

BACKGROUND: Flexible intramedullary nailing (IMN) is a valuable tool in the treatment of femoral fractures in school-age children, whereas spica cast immobilization has been the standard of care for younger children. We compared these treatment modalities in a group of preschool-age children (four to five years of age). METHODS: A retrospective cohort of consecutive patients, four to five years of age, with an isolated, complete femoral shaft or subtrochanteric fracture treated with intramedullary nailing or early spica cast immobilization and followed until fracture-healing were identified from two centers. Radiographic and clinical outcomes were compared between the groups. Statistical methods included chi-square and Fisher exact tests for categorical variables and the Mann-Whitney test for continuous variables. RESULTS: Two hundred and sixty-two patients followed for a mean of thirty-two weeks were identified. One hundred and four patients underwent IMN and 158 patients were treated with immediate spica cast immobilization at the surgeon's discretion. The patients who underwent IMN were older than those who underwent spica cast immobilization (mean, 5.2 versus 4.7 years; p < 0.001), were heavier (mean, 21.5 versus 18.0 kg; p < 0.001), and were more likely to have a higher-energy mechanism of injury (p = 0.025). At the time of final follow-up, there was no difference between groups with regard to the percentages of patients who had acceptable coronal angulation (≤15°), sagittal angulation (≤20°), and early fracture shortening (≤20 mm) (96.2% in the spica group versus 99.0% in the IMN group; p = 0.09). While there was no significant difference in the percentages who had an unplanned return to the operating room (3.8% in the IMN group versus 4.4% in the spica group; p > 0.99), the patients in the IMN group had more clinic visits (mean, 5.8 versus 4.0; p < 0.001) and longer follow-up (mean, forty-four versus twenty-five weeks; p < 0.001) than the patients in the spica group and a higher percentage of them underwent repeat procedures (89.4% versus 5.1%; p < 0.001), primarily for elective implant removal. CONCLUSIONS: Preschool-age children (four to five years old) with an isolated femoral fracture have similar clinical and radiographic outcomes regardless of whether they are treated with immediate spica cast immobilization or IMN.

Ankle fractures and employment: a life-changing event for patients.

PURPOSE: Ankle fractures, one of the most common types of orthopaedic injury, have been associated with reduced functional outcome and significant changes in long-term employment. Although information on unemployment following ankle fractures can be important in cases of financial compensation, no studies have investigated rates of short-term disability and employment status among patients who have suffered isolated ankle fractures in the US. METHOD: We retrospectively reviewed 573 medical charts for patients who were treated for ankle fractures in the last 3 years at a level I trauma center. A total of 83 non-elderly patients that had isolated ankle fractures were contacted and surveyed over the phone. Patients were asked about employment history and current status, disability, type of fracture, and demographic information. RESULTS: Fifty-three (62%) patients contacted were employed at the time of injury. In all, 34% (n = 18) of patients lost their job because of their injury, of which only 8 (44%) received new employment. A total of 15% (n = 8) of patients that were previously employed decided to no longer return to work. Ten patients (56%) received disability status. CONCLUSIONS: Ankle fracture patients are likely to suffer high rates of unemployment or disability shortly after their injury. Further investigations with a larger-scale, randomized patient population can provide important information on employment status following ankle fractures.

Do practice settings influence defensive medicine in orthopedic surgery?

Defensive medicine is often practiced out of fear of legal liability. We conducted a study to compare the costs of defensive medicine among US orthopedic surgeons by practice type and American Medical Association (AMA) state medical liability classification. Two thousand surgeons registered with the American Academy of Orthopaedic Surgeons were sent a survey on defensive medicine. Costs were analyzed using 2011 Centers for Medicare and Medicaid Services data. Of the 2000 surgeons, 1214 (61%) completed the survey. Results showed that defensive tests were ordered by a higher proportion of nonacademic physicians than academic physicians in all 8 categories of orthopedic care, with a mean difference of $2348 in monthly defensive expenditures between groups. A higher rate of defensive testing by orthopedists in AMA crisis states versus safe states was also observed in 6 of the 8 areas of care studied, with mean monthly defensive expenditures ranging from $9208 in crisis states to $6596 in safe states. Defensive orthopedics contributes significantly to health care costs, with marginal benefit to patients-especially in nonacademic and crisis-state orthopedics practices.