A. Alex Jahangir

Patient variables which may predict length of stay and hospital costs in elderly patients with hip fracture.

Objectives: To investigate what factors contribute to increased length of stay (LOS) and increased costs in treatment of elderly patients with hip fractures. Design: Retrospective chart review. Setting: All patients who presented to a large tertiary care center between January 2000 and December 31, 2009. Participants: Charts for all patients older than 60 years who presented with isolated low-energy hip fractures were reviewed. Of the 719 patients identified, 660 were included. Intervention: Patients who underwent operative fixation or hemiarthroplasty secondary to hip fracture were identified using a search of Current Procedural Terminology (CPT) codes search. Main Outcome Measurements: Gender, height, weight, body mass index, length of procedure, American Society of Anesthesiologists (ASA) classification, and medical comorbidities were gathered and compared with LOS and direct daily inpatient hospital cost. Results: No correlation existed between body mass index or specific comorbidities and LOS, but ASA classification was a predictor. For each ASA increase of 1, average LOS increased 2.053 days (P < 0.001). Given total daily cost to the hospital for these patients was

Health literacy in an orthopedic trauma patient population: A cross-sectional survey of patient comprehension

4530, each increase in ASA classification translated to an increase of

Stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries

9300. Conclusions: ASA classification proved useful in estimating LOS and cost for patients undergoing operative fixation of hip fractures. Because ASA classification and cost are universally collected, this method can be employed in almost any hospital. This highlights a role for ASA classification in preoperative estimation of the elderly patients cost and a potential advantage for incorporating patient factors in the development of tiered reimbursement models. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Is there a gluteus medius tendon injury during reaming through a modified medial trochanteric portal? A cadaver study.

Objectives: The aim of this study was to evaluate the level of comprehension in an orthopedic trauma patient population regarding injury, surgery, and postoperative instructions and to determine if educational background is associated with inadequate comprehension. Design: This involved a prospective observational cohort. Setting: The study was conducted at an Academic Level 1 trauma center. Patients: From April to June 2011, 248 orthopedic trauma patients with an operatively fixed isolated fracture were found to be eligible for inclusion. One hundred forty-six eligible questionnaires were collected (58.9% response rate). Intervention: The patients were administered a questionnaire during their first postoperative visit before being seen by a physician. The questionnaire included demographic information and questions regarding (1) which bone was fractured; (2) the type of implanted fixation; (3) weight-bearing status; (4) expected recovery time; and (5) need for deep vein thrombosis (DVT) prophylaxis. Multivariable logistic regression analyses were used to examine the association between educational level and questions regarding surgical procedure and discharge instructions. Results: The overall mean score of all the patients on the patient comprehension portion was 2.54 ± 1.27 correct responses out of 5. Only 47.9% of patients knew the bone they fractured, and 18.5% knew their expected healing time. Of the patients, 66.4% knew the type of implanted fixation, and 45.2% knew their weight-bearing status. The patients (74.0%) knew their DVT prophylaxis medication(s). The mean score for patients in the group ⩽ HS (high-school education or less) was 2.26, whereas the mean score for patients in the group > HS (more than high-school education) was 3.00 (P = 0.0009). The patients in the group > HS were 2.54 times more likely to know the bone they fractured (P = 0.01), 3.82 times more likely to know the recovery time (P = 0.004), and 2.79 times more likely to know their DVT prophylaxis medication(s) than patients in the group ⩽ HS. Conclusions: Orthopedic trauma patients demonstrated limited comprehension of their injuries, surgeries, and postoperative instructions. Patients with lower educational levels did significantly worse on the questionnaire than those with higher educational levels. The results of the study highlight a lack of comprehension within this patient population and suggest that an increased focus on patient communication by orthopedic providers may be necessary. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The prevalence and costs of defensive medicine among orthopaedic trauma surgeons: a national survey study.

BACKGROUND Hyperglycemia in nondiabetic patients outside the intensive care unit is not well defined. We evaluated the relationship of hyperglycemia and surgical site infection (SSI) in stable nondiabetic patients with orthopedic injuries. METHODS We conducted a prospective observational cohort study at a single academic Level 1 trauma center over 9 months (Level II evidence for therapeutic/care management). We included patients 18 years or older with operative orthopedic injuries and excluded patients with diabetes, corticosteroid use, multisystem injuries, or critical illness. Demographics, medical comorbidities (American Society of Anesthesiologists class), body mass index, open fractures, and number of operations were recorded. Fingerstick glucose values were obtained twice daily. Hyperglycemia was defined as a fasting glucose value greater than or equal to 125 mg/dL or a random value greater than or equal to 200 mg/dL on more than one occasion before the diagnosis of SSI. Glycosylated hemoglobin level was obtained from hyperglycemic patients; those with glycosylated hemoglobin level of 6.0 or greater were considered occult diabetic patients and were excluded. SSI was defined by a positive intraoperative culture at reoperation within 30 days of the index case. RESULTS We enrolled 171 patients. Of these 171, 40 (23.4%) were hyperglycemic; 7 of them were excluded for occult diabetes. Of the 164 remaining patients, 33 were hyperglycemic (20.1%), 50 had open fractures (6 Type I, 22 Type II, 22 Type III), and 12 (7.3%) had SSI. Hyperglycemic patients were more likely to develop SSI (7 of 33 [21.2%] vs. 5 of 131 [3.8%], p = 0.003). Open fractures were associated with SSI (7 of 50 [14%] vs. 5 of 114 [4.4%], p = 0.047) but not hyperglycemia (10 of 50 [20.0%] vs. 23 of 114 [20.2%], p = 0.98). There was no significant difference between infected and noninfected patients in terms of age, sex, race, American Society of Anesthesiologists class, obesity (body mass index > 29), tobacco use, or number of operations. CONCLUSION Stress hyperglycemia was associated with SSI in this prospective observational cohort of stable nondiabetic patients with orthopedic injuries. Further prospective randomized studies are necessary to identify optimal treatment of hyperglycemia in the noncritically ill trauma population. LEVEL OF EVIDENCE Therapeutic study, level III.

Occupational Injury Among Orthopaedic Surgeons

Objectives: The purpose of this cadaveric study was to evaluate whether there is any damage to the gluteus medius tendon when reaming through a modified medial trochanteric portal for antegrade intramedullary femoral nailing. Methods: Ten cadaver hips were used in this study. A guidewire was placed in the modified medial trochanteric portal using the assistance of C-arm fluoroscopy and a 14-mm reamer was advanced over the wire. After the reaming was complete, each hip was dissected and the gluteus medius muscle and tendon were inspected to evaluate the amount of intrasubstance and medial tendon damage. Results: Precise localization of the modified medial trochanteric portal was achieved in 9 of 10 cadaver hips. Of those nine hips, the use of the modified medial trochanteric portal did not result in any visible damage to the tendinous insertion of the gluteus medius or the medial aspect of the tendon in any of the specimens. Conclusions: There is no damage to the gluteus medius tendon with the use of the modified medial trochanteric portal. Although the clinical implications of this finding are not known with certainty, the use of the modified medial trochanteric entry portal for antegrade femoral nailing could possibly result in less postoperative morbidity because it does not damage the gluteus medius tendon as compared to the traditional more lateral trochanteric portal.

Gunshot victims at a major level i trauma center: a study of 343,866 emergency department visits

Objectives: Defensive medicine includes medical practices that exonerate physicians from liability without benefit to patients. The national prevalence of defensive medicine in orthopaedic trauma surgery has not been investigated. Methods: In September 2010, 2000 orthopaedic surgeons randomly chosen from the American Academy of Orthopaedic Surgeons registry received invitations to answer a survey on defensive medicine. Among these surgeons, 1214 (61%) completed the survey and 222 (18.5%) identified themselves as nonmilitary orthopaedic traumatologists. Cost analysis was performed using Centers for Medicare and Medicaid data at the 2011 current procedural terminology code level and then aggregated to reflect the 8 domains of care assessed. Results: For orthopaedic traumatologists, on average 22% of all ordered tests were for defensive reasons (radiography, 19%; computed tomographic scanning, 23%; magnetic resonance imaging, 27%; ultrasound, 42%; referrals, 29%; laboratory tests, 23%; and biopsies, 16%). Defensive hospital admissions averaged 9% each month. Orthopaedic traumatologists reported fewer referrals to specialists compared with non-trauma orthopaedists (P = 0.02), with no significant difference in overall monthly defensive expenditures. Using 2011 current procedural terminology code reimbursement data, defensive medicine costs per respondent were calculated to be approximately

The effects of American Society of Anesthesiologists physical status on length of stay and inpatient cost in the surgical treatment of isolated orthopaedic fractures.

7800 monthly or

Value-based purchasing of medical devices.

94,000/y, which is 20% of each physicians spending. Given the approximately 2724 orthopaedic trauma surgeons in practice in the United States according to the 2010 American Academy of Orthopaedic Surgeons Census, the national cost of defensive medicine for orthopaedic trauma surgery is estimated to be

Ankle radiographs in the early postoperative period: do they matter?

256.3 million annually. Conclusions: Defensive medicine among orthopaedic trauma surgeons is a significant factor in health care costs and of marginal benefit to patients. Policies aimed at managing liability risk may be useful in containing such practices. Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.