Austin D. Hill

Use of Continuous Passive Motion in the Postoperative Treatment of Intra-Articular Knee Fractures

BACKGROUND The use of continuous passive motion in the postoperative treatment of intra-articular fractures around the knee is increasing. The purpose of this study was to determine the effects of a continuous passive motion device on knee range of motion after operative treatment of intra-articular fractures around the knee. METHODS Forty patients with intra-articular fractures of either the proximal part of the tibia or the distal end of the femur were prospectively randomized to the use of continuous passive motion or standardized physical therapy in the immediate postoperative period for forty-eight hours. The primary outcome was knee range of motion. Secondary outcome measures included pain scores, Lower Limb Outcomes Questionnaire scores, and Short Musculoskeletal Function Assessment scores. Evaluations were conducted at forty-eight hours, two weeks, six weeks, three months, and six months postoperatively. RESULTS There was no significant difference in knee extension between the groups at any time point measured. Knee flexion was significantly greater at forty-eight hours in the group managed with the continuous passive motion device than in the group managed without the continuous passive motion device (p < 0.005). However, there was no significant difference in knee flexion at any other time point. There was no significant difference in knee pain at forty-eight hours between groups. Six (30%) of twenty patients were unable to tolerate the use of the continuous passive motion device. There were no significant differences in overall complications. CONCLUSIONS The results of this study suggest that the use of continuous passive motion in the immediate postoperative period following the treatment of intra-articular fractures offers no benefit with regard to knee motion at six months and is not tolerated by all patients. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Clinical and Economic Impact of Duplicated Radiographic Studies in Trauma Patients Transferred to a Regional Trauma Center.

Objectives: Many trauma patients are evaluated at community hospitals and rural emergency departments before transfer to regional trauma centers. Radiographic studies are often duplicated, leading to significant additional costs to the healthcare system. Our purpose is to identify the reasons for duplicate studies, the costs associated with this practice, and potential clinical effects to patients. Methods: The institutional trauma database was queried to identify patients with orthopaedic injuries transferred to our regional trauma center. Patient demographics, mechanism of injury, referring hospital, reason for transfer, payor source, injury severity score, and Glasgow Coma Score (GCS) were recorded. Duplicate imaging studies were identified and confirmed with each outlying hospital radiology department. The radiation exposure was estimated based on average reported values. The cost of duplicated studies was derived from the Medicare fee schedule. Results: In 1 calendar year, a total of 513 patients were accepted in transfer from 36 outlying facilities. Almost half of the patients (47.7%) had at least 1 radiographic study repeated. There was a significant association between repeated study and age (P < 0.0001), Injury Severity Score (P < 0.0001), and GCS (P < 0.0001). No association was identified for size of transferring institution, injury mechanism, or payor status. Reasons listed for duplication included inadequate data transfer, poor quality, inadequate study, and physician preference. The additional cost to the healthcare system is estimated to be

Improving business IQ in medicine through mentorship and education.

94,000. Conclusions: The duplication of imaging studies at regional trauma centers is a common problem that represents a significant opportunity for cost savings and reduction of patient exposure to radiation by implementing imaging protocols at outlying facilities and improving the transfer of imaging data through information technology solutions. Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Why veteran orthopaedic trauma surgeons are being fired and what we can do about it

Summary: Business intelligence in the field of medicine, particularly with physicians, has been an abstract concept at best with no objective metric. Furthermore, in many arenas, it was taboo for medical students, residents, and physicians to discuss the business and finances of their work for fear that it would interfere with their sacred duties as health care providers. There has been a substantial shift in this philosophy over the last few decades with the growth and evolution of the health care industry in the United States. In 2012, health care expenditures accounted for 17.2% of the United States Gross Domestic Product, averaging

Health Utility of Early Hemiarthroplasty vs Delayed Total Hip Arthroplasty for Displaced Femoral Neck Fracture in Elderly Patients: A Markov Model

8915 per person. The passage of the Affordable Care Act in March of 2010 sent a clear message to all that change is coming, and it is more important now than ever to have physician leaders whose skills and knowledge in business, management, and health care law rival their acumen within their medical practice. Students, residents, and fellows all express a desire to gain more business knowledge throughout their education and training, but many do not know where to begin or have access to programs that can further their knowledge. Whether you are an employed or private practice physician, academic or community based, improving your business intelligence will help you get a seat at the table where decisions are made and give you the skills to influence those decisions.

Reno orthopaedic trauma fellowship business curriculum

The financial realities of providing trauma care to injured patients can make it difficult to produce an accurate assessment of the cumulative value orthopaedic trauma surgeons provide to healthcare and university institutions. As with many political battles in the field of medicine, physicians who have been diligently focused on providing patient care were completely unaware of the impending upheaval around them. Whether orthopaedic trauma surgeons are employed or in some type of partnership with hospitals, too often surgeons find the relationship one-sided. In order to effectively negotiate with hospitals, surgeons must demonstrate the comprehensive value they provide to their respective healthcare institutions and universities. Orthopaedic trauma surgeons make direct and indirect financial contributions to the hospital in addition to educational and community services. The sum total of these valued contributions helps fund non-revenue generating programs, provides marketing opportunities, and improves the regional and national reputation of the healthcare institution. This paper provides a comprehensive review of the value contributed to healthcare institutions by orthopaedic trauma surgeons and will serve as a blueprint for all surgeons to accurately account for and demonstrate their value to hospitals while providing efficient and compassionate care to our patients.

Radial Head and Neck Fracture

BACKGROUND Treatment for femoral neck fracture among patients aged 65 years or older varies, with many surgeons preferring hemiarthroplasty (HA) over total hip arthroplasty (THA). There is evidence that THA may lead to better functional outcomes, although it also carries greater risk of mortality and dislocation rates. METHODS We created a Markov decision model to examine the expected health utility for older patients with femoral neck fracture treated with early HA (performed within 48 hours) vs delayed THA (performed after 48 hours). Model inputs were derived from the literature. Health utilities were derived from previously fit patients aged more than 60 years. Sensitivity analyses on mortality and dislocation rates were conducted to examine the effect of uncertainty in the model parameters. RESULTS In the base case, the average cumulative utility over 2 years was 0.895 for HA and 0.994 for THA. In sensitivity analyses, THA was preferred over HA until THA 30-day and 1-year mortality rates were increased to 1.3× the base case rates. THA was preferred over HA until the health utility for HA reached 98% that of THA. THA remained the preferred strategy when increasing the cumulative incidence of dislocation among THA patients from a base case of 4.4% up to 26.1%. CONCLUSION We found that delayed THA provides greater health utility than early HA for older patients with femoral neck fracture, despite the increased 30-day and 1-year mortality associated with delayed surgery. Future studies should examine the cost-effectiveness of THA for femoral neck fracture.

Personal finances for the physician: A primer on maintaining and protecting your earnings

Summary: The Reno Orthopaedic Center (ROC) Trauma Fellowship business curriculum is designed to provide the fellow with a graduate level business practicum and research experience. The time commitments in a typical 12-month trauma fellowship are significant, rendering a traditional didactic masters in business administration difficult to complete during this short time. An organized, structured, practical business education can provide the trauma leaders of tomorrow with the knowledge and experience required to effectively navigate the convoluted and constantly changing healthcare system. The underlying principle throughout the curriculum is to provide the fellow with the practical knowledge to participate in cost-efficient improvements in healthcare delivery. Through the ROC Trauma Fellowship business curriculum, the fellow will learn that delivering healthcare in a manner that provides better outcomes for equal or lower costs is not only possible but a professional and ethical responsibility. However, instilling these values without providing actionable knowledge and programs would be insufficient and ineffective. For this reason, the core of the curriculum is based on individual teaching sessions with a wide array of hospital and private practice administrators. In addition, each section is equipped with a suggested reading list to maximize the learning experience. Upon completion of the curriculum, the fellow should be able to: (1) Participate in strategic planning at both the hospital and practice level based on analysis of financial and clinical data, (2) Understand the function of healthcare systems at both a macro and micro level, (3) Possess the knowledge and skills to be strong leaders and effective communicators in the business lexicon of healthcare, (4) Be a partner and innovator in the improvement of the delivery of orthopaedic services, (5) Combine scientific and strategic viewpoints to provide an evidence-based strategy for improving quality of care in a cost-efficient manner, (6) Understand the political, economic, and strategic basics of private practice orthopaedics.

Complications of clavicle fractures-diagnosis and management

Radial head fracture could present as an isolated injury or be part of a combined fracture injury involving the other structures of the elbow joint. The combination of radial head fracture, medial collateral ligament injury and coronoid process fracture comprised the so called ‘terrible triad’ of the elbow. Usually operative intervention aiming at restoration of movement and joint stability is indicated if the fracture comprises more than 33% of the articular surface, is angulated more than 30°, or is displaced more than 3 mm. In this chapter the issues surrounding the surgical management of radial head fracture are discussed.