Cesar S. Molina

Use of the National Surgical Quality Improvement Program in Orthopaedic Surgery

BackgroundThe goal of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) is to improve patient safety. The database has been used by hospitals across the United States to decrease the rate of adverse events and improve surgical outcomes, including dramatic decreases in 30-day mortality, morbidity, and complication rates. However, only a few orthopaedic surgical studies have employed the ACS NSQIP database, all of which have limited their analysis to either single orthopaedic procedures or reported rates of adverse events without considering the effect of patient characteristics and comorbidities.Question/purposesOur specific purposes included (1) investigating the most common orthopaedic procedures and 30-day adverse events, (2) analyzing the proportion of adverse events in the top 30 most frequently identified orthopaedic procedures, and (3) identifying patient characteristics and clinical risk factors for adverse events in patients undergoing hip fracture repair.MethodsWe used data from the ACS NSQIP database to identify a large prospective cohort of patients undergoing orthopaedic surgery procedures from 2005 to 2011 in more than 400 hospitals around the world. Outcome variables were separated into the following three categories: any complication, minor complication, and major complication. The rate of adverse events for the top 30 orthopaedic procedures was calculated. Bivariate and multivariate analyses were used to determine risk factors for each of the outcome variables for hip fracture repair.ResultsOf the 1,979,084 surgical patients identified in the database, 146,774 underwent orthopaedic procedures (7%). Of the 30 most common orthopaedic procedures, the top three were TKA, THA, and knee arthroscopy with meniscectomy, which together comprised 55% of patients (55,575 of 101,862). We identified 5368 complications within the top 30 orthopaedic procedures, representing a 5% complication rate. The minor and major complication rates were 3.1% (nxa0=xa03174) and 2.8% (nxa0=xa02880), respectively. The most common minor complication identified was urinary tract infection (nxa0=xa01534) and the most common major complication identified was death (nxa0=xa0850). An American Society of Anesthesiologists class of 3 or higher was a consistent risk factor for all three categories of complications in patients undergoing hip fracture repair.ConclusionsThe ACS NSQIP database allows for evaluating current trends of adverse events in selected surgical specialties. However, variables specific to orthopaedic surgery, such as open versus closed injury, are needed to improve the quality of the results.

Hip fractures are risky business: an analysis of the NSQIP data.

INTRODUCTIONnHip fractures are one of the most common types of orthopaedic injury with high rates of morbidity. Currently, no study has compared risk factors and adverse events following the different types of hip fracture surgeries. The purpose of this paper is to investigate the major and minor adverse events and risk factors for complication development associated with five common surgeries for the treatment of hip fractures using the NSQIP database.nnnMETHODSnUsing the ACS-NSQIP database, complications for five forms of hip surgeries were selected and categorized into major and minor adverse events. Demographics and clinical variables were collected and an unadjusted bivariate logistic regression analyses was performed to determine significant risk factors for adverse events. Five multivariate regressions were run for each surgery as well as a combined regression analysis.nnnRESULTSnA total of 9640 patients undergoing surgery for hip fracture were identified with an adverse events rate of 25.2% (n=2433). Open reduction and internal fixation of a femoral neck fracture had the greatest percentage of all major events (16.6%) and total adverse events (27.4%), whereas partial hip hemiarthroplasty had the greatest percentage of all minor events (11.6%). Mortality was the most common major adverse event (44.9-50.6%). For minor complications, urinary tract infections were the most common minor adverse event (52.7-62.6%). Significant risk factors for development of any adverse event included age, BMI, gender, race, active smoking status, history of COPD, history of CHF, ASA score, dyspnoea, and functional status, with various combinations of these factors significantly affecting complication development for the individual surgeries.nnnCONCLUSIONSnHip fractures are associated with significantly high numbers of adverse events. The type of surgery affects the type of complications developed and also has an effect on what risk factors significantly predict the development of a complication. Concerted efforts from orthopaedists should be made to identify higher risk patients and prevent the most common adverse events that occur postoperatively.

ASA score as a predictor of 30-day perioperative readmission in patients with orthopaedic trauma injuries: an NSQIP analysis.

Objective: Our purpose was to identify the impact of the physical status of the American Society of Anesthesiologists (ASA) on the 30-day readmission of patients receiving operative management of orthopaedic fractures using the National Surgical Quality Improvement Program (NSQIP) database. Methods: We analyzed all patients with orthopaedic trauma injuries in the American College of Surgeons NSQIP database from 2005 to 2011. A total of 8761 patients representing 91 orthopaedic trauma procedures were identified and included in analysis after selection. Logistic regressions were conducted to identify the predictive ability of ASA on the likelihood of readmission for patients in each anatomic category (upper extremity, pelvis/acetabulum, lower extremity) and the combined study population. Results: The ASA physical status proved the strongest predictor of 30-day readmission for the selected orthopaedic trauma procedures. After controlling for age, gender, race, and medical comorbidities that were shown to be significant independent risk factors for readmission, ASA score continued to have a significant association on 30-day readmissions in the combined population (odds ratio = 1.45, 95% confidence interval = 1.13–1.88, P = 0.001). For the combined analysis, compared with patients with an ASA score of 1, patients with an ASA score of 2 were 1.04 times as likely to have a readmission (P = 0.001), patients with an ASA score of 3 were 3.77 times as likely to have a readmission (P = 0.001), and patients with an ASA score of 4 were 13.7 times as likely to have a readmission (P = 0.001). Conclusions: ASA classification is an indicator for variance in readmission for patients receiving operative treatment of orthopaedic fractures. Given that ASA classification is a universally collected data point, this method can be used in almost any hospital system and for any operative service. This model may be used to more accurately predict a patients postoperative course and the expected risk for readmission, such that hospitals can target these “at-risk” individuals and reduce 30-day readmissions. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Current Practice in the Management of Open Fractures Among Orthopaedic Trauma Surgeons. Part A: Initial Management. A Survey of Orthopaedic Trauma Surgeons.

Objectives: Open fractures are one of the injuries with the highest rate of infection that orthopaedic trauma surgeons treat. The main purpose of this survey was to determine current practice and practice variation among Orthopaedic Trauma Association (OTA) members and make treatment recommendations based on previously published resources. Design: Survey. Setting: Web-based survey. Participants: Three hundred seventy-nine orthopaedic trauma surgeons. Methods: A 15-item questionnaire-based study titled “OTA Open Fracture Survey” was constructed. The survey was delivered to all OTA membership categories. Different components of the data charts were used to analyze numerous aspects of open fracture management, focusing on parameters of initial and definitive treatment. Results: Eighty-six percent of participants responded that a period of time of less than 1 hour is the optimal time to antibiotic administration after identification of open fracture. Despite concerns with nephrotoxicity, 24.0%–76.3% of respondents reported the use of aminoglycosides in management of open fractures. A little over half of survey respondents continue antibiotics until next debridement in wounds that were not definitively closed after initial debridement and stabilization. Conclusions: Rapid administration of antibiotics in open fracture management is important. Aminoglycoside use is still prevalent despite evidence questioning efficacy and toxicity concerns. Time to debridement of open fractures is controversial among OTA members. Antibiotic administration is commonly continued >48 hours despite concerns raised by Surgical Infection Society and The Eastern Association of the Surgery of Trauma. Regarding study logistics, survey participation reminders should be used when conducting this type of study as it can increase data accrual by 50%. Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Regional anaesthesia for hip fracture surgery is associated with significantly more peri-operative complications compared with general anaesthesia

IntroductionAlthough several studies have advocated the use of regional versus general anaesthesia as a means of reducing peri-operative complications from hip fracture surgery, the ideal method of anaesthesia remains controversial. Our purpose was to investigate the association between anaesthesia type and peri-operative complications in hip fracture surgery.MethodsFrom the 2005–2011 ACS-NSQIP database, all patients with operatively treated hip fractures were identified using CPT codes, and fifteen peri-operative complications were recorded and categorized as either minor or major. Rates of minor, major, and total complications by anaesthesia type were compared using chi-square and Fischer’s exact tests. A multivariate model was used to determine odds of minor, major, and total complications between anaesthesia types. Multivariate analysis was then repeated after combining patients who received regional nerve blocks or spinal anaesthesia.ResultsA total of 7,764 hip fracture patients were included in our analysis. Spinal anaesthesia had the highest total complication rate (19.6xa0%), followed by general (17.9xa0%) and regional nerve blocks (12.6xa0%). Multivariate analysis demonstrated that spinal anaesthesia was associated with significantly greater odds of minor complications and total complications compared with general anaesthesia. After combining the regional nerve block and spinal anaesthesia groups, multivariate analysis again showed significantly greater odds of minor and total complications with regional versus general anaesthesia.ConclusionsUsing a large multi-centre database, we demonstrate that regional anaesthesia was associated with significantly greater odds of minor and total peri-operative complications compared with general anaesthesia. Our results challenge the notion that regional anaesthesia is the preferred method of anaesthesia for hip fractures in the elderly.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Current Practice in the Management of Open Fractures Among Orthopaedic Trauma Surgeons. Part B: Management of Segmental Long Bone Defects. A Survey of Orthopaedic Trauma Association Members.

Objectives: Treatment of segmental long bone defects is one of the areas of substantial controversy in current orthopaedic trauma. The main purpose of this survey was to determine current practice and practice variation within the Orthopaedic Trauma Association (OTA) membership on this topic. Design: Survey. Setting: Web-based survey. Participants: Three hundred seventy-nine orthopaedic trauma surgeons. Methods: A 15-item questionnaire-based study titled “OTA Open Fracture Survey” was constructed. The survey was delivered to all OTA membership categories. Different components of the data charts were used to analyze various aspects of open fracture management, focusing on definitive treatment and materials used for grafting in “critical-sized” segmental bone defects. Results: Between July and August 2012, a total of 379/1545 members responded for a 25% response rate. Overall, 89.5% (339/379) of respondents use some sort of antibiotic cement spacer before bone grafting. It was found that 92% of respondents preferred to use some type of autograft at time of definitive grafting of segmental defects. When using a grafting technique, 88% said they used some type of antibiotic cement. Within that context, 60.1% said graft placement should be done at 6 weeks. Conclusions: There continues to be substantial variation in the timing of bone graft placement after soft tissue healing and the source and form of graft used. The use of antibiotic cement is common in segmental defects that require delayed bone grafting. Obtaining base-line practice characteristics on controversial topics will help provide a foundation for assessing research needs and, therefore, goals. Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Adverse Events in Orthopaedics: Is Trauma More Risky? An Analysis of the NSQIP Data.

Objectives: As our healthcare system moves toward bundling payments, orthopaedic trauma surgeons will be increasingly benchmarked on perioperative complications. We therefore sought to determine financial risks under bundled payments by identifying adverse event rates for (1) orthopaedic trauma patients compared with general orthopaedic patients and (2) based on anatomic region and (3) to identify patient factors associated with complications. Design: Prospective. Setting: Multicenter. Patients/Participants: A total of 146,773 orthopaedic patients (22,361 trauma) from 2005 to 2011 NSQIP data were identified. Interventions: Minor and major adverse events, demographics, surgical variables, and patient comorbidities were collected. Main Outcome Measurements: Multivariate regressions determined significant risk factors for the development of complications. Results: The complication rate in the trauma group was 11.4% (2554/22,361) versus 4.1% (5137/124,412) in the general orthopaedic group (P = 0.001). When controlling for all variables, trauma was a risk factor for developing complications [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.57–1.81]. After controlling for several patient factors, hip and pelvis patients were 4 times more likely to develop any perioperative complication than upper extremity patients (OR: 3.79, 95% CI: 3.01–4.79, P = 0.01). Lower extremity patients are 3 times more likely to develop any complication versus upper extremity patients (OR: 2.82, 95% CI: 2.30–3.46, P = 0.01). Conclusions: Our study is the first to show that orthopaedic trauma patients are 2 times more likely than general orthopaedic patients to sustain complications, despite controlling for identical risk factors. There is also an alarming difference in complication rates among anatomic regions. Orthopaedic trauma surgeons will face increased financial risk with bundled payments. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk factors of deep infection in operatively treated pilon fractures (AO/OTA: 43)

BACKGROUND/AIMSnThe purpose of this study is to evaluate risk factors of deep infection following pilon fractures.nnnMETHODSnThis investigation was performed after gathering a six-year retrospective database from a single academic trauma center.nnnRESULTSnThese include an overall incidence of deep infection of 16.1% (57/355). Deep infection was diagnosed at an average of 88 days (±64 days) from initial injury with a range of 10-281 days. Development of deep infection occurred in 23.2% (33/142) of open fractures, vs 11.3% (24/213) of closed fractures.nnnCONCLUSIONnOpen fractures, hypertension and male gender were associated with an increased risk of developing deep infection. In addition, even optimal surgical management may not significantly modify rates of deep surgical site infection.

Course of treatment and rate of successful salvage following the diagnosis of deep infection in patients treated for pilon fractures (AO/OTA: 43)

BACKGROUND/AIMSnThe purpose of this study is to report the rate of successful salvage and describe typical treatment course for patients with infected pilon fractures.nnnMETHODSnThis investigation was performed after gathering a Six-year retrospective database from a single academic trauma center including patients with pilon fractures diagnosed with post-operative deep infection.nnnRESULTSnThese include a rate of successful salvage in patients diagnosed with deep infection of 88.5% (46/52). Patients who were successfully salvaged required an average of 3.5 (±2.3) procedures following diagnosis of infection, 2.5 (±1.5) debridements and 1.1 (±1.2) reconstructive procedures.nnnCONCLUSIONSnConsiderable morbidity follows the diagnosis of deep infection, with 14% of patients ultimately treated with amputation. Successful salvage can be reliably anticipated in over 80% of patients, but typically requires more than 3 additional procedures.