Rachel V. Thakore

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

INTRODUCTION Hip 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. METHODS Using 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. RESULTS A 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. CONCLUSIONS Hip 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.

Prospective randomized controlled trial using telemedicine for follow-ups in an orthopedic trauma population: a pilot study.

Objectives: To compare patient satisfaction between telemedicine and in-person follow-up appointments for orthopedic trauma. Design: Prospective randomized controlled trial (pilot study). Setting: Level I trauma center. Patients/Participants: Twenty-four patients were enrolled and randomized into 2 groups. Eight patients who had telemedicine follow-up appointments and 9 who had in-person follow-up visits were included in a per-protocol analysis. In the telemedicine group, 2 patients left the study because of nonadherence, 1 patient withdrew because of a weak Internet connection, and 1 patient sustained an open fracture. Three control patients left the study because of nonadherence. Intervention: The patients had 4 follow-up appointments during a 6-month period. Patients either had their 6-week and 6-month follow-ups through video calls or in the clinic. Main Outcome Measurements: After 6-week and 6-month follow-up appointments, the patients were given survey questions that were developed using literature-supported methods to compare follow-up experiences. The patients were monitored for complications. Results: There was no significant difference in patient satisfaction between telemedicine and in-person clinic visits (telemedicine: 89% satisfied; control: 100% satisfied; P = 0.74). Zero percent of patients in the telemedicine group took time off their work for their appointment compared with 55.6% in the control (P = 0.03). Telemedicine patients spent significantly less time on their visits (P = 0.01). The majority of the patients in the telemedicine group reported clear visual (87.5%) and sound quality (100%) through and agreed to future follow-up visits through telemedicine (75.0%). One patient in each group developed complications. Conclusions: Telemedicine may be a viable alternative to some in-person clinic visits because of similar measures of patient satisfaction but with significantly less time and distance traveled. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Geographic variations in hospital charges and Medicare payments for major joint arthroplasty

National data on hospital-level charges and Medicare payments have shown that joint arthroplasty is the most common surgical procedure among the elderly. Yet, no study has investigated micro and macro level geographic variations in hospital charges and payment. We used the Medicare Provider Charge Data to investigate Medicare payments and charges for 2750 hospitals accounting for 427,207 patients who underwent major joint arthroplasty and 932 hospitals for 18,714 patients who had a complication/comorbidity. We found a significant difference in hospital charges and payments based on geographic region (P<0.001). We concluded that hospital charges demonstrate a high variability even when using areas to control for differences in hospital wages and high variation in reimbursements in some areas remains unexplained by Medicares current method of calculating reimbursement.

Gunshot-induced fractures of the extremities: a review of antibiotic and debridement practices.

The use of antibiotic prophylaxis and debridement is controversial when treating low- and high-velocity gunshot-induced fractures, and established treatment guidelines are currently unavailable. The purpose of this review was to evaluate the literature for the prophylactic antibiotic and debridement policies for (1) low-velocity gunshot fractures of the extremities, joints, and pelvis and (2) high-velocity gunshot fractures of the extremities. Low-velocity gunshot fractures of the extremities were subcategorized into operative and non-operative cases, whereas low-velocity gunshot fractures of the joints and pelvis were evaluated based on the presence or absence of concomitant bowel injury. In the absence of surgical necessity for fracture care such as concomitant absence of gross wound contamination, vascular injury, large soft-tissue defect, or associated compartment syndrome, the literature suggests that superficial debridement for low-velocity ballistic fractures with administration of antibiotics is a satisfactory alternative to extensive operative irrigation and debridement. In operative cases or those involving bowel injuries secondary to pelvic fractures, the literature provides support for and against extensive debridement but does suggest the use of intravenous antibiotics. For high-velocity ballistic injuries, the literature points towards the practice of extensive immediate debridement with prophylactic intravenous antibiotics. Our systematic review demonstrates weak evidence for superficial debridement of low-velocity ballistic fractures, extensive debridement for high-velocity ballistic injuries, and antibiotic use for both types of injury. Intra-articular fractures seem to warrant debridement, while pelvic fractures with bowel injury have conflicting evidence for debridement but stronger evidence for antibiotic use. Given a relatively low number of studies on this subject, we recommend that further high-quality research on the debridement and antibiotic use for gunshot-induced fractures of the extremities should be conducted before definitive recommendations and guidelines are developed.

Olecranon fractures: factors influencing re-operation

PurposeWe evaluated factors influencing re-operation in tension band and plating of isolated olecranon fractures.MethodsFour hundred eighty-nine patients with isolated olecranon fractures who underwent tension band (TB) or open reduction internal fixation (ORIF) from 2003 to 2013 were identified at an urban level 1 trauma centre. Medical records were reviewed for patient information and complications, including infection, nonunion, malunion, loss of function or hardware complication requiring an unplanned surgical intervention. Electronic radiographs of these patients were reviewed to identify Orthopaedic Trauma Association (OTA) fracture classification and patients who underwent TB or ORIF.ResultsOne hundred seventy-seven patients met inclusion criteria of isolated olecranon fractures. TB was used for fixation in 43 patients and ORIF in 134. No statistical significance was found when comparing complication rates in open versus closed olecranon fractures. In a multivariate analysis, the key factor in outcome was method of fixation. Overall, there were higher rates of infection and hardware removal in the TB compared with the ORIF group.ConclusionsOur results demonstrate that the dominant factor driving re-operation in isolated olecranon fractures is type of fixation. When controlling for all variables, there is an increased chance of re-operation in patients with TB fixation.

The Costs of Operative Complications for Ankle Fractures: A Case Control Study

As our healthcare system moves towards bundling payments, it is vital to understand the potential financial implications associated with treatment of surgical complications. Considering that surgical treatment of ankle fractures is common, there remains minimal data relating costs to postsurgical intervention. We aimed to identify costs associated with ankle fracture complications through case-control analysis. Using retrospective analysis at a level I trauma center, 28 patients with isolated ankle fractures who developed complications (cases) were matched with 28 isolated ankle fracture patients without complications (controls) based on ASA score, age, surgery type, and fracture type. Patient charts were reviewed for demographics and complications leading to readmission/reoperation and costs were obtained from the financial department. Wilcoxon tests measured differences in the costs between the cases and controls. 28 out of 439 patients (6.4%) developed complications. Length of stay and median costs were significantly higher for cases than controls. Specifically, differences in total costs existed for infection and hardware-related pain. This is the first study to highlight the considerable costs associated with the treatment of complications due to isolated ankle fractures. Physicians must therefore emphasize methods to control surgical and nonsurgical factors that may impact postoperative complications, especially under a global payment system.

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.

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

Objectives: To evaluate the utility of postoperative ankle radiographs via a comparison of complication rates among patients who had ankle radiographs in the early postoperative period versus those who obtained radiographs in a delayed fashion. Design: Retrospective chart review. Setting: Urban level I trauma center. Patients/Participants: Approximately 1411 patients who underwent surgical fixation of an ankle fracture between 2001 and 2010 who received postoperative ankle radiographs in postoperative days 7–120. Intervention: Patients were identified using a current procedural terminology search and were divided between 2 groups based on the timing of the first postoperative ankle radiograph. Each chart was reviewed for complications. Main Outcome Measurements: The rate of complications for patients with early postoperative ankle radiographs (7–21 days) was compared with those of patients with late postoperative radiographs (22–120 days) using &khgr;2 and Fisher exact tests. Results: Approximately 889 patients were included in the early group and 522 patients were in the late group. Overall, 93 patients with complications were identified (6.59%): 62 patients (6.97%) in the early group and 31 patients (5.93%) in the late group. The results showed no statistically significant difference in the rate of complications between the early and late groups. Conclusions: There is insufficient evidence to suggest that complication rates following ankle fracture fixation differ by the timing of postoperative radiographs. This investigation questions the justification of routine radiographs of operatively treated ankle fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

Abstract 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. Implications for Rehabilitation A total of 47.0% of ankle fracture patients are unable to return to work within 5 years following injury. Patients in labour-intensive jobs are especially vulnerable to job loss and disability. Rehabilitation should have a greater focus on occupational therapy and work-related functioning. Improving patient compliance with attendance for rehabilitation may improve employment outcomes.