Orthopedic Surgery Volume Trends During the COVID-19 Pandemic and Postvaccination Era: Implications for Healthcare Planning

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic decreased surgical volumes, but prior studies have not investigated recovery through 2022, or analyzed specific procedures or cases of urgency within orthopedic surgery. The aims of this study were to (1) quantify the declines in orthopedic surgery volume during and after the pandemic peak, (2) characterize surgical volume recovery during the postvaccination period, and (3) characterize recovery in the 1-year postvaccine release period.

METHODS

We conducted a retrospective cohort study of 27,476 orthopedic surgeries from January 2019 to December 2022 at one urban academic quaternary referral center. We reported trends over the following periods: baseline pre-COVID-19 period (1/6/2019 to 1/4/2020), COVID-19 peak (3/15/2020 to 5/16/2020), post-COVID-19 peak (5/17/2020 to 1/2/2021), postvaccine release (1/3/2021 to 1/1/2022), and 1-year postvaccine release (1/2/2022 to 12/30/2022). Comparisons were performed with 2 sample t-tests.

RESULTS

Pre-COVID-19 surgical volume fell by 72% at the COVID-19 peak, especially impacting elective procedures (P < .001) and both hip and knee joint arthroplasty (P < .001) procedures. Nonurgent (P = .024) and urgent or emergency (P = .002) cases also significantly decreased. Postpeak recovery before the vaccine saw volumes rise to 92% of baseline, which further rose to 96% and 94% in 2021 and 2022, respectively. While elective procedures surpassed the baseline in 2022, nonurgent and urgent or emergency surgeries remained low.

CONCLUSIONS

The COVID-19 pandemic substantially reduced orthopedic surgical volumes, which have still not fully recovered through 2022, particularly nonelective procedures. The differential recovery within an orthopedic surgery program may result in increased morbidity and can serve to inform department-level operational recovery.

Analysis of the diversity pipeline for the orthopedic trauma surgeon workforce in the United States

INTRODUCTION

There is a lack of research on the state of racial, ethnic, and gender diversity in the emerging orthopedic trauma workforce. The purpose of this study was to analyze the training pathway for diverse candidates in orthopedic trauma as it relates to race, ethnicity, and sex.

METHODS

Self-reported demographic data were compared among allopathic medical students, orthopedic surgery residents, orthopedic trauma fellows, and the general population in the United States (2013-2022). Race categories consisted of White, Asian, Black, and Native American/Alaskan Native (NA/AN), and Native Hawaiian/Pacific Islander (NH/PI). Ethnicity categories were Hispanic/Latino or non-Hispanic/Latino. Sex categories were male and female. Representation was calculated at each stage of accredited training. Participation-to-prevalence ratios (PPRs) quantified the equitable representation of demographic groups in the emerging orthopedic trauma workforce relative to the US population. PPR thresholds were used to classify representation as overrepresented (PPR > 1.2), equitable (PPR = 0.8-1.2), and underrepresented (PPR < 0.8).

RESULTS

Relative to medical school and orthopedic surgery residency, fewer female (48.5 % vs 16.7 % vs 18.7 %, P < 0.001), Hispanic (6.1 % vs 4.5 % vs 2.6 %, P < 0.001), Black (6.9 % vs 5.0 % vs 3.1 %, P < 0.001), and Asian (24.0 % vs 14.3 % vs 12.2 %, P < 0.001) trainees existed in orthopedic trauma fellowship training. In contrast, more male (51.5 % vs 83.3 % vs 81.3 %, P < 0.001) and White (62.8 % vs 79.1 % vs 84.0 %, P < 0.001) trainees existed in orthopedic trauma fellowship relative to earlier training stages. There were zero NA/AN or NH/PI trainees in orthopedic trauma (PPR = 0). Relative to the US population, Hispanic (PPR = 0.14), Black (PPR = 0.25), and female (PPR = 0.37) trainees were underrepresented in orthopedic trauma. In contrast, Asian (PPR = 2.04), male (PPR = 1.64), and White (PPR = 1.36) trainees were overrepresented in orthopedic trauma.

CONCLUSION

Women, racial, and ethnic minorities are underrepresented in the emerging orthopedic trauma workforce relative to the US population, and earlier stages of training. Targeted recruitment and guided mentorship of these groups may lead to greater interest, engagement, and diversity in orthopedic trauma.

Establishing surgical volume benchmarks for Orthopaedic Trauma Association (OTA)-accredited fellowship training

INTRODUCTION

Case volumes of trauma centers and surgeons influence clinical outcomes following orthopaedic trauma surgery. This study quantifies surgical volume benchmarks for Orthopaedic Trauma Association (OTA)-accredited fellowship training in the United States.

METHODS

This was a retrospective cross-sectional study of orthopaedic trauma fellows graduating between 2018 and 2019 to 2022-2023. Case volume percentiles were calculated across categories and variability defined as the fold-difference between 90th and 10th percentiles. Temporal trends were assessed with linear regression.

RESULTS

446 orthopaedic trauma fellows were included in this study. Mean reported case volume increased from 898 ± 245 in 2018-2019 to 974 ± 329 in 2022-2023 (P = 0.066). Mean case volume was 924 over the study period and mostly consisted of other (418 cases, 45 %), subtrochanteric/intertrochanteric femoral neck (84 cases, 9 %), open fracture debridement (72 cases, 8 %), pelvic ring disruption / fracture (55 cases, 6 %), acetabular fracture (41 cases, 4 %), tibial shaft fracture (39 cases, 4 %), and femoral shaft fracture (38 cases, 4 %) cases. Overall variability in total reported case volume was 2.0. Variability was greatest in distal radius fracture (14.8), amputation (9.5), fasciotomy (8.0), and proximal humerus repair (5.0).

CONCLUSION

Graduates from OTA-accredited fellowship training perform 924 cases on average, which exceeds the current minimum requirement of 600 cases. Case volume benchmarks can assist trainees and faculty align training goals with fellowship program strengths. More research is needed to determine evidence-based case minimum requirements for core competency training in orthopaedic trauma surgery.

Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention

OBJECTIVES

To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Three academic Level 1 trauma centers.

PATIENT SELECTION CRITERIA

Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC.

OUTCOME MEASURES AND COMPARISONS

Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality.

RESULTS

Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons).

CONCLUSIONS

Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Use of the Lateral Tibial Line to Assess Ankle Alignment: A Preliminary Investigation

BACKGROUND

Although the medial clear space (MCS) is commonly used to assess talar alignment and ankle stability, its measurement is variable with multiple reported normal values. We have observed that the lateral tibial shaft is a reliable landmark to assess talar alignment. The objective of the current investigation was to determine the normal relationship of the lateral tibia to the superolateral talus using a tangent drawn inferiorly from the lateral tibial shaft, which we refer to as the "lateral tibial line" (LTL).

METHODS

The relationship of the LTL to the superolateral talus was assessed by three reviewers on 99 standing ankle mortise radiographs in uninjured patients. This relationship was quantified by measuring the distance (in millimeters) between the LTL and the superolateral talus. In addition, the interobserver reliability of the LTL measurement was recorded and compared with that of the MCS.

RESULTS

The median value for the distance between the superolateral talus and LTL was -0.50 mm with an interquartile range of -1.4 to 0.0 mm. The LTL was within 1 mm of the lateral talus in 176 of 297 reviewer measurements (59.3%). Moreover, it was either lateral to or at most 1 mm medial to the lateral talus in 90.9% of cases. The LTL measurement also demonstrated good interobserver reliability (0.764, 95% confidence interval, 0.670 to 0.834), similar to the measurement of MCS (0.742, 95% confidence interval, 0.539 to 0.846).

CONCLUSIONS

The relationship between the LTL and superolateral talus is easily measured with good reliability for assessing the anatomic relationship of the tibia and talus. The LTL uncommonly fell more than 1 mm medial to the superolateral talus, as might be seen with displaced ankle fractures. These findings will hopefully serve as a basis for future studies evaluating its role in assessing lateral displacement and stability of isolated fibula fractures.

LEVEL OF EVIDENCE

Level III, retrospective review.

Musculoskeletal health: an ecological study assessing disease burden and research funding

Background

Exacerbated by an aging population, musculoskeletal diseases are a chronic and growing problem in the United States that impose significant health and economic burdens. The objective of this study was to analyze the correlation between the burden of diseases and the federal funds assigned to health-related research through the National Institutes of Health (NIH).

Methods

An ecological study design was used to examine the relationship between NIH research funding and disease burden for 60 disease categories. We used the Global Burden of Disease (GBD) Study 2019 to measure disease burden and the NIH Research, Condition, and Disease Categories (RCDC) data to identify 60 disease categories aligned with available GBD data. NIH funding data was obtained from the RCDC system and the NIH Office of Budget. Using linear regression models, we observed that musculoskeletal diseases were among the most underfunded (i.e., negative residuals from the model) with respect to disease burden.

Findings

Musculoskeletal diseases were underfunded, with neck pain being the most underfunded at only 0.83% of expected funding. Low back pain, osteoarthritis, and rheumatoid arthritis were also underfunded at 13.88%, 35.08%, and 66.26%, respectively. Musculoskeletal diseases were the leading cause of years lived with disability and the third leading cause in terms of prevalence and disability-adjusted life years. Despite the increasing burden of these diseases, the allocation of NIH funding to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) has remained low compared to other institutes.

Interpretation

Despite the increasing health burden and economic cost of $980 billion annually, the allocation of NIH funding to the NIAMS has remained low compared to other institutes. These findings suggest that the NIH may need to reassess its allocation of research funding to align with the current health challenges of our country. Furthermore, these clinically relevant observations highlight the need to increase research funding for musculoskeletal diseases and improve their prevention, diagnosis, and treatment.

Funding

No funding.

Impact of the SARS-CoV-2 outbreak on ACGME-accredited orthopaedic trauma fellowship training

INTRODUCTION

The SARS-CoV-2 viral outbreak created unprecedented challenges in surgical education. Yet, its impact on reported case volume during orthopaedic trauma fellowship training remains poorly understood. We hypothesized that cases performed during orthopaedic trauma fellowship training would decrease by 8 %-17 % during the 2019-2020 academic year corresponding to the 1-2 month moratorium of non-essential cases during the initial SARS-CoV-2 outbreak in the United States.

METHODS

We designed a retrospective cohort study of orthopaedic trauma fellows at Accreditation Council for Graduate Medical Education (ACGME)-accredited training programs (2018-2019 to 2021-2022). Mean case volumes were compared by case category across academic years.

RESULTS

There was a -13 % year-over-year decrease in reported case volume during the 2019-2020 academic year (505 ± 126 vs 441 ± 94, P = 0.079, Fig. 1). Case categories with the greatest percentage declines were Treatment of Nonunion / Malunion (-31 %), Fasciotomy (-25 %), External Fixation (-21 %), Forearm / Wrist (-21 %), and Intra-articular Distal Humerus Fracture (-17 %). There was a 7 % year-over-year increase in case volume during the subsequent 2020-2021 academic year with near universal increases in case volume across case categories.

CONCLUSION

There was a 13 % decrease in orthopaedic trauma case volume during the 2019-2020 academic year, corresponding to the SARS-CoV-2 outbreak. Certain trauma case categories experienced the greatest negative impact, which subsequently recovered during the next academic year. These results may help inform accrediting bodies and surgical educators on the impact of future viral outbreaks on orthopaedic trauma fellowship training.

OrthoPass: Long-term Outcomes following Implementation of an Orthopaedic Patient Handoff Template

Standardized handoff tools improve communication and patient care; however, their widespread use in surgical fields is lacking. OrthoPass, an orthopaedic adaptation of I-PASS, was developed in 2019 to address handoff concerns and demonstrated sustained improvements across multiple handoff domains over an 18-month period. We sought to characterize the longitudinal effect and sustainability of OrthoPass within a single large residency program 3.5 years after its implementation. This mixed methods study involved electronic handoff review for quality domains in addition to survey distribution and evaluation. We conducted comparative analyses of handoff adherence and survey questions as well as a thematic analysis of provider-free responses. We evaluated 146 electronic handoffs orthopaedic residents, fellows, and advanced practice providers 3.5 years after OrthoPass implementation. Compared with 18-month levels, adherence was sustained across five of nine handoff domains and was markedly improved in two domains. Furthermore, provider valuations of OrthoPass improved regarding promoting communication and patient safety (83% versus 70%) and avoiding patient errors and near misses (72% versus 60%). These improvements were further substantiated by positive trends in Agency for Healthcare Research and Quality Surveys on Patient Safety Culture hospital survey data. Thematic analysis of free responses shared by 37 providers (42%) generated favorable, unfavorable, and balanced themes further contextualized by subthemes. At 3.5 years after its introduction, OrthoPass continues to improve patient handoff quality and to support provider notions of patient safety. Although providers acknowledged the benefits of this electronic handoff tool, they also shared unique insights into several drawbacks. This feedback will inform ongoing efforts to improve OrthoPass.

Degree of articular injury as measured by CT cross sectional area is associated with physical function following the treatment of bicondylar tibial plateau fractures

BACKGROUND

Bicondylar tibial plateau fractures are complex injuries that commonly require surgical repair. Long-term clinical outcome has been associated with discrepancies in leg alignment, instability and condylar width abnormalities. While intuitive, the degree of articular damage at time of injury has not been linked to outcomes in patients with bicondylar tibial plateau fractures. The aim of this study was to quantify percentage of articular surface cross sectional area disruption and assess for correlation between the degree of articular injury and patient reported physical function.

METHODS

Retrospective cohort study at two level 1 trauma centers. 57 consecutive patients undergoing surgical repair for bicondylar tibial plateau fractures between 2013 and 2016.

MAIN OUTCOME MEASURE

Preoperative CT scans were reviewed, and the percentage of articular surface disruption cross sectional area was calculated. PROMIS® scores were collected from patients at a minimum of 2 years.

RESULTS

57 patients with an average age of 58 ± 14.3 years were included. The average PROMIS® score was 45.5. There was a correlation between percentage of articular surface disruption and total PROMIS® scores (0.4, CI: 0.2-0.5, p = .007) and the physical function of the PROMIS® score (0.4, CI: 0.2-0.6, p < .001).

CONCLUSION

Our method for calculating articular surface disruption on CT is a simple, reproducible and accurate method for assessing the degree of articular damage in patients with bicondylar tibial plateau fractures. We found that the percentage of cross-sectional articular surface disruption correlates with patient reported outcomes and physical function.

Upper cervical spine fracture patterns and blunt cerebrovascular injuries

PURPOSE

To determine patterns of C1 and C2 vertebral fractures that are associated with blunt cerebrovascular injury (BCVI).

METHODS

Retrospective chart review of clinical and imaging reports at a level 1 trauma center over 10 consecutive years was conducted in patients with C1 and C2 fractures. Student t-test and chi-squared analyses were used to determine associations between fracture levels and fracture types with the presence of BCVI on CTA and/or MRI or stroke on CT and/or MRI.

RESULTS

Multilevel fractures were associated with higher incidence of BCVI compared to isolated C1 or C2 fractures (p < 0.01), but not with stroke (p = 0.16). There was no difference in incidence of BCVI or stroke between isolated C1 and isolated C2 fractures (p = 0.46, p = 0.25). Involvement of the transverse foramen (TF) alone was not associated with BCVI or stroke (p = 0.10-0.40, p = 0.34-0.43). However, TF fractures that were comminuted or contained fracture fragment(s) were associated with increased BCVI (p < 0.01, p = 0.02), though not with stroke (p = 0.11, p = 0.09). In addition, high-energy mechanism of injury was also associated with BCVI (p < 0.01) and stroke (p < 0.01).

CONCLUSION

C1 and C2 fractures are associated with BCVI in the presence of high-energy mechanism of injury, concomitant fractures of other cervical vertebral body levels, comminuted TF fractures, or TF fractures with internal fragments. Attention to these fracture parameters is important in evaluating C1 and C2 fractures for BCVI.

Thoracolumbar Injury Classification Systems: The Importance of Concepts and Language in the Move Toward Standardization

STUDY DESIGN

Narrative review.

OBJECTIVE

To describe the evolution of acute traumatic thoracolumbar (TL) injury classification systems; to promote standardization of concepts and vocabulary with respect to TL injuries.

SUMMARY OF BACKGROUND DATA

Over the past century, numerous TL classification systems have been proposed and implemented, each influenced by the thought, imaging modalities, and surgical techniques available at the time. While much progress has been made in our understanding and management of these injuries, concepts, and terms are often intermixed, leading to potential confusion and miscommunication.

METHODS

We present a narrative review of the current state of the literature regarding classification systems for TL trauma.

RESULTS

The evolution of TL classification systems has broadly been characterized by a transition away from descriptive categorizations of fracture patterns to schema incorporating morphology, stability, and neurological function. In addition to these features, more recent systems have demonstrated the importance of predictive/prognostic capability, reliability, validity, and generalizability. The Arbeitsgemeinschaft fur Osteosynthesenfragen Spine Thoracolumbar Injury Classification System/Thoracolumbar Arbeitsgemeinschaft fur Osteosynthesenfragen Spine Injury Score represents the most modern and recently updated system, retiring past concepts and terminology in favor of clear, internationally agreed upon descriptors.

CONCLUSIONS

Advancements in our understanding of blunt TL trauma injuries have led to changes in management. Such advances are reflected in modern, dedicated classification systems. Over time, various key factors have been acknowledged and incorporated. In an effort to promote standardization of thought and language, past ideas and terminology should be retired.

Analyzing risk factors for treatment failure in fracture-related infection

INTRODUCTION

Fracture-related infection (FRI) represents a challenging clinical scenario. Limited evidence exists regarding treatment failure after initial management of FRI. The objective of our investigation was to determine incidence and risk factors for treatment failure in FRI.

MATERIALS AND METHODS

We conducted a retrospective review of patients treated for FRI between 2011 and 2015 at three level 1 trauma centers. One hundred and thirty-four patients treated for FRI were identified. Demographic and clinical variables were extracted from the medical record. Treatment failure was defined as the need for repeat debridement or surgical revision seven or more days after the presumed final procedure for infection treatment. Univariate comparisons were conducted between patients who experienced treatment failure and those who did not. Multivariable logistic regression was conducted to identify independent associations with treatment failure.

RESULTS

Of the 134 FRI patients, 51 (38.1%) experienced treatment failure. Patients who failed were more likely to have had an open injury (31% versus 17%; p = 0.05), to have undergone implant removal (p = 0.03), and additional index I&D procedures (3.3 versus 1.6; p < 0.001). Most culture results identified a single organism (62%), while 15% were culture negative. Treatment failure was more common in culture-negative infections (p = 0.08). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common organism associated with treatment failure (29%; p = 0.08). Multivariate regression demonstrated a statistically significant association between treatment failure and two or more irrigation and debridement (I&D) procedures (OR 13.22, 95% CI 4.77-36.62, p < 0.001) and culture-negative infection (OR 4.74, 95% CI 1.26-17.83, p = 0.02).

CONCLUSIONS

The rate of treatment failure following FRI continues to be high. Important risk factors associated with treatment failure include open fracture, implant removal, and multiple I&D procedures. While MRSA remains common, culture-negative infection represents a novel risk factor for failure, suggesting aggressive treatment of clinically diagnosed cases remains critical even without positive culture data.

LEVEL OF EVIDENCE

Retrospective cohort study; Level III.

Epidemiology of pelvic and acetabular fractures in the USA from 2007 to 2014

Incidence of pelvic and acetabular fracture is increasing in Europe. From 2007 to 2014 in the USA, this study found an age-adjusted incidence of 198 and 40 fractures/100,000/year, respectively, much higher than what has been described before. Incidence remained steady over that period and only a small increase in incidence of pelvic fracture in men was identified.

PURPOSE

To determine the incidence of pelvic ring and acetabular fractures in the USA over the period 2007-2014 and to examine trends over time.

METHODS

Retrospective population-based observational study using data from the Nationwide Emergency Department Sample (NEDS), a 20% stratified all-payer sample of US hospital-based emergency departments (EDs). All patients seen in the ED and diagnosed with pelvic/acetabular fracture from 2007 to 2014 were included. The primary outcome was age-adjusted incidence of pelvic and acetabular fractures per 100,000 persons/years. Secondary outcomes included incidence stratified by age and sex, patient- and hospital-related characteristics, and ED procedures. Tests for linear trends were used to determine if there were statistically significant differences by sex and age groups over time.

RESULTS

The age-adjusted incidence of pelvic fracture was 198 fractures/100,000/year, 323 in women and 114 in men. The age-adjusted incidence of acetabular fracture was 40 fractures/100,000/year, 36 in women and 51 in men. A small increase in the age-adjusted incidence of pelvic fracture in men was the only significant trend observed during the study time (p = 0.03). Over that period, the mean age of patients at presentation increased, as well as their number of comorbidities and associated fragility fractures, and they were more often sent home or to nursing facilities.

CONCLUSIONS

When considering all patients coming to the ED, not only those admitted to the hospital, adjusted incidence of pelvic and acetabular fracture is much higher than what has been described before. Contrarily to the global increase seen in other countries, incidence of pelvic and acetabular fractures dropped in the USA from 2007 to 2014 and only a small increase in age-adjusted incidence of pelvic fracture in men was identified.

External validation of a predictive algorithm for in-hospital and ninety-day mortality after spinal epidural abscess

BACKGROUND CONTEXT

Mortality in patients with spinal epidural abscess (SEA) remains high. Accurate prediction of patient-specific prognosis in SEA can improve patient counseling as well as guide management decisions. There are no externally validated studies predicting short-term mortality in patients with SEA.

PURPOSE

The purpose of this study was to externally validate the Skeletal Oncology Research Group (SORG) stochastic gradient boosting algorithm for prediction of in-hospital and 90-day postdischarge mortality in SEA.

STUDY DESIGN/SETTING

Retrospective, case-control study at a tertiary care academic medical center from 2003 to 2021.

PATIENT SAMPLE

Adult patients admitted for radiologically confirmed diagnosis of SEA who did not initiate treatment at an outside institution.

OUTCOME MEASURES

In-hospital and 90-day postdischarge mortality.

METHODS

We tested the SORG stochastic gradient boosting algorithm on an independent validation cohort. We assessed its performance with discrimination, calibration, decision curve analysis, and overall performance.

RESULTS

A total of 212 patients met inclusion criteria, with a short-term mortality rate of 10.4%. The area under the receiver operating characteristic curve (AUROC) of the SORG algorithm when tested on the full validation cohort was 0.82, the calibration intercept was -0.08, the calibration slope was 0.96, and the Brier score was 0.09.

CONCLUSIONS

With a contemporaneous and geographically distinct independent cohort, we report successful external validation of a machine learning algorithm for prediction of in-hospital and 90-day postdischarge mortality in SEA.

Development and external validation of predictive algorithms for six-week mortality in spinal metastasis using 4,304 patients from five institutions

BACKGROUND CONTEXT

Historically, spine surgeons used expected postoperative survival of 3-months to help select candidates for operative intervention in spinal metastasis. However, this cutoff has been challenged by the development of minimally invasive techniques, novel biologics, and advanced radiotherapy. Recent studies have suggested that a life expectancy of 6 weeks may be enough to achieve significant improvements in postoperative health-related quality of life.

PURPOSE

The purpose of this study was to develop a model capable of predicting 6-week mortality in patients with spinal metastases treated with radiation or surgery.

STUDY DESIGN/SETTING

A retrospective review was conducted at five large tertiary centers in the United States and Taiwan.

PATIENT SAMPLE

The development cohort consisted of 3,001 patients undergoing radiotherapy and/or surgery for spinal metastases from one institution. The validation institutional cohort consisted of 1,303 patients from four independent, external institutions.

OUTCOME MEASURES

The primary outcome was 6-week mortality.

METHODS

Five models were considered to predict 6-week mortality, and the model with the best performance across discrimination, calibration, decision-curve analysis, and overall performance was integrated into an open access web-based application.

RESULTS

The most important variables for prediction of 6-week mortality were albumin, primary tumor histology, absolute lymphocyte, three or more spine metastasis, and ECOG score. The elastic-net penalized logistic model was chosen as the best performing model with AUC 0.84 on evaluation in the independent testing set. On external validation in the 1,303 patients from the four independent institutions, the model retained good discriminative ability with an area under the curve of 0.81. The model is available here: https://sorg-apps.shinyapps.io/spinemetssurvival/.

CONCLUSIONS

While this study does not advocate for the use of a 6-week life expectancy as criteria for considering operative management, the algorithm developed and externally validated in this study may be helpful for preoperative planning, multidisciplinary management, and shared decision-making in spinal metastasis patients with shorter life expectancy.

PA, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Mayfield A, Sweeney J, Jaeblon T, Beer R, Bauer B, Meredith S, Talwar S, Domes CM, Gage MJ, Reilly RM, Paniagua A, Dupree J, Weaver MJ, von Keudell AG, Sagona AE, Mehta S, Donegan D, Horan A, Dooley M, Heng M, Harris MB, Lhowe DW, Esposito JG, Alnasser A, Shannon SF, Scott AN, Clinch B, Weber B, Beltran MJ, Archdeacon MT, Sagi HC, Wyrick JD, Le TT, Laughlin RT, Thomson CG, Hasselfeld K, Lin CA, Vrahas MS, Moon CN, Little MT, Marecek GS, Dubuclet DM, Scolaro JA, Learned JR, Lim PK, Demas S, Amirhekmat A, Dela Cruz YM. Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

BACKGROUND

Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture.

METHODS

We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304.

FINDINGS

Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4).

INTERPRETATION

For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds.

FUNDING

US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Single versus dual incision approaches for dual plating of bicondylar tibial plateau fractures have comparable rates of deep infection and revision surgery

OBJECTIVES

The use of one midline incision versus dual medial/lateral incisions for dual plating of bicondylar tibial plateau (BTP) fractures is controversial. This study aimed to compare rates of infection and secondary surgery in patients treated with dual plating for a BTP fracture using a single versus double incisions.

DESIGN

Retrospective cohort study.

SETTING

Two Level-1 trauma centers.

PATIENTS/PARTICIPANTS

Patients > 18 years with a closed AO/OTA 41-C BTP fracture without compartment syndrome treated with a single midline or dual incision (lateral with medial or posteromedial) approach for dual plating.

INTERVENTION

Dual plating through either a single anterior incision, or dual medial/lateral incisions.

MAIN OUTCOME MEASUREMENTS

Rates of deep infection and reoperation were compared using Chi-square analysis (p-value of < 0.05).

RESULTS AND CONCLUSIONS

In total 636 AO/OTA 41-C BTP fractures treated between 1/1/01 and 12/31/18 were identified and assessed. After exclusions for limited follow up, other techniques, open fracture and the need for fasciotomies, 346 patients were studied. Of these 254 had been treated with a single plate / single approach technique while 92 had been dual plated, 41 through a single anterior incision while 51 had dual plating through separate lateral and medial or posteromedial incisions. For these 92 fractures, there was no significant difference in the rate of deep infection (22.0% vs 23.5%, s=0.858) or reoperation (31.7% vs 31.4%, p=0.973) between the single and dual incision groups. Injuries that had been treated with single plating via a single incision had comparably lower rates of deep infection (10.2% vs. 22.8%, p=0.003) and reoperation (12.2% vs. 31.5%, p<0.001). There were no significant differences in any demographic parameters between patients undergoing single versus dual plating. Although retrospective, not randomized and subject to single surgeon bias these data suggest that these complications are more based on injury than the approach.

LEVEL OF EVIDENCE

III.

What Is the Clinical Benefit of Common Orthopaedic Procedures as Assessed by the PROMIS Versus Other Validated Outcomes Tools?

BACKGROUND

Patient-reported outcome measures (PROMs), including the Patient-reported Outcomes Measurement Information System (PROMIS), are increasingly used to measure healthcare value. The minimum clinically important difference (MCID) is a metric that helps clinicians determine whether a statistically detectable improvement in a PROM after surgical care is likely to be large enough to be important to a patient or to justify an intervention that carries risk and cost. There are two major categories of MCID calculation methods, anchor-based and distribution-based. This variability, coupled with heterogeneous surgical cohorts used for existing MCID values, limits their application to clinical care.

QUESTIONS/PURPOSES

In our study, we sought (1) to determine MCID thresholds and attainment percentages for PROMIS after common orthopaedic procedures using distribution-based methods, (2) to use anchor-based MCID values from published studies as a comparison, and (3) to compare MCID attainment percentages using PROMIS scores to other validated outcomes tools such as the Hip Disability and Osteoarthritis Outcome Score (HOOS) and Knee Disability and Osteoarthritis Outcome Score (KOOS).

METHODS

This was a retrospective study at two academic medical centers and three community hospitals. The inclusion criteria for this study were patients who were age 18 years or older and who underwent elective THA for osteoarthritis, TKA for osteoarthritis, one-level posterior lumbar fusion for lumbar spinal stenosis or spondylolisthesis, anatomic total shoulder arthroplasty or reverse total shoulder arthroplasty for glenohumeral arthritis or rotator cuff arthropathy, arthroscopic anterior cruciate ligament reconstruction, arthroscopic partial meniscectomy, or arthroscopic rotator cuff repair. This yielded 14,003 patients. Patients undergoing revision operations or surgery for nondegenerative pathologies and patients without preoperative PROMs assessments were excluded, leaving 9925 patients who completed preoperative PROMIS assessments and 9478 who completed other preoperative validated outcomes tools (HOOS, KOOS, numerical rating scale for leg pain, numerical rating scale for back pain, and QuickDASH). Approximately 66% (6529 of 9925) of patients had postoperative PROMIS scores (Physical Function, Mental Health, Pain Intensity, Pain Interference, and Upper Extremity) and were included for analysis. PROMIS scores are population normalized with a mean score of 50 ± 10, with most scores falling between 30 to 70. Approximately 74% (7007 of 9478) of patients had postoperative historical assessment scores and were included for analysis. The proportion who reached the MCID was calculated for each procedure cohort at 6 months of follow-up using distribution-based MCID methods, which included a fraction of the SD (1/2 or 1/3 SD) and minimum detectable change (MDC) using statistical significance (such as the MDC 90 from p < 0.1). Previously published anchor-based MCID thresholds from similar procedure cohorts and analogous PROMs were used to calculate the proportion reaching MCID.

RESULTS

Within a given distribution-based method, MCID thresholds for PROMIS assessments were similar across multiple procedures. The MCID threshold ranged between 3.4 and 4.5 points across all procedures using the 1/2 SD method. Except for meniscectomy (3.5 points), the anchor-based PROMIS MCID thresholds (range 4.5 to 8.1 points) were higher than the SD distribution-based MCID values (2.3 to 4.5 points). The difference in MCID thresholds based on the calculation method led to a similar trend in MCID attainment. Using THA as an example, MCID attainment using PROMIS was achieved by 76% of patients using an anchor-based threshold of 7.9 points. However, 82% of THA patients attained MCID using the MDC 95 method (6.1 points), and 88% reached MCID using the 1/2 SD method (3.9 points). Using the HOOS metric (scaled from 0 to 100), 86% of THA patients reached the anchor-based MCID threshold (17.5 points). However, 91% of THA patients attained the MCID using the MDC 90 method (12.5 points), and 93% reached MCID using the 1/2 SD method (8.4 points). In general, the proportion of patients reaching MCID was lower for PROMIS than for other validated outcomes tools; for example, with the 1/2 SD method, 72% of patients who underwent arthroscopic partial meniscectomy reached the MCID on PROMIS Physical Function compared with 86% on KOOS.

CONCLUSION

MCID calculations can provide clinical correlation for PROM scores interpretation. The PROMIS form is increasingly used because of its generalizability across diagnoses. However, we found lower proportions of MCID attainment using PROMIS scores compared with historical PROMs. By using historical proportions of attainment on common orthopaedic procedures and a spectrum of MCID calculation techniques, the PROMIS MCID benchmarks are realizable for common orthopaedic procedures. For clinical practices that routinely collect PROMIS scores in the clinical setting, these results can be used by individual surgeons to evaluate personal practice trends and by healthcare systems to quantify whether clinical care initiatives result in meaningful differences. Furthermore, these MCID thresholds can be used by researchers conducting retrospective outcomes research with PROMIS.

LEVEL OF EVIDENCE

Level III, therapeutic study.

What Do Orthopedic Trauma Surgeons Want and Expect from Anesthesiologists?

From the orthopedic trauma surgeon's perspective, successful injury management hinges on fracture fixation and restoration of patient mobility in a safe and expeditious manner. Management of critically injured polytrauma patients and shared decisions regarding regional anesthetics presents a myriad of challenges for orthopedic trauma surgeons and anesthesiologists alike. As the populations age, the typical patient sustaining traumatic orthopedic injuries are increasingly frail and elderly. This trend in demographics has mandated that care for orthogeriatric patients is coordinated by multidisciplinary teams working in concert on medically complex cases to a common end. In this article, we highlight opportunities for improved communication and care integration between orthopedic trauma surgeons and anesthesiologists.

Sociodemographic Factors Are Associated with Patient-Reported Outcome Measure Completion in Orthopaedic Surgery: An Analysis of Completion Rates and Determinants Among New Patients

Patient-reported outcome measures (PROMs) and, specifically, the Patient-Reported Outcomes Measurement Information System (PROMIS), are increasingly utilized for clinical research, clinical care, and health-care policy. However, completion of these outcome measures can be inconsistent and challenging. We hypothesized that sociodemographic variables are associated with the completion of PROM questionnaires. The purposes of the present study were to calculate the completion rate of assigned PROM forms and to identify sociodemographic and other variables associated with completion to help guide improved collection efforts.

Methods

All new orthopaedic patients at a single academic medical center were identified from 2016 to 2020. On the basis of subspecialty and presenting condition, patients were assigned certain PROMIS forms and legacy PROMs. Demographic and clinical information was abstracted from the electronic medical record. Bivariate analyses were performed to compare characteristics among those who completed assigned PROMs and those who did not. A multivariable logistic regression model was created to determine which variables were associated with successful completion of assigned PROMs.

Results

Of the 219,891 new patients, 88,052 (40%) completed all assigned PROMs. Patients who did not activate their internet-based patient portal had a 62% increased likelihood of not completing assigned PROMs (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.58 to 1.66; p < 0.001). Non-English-speaking patients had a 90% (OR, 1.90; 95% CI, 1.82 to 2.00; p < 0.001) increased likelihood of not completing assigned PROMs at presentation. Older patients (≥65 years of age) and patients of Black race had a 23% (OR, 1.23; 95% CI, 1.19 to 1.27; p < 0.001) and 24% (OR, 1.24; 95% CI, 1.19 to 1.30; p < 0.001) increased likelihood of not completing assigned PROMs, respectively.

Conclusions

The rate of completion of PROMs varies according to sociodemographic variables. This variability could bias clinical outcomes research in orthopaedic surgery. The present study highlights the need to uniformly increase completion rates so that outcomes research incorporates truly representative cohorts of patients treated. Furthermore, the use of these PROMs to guide health-care policy decisions necessitates a representative patient distribution to avoid bias in the health-care system.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Racial Differences in Orthopedic Trauma Surgery

Racial discrepancies among patients in the United States undergoing orthopedic trauma surgery have not been investigated. Issues relating to socioeconomic status and access to care have played a role in the health outcomes of racial groups. In orthopedic surgery, recent joint arthroplasty literature has shown significant racial differences in the use of elective joint arthroplasty. Furthermore, studies also suggest increased rates of early complication in racial minority groups. In general, little information exists on the postoperative outcomes of racial minority groups in orthopedic surgery. We retrospectively queried the National Surgical Quality Improvement Program database to identify patients undergoing orthopedic trauma surgery between 2008 and 2016. Patients of all ages who underwent orthopedic trauma surgery were identified using Current Procedural Terminology codes. Patients classified as either Black or White were included in the study. Demographic data, comorbidities, and basic surgical data were compared between the groups. Adverse outcomes in the initial 30 days postoperative were also examined. Higher frequencies of deep wound infection (0.5% vs 0.3%, P=.002) were noted among Black patients, with decreased mortality (0.3% vs 0.6%, P=.004) and postoperative transfusion (2.7% vs 3.8%, P<.001) rates, compared with White patients. Clear differences exist in the demographic, surgical, and outcome data between Black and White patients undergoing orthopedic trauma surgery. More epidemiological studies are required to further investigate racial differences in orthopedic trauma surgery. [Orthopedics. 2022;45(2):71-76.].