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Bérubé M, Moore L, Tardif PA, Berry G, Belzile É, Lesieur M, Paquet J. Low-value injury care in the adult orthopaedic trauma population: A systematic review. Int J Clin Pract 2021; 75:e15009. [PMID: 34816530 DOI: 10.1111/ijcp.15009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/19/2021] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices. METHODS We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes. RESULTS Of the 30,670 records screened, 70 studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60 years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias. CONCLUSION In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.
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Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Pierre-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
| | - Gregory Berry
- Division of Orthopaedic Surgery, McGill University Health Center, Montréal, Québec, Canada
| | - Étienne Belzile
- Division of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Martin Lesieur
- Division of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Jérôme Paquet
- Division of Neurosurgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
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Potential Benefits of Limited Clinical and Radiographic Follow-up After Surgical Treatment of Ankle Fractures. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202105000-00009. [PMID: 33974571 PMCID: PMC8116015 DOI: 10.5435/jaaosglobal-d-21-00074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 11/28/2022]
Abstract
Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed.
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Nair S, Nambiar M, Pope A, Parkes M, De Jong K, Hau R. Intraoperative fluoroscopy alone versus routine post-operative X-rays in identifying return to theatre after fracture fixation. ANZ J Surg 2021; 91:392-397. [PMID: 33538096 DOI: 10.1111/ans.16610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/03/2021] [Accepted: 01/06/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-operative imaging aims to assess fracture reduction and fixation with better resolution than intraoperative fluoroscopy (IF). However, this routine practice may increase costs and delay the discharge of patients. The aim of this study is to assess the role of post-operative imaging in identifying patients that require a return to theatre following the use of IF. METHODS A retrospective cohort study was conducted in a single health network comprising of two hospitals over 1 year. All fracture fixations that required IF were included. Patients who had post-operative imaging were identified and complications requiring a return to theatre were obtained. Non-trauma patients and those who did not have IF were excluded. RESULTS A total of 1319 patients had IF. Of these patients, 1131 patients had post-operative radiographs within 7 days of their operation. In total, 12 patients (1.1%) returned to theatre as a result of a finding identified in their post-operative imaging. The calculated number of X-rays required to be taken to identify a complication was 94. The main reasons identified for these cases to require a return to theatre despite having had IF included: (i) insufficient quality/views of IF, (ii) loss of position/new injury occurring in post-operative period and (iii) poor reduction/fixation demonstrated intraoperatively that was missed/accepted. CONCLUSION The use of post-operative radiographs can identify significant complications despite the use of IF in trauma patients. However, further consideration needs to be made regarding the benefits and costs of this practice in evaluating its clinical effectiveness.
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Affiliation(s)
- Sachin Nair
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Mithun Nambiar
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Alun Pope
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Muhajir Parkes
- Department of Radiology, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Kenneth De Jong
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia
| | - Raphael Hau
- Department of Orthopaedic Surgery, Box Hill Hospital, Melbourne, Victoria, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia.,Northwest Clinical School, Northern Hospital, The University of Melbourne, Melbourne, Victoria, Australia
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Abbasian M, Biglari F, Sadighi M, Ebrahimpour A. Reliability of Postoperative Radiographies in Ankle Fractures. THE ARCHIVES OF BONE AND JOINT SURGERY 2020; 8:598-604. [PMID: 33088861 DOI: 10.22038/abjs.2020.43134.2173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The accuracy of reduction of ankle fractures using postoperative plain radiographies (x-ray) remains widely controversial. Some authors have demonstrated that postoperative computed tomography (CT) scan can be useful for these patients. In current study, the efficacy of x-rays after fixation of ankle fractures was investigated based on the CT scan findings. Methods A total of 73 patients with ankle fractures who were subjected to open reduction internal fixation (ORIF) were enrolled. After surgery, if the reduction was acceptable based on the x-rays according to standard measurements, the patient was referred for CT scanning. Forty four patients were included in the study. Undesirable CT scan findings including malreduction of fragments or articular surfaces, device malpositioning, missed fractures, and undetected intra-articular fragments were documented. Results Undesirable CT findings were seen in 25 patients (56.8%). CT scan showed acceptable reduction without device malpositioning in 19 patients. The most prevalent findings in CT images were malreduction and device malpositioning in 17 and 16 patients, respectively. There was no abnormal finding in CT imaging of lateral malleolar fractures. In two thirds of the injured syndesmosis, device malpositioning, and malreduction were detected in CT scan. Conclusion Despite acceptable postoperative x-rays, a considerable number of patients with ankle fractures had inappropriate reduction or undesirable findings in their postoperative CT scan. It seems necessary to use CT scan after ORIF of ankle fractures in order to examine the accuracy of reduction. Further validation of postoperative CT scan in ankle fracture surgery should be investigated.
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Affiliation(s)
- Mohammadreza Abbasian
- Department of Orthopedic Surgery, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Center for Advanced Orthopedic Studies, BIDMC, Harvard Medical School, Boston, MA, USA
| | - Farsad Biglari
- Department of Orthopedic Surgery, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Sadighi
- Department of Orthopedic Surgery, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Adel Ebrahimpour
- Department of Orthopedic Surgery, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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van Gerven P, Krijnen P, Zuidema WP, El Moumni M, Rubinstein SM, van Tulder MW, Schipper IB, Termaat MF. Omitting Routine Radiography of Traumatic Ankle Fractures After Initial 2-Week Follow-up Does Not Affect Outcomes: The WARRIOR Trial: A Multicenter Randomized Controlled Trial. J Bone Joint Surg Am 2020; 102:1588-1599. [PMID: 32604381 DOI: 10.2106/jbjs.19.01381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The clinical consequences of routine follow-up radiographs for patients with ankle fracture are unclear, and their usefulness is disputed. The purpose of the present study was to determine if routine radiographs made at weeks 6 and 12 can be omitted without compromising clinical outcomes. METHODS This multicenter randomized controlled trial with a noninferiority design included 246 patients with an ankle fracture, 153 (62%) of whom received operative treatment. At 6 and 12 weeks of follow-up, patients in the routine-care group (n = 128) received routine radiographs whereas patients in the reduced-imaging group (n = 118) did not. The primary outcome was the Olerud-Molander Ankle Score (OMAS). Secondary outcomes were the American Academy of Orthopaedic Surgeons (AAOS) foot and ankle questionnaire, health-related quality of life (HRQoL) as measured with the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L) and Short Form-36 (SF-36), complications, pain, health perception, self-perceived recovery, the number of radiographs, and the indications for radiographs to be made. The outcomes were assessed at baseline and at 6, 12, 26, and 52 weeks of follow-up. Data were analyzed with use of mixed models. RESULTS Reduced imaging was noninferior compared with routine care in terms of OMAS scores (difference [β], -0.9; 95% confidence interval [CI], -6.2 to 4.4). AAOS scores, HRQoL, pain, health perception, and self-perceived recovery did not differ between groups. Patients in the reduced-imaging group received a median of 4 radiographs, whereas those in the routine-care group received a median of 5 radiographs (p < 0.05). The rates of complications were similar (27.1% [32 of 118] in the reduced-imaging group, compared with 22.7% [29 of 128] in the routine-care group, p = 0.42). The types of complications were also similar. CONCLUSIONS Implementation of a reduced-imaging protocol following an ankle fracture has no measurable negative effects on functional outcome, pain, and complication rates during the first year of follow-up. The number of follow-up radiographs can be reduced by implementing this protocol. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- P van Gerven
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - P Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - W P Zuidema
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - M El Moumni
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - S M Rubinstein
- Amsterdam Movement Science Research Institute, Department of Health Sciences, VU University, Amsterdam, the Netherlands
| | - M W van Tulder
- Amsterdam Movement Science Research Institute, Department of Health Sciences, VU University, Amsterdam, the Netherlands.,Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - I B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - M F Termaat
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
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ALTUN G, REİS HÇ, BAYRAM B, SAKA G. Comparison of two plain radiographic and 3D-based measurement methods for posterior malleolar fragment size in trimalleol ankle fractures. ARCHIVES OF CLINICAL AND EXPERIMENTAL MEDICINE 2020. [DOI: 10.25000/acem.641188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Potential Economic Benefits of Limited Clinical and Radiographic Follow-up After Plate Fixation of Midshaft Clavicle Fractures. J Am Acad Orthop Surg 2019; 27:405-409. [PMID: 30285986 DOI: 10.5435/jaaos-d-17-00598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The role of routine clinical and radiographic follow-up after clavicle fractures are healed was evaluated. METHODS A retrospective study performed in two level-1 trauma centers included 246 adults with healed clavicle fractures treated surgically between 2000 and 2013 and at least 24-month follow-up. Based on radiographs, changes in fracture alignment or implant position from union to final follow-up were documented. The average reimbursement for a follow-up clinical visit and a clavicle radiograph was estimated. RESULTS Mean time to union and mean time of follow-up were of 4.8 and 31.4 months, respectively. No changes in implant position or fracture alignment occurred after the fracture had healed. The amount reimbursed to our institution for two clinical visits and two clavicle radiographs was approximately $300 to $540. CONCLUSION Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. Limiting routine follow-up is safe and could be cost-effective for the healthcare system. LEVEL OF EVIDENCE Level-III retrospective cohort study.
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van Gerven P, Weil NL, Termaat MF, Rubinstein SM, El Moumni M, Zuidema WP, Hoogendoorn JM, van der Meulen HGWM, van Tulder MW, Schipper IB. Routine Follow-Up Radiographs for Ankle Fractures Seldom Add Value to Clinical Decision-Making: A Retrospective, Observational Study. J Foot Ankle Surg 2019; 57:957-960. [PMID: 30017422 DOI: 10.1053/j.jfas.2018.03.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Indexed: 02/03/2023]
Abstract
Currently, the routine use of radiographs for uncomplicated ankle fractures represents good clinical practice. However, radiographs are associated with waiting time, radiation exposure, and costs. Studies have suggested that radiographs seldom alter the treatment strategy if no clinical indication for the imaging study was present. The objective of the present study was to evaluate the effect of routine radiographs on the treatment strategy during the follow-up period of ankle fractures. All patients aged ≥18 years, who had visited 1 of the participating clinics with an eligible ankle fracture in 2012 and with complete follow-up data were included. The data were retrospectively analyzed. The sociodemographic and clinical characteristics and the number of, and indications for, the radiographs taken were collected from the medical records of the participating clinics. We assessed the changes in treatment strategy according to the radiographic findings. In 528 patients with an ankle fracture, 1174 radiographs were performed during the follow-up period. Of these radiographs, 936 (79.7%) were considered routine. Of the routine radiographs taken during the follow-up period, only 11 (1.2 %) resulted in changes to the treatment strategy. Although it is common practice to take radiographs routinely during the follow-up period for ankle fractures, the results from the present study suggest that routine radiographs seldom alter the treatment strategy. This limited clinical relevance should be weighed against the health care costs and radiation exposure associated with the use of routine radiographs. For a definitive recommendation, however, the results of our study should be confirmed by a prospective trial, which we are currently conducting.
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Affiliation(s)
- Pieter van Gerven
- PhD Candidate, Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - Nikki L Weil
- Researcher, Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marco F Termaat
- Trauma Surgeon, Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Sidney M Rubinstein
- Senior Researcher, Department of Health Sciences, Faculty of Science, Amsterdam Public Health Research Institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mostafa El Moumni
- Trauma Surgeon, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wietse P Zuidema
- Trauma Surgeon, Department of Surgery, VU Medical Centre, Amsterdam, The Netherlands
| | - Jochem M Hoogendoorn
- Trauma Surgeon, Department of Surgery, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Maurits W van Tulder
- Professor, Department of Health Sciences, Faculty of Science, Amsterdam Public Health Research Institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Inger B Schipper
- Professor of Trauma Surgery and Trauma Surgeon, Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
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Karim A, So E, Taylor BC, Degenova D, Nace WC. Ankle Fracture Fixation: Medial or Lateral First? J Foot Ankle Surg 2019; 58:75-79. [PMID: 30448377 DOI: 10.1053/j.jfas.2018.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Indexed: 02/03/2023]
Abstract
In unstable ankle fractures, the importance of reducing the lateral malleolus first to obtain an anatomic reduction of the talus is well established. Although this is a time-tested and common surgical approach, current surgical practice does not always follow the established dogma. Medial-first fixation may be a worthwhile alternative to lateral-first fixation in select instances. We performed a retrospective, cohort study in an urban level I trauma center to compare medial malleolus-first fixation of unstable ankle fractures with lateral malleolus-first fixation. Patient demographics, injury characteristics, and radiographic metrics including pre-, intra-, and final postoperative talocrural angles, medial clear space, and tibiofibular overlap were assessed. Complications were also reviewed. A total of 280 adult patients with operative bimalleolar ankle fractures from January 2010 to January 2015 met inclusion criteria. There were more open fractures (23.2% vs 9.4%, p = .01) and less isolated injuries in the medial-first group (59.2% vs 71.0%, p = .02). There were less isolated operative procedures (80.3% vs 89.1%, p = .04) and more intramedullary screw placement of the lateral malleolus (11.2% vs 4.3% p = .02) in the medial-first fixation group. There was also a strong trend in identifying more posterior tibial tendon injuries in the medial-first group compared with the lateral-first group (3.5% vs 0%, p = .06). There were no significant differences in fluoroscopy times or radiographic variables in the preoperative, intraoperative, or most recent postoperative images between either group. This approach demonstrates equivalent radiographic outcomes to lateral-first fixation and may be appropriate in select cases.
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Affiliation(s)
- Ammar Karim
- Orthopaedic Trauma Surgeon, Department of Orthopedic Surgery, Doctors Hospital, Columbus, OH
| | - Eric So
- Podiatric Surgeon, Department of Orthopedic Surgery, Doctors Hospital, Columbus, OH
| | - Benjamin C Taylor
- Fellowship Director, Orthopaedic Trauma and Reconstructive Surgery, Department of Orthopedic Surgery, Grant Medical Center, Columbus, OH.
| | - Daniel Degenova
- Medical Student, Department of Orthopedic Surgery, Doctors Hospital, Columbus, OH
| | - William C Nace
- Medical Student, Department of Orthopedic Surgery, Doctors Hospital, Columbus, OH
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Abstract
OBJECTIVES To evaluate whether immediate (0-3 days) postoperative radiography leads to alterations in the management of patients postfracture fixation. DATA SOURCES Systematic review of English-language articles in the MEDLINE (1946-2016), EMBASE (1974-2016), CDSR (2005-2016), CENTRAL (1948-2016), and Google Scholar databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. STUDY SELECTION Randomized or non-randomized controlled trials and prospective or retrospective cohort studies that addressed surgical management of the upper extremity, lower extremity or hip fractures were eligible for review. All included studies needed to have performed radiography within 0-3 days of surgery and reported any directly resulting management changes. DATA EXTRACTION Data were independently extracted by 2 reviewers using a standardized data collection form with predefined data fields for demographics, interventions, study methods, complications, and management outcomes. DATA SYNTHESIS A random-effects model was applied, and pooled effects for absolute benefit increase (ABI) and number needed to treat (NNT) were calculated. CONCLUSIONS Combining the 11/12 articles that reported by patient numbers, the ABI of immediate postoperative radiography for management change was 0.13% [95% confidence interval (CI), 0.00078%-0.60%; NNT = 753]. The ABI for identification of complications was 0.22% (95% CI, 0.0015%-1.24%; NNT = 453). Current literature suggests that immediate postoperative radiography does not lead to management change in most patients after fracture fixation. More comprehensive reporting, along with further prospective comparative research, is encouraged. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Şahin E, Kalem M. Utility of Third-Week Postoperative Radiographs in the Management of Ankle Fractures. Foot Ankle Spec 2018; 11:1938640017751188. [PMID: 29310461 DOI: 10.1177/1938640017751188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the costs and efficacy of radiographs taken in the third week after fixation of bimalleolar and trimalleolar fractures. PATIENTS AND METHOD A retrospective evaluation was made of patients who underwent surgical fixation because of bimalleolar and trimalleolar fractures between January 1, 2008, and October 1, 2013. Patient demographics (age, gender, body mass index), fracture type, follow-up periods, and fixation methods were recorded, and the radiographs taken on postoperative day 1, at 3 weeks, 6 weeks, and the final follow-up were examined by 2 orthopedists. Measurements were taken of the medial clear space (MCS ≤ 4 mm), the tibiofibular clear space (TFCS < 5 mm), and the talocrural angle (TCA = 83° ± 4°) on the mortise radiograph and of the overlap between the tibial tubercle and fibula (TFO > 10 mm) on the anteroposterior radiograph; residual step (mm) was measured on the lateral radiograph. RESULTS A total of 263 patients were examined, and of these, 112 were included for evaluation. In the measurements of postoperative day 1, third week, and sixth week and the final radiographs, no statistically significant difference was determined in the MCS, TFCS, TCA, TFO, and residual step values. Because the cost of a series of 3-way ankle radiographs in Turkey is US$3.81 per patient, the cost of the control series for the 112 patients in this study was US$ 427.3. CONCLUSIONS In patients treated surgically for bimalleolar and trimalleolar fractures, the radiographs taken in the third week rarely resulted in a change of patient management. Therefore, it simply constitutes an additional cost for the patient or the hospital. LEVELS OF EVIDENCE Level III: Retrospective Cohort study.
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Affiliation(s)
- Ercan Şahin
- Faculty of Medicine, Department of Orthopedics and Traumatology, Bülent Ecevit University, Zonguldak, Turkey (ES)
- Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey (MK)
| | - Mahmut Kalem
- Faculty of Medicine, Department of Orthopedics and Traumatology, Bülent Ecevit University, Zonguldak, Turkey (ES)
- Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey (MK)
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Meyr AJ, Mirmiran R, Naldo J, Sachs BD, Shibuya N. American College of Foot and Ankle Surgeons ® Clinical Consensus Statement: Perioperative Management. J Foot Ankle Surg 2017; 56:336-356. [PMID: 28231966 DOI: 10.1053/j.jfas.2016.10.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Indexed: 02/07/2023]
Abstract
A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.
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Affiliation(s)
- Andrew J Meyr
- Committee Chairperson and Clinical Associate Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
| | | | - Jason Naldo
- Assistant Professor, Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Brett D Sachs
- Private Practice, Rocky Mountain Foot & Ankle Center, Wheat Ridge, CO; Faculty, Podiatric Medicine and Surgery Program, Highlands-Presbyterian St. Luke's Medical Center, Denver, CO
| | - Naohiro Shibuya
- Professor, Department of Surgery, Texas A&M, College of Medicine, Temple, TX
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Articular Gap and Step-off Revisited: 3D Quantification of Operative Reduction for Posterior Malleolar Fragments. J Orthop Trauma 2016; 30:670-675. [PMID: 27479735 DOI: 10.1097/bot.0000000000000676] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Despite advanced imaging techniques, classic measurements of fracture reduction have not been revisited to date. The purpose of this study was to evaluate the reliability of innovative measurement techniques to quantify operative fragment reduction of posterior malleolar fractures by quantification of three-dimensional computed tomography (Q3DCT). METHODS Twenty-eight ankle fractures including a posterior malleolar fragment (AO/OTA type 44) were evaluated using 2DCT and Q3DCT to postoperatively quantify fragment reduction. "Classic" maximum gap and step-off of the posterior fragment were measured on 2DCT and Q3DCT. In addition, 2 innovative Q3DCT parameters were introduced and their reliability was tested using intraclass correlations (ICCs): gap surface (mm) and multidirectional 3D-displacement (mm). RESULTS "Classic" measurements showed a median maximum step-off of 1.1 mm [interquartile range (IQR) 0.0-1.8 mm] on 2DCT versus a median step-off of 0.6 mm (IQR 0.0-1.1) on Q3DCT. Median maximum gap was 1.2 mm (IQR 0.0-3.8) on 2DCT, and its equivalent on Q3DCT showed no median displacement. Q3DCT measurements revealed a median gap surface of 14.5 mm (IQR 4.7-30.0) and a median multidirectional 3D-displacement of 0.7 mm (IQR 0.0-1.1). Interrater reliability of these new Q3DCT parameters of displacement was excellent (ICC 0.92, 95% CI 0.79-0.98) for gap surface and good (ICC 0.64, 95% CI 0.28-0.88) for 3D-displacement. CONCLUSIONS Q3DCT is a reliable and promising technique for postoperative evaluation of fracture fragment reduction. In addition to "classic" gap and step-off measurements, we propose to explore total gap surface and 3D-displacement as innovative radiographic measurements in future clinical studies. LEVEL OF EVIDENCE Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Cost Savings Opportunities in Perioperative Management of the Patients With Orthopaedic Trauma. J Orthop Trauma 2016; 30 Suppl 5:S7-S14. [PMID: 27870668 DOI: 10.1097/bot.0000000000000716] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Considerable opportunities for cost savings exist surrounding the perioperative management of patients with orthopaedic fracture and trauma. Scientific evidence is available to support each potential cost savings measure. Much of these data had been documented for years but has never been adhered to, resulting in millions of dollars in unnecessary testing and treatment. Careful attention to preoperative laboratory testing can save huge amounts of money and expedite medical clearance for injured patients. The use of a dedicated orthopaedic trauma operating room has been shown to improve resource utilization, decrease costs, and surgical complications. A variety of anesthetic techniques and agents can reduce operative time, recovery room time, and hospital lengths of stay. Strict adherence to blood utilization protocols, appropriate deep venous thrombosis prophylaxis, and multimodal postoperative pain control with oversight from dedicated hip fracture hospitalists is critical to cost containment. Careful attention to postoperative disposition to acute care and management of postoperative testing and radiographs can also be another area of cost containment. Institutional protocols must be created and followed by a team of orthopaedic surgeons, hospitalists, and anesthesiologists to significantly impact the costs associated with care of patient with orthopaedic trauma and fracture.
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