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Faust AM, Dy CJ. Achieving Health Equity: Combatting the Disparities in American Access to Musculoskeletal Care : Disparities Exist in Every Aspect of Orthopaedic Care in the United States - Access to Outpatient Visits, Discretionary and Unplanned Surgical Care, and Postoperative Outcomes. What Can We Do? Curr Rev Musculoskelet Med 2024; 17:449-455. [PMID: 39222207 PMCID: PMC11464980 DOI: 10.1007/s12178-024-09926-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE OF REVIEW Healthcare disparities influence multiple dimensions of orthopaedic care including access, burden and incidence of disease, and outcome in varying populations. These disparities impact healthcare at both the micro and macro scale of the healthcare experience from individual patient-physician relationships to reimbursement rates across the United States. This article provides a review of how healthcare disparities contribute to the landscape of orthopaedic care and specifically highlights how disparities affect outpatient visits, discretionary and unplanned surgical care, and postoperative outcomes. RECENT FINDINGS Current research demonstrates the widespread presence of healthcare disparities in the field of orthopaedics and gives both objective and subjective evidence confirming disparities' measurable influence. The disparities most highlighted by our review include differences in orthopaedic care based on insurance type and race. Currently disparities in orthopaedic care are deeply connected to patient insurance status and race. In the outpatient setting insurance significantly impacts access to care, travel burden, and utilization of services. The emergent setting is similarly influenced with measurable differences in lack of access to acute care, rates of inappropriate triage, and timeliness of care based on insurance status and race. Additionally, the postoperative period is not immune to disparities with likelihood of follow up, experience of catastrophic medical expenses, and postoperative outcomes also being affected. Addressing these disparities is a pressing need and may include solutions like wider expansion and acceptance of publicly funded insurance and the development of readily available and easily measurable metrics for healthcare equity and quality in vulnerable populations.
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Affiliation(s)
- Amanda Michelle Faust
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 S Euclid. St, Louis, MO, 63108, USA
- University of Missouri-School of Medicine, Columbia, MO, USA
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 S Euclid. St, Louis, MO, 63108, USA.
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Southall WGS, Griffin JT, Foster JA, Wharton MG, Muhammad M, Sierra-Arce CR, Mounce SD, Moghadamian ES, Wright RD, Matuszewski PE, Zuelzer DA, Primm DD, Landy DC, Hawk GS, Aneja A. Does Local Aqueous Tobramycin Injection Reduce Open Fracture-Related Infection Rates? J Orthop Trauma 2024; 38:497-503. [PMID: 39016433 DOI: 10.1097/bot.0000000000002847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVES To examine the effect of local aqueous tobramycin injection adjunct to perioperative intravenous (IV) antibiotic prophylaxis in reducing fracture-related infections (FRIs) following reduction and internal fixation of open fractures. METHODS DESIGN Retrospective cohort study. SETTING Single academic Level I trauma center. PATIENTS SELECTION CRITERIA Patients with open extremity fractures treated with reduction and internal fixation with (intervention group) or without (control group) 80 mg of local aqueous (2 mg/mL) tobramycin injected during closure at the time of definitive fixation were identified from December 2018 to August 2021 based on population-matched demographic and injury characteristics. OUTCOME MEASURES AND COMPARISONS The primary outcome was FRI within 6 months of definitive fixation. Secondary outcomes consisted of fracture nonunion and bacterial speciation. Differences in outcomes between the 2 groups were assessed and logistic regression models were created to assess the difference in infection rates between groups, with and without controlling for potential confounding variables, such as sex, fracture location, and Gustilo-Anderson classification. RESULTS An analysis of 157 patients was performed with 78 patients in the intervention group and 79 patients in the control group. In the intervention group, 30 (38.5%) patients were women with a mean age of 47.1 years. In the control group, 42 (53.2%) patients were women with a mean age of 46.4 years. The FRI rate was 11.5% in the intervention group compared with 25.3% in the control group ( P = 0.026). After controlling for sex, Gustilo-Anderson classification, and fracture location, the difference in FRI rates between groups remained significantly different ( P = 0.014). CONCLUSIONS Local aqueous tobramycin injection at the time of definitive internal fixation of open extremity fractures was associated with a significant reduction in FRI rates when administered as an adjunct to intravenous antibiotics, even after controlling for potential confounding variables. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Wyatt G S Southall
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Jarod T Griffin
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Jeffrey A Foster
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Matthew G Wharton
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Maaz Muhammad
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Carlos R Sierra-Arce
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Samuel D Mounce
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Eric S Moghadamian
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Raymond D Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Paul E Matuszewski
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - David A Zuelzer
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Daniel D Primm
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - David C Landy
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Gregory S Hawk
- Dr Bing Zhang Department of Statistics, University of Kentucky, Lexington, KY
| | - Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
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Muhammad M, Foster JA, Griffin JT, Kinchelow DL, Sierra-Arce CR, Southall WGS, Albitar F, Moghadamian ES, Wright RD, Matuszewski PE, Zuelzer DA, Primm DD, Hawk GS, Aneja A. Nonoperative Treatment of Humeral Shaft Fractures With Immediate Functional Bracing Versus Coaptation Splinting and Delayed Functional Bracing: A Retrospective Study. J Orthop Trauma 2024; 38:383-389. [PMID: 38527088 DOI: 10.1097/bot.0000000000002810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 03/27/2024]
Abstract
OBJECTIVES To compare radiographic and clinical outcomes in nonoperative management of humeral shaft fractures treated initially with coaptation splinting (CS) followed by delayed functional bracing (FB) versus treatment with immediate FB. METHODS DESIGN Retrospective cohort study. SETTING Academic Level 1 Trauma Center. PATIENT SELECTION CRITERIA Patients with closed humeral shaft fractures managed nonoperatively with initial CS followed by delayed FB or with immediate FB from 2016 to 2022. Patients younger than 18 years and/or with less than 3 months of follow-up were excluded. OUTCOME MEASURES AND COMPARISONS The primary outcome was coronal and sagittal radiographic alignment assessed at the final follow-up. Secondary outcomes included rate of failure of nonoperative management (defined as surgical conversion and/or fracture nonunion), fracture union, and skin complications secondary to splint/brace wear. RESULTS Ninety-seven patients were managed nonoperatively with delayed FB (n = 58) or immediate FB (n = 39). Overall, the mean age was 49.9 years (range 18-94 years), and 64 (66%) patients were female. The immediate FB group had less smokers ( P = 0.003) and lower incidence of radial nerve palsy ( P = 0.025), with more proximal third humeral shaft fractures ( P = 0.001). There were no other significant differences in demographic or clinical characteristics ( P > 0.05). There were no significant differences in coronal ( P = 0.144) or sagittal ( P = 0.763) radiographic alignment between the groups. In total, 33 (34.0%) humeral shaft fractures failed nonoperative management, with 11 (28.2%) in the immediate FB group and 22 (37.9%) in the delayed FB group ( P = 0.322). There were no significant differences in fracture union ( P = 0.074) or skin complications ( P = 0.259) between the groups. CONCLUSIONS This study demonstrated that nonoperative treatment of humeral shaft fractures with immediate functional bracing did not result in significantly different radiographic or clinical outcomes compared to treatment with CS followed by delayed functional bracing. Future prospective studies assessing patient-reported outcomes will further guide clinical decision making. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Maaz Muhammad
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Jeffrey A Foster
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Jarod T Griffin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Daria L Kinchelow
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | | | - Wyatt G S Southall
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Ferras Albitar
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Eric S Moghadamian
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Raymond D Wright
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Paul E Matuszewski
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - David A Zuelzer
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Daniel D Primm
- Department Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Gregory S Hawk
- Dr. Bing Zhang Department of Statistics, University of Kentucky, Lexington, KY
| | - Arun Aneja
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
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Campbell ST, Earhart J, Marchand LS, Bilodeau RE, Barth K, Ricci WM, Githens MF. Intraosseous Shelf Plate Fixation for Depressed Articular Fragments in Tibial Plateau Fractures: A Technical Trick and Case Series. J Orthop Trauma 2024; 38:e272-e276. [PMID: 38578647 DOI: 10.1097/bot.0000000000002812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
SUMMARY Tibial plateau fractures with severely displaced articular injuries and significant deformity to the surrounding metaphyseal bone (including the hyperextension varus bicondylar pattern) can be challenging to stabilize due to resulting large bone voids uncontained by metaphyseal cortex. The purpose of this report was to describe a technique to support the plateau articular surface in these cases and report on outcomes of a small series. This technique uses a small or mini fragment plate, contoured to function as an intraosseous shelf plate, with the "shelf" portion inserted into the bone beneath the articular surface to support it. This technique provides fixed-angle support to the fragment. There are some advantages of this technique compared to structural allograft, large volume ceramic bone void filler, a spine cage, or other trabecular metal object, including the ability to remove the plate later, ability to tension the plate against the depressed articular surface, ability to place screws or other allograft near the implant, wide availability of the implant, and familiarity of orthopaedic trauma surgeons with placing plates and screws to hold reductions. The technique is particularly useful in patterns with uncontained articular depression and a large metaphyseal void.
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Affiliation(s)
- Sean T Campbell
- Department of Orthopaedic Surgery, University of California Davis Medical Center, Sacramento, CA
| | | | - Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | | | - Kathryn Barth
- Hospital for Special Surgery, New York City, NY; and
| | | | - Michael F Githens
- Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, WA
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Schepers T, Halm JA. Aftercare for surgically treated ankle fractures. Lancet 2024; 403:2756-2757. [PMID: 38848739 DOI: 10.1016/s0140-6736(24)00916-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 04/29/2024] [Indexed: 06/09/2024]
Affiliation(s)
- Tim Schepers
- Trauma Unit, Department of Surgery, Amsterdam UMC, Amsterdam 1105AZ, Netherlands.
| | - Jens A Halm
- Trauma Unit, Department of Surgery, Amsterdam UMC, Amsterdam 1105AZ, Netherlands
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Srinath A, Southall WGS, Nazal MR, Mechas CA, Foster JA, Griffin JT, Muhammad M, Moghadamian ES, Landy DC, Aneja A. Talar Neck Fractures With Associated Ipsilateral Foot and Ankle Fractures Have a Higher Risk of Avascular Necrosis. J Orthop Trauma 2024; 38:220-224. [PMID: 38457751 DOI: 10.1097/bot.0000000000002798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVES To determine if talar neck fractures with concomitant ipsilateral foot and/or ankle fractures (TNIFAFs) are associated with higher rates of avascular necrosis (AVN) compared with isolated talar neck fractures (ITNs). METHODS DESIGN Retrospective cohort. SETTING Single level I trauma center. PATIENT SELECTION CRITERIA Skeletally mature patients who sustained talar neck fractures from January 2008 to January 2017 with at least 6-month follow-up. Based on radiographs at the time of injury, fractures were classified as ITN or TNIFAF and by Hawkins classification. OUTCOME MEASURES AND COMPARISONS The primary outcome was the development of AVN based on follow-up radiographs, with secondary outcomes including nonunion and collapse. RESULTS There were 115 patients who sustained talar neck fractures, with 63 (55%) in the ITN group and 52 (45%) in the TNIFAF group. In total, 63 patients (54.7%) were female with the mean age of 39 years (range, 17-85), and 111 fractures (96.5%) occurred secondary to high-energy mechanisms of injury. There were no significant differences in demographic or clinical characteristics between groups ( P > 0.05). Twenty-four patients (46%) developed AVN in the TNIFAF group compared with 19 patients (30%) in the ITN group ( P = 0.078). After adjusting for Hawkins classification and other variables, the odds of developing AVN was higher in the TNIFAF group compared with the ITN group [odds ratio, 2.43 (95% confidence interval, 1.01-5.84); ( P = 0.047)]. CONCLUSIONS This study found a significantly higher likelihood of AVN in patients with talar neck fractures with concomitant ipsilateral foot and/or ankle fractures compared to those with isolated talar neck fractures after adjusting for Hawkins classification and other potential prognostic confounders. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Arjun Srinath
- Department of Orthopaedic Surgery, University of Miami, Miami, FL
| | - Wyatt G S Southall
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Mark R Nazal
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Charles A Mechas
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Jeffrey A Foster
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
| | - Jarod T Griffin
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
| | - Maaz Muhammad
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
| | - Eric S Moghadamian
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | | | - Arun Aneja
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; and
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Tolosano L, Rieussec C, Sauzeat B, Caillard G, Drevet S, Kerschbaumer G, Porcheron G, Wagner D, Rommens PM, Tonetti J, Boudissa M. Fragility fractures of the pelvis: First 48 cases of surgical treatment at a level 1 trauma center in France. Orthop Traumatol Surg Res 2024; 110:103855. [PMID: 38438109 DOI: 10.1016/j.otsr.2024.103855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 06/30/2023] [Accepted: 01/04/2024] [Indexed: 03/06/2024]
Abstract
INTRODUCTION Longer life expectancy is accompanied by a higher incidence of fragility fractures of the pelvis (FFP), which has repercussions on mortality and nursing home admissions. Given the paucity of data at French healthcare facilities, we carried out a retrospective study to (1) evaluate how surgical treatment of FFP with posterior displacement (type III and IV according to Rommens and Hofmann) affects a patient's pain, functional status and ability to stay at home and (2) evaluate the postoperative complications and mortality rate. HYPOTHESIS Surgery for posteriorly displaced FFP will relieve pain and preserve the patient's independence. METHODS All the patients over 65 years of age who were operated on for a posterior FFP between January 2015 and August 2020 were included in this prospective, single-center study. The demographics, fracture type, details of the surgical treatment, complications and mortality were analyzed. Pain (visual analog scale, VAS), functional status (Activity of Daily Living [ADL] and Instrumental Activity of Daily Living [IADL]), mobility (Parker score) and rates of nursing home admissions were compared before the fracture, after surgery and at a mean follow-up of 28 months (minimum follow-up of 1 year). RESULTS Forty-eight patients with a mean age of 75 years were included. Twenty-four of these patients (50%) had at least two comorbidities. The FFPs were either type IV (31/48; 65%) or type III (17/48; 35%). The mean VAS for pain was significantly lower on the first day postoperative (3.5 versus 4.8; p=0.02). This significant reduction continued upon discharge from the hospital (1.95; p=0.003) and persisted at the mean follow-up of 28 months (2.2; p=0.64). The complication rate was 15% (7/48) and the mortality rate at the final review was 15% (7/48). Among the surviving patients, 81% (29/36) returned to living at home. The ADL (5.1 versus 5.8; p=0.09), IADL (5.9 versus 6.9; p=0.15) and Parker score (6.8 versus 8.2; p=0.08) at the final review were not significantly different from the values before the fracture. CONCLUSION This is the first French study of patients operated on for an FPP. Fixation of posteriorly displaced fractures allows surviving patients to retain their mobility. Pain relief is achieved quickly and maintained during the follow-up period. Thus, our initial hypothesis is affirmed. The complication rate is not insignificant; given the complexity of this surgery, percutaneous treatment is preferable. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
- Luca Tolosano
- Orthopedic and Trauma Surgery Department, University Hospital, Grenoble Alpes University, 38700 La Tronche, France
| | - Clementine Rieussec
- Orthopedic and Trauma Surgery Department, University Hospital, Grenoble Alpes University, 38700 La Tronche, France
| | - Bérengère Sauzeat
- Orthopedic and Trauma Surgery Department, University Hospital, Grenoble Alpes University, 38700 La Tronche, France
| | - Gauthier Caillard
- Orthopedic and Trauma Surgery Department, University Hospital, Grenoble Alpes University, 38700 La Tronche, France
| | - Sabine Drevet
- Orthopedic and Trauma Surgery Department, University Hospital, Grenoble Alpes University, 38700 La Tronche, France
| | - Gael Kerschbaumer
- Orthopedic and Trauma Surgery Department, University Hospital, Grenoble Alpes University, 38700 La Tronche, France
| | - Geoffrey Porcheron
- Orthopedic and Trauma Surgery Department, Mayence University Hospital, Langenbeckstrasse 1, 55131 Mayence, Germany
| | - Daniel Wagner
- Orthopedic and Trauma Surgery Department, Mayence University Hospital, Langenbeckstrasse 1, 55131 Mayence, Germany
| | - Pol Maria Rommens
- Orthopedic and Trauma Surgery Department, Mayence University Hospital, Langenbeckstrasse 1, 55131 Mayence, Germany
| | - Jérôme Tonetti
- Orthopedic and Trauma Surgery Department, University Hospital, Grenoble Alpes University, 38700 La Tronche, France; TIMC-IMAG lab, CNRS UMR 5525, Grenoble Alpes University, 38700 La Tronche, France
| | - Mehdi Boudissa
- Orthopedic and Trauma Surgery Department, University Hospital, Grenoble Alpes University, 38700 La Tronche, France; TIMC-IMAG lab, CNRS UMR 5525, Grenoble Alpes University, 38700 La Tronche, France.
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Dong W, Sroka O, Campbell M, Thorne T, Siebert M, Rothberg D, Higgins T, Haller J, Marchand L. Recovery Curves for Lisfranc ORIF Using PROMIS Physical Function and Pain Interference. J Orthop Trauma 2024; 38:e175-e181. [PMID: 38381118 DOI: 10.1097/bot.0000000000002787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 02/13/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVES To determine the postoperative trajectory and recovery of patients who undergo Lisfranc open reduction and internal fixation using Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI). METHODS DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENT SELECTION CRITERIA Patients who underwent Lisfranc open reduction and internal fixation between January 2002 and December 2022 with documented PROMIS PF and/or PI scores after surgery. OUTCOME MEASURES AND COMPARISONS PROMIS PF and PI were mapped over time up to 1 year after surgery. A subanalysis was performed to compare recovery trajectories between high-energy and low-energy injuries. RESULTS A total of 182 patients were included with average age of 38.7 (SD 15.9) years (59 high-energy and 122 low-energy injuries). PROMIS PF scores at 0, 6, 12, 24, and 48 weeks were 30.2, 31.4, 39.2, 43.9, and 46.7, respectively. There was significant improvement in PROMIS PF between 6 and 12 weeks ( P < 0.001), 12-24 weeks ( P < 0.001), and 24-48 weeks ( P = 0.022). A significant difference in PROMIS PF between high and low-energy injuries was seen at 0 week (28.4 vs. 31.4, P = 0.010). PROMIS PI scores at 0, 6, 12, 24, and 48 weeks were 62.2, 58.5, 56.6, 55.7, and 55.6, respectively. There was significant improvement in PROMIS PI 0-6 weeks ( P = 0.016). A significant difference in PROMIS PI between high-energy and low-energy injuries was seen at 48 weeks with scores of (58.6 vs. 54.2, P = 0.044). CONCLUSIONS After Lisfranc open reduction and internal fixation, patients can expect improvement in PF up to 1 year after surgery, with the biggest improvement in PROMIS PF scores between 6 and 12 weeks and PROMIS PI scores between 0 and 6 weeks after surgery. Regardless the energy type, Lisfranc injuries seem to regain comparable PF by 6-12 months after surgery. However, patients with higher energy Lisfranc injuries should be counseled that these injuries may lead to worse PI at 1 year after surgery as compared with lower energy injuries. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Willie Dong
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
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Hunter J, Ramirez G, Thirukumaran C, Baumhauer J. Using PROMIS Scores to Provide Cost-Conscious Follow-up After Foot and Ankle Surgery. Foot Ankle Int 2024; 45:496-505. [PMID: 38400745 DOI: 10.1177/10711007241230544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Abstract
BACKGROUND National campaigns in the United States, such as Choosing Wisely, emphasize that decreasing low-value office visits maximizes health care value. Although patient-reported outcomes (PROs) are frequently used to quantify postoperative outcomes, they have not been assessed as a tool to help guide clinicians consider alternatives or discontinue in-person follow-up visits. The purpose of this study is to assess the frequency and cost of in-person follow-up visits after patients report substantial improvement defined as 2 consecutive improvements above preoperative Patient Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores. METHODS Retrospective PROMIS PI data were obtained between 2015 and 2020 for common elective foot (n = 759) and ankle (n = 578) surgical procedures. Patients were divided into quartiles according to their preoperative PI score. Multivariable Cox proportional hazards models were used to investigate time to substantial improvement. Substantial improvement was defined as having 2 consecutive postoperative minimal clinically important differences (MCIDs) above preoperative PROMIS PI scores. MCID was measured using the distribution-based method. Multivariable negative binomial models were used to determine the number of visits and direct associated costs after substantial improvement. The cost to payors was estimated using reimbursement rates. RESULTS Within 3 months, 12% to 46% of foot and 16% to 61% of ankle patients achieved substantial improvement. Results vary by preoperative pain quartile, with patients who report higher preoperative pain scores achieving earlier improvement. After achieving substantial improvement, foot and ankle patients averaged 3.60 and 4.01 follow-up visits during the remaining 9 months of the year. Visit costs averaged $266 and $322 per foot and ankle patient respectively. CONCLUSION Postoperative follow-up visits are time-consuming and costly. Physicians might consider objective measures, such as PROMIS PI, to determine the need, timing, and alternatives for in-person follow-up visits for elective foot and ankle surgeries after patients demonstrate reliable clinical improvement. LEVEL OF EVIDENCE Level III, retrospective cohort study at a single institution.
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Affiliation(s)
- Jefferson Hunter
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Gabriel Ramirez
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | | | - Judith Baumhauer
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Sato EH, Treu EA, Froerer DL, Zhang C, O’Neill DC, Cizik AM, Haller JM. Establishing the Patient Acceptable Symptom State Thresholds for Patient-Reported Outcomes after Operatively Treated Tibial Plateau Fractures. J Orthop Trauma 2024; 38:121-128. [PMID: 38117573 PMCID: PMC11330326 DOI: 10.1097/bot.0000000000002750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVES Define patient-acceptable symptom state (PASS) thresholds and factors affecting PASS thresholds for Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Knee Injury and Osteoarthritis Outcome Score (KOOS) following operatively treated tibial plateau fractures. METHODS DESIGN Retrospective cohort. SETTING Single Level I academic trauma center. PATIENT SELECTION CRITERIA All patients (n = 159) who underwent fixation of a tibial plateau fracture from 2016 to 2021 and completed patient-reported outcome measures (PROMs) at minimum 1-year follow-up were enrolled for the study. OUTCOME MEASURES AND COMPARISONS PASS thresholds for global outcome (PASS-Global), pain (PASS-Pain), and function (PASS-Function) were determined using anchor-based questions such as "How satisfied are you today with your injured lower extremity?" with answer choices of very satisfied, satisfied, neutral, unsatisfied, and very unsatisfied. PASS thresholds for each PROM were calculated using 3 methods: (1) 80% specificity, (2) 75th percentile, and (3) Youden Index. RESULTS Sixty percent of patients were satisfied with their global outcome and 53% with function. Using 80% specificity, 75th percentile, and Youden Index, PASS-Global thresholds were 48.5, 44.5, and 47.9 for PROMIS-PF and 56.3, 56.2, and 56.3 for KOOS-QOL, respectively. PASS-Pain threshold for KOOS-Pain was 84.4, 80.6, and 80.6, respectively. PASS-Function thresholds were 48.9, 46.8, and 48 for PROMIS-PF and 94.1, 90.2, and 86.8 for KOOS-ADL, respectively. Younger patients and those with bicondylar fractures or infections were associated with significantly lower PASS-Pain thresholds. Schatzker II fractures, lateral column involvement, or isolated lateral approach resulted in significantly higher PASS-Global and PASS-Function thresholds. CONCLUSIONS This study defines global, functional, and pain PASS thresholds for tibial plateau fractures. Patients with bicondylar fractures, infections, and medial column involvement were more often unsatisfied. These thresholds are valuable references to identify patients who have attained satisfactory outcomes and to counsel patients with risk factors for unsatisfactory outcomes following tibial plateau fractures. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Eleanor H. Sato
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Emily A. Treu
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Devin L. Froerer
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Chong Zhang
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Dillon C. O’Neill
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Amy M. Cizik
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Justin M. Haller
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
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Tucker A, Roffey DM, Guy P, Potter JM, Broekhuyse HM, Lefaivre KA. Evaluation of the trajectory of recovery following surgically treated acetabular fractures. Bone Joint J 2024; 106-B:69-76. [PMID: 38160696 DOI: 10.1302/0301-620x.106b1.bjj-2023-0499.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Aims Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years. Methods Eligible patients at a level I trauma centre were recruited into a longitudinal registry of surgical acetabular fractures between June 2004 and August 2019. Patient-reported outcome measures (PROMs), including the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS), were recorded at baseline pre-injury recall and six months, one year, two years, and five years postoperatively. Comparative analyses were performed for elementary and associated fracture patterns. The proportion of patients achieving minimal clinically important difference (MCID) was determined. The rate of, and time to, conversion to total hip arthroplasty (THA) was also established. Results We recruited 251 patients (253 fractures), with a 4:1 male to female ratio and mean age of 46.1 years (SD 16.4). Associated fracture patterns accounted for 56.5% of fractures (n = 143). Trajectory analysis showed all timepoints had significant disability versus baseline, including final follow-up (p < 0.001). Elementary fractures had higher SF-36 PCS at six months (p = 0.023) and one year (p = 0.007) compared to associated fractures, but not at two years (p = 0.135) or five years (p = 0.631). The MCID in SF-36 PCS was observed in 37.3% of patients (69/185) between six months and one year, 26.9% of patients (39/145) between one and two years, and 23.3% of patients (20/86) between two and five years, highlighting the long recovery potential of these injuries. A significant proportion of patients failed to attain the MCID after five years (38.1%; 40/105). Conversion to THA occurred in 13.1% of patients (11/110 elementary and 22/143 associated fractures). Approximately two-thirds of THAs (21/33 patients; 63.6%) were performed within two years of index surgery. Conclusion Acetabular fractures significantly impact physical function. Recovery trajectory is often elongated beyond one year, with two-thirds of our patients displaying persistent clinically relevant long-term disability.
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Affiliation(s)
- Adam Tucker
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
| | - Darren M Roffey
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver, Canada
| | - Pierre Guy
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver, Canada
| | - Jeffrey M Potter
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver, Canada
| | - Henry M Broekhuyse
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver, Canada
| | - Kelly A Lefaivre
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver, Canada
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Lee SR, Singh S, Chou TFA, Stallone S, Lo Y, Gruson KI. Missed Short-term Follow-up After Arthroscopic Rotator Cuff Surgery: Analysis of Surgical and Demographic Factors. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202401000-00003. [PMID: 38236064 PMCID: PMC10796147 DOI: 10.5435/jaaosglobal-d-23-00265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 01/19/2024]
Abstract
INTRODUCTION Few current studies have examined loss to follow-up after rotator cuff-related shoulder arthroscopy. Understanding the demographic and surgical factors for missed follow-up would help identify patients most at risk and potentially mitigate the onset of complications while maximizing clinical outcomes. METHODS A retrospective review of consecutive rotator cuff arthroscopic procedures with a minimum of 12-month follow-up done by a single, fellowship-trained surgeon was undertaken from February 2016 through January 2022. Demographic patient and surgical data, including age, sex, marital status, self-identified race, and body mass index, were collected. Follow-up at ≤3, 6 weeks, 3, 6, and 12 months was determined. Patient-related and surgical predictors for missed short-term follow-up, defined as nonattendance at the 6 and 12-month postoperative visits, were identified. RESULTS There were 449 cases included, of which 248 (55%) were women. The median age was 57 years (interquartile range [IQR], 51 to 62). Patients with commercial insurance (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.23 to 0.64; P < 0.001) or workers' compensation (OR, 0.15; 95% CI, 0.05 to 0.43; P < 0.001) were less likely to miss the 6-month follow-up compared with patients with Medicare, whereas increased socioeconomic deprivation (OR, 0.86; 95% CI, 0.77 to 0.97, P = 0.015) was associated with decreased odds of missing that visit. Patients who missed the ≤3 weeks (OR, 1.77; 95% CI, 1.14 to 2.74, P = 0.010) and 3-month (OR, 8.55; 95% CI, 4.33 to 16.86; P < 0.001) follow-ups were more likely to miss the 6-month follow-up. Use of a patient contact system (OR, 0.55; 95% CI, 0.35 to 0.87, P = 0.01) and increased number of preoperative visits (OR, 0.91; 95% CI, 0.84 to 0.99, P = 0.033) were associated with decreased odds of missing the 12-month follow-up. Patients who missed the 6-month follow-up were more likely to miss the 12-month follow-up (OR, 5.38; 95% CI, 3.45 to 8.40; P < 0.001). CONCLUSION Implementing an electronic patient contact system while increasing focus on patients with few preoperative visits and who miss the 6-month follow-up can reduce the risk of missed follow-up at 12 months after shoulder arthroscopy.
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Affiliation(s)
- Sung R. Lee
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine (Dr. Lee, Dr. Singh, Dr. Chou, Mr. Stallone, and Dr. Gruson); and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
| | - Sirjanhar Singh
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine (Dr. Lee, Dr. Singh, Dr. Chou, Mr. Stallone, and Dr. Gruson); and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
| | - Te-Feng A. Chou
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine (Dr. Lee, Dr. Singh, Dr. Chou, Mr. Stallone, and Dr. Gruson); and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
| | - Savino Stallone
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine (Dr. Lee, Dr. Singh, Dr. Chou, Mr. Stallone, and Dr. Gruson); and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
| | - Yungtai Lo
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine (Dr. Lee, Dr. Singh, Dr. Chou, Mr. Stallone, and Dr. Gruson); and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
| | - Konrad I. Gruson
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine (Dr. Lee, Dr. Singh, Dr. Chou, Mr. Stallone, and Dr. Gruson); and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
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Shi BY, Brodke DJ, O'Hara N, Devana S, Hernandez A, Burke C, Gupta J, McKibben N, O'Toole R, Morellato J, Gillon H, Walters M, Barber C, Perdue P, Dekeyser G, Steffenson L, Marchand L, Shymon S, Fairres MJ, Black L, Working Z, Roddy E, El Naga A, Hogue M, Gulbrandsen T, Atassi O, Mitchell T, Lee C. Nail Plate Combination Fixation Versus Lateral Locked Plating for Distal Femur Fractures: A Multicenter Experience. J Orthop Trauma 2023; 37:562-567. [PMID: 37828687 DOI: 10.1097/bot.0000000000002661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES To (1) report on clinical, radiographic, and functional outcomes after nail-plate fixation (NPF) of distal femur fractures and (2) compare outcomes after NPF with a propensity matched cohort of fractures treated with single precontoured lateral locking plates. DESIGN Multicenter retrospective cohort study. SETTING Ten Level 1 trauma centers. PATIENTS/PARTICIPANTS Patients with OTA/AO 33A or 33C fractures. INTERVENTION Fixation with (1) retrograde intramedullary nail combined with lateral locking plate (n = 33) or (2) single precontoured lateral locking plate alone (n = 867). MAIN OUTCOME MEASUREMENTS The main outcomes of interest were all-cause unplanned reoperation and presence of varus collapse at final follow-up. RESULTS One nail-plate patient underwent unplanned reoperation excluding infection and 2 underwent reoperation for infection at an average of 57 weeks after surgery. No nail-plate patients required unplanned reoperation to promote union and none exhibited varus collapse. More than 90% were ambulatory with no or minimal pain at final follow-up. In comparison, 7 of the 30 matched lateral locked plating patients underwent all-cause unplanned reoperation excluding infection (23% vs. 3%, P = 0.023), and an additional 3 lateral locked plating patients were found to have varus collapse on final radiographs (10% vs. 0%, P = 0.069). CONCLUSIONS Despite a high proportion of high-energy, open, and comminuted fractures, no NPF patients underwent unplanned reoperation to promote union or demonstrated varus collapse. Propensity score matched analysis revealed significantly lower rates of nonunion for NPF compared with lateral locked plating alone. Larger studies are needed to identify which distal femur fracture patients would most benefit from NPF. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | - Nathan O'Hara
- Adams Cowley Shock Trauma Center at the University of Maryland
| | | | | | - Cynthia Burke
- Adams Cowley Shock Trauma Center at the University of Maryland
| | - Jayesh Gupta
- Adams Cowley Shock Trauma Center at the University of Maryland
| | | | - Robert O'Toole
- Adams Cowley Shock Trauma Center at the University of Maryland
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O’Neill DC, Sato EH, Myhre LA, Kantor AH, Rothberg DL, Higgins TF, Marchand LS, Haller JM. Return to Skiing After Tibial Plateau Fracture. Orthop J Sports Med 2023; 11:23259671231205925. [PMID: 37868212 PMCID: PMC10585993 DOI: 10.1177/23259671231205925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/22/2023] [Indexed: 10/24/2023] Open
Abstract
Background Tibial plateau fractures in skiers are devastating injuries with increasing incidence. Few studies have evaluated patient-reported outcomes and return to skiing after operative fixation of a tibial plateau fracture. Purpose To (1) identify demographic factors, fracture characteristics, and patient-reported outcome measures that are associated with return to skiing and (2) characterize changes in skiing performance after operative fixation of a tibial plateau fracture. Study Design Case series; Level of evidence, 4. Methods We reviewed all operative tibial plateau fractures performed between 2016 and 2021 at a single level-1 trauma center. Patients with a minimum of 10-month follow-up data were included. Patients who self-identified as skiers or were injured skiing were divided into those who returned to skiing and those who did not postoperatively. Patients were contacted to complete the Patient-Reported Outcomes Measurement Information System-Physical Function domain (PROMIS-PF), the Knee injury and Osteoarthritis Outcome Score-Activities of Living (KOOS-ADL), and a custom return-to-skiing questionnaire. Multivariate logistic regression was performed with sex, injury while skiing, PROMIS-PF, and KOOS-ADL as covariates to evaluate factors predictive of return to skiing. Results A total of 90 skiers with a mean follow-up of 3.4 ± 1.5 years were included in the analysis. The rate of return to skiing was 45.6% (n = 41). The return cohort was significantly more likely to be men (66% vs 41%; P = .018) and injured while skiing (63% vs 39%; P = .020). In the return cohort, 51.2% returned to skiing 12 months postoperatively. The percentage of patients who self-reported skiing on expert terrain dropped by half from pre- to postinjury (61% vs 29.3%, respectively). Only 78% of return skiers had regained comfort with skiing at the final follow-up. Most patients (65%) felt the hardest aspect of returning to skiing was psychological. In the multivariate regression, the male sex and KOOS-ADL independently predicted return to skiing (P = .006 and P = .028, respectively). Conclusion Fewer than half of skiers who underwent operative fixation of a tibial plateau fracture could return to skiing at a mean 3-year follow-up. The knee-specific KOOS-ADL outperformed the global PROMIS-PF in predicting a return to skiing.
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Affiliation(s)
- Dillon C. O’Neill
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Eleanor H. Sato
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Luke A. Myhre
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Adam H. Kantor
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - David L. Rothberg
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Thomas F. Higgins
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Lucas S. Marchand
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Justin M. Haller
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
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Chou TF, Foley A, Rothchild E, Stallone S, Lo Y, Gruson KI. Prevalence and Risk Factors for Missed Short-term Follow-up After Primary Total Shoulder Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202310000-00007. [PMID: 37861416 PMCID: PMC10584280 DOI: 10.5435/jaaosglobal-d-23-00163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 09/03/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION The importance of consistent postoperative follow-up has been established for collecting patient-reported outcomes and surveilling for potential complications. Despite this, the prevalence of and risk factors for missed short-term follow-up after elective shoulder arthroplasty remain limited. METHODS A retrospective review of consecutive primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty cases with a minimum of 12-month follow-up performed by a single, fellowship-trained shoulder surgeon was undertaken from January 2015 to December 2021. Demographic patient and surgical data, including age, sex, marital status, self-identified race, body mass index, American Society of Anesthesiologists score, age-adjusted Charlson Comorbidity Index, prior ipsilateral shoulder surgery and/or contralateral arthroplasty, distance from home to clinic, smoking status, and hospital length of stay, were collected. The follow-up at 1 week, 6 weeks, 6 months, 12 months, and 24 months and beyond was determined. Patient-related and surgical predictors for missing the 12-month and 24-month follow-up were identified. RESULTS There were 295 cases included (168 aTSA and 127 reverse total shoulder arthroplasty), of whom 199 (67%) were women. Of the total cases, 261 (86%) were eligible for 24-month follow-up. Patients undergoing aTSA, those of younger age, those of male sex, and those who missed their 6-week and 6-month follow-up were significantly more likely to miss the 12-month follow-up visit. Following multivariable analysis, a missed 6-month follow-up (OR 10.10, 95% CI 5.32 to 19.16, P < 0.001) was associated with 12-month visit nonattendance, and increasing age (per year) (OR 0.96, 95% CI 0.93 to 0.99, P = 0.011) was associated with improved 12-month follow-up. Not having a surgical complication within 6 months postoperatively, not undergoing ipsilateral revision arthroplasty, and missing the 1-week and 12-month follow-up were significantly associated with missing the 24-month follow-up. After multivariable analysis, missing the 1-week (OR 3.07, 95% CI 1.12 to 8.41, P = 0.029) and 12-month (OR 3.84, 95% CI 2.11 to 6.99, P < 0.001) follow-ups was associated with missing the 24-month visit, whereas having a postoperative complication was associated with increased attendance at 24 months (OR 0.38, 95% CI 0.14 to 0.99, P = 0.047). DISCUSSION Strategies for preventing missed short-term follow-up should be focused on ensuring that patients undergoing TSA attend the 6-month and 12-month visit, particularly among younger patients and those with an uneventful postoperative course.
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Affiliation(s)
- Te-Feng Chou
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Dr. Chou, Mr. Stallone, and Dr. Gruson); Albert Einstein College of Medicine, Bronx, NY (Ms. Foley and Mr. Rothchild); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
| | - Angela Foley
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Dr. Chou, Mr. Stallone, and Dr. Gruson); Albert Einstein College of Medicine, Bronx, NY (Ms. Foley and Mr. Rothchild); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
| | - Evan Rothchild
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Dr. Chou, Mr. Stallone, and Dr. Gruson); Albert Einstein College of Medicine, Bronx, NY (Ms. Foley and Mr. Rothchild); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
| | - Savino Stallone
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Dr. Chou, Mr. Stallone, and Dr. Gruson); Albert Einstein College of Medicine, Bronx, NY (Ms. Foley and Mr. Rothchild); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
| | - Yungtai Lo
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Dr. Chou, Mr. Stallone, and Dr. Gruson); Albert Einstein College of Medicine, Bronx, NY (Ms. Foley and Mr. Rothchild); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
| | - Konrad I. Gruson
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Dr. Chou, Mr. Stallone, and Dr. Gruson); Albert Einstein College of Medicine, Bronx, NY (Ms. Foley and Mr. Rothchild); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Dr. Lo)
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DeKeyser G, Bunzel E, O'Neill D, Nork S, Haller J, Barei D. Single-Incision Fasciotomy Decreases Infection Risk Compared with Dual-Incision Fasciotomy in Treatment of Tibial Plateau Fractures With Acute Compartment Syndrome. J Orthop Trauma 2023; 37:519-524. [PMID: 37296085 DOI: 10.1097/bot.0000000000002644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Comparison of surgical site infection (SSI) rates in tibial plateau fractures with acute compartment syndrome treated with single-incision (SI) versus dual-incision (DI) fasciotomies. DESIGN Retrospective cohort study. SETTING Two, Level-1, academic, trauma centers. PATIENTS Between January 2001 and December 2021, one-hundred ninety patients with a diagnosis of tibial plateau fracture and acute compartment syndrome met inclusion criteria (SI: n = 127, DI: n = 63) with a minimum of 3-month follow-up after definitive fixation. INTERVENTION Emergent 4-compartment fasciotomy, using either SI or DI technique, and eventual plate and screw fixation of the tibial plateau. OUTCOMES The primary outcome was SSI requiring surgical debridement. Secondary outcomes included nonunion, days to closure, method of skin closure, and time to SSI. RESULTS Both groups were similar in demographic variables and fracture characteristics (all P > 0.05). The overall infection rate was 25.8% (49 of 190), but the SI fasciotomy patients had significantly fewer SSIs compared with the DI fasciotomy patients [SI 18.1% vs. DI 41.3%; P < 0.001; OR 2.28, (confidence interval, 1.42-3.66)]. Patients with a dual (medial and lateral) surgical approach and DI fasciotomies developed an SSI in 60% (15 of 25) of cases compared with 21.3% (13 of 61) of cases in the SI group ( P < 0.001). The nonunion rate was similar between the 2 groups (SI 8.3% vs. DI 10.3%; P = 0.78). The SI fasciotomy group required fewer debridement's ( P = 0.04) until closure, but there was no difference in days until closure (SI 5.5 vs. DI 6.6; P = 0.09). There were zero cases of incomplete compartment release requiring return to the operating room. CONCLUSIONS Patients with DI fasciotomies were more than twice as likely to develop an SSI compared with SI patients despite similar fracture and demographic characteristics between the groups. Orthopaedic surgeons should consider prioritizing SI fasciotomies in this setting. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Graham DeKeyser
- Department of Orthopaedic Surgery, Oregon Health & Sciences University, Portland, OR
| | - Eli Bunzel
- Harborview Medical Center, University of Washington Department of Orthopaedic Surgery, Seattle, WA; and
| | - Dillon O'Neill
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Sean Nork
- Harborview Medical Center, University of Washington Department of Orthopaedic Surgery, Seattle, WA; and
| | - Justin Haller
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - David Barei
- Harborview Medical Center, University of Washington Department of Orthopaedic Surgery, Seattle, WA; and
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Kibble KM, Cunningham BP, Rivard RL, Vang S, Nguyen MP. Ankle fractures: High implant cost is not associated with better patient reported outcomes. Injury 2023; 54:110963. [PMID: 37542790 DOI: 10.1016/j.injury.2023.110963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 07/12/2023] [Accepted: 07/25/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Ankle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries. Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture. METHODS All ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost. RESULTS There was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [-411.8, -54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [-74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48). CONCLUSIONS The utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.
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Affiliation(s)
- Kendra M Kibble
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, United States of America; Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, United States of America
| | - Rachael L Rivard
- Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Sandy Vang
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Mai P Nguyen
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America.
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North K, Simpson GM, Stuart AR, Kubiak EN, Petelenz TJ, Hitchcock RW, Rothberg DL, Cizik AM. Early postoperative step count and walking time have greater impact on lower limb fracture outcomes than load-bearing metrics. Injury 2023:S0020-1383(23)00388-1. [PMID: 37202224 DOI: 10.1016/j.injury.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/11/2023] [Accepted: 04/23/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Weight-bearing protocols for rehabilitation of lower extremity fractures are the gold standard despite not being data-driven. Additionally, current protocols are focused on the amount of weight placed on the limb, negating other patient rehabilitation behaviors that may contribute to outcomes. Wearable sensors can provide insight into multiple aspects of patient behavior through longitudinal monitoring. This study aimed to understand the relationship between patient behavior and rehabilitation outcomes using wearable sensors to identify the metrics of patient rehabilitation behavior that have a positive effect on 1-year rehabilitation outcomes. METHODS Prospective observational study on 42 closed ankle and tibial fracture patients. Rehabilitation behavior was monitored continuously between 2 and 6 weeks post-operative using a gait monitoring insole. Metrics describing patient rehabilitation behavior, including step count, walking time, cadence, and body weight per step, were compared between patient groups of excellent and average rehabilitation outcomes, as defined by the 1-year Patient Reported Outcome Measure Physical Function t-score (PROMIS PF). A Fuzzy Inference System (FIS) was used to rank metrics based on their impact on patient outcomes. Additionally, correlation coefficients were calculated between patient characteristics and principal components of the behavior metrics. RESULTS Twenty-two patients had complete insole data sets, and 17 of which had 1-year PROMIS PF scores (33.7 ± 14.5 years of age, 13 female, 9 in Excellent group, 8 in Average group). Step count had the highest impact ranking (0.817), while body weight per step had a low impact ranking (0.309). No significant correlation coefficients were found between patient or injury characteristics and behavior principal components. General patient rehabilitation behavior was described through cadence (mean of 71.0 steps/min) and step count (logarithmic distribution with only ten days exceeding 5,000 steps/day). CONCLUSION Step count and walking time had a greater impact on 1-year outcomes than body weight per step or cadence. The results suggest that increased activity may improve 1-year outcomes for patients with lower extremity fractures. The use of more accessible devices, such as smart watches with step counters combined with patient reported outcome measures may provide more valuable insights into patient rehabilitation behaviors and their effect on rehabilitation outcomes.
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Affiliation(s)
- Kylee North
- University of Utah Department of Biomedical Engineering, 36 S Wasatch Dr, Salt Lake City, UT 84112, United States
| | - Grange M Simpson
- University of Utah Department of Biomedical Engineering, 36 S Wasatch Dr, Salt Lake City, UT 84112, United States
| | - Ami R Stuart
- Medtronic, 710 Medtronic Parkway, Minneapolis, MN 55432-5604 USA
| | - Erik N Kubiak
- University of Nevada Las Vegas Department of Orthopaedics, University of Nevada, Las Vegas, 4505 S. Maryland Pkwy, Las Vegas, NV 89154
| | - Tomasz J Petelenz
- University of Utah Department of Biomedical Engineering, 36 S Wasatch Dr, Salt Lake City, UT 84112, United States
| | - Robert W Hitchcock
- University of Utah Department of Biomedical Engineering, 36 S Wasatch Dr, Salt Lake City, UT 84112, United States
| | - David L Rothberg
- University of Utah Department of Orthopaedics, 590 Wakara Way, Salt Lake City, Utah 84108
| | - Amy M Cizik
- University of Utah Department of Orthopaedics, 590 Wakara Way, Salt Lake City, Utah 84108.
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Brodke D, O'Hara N, Devana S, Hernandez A, Burke C, Gupta J, McKibben N, O'Toole R, Morellato J, Gillon H, Walters M, Barber C, Perdue P, Dekeyser G, Steffenson L, Marchand L, Fairres MJ, Black L, Working Z, Roddy E, El Naga A, Hogue M, Gulbrandsen T, Atassi O, Mitchell T, Shymon S, Lee C. Predictors of Deep Infection After Distal Femur Fracture: A Multicenter Study. J Orthop Trauma 2023; 37:161-167. [PMID: 36302354 DOI: 10.1097/bot.0000000000002514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To identify potentially modifiable risk factors for deep surgical site infection after distal femur fracture. DESIGN Multicenter retrospective cohort study. SETTING Ten Level-I trauma centers. PATIENTS/PARTICIPANTS Patients with OTA/AO 33A or C distal femur fractures (n = 1107). INTERVENTION Surgical fixation of distal femur fracture. MAIN OUTCOME MEASUREMENT The outcome of interest was deep surgical site infection. RESULTS There was a 7% rate (79/1107) of deep surgical site infection. In the multivariate analysis, predictive factors included alcohol abuse [odds ratio (OR) = 2.36; 95% confidence interval (CI), 1.17-4.46; P = 0.01], intra-articular injury (OR = 1.73; 95% CI, 1.01-3.00; P = 0.05), vascular injury (OR = 3.90; 95% CI, 1.63-8.61; P < 0.01), the use of topical antibiotics (OR = 0.50; 95% CI, 0.25-0.92; P = 0.03), and the duration of the surgery (OR = 1.15 per hour; 95% CI, 1.01-1.30; P = 0.04). There was a nonsignificant trend toward an association between infection and type III open fracture (OR = 1.73; 95% CI, 0.94-3.13; P = 0.07) and lateral approach (OR = 1.60; 95% CI, 0.95-2.69; P = 0.07). The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (22%), methicillin-sensitive Staphylococcus aureus (20%), and Enterobacter cloacae (11%). CONCLUSIONS Seven percent of distal femur fractures developed deep surgical site infections. Alcohol abuse, intra-articular fracture, vascular injury, and increased surgical duration were risk factors, while the use of topical antibiotics was protective. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Dane Brodke
- Department of Orthopaedic Trauma Surgery, University of California, Los Angeles, CA
| | - Nathan O'Hara
- Department of Orthopaedic Trauma Surgery, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Sai Devana
- Department of Orthopaedic Trauma Surgery, University of California, Los Angeles, CA
| | - Adolfo Hernandez
- Department of Orthopaedic Trauma Surgery, University of California, Los Angeles, CA
| | - Cynthia Burke
- Department of Orthopaedic Trauma Surgery, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Jayesh Gupta
- Department of Orthopaedic Trauma Surgery, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Natasha McKibben
- Department of Orthopaedic Trauma Surgery, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Robert O'Toole
- Department of Orthopaedic Trauma Surgery, R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - John Morellato
- Department of Orthopaedic Trauma Surgery, University of Mississippi, Oxford, MS
| | - Hunter Gillon
- Department of Orthopaedic Trauma Surgery, University of Mississippi, Oxford, MS
| | - Murphy Walters
- Department of Orthopaedic Trauma Surgery, University of Mississippi, Oxford, MS
| | - Colby Barber
- Department of Orthopaedic Trauma Surgery, Virginia Commonwealth University, Richmond, VA
| | - Paul Perdue
- Department of Orthopaedic Trauma Surgery, Virginia Commonwealth University, Richmond, VA
| | - Graham Dekeyser
- Department of Orthopaedic Trauma Surgery, University of Utah, Salt Lake City, UT
| | - Lillia Steffenson
- Department of Orthopaedic Trauma Surgery, University of Utah, Salt Lake City, UT
| | - Lucas Marchand
- Department of Orthopaedic Trauma Surgery, University of Utah, Salt Lake City, UT
| | - Marshall James Fairres
- Department of Orthopaedic Trauma Surgery, Los Angeles County Harbor-UCLA Medical Center, Los Angeles, CA
| | - Loren Black
- Department of Orthopaedic Trauma Surgery, Oregon Health & Science University, Portland, OR
| | - Zachary Working
- Department of Orthopaedic Trauma Surgery, Oregon Health & Science University, Portland, OR
| | - Erika Roddy
- Department of Orthopaedic Trauma Surgery, University of California, San Francisco, CA
| | - Ashraf El Naga
- Department of Orthopaedic Trauma Surgery, University of California, San Francisco, CA
| | - Matthew Hogue
- Department of Orthopaedic Trauma Surgery, University of Iowa, Iowa, IA; and
| | - Trevor Gulbrandsen
- Department of Orthopaedic Trauma Surgery, University of Iowa, Iowa, IA; and
| | - Omar Atassi
- Department of Orthopaedic Trauma Surgery, Baylor College of Medicine, Houston, TX
| | - Thomas Mitchell
- Department of Orthopaedic Trauma Surgery, Baylor College of Medicine, Houston, TX
| | - Stephen Shymon
- Department of Orthopaedic Trauma Surgery, Los Angeles County Harbor-UCLA Medical Center, Los Angeles, CA
| | - Christopher Lee
- Department of Orthopaedic Trauma Surgery, University of California, Los Angeles, CA
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20
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Lee C, Brodke D, O'Hara N, Devana S, Hernandez A, Burke C, Gupta J, McKibben N, O'Toole R, Morellato J, Gillon H, Walters M, Barber C, Perdue P, Dekeyser G, Steffenson L, Marchand L, Fairres MJ, Black L, Working Z, Roddy E, El Naga A, Hogue M, Gulbrandsen T, Atassi O, Mitchell T, Shymon S. Risk Factors for Reoperation to Promote Union in 1111 Distal Femur Fractures. J Orthop Trauma 2023; 37:168-174. [PMID: 36379069 DOI: 10.1097/bot.0000000000002516] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To identify modifiable and nonmodifiable risk factors for reoperation to promote union after distal femur fracture. DESIGN Multicenter retrospective cohort study. SETTING Ten Level-I trauma centers. PATIENTS/PARTICIPANTS Patients with OTA/AO 33A or C distal femur fractures (n = 1111). INTERVENTION Surgical fixation of distal femur fracture. Fixation constructs were classified as lateral plate, dual plate, nail, or nail plate combination. MAIN OUTCOME MEASUREMENTS The outcome of interest was unplanned reoperation to promote union. RESULTS There was an 11% (121/1111) rate of unplanned reoperation to promote union. In the multivariate analysis, predictive factors included body mass index [odds ratio (OR) = 1.18; 95% confidence interval (CI), 1.06-1.32; P < 0.01], intra-articular fracture (OR = 1.57; 95% CI, 1.01-2.45; P = 0.04), type III open injury (OR = 2.29; 95% CI, 1.41-3.72; P < 0.01), the presence of medial comminution (OR = 1.85; 95% CI, 1.14-3.06; P = 0.01), and medial translation on postoperative radiographs (OR = 1.23 per one 10th of condylar width; 95% CI, 1.01-1.48; P = 0.03). Construct type was not significantly predictive. CONCLUSIONS Eleven percent of distal femur fractures underwent unplanned reoperation to promote union. Body mass index, intra-articular fracture, type III open injury, medial comminution, and medial translation on postoperative radiographs were predictive factors. Construct type was not associated with unplanned reoperation; however, this conclusion was limited by small numbers in the dual plate and nail plate groups. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | | | - Nathan O'Hara
- R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Sai Devana
- University of California, Los Angeles, CA
| | | | - Cynthia Burke
- R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Jayesh Gupta
- R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Natasha McKibben
- R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | - Robert O'Toole
- R Adams Cowley Shock Trauma Center at the University of Maryland, Baltimore, MD
| | | | | | | | | | - Paul Perdue
- Virginia Commonwealth University, Richmond, VA
| | | | | | | | | | - Loren Black
- Oregon Health & Science University, Portland, OR
| | | | | | | | | | | | - Omar Atassi
- Baylor College of Medicine, Baylor College of Medicine
| | | | - Stephen Shymon
- Los Angeles County Harbor-UCLA Medical Center, Los Angeles, CA
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21
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Kellam PJ, Cutshall ZA, Dekeyser GJ, Rothberg DL, Higgins TF, Haller JM, Marchand LS. Recovery Curve for Patients With Pilon Fractures Using Patient-Reported Outcome Measurement Information System. Foot Ankle Int 2023; 44:317-321. [PMID: 36932665 DOI: 10.1177/10711007231156424] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
BACKGROUND The time frame in which patients can expect functional improvement after open reduction internal fixation (ORIF) of pilon fractures is unclear. The purpose of this study was to determine the trajectory and rate at which patients' physical function improves up to 2 years postinjury. METHODS The patients studied sustained a unilateral, isolated pilon fractures (AO/OTA 43B/C) and followed at a level 1 trauma center over a 5-year period (2015-2020). Patient-Reported Outcomes Measurement Information Systems (PROMIS) Physical Function (PF) scores from these patients at defined follow-up times of immediately, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery defined the cohorts and were retrospectively studied. RESULTS There were 160 patients with PROMIS scores immediately postoperatively, 143 patients at 6 weeks, 146 patients at 12 weeks, 97 at 24 weeks, 84 at 1 year, and 45 at 2 years postoperatively. The average PROMIS PF score was 28 immediately postoperatively, 30 at 6 weeks, 36 at 3 months, 40 at 6 months, 41 at 1 year, and 39 at 2 years. There was a significant difference between PROMIS PF scores between 6 weeks and 3 months (P < .001), and between 3 and 6 months (P < .001). Otherwise, no significant differences were detected between consecutive time points. CONCLUSION Patients with isolated pilon fractures demonstrate the majority of their improvement in terms of physical function between 6 weeks and 6 months postoperatively. No significant difference was detected in PF scores after 6 months postoperatively up to 2 years. Furthermore, the mean PROMIS PF score of patients 2 years after recovery was approximately 1 SD below the population average. This information is helpful in counseling patients and setting expectations for recovery after pilon fractures. LEVEL OF EVIDENCE Level III, prognostic.
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Affiliation(s)
- Patrick J Kellam
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Zachary A Cutshall
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Graham J Dekeyser
- Department of Orthopaedic Surgery, Oregon Health Sciences University, Portland, Oregon, USA
| | - David L Rothberg
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Thomas F Higgins
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
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22
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Schexnayder SP, Valentino JL, Leonardi C, Bronstone AB, Dasa V. Factors Associated With Loss to Follow-up During the First Year After Total Knee Arthroplasty. Orthopedics 2023; 46:93-97. [PMID: 36476176 DOI: 10.3928/01477447-20221129-04] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Despite increased pressure to capture patient-reported outcome measures for at least 1 year following total joint arthroplasty (TJA), follow-up rates during the first year after TJA are typically lower than desired and may result in biased findings if data are not missing at random. We conducted a retrospective review of medical records of primary total knee arthroplasty patients treated by a single surgeon at an urban academic private hospital. Main measures were demographics (sex, age, race, and insurance), body mass index, travel distance to clinic, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Multivariable regression analyses were performed to identify patient characteristics associated with attendance at follow-up visits and predictors of attendance at 6-month follow-up. Among the 205 study patients, follow-up visit attendance declined from a high of 95.7% at day 14 to lows of 69.2% at 6 months and 64.4% at 1 year. Attendance at the previously scheduled follow-up visit was a statistically significant predictor of attendance at 3-month (P=.0015), 6-month (P=.0002), and 1-year (P<.0001) follow-up visits, and travel distance was significantly associated with attending the 1-year follow-up visit (P=.042). Patients with the most favorable KOOS Symptom, Pain, and Function in daily living subscale scores at 3-month follow-up were significantly less likely to attend the 6-month follow-up visit than patients with the least favorable KOOS scores. Prospective studies are needed to identify the full range of factors that may contribute to high rates of loss to follow-up after TJA, which should be of concern to researchers, clinicians, and hospitals. [Orthopedics. 2023;46(2):93-97.].
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23
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Feasibility of Capturing Orthopaedic Trauma Research Outcomes Using Personal Mobile Devices. J Am Acad Orthop Surg 2023; 31:212-217. [PMID: 36729531 DOI: 10.5435/jaaos-d-21-01126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 10/23/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Patients with orthopaedic trauma are frequently lost to follow-up. Personal mobile devices have been used to ascertain clinical research outcomes. The prevalence of mobile device ownership, use patterns, and attitudes about research among patients with orthopaedic trauma would inform clinical research strategies in this population. METHODS A total of 1,434 consecutive unique adults scheduled for an orthopaedic trauma outpatient clinic from December 2019 through February 2020 at a metropolitan level 1 trauma center were identified. Associations of demographic data with clinic attendance and mobile phone registration were explored by logistic regression. One hundred one patients attending clinic were then prospectively surveyed from June 2021 through August 2021 about housing stability, personal mobile device ownership, capabilities, use patterns, and openness to communicating via the device with for orthopaedic care and research. RESULTS The prevalence of personal mobile device ownership was 91% by registration data and 90% by a survey. Ninety-nine percent of survey respondents with mobile devices reported cell service always or most of the time. Ninety-three percent kept their devices charged always or most of the time. Ninety-two percent reported e-mail access. Eighty-three percent reported video capability. Ninety-one percent would communicate with their orthopaedic trauma care team by text message. Eighty-seven percent would answer research questions by phone call, 79% by text, and 61% by video. Eighty-five percent reported stable housing, which was not associated with mobile device ownership or use, but was associated with clinic nonattendance (29% vs. 66%, P < 0.01) and changing phone number at least once in the previous year (28% vs. 58%, P = 0.04). DISCUSSION Personal mobile devices represent a feasible platform for screening and collecting outcomes from patients with orthopaedic trauma. Nine in 10 patients own personal mobile devices, keep them charged, have text and e-mail service, and would use the device to participate in research. Housing instability was not associated with mobile device ownership or use patterns.
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Bhashyam AR, Challa ST, Thomas H, Rodriguez EK, Weaver MJ. Clinic follow-up of orthopaedic trauma patients during and after the post-surgical global period: a retrospective cohort study. BMC Musculoskelet Disord 2023; 24:120. [PMID: 36782143 PMCID: PMC9926540 DOI: 10.1186/s12891-023-06218-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 02/02/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Insurance status is important as medical expenses may decrease the likelihood of follow-up after musculoskeletal trauma, especially for low-income populations. However, it is unknown what insurance factors are associated with follow-up care. In this study, we assessed the association between insurance plan benefits, the end of the post-surgical global period, and follow-up after musculoskeletal injury. METHODS This is a retrospective cohort study of 394 patients with isolated extremity fractures who were treated at three level-I trauma centers over four months in 2018. Paired t-tests were utilized to assess the likelihood of follow-up in relation to the 90-day post-surgical global period. Regression analysis was used to assess factors associated with the likelihood of follow-up. Supervised machine learning algorithms were used to develop predictive models of follow-up after the post-surgical global period. RESULTS Our final analysis included 328 patients. Likelihood of follow-up did not significantly change while within the post-surgical global period. When comparing follow-up within and outside of the post-surgical global period, there was a 20.1% decrease in follow-up between the 6-weeks and 6-month time points (68.3% versus 48.2%, respectively; p < 0.0001). Medicaid insurance compared to Medicare (OR 0.27, 95% confidence interval (CI) = [0.09, 0.84], p = 0.02) was a predictor of decreased likelihood of follow-up at 6-months post-operatively. CONCLUSIONS Our study demonstrates a statistically significant decrease in follow-up for orthopaedic trauma patients after the post-surgical global period, particularly for patients with Medicaid or Private insurance.
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Affiliation(s)
- Abhiram R. Bhashyam
- grid.32224.350000 0004 0386 9924Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Orthopaedic Trauma Initiative, Harvard Medical School, 55 Fruit St, Boston, MA 02114 USA
| | - Sravya T. Challa
- grid.32224.350000 0004 0386 9924Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Hannah Thomas
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Edward K. Rodriguez
- grid.239395.70000 0000 9011 8547Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA USA
| | - Michael J. Weaver
- grid.38142.3c000000041936754XDepartment of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, MA USA
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25
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Aneja A, Kavolus MW, Teasdall RJ, Sneed CR, Pectol RW, Isla AE, Stromberg AJ, Obremskey W. Does prophylactic local tobramycin injection lower open fracture infection rates? OTA Int 2022; 5:e210. [PMID: 36569107 PMCID: PMC9782352 DOI: 10.1097/oi9.0000000000000210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 04/14/2022] [Indexed: 06/17/2023]
Abstract
Objective: To determine whether local aqueous tobramycin injection in combination with systemic perioperative IV antibiotic prophylaxis will reduce the rate of fracture-related infection (FRI) after open fracture fixation. Other Outcomes of Interest: (1) To compare fracture nonunion rates and report differences between treatment and control groups and (2) compare bacterial speciation and antibiotic sensitivity among groups that develop FRI. Design: Phase 3 prospective, randomized clinical trial. Setting: Two level 1 trauma centers. Participants: Six hundred subjects (300 in study/tobramycin group and 300 in control/standard practice group) will be enrolled and assigned to the study group or control group using a randomization table. Patients with open extremity fractures that receive definitive internal surgical fixation will be considered. Intervention: Aqueous local tobramycin will be injected into the wound cavity (down to bone) after debridement, irrigation, and fixation, following closure. Main Outcome Measurements: Outcomes will look at the presence or absence of FRI, the rate of fracture nonunion, and determine speciation of gram-negative and Staph bacteria in each group with a FRI. Results: Not applicable. Conclusion: The proposed work will determine whether local tobramycin delivery plus perioperative standard antibiotic synergism will minimize the occurrence of open extremity FRI. Level of Evidence: Level 1.
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Affiliation(s)
- Arun Aneja
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Matthew W. Kavolus
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Robert J. Teasdall
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Chandler R. Sneed
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Richard W. Pectol
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Alexander E. Isla
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - Arnold J. Stromberg
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY; and
| | - William Obremskey
- Department of Orthopaedic Surgery, Vanderbilt University, Nashville, TN
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26
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Tucker A, Norrish AR, Fendius S, Uzoho C, Thorne T, Del Hoyo E, Nightingale J, Taylor A, Ollivere BJ. Definitive Taylor Spatial Frame management for the treatment of high-energy open tibial fractures: Clinical and patient-reported outcomes. Injury 2022; 53:4104-4113. [PMID: 36424690 DOI: 10.1016/j.injury.2022.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/02/2022] [Accepted: 10/17/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND High energy open tibial fractures are complex injuries with no consensus on the optimal method of fixation. Treatment outcomes are often reported with union and re-operation rates, often without specific definitions being provided. We sought to describe union, reoperation rates, and patient reported outcomes, using the validated EQ-VAS and Disability Rating Index (DRI) scores, following stabilisation with a Taylor Spatial Frame (TSF) and a combined orthoplastic approach for the management of soft tissues. A literature review is also provided. METHOD A prospective cross-sectional follow up of open tibial fractures, treated at a level 1 major trauma centre, managed with a TSF using a one ring per segment technique between January 2014 and December 2019 were identified. Demographic, injury and operative data were recorded, along with Patient Reported Outcome Measures (PROM) scores, specifically the EQ-VAS and Disability Rating Index (DRI). Union rates, defined by radiographic union scale in tibia (RUST) scores, and re-operation rates were recorded. Appropriate statistical analyses were performed, with a p<0.05 considered statistically significant. RESULTS Overall, 51 patients were included. Mean age was 51.2 ± 17.4 years, with a 4:1 male preponderance. Diaphyseal and distal fractures accounted for 76% of cases. Mean time in frame was 206.7 ± 149.4 days. Union was defined and was achieved in 41/51 (80.4%) patients. Deep infection occurred in 6/51 (11.8%) patients. Amputation was performed in 1 case (1.9%). Overall re-operation rate was 33%. Time to union were significantly longer if re-operation was required for any reason (uncomplicated 204±189 vs complicated 304±155 days; p = 0.0017) . EQ-VAS and DRI scores significantly deteriorated at 1 year follow-up (EQVAS 87.5 ± 11.7 vs 66.5 ± 20.4;p<0.0001 and DRI 11.9 ± 17.8 vs 39.3 ± 23.3;p<0.0001). At 1 year post op, 23/51(45.1%) required a walking aid, and 17/29 (58.6%) of those working pre-injury had returned to work. CONCLUSION Open tibial fracture have significant morbidity and long recovery periods as determined by EQVAS and DRI outcome measures. We report the largest series of open tibial feature treated primarily with a TSF construct, which has similar outcomes to other techniques, and should therefore be considered as a useful technique for managing these injuries.
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Affiliation(s)
- A Tucker
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK
| | - A R Norrish
- Academic Orthopaedics, Trauma and Sports Medicine, University of Nottingham, Nottingham, UK; Queen Elizabeth Hospital, Kings Lynn, UK
| | - S Fendius
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK
| | - C Uzoho
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK
| | - T Thorne
- University of Nottingham, Nottingham, UK
| | - E Del Hoyo
- University of Nottingham, Nottingham, UK
| | - J Nightingale
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK; Academic Orthopaedics, Trauma and Sports Medicine, University of Nottingham, Nottingham, UK
| | - A Taylor
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK
| | - B J Ollivere
- Queens Medical Centre, Nottingham University Hospitals Trust, Nottingham UK; University of Nottingham, Nottingham, UK; NIHR Nottingham Biomedical research Unit, Nottingham, UK
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Tavolaro C, Agel J, Vincent M, Dhillon E, Jung E, Zhou H. Post-operative follow-up care after acute spinal trauma: What is the reality? BRAIN AND SPINE 2022; 2:100905. [PMID: 36248134 PMCID: PMC9560691 DOI: 10.1016/j.bas.2022.100905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/20/2022] [Accepted: 06/10/2022] [Indexed: 11/26/2022]
Abstract
Only 23.7% of acute spinal trauma patients who underwent instrumentation met or surpassed one-year of clinical follow-up care. Factors associated with lower rates of completed follow-up are ISS, presence of non-ambulatory spinal cord injury, history of IVDA, and insurance. Increased rates of completed follow-up were seen in patients with a Workers'.
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Affiliation(s)
| | - Julie Agel
- Corresponding author. Department of Orthopedics and Sports Medicine, Harborview Medical Center, Box 359798, 325 9th Ave., Seattle, WA, 98104, USA.
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