[Skin cancer screening in the aging population in Saxony-Anhalt : Utilization, facilitating, and hindering factors]

BACKGROUND

Statutory skin cancer screening (gHKS) can counteract severe courses of various types of skin cancer. The example of malignant melanoma shows that screening is important for older adults in view of the average age of onset of this disease: 62 (women) and 68 years (men). For Saxony-Anhalt (ST), as a state particularly affected by demographic change, little gHKS data are available regarding its usage.

OBJECTIVES

For the study, gHKS participation rates for persons aged 55 and older are presented for ST in comparison to the rest of Germany. Reasons for and barriers to participation from those eligible as well as possible fields of action are shown.

MATERIALS AND METHODS

For the target group, outpatient billing data from the Central Institute for Statutory Health Insurance Physicians in Germany (Zi) on gHKS from 2011-2020 are cross-sectionally and longitudinally analysed. Guideline-based telephone interviews with 18 residents using qualitative content analysis according to Kuckartz serve to identify reasons for and barriers to the use of gHKS.

RESULTS

The gHKS was rarely and irregularly used in ST and other federal states of Germany from 2011-2020; the annual utilisation rate was about 8.0% (national average: 8.4%). Between 2011 and 2020, 50% of eligible people aged 55 years and older did not participate in the gHKS. The highest utilisation rates were among men aged 70-79 years. In addition to district-specific differences, which indicate possible gaps in care, information deficits appear to be the main reason for low participation.

CONCLUSION

The low utilisation of gHKS, partly due to a lack of information among those entitled to it, requires target group-specific information services.

Determination of the Inter- and Intra-rater Reliability of Fusion Assessment in First Tarsometatarsal Joint Arthrodesis Using CT Scan: An Observational Study

Background

First tarsometatarsal joint arthrodesis is a common procedure performed by podiatrists and orthopedic surgeons. There remains debate on how useful CT scans are in assessing fusion status in the post-operative patient. The purpose of our study was to determine the reliability among both orthopedic surgeons and radiologists in reviewing both postoperative radiographs and CT in order to determine if fusion had occurred in patients undergoing 1st tarsometatarsal arthrodesis. A secondary purpose of this study was to determine if CT offered improved inter- and intra-rater reliability when compared to plain radiographs.

Methods

Patients who underwent 1st tarsometatarsal arthrodesis were retrospectively reviewed and those who underwent CT post-operatively for persistent pain were identified. Orthopedic surgeons and radiologists then analyzed the radiographs and CT of these patients for union with a threshold for union being set at 50% of the joint being fused. Imaging was then re-evaluated by the same provider 6 months later.

Results

24 patients were identified meeting inclusion criteria. Inter-rater reliability and intra-rater reliability for assessment of 1st tarsometatarsal arthrodesis were better with CT compared to radiographs; however, this association was not deemed reliable. Both imaging modalities were not able to assess union status confidently and reliably across reviewers, although CT scan had better intra-rater reliability.

Conclusions

While CT is frequently used to assess fusion in patients who have underwent 1st tarsometatarsal arthrodesis, it was not found to be better than radiographs. Practitioners should reconsider the use CT as the gold standard when assessing fusion in this population.

VersKiK: Study protocol of an observational registry-based study on the current state of follow-up care and adherence to follow-up guidelines after cancer in childhood or adolescence

BACKGROUND

This article describes the study design of the quantitative part of the VersKiK study, The primary objectives of this study are to examine the occurrence of late effects in survivors of childhood or adolescent cancer (module 1), investigate health-related vulnerabilities and medical service utilization within this survivor group (modules 1 and 3), and assess the alignment between documented follow-up care for cardiological and audiological late effects with guideline recommendations, along with evaluating the extent of adherence among paediatric cancer survivors (module 3).

METHODS

This is a non-interventional retrospective observational cohort study. It is based on stochastically linked insurance claims data from approximately 150,000 statutory insured persons with information concerning around 25,000-30,000 cancer survivors recorded in the German Childhood Cancer Register (GCCR). To explore adherence to selected follow-up guidelines, intention to treat treatment data from clinical study groups for particular diagnostic entities will be additionally included.

DISCUSSION

The growing group of survivors after cancer in childhood and adolescence is representing a special population with an increasing demand for life-long healthcare services through relative high probability of late effects. Currently, there is a limited evidence in Germany on utilization of corresponding medical services and adherence to follow-up guidelines. With this study design, we are aiming to address these gaps and, consequently, suggest improvements to existing follow-up guidelines and follow-up care provision in Germany.

What Is the Rate of Displacement of Occult Posterior Malleolus Fractures in Nailed Tibial Shaft Fractures?

OBJECTIVE

To describe the radiographic consequences of posterior malleolus fractures (PMF) present with tibial shaft fractures fixed with intramedullary nails.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Seven hundred thirty-three patients with tibial shaft fractures.

INTERVENTION

Intramedullary nail fixation and prophylactic articular fixation.

MAIN OUTCOME MEASURE

Displacement of PMF with intramedullary nail insertion.

RESULTS

Seven hundred thirty-three patients were identified with tibial shaft fractures treated with intramedullary nail fixation at a Level 1 trauma center without a uniform preoperative computed tomography protocol. One hundred thirty-three patients had an identifiable PMF appreciated on preoperative imaging. Of the 600 remaining patients without a known PMF, 29 had PMF identified after nail insertion: 24 patients with nondisplaced fractures that all healed radiographically at final follow-up, 3 patients had fractures <30% of the articular surface displaced 1-2 mm, and 2 patients had fractures >30% of the joint surface that displaced 1-2 mm.

CONCLUSIONS

The incidence of radiographically observable PMF associated with tibial shaft fractures is high, even without a preoperative computed tomography screening protocol in place. In patients without an appreciable PMF on injury films, less than 1% (2/600) had displacement of a large, clinically significant PMF with nail placement.

LEVEL OF EVIDENCE

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

Can Lateral X-Rays Reliably Determine Which Posterior Malleolus Ankle Fractures Need a CT?

BACKGROUND

For rotational ankle fractures with a posterior malleolus fracture (PMF), the decision to further evaluate the ankle injury with computed tomography (CT) is challenging. The objective of this study is to determine how well PMF fracture size on x-rays correlates with size on CT, and how well x-rays can predict which patients receive PMF fixation after CT review.

METHODS

This is a retrospective study of adult ankle fractures with PMFs that had preoperative radiographs and CT imaging over a 5-year period. PMF x-ray and CT measurements were recorded, and relationships between x-ray measurements and final PMF fixation plan after CT review were evaluated.

RESULTS

A total of 98 patients were identified with both x-rays and preoperative CT imaging. Pearson's rank correlation demonstrated a strong relation between PMF width percentage measured on x-ray and CT (r = 0.724). Of the 45 patients with a PMF size under 20% on x-ray, only one patient (with an apparent incarcerated fragment) underwent PMF fixation after review of the CT.

CONCLUSIONS

PMF width on lateral x-ray correlates well with CT size and is sensitive for predicting the need for dedicated posterior malleolus based on one institutional practice pattern. Below 20% fracture width on lateral x-ray, a dedicated CT rarely leads to a decision to perform PMF fixation. Limiting pre-operative CT to those with PMF width >20% could reduce CT utilization by as much as 45% without negatively affecting patient care.

LEVELS OF EVIDENCE

Level III: Diagnostic.

Long-term care, care needs and wellbeing of individuals after cancer in childhood or adolescence (VersKiK): study protocol of a large scale multi-methods non-interventional study

BACKGROUND

It has been shown previously that a relevant proportion of childhood cancer survivors suffers from late effects, which are often directly related to the cancer itself or its therapy, resulting in particular follow-up needs, additionally burdening healthcare systems. Being diagnosed with cancer at a vulnerable stage of development, this group of cancer survivors is at comparatively higher risk of relapse or subsequent cancer. Although national and international follow-up guidelines based on treatment modalities have been developed, their implementation seems to leave room for improvement. Additionally, they lack a sufficient consideration of the survivors' psychosocial needs, affecting their adherence to them. The aim of the VersKiK study is to provide representative information on late effects in childhood and adolescence cancer survivors in Germany. The main research objectives are: (1) to describe the state of follow-up care among survivors after a cancer diagnosis in childhood or adolescence; (2) to quantify the occurrence of late effects among this group of survivors; (3) to examine the adherence to selected audiological and cardiological follow-up guidelines and to identify factors affecting it; (4) to explore actual follow-up needs of paediatric cancer survivors; (5) to review selected follow-up guidelines with the aim to improve and expand them.

METHODS

VersKiK is designed as a mixed-methods non-interventional study. We will use claims data from statutory health insurance companies in combination with individually linked population-based registry data from the German Childhood Cancer Registry (GCCR). This data base will permit us to quantify diagnoses and procedures in comparison to the general population as well as the adherence to existing follow-up guidelines. Additional information will be obtained through interviews with childhood and adolescence cancer survivors and their informal caregivers, as well as in focus groups with healthcare professionals.

DISCUSSION

The present study aims to research the actual needs of individuals after cancer diagnosis and treatment in childhood or adolescence - physical, psychological and organisational - in order to improve existing follow-up guidelines. These improvements might further positively affect not only actual care provided to paediatric cancer survivors, but also benefit healthcare systems in general while decreasing consequent medical visits in this group of patients.

TRIAL REGISTRATION

Registered at German Clinical Trial Register (ID: DRKS00025960 and DRKS00026092).

Is the Direct Anterior Approach to THA Cost-effective? A Markov Analysis

BACKGROUND

The use of the direct anterior approach, a muscle-sparing technique for THA, has increased over the years; however, this approach is associated with longer procedure times and a more expensive direct cost. Furthermore, studies have shown a higher revision rate in the early stages of the learning curve. Whether the clinical advantages of the direct anterior compared with the posterior approach-such as less soft tissue damage, decreased short-term postoperative pain, a lower dislocation rate, decreased length of stay in the hospital, and higher likelihood of being discharged home-outweigh the higher cost is still debatable. Determining the cost-effectiveness of the approach may inform its utility and justify its use at various stages of the learning curve.

QUESTIONS/PURPOSES

We used a Markov modeling approach to ask: (1) Is the direct anterior approach more likely to be a cost-effective approach than the posterior approach over the long-term for more experienced or higher volume hip surgeons? (2) How many procedures does a surgeon need to perform for the direct anterior approach to be a cost-effective choice?

METHODS

A Markov model was created with three health states (well-functioning THA, revision THA, and death) to compare the cost-effectiveness of the direct anterior approach with that of the posterior approach in five scenarios: surgeons who performed one to 15, 16 to 30, 31 to 50, 51 to 100, and more than 100 direct anterior THAs during a 6-year span. Procedure costs (not charges), dislocation costs, and fracture costs were derived from published reports, and model was run using two different cost differentials between the direct anterior and posterior approaches (USD 219 and USD 1800, respectively). The lower cost was calculated as the total cost differential minus pharmaceutical and implant costs to account for differences in implant use and physician preference regarding postoperative pain management. The USD 1800 cost differential incorporated pharmaceutical and implant costs. Probabilities were derived from systematic review of the evidence as well as from the Australian Orthopaedic Association National Joint Replacement Registry. Utilities were estimated from best available literature and disutilities associated with dislocation and fracture were incorporated into the model. Quality of life was expressed in quality-adjusted life years (QALYs), which are calculated by multiplying the utility of a health state (ranging from 0 to 1) by the duration of time in that health state. The primary outcome measure was the incremental cost-effectiveness ratio, or the change in costs divided by the change in QALYs when the direct anterior approach was used for THA. USD 100,000 per quality-adjusted life years was used as a threshold for willingness to pay. One-way and probabilistic sensitivity analyses were performed for the scenario in which the direct anterior approach is cost-effective to further account for uncertainty in model inputs.

RESULTS

At a cost differential of USD 219 (95% CI 175 to 263), the direct anterior approach was associated with lower cost and higher effectiveness compared with the posterior approach for surgeons with an experience level of more than 100 operations during a 6-year span. At a cost differential of USD 1800 (95% CI 1440 to 2160), the direct anterior approach remained a cost-effective strategy for surgeons who performed more than 100 operations. At both cost differentials, the direct anterior approach was not cost-effective for surgeons who performed fewer than 100 operations. One-way sensitivity analyses revealed the model to be the most sensitive to fluctuations in the utility of revision THA, probability of revision after the posterior approach THA, probability of dislocation after the posterior approach THA, fluctuations in the probability of dislocation after direct anterior THA, cost of direct anterior THA, and probability of intraoperative fracture with the direct anterior approach. At the cost differential of USD 219 and for surgeons with a surgical experience level of more than 100 direct anterior operations, the direct anterior approach was still the cost-effective strategy for the entire range of values.

CONCLUSION

For high-volume hip surgeons, defined here as surgeons who perform more than 100 procedures during a 6-year span, the direct anterior approach may be a cost-effective strategy within the limitations imposed by our analysis. For lower volume hip surgeons, performing a more familiar approach appears to be more cost-effective.

Proximal humeral fracture-dislocations: which patterns can be reduced in the emergency department?

BACKGROUND

Shoulder fracture-dislocations can represent a challenging management scenario in the emergency department (ED) because of concern for the presence of occult fractures that may displace during a reduction attempt. The alternative, a closed reduction attempt in the operating room, has the benefit of full paralysis but requires additional resource utilization. There is limited guidance in the literature about the risks of an initial reduction attempt in the ED as a function of fracture pattern to help guide physicians with this decision.

METHODS

This was a retrospective case review of adult patients with shoulder dislocations and fracture-dislocations seen in the ED at a level 1 trauma center over a 10-year period. Imaging and medical records were reviewed to evaluate whether the reduction attempt was successful, unsuccessful without worsening, or unsuccessful with worsening alignment of any fractures, as well as the ultimate clinical outcome.

RESULTS

We identified 165 patients with fracture-dislocations and 484 patients with simple dislocations during the same period. Of the patients with fracture-dislocations, 103 had greater tuberosity fractures, 12 had nondisplaced surgical neck fractures, and 50 had displaced surgical neck fractures. None of the patients with simple dislocations had displacement during an ED reduction attempt, including 100 patients aged >65 years. Of the 103 patients with greater tuberosity fracture-dislocations, only 1 had displacement of a humeral shaft fracture during ED reduction. Displacement occurred in 6 of 8 patients with nondisplaced neck fractures who underwent an initial ED reduction attempt vs. 1 of 4 patients who underwent the initial reduction attempt in the operating room. ED reduction was attempted in 25 of the 50 displaced humeral neck fracture-dislocations and was successful in 10 of these (40%).

CONCLUSIONS

For patients with greater tuberosity fracture-dislocations, there is a low rate of displacement with a reduction attempt in the ED, but an ED reduction attempt in nondisplaced neck fractures is not recommended because of the high rate of displacement. For displaced neck fractures, closed reduction can be successful in select patients. Finally, these data confirm prior reports that closed reduction of simple shoulder dislocations in patients aged >65 years is safe in the ED.

High variability in patient reported outcome utilization following hip fracture: a potential barrier to value-based care

For patients with hip fractures, outcomes can be measured by giving surveys measuring "patient rated outcome measures" (PROMs), performance based measures (PBMS), and objective medical outcomes (e.g., mortality, living situation, resource utilization). This study reviewed articles on hip fracture published in top academic journals, and found that most studies are not reliably using a single set of outcome measures including PROMs, and no single PROM or outcome battery is being used commonly.

PURPOSE/INTRODUCTION

Osteoporotic hip fractures are associated with high levels of morbidity, mortality, and cost, while gains in mortality over the past 30 years have been modest. To improve care beyond simple mortality metrics requires identifying and then consistently measuring outcomes that are meaningful to patients and families. The purpose of this study was to review the top-tier hip fracture literature published in the past 30 years to determine if there are consensus outcome measures being routinely used and if the rate of reporting clinically meaningful patient-rated outcome measures is improving over time.

METHODS

This was a systematic review and meta-analysis on outcome measures reported in osteoporotic hip fractures. Articles were included if they had been published over the last 30 years and were from high impact factor journals. Inclusion criteria were elderly hip fractures, therapeutic or prognostic study, unique and identifiable patients, and included follow-up beyond initial hospitalization. We analyzed study type, inclusion criteria, outcomes reported, and journal specialty orientation.

RESULTS

Three hundred eighty-four articles were included in the final analysis. Sixty-seven percent of the articles were therapeutic studies; 33% were prognostic studies. The average number of patients in each study was 435; the average age was 78 years. The most commonly reported outcome was mortality, and was present in 79% of studies. There was a high degree of heterogeneity in patient-reported outcome measures, with the most popular score (Harris Hip Score) reported only 14% of the time. Only 6% of articles had all components of essential core outcome sets previously defined in the literature.

CONCLUSIONS

Despite the apparent advances that have been made in our ability to care for hip fractures, the overall rate of reporting outcomes beyond mortality rate remains low. This lack of consensus represents a major barrier to implementation of value-based care in this patient population.

A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial

Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness. Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).

A novel treatment for prevention of post-traumatic elbow stiffness using onaBotulinum toxin type A: a prospective placebo controlled randomized trial

Approximately 30% of all upper extremity fractures are elbow fractures which may result elbow stiffness. This study aimed to investigate the efficacy of onaBotulinum Toxin type A injection to prevent post-traumatic pain and elbow-stiffness. All patients were included who presented to a single surgeon with supracondylar/ intraarticular distal humerus fractures, proximal ulna and radius fractures. The study was developed in a randomized placebo controlled study between 2003-2007. The Disabilities of the Arm, Shoulder, and Hand (DASH) score as well as the arc-of-motion (AOM) were assessed after three, six, twelve-months and final follow up for evaluation. Of the 31-patients included, 15-patients (48.4%) received Botox injections. In all patients no complication was observed when injecting a dosage 100-units for the brachialis and biceps brachii muscles. Furthermore, it was an effective method to prevent post-traumatic elbow stiffness, lasting six- months. Significant differences in DASH, VAS-score and ROM after three-months between the Botox and control group (DASH 21.6±11.0 vs. 55.3±11.0 ; VAS 1.2±5.2 vs. 5.7±21.9 ; ROM 103±7.6 vs. 73±6.3 ; p>0.05) were identified in the prospective group. Botulinum toxin is a safe, reliable and effective treatment to prevent post-traumatic elbow stiffness. Our study demonstrates improved early range-of- motion (p<0.05), better extension after 6 weeks and improved functional outcome including VAS and DASH score (p<0.05).

Modern treatment of tibial shaft fractures: Is there a role today for closed treatment?

PURPOSE

The decision to attempt closed treatment on tibial shaft fractures can be challenging. At our institution, we attempt treatment of nearly all closed, isolated tibial shaft fractures. The purpose of this study was to report the results of 10 years of experience to develop a tool to identify patients for whom non-operative treatment of tibial shaft fractures may be a viable option METHOD: This was a retrospective review of patients with tibial shaft fracture seen at a level 1 trauma center over 10 years. Patients with closed, isolated injuries underwent sedation, closed reduction, long-leg casting, and outpatient follow-up. Patients were converted to surgery for inability to obtain or maintain acceptable alignment or patient intolerance. Radiographic characteristics and patient demographics were extracted. Logistic regression analysis was used to develop a model to predict which patient and injury characteristics determined success of nonoperative treatment.

RESULTS

334 patients were identified with isolated, closed tibial shaft fractures, who were reduced and treated in a long leg cast. 234 patients (70%) converted to surgical treatment due to inability to maintain alignment, patient intolerance, and nonunion. In a regression model, coronal/sagittal translation, sagittal angulation, fracture morphology, and smoking status were shown to be significant predictors of success of nonoperative treatment (p < 0.05). We developed a Tibial Operative Outcome Likelihood (TOOL) score designed to help predict success or failure of closed treatment. The TOOL score can be used to identify a subsegment of patients with injuries amenable to closed treatment (38% of injuries) with a nonoperative success rate over 60%.

CONCLUSION

Non-operative treatment of tibial shaft fractures is feasible, although there is a relatively high conversion rate to operative treatment. However, it is possible to use injury characteristics to identify a cohort of patients with a higher chance of success with closed treatment, which is potentially useful in a resource-constrained setting or for patients who wish to avoid surgery.

LEVEL OF EVIDENCE

Prognostic Level 3.

Compilation and Analysis of Web-Based Orthopedic Personalized Predictive Tools: A Scoping Review

Web-based personalized predictive tools in orthopedic surgery are becoming more widely available. Despite rising numbers of these tools, many orthopedic surgeons may not know what tools are available, how these tools were developed, and how they can be utilized. The aim of this scoping review is to compile and synthesize the profile of existing web-based orthopedic tools. We conducted two separate PubMed searches-one a broad search and the second a more targeted one involving high impact journals-with the aim of comprehensively identifying all existing tools. These articles were then screened for functional tool URLs, methods regarding the tool's creation, and general inputs and outputs required for the tool to function. We identified 57 articles, which yielded 31 unique web-based tools. These tools involved various orthopedic conditions (e.g., fractures, osteoarthritis, musculoskeletal neoplasias); interventions (e.g., fracture fixation, total joint arthroplasty); outcomes (e.g., mortality, clinical outcomes). This scoping review highlights the availability and utility of a vast array of web-based personalized predictive tools for orthopedic surgeons. Increased awareness and access to these tools may allow for better decision support, surgical planning, post-operative expectation management, and improved shared decision-making.

Can we predict failure of percutaneous fixation of femoral neck fractures?

PURPOSE

This study evaluated a series of geriatric femoral neck fracture treated with closed reduction percutaneous pinning (CRPP) at a single level-1 trauma center to determine if there are any simple, reliable, radiographic characteristics that can be used to predict increased risk of post-operative failure in nondisplaced and valgus impacted fracture patterns.

METHODS

We conducted a retrospective cohort study of all patients with femoral neck fractures (AO/OTA 31B) who underwent CRPP over a 12-year period at a single Level 1 trauma center. Failure was defined as radiographic failure within the first year after the index operation requiring revision surgery. Common patterns identified on initial review were the presence of a visible medial transcervical line (MTL) felt to indicate a tension-sided failure, a straight inferior calcar (SIC) indicating severe valgus impaction, and quality of intra-operative screw positioning. X-rays of patients were then reviewed for these characteristics in a blinded manner by three different trauma-fellowship trained orthopedic surgeons. Inter-rater reliability was calculated using Fleiss' Kappa Coefficient. Comparisons of failure rates between groups were made using a Fisher's Exact test.

RESULTS

139 patients who underwent CRPP for a femoral neck fracture and follow-up for at least 90 days were identified and reviewed. There were a total of 19 failures (13.6%) within one year. The patients with a varus fracture had a failure rate of 9/24 (37.5%). Of the valgus/nondisplaced fractures, MTL was identified in 42/115 (36%) patients. Inter-rater agreement was high for the presence of an MTL (84%, Kappa 0.69). Patients with an MTL had a fourfold increase in risk of failure (7/42=17% with an MTL vs. 3/73=4% without, p  0.03). The presence of a SIC and quality of screw placement were not predictive of failure.

CONCLUSION

Varus femoral neck fractures fixed with CRPP have a high rate of failure (37.5%). Nondisplaced or valgus impacted fractures with the presence of a visible medial transcervical line on pre-operative radiographic imaging resulted in a fourfold increase in the risk of failure after CRPP. Identification of the MTL will help treating surgeons better council patients when making pre-operative decisions between arthroplasty and CRPP.

"Found Down" Compartment Syndrome: Experience from the Front Lines of the Opioid Epidemic

BACKGROUND

With the worsening of the opioid epidemic, there has been an increasing number of cases in which patients are "found down" following a drug overdose and develop a crush injury resulting in muscle necrosis, rhabdomyolysis, and elevated compartment pressures in a unique presentation of compartment syndrome. The purpose of the present study is to summarize our experience at a trauma center in a region with a high endemic rate of opiate abuse to provide guidance for the management of patients with "found down" compartment syndrome.

METHODS

We performed a retrospective review of the records of patients who had been found unconscious as the result of overdose, with findings that were concerning for compartment syndrome, and had been managed with fasciotomy or observation at the discretion of the surgeon. The patients were divided into 3 groups based on presentation (partial deficits, complete deficits, or unexaminable), and the operative findings, hospital course, laboratory values, and functional status were compared between the groups.

RESULTS

Over 12 years, we identified 30 "found down" patients who had an examination that was concerning for compartment syndrome. Twenty-five patients were managed with fasciotomy; this group required an average of 4.2 operations and had a 20% infection rate and a 12% amputation rate. Lactate, creatine phosphokinase, and creatinine levels typically were elevated but did not correspond with muscle viability or return of function. At the time of initial debridement, 56% of patients had muscle that appeared nonviable, although muscle function returned in 28% of the patients who had questionable viability. Four patients had no motor or neurological function on initial examination, and none had meaningful return of function at the time of the latest follow-up. Of the 10 patients who had partial neurological deficits at the time of presentation and underwent fasciotomy, over half (70%) had some improvement in ultimate function.

CONCLUSIONS

Patients who are "found down" following an opiate overdose with crush injuries resulting in compartment syndrome have a high surgical complication rate and poor recovery of function. The limited data from the present study suggest that those with absent function at the time of presentation are unlikely to gain function after fasciotomy, and the risk-benefit ratio of fasciotomy in this patient population may be different from that for patients with traumatic compartment syndrome.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic Faculty and Resident Sex Diversity Are Associated with the Orthopaedic Residency Application Rate of Female Medical Students

BACKGROUND

The representation of women in orthopaedics in the United States remains among the lowest in all fields of medicine, and prior research has suggested that this underrepresentation may stem from lower levels of interest among female medical students. Of the many proposed reasons for this lack of interest, the male-dominated nature of the field is one of the most commonly cited. The purpose of this study was to determine the degree to which the representation of women among orthopaedic faculty and residents influences female medical students at that institution to apply for a residency in orthopaedics.

METHODS

Using data provided by the Association of American Medical Colleges, we identified all U.S. medical schools that were affiliated with an orthopaedic surgery department and an orthopaedic surgery residency program (n = 107). For each institution, data on the representation of women among the orthopaedic faculty and residents from 2014 through 2016 were collected, as well as data on the proportion of female medical school graduates who applied to an orthopaedic residency program from 2015 through 2017. The association between institutional factors and the female medical student orthopaedic application rate was assessed.

RESULTS

Of 22,707 women who graduated from medical school during the 3-year study period, 449 (1.98%) applied to an orthopaedic surgery residency program. Women who attended medical school at institutions with high orthopaedic faculty sex diversity were more likely to apply for a residency in orthopaedics (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.04 to 1.64; p = 0.023), as were women who attended medical school at institutions with high orthopaedic resident sex diversity (OR, 1.30; 95% CI, 1.05 to 1.61; p = 0.019).

CONCLUSIONS

In this study, we found that increased sex diversity among orthopaedic faculty and residents was associated with a greater likelihood that female medical students at that institution would apply for an orthopaedic residency. These results suggest that at least some of the factors currently impeding female medical student interest in orthopaedics may be modifiable. These findings may have important implications for efforts to improve the sex diversity of the field of orthopaedics going forward.