Journal of Orthopaedic Trauma最新文献

Objectives: To evaluate a new triage workflow aimed at improving time to intravenous antibiotics in open fractures to under 60 minutes of arrival to the Pediatric Emergency Department.

Methods: Design: A prospective, multi-disciplinary, quality improvement project.

Setting: A tertiary care, Level 1 Pediatric Trauma hospital in New York.

Patient selection criteria: Patients aged 17 and under with long bone open fractures between June 1, 2020 and May 31, 2021, excluding those transferred from an outside hospital, with non-long bone fractures and non-fractured, injured extremities.Outcome Measures and Comparisons: The new workflow involved splint removal and skin assessment during triage to identify open fractures. Serial Plan-Do-Study-Act (PDSA) cycles aimed to refine this workflow and reduce antibiotic administration time. Primary outcome: Percentage of open fracture patients receiving intravenous (IV) antibiotics within 60 minutes. Secondary outcome: Assessment of triage documentation regarding splint presence and removal. An exact Wilcoxon two-sample test compared time from patient arrival (quick-registration) to antibiotic administration before, during and after workflow implementation on 6/1/2020.

Results: A total of 51 patients (33 male) aged 17 and under, with open fractures were reviewed: 25 during the pre-intervention phase 1/1/18-5/31/20, 14 during the intervention phase 6/1/20-5/31/21, and 12 during the post-intervention phase 6/1/21-11/30/21. Continuous improvement efforts via PDSA cycles focusing on education, reinforcement, recognition, and barrier identification increased the percentage of patients receiving antibiotics within 60 minutes from 36% to 87.5%. Median time and Interquartile range (IQR: 25th percentile-75th percentile) from quick-registration to administration was 86 minutes (IQR: 51-147) before 6/1/2020, and 34 minutes (IQR: 16- 42) thereafter.

Conclusion: The implemented triage workflow led to improved time to antibiotics to within 60 minutes for patients with long bone open fractures in the Pediatric Emergency Department.

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

Objectives: To compare outcomes and complications between non-operative and operative management of femur and tibia fractures in patients with paraplegia or quadriplegia from chronic spinal cord injury (SCI).

Methods: Design: Retrospective cohort study.

Setting: Three Level-1 Trauma centers.

Patient selection criteria: All adult patients with paraplegia or quadriplegia due to a chronic SCI with operative or nonoperative treatment of a femoral or tibial shaft fracture from 01/01/2009 through 12/31/2019 were included.

Outcome measures and comparisons: Outcomes collected included range of motion, pain, return to baseline activity, extent of malunion and treatment complications (infection, pressure ulcers, nonunion, DVT/PE, stroke, amputation, death). Comparison between operative and nonoperative treatment were made for each outcome.

Results: Fifty-nine patients with acute lower extremity fracture in the setting of chronic SCI fulfilled inclusion criteria with a median age of 46 years in the operative group and 47 years in the non-operative group. Twelve patients (70.6%) in the nonoperative group were male with 32 (76.2%) male patients in the operative group. Forty-six patients (78%) presented as low energy trauma. Differences were seen between operative and non-operative management for pressure ulcers (19% vs 52.9%, p=0.009) and mean VAS pain score at first follow-up (1.19 vs 3.3, p=0.03). No difference was seen for rates of infection, nonunion, DVT/PE, stroke, amputation, death, return to baseline activity, and range of motion.

Conclusions: Tibial and femoral shaft fractures commonly resulted from low energy mechanisms in patients with chronic SCI. Operative treatment seemed to decrease morbidity in these patients via lowered rates of pressure ulcers and decreased pain compared to non-operative management.

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

Objectives: This study seeks to evaluate the variability of Medicaid reimbursement and compare it to Medicare reimbursement using the 20 most commonly billed orthopedic trauma CPT codes nationwide. The authors anticipate significant variability between states and hypothesize that Medicaid payment will be significantly less than Medicare payment.

Methods: The top 20 most common orthopedic trauma surgery procedural codes were identified from a previous analysis performed by Haglin et al.1 The Centers for Medicare and Medicaid services physician fee schedule was used to determine reimbursement rates from Medicare, and state Medicaid fee schedules were used to determine reimbursement rates for Medicaid. State Medicaid rates were compared to their corresponding Medicare rates to determine a dollar difference. Additionally, the dollar difference for each CPT code was divided by its respective physician relative value unit (RVU). This was utilized to acknowledge the possible variability in the complexity of orthopedic procedures and the related physician effort. The Medicare Wage Index was used to adjust Medicaid rates based on the cost of living for the state as well. Coefficients of variation were calculated to represent overall variability in Medicaid and Medicare reimbursement rates.

Results: The mean reimbursement rates for Medicaid were lower for all 20 procedures compared to Medicare. On average, Medicaid reimbursed 16.0% less than Medicare, and 29.6% less when adjusting for cost-of-living. MCD reimbursed at a higher rate than MCR for all procedures in only nine states (Alaska, Arizona, Arkansas, Montana, Nebraska, New Jersey, New Mexico, and North Dakota, and South Dakota) while 38 states reimbursed at a lower rate than MCR, on average. The coefficient of variation ranged from 0.24 to 0.34 for the Medicaid unadjusted group and from 0.35 to 0.46 for the Medicare Wage-Index adjusted group. In contrast, the Medicare group was consistent at 0.06 for all 20 procedures. The average dollar difference across the 20 CPT codes for Medicaid reimbursement compared to Medicare ranged from -$76.89 to -$225.17, and the dollar difference per relative value unit ranged from -$5.96 to -$15.16.

Conclusion: This study found a high amount of variation between state Medicaid reimbursement rates and average rates that were significantly lower than Medicare reimbursement rates for the top twenty most utilized orthopedic trauma CPT codes as identified by Haglin et al. The discrepancy in reimbursement was increased when Medicaid rates were adjusted for state cost-of-living.

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

Objectives: This study explored the hypothesis that social determinants of health (SDOH), including racial and economic differences, may impact orthopaedic trauma outcomes in patients undergoing open reduction and internal fixation (ORIF) of humeral shaft fractures.

Methods: Design: Retrospective.

Setting: Single, academic, tertiary Level-I trauma center.

Patient selection criteria: Adults with midshaft humerus fractures (AO/OTA 12) treated operatively with plate fixation from 05/2011 to 05/2021 with a minimum follow-up of nine months.

Outcome measures and comparisons: Radiographic fracture healing, complication rates, and patient-reported outcomes were investigated. SDOH were assessed using the Area Deprivation Index (ADI). Demographics, complications rates, and patient-reported clinical outcomes were compared between the first and fourth ADI quartiles.

Results: 196 patients fit the study criteria. The average age of the cohort was 47 years with 50 women (51%). Comparisons of the least deprived quartile (n=49) to the most deprived quartile (n=49) yielded similar sex distribution (59% vs 43% female, p=0.15), fewer non-white patients (8% vs 51%, p<0.01), older average age (51 years vs 43 years, p=0.05), similar BMI (30.5 vs. 31.8, p=0.45), and higher Charlson Comorbidity Index (CCI) (2.2 vs.1.1, p=0.03). While nonunion rates were similar (p=0.20) between groups, the most deprived quartile had 2.3 times greater odds of post-operative complications (p=0.04). Patients in the most deprived group exhibited higher PROMIS Pain Interference (PI) scores (p<0.01) and PROMIS Depression (D) scores (p=0.01), with lower PROMIS Physical Function (PF) scores (p<0.01) at 6-month follow-up than the least depriver cohort. The most deprived cohort had three times higher odds of missing scheduled appointments within the first post-operative year (p<0.01), resulting in a significantly higher no-show rate (p<0.01) than the least deprived cohort. Regression analysis including several demographic and injury factors identified that ADI was significantly associated with the occurrence of any missed appointments (p<0.01), no-show rates (p=0.04), and experiencing one of the following post-operative complications during recovery: Nonunion, radial nerve injury, or dysfunction (p=0.03).

Conclusions: Patients experiencing greater resource deprivation faced increased odds of complications, missed appointments, and poorer PROMIS outcomes following humeral shaft fracture fixation, emphasizing that baseline socioeconomic disparities predict unfavorable post-operative outcomes even given favorable baseline health status according to the CCI score.

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

Video available at: https://ota.org/education/ota-online-resources/video-library-procedures-techniques/icg-based-fluorescence-imaging.

Objectives: To evaluate the orthopaedic management, associated injuries, and outcomes in patients treated for low-velocity ballistic pelvic fractures.

Methods: Design: Retrospective chart review.

Setting: Single urban Level I Trauma Center.

Patient selection criteria: Patients aged 15 years or older treated for low-velocity ballistic pelvic (OTA/AO 61 and 62) fractures from May 2018 to August 2021.

Outcome measures and comparisons: Primary study measures included pelvic fracture location, concomitant associated injuries, surgical interventions, and antibiotic treatment. Post-injury sequelae evaluated include infection, neurologic deficit, and need for orthopaedic removal of foreign body. Risk factors for post-injury sequelae were investigated.

Results: A total of 156 patients with ballistic pelvic fractures were included. The cohort consisted of 135 (86.5%) males and a mean age of 29.8 years. One hundred and ten (70.5%) patients sustained two or more GSWs. Ninety-eight (62.8%) patients underwent an exploratory laparotomy with 79 (50.6%) having a confirmed concomitant intestinal injury. Additional associated injuries included nerve injury (13.5%), vascular injury requiring repair or embolization (10.9%), and bladder injury (10.3%). Nine (5.7%) patients underwent orthopaedic operative management - five (3.2%) patients for operative fixation and four (2.5%) patients for removal intra-articular foreign bodies. Diabetes (OR: 33.1, p=0.025), neurologic deficit on presentation (OR: 525.2, p<0.001), vascular injury requiring repair or embolization (OR 8.7, p=0.033), and orthopaedic pelvic fixation (OR: 163.5, p=0.004) were positively associated with the defined post-injury sequelae at 30 and 90 days of follow-up. There was not a statistically significant association between infection and retained foreign body (OR: 3.95 [95% CI 0.3 - 58.7, p = 0.318]) or bowel contamination (OR: 6.91 [95% CI 0.4 - 58.7, p = 0.178]).

Conclusions: Ballistic fractures of the pelvis and acetabulum rarely underwent operative fixation (3.2%) or irrigation and debridement. Neither retained foreign body nor presumed bowel contamination of pelvic fractures had a statistically significant association with infection which further supports conservative management of these injuries. Patients with diabetes, neurologic deficit on presentation, vascular injury necessitating intervention, and orthopaedic fixation of pelvic fracture are associated with increased risk of post-injury sequelae.

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

Objective: To determine the effect of deltoid ligament repair on the development of posttraumatic arthritis in logsplitter ankle injuries.

Methods: Design: Retrospective cohort.

Setting: Academic, Level I trauma center.

Patient selection criteria: Patients ≥18 years of age with logsplitter injuries (OTA/AO 44B, 44C) treated with open reduction internal fixation with or without deltoid ligament repair from January 2008 to October 2021.

Outcome measures and comparison: The rate of posttraumatic arthritis (PTOA) development at final follow-up (minimum 6 months) after open reduction internal fixation was evaluated using the Kellgren-Lawrence scale. The achievement of acceptable reduction indicated by articular reduction <2mm, and a medial clear space ≤4mm was assessed at 6 weeks postoperatively with weightbearing radiographs. The effect of deltoid ligament repair on the development of PTOA was investigated.

Results: Fifty-nine patients aged 49.1 ± 17.2 years met inclusion criteria with a mean follow up of 16.6 months (range = 6 to 96). Twenty-six of 59 patients (44%) had developed PTOA at final follow-up. Acceptable reduction was achieved in 83.1% (49/59) of fractures. The acceptable reduction rate in fractures undergoing deltoid ligament repair was 100% versus 78% in those without deltoid ligament repair (13/13 vs. 36/46, p=0.017). The rate of PTOA development was significantly lower in patients who underwent deltoid ligament repair (15%) compared to those who did not (52%), p=0.026. Patients who underwent deltoid ligament repair had a significantly reduced rate of PTOA development leading to arthrodesis compared to those who did not (0% vs. 17%, p=0.013).

Conclusions: Logsplitter injuries resulted in a high rate of development of posttraumatic arthritis. An acceptable reduction is required to minimize risk of development of PTOA and progression to arthrodesis. Deltoid ligament repair during open reduction internal fixation may facilitate acceptable reduction, decrease the rate of PTOA and progression to arthrodesis in these injuries.

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