Orthopaedic Trauma Care Research Articles

Posterior cruciate ligament injury: characteristics and associations of most frequent injuries

ObjectiveTo investigate the prevalence and combinations of PCL injuries and their correlations with the mechanism, the occurrence of evident dislocation and associated fracture. MethodA retrospective study of 85 lesions of PCL operated between 2003 and 2010. Diagnosis by physical examination and dynamic radiography, compared with surgical findings. ResultsInjuries involving the PCL were more prevalent in men (78.8%) with a mean age of 33 years. The main cause was traffic accidents (73.80%), and (49.4%) motorcycle. Isolated PCL injury occurred in (15.3%) cases, and combined (84.7%). Among the isolated lesions, bone avulsions were nine (10.6%). The most associated PCL injuries were the ACL (48.2%), followed by LCL PCL/PLC (22.4%). Fractures were more associated with combining PCL+LCL/PLC injuries and did not appear in the PCL+MCL/PMC. Complications beyond fractures: peripheral nerve injury (4.8%) and vascular (1.2%). Evident dislocation in primary care (16.7%) was more prevalent in combined ACL+PCL+MCL/PMC (44.4%). Half the patients were operated during the acute phase. There was a statistically significant difference (p<0.05) comparing each combination of ligament injuries with the presence of fracture, dislocation or clear mechanism of injury. ConclusionSurgical treatment of PCL injuries in a center for orthopedic trauma care was mostly multiligament and mainly involving the ACL. A significant association was seen between the type of injury with mechanism of injury, presentation of the knee, if dislocated or reduced, and the presence of associated fracture.

Current Practice in Paediatric Orthopaedic Trauma Care: A Retrospective Comparison Study

Accidental injury has been demonstrated repeatedly to be the leading cause of morbidity, mortality and hospital admission in children aged 5–16 years in the UK, with an estimated annual cost of £200 million. The past 40 years have seen an increase in paediatric fracture rates by at least 30 per cent, as reflected by increased hospital admission rates. This illustrates the continuation of a trend identified by a large swedish study of more than 8,000 paediatric fractures between the years 1950 and 1979, which showed a doubling of the incidence of fractures for boys and girls below the age of 16 during the course of this 30-year period.

Lesões do ligamento cruzado posterior: características e associações mais frequentes

ObjectiveTo investigate the prevalence and combinations of PCL injuries and their correlations with the mechanism, the occurrence of evident dislocation and associated fracture. MethodA retrospective study of 85 lesions of PCL operated between 2003 and 2010. Diagnosis by physical examination and dynamic radiography, compared with surgical findings. ResultsInjuries involving the PCL were more prevalent in men (78.8%) and mean age of 33 years. The main cause was traffic accidents (73.80%), and (49.4%) motorcycle. Isolated PCL injury occurred in (15.3%) cases, and combined (84.7%). Among the isolated lesions, bone avulsions were nine (10.6%). The most associated PCL injuries was the ACL (48.2%), followed by LCL PCL/PLC (22.4%). Fractures were more associated with combining PCL+LCL/PLC injuries and did not appear in the PCL+MCL/PMC. Complications beyond fractures: peripheral nerve injury (4.8%) and vascular (1.2%). Evident dislocation in primary care (16.7%) were more prevalent in combined ACL+PCL+MCL/PMC (44.4%). Half the patients were operated during the acute phase. There was a statistically significant difference (p<0.05) comparing each combination of ligament injuries with the presence of fracture, dislocation or clear mechanism of injury. ConclusionSurgical treatment of PCL injuries in a center for orthopedic trauma care were mostly multiligament and mainly involving the ACL. A significant association was seen between the type of injury with mechanism of injury, presentation of the knee, if dislocated or reduced, and the presence of associated fracture.

Impact of Hospital-Employed Physician Assistants on a Level II Community-Based Orthopaedic Trauma System

The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospital-based PAs on orthopaedic trauma care at a level II community hospital. Retrospective case series. Level II trauma center. One thousand one hundred four trauma patients with orthopaedic injuries. PA involvement. Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients. At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P > 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27). Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well.

Orthopaedic Trauma Care in Haiti: A Cost-Effectiveness Analysis of an Innovative Surgical Residency Program

ObjectiveIn an effort to sustainably strengthen orthopaedic trauma care in Haiti, a 2-year Orthopaedic Trauma Care Specialist (OTCS) program for Haitian physicians has been developed. The program will provide focused training in orthopaedic trauma surgery and fracture care utilizing a train-the-trainer approach. The purpose of this analysis was to calculate the cost-effectiveness of the program relative to its potential to decrease disability in the Haitian population. MethodsUsing established methodology originally outlined in the World Health Organization's Global Burden of Disease project, a cost-effectiveness analysis was performed for the OTCS program in Haiti. Costs and disability-adjusted life-years (DALYs) averted were estimated per fellow trained in the OTCS program by using a 20-year career time horizon. Probabilistic sensitivity analysis was used to simultaneously test the joint uncertainty of the cost and averted DALY estimates. A willingness-to-pay threshold of $1200 per DALY averted, equal to the gross domestic product per capita in Haiti, was selected on the basis of World Health Organization's definition of highly cost-effective health interventions. ResultsThe OTCS program results in an incremental cost of $1,542,544 ± $109,134 and 12,213 ± 2,983 DALYs averted per fellow trained. The cost-effectiveness ratio of $133.97 ± $34.71 per DALY averted is well below the threshold of $1200 per DALY averted. Furthermore, sensitivity analysis suggests that implementing the OTCS program is the economically preferred strategy with more than 95% probability at a willingness-to-pay threshold of $200 per DALY averted and across the entire range of potential variable inputs. ConclusionsThe current economic analysis suggests the OTCS program to be a highly cost-effective intervention. Probabilistic sensitivity analysis demonstrates that the conclusions remain stable even when considering the joint uncertainty of the cost and DALY estimates.

An overview of pelvic ring disruption

Pelvic ring disruption after trauma is uncommon, occurring in 20–37/100,000 people in the general population. However, in high velocity poly trauma up to 20% of cases have this injury contributing significantly to morbidity and mortality. The management of pelvic and acetabular trauma has become a subspecialty within the orthopaedic trauma care. The injury patterns are now better understood, there is agreement on a classification system and operative stabilisation has become a viable treatment option.

Outcome of road traffic injuries received in the emergency room of a teaching hospital, Southeast Nigeria

Road traffic injuries (RTI) are a rapidly growing public health problem in developing countries. This study was aimed at assessing the early outcome of RTIs received in our hospital emergency room. Understanding this will help to achieve optimum injury outcome. A prospective study was conducted on all patients presenting with RTIs to the emergency room of the Ebonyi University Teaching Hospital, Abakaliki, from 1 March 2007 to 29 February 2008. Out of 363 patients: 72.45% were treated in the emergency unit and discharged; 12.7% left against medical advice; 10.9% were admitted to the ward; and 4.7% died. Self-discharge against medical advice was significantly related to the type of injury (78.3% had fracture/dislocation) and gender (P = 0.001). The patronage of traditional bone setters, because of cultural belief that they have supernatural ability to treat fractures, was the major reason given by those who left against medical advice. The morbidity and mortality rate was significantly related to the road type (P = 0.005 - a higher rate was observed for RTIs received on intercity roads than intracity ones) and the type of crash (P = 0.03 - more than half from head on collisions). Although the mortality rate was within the expected range, the preventable death rate was high, and the majority of deaths occurred within the 'golden hour' . Improvement in pre-hospital and emergency room care of patients with RTIs, as well as public awareness of the availability and efficacy of orthodox orthopaedic trauma care, are needed in the developing countries.

Research in a Non-academic Setting: It Can Be Done

The need for quality research to promote evidence-based practice and optimize patient care is well recognized. This is particularly relevant in orthopedic trauma care, as trauma is a leading cause of morbidity and mortality worldwide. Across the spectrum of academic, clinical, and health care administration physician roles, research remains fundamental to bridging theory, practice, and education. A gap exists, however, between research and practice, especially for those physicians practicing outside traditional academic centers. Orthopedic trauma surgeons are well situated to contribute to important research; however the majority of those in practice at non-academic centers do not have a significant research component structured into their physician role. In this article, the authors outline the importance of orthopedic trauma surgeons outside of academic centers being engaged in research and present some advice on how to effectively participate in these endeavors. In this setting, orthopedic trauma research involvement includes asking researchable questions, being a savvy manager of research collaborators, staff, and funding, and finding one's own level of research involvement.

Thoughts on Teaching (for Orthopaedic Graduates) *

The house of academic medicine is supported by four pillars, which include clinical care, administration, research, and teaching. These pillars sustain the diverse missions of academic medical centers. Our subspecialty of orthopaedic surgery is also supported by these pillars. Clinical care is the largest and strongest pillar of academic medicine and orthopaedics. All value in health care begins with service to patients, and providing high-quality, safe health care is critical to the success of all medical centers and all orthopaedic practices. Administration is a necessary pillar. Competent, knowledgeable, and diligent administrators are very important for medical centers and orthopaedic practices, as they manage the complex processes associated with the clinical and academic missions. Research is an essential pillar of academic medicine and orthopaedic surgery. Besides providing new knowledge, new services, new products, and innovations that improve the care we offer to our patients, research can generate additional revenue for medical centers. During my career, research in orthopaedics has led to subspecialization in orthopaedic surgery, which, in general, has improved patient care. Specific clinical advances that I have observed include arthroscopic surgery, microsurgery for neurovascular reconstruction, cartilage restoration, cementless hip replacement, instruments and navigation for total knee arthroplasty, advances in spine surgery, and techniques and products for orthopaedic trauma care. These innovations have succeeded because they relieve pain and improve function for orthopaedic patients. Orthopaedic research improves the lives of our patients, and research is an essential pillar in the house of orthopaedics. Teaching is the fourth pillar of academic medicine and orthopaedics, although teaching can be an undervalued and overlooked pillar. Teaching generates less revenue than clinical care and research, generates administrative costs, and takes time to do well. Despite the critically important fact that teaching programs train the next generation of physicians and orthopaedic surgeons, the importance of the …

Como o especialista em ortopedia e traumatologia avalia o atendimento ao trauma ortopédico no Brasil

OBJETIVO: Apresentar os resultados de pesquisa Datafolha, realizada no periodo de 23 de setembro a 18 de outubro de 2010, sobre as condicoes existentes para o exercicio profissional na area do trauma ortopedico no Brasil. METODOS: pesquisa quantitativa, com abordagem telefonica dos entrevistados, por meio de sorteio aleatorio de membros da Sociedade Brasileira de Ortopedia e Traumatologia, em cadastro contendo mais de 7.000 nomes. As entrevistas foram realizadas mediante aplicacao de questionario estruturado, com aproximadamente 25 minutos de duracao. RESULTADOS: 97% dos entrevistados dedica parte do seu tempo ao trauma ortopedico. 87% dos entrevistados exercem outra sub-especialidade, que nao o trauma ortopedico. Na media dos atendimentos no pais, 43% dos pacientes pertencem a rede publica de saude e 41% pertencem a rede de convenios. O uso de implantes importados ocorre na minoria das situacoes (36%) e 83% dos medicos que utilizam ambos os tipos de implantes julga que os nacionais apresentam qualidade inferior. 61% dos entrevistados julga a qualidade do atendimento em servicos publicos regular, ruim ou pessima. Metade dos entrevistados declara ter problemas para a liberacao de suas solicitacoes de procedimentos junto aos planos de saude em pelo menos 25% das vezes em que encaminham tais pedidos. CONCLUSAO: O trauma ortopedico e uma especialidade exercida pela grande maioria dos ortopedistas brasileiros. A estrutura dos servicos publicos e considerada insatisfatoria pela maioria dos ortopedistas entrevistados. A maioria dos ortopedista deseja uma reformulacao nos honorarios medicos e na infra-estrutura de servicos.

Common errors in billing and coding for orthopaedic trauma care

Physician compensation for services rendered is an extremely complex process in the United States. Because this system is so complex, physicians often do not put forth the effort to learn how to appropriately report their services. The result is lost revenue for services provided. This review will discuss coding from the initial trauma patient evaluation through the last reconstructive procedure and common errors. Both Evaluation and Management (E&M) coding and surgical Current Procedural Terminology (CPT) codes will be explored as they pertain to initial, subsequent, and reconstructive trauma care.

Prophylaxis for venous thromboembolism: guidelines translated for the clinician

Venous thromboembolism is a major cause of morbidity and mortality worldwide and most often affects hospitalized postoperative surgical and medical patients. Venous thromboembolism prophylaxis undoubtedly improves the care of these patients, as demonstrated by the current literature and guidelines. Failure to prescribe prophylaxis when indicated, however, remains a vital health care concern. The American College of Chest Physicians (ACCP) published their most recent guidelines regarding venous thromboembolism prophylaxis in 2008. In this review, we aim to summarize the most recent ACCP prophylaxis guidelines with practical application and interpretation for the practicing physician. Here we present the most practical information from these guidelines and summarize essential recommendations in key tables. We will briefly review the grading system used in the guidelines for the level of evidence and the strength of the recommendation. We will then discuss the recommendations for prophylaxis in the various patient populations described in these guidelines including general and orthopedic surgery, gynecologic surgery, urologic surgery, thoracic surgery, neurosurgery, trauma, medical conditions, cancer patients, and critical care. In addition, we will discuss recent clinical trials regarding novel anticoagulants for venous thromboembolism prophylaxis and share some conclusions.

October 2010 Book Reviews

The JOSPT offers invited reviews of current titles. The October 2010 column includes 7 reviews of the following books: Orthopaedic Trauma Care; Mechanisms and Management of Pain for the Physical Therapist; Fundamentals of Musculoskeletal Imaging, Third Edition; Gait Analysis: Normal and Pathological Function, Second Edition; The Lumbar Intervertebral Disc; Spine Classifications and Severity Measures; and Physical Agents in Rehabilitation: From Research to Practice, Third Edition. J Orthop Sports Phys Ther 2010;40(10):668–673. doi:10.2519/jospt.2010.40.10.668

Review of Orthopedic Trauma Care

Review of Orthopedic Trauma Care

Perioperative Antibiotic Administration in Orthopaedic Trauma

Perioperative antibiotic prophylaxis has been a mainstay of orthopaedic trauma care for decades. Despite ongoing controversy regarding the optimal number of doses required, established guidelines for use have been in place for years. A retrospective quality assurance project was conducted in Calgary, Alberta, Canada, to review local practice regarding perioperative antibiotic administration in orthopaedic trauma and compare that to what is suggested in the literature.

Gastroprotection for Orthopedic Trauma Patients

Nonsteroidal anti-inflammatory drugs (NSAIDs) — commonly prescribed as first-line pain medications in orthopedic trauma care — increase the likelihood of upper gastrointestinal bleeding. This risk is exacerbated by several factors, including age ≥65, major comorbidities, history of peptic ulcer disease, and use of use of oral steroids or anticoagulation agents. Although multiple guidelines …

Autologous bone graft versus demineralized bone matrix in internal fixation of ununited long bones

BackgroundNon-unions are severe complications in orthopaedic trauma care and occur in 10% of all fractures. The golden standard for the treatment of ununited fractures includes open reduction and internal fixation (ORIF) as well as augmentation with autologous-bone-grafting. However, there is morbidity associated with the bone-graft donor site and some patients offer limited quantity or quality of autologous-bone graft material. Since allogene bone-grafts are introduced on the market, this comparative study aims to evaluate healing characteristics of ununited bones treated with ORIF combined with either iliac-crest-autologous-bone-grafting (ICABG) or demineralized-bone-matrix (DBM).Methods and resultsFrom 2000 to 2006 out of sixty-two consecutive patients with non-unions presenting at our Level I Trauma Center, twenty patients had ununited diaphyseal fractures of long bones and were treated by ORIF combined either by ICABG- (n = 10) or DBM-augmentation (n = 10). At the time of index-operation, patients of the DBM-group had a higher level of comorbidity (ASA-value: p = 0.014). Mean duration of follow-up was 56.6 months (ICABG-group) and 41.2 months (DBM-group). All patients were clinically and radiographically assessed and adverse effects related to bone grafting were documented. The results showed that two non-unions augmented with ICABG failed osseous healing (20%) whereas all non-unions grafted by DBM showed successful consolidation during the first year after the index operation (p = 0.146). No early complications were documented in both groups but two patients of the ICABG-group suffered long-term problems at the donor site (20%) (p = 0.146). Pain intensity were comparable in both groups (p = 0.326). However, patients treated with DBM were more satisfied with the surgical procedure (p = 0.031).ConclusionWith the use of DBM, the costs for augmentation of the non-union-site are more expensive compared to ICABG (calculated difference: 160 €/case). Nevertheless, this study demonstrated that the application of DBM compared to ICABG led to an advanced outcome in the treatment of non-unions and simultaneously to a decreased quantity of adverse effects. Therefore we conclude that DBM should be offered as an alternative to ICABG, in particular to patients with elevated comorbidity and those with limited availability or reduced quality of autologous-bone graft material.

Economic impact of orthopaedic trauma care on hospitals and hospital systems

Trauma is a major public health issue. The management of seriously injured patients requires the integration of rescue and transport services, resuscitation and reconstructive care in dedicated centers with access to physical and vocational rehabilitation. The management of injury is exceedingly complex and expensive. We are entering a period of uncertainty due to the convergence of decreased reimbursement, more uncompensated care and fewer specialists willing to provide on-call services. The management of injury is costly yet has clear economic benefits based upon the potential to reduce mortality and mitigate disability. Trauma care also is very sustainable under favorable conditions including regionalized systems to support volume-driven proficiency, productive specialist staffing models, an evidence-based approach to technology and a high degree of physician-hospital integration.

Expanding Pediatric Orthopaedic Trauma Volume at a Pediatric Level 1 Trauma Hospital

Trauma continues to be the leading cause of morbidity and mortality among children. There is a perception among pediatric orthopaedists that the volume of pediatric orthopaedic trauma care is increasing. We hypothesized that the change in trauma volume was greater than the local and regional population change. This retrospective analysis (1996 to 2006) of our institution's trauma registry analyzed changes in general trauma and orthopaedic trauma admissions, surgical volumes, patient and population demographics, and hospital reimbursement. For the decade, the local pediatric population increased annually by only 2% to 3%. During that same period, there was an increase in the proportion of patients treated from outside the immediate county, from 13% in 1996 to 28% in 2006. Total general trauma patient admissions increased at an average of 10% per year from 1996 to 2006, whereas total orthopaedic trauma admissions and orthopaedic trauma admissions requiring operative treatment increased by an annual average of 18%. Orthopaedic trauma admissions as a percentage of total trauma admissions steadily increased from 26% in 1996 to 45% in 2006. During 2005 and 2006, an average total of 1216 orthopaedic trauma cases per year were performed generating an average 10,465 work relative value units per year. Between 1996 and 2005, the hospital's gross charges for pediatric orthopaedic trauma increased by an average of 26% annually; however, the percentage of total charges collected decreased from 67% in 1999 to 28% in 2005. Pediatric orthopaedic trauma at this level 1 trauma center increased dramatically and more rapidly than the local population over the last decade, increasing the demand for physician and hospital resources. Physicians, hospitals, and the communities they serve face financial and logistical problems of providing care for an expanding volume of pediatric orthopaedic trauma patients with decreasing reimbursements, changing referral patterns and a decreasing population of pediatric orthopaedic specialists. Care of the pediatric orthopaedic trauma patient could become a national crisis. Economic analysis-level III.

Intramedullary Nailing of the Femur: Current Concepts Concerning Reaming

Intramedullary fixation has advanced to the standard of care for fractures of the femoral shaft. Current controversies center on whether to prepare the intramedullary canal by reaming, particularly in certain subsets of patients. As understanding of the local and systemic effects of reaming deepens, there is a role for maximizing the benefits of intramedullary preparation before nail fixation, while attempting to minimize the major disadvantages of this technique. Several treatment strategies have emerged to address the downsides of intramedullary reaming. The purpose of this review is to discuss the history and current knowledge of intramedullary reaming with respect to problems associated with its use and the evolution of treatment modalities and their clinical applicability for orthopaedic trauma care.