Orthopaedic Trauma Procedures Research Articles

Medicaid Reimbursement for Common Orthopedic Trauma Procedures is 16.0% Less Compared to Medicare with Substantial Variability Between States.

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

Validation of Patient-Reported Outcome Measurement Information System for Detection of Posttraumatic Stress in Children and Adolescents Following Procedures for Acute Orthopaedic Trauma.

The efficiency and validity of the Patient-Reported Outcomes Measurement Information System (PROMIS) surveys were determined for pediatric orthopaedic trauma patients with posttraumatic stress disorder (PTSD) symptoms in a clinic setting. Prospective cohort study. Single-institution, Level I trauma center. All consecutive children aged 8-18 years undergoing procedures or surgery for orthopaedic trauma. The convergent, divergent, and discriminant validity of the PROMIS Anger and Anxiety computerized adaptive tests (CATs) were evaluated and compared with the previously validated Child PTSD Symptom Scale (CPSS). The efficiency in time to completion of the outcome measures was compared between the CPSS and PROMIS surveys. Cutoffs for increased likelihood of PTSD were established for the PROMIS questionnaires. A total of 233 subjects were included in this study (mean age 13.1 years with SD 2.8 years, 71% male). The majority (51%) of injuries were related to sports, and most (60%) involved the upper extremity. Of those included, 41 patients had high levels of PTSD symptoms on the CPSS (18%; 95% CI, 13.1-23.2%). The CPSS took 182 (interquartile range [IQR] 141-228) seconds versus 52 (IQR 36-84) and 52 (IQR 36-70) seconds for PROMIS Anger and Anxiety CATs, respectively. Convergent validity showed patient scores on both PROMIS instruments significantly correlated with CPSS scores (Anger: P < 0.001, r = 0.51; Anxiety: P < 0.001, r = 0.41). Neither PROMIS score correlated with University of California Los Angeles Activity Score (Anger: r = -0.26; Anxiety: r = -0.22), a functional outcome measure, demonstrating divergent validity. Both PROMIS instruments sufficiently discriminated across PTSD risk groups (Anger P < 0.001; Anxiety P < 0.001). A score of at least 53 on PROMIS Anger or at least 48 on PROMIS Anxiety indicated an increased likelihood of PTSD risk. PROMIS Anger and Anxiety CATs are efficient and valid for evaluating posttraumatic stress in children following orthopaedic trauma procedures. Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Generic orthopaedic trauma implants: implementation, outcomes, and cost savings

Background: As healthcare costs continue to rise, there has been increasing emphasis placed on providing value-based care. In orthopaedics, one way to influence cost is through the use of generic implants. The purpose of this study was to evaluate cost-savings and surgical outcomes with the implementation of generic orthopaedic trauma implant use. Methods: This was a retrospective case series of 154 primary orthopaedic trauma patients from April – December 2022 within a level II trauma center. Patients were included if treated solely with generic implants. Exclusion criteria consisted of revision procedures for any reason, and the use of conventional name brand implants. Eleven different primary orthopaedic trauma procedures in which generic implants were evaluated. Main outcome measurements included operative time, perioperative complications, reoperation rates, patient mortality, implant cost, cost-savings. Results: Cost-savings per procedure with the use of generic implants in eleven different primary orthopaedic trauma procedures ranged from 16% to 73%. The average cost-savings was 48.8% among the 11 procedures evaluated, with a yearly cost-savings of 56.0% when case volume is considered. Maintaining the 2021 case volume for one surgeon constant, an overall savings of $256,794 could be generated. Conclusions: This study demonstrated that generic implants can provide an opportunity for relatively good patient outcomes with minimal overall risk. Generic implants are a valid alternative to decrease costs while maintaining acceptable patient outcomes. Future studies should seek to provide patient-reported outcome measures for generic implants and compare them to conventional implant use.

Analysis of Medicaid and Medicare Reimbursement Variations for Common Orthopaedic Trauma Procedures

OBJECTIVES: Medicaid (MCD) reimbursement for surgery is determined by state governments and is subject to substantial variation in comparison to Medicare (MCR), which is determined by the federal government and invariable across the United States. This mismatch in reimbursement has previously been described as a component of the disparity in access to care in orthopaedics. While this variation has been previously quantified for general orthopaedics and orthopaedic hand surgery, no such analysis has been performed for orthopaedic trauma. This study aims to quantify the variation in MCD and MCR reimbursement for common orthopaedic trauma procedures.&#x0D; DESIGN: Billing data obtained from a Level I trauma center were retrospectively reviewed and the ten most commonly billed Current Procedural Terminology (CPT) codes were extracted. State and federal physician fee schedules were collected and assessed to determine MCD- and MCR-specific reimbursement rates, or relative value units (RVUs), for these ten procedures. An economic analysis was then conducted to evaluate the disparities between MCD and MCR reimbursement.&#x0D; MAIN OUTCOME MEASURES: MCD and MCR RVUs for each procedure were compared using dollar difference and coefficient of variation (CV).&#x0D; RESULTS: Our analysis showed considerable variance in MCD reimbursement rates between states. Additionally, we found that the majority of RVUs for MCD were higher than MCR for the evaluated trauma procedures.&#x0D; CONCLUSION: The variance in MCD reimbursement values may be driven by differences in the underlying characteristics of each systems’ patient population. This variance, particularly in bordering states, could represent a barrier to healthcare access for some populations.

Attitudes and Practices Surrounding Opioid Prescriptions following Open Reduction Internal Fixation of Distal Radius and Ankle Fractures: A Survey of the Canadian Orthopaedic Association Membership.

The past two decades have seen a significant increase in consequences associated with nonmedical misuse of prescription opioids, such as addiction and unintentional overdose deaths. This study aimed to use an electronic survey to assess attitudes and opioid-prescribing practices of Canadian orthopaedic surgeons and trainees following open reduction internal fixation (ORIF) of distal radius and ankle fractures. This study was the first to assess these factors following ORIF of distal radius and ankle fractures using a survey design. A 40-item survey was developed focusing on four themes: respondent demographics, opioid-prescribing practice, patients with substance use disorders, and drug diversion. The survey was distributed among members of the Canadian Orthopaedic Association. Descriptive statistics were used to summarize respondent demographics and outcomes of interest. A Chi-square test was used to determine if proportion of opioid prescriptions between attending surgeons and surgeons in training was equal. 191 surveys were completed. Most respondents prescribed 10-40 tabs of immediate-release opioids, though this number varied considerably. While most respondents believed patients consumed only 40-80% of the prescribed opioids (73.6%), only 28.7% of respondents counselled patients on safe storage/disposal of leftover opioids. 30.5% of respondents felt confident in their knowledge of opioid use and mechanisms of addiction. Most respondents desired further education on topics such as procedure-based opioid-prescribing protocols (74.2%), alternative pain management strategies (69.7%), and mechanisms of opioid addiction (49.0%). The principle finding of this study is the lack of a standardized approach to postoperative prescribing in distal radius and ankle fractures, illustrated by the wide range in number of opioids prescribed by Canadian orthopaedic surgeons. Our data suggest a trend towards overprescription among respondents following distal radius and ankle ORIF. Future studies should aim to rationalize interventions targeted at reducing postoperative opioid prescribing for common orthopaedic trauma procedures.

Comparisons of Procedures Performed in Training vs in Early Practice by Orthopaedic Trauma Surgeons.

The Orthopaedic Trauma Association (OTA) has maintained an accreditation process of orthopaedic trauma fellowships with various requirements including an annually reviewed list of qualifying trauma cases in the form of American Medical Association Current Procedural Terminology (CPT) codes. The correlation between these established and monitored CPTs and the actual practices of orthopaedic trauma surgeons has not been studied. American Board of Orthopaedic Surgery part II case logs (trauma subspecialty) (2012 to 2018) were compared with OTA fellowship case logs (2015 to 2019). Case logs from 447 surgeons and 166 trauma fellowship programs were compared. Four CPT code categories were defined: complex trauma (OTA required CPT codes, excluding Accreditation Council for Graduate Medical Education [ACGME] orthopaedic residency requirements), general trauma (ACGME residency required trauma codes), general orthopaedics (nontrauma ACGME residency requirements), and others (codes not included in residency or trauma fellowship requirements). OTA fellows performed a higher median percentage of complex trauma compared with American Board of Orthopaedic Surgery candidates (34% vs. 21%, P < 0.001): Both cohorts performed a similar percentage of general trauma (23%). OTA fellows performed more general orthopaedics (40% vs. 1%, P < 0.001). Several OTA required codes were performed infrequently (0 to 3 during board collection) by most surgeons, and several procedures are being performed that are not included in current CPT code requirements. Early-career traumatologists are performing orthopaedic trauma procedures they were trained on during residency and fellowship, with varying complexity. Trauma fellows perform a higher percentage of complex trauma compared with early-career trauma surgeons. Continued surveillance is necessary such that educational improvements can be made to maximize the quality of trauma fellowship education. Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The Routine Use of Running Subcuticular Closures in Orthopaedic Trauma Patients Does Not Increase Wound Complications.

To investigate if the routine use of running subcuticular closures (RSC) in orthopaedic trauma patients increases the rate of wound complications and reoperations. Retrospective comparative study. Urban level 1 trauma centerPatients/Participants: 266 patients undergoing orthopaedic trauma procedures between June 2020 and March 2022. Adoption of a RSC protocol where any incision/wound that could be approximated with interrupted subcuticular 2-0 monofilament sutures was instead closed with a running subcuticular 3-0 monofilament suture. Wound complications and subsequent reoperations. With adoption of the RSC protocol, 91.0% of all orthopaedic trauma procedures were closed with RSC compared to 7.5% of the historical control group. There were no observed differences in the rate of wound complications (proportional difference (PD) 6.0%, confidence interval (CI) -2.3 to 14.1%; p=0.15) or reoperations (PD 5.2%, CI -1.9 to 12.2%; p=0.14) between the RSC and the control group. Wound complications were not associated with RSC on univariate analysis (PD 7.2%, CI -10.0 to 24.0%; p=0.41). On multivariate analysis, an ASA>2 (odds ratio (OR) 2.4, CI 1.0 to 5.7; p=0.03), lower extremity injuries (OR 4.9, CI 1.3 to 17.8; p=0.01), and open reduction internal fixation procedures (OR 2.8, CI 1.1 to 7.2; p=0.02) were found to be independently associated with wound complications. RSC for orthopaedic trauma procedures was not associated with increased wound complications when compared to a historical cohort.

Application of Virtual Reality Systems in Bone Trauma Procedures.

Background and Objectives: Bone fractures contribute significantly to the global disease and disability burden and are associated with a high and escalating incidence and tremendous economic consequences. The increasingly challenging climate of orthopaedic training and practice re-echoes the established potential of leveraging computer-based reality technologies to support patient-specific simulations for procedural teaching and surgical precision. Unfortunately, despite the recognised potential of virtual reality technologies in orthopaedic surgery, its adoption and integration, particularly in fracture procedures, have lagged behind other surgical specialities. We aimed to review the available virtual reality systems adapted for orthopaedic trauma procedures. Materials and Methods: We performed an extensive literature search in Medline (PubMed), Science Direct, SpringerLink, and Google Scholar and presented a narrative synthesis of the state of the art on virtual reality systems for bone trauma procedures. Results: We categorised existing simulation modalities into those for fracture fixation techniques, drilling procedures, and prosthetic design and implantation and described the important technical features, as well as their clinical validity and applications. Conclusions: Over the past decade, an increasing number of high- and low-fidelity virtual reality systems for bone trauma procedures have been introduced, demonstrating important benefits with regard to improving procedural teaching and learning, preoperative planning and rehearsal, intraoperative precision and efficiency, and postoperative outcomes. However, further technical developments in line with industry benchmarks and metrics are needed in addition to more standardised and rigorous clinical validation.

A Dedicated Orthopaedic Trauma Room Improves Efficiency While Remaining Financially Net Positive.

To determine the impact of dedicated orthopaedic trauma room (DOTR) implementation on operating room efficiency and finances. Retrospective cost-analysis. Single midsized academic-affiliated community hospital in Toronto, Canada. All patients that underwent the most frequently performed orthopaedic trauma procedures (hip hemiarthroplasty, open reduction internal fixation of the ankle, femur, elbow and distal radius), over a 4-year period from 2016 to 2019 were included. Patient data acquired for 2 years before the implementation of a DOTR was compared with data acquired for a 2-year period after its implementation, adjusting for the number of cases performed. The primary outcome was surgical duration. The secondary outcome was financial impact, including after-hours costs incurred and opportunity cost of displaced elective surgeries. One thousand nine hundred sixty orthopaedic cases were examined pre- and post-DOTR. All procedures had reduced total operative time post-DOTR (mean improvement of 33.4%). The number of daytime operating hours increased 21%, whereas after-hours decreased by 37.8%. Overtime staffing costs were reduced by $24,976 alongside increase in opportunity costs of $22,500. This resulted in a net profit of $2476. Our results support the premise that DOTRs improve operating room efficiency and can be cost efficient. Our study also specifically addresses the hesitation regarding potential loss of profit from elective surgeries. Widespread implementation can improve patient care while still remaining financially favorable. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Viscoelastic Hemostatic Assays for Orthopedic Trauma and Elective Procedures.

The application of viscoelastic hemostatic assays (VHAs) (e.g., thromboelastography (TEG) and rotational thromboelastometry (ROTEM)) in orthopedics is in its relative infancy when compared with other surgical fields. Fortunately, several recent studies describe the emerging use of VHAs to quickly and reliably analyze the real-time coagulation and fibrinolytic status in both orthopedic trauma and elective orthopedic surgery. Trauma-induced coagulopathy—a spectrum of abnormal coagulation phenotypes including clotting factor depletion, inadequate thrombin generation, platelet dysfunction, and dysregulated fibrinolysis—remains a potentially fatal complication in severely injured and/or hemorrhaging patients whose timely diagnosis and management are aided by the use of VHAs. Furthermore, VHAs are an invaluable compliment to common coagulation tests by facilitating the detection of hypercoagulable states commonly associated with orthopedic injury and postoperative status. The use of VHAs to identify hypercoagulability allows for an accurate venous thromboembolism (VTE) risk assessment and monitoring of VTE prophylaxis. Until now, the data have been insufficient to permit an individualized approach with regard to dosing and duration for VTE thromboprophylaxis. By incorporating VHAs into routine practice, orthopedic surgeons will be better equipped to diagnose and treat the complete spectrum of coagulation abnormalities faced by orthopedic patients. This work serves as an educational primer and up-to-date review of the current literature on the use of VHAs in orthopedic surgery.

Infected or Not Infected? Next-Generation DNA Sequencing Is Not the Answer...Yet: Commentary on an article by Roman M. Natoli, MD, PhD, et al.: "Poor Agreement Between Next-Generation DNA Sequencing and Bacterial Cultures in Orthopaedic Trauma Procedures".

Commentary Infections of the musculoskeletal system continue to be a vexing challenge for orthopaedic surgeons. Postoperative infections, particularly those in cases in which implants are used for fixation or reconstruction, are common complications in orthopaedic surgery. Metallic implants serve as a nidus for the formation of biofilm, on which bacteria can survive, colonize, and hide from the immune system1. The presence of a biofilm prevents systemic antibiotics from effectively eradicating pathogenic bacteria, leading to high rates of reoperation in which the wounds undergo irrigation, debridement, and implant removal. The infection rates in orthopaedic trauma and arthroplasty cases have been reported to range from 1% to 30%2,3. The diagnosis of a surgical site infection, particularly indolent infection, can be challenging4. The clinical signs can be subtle, often without fever or obvious purulence. Systemic markers are not always reliable, and tissue and fluid bacterial cultures can lack sensitivity5-7. Often, the diagnosis of surgical site infection is made by the treating surgeon on the basis of radiographic findings of implant loosening or new radiolucencies at the bone-implant interface. However, these findings also can be found in cases of aseptic loosening. Therefore, there is a critical need for sensitive and specific assays to identify and characterize pathogenic bacteria in orthopaedic surgical wounds. Assays that can detect bacterial DNA through highly sensitive molecular biology techniques have the potential to improve diagnostic accuracy. Next-generation DNA sequencing (NGS) is under investigation as a tool to diagnose infection by identifying the presence of bacterial DNA (specifically, the gene for 16S ribosomal RNA) and characterizing the bacterial species through DNA sequencing8. The potential advantages of NGS include the ability to identify the presence of bacteria with use of a very small sample. In addition, such techniques do not require the varied culture environments needed to identify specific bacterial species. Point-of-care NGS analysis of musculoskeletal tissue and implant biofilm, if accurate, would be a major advance in orthopaedic care. Natoli et al. report on a prospective study in which patients undergoing “clean” orthopaedic trauma procedures (i.e., procedures for the treatment of closed fractures, hardware removal, or nonunion management) had intraoperative tissue sent for both bacterial culture and NGS. The authors found very little correlation between bacterial cultures and NGS results. Only 3 of 9 positive culture cases were also positive on NGS, with common species in only 2 of the 3. The vast majority of bacteria identified by NGS were either nonpathogenic bacteria or bacteria that are infrequently associated with clinical infection. The authors also found no correlation between the diagnostic assay results and the outcome of clinical infection. Two of 9 patients who had positive cultures developed a clinical infection, only 1 of 27 patients with a positive NGS finding developed an infection, and the NGS speciation in the latter case did not match the culture results of the clinical infection. It should be noted that the study was not designed to follow patients for clinical infection, and therefore some infections may have been missed. It is clear from the data by Natoli et al., as well as data from the shoulder arthroplasty literature9,10 and lower extremity arthroplasty literature11, that NGS should not be considered as a substitute for, or even a complement to, bacterial cultures in clean trauma cases. NGS is extremely sensitive and can identify bacteria that are generally innocuous and clinically unimportant or that present at sufficiently low levels so as to not result in clinical infection. These “false positive” results could lead to overtreatment and increased morbidity. Nevertheless, advances that can address the limitations of conventional bacterial culturing methods are desperately needed. Further work on developing molecular biology techniques that can detect and characterize specific pathogenic bacteria with greater sensitivity than cultures would allow for a more accurate approach12. In addition, NGS can be studied in cases of clinic infection to determine the agreement between culture results showing pathogenic bacteria and specific NGS findings for these pathogens. In the meantime, the study by Natoli et al. takes an important step toward improving our understanding of the clinical utility and the limitations of NGS in the diagnosis of surgical site infections, specifically in orthopaedic trauma surgery.

Poor Agreement Between Next-Generation DNA Sequencing and Bacterial Cultures in Orthopaedic Trauma Procedures.

Next-generation DNA sequencing (NGS) detects bacteria-specific DNA corresponding to the 16S ribosomal RNA gene and can identify bacterial presence with greater accuracy than traditional culture methods. The clinical relevance of these findings is unknown. The purpose of the present study was to compare the results from bacterial culture and NGS in order to characterize the potential use of NGS in orthopaedic trauma patients. A prospective cohort study was performed at a single academic, level-I trauma center. Three patient groups were enrolled: (1) patients undergoing surgical treatment of acute closed fractures (presumed to have no bacteria), (2) patients undergoing implant removal at the site of a healed fracture without infection, and (3) patients undergoing a first procedure for the treatment of a fracture nonunion who might or might not have subclinical infection. Surgical site tissue was sent for culture and NGS. The proportions of culture and NGS positivity were compared among the groups. The agreement between culture and NGS results was assessed with use of the Cohen kappa statistic. Bacterial cultures were positive in 9 of 111 surgical sites (110 patients), whereas NGS was positive in 27 of 111 surgical sites (110 patients). Significantly more cases were positive on NGS as compared with culture (24% vs. 8.1%; p = 0.001), primarily in the acute closed fracture group. No difference was found in terms of the percent positivity of NGS when comparing the acute closed fracture, implant removal, and nonunion groups. With respect to bacterial identification, culture and NGS agreed in 73% of cases (κ = 0.051; 95% confidence interval, -0.12 to 0.22) indicating only slight agreement compared with expected chance agreement of 50%. NGS identified bacterial presence more frequently than culture, but with only slight agreement between culture and NGS. It is possible that the increased frequency of bacterial detection with molecular methods is reflective of biofilm presence on metal or colonization with nonpathogenic bacteria, as culture methods have selection pressure posed by restrictive, artificial growth conditions and there are low metabolic activity and replication rates of bacteria in biofilms. Our data suggest that NGS should not currently substitute for or complement conventional culture in orthopaedic trauma cases with low suspicion of infection. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Are Orthopaedic Trauma Surgeons Adequately Compensated for Longer Procedures? An Analysis of Relative Value Units and Operative Times From the American College of Surgeons National Surgical Quality Improvement Program Database.

The physician work relative value unit (wRVU) scale is the primary determinant of compensation. Operative time, technical skill, effort, and surgical complexity contribute to wRVU allocation. The aim of this study was to identify the relationship between these factors and reimbursement for trauma procedures. The National Surgical Quality Improvement Program database was queried for orthopaedic trauma procedures from 2016 to 2018. Physician wRVU data were obtained from the 2020 Centers for Medicare & Medicaid Services fee schedule. The primary outcome measured was mean wRVU per minute of operative time (wRVU/min). Wilcoxon rank sum test and quantile regression were used to determine the association between wRVU, operative time, complication rate, upper or lower extremity procedure, and wRVU/min. Sixty-three current procedural terminology codes or 107,171 cases were queried. Median wRVU/min was significantly lower for longest 50% of procedures (0.119 vs. 0.160, P < 0.001) and higher for the top 50% with regard to complication rate (0.161 vs. 0.124, P < 0.001). Upper extremity procedures were reimbursed less than lower extremity (0.110 vs. 0.145, P < 0.001). Quintile regression showed that adjusted for complication rate, median wRVU/min decreased by 0.0005 (95% confidence interval: 0.0007-0.0003, R1 = 0.27, P < 0.001) for every additional minute of operative time. The 2020 wRVU scale does not allocate sufficient wRVUs to orthopaedic trauma procedures with longer mean operative time or to procedures performed on the upper extremity. There is a negative correlation between operative time and hourly reimbursement, equating to a decrease of $64.96/h per hour of operation.

Use of abbreviations in consent forms for orthopaedic surgery: A pilot study

BackgroundConsent is a process of communication and the consent form is an important legal document of the evidence of discussion between doctor and patients. We observed frequent use of abbreviations in the consent forms in our department that can result in misunderstanding and miscommunication when consenting patients for orthopaedic procedures. MethodsWe completed an audit cycle starting by reviewing a total of 350 consent forms retrospectively in level one trauma centres in October–November of 2019 for different orthopaedic trauma procedures. The standards for the project were guidelines published by the general medical council (GMC), The royal college of surgeons (RCS) Glasgow, and the British orthopaedic association (BOA).The results were presented at our mortality and morbidity meeting. Written Feedback was obtained from the attending members on how a change can be implemented to increase ccompliance in filling consent forms. A generic email was sent to all medical professionals to avoid the use of abbreviations on the document and encourage colleagues to point out errors if they spot them. The use of full medical terms and to avoid abbreviations in consent form was well advertised, The re-audit was performed for the period of January & February 2020 that included 400 consent forms. The results were analysed and compared with our original audit results. ResultsThe use of abbreviations declined from 54% in first audit to 22% in the re-audit. DVT and PE were the most common abbreviations. ConclusionThis audit cycle has shown the importance of education and reminders to the health professionals in achieving better adherence to the guidelines and improves patient care.

764 Is Consent Valid in Common Orthopaedic Surgeries?

Abstract Aim Consent is at the heart of the doctor-patient relationship. Valid consent should be voluntary, informed and the patient must have the capacity to make the decision. It is the doctor’s responsibility to ensure the patient can make an informed decision. The aim of this audit is to assess the validity of consent within Salford Royal Foundation Trust Orthopaedic department. Method We retrospectively reviewed 225 consent forms for four common orthopaedic trauma procedures: 44 wrist ORIF, 48 ankle fixation, 71 hip hemiarthroplasty and 62 fixations with DHS. BOA-endorsed OrthoConsent and SRFT-produced leaflets were utilised as a standard for reported surgical risks and complications. Collated patient consents were compared against these standards. Exclusion criteria included consent four and polytrauma patients. Results 96 forms were excluded leaving 129 consent forms. In all four procedures, 86%-100% had documented infection, nerve injury and bleeding. Compartment syndrome was not documented for any wrist ORIF patients. CRPS was recorded in only 57% of wrist and 31% of ankle ORIF patients. Wound healing complications was documented in 17% of ankle ORIF. In 71% of DHS and 64% of hemiarthroplasty patients, risk of death was not recorded. Conclusions Targets for achieving satisfactory consent form documentation were not met and showed significant variation amongst clinicians. It suggests that patients are not being fully informed of benefits and risks of surgery. Recommendations include the introduction of posters and encouraging printing off patient information leaflets and improving education on valid consent for rotational doctors.

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

A Dedicated Orthopaedic Trauma Room Increases Operating Room Throughput without Increasing After-Hours Minutes

BackgroundThe scheduling and execution of both elective and urgent orthopaedic cases prove challenging for many hospital systems. In this study, we examine the operational and cost efficiency of creating a dedicated orthopaedic trauma (DOTOR) block using operating room management data as a surrogate for financial analyses and decision-making. MethodsUsing WiseOR® (Palo Alto, CA), we extracted the total number of cases, after-hours minutes, opportunity-unused time, and in-block time for the orthopaedic trauma service (OTS) and the dedicated orthopaedic trauma room for the nine months prior to our reallocation of block time (December 2015 – August 2016) and the twenty months after this change (October 2016 – May 2018). Unused elective time was either released to the OR or used to accommodate additional trauma cases. We defined after-hours minutes as the time utilized after 1730 Monday through Friday; opportunity-unused minutes as the time within a block allocation in which a service could have adequately performed another case; and in-block as the time in which a service actively used a block allocation. For each month, we analyzed the data for the orthopaedic traumatologists individually (A, B, C) and for the OTS collectively. Before- and after-implementation data were compared using a two-tailed Student t-test (α=0.05). We calculated the total length of after-hours minutes, in-block time, and caseload for each month spanning from December 2015 to May 2018.1 Pareto optimality was graphically represented using GraphPad Prism (v7.01 La Jolla, CA). ResultsOf 1485 orthopaedic procedures analyzed, 382 occurred before the implementation of the dedicated orthopaedic trauma room, and 1103 cases were performed after the implementation. There was a significant increase in total case volume per month for the surgeons (A & B) who were assigned the additional blocks (32.2 vs 45.4 cases per month, p = 0.0001). There was no significant difference in the total case volume performed by the surgeon (C) whose operating schedule had not changed (10.2 vs. 9.8 cases per month, p = 0.804). There was no significant difference in after-hours minutes per month by the two affected orthopaedic traumatologists (A&B) (1030 min vs. 1180 min, p = 0.452) or by the unaffected traumatologist (C) (8.3 min vs. 16.5 min, p = 0.455). There was no significant difference in opportunity-unused minutes after establishing a DOTOR (2542 min. vs. 2895 min., p = 0.4212). Pareto efficiency for OTS opportunity unused time and after hours minutes per block qualitatively improved (Figure 1). Pareto cost efficiency for after hours minutes qualitatively improved (Figure 2). There was no significant difference in monthly associated after-hours costs ($41,752 vs. $51,722, p = 0.2510). ConclusionsIn this study, we demonstrate that a shift towards the DOTOR system can increase OR efficiency by increasing OR throughput without increasing after-hours minutes. This tactical allocation permitted the orthopaedic traumatologists to meet an increasing need for orthopaedic trauma procedures, both semi-elective and urgent, from a growing health network. Furthermore, with the increase in OR availability, the orthopaedic traumatologists were able to offload a small percentage of cases from our general orthopaedic surgeons, shifting add-on cases performed after-hours to scheduled cases performed by a more efficient team.

Orthopedic Trauma Surgeries in COVID-19 Pandemic; A Trauma Management Algorithm.

After the COVID-19 outbreak worldwide, we will sooner or later encounter trauma patients with COVID-19 in the developing countries. It is a challenging decision-making process for an orthopedic surgeon to provide the patients with the best practice in the crisis. Here we discuss the issue in terms of clinical severity of COVID-19 pneumonia, priority of orthopedic surgical trauma procedures and standard of care for the treatment of trauma injuries. We finally propose an algorithm for better management of trauma patients in the setting of COVID-19 mass spread.

Teaching in the operating room: A risk for surgical site infections?

Background/aimTo investigate whether teaching procedures and surgical experience are associated with surgical site infection (SSI) rates. MethodsThis prospective cohort study of patients undergoing general, orthopedic trauma and vascular surgery procedures was done between 2012 and 2015 at two tertiary care hospitals in Switzerland/Europe. ResultsOut of a total of 4560 patients/surgeries, 1403 (30.8%) were classified as teaching operations. The overall SSI rate was 5.1% (n = 233). Teaching operations (OR 0.78, 95% CI 0.57–1.07, p = 0.120), junior surgeons (OR 0.80, 95% CI 0.55–1.15, p = 0.229) and surgical experience (OR 0.997, 95% CI 0.982–1.012, p = 0.676) were overall not independently associated with the odds of SSI. However, for surgeons’ seniority and experience, these associations depended on the duration of surgery. ConclusionsIn procedures of shorter and medium duration, teaching procedures and junior as well as less experienced surgeons are not independently associated with increased odds of SSI.

Healthcare disparities among orthopedic trauma patients in the USA: socio-demographic factors influence the management of calcaneus fractures

BackgroundSocio-demographic factors have been suggested to contribute to differences in healthcare utilization for several elective orthopedic procedures. Reports on disparities in utilization of orthopedic trauma procedures remain limited. The purpose of our study is to assess the roles of clinical and socio-demographic variables in utilization of operative fixation of calcaneus fractures in the USA.MethodsThe National Inpatient Sample (NIS) dataset was used to analyze all patients from 2005 to 2014 with closed calcaneal fractures. Multivariate logistic regression analyses were performed to evaluate the impact of clinical and socio-demographic variables on the utilization of surgical versus non-surgical treatment.ResultsA total of 17,156 patients with closed calcaneus fractures were identified. Operative treatment was rendered in 7039 patients (41.03%). A multivariate logistic regression demonstrated multiple clinical and socio-demographic factors to significantly influence the utilization of surgical treatment including age, gender, insurance status, race/ethnicity, income, diabetes, peripheral vascular disease, psychosis, drug abuse, and alcohol abuse (p < 0.05). In addition, hospital size and hospital type (teaching versus non-teaching) showed a statistically significant difference (p < 0.05).ConclusionsBesides different clinical variables, we identified several socio-demographic factors influencing the utilization of surgical treatment of calcaneus fractures in the US patient population. Further studies need to identify the specific patient-related, provider-related, and system-related factors leading to these disparities.