Traumatic Orthopedic Injuries Research Articles

Malpractice Litigation Following Traumatic Fracture.

Poor clinical outcomes and adverse events following orthopaedic trauma are common, which may lead to litigation. To our knowledge, factors associated with litigation following fracture care have not previously been evaluated. A retrospective review of fracture-related malpractice lawsuits from 1988 to 2015 was completed utilizing VerdictSearch (ALM Media Properties), a medicolegal database. Defendant and plaintiff characteristics along with fracture type, allegations, litigation outcomes, and the association of case characteristics with outcomes were analyzed. A total of 561 cases were evaluated; 360 cases were excluded, resulting in a total of 201 cases that were analyzed in detail. The mean age of the plaintiff was 43.1 years (standard deviation [SD],19.4 years). Twenty-four fracture types were represented among the analyzed cases. The most common fractures were of the radius (44), the femur (32), the tibia (30), the ulna (29), the humerus (26), the spine (24), the hip (17), and the fibula (15). Overall, 129 (64.2%) cases resulted in a defense verdict, 41 (20.4%) cases resulted in a plaintiff verdict, and 31 (15.4%) cases resulted in a settlement. For plaintiff verdicts, the mean indemnity payment was $3,778,657 (median, $753,057; range, $89,943 to $27,926,311). For settlements, the mean indemnity payment was $1,097,439 (median, $547,935; range, $103,541 to $9,445,113). The mean indemnity for plaintiff verdicts was significantly greater than the mean indemnity for settlements (p = 0.03). The presence of a neurological deficit was associated with a significantly greater likelihood of a favorable outcome for the plaintiff (52.8% for plaintiffs with neurological deficit versus 32.1% for plaintiffs without neurological deficit; p = 0.019). This study examined malpractice litigation following traumatic orthopaedic injuries. In cases with decisions for the plaintiff, indemnity payments were on average more than $2.5 million larger than payments for settlements. In fracture cases with neurological deficit, malpractice cases were more likely to result in a favorable outcome for the plaintiff.

Risk of Posttraumatic Stress Disorder and Major Depression in Civilian Patients After Mild Traumatic Brain Injury

Traumatic brain injury (TBI) has been associated with adverse mental health outcomes, such as posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), but little is known about factors that modify risk for these psychiatric sequelae, particularly in the civilian sector. To ascertain prevalence of and risk factors for PTSD and MDD among patients evaluated in the emergency department for mild TBI (mTBI). Prospective longitudinal cohort study (February 2014 to May 2018). Posttraumatic stress disorder and MDD symptoms were assessed using the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9 Item. Risk factors evaluated included preinjury and injury characteristics. Propensity score weights-adjusted multivariable logistic regression models were performed to assess associations with PTSD and MDD. A total of 1155 patients with mTBI (Glasgow Coma Scale score, 13-15) and 230 patients with nonhead orthopedic trauma injuries 17 years and older seen in 11 US hospitals with level 1 trauma centers were included in this study. Probable PTSD (PTSD Checklist for DSM-5 score, ≥33) and MDD (Patient Health Questionnaire-9 Item score, ≥15) at 3, 6, and 12 months postinjury. Participants were 1155 patients (752 men [65.1%]; mean [SD] age, 40.5 [17.2] years) with mTBI and 230 patients (155 men [67.4%]; mean [SD] age, 40.4 [15.6] years) with nonhead orthopedic trauma injuries. Weights-adjusted prevalence of PTSD and/or MDD in the mTBI vs orthopedic trauma comparison groups at 3 months was 20.0% (SE, 1.4%) vs 8.7% (SE, 2.2%) (P < .001) and at 6 months was 21.2% (SE, 1.5%) vs 12.1% (SE, 3.2%) (P = .03). Risk factors for probable PTSD at 6 months after mTBI included less education (adjusted odds ratio, 0.89; 95% CI, 0.82-0.97 per year), being black (adjusted odds ratio, 5.11; 95% CI, 2.89-9.05), self-reported psychiatric history (adjusted odds ratio, 3.57; 95% CI, 2.09-6.09), and injury resulting from assault or other violence (adjusted odds ratio, 3.43; 95% CI, 1.56-7.54). Risk factors for probable MDD after mTBI were similar with the exception that cause of injury was not associated with increased risk. After mTBI, some individuals, on the basis of education, race/ethnicity, history of mental health problems, and cause of injury were at substantially increased risk of PTSD and/or MDD. These findings should influence recognition of at-risk individuals and inform efforts at surveillance, follow-up, and intervention.

Beyond Jeannerod's motor simulation theory: An approach for improving post-traumatic motor rehabilitation

This paper depicts an approach aiming to allow individuals with orthopedic trauma injuries to optimize recovery and safely return to daily life. The core of this approach is motor simulation, used in complement to conventional physical rehabilitation methods. This paper provides recent scientific insights on the basis of motor simulation, discusses benefits of this approach in motor rehabilitation, and provides applied perspectives.

Investigation of the Association Between the Acute Ankle Injury Caused by Fall From Own Height and Body Mass Index

In the emergency settings, increased body mass index (BMI) is a risk factor for traumatic orthopedic injuries. The aim of this study was to assess the association between the acute ankle injuries (sprain or fracture) and BMI. This prospective cohort study included patients ≥18 years of age with acute traumatic ankle injuries (either sprain or fracture) caused by fall from own height when walking at ground level and who received primary treatment at the emergency room of a university hospital between May and October 2017. Of the 107 patients who met the inclusion criteria, 58 (54%) patients experienced acute ankle sprains and 49 (46%) experienced acute ankle fractures. No significant association was detected between fracture severity (as assessed by the Danis-Weber classification) and BMI (p = .860). The most frequent ankle injury in patients with normal BMI was ankle sprain. In our cohort, obesity was not the primary determinant of the severity of ankle injury. However, age was a key determinant of the type of injury; patients >30 years of age were 20% more likely to suffer an ankle fracture.

Relationship between traumatic orthopedic injuries and attention deficit hyperactivity disorder symptoms in children

Relationship between traumatic orthopedic injuries and attention deficit hyperactivity disorder symptoms in children

Sleep Disturbance in Orthopaedic Trauma Patients.

To evaluate the prevalence and severity of sleep disturbance experienced by patients who have sustained a traumatic orthopaedic injury, how sleep disturbance affects the patient's perceived health quality, and identify factors associated with sleep disturbance. Cross-sectional cohort study. Urban Level I trauma center. Three hundred thirty-five nonconsecutive patients who presented to clinic at various stages of treatment for their traumatic orthopaedic injuries. Pittsburgh sleep quality index (PSQI) and 36-item short form-36 (SF-36) survey questionnaires; injury severity score (ISS). The average PSQI score was 10.3 (±4.8). Two hundred eighty-eight (86.0%) patients had a PSQI score ≥5, indicating the presence of sleep disturbance. The PSQI score was ≥10 in 183 (54.6%) patients, which is sleep disturbance similar to the level seen in clinical depression. Patients reported an average sleep latency of 38.9 (±37.5) minutes, with a total nightly sleep time of 6.3 (±1.9) hours. Univariate statistical analysis demonstrated that age, time since injury, and all components of the SF-36 were significantly associated with increased PSQI scores. When these variables were assessed with multivariate analysis to control for confounding variables, the bodily pain, vitality, and mental health components of the SF-36 remained independently associated with PSQI (P ≤ 0.001, 0.002, and 0.001, respectively). ISS measurements at the time of presentation were not associated with PSQI scores. Our findings suggest that sleep disturbance is both highly prevalent (86% PSQI ≥5) and severe (54.6% PSQI ≥10) in patients recovering from a traumatic orthopaedic injury. The bodily pain, vitality, and mental health components of the SF-36 were independently associated with worse sleep quality. The average orthopaedic trauma patient presents with a sleep score similar to that seen in clinical sleep disorders and clinical depression. Interestingly, in our study, the severity of the overall injury burden as measured by ISS and time since injury were not independently associated with the severity of sleep disturbance, as one might expect. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Role of North-South Partnership in Trauma Management: Uganda Sustainable Trauma Orthopaedic Program.

Uganda, as do many low-middle income countries, has an overwhelming volume of orthopaedic trauma injuries. The Uganda Sustainable Trauma Orthopaedic Program (USTOP) is a partnership between the University of British Columbia, McMaster University and Makerere University that was initiated in 2007. The goal of the project is to reduce the disabilities that occur secondary to musculoskeletal trauma in Uganda. USTOP works with local collaborators to build orthopaedic trauma capacity through teaching, innovation, and research. USTOP has maintained a multidisciplinary approach to training, involving colleagues in anesthesia, nursing, rehabilitation, and sterile reprocessing. The project was initiated at the invitation of the Department of Orthopaedics at Makerere University and Mulago Hospital in Kampala. The project is a collaboration between Canadian and Ugandan orthopaedic surgeons and is driven by the needs identified by the Ugandan surgeons. The program has also worked with collaborators to develop several technologies aimed at reducing the cost of providing orthopaedic care without compromising quality. As orthopaedic trauma capacity in Uganda advances, USTOP strives to continually evolve and provide relevant support to colleagues in Uganda to ensure that changes result in sustainable improvements in patient care.

Frailty predicts mortality and complications in chronologically young patients with traumatic orthopaedic injuries

BackgroundAs morbidity and mortality from traumatic orthopaedic injuries continues to rise, increased research is being conducted on how to best predict complications in at risk patients. Recently, frailty indices have been validated in a variety of surgical subspecialties as predictors of morbidity and mortality. However, the vast majority of research has been conducted on geriatric patient populations, with little evidence on patients who are chronologically young. The purpose of this study was to evaluate the role of a modified frailty index (mFI) in predicting mortality and complications after pelvis, acetabulum, and lower extremity trauma in patients of all ages. MethodsThe American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2014 for all patients who underwent surgery for pelvis, acetabulum, and lower extremity trauma. The sample size was divided into geriatric (age ≥ 60) and young (age < 60) cohorts. The mFI score was calculated for each patient. Bivariate analysis was performed using logistic regression and a chi-square test to determine the relationship between mFI and both primary and secondary outcomes while adjusting for age. Univariate analysis and multivariate analyses were performed. All analyses were done using SAS 9.4 (Cary, NC) and a p < 0.05 was considered significant. Results56,241 patients were identified to have undergone surgery for pelvis, acetabulum, or lower extremity trauma. 28% of patients were identified under the age of 60. In the young cohort, mFI was a strong predictor of thirty-day mortality (OR 11.02, 95% CI 6.26–19.39, p < 0.001). With regards to Clavien-Dindo grade IV complications, MFI is also a strong predictor in the young cohort (OR 28.82, 95% CI 16.05–51.77, p < 0.001). Conclusion and relevanceThe mFI score was a significant predictor of morbidity and mortality in chronologically young orthopaedic trauma patients. The use of the mFI score can provide an individualized risk assessment to interdisciplinary teams for perioperative counseling and to improve outcomes.

Orthopedic Knowledge and Need in the Provincial Philippines: Pilot Study of a Population-Based Survey.

Two independent surveys were conducted of households and mid-level providers who represent the first contact of care. The goal of the survey was to describe the local health care system, to identify barriers to care, and to assess gaps in knowledge for acute traumatic orthopedic injuries. Both surveys were conducted in June of 2015.Population proportional sampling assessed a total of 100 households from 25 local Barangay communities. Questions focused on existing knowledge of acute traumatic orthopedic injuries and barriers to care.The mid-level provider survey focused on knowledge and barriers to care regarding acute traumatic orthopedic injuries. A total of 10 school nurses and Barangay midwives representing 25 local Barangay were surveyed. In the household population survey, 84% of respondents reported cost was either always or sometimes a barrier to care; 73% cited transportation as a barrier to care. A total of 68% of respondents reported that they would seek care at the provincial hospital for a suspected broken bone; 28% percent of respondents did not believe broken bones making an arm or leg crooked could be corrected without surgery. Only 55% percent believed care should be sought within six hours of injury, and 37% stated that more than three days after an injury was an appropriate timeframe to seek care.Of the mid-level providers surveyed, 90% reported that they would refer possible broken bones to a higher level of care. Aggregate ranking of barriers to care from greatest to least were: cost, transportation, knowledge of time sensitive nature of treatment, religious beliefs, and other (not specified). In all, 100% reported that an education initiative regarding acute orthopedic injuries would increase the number of patients seeking care within 12 hours. The survey describes perceived barriers to care and gaps in knowledge for acute orthopedic injuries. With some modification, this survey tool could be expanded and utilized on a regional or national level to assess gaps in knowledge and barriers to acute orthopedic care. CourtneyCS, KirschTD. Orthopedic knowledge and need in the Provincial Philippines: pilot study of a population-based survey. Prehosp Disaster Med. 2018;33(3):293-298.

Current therapies in treatment and prevention of fracture wound biofilms: why a multifaceted approach is essential for resolving persistent infections.

Traumatic orthopedic injuries, particularly extremity wounds, are a significant cause of morbidity. Despite prophylactic antibiotic treatment and surgical intervention, persistent infectious complications can and do occur. Persistent bacterial infections are often caused by biofilms, communities of antibiotic tolerant bacteria encased within a matrix. The structural and metabolic differences in this mode of growth make treatment difficult. Herein, we describe both established and novel, experimental treatments targeted at various stages of wound healing that are specifically aimed at reducing and eliminating biofilm bacteria. Importantly, the highly tolerant nature of these bacterial communities suggests that most singular approaches could be circumvented and a multifaceted, combinatorial approach will be the most effective strategy for treating these complicated infections.

Pre-injury depression and anxiety in patients with orthopedic trauma and their treatment

PurposeDepressive symptoms have a known negative impact on outcomes following musculoskeletal injury. This study determined the pre-injury prevalence of psychiatric diagnoses of depression and anxiety, medication lapses and psychiatric consult services among patients admitted for orthopaedic trauma. MethodsThis is a retrospective study of data from our Level-1 trauma center. Patients admitted to the orthopaedic trauma service during 2010–2015 were included (N = 4053). Demographics, Injury Severity Scores (ISS), mental health diagnoses, psychotropic medications, medication type and delay, psychiatric consultation use, intensive care unit (ICU) stay and total hospital length of stay (LOS) were abstracted from medical records and the institutional trauma registry. ResultsThe 12-month prevalence of a major depressive episode is 6.6%–8.6% in adults in the United States. In our database, only 152/4053 (3.8%) of the patients had documented medical history of depression (80%) or anxiety (30%), and these patients had a 32% longer LOS (p < 0.016). Nearly two-thirds of patients who used psychotropic medications prior to injury experienced a delay in receiving these medications in the hospital (median = 1.0 day, range 0–14 days). Sixteen percent of patients also received a new psychotropic medication while hospitalized: an antipsychotic (8/16 patients, to treat delirium), an anxiolytic (3/16 patients for acute anxiety), or an antidepressant (1/16). Among patients with depression or anxiety, 16.7% received a psychiatric consult. Patients with psychiatric consults had higher ISS, were more likely to have longer ICU LOS and had longer hospital LOS than those without consults (all p < 0.05). ConclusionThe prevalence of depression and anxiety is grossly under-reported in our registry compared to national prevalence data. Patients with pre-existing disease had longer LOS and a higher rate of extended ICU care. Further studies are needed to characterize the true prevalence of disease in this patient population and its effect on patient outcomes after traumatic orthopaedic injury.

An integrated-delivery-of-care approach to improve patient reported physical function and mental wellbeing after orthopedic trauma: study protocol for a randomized controlled trial

BackgroundOrthopedic trauma injury impacts nearly 2.8 million people each year. Despite surgical improvements and excellent survivorship rates, many patients experience poor quality of life (QOL) outcomes years later. Psychological distress commonly occurs after injury. Distressed patients more frequently experience rehospitalizations, pain medication dependence, and low QOL. This study was developed to test whether an integrative care approach (IntCare; ten-step program of emotional support, education, customized resources, and medical care) was superior to usual care (UsCare). The primary aim was to assess patient functional QOL (objective and patient-reported outcomes) with secondary objectives encompassing emotional wellbeing and hospital outcomes. The primary outcome was the Lower Extremity Gain Scale score.Methods/designA single-blinded, single-center, repeated measures, randomized controlled study is being conducted with 112 orthopedic trauma patients aged 18–85 years. Patients randomized to the IntCare group have completed or are receiving a guided ten-step support program during acute care and at follow-up outpatient visits. The UsCare group is being provided the standard of care. Patient-reported outcomes and objective functional measures are collected at the hospital and at weeks 2, 6, and 12 and months 6 and 12 post surgery. The main study outcomes are changes in Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires of Physical Function quality of life, Satisfaction with Social Roles, and Positive-Illness Impact, Post-Traumatic Stress Disorder Check List, and the Tampa Scale of Kinesiophobia-11 from baseline to month 12. Secondary outcomes are changes in objective functional measures of the Lower Extremity Gain Scale, handgrip strength, and range of motion of major joints from week 2 to month 12 post surgery. Clinical outcomes include hospital length of stay, medical complications, rehospitalizations, psychological measures, and use of pain medications. A mixed model repeated measures approach assesses the main effects of treatment and time on outcomes, as well as their interaction (treatment × time).DiscussionThe results from this study will help determine whether an integrative care approach during recovery from traumatic orthopedic injury can improve the patient perceptions of physical function and emotional wellbeing compared to usual trauma care. Additionally, this study will assess the ability to reduce the incidence or severity of psychological distress and mitigate medical complications, readmissions, and reduction of QOL after injury.Trial registrationClinicalTrials.gov, NCT02591472. Registered on 28 October 2015.

Epidemiology of traumatic orthopaedic injuries at Princess Marina Hospital, Botswana

Background: Traumatic injuries pose a significant and increasing challenge to healthcare systems worldwide. One major type of traumatic injury is the traumatic orthopaedic injury, whose epidemiology is unknown in Botswana. The aim of the study, therefore, was to evaluate the age, sex, type, and determinants of traumatic orthopaedic injuries for inpatients at Princess Marina Hospital from August 2014 to January 2015.Methods: We performed a descriptive study by retrospectively collecting data on age, sex, date of admission, date of injury, date of discharge, radiological investigation, and injury types and determinants from medical records of patients admitted to orthopaedic wards.Results: The median age of patients with traumatic orthopaedic injuries was 33.5 years (n=372). Males were more frequently injured than females, with a sex ratio of 7:3. Fractures were the most common type of traumatic orthopaedic injury (413 injuries, 75.5%). The most common injury determinants were falls (145 patients/39.0%), road traffic accidents (95 patients/25.5%), and assaults (57 patients/15.3%).Conclusions: Young adult males were the group most affected by traumatic orthopaedic injuries. Fractures were the most common type of traumatic orthopaedic injuries, with falls being the most common injury determinant. These findings may guide efforts to improve healthcare delivery and public health policy.Level of evidence: Level 4

Blood Flow Restriction Therapy after Non-Operative Management of Distal Radius Fracture: A Randomized Controlled Pilot Study

Distal radius fracture is one of the most commonly sustained traumatic orthopedic injuries in the United States. Often, rehabilitation can be slow and returning to a normal level of function can be difficult. Recovery can be complicated by post-fracture restrictions on the amount of resistance that can safely be applied through the affected joint or across the fracture. Blood flow restriction (BFR) therapy uses low load resistance exercises, typically 20-30% of a one repetition max (1RM) during a brief and partial restriction of venous outflow from an extremity. This brief period of venous occlusion creates an anerobic environment, thereby inducing localized cellular and hormonal changes which stimulate muscle hypertrophy. Our hypothesis was that low intensity upper extremity training with occlusion of venous blood flow will be safe, well-tolerated, and enhance recovery of hand strength compared to standard rehabilitation in patients with non-operatively treated distal radius fractures.

Access to Follow up Care for Traumatic Orthopaedic Injuries for Rural Children in Northern California

Access to Follow up Care for Traumatic Orthopaedic Injuries for Rural Children in Northern California

Preexisting psychiatric illness worsens acute care outcomes after orthopaedic trauma in obese patients

PurposePre-existing psychiatric illness, illicit drug use, and alcohol abuse adversely impact patients with orthopaedic trauma injuries. Obesity is an independent factor associated with poorer clinical outcomes and discharge disposition, and higher hospital resource use. It is not known whether interactions exist between pre-existing illness, illicit drug use and obesity on acute trauma care outcomes. Patients and methodsThis cohort study is from orthopaedic trauma patients prospectively measured over 10 years (N = 6353). Psychiatric illness, illicit drug use and alcohol were classified by presence or absence. Body mass index (BMI) was analyzed as both a continuous and categorical measure (<30 kg/m2 [non-obese], 30–39.9 kg/m2 [obese] and ≥40 kg/m2 [morbidly obese]). Main outcomes were the number of acute care services provided, length of stay (LOS), discharge home, hospital readmissions, and mortality in the hospital. ResultsStatistically significant BMI by pre-existing condition (psychiatric illness, illicit drug use) interactions existed for LOS and number of acute care services provided (β values 0.012–0.098; all p < 0.05). The interaction between BMI and psychiatric illness was statistically significant for discharge to locations other than home (β = 0.023; p = 0.001). DiscussionObese patients with orthopaedic trauma, particularly with preexisting mental health conditions, will require more hospital resources and longer care than patients without psychiatric illness. Early identification of these patients through screening for psychiatric illness and history of illicit drug use at admission is imperative to mobilize the resources and provide psychosocial support to facilitate the recovery trajectory of affected obese patients.

Economic Burden of Inpatient Admission of Ankle Fractures.

Ankle fractures are among the most prevalent traumatic orthopaedic injuries. A large proportion of patients sustaining operative ankle fractures are admitted directly from the emergency department prior to operative management. In the authors' experience, however, many closed ankle injuries may be safely and effectively managed on an outpatient basis. The aim of this study was to characterize the economic impact of routine inpatient admission of ankle fractures. A retrospective review of all outpatient ankle fracture surgery performed by a single foot and ankle fellowship-trained surgeon at a tertiary level academic center in 2012 was conducted to identify any patients requiring postoperative inpatient admission. The National Inpatient Sample was queried for operative management of lateral malleolus, bimalleolar, and trimalleolar ankle fractures in 2012 with regard to national estimates of total volume and length of stay by age. The maximum allowable Medicare inpatient facility reimbursements for diagnosis related group 494 and Medicare outpatient facility reimbursements for Current Procedural Terminology codes 27792, 27814, and 27822 were obtained from the Medicare Acute Inpatient Prospective Pricer and the Medicare Outpatient Pricer Code, respectively. Private facility reimbursement rates were estimated at 139% of inpatient Medicare reimbursement and 280% of outpatient reimbursement, as described in the literature. Surgeon and anesthesiologist fees were considered similar between both inpatient and outpatient groups. A unique stochastic decision-tree model was derived from probabilities and associated costs and evaluated using modified Monte Carlo simulation. Of 76 lateral malleolar, bimalleolar, and trimalleolar ankle fracture open reduction internal fixation cases performed in 2012 by the senior author, 9 patients required admission for polytrauma, medical comorbidities, or age. All 67 outpatients were discharged home the day of surgery. In the 2012 national cohort analyzed, 48,044 estimated inpatient admissions occurred postoperatively for closed ankle fractures. The median length of stay was 3 days for each admission and was associated with an estimated facility reimbursement ranging from $12,920 for Medicare reimbursement of lateral malleolus fractures to $18,613 for private reimbursement of trimalleolar fractures. Outpatient facility reimbursements per case were estimated at $4,125 for Medicare patients and $11,459 for private insurance patients. Nationally, annual inpatient admissions accounted for $796,033,050 in reimbursements, while outpatient surgery would have been associated with $419,327,612 for treatment of these same ankle fractures. In the authors' experience, closed lateral malleolus, bimalleolar, and trimalleolar fractures were safely and effectively treated on an outpatient basis. Routine perioperative admission of patients sustaining ankle fractures likely results in more than $367 million of excess facility reimbursements annually in the United States. Even if a 25% necessary admission rate were assumed, routine inpatient admission of ankle fractures would result in a $282 million excess economic burden annually in the United States. Although in certain cases, inpatient admission may be necessary, with value-based decision making becoming increasingly the responsibility of the orthopaedic surgeon, understanding the implications of inpatient stays for ankle fracture surgery can ultimately result in cost savings to the US health care system and patients individually. Level III, comparative series.

Orthopaedic Tips: The Mangled Extremity

The mangled extremity is a complex and multifaceted traumatic orthopaedic injury. This injury results in damage to bone, nerve, soft tissue, and/or vascular structures, and often requires multiple surgeries. The treatment decision between limb salvage and amputation is complicated, but must be made. A systematic approach to the evaluation and medical decision-making process can help an orthopaedic provider to make an informed medical decision. This article will provide a detailed overview of the evaluation, medical decision-making, and treatment of the mangled extremity.

Economic Burden of Inpatient Admission of Ankle Fractures

Category: Trauma Introduction/Purpose: Ankle fractures are one of the most prevalent traumatic orthopaedic injuries. A large proportion of patients sustaining operative ankle fractures are admitted directly from the emergency room prior to surgical management. In our experience, however, many closed ankle injuries may be safely and effectively managed on an outpatient basis. This study aims to characterize the economic impact of routine inpatient admission of ankle fractures. Methods: A retrospective review of all closed ankle fracture surgery performed by a single foot and ankle fellowship trained surgeon at a tertiary level academic center in 2012 was conducted to identify patients requiring postoperative inpatient admission. The National Inpatient Sample was queried for operative lateral malleolus, bimalleolar, and trimalleolar ankle fractures in 2012 to evaluate national estimates and length of stay by age. The maximum allowable Medicare inpatient facility reimbursements and Medicare outpatient facility reimbursements were obtained from the Medicare Acute Inpatient Prospective Pricer and a Medicare Outpatient Pricer Code respectively. Private facility reimbursement rates were estimated at 139% of inpatient Medicare reimbursement and 280% of outpatient reimbursement as described in the literature. Surgeon and anesthesiologist fees were considered similar between both inpatient and outpatient groups. A unique stochastic decision tree model was derived from probabilities and associated costs and evaluated with modified Monte Carlo simulation. Results: Of 76 lateral malleolar, bimalleolar, and trimalleolar ankle fracture ORIF performed in 2012 by the senior author, 7 required admission due to polytrauma, medical comorbiditites or age. Of the 67 outpatient cases, all were discharged home the day of surgery. In the 2012 national cohort analyzed, 48,044 estimated inpatient admissions occurred postoperatively for closed ankle fractures. Median length of stay was three days, and associated with facility reimbursement ranging from $12,920 for Medicare lateral malleolus fractures to $18,613 for private reimbursement of trimalleolar fractures. Outpatient facility reimbursements per case were $4,125 for Medicare patients and $11,459 for private insurance patients. The national cohort’s inpatient admission accounted for $796,033,050 in reimbursements, while outpatient surgery would have been associated with $419,327,612 for treatment of these ankle fractures. Conclusion: Closed lateral malleolus, bimalleolar, and trimalleolar fractures may be safely and effectively treated as outpatient procedures. Routine perioperative admission for ankle fractures results in over $367 million of excess facility reimbursements annually in the US. Even if a conservative 25% necessary admission rate was assumed, routine inpatient admission of ankle fractures results in a $282 million dollar excess economic burden annually. While certain cases necessitate inpatient admission, with value based decision making becoming increasingly the responsibility of the orthopaedic surgeon, understanding cost implications of inpatient ankle fracture management may result in savings to the US healthcare system and patients individually.

Cell-Mediated Pathologies in Traumatic Orthopaedic Injuries

Physical trauma is one of the most common mechanisms leading to orthopaedic injury. The trauma and associated inflammatory response initiates the process of tissue regeneration and repair, which includes the recruitment and induction of multipotential cells to participate in the process. Too much inflammation can overwhelm this response to cause scarring. Although stem cells have been extensively studied as therapy for regenerating functional tissues, concerns of ethics, availability, and ease of clinical utility call for investigation into an alternative source of multipotential cells for potential therapeutic use. Here, we describe trauma-derived mesenchymal progenitor cells (MPCs). These cells are morphologically and functionally similar to bone marrow-derived mesenchymal stems cells. MPCs, which are not present in large numbers in untraumatized tissue, but are abundant in injured muscle tissue and after isolation have the potential for clinical application in regenerative medicine. MPCs appear to be activated by injury, enhancing their capability of differentiating into multiple cell lines, generating trophic factors, and producing functional tissue. This cell lineage is now thought to be involved in the pathologic process of heterotopic ossification, whereby inflammation and scarring dominates the local tissue response to injury. The utility of MPCs as a therapeutic arm for regenerative medicine can be further realized when the microenvironment commands that trigger these cells to activate are elucidated. This in turn can create patient-specific resource of nongenetically modified induced multipotent cells for regenerative therapy after orthopaedic injury.