Orthopaedic Trauma Population Research Articles

Venous thromboembolism testing practices after orthopaedic trauma: prophylaxis regimen does not influence testing patterns.

To determine venous thromboembolism (VTE) testing patterns in an orthopaedic trauma population and to evaluate for differences in VTE surveillance by prophylaxis regimen through a secondary analysis of the ADAPT trial. Prospective randomized trial. Level I trauma center. Three hundred twenty-nine adult (18 years and older) trauma patients presenting with an operative extremity fracture proximal to the metatarsals/carpals or any pelvic or acetabular fracture requiring VTE prophylaxis. VTE imaging studies recorded within 90 days post injury. Percentage of patients tested for VTE were compared between treatment groups using Fisher's exact test. Subsequently, multivariable regression was used to determine patient factors significantly associated with risk of receiving a VTE imaging study. Sixty-seven patients (20.4%) had VTE tests ordered during the study period. Twenty (29.9%) of these 67 patients with ordered VTE imaging tests had a positive finding. No difference in proportion of patients tested for VTE by prophylaxis regimen (18.8% on aspirin vs. 22.0% on LMWH, P = 0.50) was observed. Factors associated with increased likelihood of VTE testing included White race (adjusted odds ratio [aOR]: 2.61, 95% CI: 1.26-5.42), increased Injury Severity Score (aOR for every 1-point increase: 1.10, 95% CI: 1.05-1.15), and lower socioeconomic status based on the Area Deprivation Index (aOR for every 10-point increase: 1.14, 95% CI: 1.00-1.30). VTE surveillance did not significantly differ by prophylaxis regimen. Patient demographic factors including race, injury severity, and socioeconomic status were associated with differences in VTE surveillance. Level I, Therapeutic.

Traumatic brain injury is common and undertreated in the orthopaedic trauma population

IntroductionTraumatic brain injuries (TBIs) can be difficult to diagnose and are often marginalized when compared to more obvious physical injuries. Despite this, recognition and early treatment can lead to improved outcomes. Even mild TBIs have the potential to cause significant long-term consequences for patients, which may affect their physical recovery from orthopaedic injuries. The objective of this study was to examine the incidence and treatment of TBI within the orthopaedic trauma population. MethodsInclusion criteria were all patients presenting after an acute trauma with an orthopaedic surgery consult over a continuous 3 month timeframe (n = 187). A retrospective review was completed at an academic tertiary referral trauma center. The primary outcome was the rate of TBI. Secondary outcomes included rate of TBI listed as a discharge diagnosis and rate of follow up plan. Several secondary variables were noted and their associations with TBI evaluated. Results27 % of the 187 patients had an acute TBI. 61 % of TBI patients had the diagnosis listed in their discharge summary. 6 % had a follow up plan. The positive TBI group was associated with more high energy injuries (p = 0.032), average limbs involved (p = 0.007), upper extremity injury (p < 0.001), bilateral lower extremity injury (p = 0.004), and Injury Severity Score (p < 0.001). 82 % of patients with an acute TBI had an occupational therapy consult and 39 % had a neurosurgery consult. 24 % of patients with a TBI were admitted to the orthopaedic primary service. ConclusionsPatients presenting after an acute trauma with orthopaedic injuries have high rates of TBI, but low rates of diagnosis and treatment. This lack of diagnosis and treatment can negatively impact recovery from orthopaedic injuries. Orthopaedic providers should be aware of the diagnostic criteria and initial treatment steps for TBI to ensure prompt and effective treatment, which has been shown to improve outcomes.

Socioeconomic status is associated with greater hazard of post-discharge mortality than race, gender, and ballistic injury mechanism in a young, healthy, orthopedic trauma population

ObjectivesTo explore the utility of legacy demographic factors and ballistic injury mechanism relative to popular markers of socioeconomic status as prognostic indicators of 10-year mortality following hospital discharge in a young, healthy patient population with isolated orthopedic trauma injuries. MethodsA retrospective cohort study was performed to evaluate patients treated at an urban Level I trauma center from January 1, 2003, through December 31, 2016. Current Procedure Terminology (CPT) codes were used to identify upper and lower extremity fracture patients undergoing operative fixation. Exclusion criteria were selected to yield a patient population of isolated extremity trauma in young, otherwise healthy individuals between the ages of 18 and 65 years. Variables collected included injury mechanism, age, race, gender, behavior risk factors, Area Deprivation Index (ADI), and insurance status. The primary outcome was post-discharge mortality, occurring at any point during the study period. ResultsWe identified 2539 patients with operatively treated isolated extremity fractures. The lowest two quartiles of socioeconomic status (SES) were associated with higher hazard of mortality than the highest SES quartile in multivariable analysis (Quartile 3 HR: 2.2, 95% CI: 1.2–4.1, p = 0.01; Quartile 4 HR: 2.2, 95% CI: 1.1–4.3, p = 0.02). Not having private insurance was associated with higher mortality hazard in multivariable analysis (HR 2.0, 95% CI: 1.3–3.2, p = 0.002). The presence of any behavioral risk factor was associated with higher mortality hazard in univariable analysis (HR: 1.8, p < 0.05), but this difference did not reach statistical significance in multivariable analysis (HR: 1.4, 95%: 0.8–2.3, p = 0.20). Injury mechanism (ballistic versus blunt), gender, and race were not associated with increased hazard of mortality (p > 0.20). ConclusionLow SES is associated with a greater hazard of long-term mortality than ballistic injury mechanism, race, gender, and medically diagnosable behavioral risk factors in a young, healthy orthopedic trauma population with isolated extremity injury.

Comparison of Lower Extremity Long Bone Fracture Surgery Results between Obese and Non-obese Patients

Background: Obesity is a growing epidemic in developed countries which leads to an increase in the percentage of obese people in the orthopedic trauma population and affects patients’ postoperative period. Lower extremity long bone fractures are among the most common fractures and lead to significant complications, prolonged hospitalization, and heavy financial burden on the community health networks. Methods: In this cohort study, all patients with lower extremity long bone fractures (tibia or femur) treated in Bahonar hospital in Kerman were included using the simple sampling method. Then, they were divided into two groups based on BMI (patients with BMI greater than or equal to 30 were considered obese, and with BMI less than 30 were considered non-obese) and followed up for one year after treatment. Results: Our study was conducted on two groups, each including 65 people, of obese and non-obese people with lower extremity fractures. In statistical studies, no significant difference was found between the obese and non-obese groups in terms of underlying disease (P=0.1), fracture site (P=0.130), open or closed fracture (P=0.283), type of surgery (P=0.217), and fracture complications (P=0.699). Conclusion: According to this study, there is no significant relationship between the complications of lower extremity long bone fractures in obese and non-obese people; it seems that after the incidence of fracture, mostly systemic complications should be considered in obese people. Finally, considering the differences between the results of this study and similar studies and genetic and ethnic differences in other parts of Iran, conducting further studies in this field with larger sample sizes in different geographical locations is recommended.

Illicit drug and alcohol use and measures of musculoskeletal function and mental health in orthopaedic trauma patients.

The objective of this study was to describe the relationship between positive toxicology screens and measures of preinjury mental health and physical function in an orthopaedic trauma population. This was a cross-sectional study. Urban Level 1 trauma center. A total of 125 trauma patients gave written consent for this study. Questionnaires such as, Patient Health Questionnaire-9, General Anxiety Disorder-7, PCL-5, and Short Musculoskeletal Function Assessment, were used to survey patients after surgical intervention. Patient Health Questionnaire-9 (P = 0.05) and PCL-5 (P = 0.04) were not found to have significant differences between positive and negative toxicology screens. Both General Anxiety Disorder-7 (P = 0.004) and Short Musculoskeletal Function Assessment function (P = 0.006) were significantly higher in patients with positive toxicology screens. Positive toxicology seems to be associated with preinjury anxiety. Patient reported preinjury function was not adversely affected by the presence of illicit substances or alcohol, nor were levels of post-traumatic stress disorder and depression found to be higher in patients with positive toxicology screens. Level IV Cross-Sectional Study.

A systematic review of patient-centered interventions for improving pain outcomes and reducing opioid-related risks in acute care settings.

This systematic review evaluates the literature for patient-oriented opioid and pain educational interventions that aim to optimize pain management using opioid-sparing approaches in the orthopaedic trauma population. The study protocol was registered with PROSPERO (CRD42021234006). A review of English-language publications in CINAHL (EBSCO), MEDLINE through PubMed, Embase.com, PsycInfo (EBSCO), and Web of Science Core Collection literature databases published between 1980 and February 2021 was conducted using PRISMA guidelines. Only studies implementing patient-oriented opioid and/or pain education in adult patients receiving acute orthopaedic care were eligible. Outcomes were required to include postinterventional opioid utilization, postoperative analgesia and amount, or patient-reported pain outcomes. A total of 480 abstracts were reviewed, and 8 publications were included in the final analysis. Two reviewers independently extracted data from selected studies using a standardized data collection form. Disagreements were addressed by a third reviewer. Quality of studies was assessed using the Cochrane Risk of Bias Tool. Descriptive statistics characterized study findings, and content analysis was used to discern themes across studies. Our findings indicate the merit for patient-centered educational interventions including verbal/written/audio-visual trainings paired with multimodal approaches to target opioid-sparing pain management and reduce short-term pain scores in urgent and acute care settings after acute orthopaedic injuries. The scarcity of published literature warrants further rigorously designed studies to substantiate the benefit of patient-centric education in reducing prolonged opioid utilization and associated risks after orthopaedic trauma. Therapeutic level III.

Regional anesthesia provides limited decreases in opioid use following distal tibia and ankle fracture surgery.

Regional anesthesia (RA) is used for pain control, but its impacts on the orthopedic trauma population are not well known. This study evaluated the impact of peripheral nerve blocks after distal tibia and ankle fracture repair on opioid use and pain scores and quantified the magnitude and duration of any changes. This retrospective cohort study included patients treated operatively for distal tibia and ankle fractures over a 5-year period, both with and without peripheral nerve blocks. Total inpatient 5mg oxycodone equivalents (OEs) used in the post-operative period, from 0-24, 24-48, to 48-72h and maximum visual analog scale (VAS) pain ratings from 0-24, 24-48, to 48-72h were recorded. 540 non-polytrauma patients and 183 polytrauma patients were included. Patients in the non-polytrauma group who received nerve blocks required fewer opioids on post-operative day (POD) 1 compared to the non-nerve block group (4.8 [95% CI 4.2-5.4] vs. 10.5 [95% CI: 9.2-11.8]; p < 0.001) and had lower VAS scores on POD1 (5.0 [95% CI 4.6-5.4] vs. 7.7 [95% CI: 7.3-8.1]; p < 0.001). However, there were no differences between these groups on POD2 or POD3 and no differences at any timepoints in the polytrauma group. Patients with isolated distal tibia and ankle fractures who receive peripheral nerve blocks demonstrate modest reductions in inpatient opioids and pain scores on POD1. However, there are no clear benefits beyond this point. Furthermore, polytrauma patients do not experience any reductions in opioid consumption or pain scores.

Health Literacy Is Associated with Depression in Orthopaedic Trauma Patients

Introduction: Patients with poor health literacy are at increased risk of adverse outcomes when under medical care. Little is known how health literacy affects outcomes in orthopaedic trauma patients. This study aimed to evaluate the prevalence of poor health literacy in the orthopaedic trauma population, as well as any association with health outcomes and healthcare use. Methods: Patients included were enrolled as part of a larger, comprehensive prospective study at a level 1 trauma center from 2019-2020. Health literacy status (poor/adequate) was assessed using three validated screening questions answered on a multi-item Likert Scale. The Patient Health Questionnaire 2-item depression screen (PHQ-2), criminal background, education level, housing status and access to transportation were also included. Chart review provided demographic data, comorbidities, in-hospital complication, and resource-use. Chi-squared and logistic regression analyses were performed to evaluate associations between health literacy and other data. Results: 166 consecutive patients were included (female: 60%, age:42±17). Poor health literacy was identified in 17%. Patients with poor health literacy had higher odds of major depression (OR:3.97, 95%CI:1.01-15.3), limited access to transportation for medical appointments (OR:4.51, 95%CI:1.4-14.9), limited access to personal transportation (OR:3.93, 95%CI:1.2-3.2). Comorbidities, in-hospital complication and length of stay were not significantly associated with poor health literacy (p>0.05). Conclusion: Findings demonstrate that orthopaedic trauma patients are at risk for poor health literacy, with associations with depression and poor access to transportation for medical appointments. This highlights the need to identify at-risk patients during the initial hospitalization, to allow for targeted navigation in post-trauma care needs.

Association of Nerve Block and Opioid Administration for Patellar Surgery

Introduction: Multimodal pain control after orthopaedic surgery is a topic of growing interest in opioid-related risk mitigation. However, little evidence exists in the orthopaedic trauma setting. We aim to analyze the impact of perioperative peripheral nerve blocks (PNB) on opioid pain management in patients undergoing open reduction and internal fixation (ORIF) of patella fractures. Methods: This analysis included 47 patients with isolated patella fractures who underwent ORIF (2017-2021). Our dedicated PNB service provided 28 cases with PNBs. Extracted variables during hospitalization included demographic data, pain scores on visual analog scale (VAS), intra-, and postoperative opioid administration measured as morphine milligram equivalents (MME). Follow-up data included prescription refills, ED visits for pain within 90 days, and VAS pain scores. Chi-squared and logistic regression analyses were performed to evaluate the impact of PNB on opioid based pain management. Results: Patients with a PNB had lower average total MME (126.54±18.96) than those without a PNB (160.62±35.81); however, this was not statistically significant (p = 0.201). Use of PNB was not associated with total prescription refills, ED visits, or pain on VAS for all time points. However, at two-weeks follow-up, patients without PNB had 4x higher odds of receiving a refill (OR:4.13, CI:1.13-15.10). Subgroup analysis revealed no significant association between PNB timing (preoperative/postoperative) and intraoperative, postoperative, or total inpatient MME. Conclusion: With the observed inconsequential effect of PNB, findings suggest that opioid administration in the orthopaedic trauma population is multifaceted. Continued conscious prescribing practices with multimodal pain control should be encouraged to mitigate opioid-related risks.

Statistical Literacy in the Orthopaedic Trauma Population.

To evaluate the baseline level and demographic predictors of statistical literacy in orthopaedic patients who sustained traumatic injuries. Prospective observational. Level 1 trauma center. One hundred ninety-eight patients presenting to the orthopaedic trauma clinic. Berlin Numeracy Test (BNT) and General Health Numeracy Test-6 (GHNT-6). When assessed using the BNT, 67% of patients had results that placed them into the lowest quartile of objective numeracy skills. Only 3.5% of patients had results that scored in the top quartile. Our multivariate ordinal regression model demonstrated lower education level ( P = 0.01), and older age ( P = 0.03) were significant predictors of poor performance on the BNT. The mean score on the GHNT-6 was 36% (SD 30%). In a cohort of traumatically injured patients, poor statistical literacy was common, occurring in more than two-thirds of patient surveyed. Older age and lower levels of education were predictive of poor BNT performance and should be considered when discussing surgical options, associated risks, and likelihood of potential complications.

Food Insecurity Is Common in the Orthopedic Trauma Population: A Multicenter Cross-Sectional Study

ObjectivesMalnutrition increases the risk for adverse outcomes after musculoskeletal trauma. Food insecurity is an increasingly recognized risk factor for malnutrition. The purpose of this investigation is to evaluate the prevalence and risk factors for food insecurity in a diverse population treated for operative fracture fixation. MethodsA two-center study (Midwest and Pacific Northwest) enrolled participants of any age within 6 months of operative fixation of pelvis or extremity fractures. Food insecurity was assessed using the USDA Household Food Insecurity questionnaire. A score ≥3 indicated food insecurity, 1 or 2 indicated marginal food security, and 0 indicated high food security. Subgroup analysis was performed for participants with available demographic, income, and food access data. Differences between food insecure and food secure participants in continuous and categorical variables were evaluated using the Wilcoxon sum rank test and Fisher’s exact test, respectively. Spearman’s correlation was used to describe associations between food security scores and participant characteristics. Logistic regression was used to relate patient demographics and odds of food insecurity. ResultsOf the 476 participants enrolled, 53 (11%) were food insecure, 48 (10%) had marginal food security, and 375 (79%) were food secure. Those with food insecurity were more commonly female (p < 0.0001). Participants with a household income ≤$15,000 were 5.7 times more likely to be food insecure (95% CI 1.8–18.1). Widowed/single/divorced participants were 10.2 times more likely to experience food insecurity than married/partnered participants (95% CI 2.3–45.6). Median time to the nearest full-service grocery store was significantly longer for food insecure (t = 10 minutes) than for food secure participants (t = 7 minutes, p = 0.0202). Time to store demonstrated a weak correlation with food security score (r = 0.23, p = 0.0041). Age (r = –0.08, p = 0.327) and hours working (r = –0.10, p = 0.429) demonstrated no correlation with food security score. ConclusionsFood insecurity is common in the musculoskeletal trauma population. Those with lower household incomes and living alone are more likely to experience food insecurity. Food insecurity is a potentially modifiable risk factor for malnutrition-related complications after operative fracture fixation. Funding SourcesNone.

Low-value injury care in the adult orthopaedic trauma population: A systematic review.

Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices. We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes. Of the 30,670 records screened, 70studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias. In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.

Reduction of Opioid Consumption After Outpatient Orthopaedic Trauma Surgeries Using a Multimodal Pain Protocol.

Because of the dearth of literature in the orthopaedic trauma population, we aimed to analyze how a multimodal pain protocol after outpatient surgery affects opioid consumption, pain scores, and patient satisfaction. This was a cohort study with a historical control at an urban level 1 trauma center. Forty consecutive outpatients were given a peripheral nerve block and a multimodal pain protocol between September 2019 and March 2020 and compared with 70 consecutive preprotocol patients who received a peripheral nerve block and hydrocodone-acetaminophen. The primary outcome was morphine milligram equivalents (MMEs) consumed. Our secondary aims were pain scores and satisfaction. Patients in the protocol were younger (36.45 versus 45.09 years, P = 0.007), butthere was no difference in sex, body mass index, American Society of Anesthesiologists, or surgical duration. There was a 59% reduction in opioids consumed in the first 4 days after surgery (3.83 MME versus 9.29 MME, P < 0.001). At the postoperative day-14 time point, protocol patients consumed a total of 5.59 MMEs, which is 40% less than just the first 4 days of the preprotocol (P = 0.02). Protocol patients assigned a higher rating of "least pain" on postoperative day 1 (1.24 versus 0.52, P = 0.04) but had higher satisfaction scores on day 1 (9.68 versus 8.54, P < 0.001) and day 2 (9.66 versus 8.61, P < 0.001). Implementation of a multimodal pain management protocol after outpatient orthopaedic trauma surgeries reduced opioid consumption by >50% in the first 4 days postoperatively. Additional studies are needed to refine the multimodal pain protocol used in this study. II.

Nutrition and Vitamin Deficiencies Are Common in Orthopaedic Trauma Patients.

Macro- and micronutrients play important roles in the biological wound-healing pathway. Although deficiencies may potentially affect orthopaedic trauma patient outcomes, data on nutritional deficiencies in orthopaedic trauma patients remain limited in the literature. The purpose of this study was to (1) evaluate the prevalence of macro- and micronutrient deficiencies in orthopaedic trauma patients with lower extremity fractures and (2) evaluate the impact of such deficiencies on surgical site complications. This retrospective study identified 867 patients with lower extremity fractures treated with surgical fixation from 2019 to 2020. Data recorded included albumin, prealbumin, protein, vitamins A/C/D, magnesium, phosphorus, transferrin and zinc, as well as wound complications. Nutritional deficiencies were found for prealbumin, albumin and transferrin at 50.5%, 23.4% and 48.5%, respectively. Furthermore, a high prevalence of micronutrient deficiencies (vitamin A, 35.4%; vitamin C, 54.4%; vitamin D, 75.4%; and zinc, 56.5%) was observed. We also recorded a statistically significant difference in wound complications in patients who were deficient in prealbumin (21.6% vs. 6.6%, p = 0.0142) and vitamin C (56.8% vs. 28.6%, p = 0.0236). Our study outlines the prevalence of nutritional deficiencies in an orthopaedic trauma population and identifies areas for possible targeted supplementation to decrease wound complications.

Cannabis Exposure Decreases Need for Blood Pressure Support During General Anesthesia in Orthopedic Trauma Surgery.

Introduction:As cannabis use continues to increase in popularity, it is important to investigate how it impacts public health in all sectors of the population, including patients undergoing anesthetic management. This retrospective study focuses on the orthopedic trauma population presenting through an emergency department (ED) and receiving a urine drug screen (UDS) with subsequent urgent surgical intervention. We aimed to evaluate differences in response to general anesthesia in patients with exposure to THC, a major cannabinoid, compared to controls that screened negative for THC.Materials and Methods:All ED visits at UC Irvine, a level 1 trauma center between November 4, 2017 and January 7, 2020, were evaluated in this study. Only adult patients who received a UDS and underwent urgent orthopedic trauma surgery within 48 h of ED visit were included in this study. Additional inclusion criteria required an anesthesia time greater than 1 h as well as anesthesia induction and intubation while in the operating room. Overall, we analyzed a total of 221 adult patients.Discussion:When adjusting for demographic variability, there were statistically significant differences in response to general anesthesia between these two groups. The THC-positive (THC(+)) group was less likely to receive intraoperative vasopressors, had higher mean arterial blood pressure and mean diastolic blood pressure, needed less total fluid input and had a lower overall fluid balance. Chronic exposure to THC has been shown to downregulate cannabinoid 1 receptors and cause alterations in endocannabinoid tone. These are two potential mechanisms by which the THC(+) group in our study may have become more resistant to the typically observed hypotensive effects of general anesthesia.Conclusion:The present study suggests that prior use of cannabis, objectively assessed by urinalysis, results in a decreased need for blood pressure support during general anesthesia. The physiological basis for this phenomenon is unclear, but possible causes might include the downregulation of vascular cannabinoid receptor 1 and/or altered endocannabinoid levels after exposure to cannabis.

Comparing the responsiveness of a generic and a musculoskeletal specific functional outcome measure in orthopaedic patients with operative fixation of pelvic ring, acetabulum, or tibia fractures: a comparison between single injury and multiply injured patients.

Objectives:This study compares the responsiveness, or the ability to detect clinical change in a disease, between the generic Short Form-36 (SF-36) and musculoskeletal specific Short Musculoskeletal Functional Assessment (SMFA) patient-reported outcome measures (PROMs) in the orthopaedic trauma population. Stratified analysis was performed to compare whether responsiveness differs between patients with single or multiple orthopaedic injuries.Design:Prospective case series.Setting:Level 1 Trauma Center.Patients:A total of 659 patients with orthopaedic trauma injuries to the pelvis, acetabulum, or tibia were included for analysis. There were 485 patients with a single isolated injury and 174 patients with multiple orthopaedic injuries.Intervention:None.Main Outcome Measurements:Responsiveness was calculated through the standard response mean (SRM), the proportion meeting a minimal clinically important difference, and floor and ceiling effects.Results:Between baseline and 6 months the magnitude of the SRM for SF-36 was consistently greater than that of SMFA in patients with single (P < .01) and multiple injuries (P < .01). Between 6 and 12 months, there were no differences in SRM across all cohorts. The proportion of patients who achieved minimal clinically important difference was consistently higher when assessed with SF-36 compared with SMFA between baseline and 6 months (81.8% vs 68.1%, P < .0001) and between 6 and 12 months (63.3% vs 55.4%, P = .01).A ceiling effect was only observed at baseline for the SMFA with 16.6% of patients achieving the maximal level of functioning detectable. No floor effects were seen in either PROM.Conclusion:This study demonstrates that SF-36 has superior responsiveness versus SMFA in both polytrauma and isolated injury patients and supports the collection of SF-36 as the primary PROM in prospective orthopaedic trauma studies irrespective of whether the patient has an isolated injury or multiple injuries.

Can financial payments incentivize short-term smoking cessation in orthopaedic trauma patients? Evidence from a discrete choice experiment

BackgroundSmoking increases the risk of complications and related costs after an orthopaedic fracture. Research in other populations suggests that a one-time payment may incentivize smoking cessation. However, little is known on fracture patients’ willingness to accept financial incentives to stop smoking; and the level of incentive required to motivate smoking cessation in this population. This study aimed to estimate the financial threshold required to motivate fracture patients to stop smoking after injury.MethodsThis cross-sectional study utilized a discrete choice experiment (DCE) to elicit patient preferences towards financial incentives and reduced complications associated with smoking cessation. We presented participants with 12 hypothetical options with several attributes with varying levels. The respondents’ data was used to determine the utility of each attribute level and the relative importance associated with each attribute.ResultsOf the 130 enrolled patients, 79% reported an interest in quitting smoking. We estimated the financial incentive to be of greater relative importance (ri) (45%) than any of the included clinical benefits of smoking cessations (deep infection (ri: 24%), bone healing complications (ri: 19%), and superficial infections (ri: 12%)). A one-time payment of $800 provided the greatest utility to the respondents (0.64, 95% CI: 0.36 to 0.93), surpassing the utility associated with a single $1000 financial incentive (0.36, 95% CI: 0.18 to 0.55).ConclusionsFinancial incentives may be an effective tool to promote smoking cessation in the orthopaedic trauma population. The findings of this study define optimal payment thresholds for smoking cessation programs.

Can You Believe Your Patients If They Say They Have Quit Smoking?

To determine the reliability of self-reported smoking status in the orthopaedic trauma population and determine if certain patient factors might predispose inaccurate self-reported smoking cessation. Prospective. Level I trauma center. Two hundred forty-seven orthopaedic trauma patients were included in the study. In-office measurement of exhaled carbon monoxide (CO). Self-reported smoking cessation with exhaled CO measurements. A total of 906 self-reported surveys were completed over 4 follow-up visits. Of the responses indicating smoking cessation (n = 174), 12.6% [95% confidence interval (CI), 0.081-0.185] reported smoking cessation with positive CO readings, suggesting inaccurate self-reporting of smoking status. Over 20% of those patients inaccurately reporting abstinence did so more than once. The odds of inaccurate self-reporting was 3 times higher in patients with no insurance or government insurance [odds ratio (OR), 3.5; 95% CI, 1.1-11.0; P = 0.043] and in the unemployed (OR, 3.3; 95% CI, 0.97-8.57; P = 0.049). Self-reported smoking status in the orthopaedic population is fairly reliable, with 13% of patient's inaccurately self-reporting smoking cessation despite knowing their smoking status was being measured. Clinicians should be aware of the potential for inaccuracy in self-reported smoking cessation, particularly in patients with the identified socioeconomic factors. Point-of-care testing before elective trauma procedures to confirm smoking status might have a role if the procedure outcome is highly dependent on smoking status. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Mental health of orthopaedic trauma patients during the 2020 COVID-19 pandemic

PurposeThe outbreak of the SARS-CoV-2 virus has been associated with reports of increased anxiety, depression and fear among the general population. People with underlying psychiatric disorders are more susceptible to stress than the general population. The purpose of this study was to determine the prevalence of concomitant psychiatric conditions in the orthopaedic trauma population during the COVID-19 pandemic.MethodsThis retrospective cohort study evaluated orthopaedic trauma patients who received care at our institution between February through April of 2019 and February through April of 2020. Patient sex, age, mechanism of injury, associated injuries, fracture location, tobacco use, employment status, mental health diagnosis and presence of interpersonal violence were documented. Mental health diagnoses were defined based on International Classification of Diseases-10 classification.ResultsThe study included 553 orthopaedic patients evaluated at our institution during the defined time period. Patients in the 2020 cohort had a higher prevalence of mental health diagnoses (26% vs. 43%, p < 0.0001) compared with the 2019 group. The odds ratio for mental health disorder in the 2020 patients was 2.21 (95% CI 1.54, 3.18) compared with the 2019 cohort. The 2020 cohort had a higher percentage of patients who reported interpersonal violence (20% vs. 11%, p = 0.005).ConclusionOur study showed a higher prevalence of psychiatric disease among orthopaedic trauma patients during the COVID-19 pandemic when compared with those seen during the same time of the year in 2019. Stress induced by the coronavirus pandemic can place patients with mental illness at a higher risk for perilous behaviours and subsequent fractures.

Transcutaneous Hemoglobin Screening in an Adult Orthopaedic Trauma Population.

To evaluate a noninvasive hemoglobin measurement device in an orthopaedic trauma population. Prospective. Level 1 trauma center. One hundred five patients consecutively admitted to the orthopaedic trauma service after surgical treatment of fracture. Transcutaneous hemoglobin (TcHgb) monitoring using the Masimo Pronto Pulse CO-Oximeter model with Rainbow SET Technology for spot TcHgb measurement. TcHgb measurements and standard venipuncture hemoglobin (vHgb) were obtained. Patient preferences for each were recorded. TcHgb measurements were obtained in 100 patients and compared with their corresponding vHgb measurements. The mean vHgb and TcHgb were 10.2 ± 1.9 g/dL and 11.2 ± 2.1 g/dL, respectively, and the mean difference was 1.1 ± 1.6 g/dL, which was statistically different from 0 (P < 0.001). In 76% of cases, the TcHgb device overestimated vHgb. In a subgroup of patients undergoing procedures with minimal expected blood loss (external fixators of knee or ankle, irrigation and debridement, or open reduction and internal fixation of ankle or calcaneal fractures), the mean difference between vHgb and TcHgb was 0.68 ± 1.6 g/dL (P = 0.06). A preliminary study of TcHgb monitoring with the tested device as a potential screening mechanism to limit unnecessary blood draws showed statistical difference from vHgb; however, the mean bias 1.1 g/dL of hemoglobin was notably small. In a subgroup of patients undergoing procedures with minimal expected blood loss, the device may have merit. Larger studies are required to determine the clinical relevance of differences in measurements between the 2 methods. Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.