Orthopaedic Trauma Population Research Articles

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.

Low-value injury care in the adult orthopaedic trauma population: a protocol for a rapid review

IntroductionOrthopaedic injuries affect almost 90% of trauma patients. A previous scoping review and expert consultation survey identified 15 potential low-value intra-hospital practices in the adult orthopaedic trauma population. Limiting the...

Current illicit drug use profile of orthopaedic trauma patients and its effect on hospital length of stay

IntroductionThe purpose of this study was to investigate the prevalence of illicit drug use among patients admitted with traumatic orthopaedic injuries and to determine its effect on hospital length of stay (LOS). We hypothesized that patients with pre-injury drug use would have a longer hospital LOS compared to those who do not use drugs. MethodsWe conducted a retrospective cohort study at our level 1 urban trauma center of patients admitted with traumatic orthopaedic injuries between 2013 and 2015 with urine toxicology screening. We collected demographic and hospital LOS data from chart review. ResultsOf 611 patients, over half (55%) had a positive drug screen: marijuana (41%), amphetamine (19%), cocaine (7%), and/or PCP (2%). The highest incidence of drug use was in males under 19 years of age (81%). Patients with any drug use had a longer hospital LOS compared to those who did not use drugs (8.3 vs. 6.3 days; p = 0.03). Patients who used amphetamines had a longer hospital LOS than those patients who did not (9.5 vs. 6.9 days; p = 0.01). ConclusionCompared to the orthopaedic trauma population two decades ago, the current population using illicit drugs is younger (<30 years) with an increased preference for amphetamine and marijuana and a decreased preference for cocaine. Pre-injury drug use was associated with a longer hospital LOS in patients with a traumatic orthopaedic injury. Knowledge of the current trends in illicit drug use amongst orthopaedic trauma patients could facilitate medical decision-making regarding clinical care and optimizing resource utilization in this complex population of individuals.

Who Is the Geriatric Trauma Patient? An Analysis of Patient Characteristics, Hospital Quality Measures, and Inpatient Cost.

Purpose:The purpose of this study was 2-fold: 1) to investigate the age-related frequency, demographics and distribution of the middle-aged and geriatric orthopedic trauma population and 2) to describe the age-related frequency and distribution of hospital quality measure outcomes and inpatient cost.Methods:All patients > 55 years of age who required orthopedic, trauma, or neurosurgery consults at 3 hospitals within an academic medical center from 2014 to 2017 were prospectively followed. On initial evaluation, each patient’s demographics, injury severity, and functional status were collected. Patients were grouped into low and high-energy mechanism cohorts and divided into 5 groups based on age. Hospital quality measures including length of stay, complications, discharge location, and cost of care was compared between age groups. Data were analyzed using ANOVA and Chi-square tests.Results:A total of 3965 patients were included in this study of which 3268 (82%) sustained low-energy trauma and 697 (18%) sustained high-energy trauma. With increasing age, more patients had more comorbidities, were less likely to be community ambulators, and more likely to use assistive devices (p < 0.05). Patients in older age groups had longer lengths of stay, more complications, were more likely to need ICU level care, and were less likely to be discharged home (p < 0.05). Rates of mortality were also greater in patients of more advanced age in both low and high-energy cohorts, and the calculated risk triage tool (STTGMA) score increased with each age bracket (p < 0.05). Total cost of care differed between age groups in the low-energy cohort (p = 0.003).Conclusion:This epidemiological study provides a clear picture of the frequency and distribution of demographic, physiologic characteristics, outcomes, and cost of care in a middle-aged and geriatric orthopedic trauma population as evaluated by the STTGMA risk tool. Risk profiling of geriatric trauma patients allows for the establishment of baseline norms.

Interventional Efforts to Reduce Psychological Distress After Orthopedic Trauma: A Systematic Review.

Unanticipated severe injury to part of the musculoskeletal system, referred to as orthopedic trauma, can be debilitating. It can also be accompanied by equally debilitating psychological distress, but little is known about the effective interventions for psychological sequelae of orthopedic trauma. We sought to determine the effectiveness of interventions on psychological outcomes, such as post-traumatic stress disorder (PTSD), depression, and pain catastrophizing (feelings of helplessness, excessive rumination, and exaggerated description of pain), after major orthopedic trauma. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement as guidelines, we systematically searched Scopus, PubMed, and Google Scholar. Studies included for review were English-language interventional studies in an orthopedic trauma population that included assessment of post-injury psychological distress or disability as either a primary or secondary aim. Twelve studies were identified, including six randomized trials, three prospective cohort studies, and three retrospective cohort studies. Study sample sizes ranged from 48 to 569 patients, the mean age ranged from 29 to 52.8 years, and the percentage of male patients ranged from 38 to 90%. We examined four categories of interventions. Peer group treatment (one study) significantly reduced rates of depression but had low participation rates. Brief interventions to teach coping and self-efficacy skills (two studies) decreased depression, pain catastrophizing, and anxiety scores while increasing self-efficacy on short-term follow-up. Individualized counseling and rehabilitation (four studies) resulted in a consistent reduction in the risk of PTSD. Early amputation was found to result in lower rates of PSTD than limb salvage in US military personnel (four studies). One study examined surgeons' confidence in dealing with possible psychological distress; surgeons who participated in a program on collaborative care were significantly more confident that they could help their patients with such issues. Interventional strategies, including group interventions, brief individual interventions, longitudinal counseling, and consideration of early amputation in selected populations have proved effective in reducing negative psychological sequelae of major orthopedic trauma. Further research that determines the effects of interventions in this population is needed.

Understanding and Perception of Overlapping Surgery in an Orthopaedic Trauma Population: A Survey Study.

Recently, overlapping surgery has received attention on the national scale. This study quantifies orthopaedic trauma patients' familiarity and concern with overlapping surgery as it relates to their care. A 15-question survey was voluntarily completed by 200 orthopaedic trauma patients in the outpatient setting of a level I trauma center. Three domains were evaluated in the survey: demographic data, familiarity with overlapping surgery, and the degree of concern with overlapping surgery. Patients read a position statement explaining the practice of overlapping surgery, and their changes in level of concern were evaluated. Descriptive statistics were used to evaluate the data. A total of 200 patients completed the survey, of which 98 (49%) were male. The age range was broadly distributed. After surgery, 124 patients (62%) were seen for follow up. The remaining 76 patients (38%) did not undergo surgery. Regarding the practice of overlapping surgery, 116 respondents (58%) had no knowledge. There were 127 patients (63%) who reported their concern level as a 1 on an ordinal scale from 1 to 5, corresponding to the lowest possible level. Overall, 182 patients (91%) reported a level of concern of 3 (the median) or less with an average score of 1.7, indicating a low average level of concern. Six patients (3%) reported the maximum level of concern. On the whole, 160 patients (80%) reported either a decreased level of concern or no change after reading our department's position statement on overlapping surgery. Of the 124 patients, 81 (65%) postoperatively reported that they perceived no effect by overlapping surgery. The most common factors cited as areas of concern by patients were the absence of attending physician in the operating room (26%), risk of error by the resident (34%), and risk of a missed step in the surgical procedure (31%). These data indicate that most respondents had no previous knowledge of overlapping surgery and had a generally low level of concern with its use as practiced at our institution. Disclosing the use of overlapping surgery and its purpose to patients is an important component of preoperative counseling. Level V.

Comorbid tobacco and other substance use and symptoms of anxiety and depression among hospitalised orthopaedic trauma patients

BackgroundNo study has examined the prevalence of tobacco, other substance use, and symptoms of anxiety and depression, and rates of comorbidities among the orthopaedic trauma population, despite the impact they have on recovery from surgery. This study aims to 1) describe the rates of symptoms and substance use; 2) compare rates of symptoms and substance use among smokers versus non-smokers; and 3) examine the relationship between symptoms and substance use with smoking status.MethodsA cross-sectional survey of orthopaedic trauma patients was conducted in two Australian public hospitals. Demographic characteristics, smoking status, alcohol consumption, recent cannabis use, and symptoms of anxiety and/or depression were examined. Differences between current and non-smokers were compared using Pearson Chi2 tests. Multivariate logistic regression explored variables related to tobacco smoking.ResultsEight hundred nineteen patients participated. Over one-fifth (21.8%) identified as a current smoker, half (51.8%) reported consuming alcohol at hazardous levels in the last 12 months, and about 10% stated that they had used cannabis in the last 30 days (9.7%), or experienced symptoms of either anxiety (12.4%), or depression (12.9%) in the last two weeks. Over one-fifth of current tobacco smokers (21.8%) reported drinking heavily in the last 12 months and using cannabis recently. Males, with a lower educational attainment, who were unmarried, had used cannabis recently, and report drinking heavily were more likely to be current smokers.ConclusionsHealth behaviour interventions addressing comorbidities are warranted among the orthopaedic trauma population given the high rate of comorbidity and impact these may have on recovery.

Treatment of Hypovitaminosis D in an Orthopaedic Trauma Population.

To determine the incidence of hypovitaminosis D and to evaluate a supplementation intervention. We hypothesized that patients would exhibit high adherence with a free sample, and levels would become sufficient. Prospective observational study. Level 1 trauma center. One hundred forty-four consecutive, skeletally mature patients treated for acute fractures. All were provided 600 mg calcium and 800 IU vitamin D3 capsules twice daily. Serum 25(OH) D levels were obtained on presentation and after supplementation. Patient surveys determined adherence, vitamin D intake, and sun exposure. Ninety-one men and 53 women, mean age 45 years, mean body mass index 28.1, were studied. Mean baseline 25(OH) D level was 20.2 ng/mL, including 9 patients taking vitamin D supplements before injury. All others (mean baseline 16.9 ng/mL) were prescribed calcium and vitamin D and were offered free supplements when discharged. Seventy-seven patients completed surveys, and mean 25(OH) D level was 36.7 ng/mL after a mean of 7.0 weeks of supplementation (P < 0.0001). Seventy-nine percent reported adherence to supplement recommendations. All adherent patients achieved normal levels. Sixteen patients were nonadherent, with 10 who forgot to take the supplement, 4 choosing not to use it, 1 choosing to sell the sample, and 1 losing the sample. Hypovitaminosis D was present in 97% of orthopaedic trauma patients who were not already taking supplements. The intervention was effective in reducing hypovitaminosis D within several weeks, with all supplemented patients achieving normal levels. Seventy-nine percent of patients adhered to recommendations. Further study to determine the long-term cost-effectiveness of this strategy seems warranted. Therapeutic, Level II. See Instructions for Authors for a complete description of levels of evidence.

Patient Comprehension and Compliance Survey to Assess Postoperative Pain Regimens in the Orthopaedic Trauma Population.

This study aims to determine the groups of patients who are at risk for noncompliance and misunderstanding of their pain regimen. Survey-based cohort study. Suburban Level-I trauma center. A total of 171 patients between the ages of 18-89 years who underwent surgical fixation of fractures involving the pelvis, long bones, or periarticular regions of the knee, ankle, elbow, and wrist. Patients who cannot accurately reproduce their prescribed pain medication list and patients who modify this pain medication regimen were analyzed by age, employment status, income level, education level, time between surgery and follow-up, and whether pain interfered with activities of daily living. Overall, 147 patients completed the survey. Seventy percent (n = 114) of patients could not accurately reproduce their pain medication regimen, regardless of age, employment status, income level, education level, time between surgery and follow-up, and whether pain interfered with activities of daily living. Patients (61.2%; n = 90), regardless of the 6 aforementioned demographic factors, also admitted to modifying their pain medication regimen with non-prescribed medications, with 55.8% (n = 82) of patients adding over-the-counter medications to surgeon-prescribed narcotic medications. Misunderstanding and noncompliance of surgeon-prescribed pain regimens are prevalent across all patient demographics. Knowledge of the potential effects these augmentative medications can have on fracture healing and any drug-drug interactions that may arise is an important aspect of patient postoperative care. Surgeons must be wary of these trends and screen for any unintended side effects a patient's pain regimen may have. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Patterns of Opioid Prescribing for an Orthopaedic Trauma Population.

To determine opioid-prescribing practices to the orthopaedic trauma (OT) population at one Level I trauma center. A retrospective study of discharge prescriptions for adult patients with OT. Prescription details, injury burden, and patient demographics were abstracted for patients from initial injury through a 2-month follow-up. Level I trauma center. Adult patients with OT admitted over a 30-day period (n = 110). All discharge and follow-up opioid prescriptions were recorded. Morphine milligram equivalents (MMEs) per day, number of opioid prescriptions, type/dose of medication prescribed. One hundred thirty-five discharge prescriptions were written for 110 patients with orthopaedic injuries during the review period. All patients received opioids at the time of discharge. The MMEs prescribed at the time of discharge was 114 mg (54-300 mg) for a mean of 7.21 days (2-36.7 days). Although patients with preinjury risk factors were prescribed discharge opioids for a similar duration (7.00 days vs. 7.30 days, P = 0.81) than those without risk factors, they were prescribed significantly more MMEs than those without (130 vs. 108, P < 0.05) and were more likely to receive extended-release and long-acting opioids than those without (42.11% vs. 21.98%). Pain management after OT continues to be opioid-centric despite involving a population at risk. Further focus on prescriber and patient education, risk evaluation with mitigation, guideline development, and comprehensive pain management strategies are warranted in the OT population. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Development of an online smoking cessation program for use in hospital and following discharge: smoke-free recovery

BackgroundTobacco smoking can have negative health outcomes on recovery from surgery. Although it is recommended best practice to provide patients with advice to quit and follow-up support, provision of post-discharge...

Efficacy of Surgical-Site, Multimodal Drug Injection Following Operative Management of Femoral Fractures: A Randomized Controlled Trial.

Multimodal analgesia inclusive of periarticular injection with a local anesthetic agent has been rapidly assimilated, with demonstrated safety and efficacy, into the care of patients undergoing elective lower-extremity arthroplasty. The present study was performed to evaluate the efficacy and safety of a surgical-site, multimodal drug injection for postoperative pain control following operative management of femoral fractures. There were 102 patients undergoing operative intervention (plate fixation, intramedullary device, or arthroplasty) for a broad range of femoral fracture patterns who were prospectively randomized either to receive an intraoperative, surgical-site injection into the superficial and deep tissues containing ropivacaine, epinephrine, and morphine or to receive no injection. Visual analog scale (VAS) scores were recorded at regular intervals as the primary outcome measure. Narcotic consumption and medication-related side effects were also monitored. The injection group demonstrated significantly lower VAS scores (p < 0.05) than the control cohort in the recovery room and at the 4, 8, and 12-hour postoperative time points. The median score (and interquartile range) was 1.6 (0 to 4.0) for the injection group and 3.2 (1.3 to 5.7) for the control group immediately postoperatively, 1.0 (0 to 3.0) for the injection group and 5.0 (2.0 to 7.0) for the control group at 4 hours, 2.0 (0 to 4.0) for the injection group and 5.0 (2.0 to 6.8) for the control group at 8 hours, and 3.5 (0 to 5.0) for the injection group and 5.0 (2.0 to 8.0) for the control group at 12 hours. Additionally, narcotic consumption was significantly lower (p = 0.007) in the injection group (5.0 mg [1.3 to 8.0 mg]) compared with the control group (9.7 mg [3.9 to 15.6 mg]) over the first 8 hours following the surgical procedure. No cardiac or central nervous system toxicity was observed secondary to infiltration of the local anesthetic. Surgical-site injection with a multimodal analgesic cocktail provides improved pain control and reduces narcotic utilization over the first postoperative day, with no observed adverse effects attributable to the local injection, across a diverse orthopaedic trauma population undergoing operative intervention for femoral fractures. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Health Literacy in Orthopaedic Trauma Patients.

This study aimed to determine the level of health literacy in a postoperative orthopaedic trauma population and to evaluate the efficacy of a simple predischarge discussion strategy, targeted at improving health literacy. A pre-post intervention study was conducted from April 2014 to January 2015. Academic Level 1 trauma center. One hundred ninety consecutive orthopaedic trauma patients with operatively managed lower limb fractures were recruited. All eligible participants agreed to participate. The first ninety-nine patients received usual care (UC). The following 91 patients received a structured predischarge discussion, including x-rays, written and verbal information, from the orthopaedic staff (DG). Patients were then randomized into health literacy evaluation before first outpatient review or after first outpatient review. The primary outcome measure was a questionnaire determining health literacy. Ninety-six (97%) of the UC patients and 87 (96%) of the discussion patients (DG) completed the interview. UC preoutpatient (n = 46) demonstrated a mean score of 4.67 of a maximum 8. UC postoutpatient (n = 50) demonstrated a mean score of 5.42. DG preoutpatient (n = 47) demonstrated a mean score of 6.70. DG postoutpatient (n = 40) demonstrated a mean score of 7.08. Australian orthopaedic trauma patients demonstrate poor health literacy, with this not showing improvement after their first outpatient follow-up visit. The use of a time efficient, structured predischarge discussion improved patient health literacy. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

The risk of deep vein thrombosis in total joint patients compared to orthopaedic trauma patients: Need for new prevention guidelines

The development of Deep Vein Thrombosis (DVT) is a major concern following orthopaedic surgery. No study has yet to compare the rate and risk factors for DVT between total joint and orthopaedic trauma patients. To evaluate if DVT prophylaxis for trauma should differ from total joints, we explored the rate and risk factors for DVT between both cohorts. Using a CPT code search from 2005 to 2013 in the ACS-NSQIP database, 150,657 orthopaedic total joint patients and 44,594 orthopaedic trauma patients were identified. DVT complications, patient demographics, preoperative comorbidities, and surgical characteristics were collected for each patient. A chi-squared test was used to compare the risk factors for DVT between orthopaedic trauma and total joint patients. A multivariable logistic regression model was built to adjust for comorbidities for each cohort. The rate of DVT diagnosis in the total joint population was 0.8% (N=1186) and 0.98% (N=432) in the orthopaedic trauma population (p=0.57). After controlling for individual comorbidities, dyspnea, peripheral vascular disease, and renal failure were significant risk factors for DVT in total joint patients (p<0.05), whereas age, ascites and steroid use were significant risk factors for DVT in orthopaedic trauma patients (p<0.05). Historically, the risks for DVT in total joints have been emphasized, yet based on our results, the incidence of DVT is the same for orthopaedic trauma. However, the risk factors varied. It is therefore important to consider specialty-specific DVT prophylaxis for orthopaedic trauma patients in order to improve care and reduce postoperative complications.

The Effect of Preoperative Counseling on Duration of Postoperative Opiate Use in Orthopaedic Trauma Surgery

The prudent use of prescription opiates is a central aspect of current postsurgical pain management, but surgeons have no guidelines on appropriate duration of opiate treatment. Furthermore, there are no established data on the effect of physician counseling on the duration of opiate use postoperatively. Retrospective surgeon-controlled cohort study. Level I regional academic trauma center. All Utah residents admitted to the orthopaedic trauma service with isolated operative musculoskeletal injury. One group of patients was instructed at the time of index procedure that they would receive prescription opiates for a maximum of 6 weeks. The remaining patients were not counseled preoperatively on duration of opiate use postoperatively. The presence and frequency of prescription opiate use before injury, cessation of opiate use by 6 weeks postoperatively, cessation of opiates by 12 weeks postoperatively, and continuation of prescription opiates greater than 12 weeks postoperatively. Six hundred thirteen patients met inclusion criteria. Those counseled preoperatively to cease opiate use by 6 weeks were significantly more likely to do so than those who did not receive counseling (73% and 64%, respectively; P = 0.012). By 12 weeks, this effect was no longer seen, and patients were just as likely to have stopped (80% and 80%, respectively; P = 0.90). The orthopaedic trauma population is significantly more likely than the general population to be using prescription opiates before injury. Physician discussion of 6-week opiate prescription limitation at the time of injury seems to lead to a lower rate of use at the 6-week postoperative mark but has no effect on rates of longer-term use. Twenty percent of patients in either group will continue to use opiates after 12 weeks, compared with 15% before injury. Given the scope of prescription opiate use in the United States, surgeons may want to consider preoperative discussion of this issue, but it may not have any effect on usage rates at longer intervals. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The effect of the Massachusetts healthcare reform on the uninsured rate of the orthopaedic trauma population.

The 2006 Massachusetts Healthcare Reform (MHR) has resulted in health coverage for 98.1% of residents in Massachusetts. The purpose of this study was to evaluate the effect of MHR on the actual rate of uninsured individuals in the orthopaedic trauma population in the largest metropolitan area of Massachusetts. We also sought to measure the change in uncompensated care following the implementation of MHR. We performed a retrospective review of all patients treated by the orthopaedic trauma services at three of the four level-I trauma centers in Boston from 2003 to 2010. The primary study cohort consisted of all uninsured patients, while the remaining patients were considered to have insurance. The study population was divided into two groups to compare the uninsured rate before and after MHR. Patients from 2006 to 2007 were excluded from the analysis to allow for an enrollment period in subsidized health insurance. A total of 16,338 patients with extremity and pelvic fractures and dislocations were treated from 2003 to 2010. There was a significant decrease in the uninsured rate from 23.8% to 14.4% following MHR (p < 0.001). The post-MHR risk of being uninsured is approximately 0.6 times the pre-MHR risk, with a 95% confidence interval of 0.56 to 0.65. There was also a reduction in the proportion of uncompensated care from 16.7% to 11.5% after MHR. There was an estimated 40% reduction in risk of uninsured individuals in the orthopaedic trauma population in the metropolitan Boston area following MHR. Despite a significant improvement, these results reveal a rate of uninsured individuals fivefold greater than currently reported by the state of Massachusetts and the U.S. government.

Narcotic Use and Postoperative Doctor Shopping in the Orthopaedic Trauma Population.

The negative consequences of narcotic use and diversion for nonmedical use are on the rise. A growing number of narcotic abusers obtain narcotic prescriptions from multiple providers ("doctor shopping"). This study sought to determine the effects of multiple postoperative narcotic providers on the number of narcotic prescriptions, duration of narcotics, and morphine equivalent dose per day in the orthopaedic trauma population. Our prospective cohort study used the state-controlled substance monitoring database to identify all narcotic prescriptions filled three months prior to admission and six months following discharge for enrolled patients. Patients were assigned into two groups: a single narcotic provider group with prescriptions only from the treating surgeon (or extenders) or a multiple narcotic provider group with prescriptions from both the treating surgeon and an additional provider or providers. Complete data were available for 130 of 151 eligible patients. Preoperative narcotic use, defined by three or more narcotic prescriptions within three months of admission, was noted in 8.5% of patients. Overall, 20.8% of patients sought multiple narcotic providers postoperatively. There were significant increases in postoperative narcotic prescriptions (p < 0.001) between the single narcotic provider group (two prescriptions) and the multiple narcotic provider group (seven prescriptions), in duration of postoperative narcotic use (p < 0.001) between the single narcotic provider group (twenty-eight days) and the multiple narcotic provider group (110 days), and in morphine equivalent dose per day (p = 0.002) between the single narcotic provider group (26 mg) and the multiple narcotic provider group (43 mg). Patients with a high school education or less were 3.2 times more likely to seek multiple providers (p = 0.02), and patients with a history of preoperative narcotic use were 4.5 times more likely to seek multiple providers (p < 0.001). There is a 20.8% prevalence of postoperative doctor shopping in the orthopaedic trauma population. Patients with multiple postoperative narcotic providers had a significant increase in postoperative narcotic prescriptions, duration of narcotics, and morphine equivalent dose per day.

Rehabilitation needs change with time after orthopaedic major trauma

Background: To comply with the Best Practice Tariff for Major Trauma, rehabilitation prescriptions are completed for patients with an Injury Severity Score above 8, which covers a broader, previously-undefined population. This project uses the rehabilitation prescription to define the characteristics and rehabilitation needs of the orthopaedic major trauma population. Methods: A total of 336 patients with orthopaedic major trauma had an initial rehabilitation prescription completed in 1 year. Over a 7-month period, 143 of these patients were clinically assessed by a trauma rehabilitation specialist physiotherapist. Demographic data and rehabilitation needs identified from initial and follow-up rehabilitation prescriptions were recorded and analysed. Results: Orthopaedic injuries affect the largest number of major trauma patients (n=336/692). Falls (30%) and road accidents (29%) are the most common mechanisms of trauma for patients of all ages (mean 55.6 years). At initial assessment, mobility (97%), pain (95%), and independence with activities of daily living (IADL) (79%) were the most prevalent rehabilitation needs identified. Five months after injury, patients had a reduced rehabilitation need for mobility (60%), IADL (30%), and pain (27%). The need for psychological support increased from 2% to 22%, while vocational needs remained stable (initial 29%, review 26%). Difficulties with mood were first identified at the review stage in 94% of cases. Of patients who were reassessed, 48% had unmet rehabilitation needs requiring referral to physiotherapy (25%), health psychology (13%), and orthopaedic review (6%). Conclusions: Rehabilitation from orthopaedic major trauma continues beyond the acute hospital admission. Mobility, pain and IADL are most affected by injury, and mobility problems can persist for many months after injury. Rehabilitation needs can change, with difficulties managing emotions developing over time. Physiotherapists play a lead role in addressing the most frequent rehabilitation needs, but patients need multidisciplinary support, including health psychology and pain specialists, to meet their ongoing rehabilitation needs. Implications: Orthopaedic major trauma patients require access to specialist multidisciplinary rehabilitation throughout their recovery journey. Reassessment of the rehabilitation prescription is necessary to evaluate an individual's changing rehabilitation needs and improve access to appropriate professionals.