Organization of orthopaedic trauma services: a survey of the Orthopaedic Trauma Association

Routine Postoperative Computed Tomography Scans Following Posterior Pelvic Fixation of Pelvic Ring Fractures: A Survey of (OTA) Orthopaedic Traumatologists

OBJECTIVE

To assess practices related to ordering computed tomography (CT) scans routinely after posterior pelvic ring fixation and revision surgery rates.

DESIGN

A 20-question cross-sectional survey.

PARTICIPANTS

Fellowship-trained orthopaedic traumatologists.

MAIN OUTCOME MEASUREMENTS

(1) Percentage of surgeons ordering a routing postoperative CT after posterior pelvic ring fixation, (2) Revision surgery rates based on routine CT scan results.

RESULTS

Responses were received from 57 surgeons. Practices varied regarding postoperative CT scans, with 20 surgeons (35%, group A) routinely ordering them and 37 surgeons (65%, group B) not ordering them on all patients. Group A were younger and with less years of experience than those in Group B. Most group A surgeons report a revision surgery rate of <1% based on results of the postoperative CT. Group A report routine postoperative scans were obtained to assess reduction, instrumentation placement, and for educational purposes. Group B did not obtain routine postoperative CTs because of the following: unlikely to change postoperative treatment course, adequate reduction and instrumentation placement assessed intraoperatively and by postoperative radiographs, and increased radiation exposure and cost to patients. Group B did report obtaining postop CT scans on select patients, with postoperative neurological deficit being the most common indication.

CONCLUSIONS

The routine use of postoperative CTs following posterior fixation of pelvic ring fractures is a controversial topic. Although we recognize the role for postoperative CT scans in select patients, our study questions the clinical utility of these scans in all patients and in conclusion do not recommend this protocol.

Surveying the POSNA Landscape: What Can We Learn From Society Survey Studies?

BACKGROUND

A growing trend of survey-based research has been seen in the field of pediatric orthopaedics. The purpose of this study was to describe patterns of surveys of Pediatric Orthopaedic Society of North America (POSNA) membership and evaluate for associations between study characteristics and response rates in order to inform future research efforts. We hypothesized that studies with fewer survey questions and study group or committee involvement would demonstrate higher response rates.

METHODS

A systematic review of the literature was performed to identify all peer-reviewed survey publications targeting POSNA members published up to December 2017. Included studies were reviewed to identify author and publication characteristics, survey development and methodology, survey distribution procedures, and response rates. Statistical analyses were performed to describe publication patterns and evaluate for associations between study characteristics and response rates.

RESULTS

Thirty-four studies published from 1991 to 2017 were identified as meeting inclusion criteria, with a substantial increase noted over the last 3 years. Studies included 4.6 (SD 1.9) authors and 14.7% had affiliations with study groups or committees. Survey development methodology was detailed in only 1 study. Surveys included a median of 19.5 questions (3 to 108) and were primarily electronically distributed. The mean survey response rate was 42% with a downward trend noted over the studied time period. None of the studied author, publication, and design characteristics were associated with increased response rates.

CONCLUSIONS

Survey-based studies of the POSNA membership have become increasingly popular study designs in recent years. Response rates are lower than reports in other physician cohorts, and appear to be declining, possibly representative of respondent fatigue. No associations were identified between response rates and the modifiable study characteristics evaluated (number of authors, committee or subgroup affiliation, number of questions, and mode of distribution). Efforts should be made to identify tactics to sustain participation as these studies become more widely utilized within our field. Optimizing study design and implementation features while valuing physician time and effort spent on survey completion is important to avoid member survey fatigue.

LEVEL OF EVIDENCE

Level V-systematic review of Level V research.

Therapeutic outcomes of low-level laser therapy for closed bone fracture in the human wrist and hand

OBJECTIVE

The therapeutic outcomes of low-level laser therapy (LLLT) on closed bone fractures (CBFs) in the wrist and hand were investigated in this controlled study.

BACKGROUND DATA

Animal research has confirmed that LLLT increases osteocyte quantity; however, little research has been conducted to determine the effect of LLLT on the treatment of human bone fractures.

METHODS

In this study, the therapeutic outcomes of administering 830 nm LLLT to treat CBFs in the wrist or hand were examined. Fifty patients with CBFs in the wrist and hand, who had not received surgical treatment, were recruited and randomly assigned to two groups. The laser group underwent a treatment program in which 830 nm LLLT (average power 60 mW, peak power 8 W, 10 Hz, 600 sec, and 9.7 J/cm(2) per fracture site) was administered five times per week for 2 weeks. Participants in a placebo group received sham laser treatment. The pain, functional disability, grip strength, and radiographic parameters of the participants were evaluated before and after treatment and at a 2-week follow-up.

RESULTS

After treatment and at the follow-up, the laser group exhibited significant changes in all of the parameters compared with the baseline (p<0.05). The results of comparing the two groups after treatment and at the follow-up indicated significant between-group differences among all of the parameters (p<0.05).

CONCLUSIONS

LLLT can relieve pain and improve the healing process of CBFs in the human wrist and hand.

Finding your first job in a community hospital

Community hospitals offer excellent opportunities for graduating orthopaedic trauma fellows. To successfully compete for these jobs, applicants today must be better prepared than their predecessors. Organizing your practice aspirations and researching job opportunities before the interview are necessary for an effective job search. Often, a collaborative effort with hospital administrators is required to establish a viable practice that fulfills the unique needs of the hospital and surrounding community while concurrently satisfying your practice goals. Issues to consider in defining your desired practice, guidelines on how to prepare for an interview with a community hospital, and suggestions on how to justify the expense of establishing your practice are presented.

A survey of physician opinion: adolescent midshaft clavicle fracture treatment preferences among POSNA members

BACKGROUND

Based on recent evidence of inconsistent outcomes after the closed treatment of adult midshaft clavicle fractures, the management of similar fracture patterns in adolescents is being reevaluated. The primary aim of this study is to report current treatment preferences for adolescent midshaft clavicle fractures among pediatric orthopaedic physicians and to determine if recent adult literature has influenced clinical decision making.

METHODS

An invitation email to a cross-sectional, web-based survey was sent to all members of the Pediatric Society of North America. With reference to adolescent sex and age, respondents were prompted to indicate their treatment preference (operative vs. nonoperative) in 4 common midshaft clavicle fracture patterns. The respondents were also asked to indicate if the following factors: findings in current literature supporting operative fixation in adults, arm dominance, and/or athletic status, influenced their preference for operative versus nonoperative management.

RESULTS

Of the 949 Pediatric Society of North America members, 302 responded in full (32% response rate). The majority of physicians preferred nonoperative treatment for all fracture patterns. A logistic regression analysis revealed: older adolescent age (12 to 15 y vs. 16 to 19 y.) and evidence in recent adult literature (influence vs. no influence) to be significantly (P < 0.01) predictive of physician preference toward operative fixation in angulated, displaced, and isolated segmental clavicle fracture patterns. Physician years of experience (< 5 y vs. > 5 y) significantly predicted treatment preferences in isolated segmental fractures only.

CONCLUSIONS

The percentage of physicians in favor of operative fixation tended to increase in reference to older adolescents and more severe fracture patterns but, nonoperative management was preferred in all fracture patterns. Evidence in recent adult literature was found to be the most significant factor influencing treatment preferences in this survey. Randomized controlled trials are needed to evaluate the efficacy of primary operative fixation of midshaft clavicle fractures in adolescent populations.

LEVEL OF EVIDENCE

Cross-sectional electronic survey; level V-expert opinion.

The organizational and financial viability of an orthopedic trauma service

BACKGROUND

This study was designed to explore the effect of establishing an Orthopedic Trauma Service (OTS) on departmental revenue within an academic orthopedic department. The effect of the OTS on physician and resident perceptions of job satisfaction, education, and quality of patient care were also evaluated.

METHODS

A proforma financial analysis was undertaken using an optimization model to predict the potential financial performance of an OTS before its implementation. Financial data were then collected prospectively for the first year of the OTS and compared with the preceding year's financial data. All residents and faculty in the department completed visual analog scale surveys after the formation of the service.

RESULTS

While maintaining a fixed amount of work production (work relative value units [WRVUs]) per year, our model predicted an $111,000 increase in departmental charges as a result of a shift in the elective case mix. After implementation of the OTS, elective charges/WRVU increased by 7.4% while trauma charges/WRVU increased by 2.6%. This, combined with a minor increase in departmental work volume (115,661 WRVUs pre-OTS vs. 117,577 WRVUs post-OTS) and an improvement in collections/charge (47-48%), yielded a departmental collection increase of 11% ($1.1 million). Resident and faculty job satisfaction improved, as did the perception of the quality of trauma care that was being provided.

CONCLUSIONS

The organization and implementation of an OTS within an academic orthopedic department can lead to an improved professional experience for residents and faculty, the perception of improved patient care for the trauma patient, and an increase in departmental revenue.

Orthopaedic faculty trauma call policies: a survey of accredited orthopaedic residency programs

The purpose of the study was to determine the practices and policies for trauma call for orthopaedic faculty at residency training programs. A 2-page survey was mailed to the chairs of 141 nonmilitary, accredited residency programs. Responses were received from 106 (75% response rate). Of the responders, 97 (91.5%) of the programs were associated with a Level 1 trauma center. All faculty took trauma call in 44% of programs. The chair took trauma call in 60% of the programs. In 35% of programs, full-time faculty earned additional compensation for taking call. The source of this compensation for full-time faculty was the hospital alone in 72%. In 32 programs, a per-diem stipend (mean $696, range $100-1,500) was provided. In 59% of programs, there was a specific orthopaedic "trauma team" that took over patient care from other faculty members after call. Thirty-three percent of programs had a policy concerning age when a full-time faculty member went off trauma call. Of these, faculty came off call at age 50 years in 11% of programs; at age 55 years in 29%; at age 60 years in 40%; at age 65 years in 9%; and "other" in 11%. Twenty percent of chairs responded that trauma call adversely affected the chair's ability to recruit new faculty. There was a wide variety of policies concerning orthopaedic faculty trauma call. Additional studies on faculty trauma call are warranted.

Towards Regionalized Care of Severe Orthopedic Injuries: A Survey on Non-university Hospitals in Finland

INTRODUCTION

The principles of a designated trauma system and regionalization of trauma care exist in very limited areas in Finland. In this study, we obtained information on the current personal opinions of orthopedicsin-chief (OICs) and surgeons-in-chief (SICs) towards regionalization of severe orthopedic trauma care in Finland.

MATERIALS AND METHODS

A questionnaire was sent to OICs and SICs working in 36 primary and secondary hospitals providing acute surgical care asking to give their personal opinions whether certain severe orthopedic injuries should be managed in their hospitals or be referred.

RESULTS

The overall response rate was 49/67 (73%). In general, SICs tended to be more reluctant to refer patients to higher level facilities. Both OICs and SICs were more willing to refer spinal and pelvic injuries than complicated long bone fractures.

CONCLUSIONS

There seems to be major differences in personal views on referral policy between OICs and SICs. This information is useful prior to discussions by the professional organizations, hospitals, and the government in establishing a modern orthopedic trauma system in Finland.

Excessive volume of trauma workload out of hours: is it really true?

To determine whether an excessive out of hours workload might contribute to the current lack of interest in trauma orthopaedics as a sub-specialty in the United Kingdom we reviewed data collected prospectively on 467 multiple trauma patients (ISS > 15) presenting to a teaching hospital over a 5 year period (January 1996-January 2001). Almost half of the patients (48.6%) presented between the hours of 18:00 and 08:00 with the trauma team called more frequently out of normal working hours. Two hundred and eleven (45.2%) patients underwent an operative procedure during their admission with an orthopaedic surgeon involved in the procedure in the majority of cases. Nearly half (41.5%) of these cases started between 18:00 and 08:00 with a larger portion (49.6%) finishing between these hours. A Consultant was the primary surgeon in 123 (82.0%) cases and involved in the majority of out of hours operating. Intensive care was required for 151 (32.3%) patients. The median hospital stay was 9 days (1-93). The out of hours workload for Orthopaedic consultants working in a busy teaching hospital is considerable. Planning issues need to be addressed to ensure that a career in trauma surgery is made attractive to current and future orthopaedic trainees.