Effect of Aspirin Versus Low-Molecular-Weight Heparin Thromboprophylaxis on Medication Satisfaction and Out-of-Pocket Costs: A Secondary Analysis of a Randomized Clinical Trial

BACKGROUND

Current guidelines recommend low-molecular-weight heparin for thromboprophylaxis after orthopaedic trauma. However, recent evidence suggests that aspirin is similar in efficacy and safety. To understand patients' experiences with these medications, we compared patients' satisfaction and out-of-pocket costs after thromboprophylaxis with aspirin versus low-molecular-weight heparin.

METHODS

This study was a secondary analysis of the PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT) trial, conducted at 21 trauma centers in the U.S. and Canada. We included adult patients with an operatively treated extremity fracture or a pelvic or acetabular fracture. Patients were randomly assigned to receive 30 mg of low-molecular-weight heparin (enoxaparin) twice daily or 81 mg of aspirin twice daily for thromboprophylaxis. The duration of the thromboprophylaxis, including post-discharge prescription, was based on hospital protocols. The study outcomes included patient satisfaction with and out-of-pocket costs for their thromboprophylactic medication measured on ordinal scales.

RESULTS

The trial enrolled 12,211 patients (mean age and standard deviation [SD], 45 ± 18 years; 62% male), 9725 of whom completed the question regarding their satisfaction with the medication and 6723 of whom reported their out-of-pocket costs. The odds of greater satisfaction were 2.6 times higher for patients assigned to aspirin than those assigned to low-molecular-weight heparin (odds ratio [OR]: 2.59; 95% confidence interval [CI]: 2.39 to 2.80; p < 0.001). Overall, the odds of incurring any out-of-pocket costs for thromboprophylaxis medication were 51% higher for patients assigned to aspirin compared with low-molecular-weight heparin (OR: 1.51; 95% CI: 1.37 to 1.66; p < 0.001). However, patients assigned to aspirin had substantially lower odds of out-of-pocket costs of at least $25 (OR: 0.15; 95% CI: 0.12 to 0.18; p < 0.001).

CONCLUSIONS

Use of aspirin substantially improved patients' satisfaction with their medication after orthopaedic trauma. While aspirin use increased the odds of incurring any out-of-pocket costs, it protected against costs of ≥$25, potentially improving health equity for thromboprophylaxis.

LEVEL OF EVIDENCE

Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Fix or Replace? Patient Preferences for the Treatment of Geriatric Lower Extremity Fractures: A Discrete Choice Experiment

Introduction

When considering treatment options for geriatric patients with lower extremity fractures, little is known about which outcomes are prioritized by patients. This study aimed to determine the patient preferences for outcomes after a geriatric lower extremity fracture.

Materials and Methods

We administered a discrete choice experiment survey to 150 patients who were at least 60 years of age and treated for a lower extremity fracture at a Level I trauma center. The discrete choice experiment presented study participants with 8 sets of hypothetical outcome comparisons, including joint preservation (yes or no), risk of reoperation at 6 months and 24 months, postoperative weightbearing status, disposition, and function as measured by return to baseline walking distance. We estimated the relative importance of these potential outcomes using multinomial logit modeling.

Results

The strongest patient preference was for maintained function after treatment (59%, P < .001), followed by reoperation within 6 months (12%, P < .001). Although patients generally favored joint preservation, patients were willing to change their preference in favor of joint replacement if it increased function (walking distance) by 13% (SE, 66%). Reducing the short-term reoperation risk (12%, P < .001) was more important to patients than reducing long-term reoperation risk (4%, P = .33). Disposition and weightbearing status were lesser priorities to patients (9%, P < .001 and 7%, P < .001, respectively).

Discussion

After a lower extremity fracture, geriatric patients prioritized maintained walking function. Avoiding short-term reoperation was more important than avoiding long-term reoperation. Joint preservation through fracture fixation was the preferred treatment of geriatric patients unless arthroplasty or arthrodesis provides a meaningful functional benefit. Hospital disposition and postoperative weightbearing status were less important to patients than the other included outcomes.

Conclusions

Geriatric patients strongly prioritize function over other outcomes after a lower extremity fracture.

Frequency and Characteristics of Posterior Labral Injuries in Operative Acetabular Fractures Treated Through a Posterior Approach: A Prospective Observational Study

OBJECTIVES

The association between labral injuries and acetabular fractures is unknown. This study aimed to identify the frequency and characteristics of labral injuries in operatively treated acetabular fractures that cannot be identified on preoperative imaging.

METHODS

 .

DESIGN

Prospective observational cohort.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Adult patients with an acetabular fracture operatively treated through a posterior approach.

OUTCOME MEASURES AND COMPARISONS

The frequency and characteristics of labral injuries.

RESULTS

Fifty-three of 71 acetabular fractures (75%; 95% confidence interval, 63%-83%) demonstrated a labral injury visible via the posterior approach. Posterior labral injuries occurred in 89% of operative acetabular fracture patterns involving the posterior wall and most commonly represent a detachment of the posteroinferior labrum (n = 39, 75%). Fractures with a labral injury were more likely to have gluteus minimus damage (93% vs. 61%, P = 0.02), femoral head lesions (38% vs. 17%, P = 0.03), joint capsule detachment (60% vs. 33%, P = 0.05), and fracture patterns involving the posterior wall (89% vs. 50%, P = 0.05).

CONCLUSIONS

This study describes the high rate (89%) of posterior labral injuries in posterior wall fractures, the most common injury pattern being a detachment of the posteroinferior labrum. Labral injuries in acetabular fractures may have important clinical implications and this study is the first to identify the frequency and characteristics of these injuries. Further studies should assess the relationship between labral injuries, treatment strategies, and the progression to post-traumatic osteoarthritis.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Work Productivity Loss After Minimally Displaced Complete Lateral Compression Pelvis Fractures

OBJECTIVE

To quantify work impairment and economic losses due to lost employment, lost work time (absenteeism), and lost productivity while working (presenteeism) after a lateral compression pelvic ring fracture. Secondarily, productivity loss of patients treated with surgical fixation versus nonoperative management was compared.

METHODS

DESIGN

Secondary analysis of a prospective, multicenter trial.

SETTING

Two level I academic trauma centers.

PATIENT SELECTION CRITERIA

Adult patients with a lateral compression pelvic fracture (OTA/AO 61-B1/B2) with a complete posterior pelvic ring fracture and less than 10 mm of initial displacement. Excluded were patients who were not working or non-ambulatory before their pelvis fracture or who had a concomitant spinal cord injury.

OUTCOME MEASURES AND COMPARISONS

Work impairment, including hours lost to unemployment, absenteeism, and presenteeism, measured by Work Productivity and Activity Impairment assessments in the year after injury. Results after non-operative and operative treatment were compared.

RESULTS

Of the 64 included patients, forty-seven percent (30/64) were treated with surgical fixation, and 53% (30/64) with nonoperative management. 63% returned to work within 1 year of injury. Workers lost an average of 67% of a 2080-hour average work year, corresponding with $56,276 in lost economic productivity. Of the 1395 total hours lost, 87% was due to unemployment, 3% to absenteeism, and 10% to presenteeism. Surgical fixation was associated with 27% fewer lost hours (1155 vs. 1583, P = 0.005) and prevented $17,266 in average lost economic productivity per patient compared with nonoperative management.

CONCLUSIONS

Lateral compression pelvic fractures are associated with a substantial economic impact on patients and society. Surgical fixation reduces work impairment and the corresponding economic burden.

LEVEL OF EVIDENCE

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Association of Radial Head Fracture Treatment With Long-Term Function

BACKGROUND

Radial head fractures are often associated with poor outcomes. Both open reduction and internal fixation (ORIF) and radial head arthroplasty (RHA) might be considered in operative cases. This study aimed to compare long-term patient-reported functional outcomes among patients with operatively treated radial head fractures.

METHODS

A cross sectional study conducted at a Level I trauma center was used to identify patients with a radial head fracture who underwent ORIF or RHA between 2006 and 2018, and agreed to complete a survey in 2020. The primary outcome measure was the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score.

RESULTS

Seventy-six patients participated in the study. No significant differences in outcomes were observed between groups. QuickDASH scores were similar for both groups (ORIF: mean = 15.7, SD = 18.4; RHA: mean = 22.8, SD = 18.6; mean difference = 0.2 [-9.0 to 9.3], P = .97). Nineteen (37%) ORIF patients and 12 (48%) RHA patients reported a need for pain medication (adjusted odds ratio [OR] = 0.8 [0.3-2.4], P = .70). Thirteen (25%) ORIF patients and 6 (24%) RHA patients required additional surgery (adjusted OR = 1.7 [0.5-6.2], P = .39). A subgroup analysis of multi-fragmentary fractures revealed similar findings.

CONCLUSION

Patient-reported outcomes, which included a subgroup analysis of multi-fragmentary fractures, were similar between ORIF and RHA groups at an average of 7.5 years from surgery. Reconstructing the radial head might not result in worse outcomes than RHA when both options are employed according to the best judgment of the operating surgeon.

Transphyseal Humeral Separations: An Often-Missed Fracture

BACKGROUND

Transphyseal humeral separations (TPHS) are rare injuries often associated with non-accidental trauma, necessitating accurate diagnosis. This study aims to assess the accuracy of diagnosis of TPHS.

METHODS

A retrospective review was conducted at five academic pediatric institutions to identify all surgically treated TPHS in patients up to 4 years of age over a 25-year period. Demographics, misdiagnosis rates, and reported misdiagnoses were noted. Comparative analyses were performed to analyze the effects of patient age and injury mechanism on misdiagnosis rates.

RESULTS

Seventy-nine patients (average age: 17.4 months) were identified, with injury mechanisms including accidental trauma (n = 49), non-accidental trauma (n = 21), Cesarean-section (n = 6), and vaginal delivery (n = 3). Neither age nor injury mechanism were significantly associated with diagnostic accuracy in the emergency department (ED)/consulting physician group. ED/consulting physicians achieved an accurate diagnosis 46.7% of the time, while radiologists achieved an accurate diagnosis 26.7% of the time. Diagnostic accuracy did not correlate with Child Protective Services (CPS) involvement or with a delay in surgery of more than 24 h. However, a significant correlation (p = 0.03) was observed between injury mechanism and misdiagnosis rates.

CONCLUSION

This multicenter analysis is the largest study assessing TPHS misdiagnosis rates, highlighting the need for raising awareness and considering advanced imaging or orthopedic consultation for accurate diagnosis. This also reminds orthopedic surgeons to always have vigilant assessment in treating pediatric elbow injuries.

LEVEL OF EVIDENCE

Level III-Retrospective Cohort Study.

The Mental Health Implications of Obstetric Brachial Plexus Injuries (OBPI) on Parents

BACKGROUND

Obstetric brachial plexus injuries (OBPI) can have mental health implications on parents coping with this injury to their newborn. The purpose of this study was to assess the mental health of mothers with newborns with an OBPI and identify resources that can help screen and treat mental health needs.

MATERIAL AND METHODS

Three groups of mothers were prospectively given a self-reported survey: 1) Newborns with OBPI; 2) Newborns in the nursery without OBPI; 3) Newborns in the neonatal intensive care unit (NICU). The survey consisted of demographic questions, the PHQ-9 and PCL-S screening tools, and parents' exposure to community violence, family support and use of drugs or alcohol.

RESULTS

Fifty-seven mothers were prospectively enrolled, and 30% (17/57) of mothers screened in for post-traumatic stress disorder (PTSD). OBPI mothers had significantly higher rates of PTSD symptoms when compared to mothers of children in the full-term nursery (difference = 36.4%; p < 0.01). No statistically significant difference was found between groups regarding depression symptoms.

CONCLUSIONS

OBPI can be very difficult to cope with for parents and family members. Forty-two percent of mothers with newborns with OBPI or children in the NICU screened in for PTSD symptoms. OBPI clinics should be staffed similarly to the NICU with clinical social workers to appropriately screen and treat parents with PTSD and depression symptoms.

Unreamed Intramedullary Nailing Versus External Fixation for the Treatment of Open Tibial Shaft Fractures in Uganda: A Randomized Clinical Trial

OBJECTIVE

To compare unreamed intramedullary nailing versus external fixation for the treatment of Gustilo-Anderson type II and IIIA open tibial fractures admitted to a hospital in rural Uganda.

DESIGN

Randomized clinical trial.

SETTING

Regional referral hospital in Uganda.

PATIENTS

Fifty-five skeletally mature patients with a Gustilo-Anderson type II or IIIA open tibia shaft fracture treated within 24 hours of injury between May 2016 and December 2019.

INTERVENTION

Unreamed intramedullary nailing (n = 31) versus external fixation (n = 24).

MAIN OUTCOME MEASUREMENTS

The primary outcome was function within 12 months of injury, measured using the Function IndeX for Trauma (FIX-IT) score. Secondary outcomes included health-related quality of life (HRQoL) using the 3-level version of the 5-dimension EuroQol instrument (EQ-5D-3L), radiographic healing using the Radiographic Union Scale for Tibia (RUST) fractures score, and clinical complications.

RESULTS

Treatment with an intramedullary nail resulted in a 1.0-point higher [95% credible intervals (CrI), 0.1 to 1.9] FIX-IT score compared with external fixation. Results were similar for the secondary patient-reported outcomes, EQ-5D-3L and the visual analog scale component of the EuroQol instrument (EQ-VAS). RUST scores were not different between groups at any time point. Treatment with an intramedullary nail was associated with a 22.1% (95% CrI, -42.6% to 1.7%) lower rate of malunion and a 20.8% (95% CrI, -44.0% to 2.9%) lower rate of superficial infection.

CONCLUSION

In rural Uganda, treatment of open tibial shaft fractures with an unreamed intramedullary nail results in marginal clinically important improvements in functional outcomes, although there is likely an important reduction in malunion and superficial infection.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Understanding healthcare provider preferences for ordering respiratory cultures to diagnose ventilator associated pneumonia: A discrete choice experiment

OBJECTIVE

Ventilator-associated pneumonia (VAP) can be overdiagnosed on the basis of positive respiratory cultures in the absence of clinical findings of pneumonia. We determined the perceived diagnostic importance of 6 clinical attributes in ordering a respiratory culture to identify opportunities for diagnostic stewardship.

DESIGN

A discrete choice experiment presented participants with a vignette consisting of the same "stem" plus variations in 6 clinical attributes associated with VAP: chest imaging, oxygenation, sputum, temperature, white blood cell count, and blood pressure. Each attribute had 3-4 levels, resulting in 32 total scenarios. Participants indicated whether they would order a respiratory culture, and if yes, whether they preferred the bronchoalveolar lavage or endotracheal aspirate sample-collection method. We calculated diagnostic utility of attribute levels and relative importance of each attribute.

SETTING AND PARTICIPANTS

The survey was administered electronically to critical-care clinicians via a Qualtrics survey at a tertiary-care academic center in the United States.

RESULTS

In total, 59 respondents completed the survey. New radiograph opacity (utility, 1.15; 95% confidence interval [CI], 0.99-1.3), hypotension (utility, 0.88; 95% CI, 0.74-1.03), fever (utility, 0.76; 95% CI, 0.62-0.91) and copious sputum (utility, 0.75; 95% CI, 0.60-0.90) had the greatest perceived diagnostic value that favored ordering a respiratory culture. Radiograph changes (23%) and temperature (20%) had the highest relative importance. New opacity (utility, 0.35; 95% CI, 0.17-0.52) and persistent opacity on radiograph (utility, 0.32; 95% CI, 0.05-0.59) had the greatest value favoring bronchoalveolar lavage over endotracheal aspirate.

CONCLUSION

Perceived high diagnostic value of fever and hypotension suggest that sepsis vigilance may drive respiratory culturing and play a role in VAP overdiagnosis.

Pelvic Ring Injury Mortality: Are We Getting Better?

OBJECTIVES

To determine if changes in pelvic trauma care and treatment protocols have affected overall mortality rates after pelvic ring injury.

DESIGN

Retrospective cohort study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

A total of 3314 patients with pelvic ring injuries who presented to a single referral center from 1999 to 2018 were included in the study.

INTERVENTION

Pelvic ring management, years 1999-2006 versus years 2007-2018.

MAIN OUTCOME MEASUREMENTS

In hospital mortality. Other examined variables included change in patient demographics, fracture characteristics, date of injury, associated injuries, length of hospital stay, Abbreviated Injury Severity Score.

RESULTS

The composite mortality rate was 6.5% (214/3314). The earliest cohort presented a mortality rate of 9.1% [111/1224; 95% confidence interval (CI), 7.6%-10.8%] compared with the more recent cohort mortality rate of 4.9% (103/2090; 95% CI, 4.1%-5.9%). Overall mortality was significantly lower in the more recent period, a risk difference of 4.1% (95% CI, 2.3%-6.1%; P < 0.01). After adjusting for age and Abbreviated Injury Severity Score of the brain, chest, and abdomen, the mortality reduction was more pronounced with an adjusted risk difference of 6.4% (95% CI, 4.7%-8.1%; P < 0.01).

CONCLUSION

Significant improvement in the mortality rate of pelvic ring injuries has been demonstrated in recent years (4.9% vs. 9.1%) and the difference is even large when accounting for known confounders. Improvement appears to coincide chronologically with changes in trauma resuscitation and implementation of adjuvant treatments for managing patients with severe hemorrhagic shock. Although the exact benefit of each treatment awaits further research, these data might indicate improved care over time for these difficult patients.

LEVEL OF EVIDENCE

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

Are Pelvic Binders an Effective Prehospital Intervention?

OBJECTIVE

Widespread adoption of prehospital pelvic circumferential compression devices (PCCDs) by emergency medical services (EMS) systems has been slow and variable across the United States. We sought to determine the frequency of prehospital PCCD use by EMS providers. Secondarily, we hypothesized that prehospital PCCD use would improve early hemorrhagic shock outcomes.

METHODS

We conducted a single-center retrospective cohort study of 162 unstable pelvic ring injuries transported directly to our center by EMS from 2011 to 2020. Included patients received a PCCD during their resuscitation (prehospital or emergency department). Prehospital treatment details were obtained from the EMS medical record. The primary outcome was the proportion of patients who received a PCCD by EMS before hospital arrival. Secondarily, we explored factors associated with receiving a prehospital PCCD, and its association with changes in vital signs, blood transfusion, and mortality.

RESULTS

EMS providers documented suspicion of a pelvic ring fracture in 85 (52.8%) patients and 52 patients in the cohort (32.2%) received a prehospital PCCD. Wide variation in prehospital PCCD use was observed based on patient characteristics, geographic location, and EMS provider level. Helicopter flight paramedics applied a prehospital PCCD in 46% of the patients they transported (38/83); in contrast, the EMS organizations geographically closest to our hospital applied a PCCD in ≤5% of cases (2/47). Other predictors associated with receiving a prehospital PCCD included lower body mass index (p = 0.005), longer prehospital duration (p = 0.001) and lower Injury Severity Score (p < 0.05). We were unable to identify any improvements in clinical outcomes associated with prehospital PCCD, including early vital signs, number of blood transfusions within 24 hours, or mortality during admission (p > 0.05).

CONCLUSION

Our results demonstrate wide practice variation in the application of prehospital PCCDs. Although disparate PCCD application across the state is likely explained by differences across EMS organizations and provider levels, our study was unable to identify any clinical benefits to the prehospital use of PCCDs. It is possible that the benefits of a prehospital PCCD can only be observed in the most displaced fracture patterns with the greatest early hemodynamic instability.

Association of Postoperative Infections After Fractures With Long-term Income Among Adults

IMPORTANCE

Postoperative infections after a fracture exert tremendous costs on the health care system. However, the patient economic burden associated with a postoperative infection is unclear.

OBJECTIVE

To evaluate the association between a postoperative infection and long-term income among patients with surgically treated fractures.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study linked academic trauma center data with Maryland tax records using inverse probability of treatment weighting to estimate between-group differences among 11 673 adults who underwent surgery to treat fractures of the extremities or pelvis between January 1, 2003, and December 31, 2016. Statistical analysis was performed from November 5, 2019, to August 30, 2020.

EXPOSURE

A postoperative infection within 1 year of injury.

MAIN OUTCOMES AND MEASURES

The primary outcome was the annual household income up to 6 years after injury. Household income incorporates multiple types of income, including wage earnings, taxable Social Security benefits, workers' compensation, and disability benefits. Secondary outcomes included individual earnings, Social Security benefits, unemployment benefits, and catastrophic income loss.

RESULTS

The study included 11 673 patients (7756 male patients [66.4%]; mean [SD] age, 45.2 [19.2] years) with a mean (SD) preinjury household income of $30 505 ($89 030). A total of 403 patients (3.5%) had a postoperative infection. Postoperative infections were associated with a $6080 annual decrease (95% CI, -$12 114 to -$47; P = .048) in household income in the 6 years after injury. Postoperative infections were associated with a 6.6% increase (95% CI, 4.9%-8.3%; P < .001) in the risk of catastrophic wage loss within 2 years of the fracture and were associated with a 45% increase in the odds of receiving Social Security benefits (odds ratio, 1.45; 95% CI, 1.25-1.68; P < .001). However, incurring a postoperative infection was not associated with an increase in the value of the Social Security benefits received.

CONCLUSIONS AND RELEVANCE

This study suggests that postoperative infections have significant and sustained income-associated implications for patients who experience a fracture. Current Social Security mechanisms may not offset the decreased income.

Analysis of Patient Income in the 5 Years Following a Fracture Treated Surgically

IMPORTANCE

Orthopedic injury is assumed to bear negative socioeconomic consequences. However, the magnitude and duration of a fracture's impact on patient income and social insurance benefits remain poorly quantified.

OBJECTIVE

To characterize the association between orthopedic injury and patient income using state tax records.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included adult patients surgically treated for an orthopedic fracture at a US academic trauma center from January 2003 through December 2014. Hospital data were linked to individual-level state tax records using a difference-in-differences analysis performed from November 2019 through August 2020. The control group comprised of data resampled from fracture patients at least 6 years prior to injury.

EXPOSURES

An operatively treated fracture of the appendicular skeleton.

MAIN OUTCOMES AND MEASURES

The primary outcome was individual annual earnings up to 5 years postinjury. Secondary outcomes included annual household income and US Social Security benefits for 5 years postinjury and catastrophic wage loss within 2 years of injury.

RESULTS

A total of 9997 fracture patients (mean [SD] age, 44.6 [18.9] years; 6725 [67.3%] men) to 34 570 prefracture control participants (mean [SD] age, 40.0 [20.5] years; 21 666 [62.7%] men). The median (interquartile range) of preinjury wage earnings was $16 847 ($0 to $52 221). The mean annual decline in individual earnings during the 5 years following injury was $9865 (95% CI, -$10 686 to -$8862). Annual household income declined by $5259 (95% CI, -$6337 to -$4181) over the same period. A fracture was associated with a $206 (95% CI, $147 to $265) mean annual increase in Social Security benefits in the 5 years after injury. An injury increased the risk of catastrophic wage loss by 11.6% (95% CI, 10.5% to 12.7%). Substantial relative income loss was observed in patients with preinjury earnings in the top 3 quartiles, but changes in income were negligible for patients with preinjury earnings in the bottom quartile (19%; 95% CI, -4% to 48%).

CONCLUSIONS AND RELEVANCE

In this cohort study of patients surgically treated for an orthopedic fracture at a US academic trauma center, fractures were associated with substantial individual and household income loss up to 5 years after injury, and 1 in 5 patients sustained catastrophic income loss in the 2 years after fracture. Gains in Social Security benefits offset less than 10% of annual income losses.

Perspective on optical imaging for functional assessment in musculoskeletal extremity trauma surgery

SIGNIFICANCE

Extremity injury represents the leading cause of trauma hospitalizations among adults under the age of 65 years, and long-term impairments are often substantial. Restoring function depends, in large part, on bone and soft tissue healing. Thus, decisions around treatment strategy are based on assessment of the healing potential of injured bone and/or soft tissue. However, at the present, this assessment is based on subjective clinical clues and/or cadaveric studies without any objective measure. Optical imaging is an ideal method to solve several of these issues.

AIM

The aim is to highlight the current challenges in assessing bone and tissue perfusion/viability and the potentially high impact applications for optical imaging in orthopaedic surgery.

APPROACH

The prospective will review the current challenges faced by the orthopaedic surgeon and briefly discuss optical imaging tools that have been published. With this in mind, it will suggest key research areas that could be evolved to help make surgical assessments more objective and quantitative.

RESULTS

Orthopaedic surgical procedures should benefit from incorporation of methods to measure functional blood perfusion or tissue metabolism. The types of measurements though can vary in the depth of tissue sampled, with some being quite superficial and others sensing several millimeters into the tissue. Most of these intrasurgical imaging tools represent an ideal way to improve surgical treatment of orthopaedic injuries due to their inherent point-of-care use and their compatibility with real-time management.

CONCLUSION

While there are several optical measurements to directly measure bone function, the choice of tools can determine also the signal strength and depth of sampling. For orthopaedic surgery, real-time data regarding bone and tissue perfusion should lead to more effective patient-specific management of common orthopaedic conditions, requiring deeper penetrance commonly seen with indocyanine green imaging. This will lower morbidity and result in decreased variability associated with how these conditions are managed.

Effect of Extended Prophylactic Antibiotic Duration in the Treatment of Open Fracture Wounds Differs by Level of Contamination

OBJECTIVE

To determine the association between prophylactic antibiotic duration after the definitive wound closure of an open fracture and deep surgical site infection (SSI).

DESIGN

Retrospective cohort study.

SETTING

41 clinical sites in the United States, Canada, Australia, Norway, and India.

PARTICIPANTS

Patients (N = 2400) with open fractures of the extremities who participated in the Fluid Lavage of Open Wounds (FLOW) trial.

INTERVENTION

Extended antibiotic prophylaxis, defined as more than 72 hours of continuous antibiotic use after definitive wound closure.

MAIN OUTCOME MEASUREMENT

Deep SSI diagnosed within 1 year of enrollment.

RESULTS

Forty-two percent of participants received extended antibiotic prophylaxis. Deep SSI prevalence was 5%, 8%, and 23% for wounds with mild, moderate, and severe contamination, respectively. In open fractures with mild contamination, extended antibiotic use showed a trend toward increased odds [adjusted odds ratio (aOR) = 1.39; 95% confidence interval (CI), 0.92-2.11] of deep SSI compared with shorter use. No association was found among patients with moderate contamination (aOR = 1.09; 95% CI, 0.53-2.27). By contrast, extended antibiotic prophylaxis was strongly protective (aOR = 0.20; 95% CI, 0.07-0.60) against deep SSI in patients with severe contamination. Propensity score sensitivity analysis results were consistent with these findings.

CONCLUSIONS

The evidence suggests differential effects of extended postclosure antibiotic duration on SSI odds contingent on the degree of contamination in open fracture wounds. Although extended antibiotic duration resulted in lower odds of SSI among patients with severely contaminated wounds, we observed a trend toward higher odds of SSI in mildly contaminated wounds.

LEVEL OF EVIDENCE

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

The socioeconomic impact of orthopaedic trauma: A systematic review and meta-analysis

The overall objective of this study was to determine the patient-level socioeconomic impact resulting from orthopaedic trauma in the available literature. The MEDLINE, Embase, and Scopus databases were searched in December 2019. Studies were eligible for inclusion if more than 75% of the study population sustained an appendicular fracture due to an acute trauma, the mean age was 18 through 65 years, and the study included a socioeconomic outcome, defined as a measure of income, employment status, or educational status. Two independent reviewers performed data extraction and quality assessment. Pooled estimates of the socioeconomic outcome measures were calculated using random-effects models with inverse variance weighting. Two-hundred-five studies met the eligibility criteria. These studies utilized five different socioeconomic outcomes, including return to work (n = 119), absenteeism days from work (n = 104), productivity loss (n = 11), income loss (n = 11), and new unemployment (n = 10). Pooled estimates for return to work remained relatively consistent across the 6-, 12-, and 24-month timepoint estimates of 58.7%, 67.7%, and 60.9%, respectively. The pooled estimate for mean days absent from work was 102.3 days (95% CI: 94.8–109.8). Thirteen-percent had lost employment at one-year post-injury (95% CI: 4.8–30.7). Tremendous heterogeneity (I²>89%) was observed for all pooled socioeconomic outcomes. These results suggest that orthopaedic injury can have a substantial impact on the patient’s socioeconomic well-being, which may negatively affect a person’s psychological wellbeing and happiness. However, socioeconomic recovery following injury can be very nuanced, and using only a single socioeconomic outcome yields inherent bias. Informative and accurate socioeconomic outcome assessment requires a multifaceted approach and further standardization.

The Safety and Benefits of the Semisterile Technique for Closed Reduction and Percutaneous Pinning of Pediatric Upper Extremity Fractures

Background: Closed reduction and percutaneous pinning (CRPP) is traditionally performed following full surgical prep and draping. The semisterile technique utilizes minimal prep and draping, which was proven to be a viable alternative when treating pediatric supracondylar humerus fractures. The purpose of this study was to investigate the safety and benefits of the semisterile technique for CRPP of pediatric upper extremity fractures. Methods: A retrospective cohort study was conducted of pediatric patients who underwent CRPP of an upper extremity fracture over a 4-year period. Demographic data, fracture type/location, and the type of prep technique (full-prep vs semisterile) were recorded. Qualities of intraoperative care were assessed, and postoperative care parameters were compared. Patient outcomes for the 2 techniques were compared using bivariate analyses. Results: In total, 219 patient records were reviewed including 160 in the semisterile group and 59 in the full-prep group. When comparing intraoperative parameters between the full-prep and semisterile techniques, the average room setup time was similar (20.6 vs 18.8 minutes, P = .52). However, the procedure times (32.1 vs 26.9 minutes, P = .04) were significantly shorter in the semisterile group. Nearly a 10-minute decrease in total time in the operating room was present while utilizing the semisterile technique (62.8 vs 53.6 minutes, P < .01). There were no statistical differences in complication rates between prep groups (P = .31), and there were no infections while utilizing the semisterile technique. Conclusions: The semisterile technique is a safe and efficient alternative that may be used when performing CRPP of pediatric upper extremity fractures.

Serum 25(OH)D is associated with an altered bone turnover marker response after a hip fracture

C-terminal telopeptide of type I collagen (CTX) and procollagen type 1 N-terminal propeptide (P1NP) are bone turnover markers (BTMs) that are promising surrogate measures of fracture healing; however, it is unknown if their response is affected by other bone healing metabolites. Since 70% of fracture patients are reported to have insufficient serum vitamin D, we sought to determine if serum 25(OH)D levels are associated with differential changes in CTX and P1NP concentrations after hip fracture. This prospective cohort included hip fracture patients 65 years of age or older admitted to one of eight Baltimore-area hospitals. Serum samples were collected at baseline, 2-, 6-, and 12-month post-fracture. A mixed-effects repeated-measures analysis was used to determine the longitudinal association between vitamin D deficiency (25(OH)D < 20 ng/ml) and CTX and P1NP. Baseline lab values were obtained for 296 participants (mean age, 80.8 years; 51% male; 55% 25(OH)D < 20 ng/ml). During the acute fracture healing period P1NP concentrations increased by 14% (95%CI: 7-21%, p < 0.01) while CTX levels did not change (p = 0.07). Both CTX and P1NP decreased below baseline at 6 and 12 months. CTX levels were higher in participants with baseline 25(OH)D < 20 ng/ml (p = 0.01). There was no association between 25(OH)D < 20 ng/ml and P1NP levels over the study duration (p = 0.33). Data from this large, longitudinal cohort support claims that CTX and P1NP concentrations change during fracture healing; however, the differential response of CTX among vitamin D deficient patients highlights important questions for its utility as a reliable surrogate marker of fracture healing. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

High rate of reoperation and conversion to total hip arthroplasty after internal fixation of young femoral neck fractures: a population-based study of 796 patients

Background and purpose - Most often, the goal of non-geriatric femoral neck fracture surgery is to preserve the native hip joint. However, reoperations for painful implants, osteonecrosis, and nonunion are common. We determined the reoperation rate and time-to-reoperation following internal fixation of these fractures in a large population cohort. Patients and methods - This retrospective cohort study included patients between the ages of 18 and 50 years old who underwent internal fixation for a femoral neck fracture during 1997-2013. Patients were followed until December 2013. Primary outcomes were reoperation rate and time-to-reoperation. Time-to-event analysis was performed to estimate the rate of any reoperation and for THA specifically, while testing the dependency of time-to-reoperation on secondary variables. Results - 796 young femoral neck fracture patients were treated with internal fixation during the study period (median age 43 years, 39% women). Median follow-up was 8 years (IQR 4-13). One-third underwent at least 1 reoperation at a median 16 months after the index surgery (IQR 8-31). Half of reoperations were for implant removal, followed by conversion to total hip arthroplasty. 14% of the cohort were converted to THA. The median time to conversion was 2 years (IQR 1-4). Neither female sex nor older age had a statistically significant effect on time-to-reoperation or time-to-THA conversion. Interpretation - Following internal fixation of young femoral neck fracture, 1 in 3 patients required a reoperation, and 1 in 7 were converted to THA. These data should be considered by patients and surgeons during treatment decision-making.

Are injured workers with higher rehabilitation service utilization less likely to be persistent opioid users? A cross-sectional study

BACKGROUND

Given its role in treating musculoskeletal conditions, rehabilitation medicine may be an important factor in decreasing the use of opioids among injured workers. The primary objective was to determine if increased utilization of rehabilitation services was associated with decreased persistent opioid use among workers' compensation claimants. The secondary objective was to determine the combined association of rehabilitation service utilization and persistent opioid use with days of work lost due to injury.

METHODS

Using Chesapeake Employers' Insurance Company claims data from 2008 to 2016, claimants with at least one filled opioid prescription within 90 days of injury were eligible for inclusion. The primary outcome was persistent opioid use, defined as at least one filled opioid prescription more than 90 days from injury. The secondary outcome was days lost due to injury. The primary variable of interest, rehabilitation service utilization, was quantified based on the number of rehabilitation service claims and grouped into five levels (no utilization, and four quartiles - low, medium, high, very high).

RESULTS

Of the 9596 claimants included, 29% were persistent opioid users. Compared to claimants that did not utilize rehabilitation services, patients with very high rehabilitation utilization were nearly three times more likely (OR: 2.71, 95% CI: 2.28-3.23, p < 0.001) to be persistent opioid users and claimants with low and medium levels of rehabilitation utilization were less likely to be persistent opioid users (low OR: 0.20, 95%: 0.14-0.27, p < 0.001) (medium OR: 0.26, 95% CI: 0.21-0.32, p < 0.001). Compared to claimants that did not utilize rehabilitation services, very high rehabilitation utilization was associated with a 27% increase in days lost due to the injury (95% CI: 21.9-32.3, p < 0.001), while low (- 16.4, 95% CI: -21.3 - -11.5, p < 0.001) and medium (- 11.5, 95% CI: -21.6 - -13.8, p < 0.001) levels of rehabilitation utilization were associated with a decrease in days lost due to injury, adjusting for persistent opioid use.

CONCLUSION

Our analysis of insurance claims data revealed that low to moderate levels of rehabilitation was associated with reduced persistent opioid use and days lost to injury. Very high rehabilitation utilization was associated with increased persistent opioid use and increased time from work.

Factors Associated With Persistent Opioid Use Among Injured Workers' Compensation Claimants

Importance

There is a paucity of data on persistent opioid use and factors associated with persistent opioid use among workers' compensation claimants.

Objective

To determine the proportion of injured workers who filled an opioid prescription beyond 90 days from injury and the factors associated with persistent opioid use among workers' compensation claimants.

Design, Setting, Participants

This retrospective cohort study collected workers' compensation claims data from January 1, 2008, to December 31, 2016, from the Chesapeake Employers' Insurance Company in Maryland. All workers' compensation claimants injured during the study years and with at least 1 filled opioid prescription were eligible for inclusion. For patients who had unique injury claims in multiple years of the study, only the first claimed injury was included in our analysis. Patients who died as a result of the claimed injury were excluded. The analysis was performed between October 2017 and August 2018.

Main Outcomes and Measures

The primary outcome was persistent opioid use, defined as an opioid prescription fulfillment beyond 90 days from the date of injury. Multivariable regression was used to determine prognostic factors of persistent opioid use.

Results

Of the 9596 study participants (mean [SD] age, 43 [12.3] years; 6218 [65.1%] male), 2741 (28.6%) filled an opioid prescription more than 90 days from their date of injury. Participants aged 60 years or older (odds ratio [OR], 1.92; 95% CI, 1.56-2.36), crush injuries (OR, 1.55; 95% CI, 1.28-1.89), strain and sprain injuries (OR, 1.54; 95% CI, 1.36-1.75), annual income more than $60 000 (OR, 1.31; 95% CI, 1.07-1.61), and concomitant diagnoses for chronic joint pain (OR, 1.98; 95% CI, 1.79-2.20) were significantly associated with persistent opioid use. Compared with workers with claims designated as permanent partial disability, workers with medical-only claims were significantly less likely to have persistent opioid use at 90 days postinjury (OR, 0.17; 95% CI, 0.15-0.20).

Conclusions and Relevance

A high proportion of persistent opioid use was observed in this workers' compensation cohort. Interventions to lower persistent opioid use in this population should target patients with the characteristics identified in this study.

Engaging youth in rural Uganda in articulating health priorities through Photovoice

Youth living in rural Uganda represent over 20% of the country’s population. Despite the size of this demographic segment of the population, there is a paucity of data on their health priorities. Engaging people in understanding their own health status has proven to be an effective mechanism for health promotion. The objective of this study was to use Photovoice, a community-based, participatory action research methodology, to understand the current health priorities of youth living in rural Uganda. Thirty-two students between the ages of 13 and 17 were recruited from four schools within the region of Soroti, Uganda. Participants were given a disposable camera and were asked to photograph situations that contributed or detracted from their health status. The cameras were then returned to the investigators and each photo taken by the participant was reviewed with the investigators during a semi-structured interview. Codes were applied to the photographs and organized into overarching themes. Each participant chose one to two photos that were most representative of their health priorities for a secondary analysis. Participants provided 499 photos that met the eligibility criteria. The most common themes presented in the photographs were ‘hygiene’ ( n = 73, 12.4%), ‘nutrition’ ( n = 69, 11.7%), and ‘cleanliness’ ( n = 48, 8%). ‘Hygiene’ ( n = 6, 14.6%) and ‘exercise’ ( n = 6, 14.6%) were the most common priorities articulated in the representative photographs. Photovoice proved to be an effective method to assess and express the health concerns of youth in rural Uganda. Study participants were able to articulate their health concerns and priorities through photographs and reflect on opportunities for health promotion through subsequent interviews.

Healthcare Worker Preferences for Active Tuberculosis Case Finding Programs in South Africa: A Best-Worst Scaling Choice Experiment

Objective

Healthcare workers (HCWs) in South Africa are at a high risk of developing active tuberculosis (TB) due to their occupational exposures. This study aimed to systematically quantify and compare the preferred attributes of an active TB case finding program for HCWs in South Africa.

Methods

A Best–Worst Scaling choice experiment estimated HCW’s preferences using a random-effects conditional logit model. Latent class analysis (LCA) was used to explore heterogeneity in preferences.

Results

“No cost”, “the assurance of confidentiality”, “no wait” and testing at the occupational health unit at one’s hospital were the most preferred attributes. LCA identified a four class model with consistent differences in preference strength. Sex, occupation, and the time since a previous TB test were statistically significant predictors of class membership.

Conclusions

The findings support the strengthening of occupational health units in South Africa to offer free and confidential active TB case finding programs for HCWs with minimal wait times. There is considerable variation in active TB case finding preferences amongst HCWs of different gender, occupation, and testing history. Attention to heterogeneity in preferences should optimize screening utilization of target HCW populations.