|
1
|
Addevico F, Altomare M, Mezzadri U, Bergamini AN, Salvadori SG, Bove F, Cimbanassi S. Enhancing pelvic fracture care: The impact of extraperitoneal pelvic packing on definitive Orthopaedic treatment. Injury 2025; 56:112207. [PMID: 39929088 DOI: 10.1016/j.injury.2025.112207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2024] [Revised: 01/23/2025] [Accepted: 02/02/2025] [Indexed: 03/11/2025]
Abstract
This study investigates the impact of extraperitoneal pelvic packing (EPP) on the definitive surgical treatment of pelvic fractures (PF) in trauma patients. While EPP is recognized as an effective life-saving technique for controlling non-compressible retroperitoneal bleeding, concerns persist about its potential to complicate subsequent surgical interventions. A total of 220 trauma patients treated in a single First Level Trauma Centre from October 2016 to December 2021 were analysed. Demographic data, trauma mechanisms, hemodynamic stability, Injury Severity Scores (ISS), New ISS, PF classification (Tile), surgical timelines, and postoperative complications according to the Clavien-Dindo classification were collected. The study population was divided into two groups: those who underwent EPP (n = 42) and those who did not (n = 178). Statistical analyses included propensity score matching to balance baseline characteristics and reduce selection bias. Key findings show that EPP effectively improved survival rates in hemodynamically unstable patients, achieving a survival rate of 71.43 %. However, EPP was associated with delays in definitive surgical treatment and a higher incidence of major postoperative complications (41.67 % vs. 17.65 %, p = 0.014). Despite these delays, EPP did not significantly limit the possibility of achieving definitive surgery or the choice of fixation technique. Patients who underwent both EPP and open reduction internal fixation did not show a higher rate of severe complications compared to those managed without EPP. The study concludes that while EPP should be considered a practical emergency intervention for critically unstable PF patients, and even though it may affect the timing of definitive PF treatment, it does not prevent further surgical management.
Collapse
Affiliation(s)
- Francesco Addevico
- Orthopaedics and Traumatology department, GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy.
| | - Michele Altomare
- General Surgery and Trauma Team, GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy.
| | - Umberto Mezzadri
- Orthopaedics and Traumatology department, GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy.
| | - Alberto Nicolò Bergamini
- Orthopaedics and Traumatology department, GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy.
| | - Sara Gianna Salvadori
- Orthopaedics and Traumatology department, GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy.
| | - Federico Bove
- Orthopaedics and Traumatology department, GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy.
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy.
| |
Collapse
|
|
2
|
Chintalapudi N, Hysong A, Posey S, Hsu JR, Kempton L, Phelps KD, Sims S, Karunakar M, Seymour RB, Medda S. Are Orthopaedic Trauma Surgeons Appropriately Compensated for Treating Acetabular Fractures? An Analysis of Operative Times and Relative Value Units. J Orthop Trauma 2024; 38:143-147. [PMID: 38117575 DOI: 10.1097/bot.0000000000002749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVES To evaluate the work relative value units (RVUs) attributed per minute of operative time (wRVU/min) in fixation of acetabular fractures, evaluate surgical factors that influence wRVU/min, and compare wRVU/min with other procedures. METHODS DESIGN Retrospective. SETTING Level 1 academic center. PATIENT SELECTION CRITERIA Two hundred fifty-one operative acetabular fractures (62 A, B, C) from 2015 to 2021. OUTCOME MEASURES AND COMPARISONS Work relative value unit per minute of operative time for each acetabular current procedural terminology (CPT) code. Surgical approach, patient positioning, total room time, and surgeon experience were collected. Comparison wRVU/min were collected from the literature. RESULTS The mean wRVU per surgical minute for each CPT code was (1) CPT 27226 (isolated wall fracture): 0.091 wRVU/min, (2) CPT 27227 (isolated column or transverse fracture): 0.120 wRVU/min, and (3) CPT 27228 (associated fracture types): 0.120 wRVU/min. Of fractures with single approaches, anterior approaches generated the least wRVU/min (0.091 wRVU/min, P = 0.0001). Average nonsurgical room time was 82.1 minutes. Surgeon experience ranged from 3 to 26 years with operative time decreasing as surgeon experience increased ( P = 0.03). As a comparison, the wRVU/min for primary and revision hip arthroplasty have been reported as 0.26 and 0.249 wRVU/min, respectively. CONCLUSIONS The wRVUs allocated per minute of operative time for acetabular fractures is less than half of other reported hip procedures and lowest for isolated wall fractures. There was a significant amount of nonsurgical room time that should be accounted for in compensation models. This information should be used to ensure that orthopaedic trauma surgeons are being appropriately supported for managing these fractures. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Nainisha Chintalapudi
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
3
|
Hinz N, Dehoust J, Seide K, Kowald B, Mangelsdorf S, Frosch KH, Hartel MJ. Epidemiology and socioeconomic consequences of work-related pelvic and acetabular fractures recorded in the German Social Accident Insurance. Injury 2023; 54:110848. [PMID: 37258403 DOI: 10.1016/j.injury.2023.110848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 05/17/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Pelvic and acetabular fractures can result from work-related accidents and frequently require lengthy medical treatments. Consequently, high medical costs as well as delayed or absent return to work can be the consequence. Therefore, we aimed to study the socioeconomic consequences of work-related pelvic and acetabular fractures. MATERIALS AND METHODS This retrospective study investigated work-related pelvic and acetabular fractures recorded in the German Social Accident Insurance in 2011 and 2017, in terms of age, sex, type of accident, duration of incapacity to work, reductions in earning capacity, costs for outpatient and inpatient treatment and costs for pension and severance pay. RESULTS Among a total of 606 injuries in 2011 and 619 injuries in 2017, male patients and patients between 40 and 65 years were predominantly affected. Acetabular fractures caused higher rates of long absence from work of 6-12 months (2011: 24.7% vs. 9.5-16.9%; 2017: 26.1% vs. 6.1-11.0%) and >12 months (2011: 15.8% vs. 9.8-10.2%; 2017: 13.3% vs. 1.9-8.2%) as well as more cases with a reduction in earning capacity of at least 20% (2011: 61 vs. ≤27 cases; 2017: 39 vs. ≤12 cases) compared to pelvic ring fractures. The total costs for pelvic ring and acetabular fractures in the German social accident insurances amounted € 18,726,630 and € 9637,189 in the periods 2011-2020 and 2017-2020, respectively. The average costs per case for treatment and rehabilitation until 2020 was € 19,079 for injuries from 2011 and € 13,629 for injuries from 2017. Acetabular fractures were found to be the most cost-intensive injuries compared to anterior, posterior or complex pelvic ring fractures. CONCLUSIONS Work-related pelvic and especially acetabular fractures have a considerable socioeconomic impact in the German Social Accident Insurance. Measures to prevent work-related accidents and to improve treatment of pelvic injuries can help to reduce their socioeconomic burden.
Collapse
Affiliation(s)
- Nico Hinz
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Strasse 10, 21033 Hamburg, Germany.
| | - Julius Dehoust
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Strasse 10, 21033 Hamburg, Germany
| | - Klaus Seide
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Strasse 10, 21033 Hamburg, Germany; Laboratory for Biomechanics, BG Hospital Hamburg, Bergedorfer Strasse 10, 21033 Hamburg, Germany
| | - Birgitt Kowald
- Laboratory for Biomechanics, BG Hospital Hamburg, Bergedorfer Strasse 10, 21033 Hamburg, Germany
| | - Stefan Mangelsdorf
- Hochschule der DGUV (HGU) - University of Applied Sciences, Seilerweg 54, 10117 Bad Hersfeld, Germany
| | - Karl-Heinz Frosch
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Strasse 10, 21033 Hamburg, Germany; Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Maximilian J Hartel
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorfer Strasse 10, 21033 Hamburg, Germany; Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| |
Collapse
|
|
4
|
Alter T, Fitch A, Bailey Terhune E, Williams JC. The economics of patients undergoing periacetabular osteotomy for hip dysplasia: the financial relationship between physicians and hospitals. J Hip Preserv Surg 2022; 9:225-231. [PMID: 36908555 PMCID: PMC9993450 DOI: 10.1093/jhps/hnac041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/08/2022] [Indexed: 03/14/2023] Open
Abstract
Periacetabular osteotomy (PAO) is the gold standard for treating hip dysplasia in patients with preserved articular cartilage. The aim of this study is to evaluate the financial relationship between facility and professional revenue for patients undergoing PAO for hip dysplasia and acetabular version abnormalities. All patients who underwent PAO for hip dysplasia by a single surgeon at a tertiary academic medical center between December 2016 and November 2020 were identified. Financial records for facility and professional services were reviewed and analyzed. The orthopedic charge multiplier, the dollars of facility charge created by a single dollar of orthopedic professional charge, and orthopedic net revenue multiplier, the dollars collected by the hospital for facility services generated for each dollar collected by the orthopedic surgeon, were calculated. A total of 36 patients were included in the study. The mean total charge for all patients was $144 939.35 ± $23 726.48 (range $109 002.71 to $227 290.20), and the average total revenue for all patients was $44 218.79 ± $12 352.97 (range $29 397.39 to $90,830.62). The mean orthopedic charge multiplier was 2.47 ± 1.32 (range 0.78-6.53), and the net revenue collection multiplier was 8.62 ± 10.69 (range, 1.20-57.80). The majority of charges and revenue related to care of patients undergoing PAO return to the hospital. The significant mean orthopedic charge multiplier for this procedure increases the value of the service and the surgeon to hospital profitability. This information can help shape the relationship between the hospital and the surgeon and create a firm platform to advocate for program advancement.
Collapse
Affiliation(s)
- Thomas Alter
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612, USA
| | - Ashlyn Fitch
- School of Medicine, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, USA
| | - E Bailey Terhune
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612, USA
| | - Joel C Williams
- Department of Orthopedic Surgery, Rush University Medical Center, 1611 W Harrison St, Chicago, IL 60612, USA
| |
Collapse
|
|
5
|
Xiang H, Yang X, Huang Z, Xu W, Chen Y, Li T, Huang H, Fan S. Treatment of Delayed Acetabular Fractures by Periacetabular Osteotomy through the Lateral-Rectus Approach. Orthop Surg 2022; 14:3233-3241. [PMID: 36259635 PMCID: PMC9732581 DOI: 10.1111/os.13509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/03/2022] [Accepted: 08/25/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE There has been a controversy in the surgical approach for delayed acetabular fracture. The objective of the present study is to investigate the feasibility, surgical techniques, safety, and efficacy of periacetabular osteotomy using the single lateral-rectus approach (LRA) for the surgical treatment of delayed acetabular fracture. METHODS The retrospective study included 22 patients (16 males and six females, with an average age of 45 years) with delayed acetabular fractures from June 2012 to June 2019. For all cases, periacetabular osteotomy was performed through the single LRA. Fracture classification, mechanism of injury, associated injury, time to surgery, operation time, intraoperative blood loss, and complications were recorded and analyzed. The quality of the reduction was assessed based on Matta radiographic criteria. Potential impact factors affecting the quality of reduction were analyzed. Functional outcome was evaluated at the final follow-up according to a modified Mere D'Aubigne-Postel scoring system for each patient. RESULTS All patients were followed up for at least 12 months. The duration of surgery was 140 min on average (110-205 min) and the mean intraoperative blood loss was 1250 ml (500-2100 ml). According to Matta radiographic criteria, the accuracy of reduction was "anatomical" in seven patients, "imperfect" in 11 patients, and "poor" in four patients, with an excellent and good rate of 81.8%. The time to surgery in poor reduction group was significantly longer than anatomical or imperfect reduction group (p < 0.05). All the acetabular fractures united after 8-12 weeks. The average modified Merle D'Aubigne-Postel score evaluated at the final follow-up was 14.6 (6-18), and the clinical outcomes were rated as excellent in six patients, good in 10 patients, fair in four patients, and poor in two patients, with an excellent and good rate of 72.7%. There were two cases of osteonecrosis of the femoral head (9%). No other complication was found for all cases. CONCLUSION The LRA is an effective and minimally invasive approach in the treatment of delayed acetabular fractures excluding posterior wall fracture and posterior dislocation.
Collapse
Affiliation(s)
- Haibo Xiang
- Department of Traumatic Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Xiaodong Yang
- Department of Traumatic Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina,Department of OrthopaedicHuadu District People's Hospital of GuangzhouGuangzhouChina
| | - Zhuobin Huang
- Department of Traumatic Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Wenquan Xu
- Department of Traumatic Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Yuhui Chen
- Department of Traumatic Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Tao Li
- Department of Traumatic Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Hai Huang
- Department of Traumatic Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| | - Shicai Fan
- Department of Traumatic Surgery, Center for Orthopaedic SurgeryThe Third Affiliated Hospital of Southern Medical UniversityGuangzhouChina
| |
Collapse
|
|
6
|
Patterson JT, Cook SB, Firoozabadi R. Early hip survival after open reduction internal fixation of acetabular fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1209-1216. [PMID: 35536488 DOI: 10.1007/s00590-022-03273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/20/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To estimate survival of acetabular fracture repair by tracking patients across healthcare encounters. We hypothesized that hip survival estimated this way would be lower than reported by single-surgeon or single-center series not capturing censored reoperations. METHODS Retrospective health insurance administrative database cohort study. All claimed healthcare encounters for employer-sponsored health insurance beneficiaries aged 18-65 years without pre-existing hip pathology with a newly diagnosed acetabular fracture were identified between October 1, 2015, through December 31, 2018. The intervention was open reduction internal fixation of acetabular fracture during index admission. The primary outcome was survival of the acetabular fracture repair to subsequent reoperation by arthroscopy, arthrotomy for drainage of infection, implant removal, revision acetabular fixation, hip arthroplasty, hip resection, or arthrodesis. RESULTS 38 reoperation procedures on the fractured acetabulum in 852 patients occurred within 2 years (incidence 4.5%). Total hip arthroplasty (2.5%) and revision internal fixation (1.5%) accounted for most early reoperations. Multivariable Cox regression identified an association between reoperation and increasing patient age (hazard ratio = 1.4 per decade, p < 0.01). The prevalence of any mental health condition was 29%. CONCLUSIONS Non-elderly adults with employer-sponsored insurance who sustain acetabular fractures have a greater burden of mental health disease than similarly insured patients without these injuries. Survival of the native acetabulum after fracture fixation exceeded 95% at 2 years and decreased with increasing patient age. LEVEL OF EVIDENCE Level III, Prognostic Study.
Collapse
Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA, 90033-5322, USA.
| | - Sara B Cook
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, WA, USA
| | - Reza Firoozabadi
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
|
7
|
Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue. J Orthop Trauma 2016; 30:306-11. [PMID: 26741643 DOI: 10.1097/bot.0000000000000524] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We hypothesized that a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay. DESIGN Prospective consecutive series. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Two hundread and fifty-three adult patients with a mean age of 40.7 years and mean Injury Severity Score of 26.0. INTERVENTION Femur, pelvis, or spine fractures treated surgically. MAIN OUTCOME MEASUREMENTS Hospital and professional charges and collections were analyzed. Fixation was defined as early (<36 hours) or delayed. Complications and hospital stay were recorded. RESULTS Mean charges were US $180,145 with a mean of US $66,871 collected (37%). The revenue multiplier was US $59,882/$6989 (8.57), indicating hospital collection of US $8.57 for every professional dollar, less than half of which went to orthopaedic surgeons. Delayed fracture care was associated with more intensive care unit (4.5 vs. 9.4) and total hospital days (9.4 vs. 15.3), with mean loss of actual revenue US $6380/patient delayed (n = 47), because of the costs of longer length of stay. Complications were associated with the highest expenses: mean of US $291,846 charges and US $101,005 collections, with facility collections decreased by 5.1%. An uncomplicated course of care was associated with the most favorable total collections: (US $60,017/$158,454 = 38%) and the shortest mean stay (8.7 days). CONCLUSIONS Facility collections were nearly 9 times more than professional collections. Delayed fixation was associated with more complications, and facility collections decreased 5% with a complication. Furthermore, delayed fixation was associated with longer hospital stay, accounting for US $300K more in actual costs during the study. A standardized protocol to expedite definitive fixation enhances the profitability of the trauma service line. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
|
8
|
Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue. J Orthop Trauma 2016. [DOI: 10.1097/00005131-201606000-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
|
|
9
|
Aprato A, Joeris A, Tosto F, Kalampoki V, Stucchi A, Massè A. Direct and indirect costs of surgically treated pelvic fractures. Arch Orthop Trauma Surg 2016; 136:325-30. [PMID: 26660303 DOI: 10.1007/s00402-015-2373-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Pelvic fractures requiring surgical fixation are rare injuries but present a great societal impact in terms of disability, as well as economic resources. In the literature, there is no description of these costs. Main aim of this study is to describe the direct and indirect costs of these fractures. Secondary aims were to test if the type of fracture (pelvic ring injury or acetabular fracture) influences these costs (hospitalization, consultation, medication, physiotherapy sessions, job absenteeism). MATERIALS AND METHODS We performed a retrospective study on patients with surgically treated acetabular fractures or pelvic ring injuries. Medical records were reviewed in terms of demographic data, follow-up, diagnosis (according to Letournel and Tile classifications for acetabular and pelvic fractures, respectively) and type of surgical treatment. Patients were interviewed about hospitalization length, consultations after discharge, medications, physiotherapy sessions and absenteeism. RESULTS The study comprised 203 patients, with a mean age of 49.1 ± 15.6 years, who had undergone surgery for an acetabular fracture or pelvic ring injury. The median treatment costs were 29.425 Euros per patient. Sixty percent of the total costs were attributed to health-related work absence. Median costs (in Euros) were 2.767 for hospitalization from trauma to definitive surgery, 4.530 for surgery, 3.018 for hospitalization in the surgical unit, 1.693 for hospitalization in the rehabilitation unit, 1.920 for physiotherapy after discharge and 402 for consultations after discharge. Total costs for treating pelvic ring injuries were higher than for acetabular fractures, mainly due to the significant higher costs of pelvic injuries regarding hospitalization from trauma to definitive surgery (p < 0.001) and hospitalization in the surgical unit (p = 0.008). CONCLUSIONS Pelvic fractures are associated with both high direct costs and substantial productivity loss.
Collapse
Affiliation(s)
| | - Alexander Joeris
- Clinical Investigation and Documentation (C.I.D.) Department, AO Foundation, Dübendorf, Switzerland
| | | | - Vasiliki Kalampoki
- Clinical Investigation and Documentation (C.I.D.) Department, AO Foundation, Dübendorf, Switzerland
| | | | | |
Collapse
|
|
10
|
Vallier HA, Moore TA, Como JJ, Wilczewski PA, Steinmetz MP, Wagner KG, Smith CE, Wang XF, Dolenc AJ. Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation. J Orthop Surg Res 2015; 10:155. [PMID: 26429572 PMCID: PMC4590279 DOI: 10.1186/s13018-015-0298-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 09/20/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Our group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36 h would have fewer complications than those treated at a later time. METHODS Three hundred thirty-five patients with mean age 39.2 years and mean Injury Severity Score (ISS) 26.9 and 380 fractures of the femur (n = 173), pelvic ring (n = 71), acetabulum (n = 57), and/or spine (n = 79) were prospectively evaluated. The EAC protocol recommended definitive fixation within 36 h if lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥-5.5 mmol/L. Complications including infections, sepsis, DVT, organ failure, pneumonia, acute respiratory distress syndrome (ARDS), and pulmonary embolism (PE) were identified and compared for early and delayed patients and with a historical cohort. RESULTS All 335 patients achieved the desired level of resuscitation within 36 h of injury. Two hundred sixty-nine (80%) were treated within 36 h, and 66 had protocol violations, treated on a delayed basis, due to surgeon choice in 71%. Complications occurred in 16.3% of patients fixed within 36 h and in 33.3% of delayed patients (p = 0.0009). Hospital and ICU stays were shorter in the early group: 9.5 versus 17.3 days and 4.4 versus 11.6 days, respectively, both p < 0.0001. This group of patients when compared with a historical cohort of 1443 similar patients with 1745 fractures had fewer complications (16.3 versus 22.1%, p = 0.017) and shorter length of stay (LOS) (p = 0.018). CONCLUSIONS Our EAC protocol recommends definitive fixation within 36 h in resuscitated patients. Early fixation was associated with fewer complications and shorter LOS. The EAC recommendations are safe and effective for the majority of severely injured patients with mechanically unstable femur, pelvis, acetabular, or spine fractures requiring fixation.
Collapse
Affiliation(s)
- Heather A Vallier
- Department of Orthopaedic Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
| | - Timothy A Moore
- Department of Orthopaedic Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA. .,Departments of Orthopaedic Surgery and Neurosciences, MetroHealth Medical Center affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, USA.
| | - John J Como
- Division of Trauma, Department of Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, Cleveland, OH, USA.
| | - Patricia A Wilczewski
- Division of Trauma, Department of Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, Cleveland, OH, USA.
| | - Michael P Steinmetz
- Department of Neurosciences, MetroHealth Medical Center affiliated with Case Western Reserve University, Cleveland, OH, USA.
| | - Karl G Wagner
- Department of Anesthesiology, MetroHealth Medical Center affiliated with Case Western Reserve University, Cleveland, OH, USA.
| | - Charles E Smith
- Department of Anesthesiology, MetroHealth Medical Center affiliated with Case Western Reserve University, Cleveland, OH, USA.
| | - Xiao-Feng Wang
- Department of Orthopaedic Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
| | - Andrea J Dolenc
- Department of Orthopaedic Surgery, MetroHealth Medical Center affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH, 44109, USA.
| |
Collapse
|
|
11
|
Sathiyakumar V, Shi H, Thakore RV, Lee YM, Joyce D, Ehrenfeld J, Obremskey WT, Sethi MK. Isolated sacral injuries: Postoperative length of stay, complications, and readmission. World J Orthop 2015; 6:629-635. [PMID: 26396939 PMCID: PMC4573507 DOI: 10.5312/wjo.v6.i8.629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 06/17/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate inpatient length of stay (LOS), complication rates, and readmission rates for sacral fracture patients based on operative approach.
METHODS: All patients who presented to a large tertiary care center with isolated sacral fractures in an 11-year period were included in a retrospective chart review. Operative approach (open reduction internal fixation vs percutaneous) was noted, as well as age, gender, race, and American Society of Anesthesiologists’ score. Complications included infection, nonunion and malunion, deep venous thrombosis, and hardware problems; 90-d readmissions were broken down into infection, surgical revision of the sacral fracture, and medical complications. LOS was collected for the initial admission and readmission visits if applicable. Fisher’s exact and non-parametric t-tests (Mann-Whitney U tests) were employed to compare LOS, complications, and readmissions between open and percutaneous approaches.
RESULTS: Ninety-four patients with isolated sacral fractures were identified: 31 (30.4%) who underwent open reduction and internal fixation (ORIF) vs 63 (67.0%) who underwent percutaneous fixation. There was a significant difference in LOS based on operative approach: 9.1 d for ORIF patients vs 6.1 d for percutaneous patients (P = 0.043), amounting to a difference in cost of $13590. Ten patients in the study developed complications, with no significant difference in complication rates or reasons for complications between the two groups (19.4% for ORIF patients vs 6.3% for percutaneous patients). Eight patients were readmitted, with no significant difference in readmission rates or reasons for readmission between the two groups (9.5% percutaneous vs 6.5% ORIF).
CONCLUSION: There is a significant difference in LOS based on operative approach for sacral fracture patients. Given similar complications and readmission rates, we recommend a percutaneous approach.
Collapse
|
|
12
|
Pishnamaz M, Dienstknecht T, Hoppe B, Garving C, Lange H, Hildebrand F, Kobbe P, Pape HC. Assessment of pelvic injuries treated with ilio-sacral screws: injury severity and accuracy of screw positioning. INTERNATIONAL ORTHOPAEDICS 2015; 40:1495-501. [PMID: 26260867 DOI: 10.1007/s00264-015-2933-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 07/08/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this study was to analyse possible indicative parameters for percutaneous ilio-sacral stabilisation and to identify parameters associated with screw misplacement. METHODS Cohort study, level I trauma centre. INCLUSION CRITERIA (1) unstable pelvic injury, (2) percutaneous ilio-sacral screws placement. EXCLUSION CRITERIA (1) sacral dysmorphy, (2) failed closed reduction, (3) navigated techniques. Indicative parameters were age, gender, body mass index, number of screws, screw angulation, fracture type and injury severity. End points were ilio-sacral screw position and associated complications. Screw placement accuracy was graded as follows: grade 0, no perforation; grade 1, perforation <2 mm; grade 2, perforation from 2 to 4 mm; grade 3, ≥4 mm perforation. RESULTS Between March 2008 and March 2013, 102 (53 women) patients were included (mean age, 48.5 ± 21.4 years). The Injury Severity Score (ISS) and New Injury Severity Score (NISS) were 18.9 ± 9.9 and 22.3 ± 22.3, respectively. The positions of 137 ilio-sacral screws were analysed. Of all screws, 87.6 % (120) were placed satisfactory (<2 mm perforation). The incidence of screw misplacement was significantly higher in the case of two unilateral S1 screws compared with a single screw (failure rate: two unilateral screws 23.1 % vs single screw 7.0 %; p < 0.05). Screw perforation anterior to the lateral mass (in-out-in) represented the most frequent malposition. Revision was necessary in three cases due to malpositioning. Furthermore, no major complication occurred. CONCLUSIONS We conclude, that twofold ilio-sacral screw positioning from one side increases the risk for screw misplacement. In this case, alternative techniques like navigation should be considered. Anterior screw perforation represents a common problem with a high incidence and warrants particular attention.
Collapse
Affiliation(s)
- Miguel Pishnamaz
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Pauwelsstreet 30, 52074, Aachen, Germany.
| | - Thomas Dienstknecht
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Barbara Hoppe
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Christina Garving
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Henning Lange
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Philipp Kobbe
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Pauwelsstreet 30, 52074, Aachen, Germany
| | - Hans-Christoph Pape
- Department of Orthopaedic Trauma, University of Aachen Medical Center, Pauwelsstreet 30, 52074, Aachen, Germany
| |
Collapse
|
|
13
|
Late surgery for acetabular fractures in a Chinese level I trauma centre: surgical experience and outcomes. INTERNATIONAL ORTHOPAEDICS 2015; 39:1865-71. [PMID: 26243451 DOI: 10.1007/s00264-015-2932-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 07/07/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE Delayed surgical management of acetabular fractures, often necessary due to life-threatening concomitant injuries, is a great challenge because delays may potentially increase complications and decrease outcomes. We report clinical outcomes of 61 acetabular fractures treated by delayed open reduction and internal fixation (ORIF) with an injury-to-surgery interval (ISI) of 22-399 days. METHODS Operations were performed between April 2001 and December 2008. There were 61 cases (42 men 19 women), with an average age of 38 years. All patients were followed for an average of 82 months. Demographic data, fracture pattern, ISI, concomitant injuries, surgical approach, complications and clinical outcomes were recorded and analysed. There were 16 simple fractures (26.2%) and 45 associated fractures (73.8%). Matta criteria were used to evaluate reduction quality. The Merle d'Aubigné and Postel scoring system was employed to assess post-operative functionality. RESULTS Anatomical reduction was achieved in 45 cases (73.8%). The clinical result was excellent in 38 cases, good in 13, fair in six and poor in four. Osteonecrosis of the femoral head was observed in three cases, and heterotopic ossification was found in 28 cases. Four patients had transient palsy of the sciatic nerve. CONCLUSIONS ORIF for fresh acetabular fractures might yield a better prognosis; however, for delayed acetabular fractures, clinical outcomes are also predictable when sophisticated surgical techniques are employed. Our results indicate that delayed ORIF could yield satisfactory clinical outcomes in the majority of patients with acetabular fractures.
Collapse
|
|
14
|
Does Fracture Care Make Money for the Hospital? An Analysis of Hospital Revenues and Costs for Treatment of Common Fractures. J Orthop Trauma 2015; 29:e219-24. [PMID: 25463424 DOI: 10.1097/bot.0000000000000263] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the relative profitability for a hospital of treatment of common fractures within a state-regulated reimbursement system. DESIGN Retrospective cohort. SETTING Regional trauma referral center with state-regulated hospital reimbursement system. METHODS We reviewed hospital medical and financial records of 1228 patients admitted from 2008 through 2012 with a principle diagnosis of acute traumatic fracture requiring surgical treatment. Patients whose principle diagnosis fit into 1 of 6 common anatomic categories were included. Sixty-five pelvic, 275 acetabular, 277 hip, 255 femoral shaft, 148 tibial shaft, and 208 ankle fractures were identified. Patients with a different principle diagnosis were excluded. Net revenue, total cost of inpatient care, and direct margin for each patient's acute inpatient hospital course were recorded. MAIN OUTCOME MEASUREMENT Direct margins, costs. RESULTS Per patient, the overall mean net revenue was $39,813, overall mean cost of inpatient care was $21,231, and overall mean direct margin (profitability) was $18,582. Mean direct variable expense was $14,898 per patient, and mean direct fixed expense was $6333 per patient. Factors most influencing cost included length of stay, supplies, and operating room use. Of 1228 patients, 46 (3.7%) had a negative direct margin (net loss to hospital). The most profitable diagnosis was pelvic fracture (mean direct margin, $21,767). CONCLUSIONS The state-regulated reimbursement system allows analysis of hospital profitability in the context of a normalized revenue stream that should approximate the overall fiscal realities of other states. Providing orthopaedic trauma care can be economically feasible and profitable for a hospital. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
|
15
|
Abstract
OBJECTIVE Our purpose was to compare patients transferred from another hospital to our trauma center with those arriving directly, to identify barriers to care for similar fractures. We hypothesized that the most frequent reason for delayed definitive fixation would be interhospital transfer and that patients would be transferred primarily for 2 reasons: complex patients with more severe injuries and less complex patients without insurance. DESIGN Retrospective review. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS A total of 1549 skeletally mature patients with 1655 fractures: 379 acetabulum, 301 pelvic ring, 876 femur, and 99 spine. INTERVENTION All patients were treated surgically, with early fixation defined as <24 hours after injury. MAIN OUTCOME MEASUREMENTS Demographic and injury characteristics were recorded. Reasons for and timing of transfer were determined. RESULTS A total of 814 patients (53%) were transferred from another hospital, including 66% of acetabular and 62% of pelvic ring fractures. Transferred patients were older (39.1 vs. 36.6 years, P = 0.002), had more commercial insurance (21% vs. 17%, P = 0.10), and were less often uninsured (27% vs. 31%, P = 0.11). However, the mean Injury Severity Score of uninsured transferred patients was lower than that of the other transferred patients (22.9 vs. 25.8, P < 0.0001). Transfer was not related to weekday or time of injury. A total of 973 patients (63%) had early definitive fixation. Delayed fixation was often for surgeon preference (57%). Transferred patients were more likely to have delayed fixation (43% vs. 31% of nontransferred, P < 0.0001). CONCLUSIONS Internal barriers to definitive fracture care were noted, the most frequent of which is surgeon preference. Treatment delays due to transfer accounted for 12% of all delays. Many transferred patients appeared appropriate based on injury complexity. However, over one-fourth of those transferred had low Injury Severity Score and a significantly higher incidence of no insurance. Communication and transparency about these issues may serve to expedite care and to enhance financial stability of larger trauma centers. LEVEL OF EVIDENCE Prognostic level II.
Collapse
|