United States

Background
The current study aimed to: (1) evaluate the prevalence of delays in first-start case times over the course of one year for trauma-related orthopedic surgery on weekends, (2) identify the cited cause for delay, and (3) estimate the cost created by delays identified in this study. We hypothesize that weekend days with first-start orthopedic trauma cases will experience delays more frequently that weekdays with similar cases.

Methods
An institutional database was used to query weekend first start OR cases from 2022-2023. Patients undergoing operative intervention for orthopedic trauma related hospital presentations were identified by retrospective chart review. Incidence and documented reasons for weekend first start cases were recorded. On-time first start case was defined as in-room time of 7:30AM.

Results
Of the 106 weekend days included in this study, 88 first-start cases were recorded, while 18 days did not have a first-start case that met the inclusion criteria outlined in this study. The mean time (AM =/- SD minutes) for assigned room, pre-op, surgeon ready, in room, OR ready, anesthesia ready, anesthesia start, and case start were 4:47 (± 2:14), 07:25 (± 0:56), 7:26 (± 0:38), 8:09 (± 0:38), 7:46 (±0:35), 8:26 (± 0:39), 8:07 (± 0:38), 8:50 (± 0:41) respectively. Of the possible causes, a reason was not recorded in 27% of cases. This was followed by patient factors, insufficient anesthesia coverage, transport, OR delays, surgeon factors, “weekend” as the stated reason, and pre-op delays. There was no notable difference in on-time first start cases based on weekend day or time of year. Of the 88 cases included in this study, the median “in room” time was 08:02. This represents a 32-minute delay based on the scheduled “in room” time of 07:30. When totaled over all 88 cases, this amounts to 2,816 minutes of delay, or roughly $84,000 in lost revenue, in first start orthopedic trauma cases on weekends in 2022. 

Conclusion

Our institution had 0% of weekend first-start cases start on time. The common occurrence of delays in weekend cases highlights the need for process improvement and schedule adjustment to maximize efficiency and personnel usage.


AMA Research Challenge 2024 

Evaluation of Causes and Financial Impact of Weekend Operating Room Delays at a Level 1 Trauma Center: A One-Year Retrospective Analysis

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Abstract Title
Factors predictive of season-ending upper extremity injuries in MLB pitchers and the implementation of the pitch clock.

Background
The 2024 MLB season has seen high profile pitchers succumb to season ending upper extremity injuries (SEI), raising concerns regarding pitcher injuries. The sports community remains divided between factors such as the newly initiated pitch clock, banning of sticky substances and increasing pitch velocity as the main culprit. No study has yet demonstrated a correlation between any one factor and pitcher injuries. This study attempts to identify specific factors associated with season ending injuries in MLB pitchers.

Methods
A retrospective cohort study of all MLB pitchers from 2015–2023 was performed utilizing publicly available data on MLB injuries (prosportstransactions.com) and pitch-by-pitch metrics (baseballsavant.mlb.com). Pitcher demographics, average number of pitches thrown per game, and pitch-specific metrics were analyzed for each pitcher. Multivariable binary logistic regression was utilized to determine metrics predictive of SEI. Comparison of seasons surrounding the initiation of the pitch clock were done utilizing Pearson's Chi-squared test.

Results
6,569 pitcher-seasons were analyzed with 405 instances resulting in an SEI from the 2015 - 2023 seasons, excluding 2020. Multivariable logistic regression showed SEI is significantly associated with increasing number of pitches per game (OR, 1.011, 95% CI, 1.008-1.015, p < 0.001), pitch velocity (OR, 1.049, 95% CI, 1.009-1.091, p < 0.05) and acceleration (OR, 1.034, 95% CI, 1.003-1.065, p < 0.05) in the x-dimension. SEI’s were not associated with pitch release speed, release extension, velocity/acceleration in the y- or z-dimension or pitcher demographic measures (pitcher height, weight, BMI). SEI decreased significantly following initiation of the pitch clock from 50 (5.9%) in 2022 to 17 (2.0%) in 2023 (p<0.0001). SEI did not significantly change after banning of sticky substances.

Conclusion
Increasing SEI’s with increasing pitch count, velocity, and acceleration per game reflects an expected consequence of higher volume and faster pitching in the MLB year-over-year. The significant decrease in upper extremity SEI’s after introduction of the pitch clock could be due to anything from teams managing pitchers more carefully, to biomechanical differences with less rest between pitches. More seasons with the pitch clock will help elucidate the cause. Banning of sticky substances had no effect on injuries likely because sticky substance helps pitchers add spin and movement which are not associated with SEI’s. Further research is underway to evaluate injuries further by anatomic location and/or structure, as well as other positions.

Factors predictive of season-ending upper-extremity injuries in MLB pitchers and the implementation of the pitch clock

Background
Hip fractures present a significant public health challenge, with between 260,000 to
300,000 admissions for hip fractures in the US and projections of more than 500,000 per year by 2040. The rising incidence and substantial burden on healthcare systems necessitate proper evaluation and management of these already frail patients as hip fractures are associated with increased mortality and morbidity. Frailty scales have been used extensively within the orthopedic literature as a potential preoperative risk stratification tool. This study aims to compare the effectiveness of frailty as measured by the Revised Risk Analysis Index (RAI-rev) and the 5-Factor Modified Frailty Index (mFI-5) in predicting 30-day postoperative outcomes in surgically managed hip fracture.

Methods
The ACS-NSQIP database was queried for patients with a diagnosis of traumatic hip
fracture undergoing surgical intervention from (2011-2020). Frailty was assessed using the RAI-rev and mFI-5. Thirty-day outcomes included mortality, extended length of stay (eLOS) and non-home discharge (NHD). Multivariate analysis was conducted to assess predictive value of frailty scales, presented as odds ratio (OR). Discriminatory accuracy was assessed using Receiver operating characteristic (ROC) curve and quantified using C-statistic. Significance was determined by p<0.05.

Results
There were 160,446 patients included with a median age of 83 years, with 68.9% females and 91.86% white. The RAI-rev classified 16,175 patients as robust, 89,815 as normal, 46,531 as frail, and 7,925 as very frail. Multivariate analysis revealed increasing frailty as measured by the RAI-rev had greater odds for 30-day mortality (normal: OR 2.10 (1.73 -2.59), frail: OR 5.35 (4.35 - 6.63), very frail: OR 11.32 (9.13 - 14.13), p<0.001) than the mFI-5 (prefrail: OR 1.39 (1.29 - 1.50), frail: OR 2.15 (1.99 - 2.32) severely frail: OR 3.70 (3.39 -4.04) , p<0.001). ROC analysis demonstrated that compared to the mFI-5, the RAI-rev had superior discriminatory accuracy for 30-day mortality (RAI: 0.74, mFI-5: 0.62, p<0.001), eLOS (RAI-rev: 0.57, mFI-5: 0.56, p<0.001), and NHD (RAI-rev: 0.57, mFI-5: 0.54, p<0.001).

Conclusion
The RAI-rev demonstrated superior predictive capability and discriminatory accuracy for assessing 30-day mortality, eLOS, and NHD, when compared to the mFI-5. These findings support the use of the RAI-rev in preoperative risk assessment for hip fractures in an increasingly frail population. In doing so, surgeons may identify high risk patients missed without obvious multimorbidity, thus reducing postoperative morbidity and mortality in patients with traumatic hip fracture.

Frailty as a Predictor of 30-Day Postoperative Mortality in Hip Fracture Patients

Title: Fructosamine as a Predictor of Adverse Post-Operative Outcomes in Total Shoulder Arthroplasty Patients
Background: Serum fructosamine has been shown to be a significant predictor of post-operative adverse outcomes in joint replacement patients. Fructosamine is a measure of blood sugar over a shorter time period of 14 to 21 days, making it a more useful marker of blood sugar control pre-operatively. The objective is to assess adverse post-operative outcomes after both anatomic and reverse total shoulder arthroplasty (TSA) in relation to fructosamine, HbA1c, and blood glucose.
Methods: This prospective cohort study includes patients undergoing TSA from multiple providers. Pre-operative data was collected that includes demographics, diabetic status, insulin dependence, Visual Analog Scale (VAS), Range of Motion data (ROM), PROMIS surveys, and patient fructosamine, HbA1c, and fasting blood glucose levels. Follow-up data was obtained at 6 weeks and 3 months post-operatively. This included data for superficial infection, deep infection, medical complications, emergency room visits, hospital readmissions, reoperations, VAS scores, and updated ROM.
Results: A total of 101 patients were recruited for the study, comprised of 44 males and 57 females. Mean age was 68.5, ranging from 34 to 90 years. Of the total, 25 patients had a pre-operative diagnosis of diabetes. None of these patients experienced medical complications, superficial infections, deep infections, hospital readmissions, or reoperations. A total of 7 patients experienced medical complications with only 2 having reoperation. Only 1 of these patients that reoperated had elevated fructosamine (>292 µmol cut-off) and an elevated HbA1c (>6.5% cut-off). The average fructosamine was 221.8 µmol, with a range from 106.6 µmol to 404.2 µmol. The average HbA1c was 5.8, with a range from 3.4 to 8.7. Blood glucose and HbA1c showed no significant relationship with any of the tested variables. Elevated fructosamine showed a positive association with a decreased active external rotation (ER) (p=0.01) which is lost at the 3-month follow-up post-operatively (p=0.59). No other significance was found with VAS, ROM, or PROMIS through 3 months post-operatively. 
Conclusions: Preliminary data analysis suggests that fructosamine, HbA1c, and blood glucose are not reliable predictors of post-operative outcomes. The only significant outcome was decreased active ER with higher levels of fructosamine 6 weeks post-operatively. No significant determination can be made at this time as the study is actively recruiting patients to increase study power.

Fructosamine as a Predictor of Adverse Post-Operative Outcomes in Total Shoulder Arthroplasty

Introduction
In the United States, deep vein thrombosis (DVT) and pulmonary embolism (PE) rank high in terms of preventable hospital deaths. Victims of trauma are at a higher risk of developing thromboembolic complications. The aim of this study is to compare the incidence of DVT/PE in trauma patients before and after a June 2022 policy intervention to continue prophylactic anticoagulation at an academic trauma center.

Methods
A retrospective review was conducted to compare DVT/PE rates in trauma patients requiring surgery from January 1, 2018, through December 31, 2023. Clinical information relating to trauma date, surgery date, injury type, anticoagulant administration, DVT/PE development, and death, if applicable, was obtained from patient charts.

Results
DVT/PE development was 14.553 times more likely pre-policy change when anticoagulation was held prior to surgery compared to post-policy change when anticoagulation was administered before surgery (X2 (3, N=374) =14.553, p=.002).

Conclusions
Findings suggest that DVT/PE rates have significantly decreased post policy change. Limitations include the presence of comorbidities in patients, varying trauma mechanisms and injury severity, and missing documentation. 

Authors
1. Armarion Stegall
2. John T. Watson, MD
3. Heidi Israel, PhD
4. Letitia Bradford, MD, FAAOS, FACS, Nth Dimensions

Affiliations
1. Mercer University School of Medicine, Columbus, GA
2. Saint Louis University, St. Louis, MO
3. Nth Dimensions


Harmless Bleeding: Assessing the Impact of Preoperative Anticoagulant Continuation on DVT/PE Rates in Trauma Patients

Intro: Compartment syndrome, a surgical emergency, often requires fasciotomy within 6-8 hours of diagnosis. Prophylactic fasciotomy can also be considered in patients with a high risk of developing compartment syndrome. Current guidelines are unclear as to the impact of fasciotomy timing on patient outcomes. This study investigates the relationship between fasciotomy timing and rates of amputation and infection.

Methods: Data from 2017-2021 was accessed through the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP). ICD-10 codes were then used to quantify fasciotomy procedures, limb amputations, and infection rates.

Results: 22,004 patients analyzed in the TQIP database underwent fasciotomy. Of the fasciotomies performed there were 1,625 (5.35%) corresponding amputations. Rate of amputations were significantly lower in patients where fasciotomies were performed 1-4 hours compared to 4-8 hours (p<0.0001, OR=0.6088, 95% Cl=0.5180 to 0.7156) after presentation. There was no significant change in rate of amputation from 4-24 hours only, showing a significant increase after 48 hours. Deep surgical site infection rates showed a similar decrease from the 1-4 hour to the 4–8-hour time frame (p=0.0354, OR=0.6794, 95% Cl=0.4742 to 0.9736) with a significant increase after 12 hours (p=0.0283, OR=1.823, 95% Cl=1.095 to 3.033).

Conclusion: Although there was no significant correlation with fasciotomy timing and amputation within the first 24 hours, there was a significant increase in deep SSI and sepsis rates after the 8-hour time frame, suggesting that fasciotomy be performed within 4-8 hours of presentation. Interestingly, fasciotomy within the first 4 hours showed significantly elevated risk of both amputation and infection. This could be due to an increased injury severity, thus increasing the patient’s risk of further morbidity early in the hospital stay. This shows that initial management of patients requiring fasciotomy within the first 4 hours provides opportunities for more optimal outcomes in the future.

Implications of Emergent Fasciotomy Timing on Limb Salvage and Infection: 
A Trauma Quality Improvement Program (TQIP) Study

Introduction:
A challenge for orthopedic surgeons dealing with post-traumatic osteoarthritis of the elbow is a therapeutic procedure that maintains good mobility and functionality. Interposition Arthroplasty is a conservative procedure to alleviate arthritis and increase range of motion in a stiff elbow. This is achieved by placing graft tissues in the joint space of the elbow creating a false, but more mobile joint. It is especially popular in the younger, high demand population who desire a high functioning elbow that a total elbow arthroplasty would limit in regard to weight-bearing exercises and activities of daily living. 

Methods:
Through our institutions elbow pathology database, we were able to review records of patients who have received an Interposition Arthroplasty procedure from 2020-2024. We reviewed past medical history, comorbidities, time of injury, intraoperative complications, postoperative complications, pre/post operation x-rays, range of motion, and follow-up. 


Results:
There were 8 (3 female and 5 male) patients in this study who underwent the corrective surgery. The average age of the patient was 36 with a standard deviation of 12 years. The average follow -up time has been 5.44 months with a standard deviation of 7.85 months. 3 postoperative complications were reported which include elbow contracture with significant scarring adhesion, elbow pain, and broken medial plate involving another procedure (internal joint stabilizer).


Discussion/Conclusion:
Interposition arthroplasty serves as a viable substitute for total elbow arthroplasty, especially for younger patients needing a robust and functional elbow for everyday tasks and professional activities. It is imperative for more research to develop in this area of orthopedic surgery to improve the procedure's effectiveness and longevity for the patient’s desired elbow function. 


Interposition Arthroplasty of the Elbow for Post-Traumatic Injury Patients

Introduction: It is estimated that 58.5 million US adults have arthritis. Osteoarthritis (OA) is the most common form. Current American Academy of Orthopedic Surgeons (AAOS) treatment recommendations include conservative management (education, rest, activity modification, physical therapy (PT)) and medications (acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), knee injections) with a recommendation against opioids and if conservative care is no longer helpful, knee replacement surgery is the next course of action. 

Objective: To describe the current population and treatment trends in patients with symptomatic knee osteoarthritis.

Methods: A quality assurance project was completed to define the knee OA population in a private practice, and how their treatment aligns with AAOS guidelines and recommendations. Medical records were reviewed to identify patients and their age, gender, body mass index (BMI), numeric rating pain score (NRS) 0-10, where 0 means no pain and 10 is worst, and previous and present treatments. Treatments were evaluated against current non-arthroplasty and surgical AAOS Evidenced-based Clinical Treatment Guidelines. 

Results: Two hundred ninety-two radiographically confirmed OA patients (35% male, 65% female) who are currently following up with the practice were analyzed. The average age and BMI were 69 and 32, respectively. Most commonly reported symptom was pain with an average score of 7. There were more patients (67%) with unilateral knee OA than bilateral knee OA. Over the counter medications (Acetaminophen, 25%, NSAIDs, i.e., Ibuprofen and Naproxen, 54%) were the most common treatment. Prescription NSAIDs (i.e., diclofenac, meloxicam) at 27% and opioids at less than 1% were used. Knee injections significantly delayed time to surgery since presentation (p<.05) with a mean of 411 days using injections (95% CI, 323 – 498) and visco-supplementation knee injections significantly delayed surgery compared to only corticosteroid knee injections (p<.05) with a mean of 579 days using visco-supplementation (95% CI, 400 – 757).

Discussion: Nearly half of patients had PT and 86% received knee injections (steroids, visco-supplementation). At the time of review, 28% underwent total knee arthroplasty. Knee injections were able to delay a patient’s time between presentation and surgery, with visco-supplementation delaying the time to a greater degree than corticosteroids. 

Conclusion: Advanced age (greater than 65 years old) and obesity (BMI greater than 30) was common in this predominantly female population. Knee pain was the primary symptom at initial consultation. Rest, activity modification, oral medications, physical therapy, and knee injections were commonly used to treat OA. The results show conservative treatment options were exhausted prior to total knee arthroplasty.

Knee Osteoarthritis: A Snapshot of An Affected Population, their Symptoms and Treatment Options

Background: Osteochondritis dissecans of the capitellum is a common condition in adolescent overhead athletes, causing pain during physical activity, limited motion range, and functional impairments. While its exact cause is not fully understood, repetitive microtrauma and reduced blood supply are thought to contribute to lesion development. Traditional surgeries for unstable OCD lesions often fail to restore cartilage or subchondral bone, potentially leading to further joint problems. Osteochondral autograft transfers have emerged as a promising alternative that aims to both restore osteochondral structure and improve sports-related outcomes. This study examines the long-term impact of OATs on capitellar OCD lesions with the hypothesis that such interventions can prevent long-term elbow disability and facilitate a return to athletic activities
Hypothesis: We hypothesize osteochondral autologous transplantation surgery (OATS) provides long-term pain relief and maintains elbow function in adolescent athletes with capitellar osteochondritis dissecans (OCD) lesions.
Methods: A retrospective review of patients who underwent OATS between 2009 and 2023 was performed. Patients were identified by CPT code. Clinical assessment and surgeries were performed at a single institution by a single orthopaedic surgeon. Demographic data, preoperative clinical information, radiographic assessments, intraoperative findings, and postoperative outcomes were collected. Clinical and radiographic evaluations were performed, and preoperative MRI was analyzed. Intraoperative data, including graft dimensions and histopathology, were recorded. Postoperative data included MRI, complications, range of motion, return to sports, and patient satisfaction.
Results: 17 patients (15 males, 2 females) met inclusion criteria, with a mean follow-up duration of 62 months (range 12-170). The average age at time of surgery was 14 years old (±3, range 11-19). All but one patient presented with involvement of the dominant arm. All patients were athletes, with 15 competing at the elite level and 2 at the recreational level. Baseball was the most prevalent sport among these athletes. Preoperatively, every patient reported pain, and 6 of them present with a limited range of motion. The average passive pre-operative arc of motion increased from 127° ± 19 (range 80-150), with 136° of flexion and 8.9° of extension. All patients had undergone nonsurgical treatment involving rest and immobilization, and four had previously received surgical treatment at outside institutions. Intraoperatively, 4 patients had loose bodies. Synovial biopsies, performed in all cases, revealed papillary hypertrophy in 53% and mucoid/myxomatous degeneration in 59% of patients. A single osteochondral plug was used in each surgery. Postoperatively, there were no instances of instability or infections. The average passive arc of motion improved to 136.5°, consisting of 139° flexion and 3.2° extension. All athletes resumed sports activities, although one elite athlete did not return to the previous competitive level in the same sport. Additionally, one patient underwent a subsequent contracture release due to stiffness. No sign or evidence of decline in function was observed throughout the follow-up period.
Summary: 
• This study has identified synovial inflammation as a component of this disease process. 
• OATS has proven to be an effective treatment for capitellar OCD in adolescent athletes. 
• The restoration of osteochondral architecture provides both short-term and long-term elbow pain relief and restoration of high-level function.


Long-Term Outcomes of Osteochondral Autologous Transplantation Surgery in Adolescent Athletes with Capitellar Osteochondritis Dissecans

Abstract Title
Nationwide Surgical Trends in Distal Radius Fixation in Medicare Beneficiaries: Increased Utilization by Plastic Surgeons and Subspecialty Hand Surgeons

Background
In recent years, several randomized controlled trials have been published concerning the treatment of distal radius fractures (DRFs) in elderly patients. It remains unclear to what extent these studies have influenced clinical practice among different surgical specialties. This study aims to investigate both overarching trends and specialty-specific patterns in the surgical management of DRFs within the Medicare population.

Methods
Utilizing data from the Centers for Medicare & Medicaid Services, between 2013 and 2022, all claims associated with surgical management of DRFs were identified (Current Procedural Terminology [CPT] codes: 25606, 25607, 25608, and 25609). The results were further categorized based on primary operator type (general orthopedist, general plastics, general surgeon, subspecialty hand surgeon) and place of service (inpatient, outpatient, other).

Results
A total of 101,857 DRFs requiring surgical intervention were identified. Over a span of 10 years, the overall rate of distal radius fracture interventions (DRFIs) declined from 29.5 to 26.1 per 100,000 individuals, representing a 12% decrease. During this period, the utilization of closed reduction percutaneous pinning experienced a substantial 63% decrease, dropping from 4.8 to 1.8 per 100,000. Conversely, open treatment for distal radial intra-articular fractures of three or more fragments saw an 11% increase in utilization, rising from 10.0 to 11.1 per 100,000. After correction for the number of claims, general orthopedic and general surgeons experienced a notable decrease in utilization for DRFIs, 22% and 6% respectively, However, plastic surgeons and hand surgeons saw an increase in utilization for DRFIs, 74% and 13% respectively, over the same 10-year period. Additionally, there was an increasing shift towards outpatient DRFIs, with an 11% increase, whereas inpatient and other experienced a 17% and 36% decrease, respectively.

Conclusion
Between 2013 and 2022, there has been a notable decline in surgical interventions for distal radius fractures (DRFIs) within the Medicare population. While general orthopedic surgeons traditionally led the provision of DRFIs, recent trends indicate a shifting landscape. We observe a diminishing procedure share among general orthopedic surgeons and general surgeons, accompanied by a rising utilization of plastic surgeons and hand surgeons in addressing DRFIs.


Nationwide Surgical Trends in Distal Radius Fixation in Medicare Beneficiaries: Increased Utilization by Plastic Surgeons and Subspecialty Hand Surgeons

Background: Ankle fractures are one of the most common fractures that occur in the United States with an estimated incidence of 4.22/10,000 per year. Trimalleolar ankle fractures make up about 7% of all ankle fractures, but these fractures traditionally have worse recovery outcomes as well as a risk of future osteoarthritis. Surgical repair of the ankle after this type of fracture requires the reduction of the malleoli and stabilization of the syndesmosis. However, postoperative complications from this type of fracture include restricted mobility, pain, swelling, and limitation to activities of daily living. Smoking and nicotine use are well described in the literature to increase the risk of bone loss, decrease bone mineral density, and delay the union of fracture sites. The purpose of this study is to evaluate specific postoperative complications between nicotine- and non-nicotine-dependent patients who had surgical open treatment of trimalleolar ankle fracture.

Methods: TriNetX, a global health database with de-identified patient information, was used and analyzed for this study. Cohort A was defined as patients who had surgical open treatment of trimalleolar ankle fractures with or without fixation (Current Procedural Terminology [CPT]: 27822, 27823) and had a dependence to nicotine (International Classification of Diseases, Tenth Revision, code: F17.2). Cohort B was defined as patients who had surgical open treatment of trimalleolar ankle fractures but did not have a dependence to nicotine. Data were gathered from healthcare organizations over the past 20 years. All post-diagnostic complications were analyzed between 1 and 120 days after the surgical open treatment of trimalleolar ankle fractures.

Results: 4,827 patients in cohort A were propensity matched with 25,467 patients in cohort B for age at the event, ethnicity, race, sex, type 2 diabetes mellitus, and body mass index. Nicotine-dependent patients who had surgical open treatment of trimalleolar ankle fractures experienced a higher associated risk for numerous post-operative complications. When compared to non-dependent patients, nicotine-dependent patients had an increased risk for wound disruption (risk ratio [RR] 1.656, 95% confidence interval [CI] 1.28 – 2.14) and infection (RR 1.836, 95% CI 1.5 – 2.25) following a procedure within 120 days post open treatment of trimalleolar ankle fractures. Instances of avascular necrosis, deep vein thrombosis, pulmonary embolism, and revision surgeries were found not to be statistically different between the two cohorts.

Conclusion: This propensity-matched study showed that nicotine-dependent patients who were surgically treated with open treatment of trimalleolar ankle fractures were correlated with an increased risk for wound disruption and infection compared to their non-nicotine-dependent counterparts.

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