Purpose: Outcomes are excellent following surgical management of displaced supracondylar humerus fractures. Short delays until surgical fixation have been shown to be equivalent to immediate fixation with regards to complications. We hypothesized that insurance coverage may impact access to care and the patient’s ability to return to the operating room for outpatient surgery. Methods: A retrospective review of supracondylar humerus fractures treated at a large urban pediatric hospital from 2008 to 2012 was performed. Fractures were classified by the modified Gartland classification and baseline demographics were collected. Time from discharge to office visits and subsequent surgical fixation was calculated for all type II fractures discharged from the emergency department. Insurance status and primary carrier were collected for all patients. Results: 2584 supracondylar humerus fractures were reviewed, of which 584 were type II fractures. Of the 577 type II fractures with complete records, 383 patients (61 %) were admitted for surgery and the remaining 194 were discharged with plans for outpatient follow-up. There was no difference in insurance status between patients admitted for immediate surgery. Of the 194 patients who were discharged with type 2 fractures after gentle reduction, 59 patients (30.4 %) ultimately underwent surgical fixation. Of these, 42 patients were privately insured (58.3 % of patients with private insurance), 16 had governmental insurance (15.1 %), and 1 was uninsured (6.3 %). Patients with private insurance were 2.46 times more likely to have surgery than patients with public or no insurance (p = 0.005). Of the 135 patients who did not eventually have surgery, 92 (68.1 %) were seen in the clinic. Patients with private insurance were 2.78 times more likely to be seen back in the clinic when compared to publicly insured or uninsured patients (p = 0.0152). Conclusions: Despite an equivalent number of privately insured and publicly insured patients undergoing immediate surgery for type II fractures, those with public or no insurance who were discharged were 2.46 times less likely to obtain outpatient surgery when compared to privately insured patients. Patient insurance status and the ability to follow up in a timely manner should be assessed at the time of initial evaluation in the emergency department. Level of evidence Level 3
Delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) was first introduced in 1996 by Bashir et al. as a method of indirectly evaluating glycosaminoglycan (GAG) changes in cartilage microstructure. Following publications originating from the Boston Children’s research group describing the association of early joint failure following periacetabular osteotomy (PAO) in patients with diminished preoperative cartilage T1 relaxation values, the interest in this imaging technique spread. dGEMRIC imaging was introduced into our clinical practice in 2013 with enrollment of both pediatric and adult patients. However, since the program’s apex in 2015, a marked decline in referral of adolescent patients for preoperative dGEMRIC imaging has occurred. Using data acquired during a quality analysis of the dGEMRIC program, this project was designed to investigate the utility of the dGEMRIC exam in our adolescent imaging cohort from 2013-2015 and to identify potential factors leading to decreased utilization from 2015-2018.
BACKGROUND: Closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures is one of the most common procedures performed in pediatric orthopaedics. The use of full, standard preparation and draping with standard personal protective equipment (PPE) may not be necessary during this procedure. This is of particular interest in the current climate as we face unprecedented PPE shortages due to the current COVID-19 pandemic. METHODS: This is a retrospective chart review of 1,270 patients treated with CRPP of a supracondylar humeral fracture at 2 metropolitan pediatric centers by 10 fellowship-trained pediatric orthopaedic surgeons. One surgeon in the group did not wear a mask when performing CRPP of supracondylar humeral fractures, and multiple surgeons in the group utilized a semisterile preparation technique (no sterile gown or drapes). Infectious outcomes were compared between 2 groups: full sterile preparation and semisterile preparation. We additionally analyzed a subgroup of patients who had semisterile preparation without surgeon mask use. Hospital cost data were used to estimate annual cost savings with the adoption of the semisterile technique. RESULTS: In this study, 1,270 patients who underwent CRPP of a supracondylar humeral fracture and met inclusion criteria were identified. There were 3 deep infections (0.24%). These infections all occurred in the group using full sterile preparation and surgical masks. No clinically relevant pin-track infections were noted. There were no known surgeon occupational exposures to bodily fluid. It is estimated that national adoption of this technique in the United States could save between 18,612 and 22,162 gowns and masks with costs savings of $3.7 million to $4.4 million annually. CONCLUSIONS: We currently face critical shortages of PPE due to the COVID-19 pandemic. Data from this large series suggest that a semisterile technique during CRPP of supracondylar humeral fractures is a safe practice. We anticipate that this could preserve approximately 20,000 gowns and masks in the United States over the next year. Physicians are encouraged to reevaluate their daily practice to identify safe opportunities for resource preservation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Background:
The novel coronavirus and associated Coronavirus Disease 2019 (COVID-19) is rapidly spreading throughout the world, with robust growth in the United States. Its drastic impact on the global population and international health care is swift, evolving, and unpredictable. The effects on orthopaedic surgery departments are predominantly indirect, with widespread cessation of all nonessential orthopaedic care. Although this is vital to the system-sustaining measures of isolation and resource reallocation, there is profound detriment to orthopaedic training programs.
Methods:
In the face of new pressures on the finite timeline on an orthopaedic residency, the Emory University School of Medicine Department of Orthopaedics has devised a 5-pronged strategy based on the following: (1) patient and provider safety, (2) uninterrupted necessary care, (3) system sustainability, (4) adaptability, and (5) preservation of vital leadership structures.
Results:
Our 5 tenants support a 2-team system, whereby the residents are divided into cycling “active-duty” and “working remotely” factions. In observation of the potential incubation period of viral symptoms, phase transitions occur every 2 weeks with strict adherence to team assignments. Intrateam redundancy can accommodate potential illness to ensure a stable unit of able residents. Active duty residents participate in in-person surgical encounters and virtual ambulatory encounters, whereas remotely working residents participate in daily video-conferenced faculty-lead, case-based didactics and pursue academic investigation, grant writing, and quality improvement projects. To sustain this, faculty and administrative 2-team systems are also in place to protect the leadership and decision-making components of the department.
Conclusions:
The novel coronavirus has decimated the United States healthcare system, with an unpredictable duration, magnitude, and variability. As collateral damage, orthopaedic residencies are faced with new challenges to provide care and educate residents in the face of safety, resource redistribution, and erosion of classic learning opportunities. Our adaptive approach aims to be a generalizable tactic to optimize our current landscape.
Objective: To evaluate the clinical and economic impact of a novel postoperative pathway following posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS). Methods: Patient charts were reviewed for demographic data and to determine length of surgery, implant density, use of osteotomies, estimated blood loss, American Society of Anesthesiologists (ASA) score, length of hospital stay, and any subsequent complications. Hospital charges were divided by charge code to evaluate potential savings. Results: Two hundred and seventy-nine of 365 patients (76.4 %) treated with PSF carried a diagnosis of AIS and had completed 6 months of clinical and radiologic follow-up, a period of time deemed adequate to assess early complications. There was no difference between groups in age at surgery, sex, number of levels fused, or length of follow-up. Patients managed under the accelerated discharge (AD) pathway averaged 1.36 (31.7 %) fewer days of inpatient stay. Operative time was associated with a shorter length of stay. There was no difference in complications between groups. Hospital charges for room and board were significantly less in the AD group ($1.885 vs. $2,779, p < 0.001). Conclusions: A pathway aimed to expedite discharge following PSF for AIS decreased hospital stay by nearly one-third without any increase in early complication rate. A small but significant decrease in hospital charges was seen following early discharge. Early discharge following PSF for AIS may be achieved without increased risk of complications, while providing a small cost savings.
The complex nature of the surgical treatment of adolescent idiopathic scoliosis (AIS) requires a wide variety of health care providers. A well-coordinated, multidisciplinary team approach to the care of these patients is essential for providing high-quality care. This review offers an up-to-date overview of the numerous interventions and safety measures for improving outcomes after AIS surgery throughout the perioperative phases of care. Reducing the risk of potentially devastating and costly complications after AIS surgery is the responsibility of every single member of the health care team. Specifically, this review will focus on the perioperative measures for preventing surgical site infections, reducing the risk of neurologic injury, minimizing surgical blood loss, and preventing postoperative complications. Also, the review will highlight the postoperative protocols that emphasize early mobilization and accelerated discharge.