Background: Pain is a highly common and costly health problem that is strongly linked to cigarette smoking. Pain interference, the degree to which pain impedes physical, occupational, recreational, and social functioning, may have an important role in terms of smoking cessation. However, no study has examined the role of pain interference as a predictor of relapse following a quit attempt in a smoking cessation trial. Objectives: The current study examined the role of pain interference, above the effects of pain intensity, on relapse following a quit attempt. Participants were 121 treatment-seeking adult cigarette smokers (29% female; Mage = 29.32, SD = 7.52) who attended a randomized-controlled trial (RCT) testing the effect of a digital single-session personalized feedback intervention (PFI) for distress tolerance and cigarette smoking behavior. Multiple logistic regressions were conducted to examine pain intensity and pain interference scores as predictors of 7-day point prevalence abstinence (PPA) at 2 weeks and 4 weeks following the 1-session intervention. Models controlled for sex, baseline cigarette dependence, treatment condition, and baseline distress tolerance. Results: Pain interference was associated with higher odds of reporting relapse at 4-week post intervention (OR: 1.54, 95% CI [1.06, 2.25]).), while pain intensity only showed a non-significant association with higher odds of reporting relapse at 2-week (OR: 1.40, 95% CI [0.67, 2.94]). Conclusions: This prospective study highlights the effect of pain interference on later-stage relapse outcomes following participation in a cigarette smoking cessation program.

Supplemental Digital Content is Available in the Text. OBJECTIVES:To report on adverse events during magnetic resonance imaging (MRI) in patients with external fixators.Design:Retrospective case series.Setting:Two Level 1 trauma centers.Patient Selection Criteria:Patients with external fixators on the appendicular skeleton or pelvis undergoing MRI between January 2005 and September 2023.Outcome Measures and Comparisons:Adverse events, defined as any undesirable event associated with the external fixator being inside or outside the MRI bore during imaging, including (subjective) heating, displacement or pullout of the external fixator, or early MRI termination for any reason.RESULTS:A total of 97 patients with 110 external fixators underwent at least one MRI scan with an external fixator inside or outside of the MRI bore. The median age was 51 years (interquartile range: 39-63) and 56 (58%) were male. The most common external fixator locations were the ankle (24%), knee (21%), femur (21%), and pelvis (19%). The median duration of the MRI was 40 minutes (interquartile range: 26-58), 86% was performed using 1.5-Tesla MRI, and 14% was performed using 3.0-Tesla MRI. Ninety-five percent of MRI was performed for the cervical spine/head. Two MRI scans (1.6%), one of the shoulder and one of the head and cervical spine, with the external fixator outside of the bore were terminated early because of patient discomfort. There were no documented events of displacement or pullout of the external fixator.CONCLUSIONS:These findings suggest that MRI scans of the (cervical) spine and head can be safely obtained in patients with external fixators on the appendicular skeleton or pelvis. Given the low numbers of MRI scans performed with the external fixator inside the bore, additional studies are necessitated to determine the safety of this procedure. The results from this study can aid orthopaedic surgeons, radiologists, and other stakeholders in developing local institutional guidelines on MRI scanning with external fixators in situ.LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Context Addressing vitamin D deficiency (VDD) is important for fracture secondary prevention. Objectives To explore the function of a fracture liaison service (FLS) to address VDD. Design, Setting and Patients An observational study of patients admitted to the Massachusetts General Hospital with fractures between January 1, 2016, and October 31, 2023, cared for by the FLS. Intervention Ergocalciferol 50 000 international units (50ku-D2) oral daily for 3 to 7 days. Main Outcomes Measures VDD prevalence. Efficacy of inpatient daily 50ku-D2 in raising serum 25-hydroxyvitamin D (25OHD) levels. Results Of the 2951 consecutive patients, 724 (24.53%) had VDD (defined by 25OHD <= 19 ng/mL). Men (252/897, or 28.09%) were more likely than women (472/2054, or 22.98%) to have VDD (P = .003). VDD was seen in 41.79% (117/280), 24.41% (332/1360), and 20.98% (275/1311) of patients of aged <= 59, 60 to 79, and >= 80 years, respectively (P < .00001). Of the 1303 patients with hip fractures, 327 (25.09%) had VDD, which was associated with a longer length of stay (8.37 +/- 7.35 vs 7.23 +/- 4.78 days, P = .009) and higher trend of 30-day-readmission rate (13.63% vs 18.35%, P = .037). In a cohort of 32 patients with complete data, each dose of 50ku-D2 increased serum 25OHD by 3.62 +/- 2.35 ng/mL without affecting serum calcium or creatinine levels. Conclusion VDD was seen in nearly 25% of Massachusetts General Hospital FLS patients and more prevalent in male and younger patients. VDD was associated with longer length of stay and higher 30-day-readmission risk in patients with hip fracture. Daily 50ku-D2 appeared to be a practical way to quickly replete vitamin D in the inpatient setting.

Background Approximately 20% to 50% of patients develop persistent pain after traumatic orthopaedic injuries. Psychosocial factors are an important predictor of persistent pain; however, there are no evidence-based, mind-body interventions to prevent persistent pain for this patient population. Questions/purposes (1) Does the Toolkit for Optimal Recovery after Injury (TOR) achieve a priori feasibility benchmarks in a multisite randomized control trial (RCT)? (2) Does TOR demonstrate a preliminary effect in improving pain, as well as physical and emotional function? Methods This pilot RCT of TOR versus a minimally enhanced usual care comparison group (MEUC) was conducted among 195 adults with an acute orthopaedic traumatic injury at risk for persistent pain at four geographically diverse Level 1 trauma centers between October 2021 to August 2023. Fifty percent (97 of 195) of participants were randomized to TOR (mean age 43 ± 17 years; 67% [65 of 97] women) and 50% (98) to MEUC (mean age 45 ± 16 years; 67% [66 of 98] women). In TOR, 24% (23 of 97) of patients were lost to follow-up, whereas in the MEUC, 17% (17 of 98) were lost. At 4 weeks, 78% (76 of 97) of patients in TOR and 95% (93 of 98) in the MEUC completed the assessments; by 12 weeks, 76% (74 of 97) of patients in TOR and 83% (81 of 98) in the MEUC completed the assessments (all participants were still included in the analysis consistent with an intention-to-treat approach). The TOR has four weekly video-administered sessions that teach pain coping skills. The MEUC is an educational pamphlet. Both were delivered in addition to usual care. Primary outcomes were feasibility of recruitment (the percentage of patients who met study criteria and enrolled) and data collection, appropriateness of treatment (the percent of participants in TOR who score above the midpoint on the Credibility and Expectancy Scale), acceptability (the percentage of patients in TOR who attend at least three of four sessions), and treatment satisfaction (the percent of participants in TOR who score above the midpoint on the Client Satisfaction Scale). Secondary outcomes included additional feasibility (including collecting data on narcotics and rescue medications and adverse events), fidelity (whether the intervention was delivered as planned) and acceptability metrics (patients and staff), pain (numeric rating scale), physical function (Short Musculoskeletal Function Assessment questionnaire [SMFA], PROMIS), emotional function (PTSD [PTSD Checklist], depression [Center for Epidemiologic Study of Depression]), and intervention targets (pain catastrophizing, pain anxiety, coping, and mindfulness). Assessments occurred at baseline, 4 and 12 weeks. Results Several outcomes exceeded a priori benchmarks: feasibility of recruitment (89% [210 of 235] of eligible participants consented), appropriateness (TOR: 73% [66 of 90] scored > midpoint on the Credibility and Expectancy Scale), data collection (79% [154 of 195] completed all surveys), satisfaction (TOR: 99% [75 of 76] > midpoint on the Client Satisfaction Scale), and acceptability (TOR: 73% [71 of 97] attended all four sessions). Participation in TOR, compared with the MEUC, was associated with improvement from baseline to postintervention and from baseline to follow-up in physical function (SMFA, baseline to post: -7 [95% CI -11 to -4]; p < 0.001; baseline to follow-up: -6 [95% CI -11 to -1]; p = 0.02), PROMIS (PROMIS-PF, baseline to follow-up: 2 [95% CI 0 to 4]; p = 0.045), pain at rest (baseline to post: -1.2 [95% CI -1.7 to -0.6]; p < 0.001; baseline to follow-up: -1 [95% CI -1.7 to -0.3]; p = 0.003), activity (baseline to post: -0.7 [95% CI -1.3 to -0.1]; p = 0.03; baseline to follow-up: -0.8 [95% CI -1.6 to -0.1]; p = 0.04), depressive symptoms (baseline to post: -6 [95% CI -9 to -3]; p < 0.001; baseline to follow-up: -5 [95% CI -9 to -2]; p < 0.002), and posttraumatic symptoms (baseline to post: -4 [95% CI -7 to 0]; p = 0.03; baseline to follow-up: -5 [95% CI -9 to -1]; p = 0.01). Improvements were generally clinically important and sustained or continued through the 3 months of follow-up (that is, above the minimum clinically important different [MCID] of 7 for the SMFA, the MCID of 3.6 for PROMIS, the MCID of 2 for pain at rest and pain during activity, the MCID of more than 10% change in depressive symptoms, and the MCID of 10 for posttraumatic symptoms). There were treatment-dependent improvements in pain catastrophizing, pain anxiety, coping, and mindfulness. Conclusion TOR was feasible and potentially efficacious in preventing persistent pain among patients with an acute orthopaedic traumatic injury. Using TOR in clinical practice may prevent persistent pain after orthopaedic traumatic injury. Level of Evidence Level I, therapeutic study.

OBJECTIVE:The objective of this study was to compare the quality of syndesmotic reduction with the ankle in maximal dorsiflexion versus neutral plantarflexion (normal resting position). METHODS:Baseline computed tomography (CT) imaging of 10 cadaveric ankle specimens from 5 donors was obtained with the ankles placed in normal resting position. Two fellowship-trained orthopaedic surgeons disrupted the syndesmosis of each ankle specimen. All ankles were then placed in neutral plantarflexion and were subsequently reduced with thumb pressure under direct visualization through an anterolateral approach and stabilized with one 0.062-inch K-wire placed from lateral to medial in a quadricortical fashion across the syndesmosis. Postreduction CT scans were then obtained with the ankle in normal resting position. This process was repeated with the ankles placed in maximal dorsiflexion during reduction and stabilization. Postreduction CT scans were then obtained with the ankles placed in normal resting position. All postreduction CT scans were compared with baseline CT imaging using mixed-effects linear regression with significance set at P < 0.05. RESULTS:Syndesmotic reduction and stabilization in maximal dorsiflexion led to increased external rotation of the fibula compared with baseline scans [13.0 ± 5.4 degrees (mean ± SD) vs. 7.5 ± 2.4 degrees, P = 0.002]. There was a tendency toward lateral translation of the fibula with the ankle reduced in maximal dorsiflexion (3.3 ± 1.0 vs. 2.7 ± 0.7 mm, P = 0.096). No other statistically significant differences between measurements of reduction with the ankle placed in neutral plantarflexion or maximal dorsiflexion compared with baseline were present (P > 0.05). CONCLUSIONS:Reducing the syndesmosis with the ankle in maximal dorsiflexion may lead to malreduction with external rotation of the fibula. There was no statistically significant difference in reduction quality with the ankle placed in neutral plantarflexion compared with baseline. Future studies should assess the clinical implications of ankle positioning during syndesmotic fixation.

Purpose For polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 hours) versus delayed (>24 hours) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. Methods The 2017-2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 hours, delayed definitive fixation (DDF) as fixation of both fractures after 24 hours, and early staged fixation (ESF) as fixation of one femur within 24 hours and the other femur after 24 hours. Propensity score matching and multilevel mixed effects regression models were used to compare groups. Results 1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p=0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p=0.012), a shorter ICU LOS (5 vs 7 days, p<0.001) and a shorter hospital LOS (10 vs 15 days, p<0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p=0.007), but a longer ICU LOS (8 vs 6 days, p=0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 hours and total hospital LOS by 27 hours. Conclusion Early definitive fixation (≤ 24 hours) is preferred over delayed definitive fixation (>24 hours) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.

Fixation for suprasyndesmotic fibula fractures (AO/OTA type 44C, consistent with Weber C) is classically achieved using a single one-third tubular plate. However, these fractures may sometimes require stronger fixation due to the diaphyseal fracture location and the lack of structural support from injured ligaments. To increase stability, 3.5 mm plates can be used, but these plates are bulky and too stiff to contour. As alternative, the authors present the technique and clinical and patient-reported outcomes (PROs) of using stacked one-third tubular plating for suprasyndesmotic fibula fractures to increase stability of fixation. Between 2021 and 2023, 14 patients were treated with stacked one-third tubular plating. All patients healed uneventfully. One patient developed an infection with wound breakdown and exposed hardware after fracture healing. Thirteen patients (93%) responded to PROs. The median Olerud-Molander ankle score was 75 (interquartile range [IQR]: 30-80), the median EQ-5D-5L score was 80 (IQR: 69-81), and the median numeric rating scale (NRS) score was 3 (IQR: 0-5). The use of double-stacked one-third tubular plates is a simple and safe technique that can be used to increase stability of suprasyndesmotic fibula fractures leading to reliable healing rates and satisfactory PROs.Levels of Evidence: Level IV Retrospective Case Series.

Purpose To analyze the clinical and demographic presentation, treatment strategies, and outcomes of athletes who sustained proximal ulna stress injuries and elucidate the available evidence on management and anatomic variation. Methods A literature search was performed on the basis of the medical databases MEDLINE/PubMed and Embase. Articles reporting on sports-related physeal injuries and stress fractures of the proximal ulna were eligible for inclusion. Outcome variables included clinical presentation, imaging assessments, management, and complications. Results A total of 40 studies were included with 174 athletes who sustained physeal injuries or stress fractures of the proximal ulna. The age ranges of the 74 patients with physeal injuries and 100 patients with stress fractures were 11-26 years and 14-30 years, respectively. Of the studies reporting on clinical symptoms, athletes most commonly presented with olecranon tenderness to palpation and swelling. All athletes with physeal injuries were diagnosed with plain radiographs, whereas 47 athletes who underwent radiography for olecranon stress fractures required additional advanced imaging. Studies on nonoperative management reported return to play rates from 67% to 100% (median, 100% [interquartile range, 100-100%]) and 2 complications were reported (chondromalacia of the trochlear notch and occasional symptomology). One hundred twenty-six patients were treated operatively, of which failure of conservative management was reported in 15 of 40 studies, including 61 athletes. The return to play rates ranged from 67% to 100% (median, 100% [interquartile range, 100-100%]) and 20 complications were reported, most commonly hardware irritation (n = 15). Conclusions Proximal ulna stress injuries in athletes can be managed either nonoperatively or operatively, with both showing satisfactory rates of return to play. Although operative management was more common, almost one half of these athletes failed an initial trial of nonoperative management. Level of Evidence Level IV; systematic review of Level III-IV studies.

OBJECTIVES:Acute orthopedic traumatic musculoskeletal injuries are prevalent, costly, and often lead to persistent pain and functional limitations. Psychological risk factors (eg, pain catastrophizing and anxiety) exacerbate these outcomes but are often overlooked in acute orthopedic care. Addressing gaps in current treatment approaches, this mixed-methods pilot study explored the use of a therapeutic virtual reality (VR; RelieVRx ), integrating principles of mindfulness and cognitive-behavioral therapy, for pain self-management at home following orthopedic injury. METHODS:We enrolled 10 adults with acute orthopedic injuries and elevated pain catastrophizing or pain anxiety from Level 1 Trauma Clinics within the Mass General Brigham health care system. Participants completed daily RelieVRx sessions at home for 8 weeks, which included pain education, relaxation, mindfulness, games, and dynamic breathing biofeedback. Primary outcomes were a priori feasibility, appropriateness, acceptability, satisfaction, and safety. Secondary outcomes were pre-post measures of pain, physical function, sleep, depression, and hypothesized mechanisms (pain self-efficacy, mindfulness, and coping). RESULTS:The VR and study procedures met or exceeded all benchmarks. We observed preliminary improvements in pain, physical functioning, sleep, depression, and mechanisms. Qualitative exit interviews confirmed high satisfaction with RelieVRx and yielded recommendations for promoting VR-based trials with orthopedic patients. DISCUSSION:The results support a larger randomized clinical trial of RelieVRx versus a sham placebo control to replicate the findings and explore mechanisms. There is potential for self-guided VR to promote evidence-based pain management strategies and address the critical mental health care gap for patients following acute orthopedic injuries.

Introduction: Ongoing lower extremity long-bone nonunion is a devastating condition and associated with substantial patient morbidity. There is limited evidence regarding physical and mental function after surgical management of lower extremity nonunions. The purpose of this study was to assess general physical and mental health and lower extremity specific physical function of patients that underwent surgery for a lower extremity long-bone nonunion. Methods: One-hundred and twenty-four adult patients who underwent successful surgical management for a lower extremity long-bone nonunion between June 2002 and December 2021 were evaluated at an average follow-up of 8.6 years (interquartile range [IQR]: 4 - 12). General physical and mental health was assessed with the Short-Form 12 (SF-12) physical (PCS) and mental (MCS) component summaries, and lower extremity specific physical function with the Lower Extremity Functional Scale (LEFS). Multivariable linear regression was performed to identify variables that were independently associated with outcomes. Results: The median LEFS was 50 (IQR: 37 - 63) and the median SF-12 PCS was 43 (IQR: 33 - 52), which are both lower than normative population scores (LEFS: 77 and PCS: 51, p < 0.0001). The median SF-12 MCS was 50, which was comparable to the normative population score of 51 (p p < 0.0001). The number of previous surgeries before the index nonunion treatment (p p = 0.018 and p = 0.041) and the number of revision surgeries after the index nonunion treatment (p p = 0.022 and p = 0.041) were associated with lower LEFS and SF-12 PCS scores. Conclusion: At an average of 8.6 years after lower extremity nonunion surgery that led to bone healing, patients continue to report lower general and lower extremity specific physical functioning compared to the normative population. The number of surgical attempts to obtain definitive healing was associated with compromised physical function scores. Mental health scores may return close to normative population scores. These results can be used to inform patients and guide treatment strategies and healthcare policies.

Inpatient zoledronic acid (IP-ZA) administered during the initial fracture hospitalization significantly improves the osteoporosis treatment rate. Clinical outcomes of IP-ZA after hip fracture remains uncertain. Here we report a new-user active comparator cohort study that emulated a randomized controlled trial using real-world data and evaluated the risk of death of any cause and radiologically confirmed subsequent new fractures among patients hospitalized for a hip fracture who had received IP-ZA as compared with propensity-matched controls who were not treated with anti-osteoporosis medication within the first-year post fracture. 654 patients who had received IP-ZA and 6877 controls (for whom antiosteoporosis treatment was indicated but no IP-ZA started during index hospitalization) were included in the study. The primary cohort comprised 652 IP-ZA patients (IP-ZA group) and 1926 matched controls (Untreated group) with 71.7% female, 92.1% White, and mean age of 80.9 years. Cumulative all-cause-mortality over the 24 months follow-up for the IP-ZA group was 12.3%, and 20.7% for Untreated group [hazard ratio (HR), 0.62; 95% confidence interval (CI), 0.49-0.78, p < 0.001)]. 585 (89.7%) patients in IP-ZA group received only a single dose of ZA during the 24 months, and the death rate of this single dose group was 13.3%, which was significantly lower than that of the Untreated group (HR, 0.70; 95% CI, 0.55-0.89, p = 0.003). Rates of radiologically confirmed cumulative subsequent new vertebral fractures were 2.0% in IP-ZA group and 5.4% in Untreated group (HR, 0.40; 95% CI, 0.22-0.71, P = 0.001). A similarly lower rate of new vertebral fractures was seen in the single dose subgroup (1.9% vs. 5.4%. HR, 0.44; 95% 0.24-0.82, p = 0.008). IP-ZA, administered during the initial hospitalization for hip fracture, was associated with lower all-cause-mortality and risk of radiologically confirmed subsequent new vertebral fractures, and thus offers a mechanism to narrow the treatment gap in patients having sustained a hip fragility fracture.

Lagazzi, Emanuele; Rafaqat, Wardah; Kalva, Sanjeeva P.; Ly, Thuan V.; Velmahos, George C. Author Information

Context Zoledronic acid (ZA) administered during the initial hospitalization for a fragility fracture improves the osteoporosis pharmacotherapy rate. Distinguishing the safety profile of inpatient ZA (IP-ZA) in this context is crucial if this approach is to be widely adopted. Objective To study the acute safety profile of IP-ZA. Methods An observational study of patients admitted to the Massachusetts General Hospital with fragility fractures who were eligible to receive IP-ZA. Patients were treated with or without IP-ZA. Acetaminophen, either as a single pre-ZA dose or standing multiple-doses-per-day regimen for 48 hours or longer after ZA infusion, was also administered along with protocolized vitamin D and calcium supplementation. Changes in body temperature, serum creatinine, and serum calcium were measured. Results A total of 285 consecutive patients, meeting inclusion and exclusion criteria, are included in this analysis; 204 patients received IP-ZA. IP-ZA treatment was associated with a transient mean rise of body temperature of 0.31 degrees C on the day following its administration. Temperatures above 38 degrees C were seen in 15% of patients in the IP-ZA group and 4% in the nontreated group. Standing multiple-doses-per-day but not a single pre-ZA dose of acetaminophen effectively prevented this temperature increase. IP-ZA did not affect serum creatinine levels. Mean levels of serum total calcium and albumin-corrected calcium decreased by 0.54 mg/dL and 0.40 mg/dL, respectively, at their nadirs (Day 5). No patient experienced symptomatic hypocalcemia. Conclusion IP-ZA along with standing multiple-doses-per-day acetaminophen, administered to patients in the immediate postfracture period, is not associated with significant acute adverse effects.

Supplemental Digital Content is Available in the Text. Objective: To compare the adverse event profile and patient comorbidity profile of lower extremity orthopaedic trauma patients admitted via interfacility transfer (IT) to direct admission (DA) patients from home. Methods: A total of 39,497 patients from 2012 to 2019 were identified in the American College of Surgeon National Surgical Quality Improvement Program database. DA patients were compared with IT patients for differences in preoperative comorbidities, adverse events, length of stay, and readmissions in the 30-day postoperative period. Student t tests were used to assess continuous variables. Pearson χ2 test and odds ratios (ORs) were used for categorical variables. Results: The IT group comprised 7167 patients, and the DA group comprised 32,330 patients. IT patients were on average older (65.5 vs. 58.8 years, P < 0.01), more likely to be American Society of Anesthesiologists Status >2 (P < 0.01), and had a worse comorbidity profile for numerous preoperative risk factors. IT patients had significantly higher rates of mortality [3.3% vs. 1.4%; odds ratio (OR) 2.29; 95% confidence interval (CI), 1.96–2.77], major complications (10.2% vs. 6.1%; OR 1.74; 95% CI, 1.60–1.91), significantly higher readmission rates (5.8% vs. 4.8%, P < 0.01, OR 1.22 95% CI, 1.09–1.36), and more infectious complications (7% vs. 4.7%; OR 1.54; 95% CI, 1.38–1.71) than DA patients. Transfer remained a significant factor predicting major adverse events in regression analysis controlling for patient characteristics and fracture type (P < 0.01; B 1.197; 95% CI, 1.09–1.32). Conclusions: This study revealed that IT patients undergoing operative management of pelvic, acetabular, and lower extremity fractures are at a significantly increased risk of major complications, readmission, and have a higher morbidity burden than DA patients. As healthcare transitions to value-based care and bundled payments, hospitals that accept a high volume of ITs will face exposure to added risk and financial penalties without adequate policy protections. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Toolkit for Optimal Recovery (TOR) is a mind-body program for patients with acute orthopedic injuries who are at risk for persistent pain/disability. In preparation for a multisite feasibility trial of TOR at three orthopedic trauma centers, we aim to qualitatively identify barriers and facilitators to study implementation and strategies to mitigate the implementation barriers and leverage facilitators.We conducted 18 live video focus groups among providers and three one-on-one interviews with department chiefs at Level 1 trauma centers in three geographically diverse sites (N = 79 participants). Using a content analysis approach, we detected the site-specific barriers and facilitators of implementation of TOR clinical trial. We organized the data according to 26 constructs of the Consolidated Framework for Implementation Research (CFIR), mapped to three Proctor implementation outcomes relevant to the desired study outcomes (acceptability, appropriateness, and feasibility). Across the three sites, we mapped six of the CFIR constructs to acceptability, eight to appropriateness, and three to feasibility. Prominent perceived barriers across all three sites were related to providers' lack of knowledge/comfort addressing psychosocial factors, and organizational cultures of prioritizing workflow efficiency over patients' psychosocial needs (acceptability), poor fit between TOR clinical trial and the fast-paced clinic structure as well as basic needs of some patients (appropriateness), and limited resources (feasibility). Suggestions to maximize the implementation of the TOR trial included provision of knowledge/tools to improve providers' confidence, streamlining study recruitment procedures, creating a learning collaborative, tailoring the study protocol based on local needs assessments, exercising flexibility in conducting research, dedicating research staff, and identifying/promoting champions and using novel incentive structures with regular check-ins, while keeping study procedures as nonobtrusive and language as de-stigmatizing as possible. These data could serve as a blueprint for implementation of clinical research and innovations in orthopedic and other medical settings.

Category: Ankle, Trauma Introduction/Purpose: Tri-malleolar fractures, as compared to simple uni-malleolar fractures, are technically more challenging cases, have longer operative times and require a higher effort. The current RVU-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs. bi-malleolar vs. tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation (ORIF) for uni-malleolar vs. bi-malleolar vs. tri-malleolar ankle fractures. Methods: The 2012-2017 American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) files were queried using CPT codes for patients undergoing open reduction internal fixation (ORIF) for uni-malleolar (CPT-27766, CPT- 27769, CPT-27792), bi-malleolar (CPT-27814) and tri-malleolar (CPT-27822, CPT-27823) ankle fractures. A total of 7,830 (37.2%) uni-malleolar, 7,826 (37.2%) bi-malleolar and 5,391 (25.6%) tri-malleolar ankle fractures were retrieved. Total RVUs were calculated for each case. Mean RVU/minute was derived by dividing the total RVU of each case by the total operative time. Reimbursement rate ($/min) was calculated by multiplying the mean RVU/min of each procedure by a preset CMS-defined rate of $35.8887/RVU. Mean Reimbursement/case was calculated by multiplying the reimbursement rate by the operative time of each procedure. Kruskal-Wallis tests were used to compare RVUs, operative time and reimbursements between the three fracture groups. Results: The mean total RVU for each fracture type was as follows:- 1) Uni-malleolar: 9.99, 2) Bi-malleolar=11.71 and 3) Tri- malleolar=12.87 (p<0.001). A statistically significant difference was noted in mean operative time (uni-malleolar=63.2 vs. bi- malleolar=78.6 vs. tri-malleolar=95.5; p<0.001) between the two groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar=$7.21/min vs. bi-malleolar=$6.75/min vs. tri-malleolar=$6.10; p<0.001). The average reimbursement/case was $358, $420 and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Based on a hypothetical scenario, an orthopaedic surgeon spent 190 minutes fixing two tri-malleolar fractures and earning $924 in the process. Within a total operative time of 190 minutes, three uni-malleolar ankle fractures and two bi-malleolar ankle fractures could be managed completely with an associated earning of $1,074 and $840 respectively. Conclusion: Orthopaedic surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

BACKGROUND:Discharge to an inpatient care facility (skilled-care or rehabilitation) has been shown to be associated with adverse outcomes following elective total joint arthroplasties. Current evidence with regard to hip fracture surgeries remains limited.METHODS:The 2015-2016 ACS-NSQIP database was used to query for patients undergoing total hip arthroplasty, hemiarthroplasty and open reduction internal fixation for hip fractures. A total of 15,655 patients undergoing hip fracture surgery were retrieved from the database. Inpatient facility discharge included discharges to skilled-care facilities and inpatient rehabilitation units. Multi-variate regression analysis was used to assess for differences in 30-day post-discharge outcomes between home-discharge versus inpatient care facility discharge, while adjusting for baseline differences between the 2 study populations.RESULTS:A total of 12,568 (80.3%) patients were discharged to an inpatient care facility. Discharge to an inpatient care facility was associated with higher odds of any complication (OR 2.03 [95% CI, 1.61-2.55]; p < 0.001), wound complications (OR 1.79 [95% CI, 1.10-2.91]; p = 0.019), cardiac complications (OR 4.49 [95% CI, 1.40-14.40]; p = 0.012), respiratory complication (OR 2.29 [95% CI, 1.39-3.77]; p = 0.001), stroke (OR 7.67 [95% CI, 1.05-56.29]; p = 0.045, urinary tract infections (OR 2.30 [95% CI, 1.52-3.48]; p < 0.001), unplanned re-operations (OR 1.37 [95% CI, 1.03-1.82]; p = 0.029) and readmissions (OR 1.38 [95% CI, 1.16-1.63]; p < 0.001) following discharge.CONCLUSION:Discharge to inpatient care facilities versus home following hip fracture surgery is associated with higher odds of post-discharge complications, re-operations and readmissions. These results stress the importance of careful patient selection prior to discharge to inpatient care facilities to minimise the risk of complications.