INTRODUCTION It is well known that patients with diabetes mellitus experience higher complication rates after torsional ankle fracture; however, the functional consequences remain less clear. The goal of this study was to determine the effects of diabetes on complications, secondary operations, and functional outcomes after torsional ankle fracture. METHODS Nine hundred seventy-nine adult patients treated surgically for a torsional ankle injury (Orthopaedic Trauma Association 44B, 44C) over 13 years were retrospectively reviewed. Demographic information, comorbidities, injury characteristics, complications, and secondary procedures were recorded. Patient-reported outcome surveys: Foot Function Index (FFI) and Short Musculoskeletal Function Assessment were obtained after minimum of 12 months. Multivariable analysis was done to account for confounding variables. RESULTS One hundred thirty-one patients (13.4%) had diabetes. Diabetic patients were older (56.4 versus 43.0 years, P < 0.001), with no difference in sex or race. Body mass index was higher among diabetics (36.0 versus 30.4, P < 0.001) as were most medical comorbidities, including stroke, neuropathy, pulmonary disease, and renal disease (all P < 0.03). There were no differences in rates of dislocations or open injuries. Diabetics experienced more complications (26.0% versus 14.6%, P = 0.001), specifically deep infections (6.9% versus 1.3%, P = 0.001), and had more secondary procedures (18.3% versus 9.1%, P = 0.001), including debridement, arthrodesis, and amputation (all P < 0.02). Diabetes was a significant independent predictor of worse FFI activity limitation scores (P = 0.032), but was not predictive of worse outcomes on any other subscore of the FFI or Short Musculoskeletal Function Assessment. CONCLUSIONS Diabetes was associated with more complications and secondary operations. However, functional outcomes including pain and dysfunction were not markedly affected by these clinical outcomes, potentially due to diminished sensory function and less baseline physical activity among diabetic patients. LEVEL OF EVIDENCE Prognostic level III.

Effects of Diabetes Mellitus on Functional Outcomes and Complications After Torsional Ankle Fracture

Despite increasing interest toward managing isolated ankle fractures in an outpatient setting, evidence of its safety remains largely limited. The 2007 to 2014 Humana Administrative Claims database was queried to identify patients undergoing open reduction internal fixation for unimalleolar, bimalleolar, or trimalleolar isolated closed ankle fractures. Two cohorts (outpatient versus inpatient) were then matched on the basis of age, sex, race, region, fracture type (uni-/bi-/trimalleolar) and Elixhauser Comorbidity Index to control for selection bias. Multivariate regression analyses were performed to report independent impact of outpatient-treated ankle fracture surgery on 90-day complications, readmission, and emergency department visit rates. Independent-samples t test was used to compare global 90-day costs between cohorts. A total of 5317 inpatient-treated and 6941 outpatient-treated closed ankle fractures were included in the final cohort. After matching and multivariate analyses, patients with outpatient ankle fractures, compared with patients with inpatient ankle fractures, had statistically lower rates of pneumonia (2.3% versus 4.0%; p

Outpatient Versus Inpatient Surgical Fixation of Isolated Ankle Fractures: An Analysis of 90-Day Complications, Readmissions, and Costs.

The recent outbreak of the novel coronavirus (SARS-CoV-2) has emphasised the need to minimise hospital admissions and utilisation of healthcare resources. The purpose of this study was to examine the outcomes of an outpatient surgery protocol for acute closed ankle fractures. In this retrospective study, 262 patients underwent outpatient surgery for their closed ankle fractures at our level-1 trauma centre. A total of 196 patients met our inclusion criteria and were ultimately included in the final analysis. Our primary outcomes’ measures included post-operative admission to the emergency department within 30 days after surgery and unplanned hospital readmission within 30 days after surgery. Our secondary outcome measure included the incidence of surgical site infection (SSI) within 12 weeks after surgery. Thirty-two patients (16.3%) had an unplanned emergency department visit within 30 days of fracture fixation and two patients (1.0%) required hospital readmission within 30 days of their surgery. Sixteen patients (8.2%) developed SSI, which included 11 (5.6%) superficial and five (2.6%) deep infections. Strategic outpatient management of acute closed ankle fractures is associated with acceptable rates of unplanned emergency department visits, hospital readmissions, and SSIs. In the context of the recent SARS-CoV-2 outbreak, outpatient management of these injuries may aide in the mitigation of nosocomial infections and the preservation of finite healthcare resources.

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Outpatient surgery in patients with ankle fractures minimises hospital admissions and utilisation of healthcare resources.

Preoperative antibiotic prophylaxis is administering antibiotics before performing surgery to help decrease the risk of postoperative infections. The evidence supporting routine preoperative use of prophylactic antibiotic administration continues to grow. The routine administration of prophylactic antibiotics is standard in cases in which a patient will have an artificial implant or foreign body implanted as part of the procedure, for bone grafting procedures, and other surgeries with extensive dissections and expectations for higher amounts of anticipated blood loss. This activity will highlight the rationale, timing, agent selection, coverage, and monitoring pertinent for members of the interprofessional team involved in the administration of preoperative antibiotic prophylaxis to patients.

Preoperative Antibiotic Prophylaxis

An occupational injury describes any type of injury or illness that occurs to a patient as related to his or her specific occupational demands or requirements. Occupational injuries or illnesses represent a substantial percentage of emergency department visits as well as primary care and subspecialty clinical practices. The most common organs involved are the hands, eyes, spine, head, lungs, skeleton, and skin.Occupational injuries result from physical, biological, chemical, or psychosocial hazards such as noise, temperature, insect or animal bites, aerosols, blood-borne pathogens, hazardous chemicals, radiation, and occupational burnout. While prevention methods are available, many injuries still occur due to poor ergonomics, manual handling of heavy loads, misuse of equipment, general hazards, and inadequate safety training.Healthcare providers should strive to maintain awareness regarding the overall financial burden of the direct and indirect costs attributed to the long-term and permanent disability, as well as the pertinent role of the workers' compensation system to facilitate the flow and efficiency of healthcare provided to these workers to mitigate associated negative downstream effects.

Occupational Injuries and Workers' Compensation Management Strategies

OBJECTIVES To determine the independent risk factors associated with increasing costs and unplanned hospital readmissions in the 90-day episode of care (EOC) for isolated operative ankle fractures at our institution. DESIGN Retrospective cohort study. SETTING Level I Trauma Center. PATIENTS Two hundred ninety-nine patients undergoing open reduction internal fixation for the treatment of an acute, isolated ankle fracture between 2010 and 2015. INTERVENTION None. MAIN OUTCOME MEASURES Independent risk factors for increasing 90-day EOC costs and unplanned hospital readmission rates. RESULTS Orthopaedic (64.9%) and podiatry (35.1%) patients were included. The mean index admission cost was $14,048.65 ± $5,797.48. Outpatient cases were significantly cheaper compared to inpatient cases ($10,164.22 ± $3,899.61 vs. $15,942.55 ± $5,630.85, respectively, P < 0.001). Unplanned readmission rates were 5.4% (16/299) and 6.7% (20/299) at 30 and 90 days, respectively, and were often (13/20, 65.0%) due to surgical site infections. Independent risk factors for unplanned hospital readmissions included treatment by the podiatry service (P = 0.024) and an American Society of Anesthesiologists score of ≥3 (P = 0.017). Risk factors for increasing total postdischarge costs included treatment by the podiatry service (P = 0.011) and male gender (P = 0.046). CONCLUSIONS Isolated operative ankle fractures are a prime target for EOC cost containment strategy protocols. Our institutional cost analysis study suggests that independent financial clinical risk factors in this treatment cohort includes podiatry as the treating surgical service and patients with an American Society of Anesthesiologists score ≥3, with the former also independently increasing total postdischarge costs in the 90-day EOC. Outpatient procedures were associated with about a one-third reduction in total costs compared to the inpatient subgroup.

Cost Determinants in the 90-Day Management of Isolated Ankle Fractures at a Large Urban Academic Hospital.

The musculature of the hand is deeply intricate, with several superimposed layers of muscles, tendons, and fascial compartments throughout. Complex interactions between these groups modulate specific movements, thus understanding their role in hand biomechanics can greatly enhance clinical evaluation and diagnosis for medical professionals. The thumb is one of the most important entities of the hand. Its versatility in movement compared to the other digits makes the hand the ultimate tool of elite dexterity. Because the thumb is orientated perpendicular to the other digits, its movements are modulated by a diverse set of specific muscles within the hand. Many muscles contribute to its movements, and one of the most important is the adductor pollicis. The adductor pollicis muscle is an intrinsic muscle of the hand which lies in the deepest muscular plane of the palm, within the adductor compartment. It is a unique muscle, in that it is triangular shaped with a 2-headed structure. The oblique head originates at the capitate as well as at the bases of the 2nd and 3rd metacarpals, while the transverse head originates from the volar aspect of the 3rd metacarpal. These two heads then merge as the fibers travel laterally, forming the tendon of the adductor pollicis which often contains a sesamoid bone. The tendon then inserts on the medial aspect of the proximal phalanx of the thumb as well as the extensor hood.

Jonathan Acosta

Papers

Cost Determinants in the 90-Day Management of Isolated Ankle Fractures at a Large Urban Academic Hospital.

Anatomy, Shoulder and Upper Limb, Hand Adductor Pollicis

P23. Inline axial forces associated with implantation of ALIF interbody devices with integrated supplemental fixation