Date of Award

January 2025

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Jonathan N. Grauer

Abstract

As over 90% of orthopaedic surgeons pursue subspecialization, it remains to be seen how subspecialization is correlated with patient outcomes for surgeries across subspecialty cohorts. Geriatric femoral neck fractures are common and typically managed with hemiarthroplasty (HA), total hip arthroplasty (THA), or percutaneous pinning (PP) by an on-call orthopaedic surgeon, who may subspecialize in arthroplasty, trauma, or other areas. Ankle fractures are also performed by orthopaedic surgeons who may subspecialize in foot & ankle, trauma, or other areas. The current study assessed if perioperative and longer-term outcomes for femoral neck fracture surgery or ankle fracture surgery are correlated with orthopaedic surgeon subspecialty. The PearlDiver M161 Ortho administrative dataset was utilized for this study. For femoral neck fractures, the dataset was queried to identify patients age 65 or greater that underwent HA, THA, or PP. The subspecialty of the treating surgeon for the femoral neck fracture patients was defined as arthroplasty, trauma, or non-arthroplasty/non-trauma. Exclusion criteria included polytrauma as well as concurrent neoplasms and infections. For ankle fractures, the dataset was queried to identify adult patients (age 18 or greater) that underwent surgery. The subspecialty of the treating orthopaedic surgeon was defined as foot & ankle, trauma, or non-foot & ankle/non-trauma. Exclusion criteria included polytrauma as well as concurrent neoplasms and infections. For each of the surgery types, 90-day perioperative adverse events were assessed and compared between surgeon cohorts using multivariate logistic regression, with “non-arthroplasty/non-trauma” serving as the reference for femoral neck fracture patients and “non-foot & ankle/non-trauma” serving as the reference for ankle fracture patients. Five-year revisions/dislocations were assessed, and Kaplan-Meier curves were compared with log rank tests. For femoral neck fractures: A total of 150,728 surgeries were identified. Arthroplasty surgeons performed THA at a higher rate than trauma or non-arthroplasty/non-trauma surgeons (28.1% versus 7.7% and 12.8% respectively, p<0.001). Ninety-day outcomes were quite similar across each of the subspecialties of treating surgeons for each of the surgery types. For HA, the only differences were that the trauma cohort demonstrated a slightly higher rate of aggregated severe adverse events (OR: 1.15, p=0.001) but a lower rate of transfusions (OR: 0.80, p=0.002), compared to the non-arthroplasty/non-trauma group as the reference cohort. For THA no differences were identified. For PP, the only differences were that the arthroplasty cohort demonstrated a lower rate of urinary tract infections (OR: 0.68, p<0.001) and the trauma cohort demonstrated a lower rate of minor adverse events (OR: 0.79, p=0.004). For HA, five-year revision rates were statistically different but were within 1% between cohorts (arthroplasty 97.2%, trauma: 97.8%, non-arthroplasty/non-trauma: 98.2%) as well as for five-year dislocation rates (arthroplasty 96.8%, trauma: 97.8%, non-arthroplasty/non-trauma: 97.5%). For THA, five-year revision (arthroplasty 93.8%, trauma: 95.0%, non-arthroplasty/non-trauma: 93.9%) and dislocation rates (arthroplasty 96.3%, trauma: 96.9%, non-arthroplasty/non-trauma: 95.7%) were not statistically different between subspecialty cohorts. For PP, five-year revision rates (arthroplasty 95.1%, trauma: 95.2%, non-arthroplasty/non-trauma: 93.8%) were not statistically different. For ankle fractures: A total of 146,490 ankle fracture patients were identified, of which 4.2% were operated on by a foot & ankle surgeon, 3.5% by a trauma surgeon, and 92.3% by a non-foot & ankle/non-trauma surgeon. Relative to non-foot & ankle/non-trauma cohort patients, foot & ankle cohort patients had lower odds of aggregated any adverse events (OR 0.85) and major adverse events (OR 0.84), as well as surgical site infections (OR 0.75), AKI (OR 0.79), pneumonia (OR 0.68), urinary tract infection (OR 0.81) and readmission (OR 0.79) (p<0.05 for each). Trauma cohort patients had increased odds of deep vein thrombosis (OR 1.23), surgical site infections (OR 1.28), acute kidney injury (OR 1.23), and readmission (OR 1.27) (p<0.05 for all). No differences were found in 5-year revision rates between subspecialty cohorts (p=0.4) Overall, orthopaedic surgeons of different subspecialties had different treatment distributions for geriatric femoral neck fractures, but 90-day adverse outcomes and five-year rates of revision/dislocation were clinically quite similar. While surgeons of different orthopaedic subspecialties may operate on ankle fractures, the current study found that foot and ankle surgeons demonstrated better outcomes for several perioperative medical complications but not five-year revision rates. This can provide confidence that those who self-select to be on orthopaedic call and treat geriatric femoral neck fractures are performing comparable to their peers using overall metrics. Specialized training in the management of complex lower extremity injuries appears to be beneficial, as evidenced by the positive outcomes reported in foot & ankle procedures

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 05/14/2027

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