Nosocomial Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia results in a significant increase in morbidity and mortality in hospitalized patients. We aimed to analyze the impact of applying 10% povidone iodine (PI) twice daily to both nares in addition to chlorhexidine (CHG) bathing on nosocomial (MRSA) bacteremia in critically ill patients. A quality improvement study was completed with pre and post-design. The study period was from January 2018 until February 2020 and February 2021 and June 2021. The control period (from January 2018 to May 2019) consisted of CHG bathing alone, and in the intervention period, we added 10% PI to the nares of critically ill patients. Our primary outcome is rates of nosocomial MRSA bacteremia, and our secondary outcome is central line associated blood stream infection (CLABSI) and potential cost savings. There were no significant differences in rates of MRSA bacteremia in critically ill patients. Nosocomial MRSA bacteremia was significantly lower during the intervention period on medical/surgical areas (MSA). CLABSIs were significantly lower during the intervention period in critically ill patients. There were no Staphylococcus aureus CLABSIs in critical care area (CCA)during the intervention period. The intervention showed potential significant cost savings. The application of 10% povidone iodine twice a day in addition to CHG bathing resulted in a significant decrease in CLABSIs in critically ill patients and a reduction in nosocomial MRSA in the non-intervention areas. Further trials are needed to tease out individual patients who will benefit from the intervention.

Vitamin D insufficiency has been linked to multiple conditions including bone disease, respiratory disease, cardiovascular disease, diabetes, and cancer. Observational studies indicate lower healthcare costs and healthcare utilization with sufficient vitamin D levels. The secondary aims of our previously published pragmatic clinical trial of vitamin D3 supplementation were comparisons of healthcare costs and healthcare utilization. Comparisons were made between the vitamin D3 at 5000 IU supplementation group and a non-supplemented control group. Costs of care between the groups differed but were not statistically significant. Vitamin D3 supplementation reduced healthcare utilization in four major categories: hospitalizations for any reason (rate difference: −0.19 per 1000 person-days, 95%-CI: −0.21 to −0.17 per 1000 person-days, p < 0.0001); ICU admissions for any reason (rate difference: −0.06 per 1000 person-days, 95%-CI: −0.08 to −0.04 per 1000 person-days, p < 0.0001); emergency room visits for any reason (rate difference: −0.26 per 1000 person-days, 95%-CI: −0.46 to −0.05 per 1000 person-days, p = 0.0131; and hospitalizations due to COVID-19 (rate difference: −8.47 × 10⁻³ per 1000 person-days, 95%-CI: −0.02 to −1.05 × 10⁻³ per 1000 person-days, p = 0.0253). Appropriately powered studies of longer duration are recommended for replication of these utilization findings and analysis of cost differences.

Objective: To investigate outcomes after early versus delayed fixation of clean open ankle fractures involving the medial malleolus. Methods: Design : Retrospective review Setting: Single-center academic Level I trauma center Patient Selection Criteria: Patients undergoing open reduction and internal fixation from November 2016 to July 2024 for an open ankle fracture involving the medial malleolus (AO/OTA A2-C3). Outcome Measures and Comparisons: Infection rate, length of stay, number of operations, and return to the operating room were compared between early and delayed fixation groups. Results: The early fixation group consisted of 55 patients (67% female; mean age 55.8 ± 21.1 years), while the delayed fixation group consisted of 44 patients (68% female; mean age 57.5 ± 15.9 years). Infection rates were 22% in the early group and 9% in the delayed group (p=0.09). Early, compared to delayed, fixation was associated with a shorter length of stay (7.8 vs. 12.8 days; p=0.0004), lower external fixation rate (11% vs 82%) and fewer operations (1.3 vs. 2.4; p0.05). A post hoc analysis excluding isolated medial malleolus fractures demonstrated a higher infection rate in the early fixation cohort (22% vs 7%; p=0.0487). Conclusion: Early fixation was associated with a higher observed infection rate, particularly in bimalleolar and trimalleolar fractures, although this difference did not reach statistical significance in the overall cohort. Early fixation may be appropriate in select cases to reduce hospital resource utilization. However, surgeons should use caution when considering early fixation of higher energy injuries such as open bimalleolar and trimalleolar ankle fractures. Level of Evidence: Therapeutic Level III

Background: Benign and malignant bone and soft-tissue tumors have a broad range of clinical presentations. Operative management ranges from limited excision to complex resection and reconstruction. The work relative value unit (wRVU) is designed to quantify physician time, technical skill, and effort, but it is unclear whether current assignments adequately reflect the overall procedural demands of musculoskeletal orthopaedic oncology. The aim of this study was to compare wRVU generation between orthopaedic oncology procedures and matched nononcologic orthopaedic procedures after controlling for measures of physician time and intensity. Methods: A retrospective observational study was conducted using the American College of Surgeons' National Surgical Quality Improvement Program. Musculoskeletal orthopaedic oncology cases were stratified by Current Procedural Terminology (CPT) code according to tumor type. Mahalanobis distance matching was used to match orthopaedic oncology cases with nononcology orthopaedic controls. Total case wRVU generation was compared between groups. Results: Among 2,138,294 orthopaedic cases, 6,700 were musculoskeletal orthopaedic oncology cases (mean age 48 years, 45% female, 61% White, 9.6% Black, 5.0% Asian, 1.4% Other, and 23% unknown/not reported). After matching, oncology cases had 19.0% lower average wRVU (16.2 vs. 20.0) than matched controls despite similar operative times and case characteristics. The mean total case wRVUs were lower for benign soft-tissue tumors (9.7 vs. 15.8, −38.6%), benign bone tumors (11.0 vs. 15.8, −30.6%), and malignant soft-tissue tumors (18.1 vs. 26.3, −31.1%) compared with matched orthopaedic controls. By contrast, malignant bone tumors generated higher mean total case wRVUs than matched controls (43.9 vs. 37.0, +18.9%). Using a standardized workload of 675 operative hours per year, orthopaedic oncology procedures were estimated to generate 6,883 annual wRVUs vs. 8,570 for matched controls, corresponding to $56,167 lower annualized Medicare-based procedural value. Conclusions: Musculoskeletal orthopaedic oncology procedures generated fewer wRVUs than matched nononcologic orthopaedic procedures. We advocate for hospital and department leaders to consider this discrepancy within the wRVU model and account for it when designing compensation models for orthopaedic oncologists. Level of Evidence: Economic and Decision Analysis Level IV . See Instructions for Authors for a complete description of levels of evidence.