Background: Increasing U.S. health-care costs raise concerns regarding the sustainability of the U.S. health-care system, with the potential for negative effects on the mental and physical health of patients. Orthopaedic injuries often impose considerable financial burdens on patients and hospitals, but the trends in, and drivers of, costs remain unclear. This study evaluated the total expenditure and out-of-pocket (OOP) costs of patients with a lower-extremity (LE) fracture in the non-institutionalized U.S. population from 2010 to 2021. Methods: A total of 3,016 participants with an LE fracture from the Medical Expenditure Panel Survey (MEPS) were propensity score matched with 15,080 MEPS participants with no LE fracture. Patients with an LE fracture were predominantly between 40 and 64 years old (43.2%), female (66.0%), and White (78.8%). Total expenditure and OOP costs were compared between the groups. A multivariable regression analysis was performed to identify factors that were associated with costs. Outcomes were adjusted on the basis of the 2022 Consumer Price Index. Results: Patients with an LE fracture had greater total expenses than the control group ($20,230 [95% confidence interval (CI), $18,916 to $21,543] versus $10,678 [95% CI, $10,302 to $11,053]; p < 0.001) as well as greater OOP costs ($1,634 [95% CI, $1,516 to $1,753] versus $1,089 [95% CI, $1,050 to $1,128]; p < 0.001). Between 2010 and 2021, total expenses increased more for patients with an LE fracture than for the control group (101.2% versus 51.4%; p < 0.001), whereas OOP costs increased to a lesser degree in both groups (61.1% versus 44.5%; p = 0.17). In the LE fracture group, total expenditure was driven by inpatient care, office-based visits, and prescription costs, whereas OOP costs were driven by office-based visits, prescription costs, and “other” sources. Femoral fracture, hospitalization, and certain comorbidities were associated with higher total expenses. Hospitalization, uninsured status, and a higher income level were associated with increased OOP costs, whereas African American or Hispanic background and a lower educational level were associated with lower OOP costs. Conclusions: An LE fracture was associated with considerable total expenditure and OOP costs, which increased disproportionately compared with general health-care costs over the past decade. Post-hospitalization care was the biggest driver of both total expenses and OOP costs. Due to limitations inherent to the MEPS database, the impact of financial burden on not only payers but also individuals and their medical decision-making remains unclear and requires further investigation. Level of Evidence: Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

PurposeThis study investigated the longitudinal assessment of step-up performance in patients undergoing total joint arthroplasty (TJA) and correlation with subjective patient reported outcome measures (PROMs).MethodsIn this sub-analysis of the ADAPT study, PROMs were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Block step-up (BS) transfers were assessed by wearable-derived measures of time. 76 patients undergoing TJA were included. Subgroups were formed isolating the worst performing quartile (low functioning (LF)) from the high functioning (HF), and outcomes were compared-ResultsOne-year post-surgery, WOMAC function demonstrated strong correlations to WOMAC pain (Pearson's r = 0.67-0.84) and moderate correlations to BS performance (Pearson's r = 0.31-0.54). Both WOMAC and BS significantly improved with a larger effect size for the HF subgroup (0.62 vs. 0.43; p < 0.05). Patients designated to the LF subgroup at 3 months had increased odds of representing the LF subgroup at 12 months (WOMAC = 19; BS = 4). WOMAC defined 18 LF patients at 12 months follow-up. BS performance identified 9 additional LF patients.ConclusionsWOMAC function scores seem pain dominated. Measures of BS performance allow assessment of otherwise hidden residual functional impairment. Lower functioning 3 months post-surgery is predictive of longer-term impairment.

Objectives: Little is known about the post-operative functional outcomes of severely frail femur fracture patients, with previous studies focusing on complications and mortality. This study investigated patient- or proxy-reported outcomes after femur fracture surgery in older adult patients with severe frailty. Methods: This was a retrospective cross-sectional study of older adult (>70 years) patients with severe frailty (defined by a Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) ≥ 0.40), who underwent femur fracture surgery at a Level 1 Trauma Center. Patients or their proxy (i.e., close relative) reported mobility, psychosocial, and functional outcomes at least 1-year after surgery. Results: Thirty-seven predominantly female (76%) patients with a median age of 85 years (IQR 79–92), and a median FI-CGA of 0.48 (IQR 0.43–0.54) were included. Eleven patients (30%) regained pre-fracture levels of ambulation, with twenty-six patients (70%) able to walk with or without assistance. The majority of patients (76%) were able to have meaningful conversations. Of the patients, 54% of them experienced no to minimal pain, while 8% still experienced a lot of pain. Functional independence varied, as follows: five patients (14%) could bathe themselves; nine patients (25%) could dress themselves; fourteen patients (39%) could toilet independently; and seventeen patients (47%) transferred out of a (wheel)chair independently. Conclusions: Despite the high risk of mortality and perioperative complications, many of the most severely frail patients with surgically treated femur fractures regain the ability to ambulate and live with a moderate degree of independence. This information can help healthcare providers to better inform these patients and their families of the role of surgical treatment during goals of care discussions.

Objectives: To evaluate the effect of obtaining consent from a healthcare proxy on time to surgery in older adult patients with hip fracture. Design: Retrospective cohort study. Setting: Single Level 1 Trauma Center. Patients: Consecutive patients over a 2-year period with a proximal femur fracture (OTA/AO 31A-C except 31A1.1) older than 70 years were included. Exclusion criteria were nonoperative management, periprosthetic fractures, multiple fracture fixations, admission to nonorthopaedic care, and delay due to anticoagulation usage. Intervention: Surgical consent forms were evaluated to categorize patients as self-consented (SC) or healthcare proxy-consented (HCPC). Outcome measures: Time of presentation-to-surgery (PTS-time) and time of admission-to-surgery (ATS-time). Results: The HCPC group had a significantly longer PTS-time compared with the SC group (median 27.1 hours vs. 22.2 hours, P = 0.036) and no significant difference in ATS-time (median 21.6 hours vs. 17.1 hours, P = 0.077). Weekend admissions and higher Frailty Index correlated with longer PTS- (ρ = 0.268, P < 0.001 and ρ = 0.252, P = 0.001, respectively) and ATS-time (ρ = 0.268, P < 0.001 and ρ = 0.198, P = 0.007, respectively). Adjusted for these variables, there was no significant difference between SC and HCPC groups in PTS-time (P = 0.996) or ATS-time (P = 1.000). In HCPC patients, postoperative delirium (OR 5.98, P = 0.002) and a hospital length of stay over 5 days (OR 2.17, P = 0.008) were more common. Conclusions: Needing healthcare proxy consent does not have a clinically relevant impact on time-to-surgery; however, it does indicate a frail and vulnerable hip fracture patient. Requiring healthcare proxy consent is associated with an increased risk of postoperative delirium and extended hospital length of stay. Level of evidence: III.