Faculty Bibliography

OBJECTIVE:To examine factors associated with lag screw slide following fixation of intertrochanteric hip fractures with 1 type of cephalomedullary nail. METHODS:Retrospective review of patients operatively treated for intertrochanteric hip fractures (OTA/AO 31A1 and 31A2) with a single cephalomedullary nail (CMN) at a single academic medical centre between November 2014 and November 2023. CMN lag screw was placed in "dynamic" mode to allow for controlled collapse, or screw "slide." Screw slide was defined as the difference in lateral prominence of the lag screw at latest follow up compared to its initial position. Patients were grouped based on the amount of screw slide (<5 mm, 5-15 mm, >15 mm) and correlation analysis was performed. RESULTS: = 0.002) was associated with >15 mm screw slide. CONCLUSIONS:Excessive lag screw slide (>15 mm) was associated with higher patient BMI. Patients with higher BMIs should be monitored to identify excessive slide. Surgeons should attempt to keep the lag screw as close to the lateral cortex as possible. While the use of anti-osteoporotic therapy was associated with more slide, this was almost exclusively seen in patients only prescribed vitamin D and calcium.

BACKGROUND/UNASSIGNED:Basicervical (BC) hip fractures represent a unique proximal femur fracture pattern for which the optimal treatment approach remains uncertain. PURPOSE/UNASSIGNED:We sought to evaluate demographic, perioperative, and outcome differences among patients with BC (31B3), intertrochanteric (IT; 31A1.2), and valgus femoral neck (VFN; 31B1.1) fractures treated with internal fixation. METHODS/UNASSIGNED:We conducted a retrospective review using prospectively collected data from October 2014 to March 2025 from a hip fracture database comprising 2 urban trauma centers. Patients with AO/OTA-classified 31B3, 31A1.2, or 31B1.1 fractures treated with non-arthroplasty fixation were included. Demographics, comorbidities, fracture characteristics, surgical constructs, and short- and long-term outcomes were compared. Multivariate regressions adjusted for baseline health and procedure type. RESULTS/UNASSIGNED:Of the 875 patients who met inclusion criteria, 122 had BC fractures, 523 had IT fractures, and 230 had VFN fractures. Patients with BC fractures were significantly younger than those with IT fractures; they had higher American Society of Anaesthesiologist scores and a greater proportion of household ambulators compared to those with VFN fractures, but were otherwise similar in comorbidity status. The BC cohort had significantly more minor in-hospital complications compared to the VFN cohort, even after multivariate adjustment. No significant differences were observed in 30-day mortality or major complications. Long-term outcomes were comparable across all groups. No significant differences in short- or long-term outcomes were observed across surgical constructs within the BC cohort. CONCLUSION/UNASSIGNED:Despite differing in baseline health status and surgical fixation strategies, BC fractures demonstrated comparable long-term outcomes to IT and VFN fractures. However, higher rates of minor complications in the BC group, even after adjustment, highlight a potentially greater perioperative risk. These findings suggest that while fixation may be effective long-term, further research is warranted to optimize acute management strategies for this anatomically and clinically distinct fracture pattern. LEVEL OF EVIDENCE/UNASSIGNED:Level IV: Prognostic retrospective study.

PURPOSE/OBJECTIVE:This study aims to determine the impact of injury mechanism energy level on clinical outcomes following Galeazzi fracture. METHODS:A retrospective review was performed on 116 skeletally mature patients treated operatively for Galeazzi fractures between January 2000 and October 2023. Patients were categorized by mechanism of injury into high-energy (HE, n = 92) and low-energy (LE, n = 24) groups. Demographics, fracture characteristics, fixation details, and postoperative outcomes, including wrist and elbow range of motion, complications, radiographic healing time, and reoperations, were collected and compared between groups using standard parametric and nonparametric tests with significance set at P < .05. Normality was assessed using the Shapiro-Wilk test, and Fisher exact test was used for categorical variables with low expected counts. RESULTS:No differences were observed in body mass index or injury characteristics between groups. The HE group was younger and included a higher proportion of men. Wrist motion was more limited in the HE group across dorsiflexion, palmar flexion, pronation, and supination, and time to radiographic healing was longer compared with the LE group. Elbow motion and rates of nonunion, fracture-related infection, contracture, readmission, and distal radioulnar joint symptoms were similar between groups. CONCLUSIONS:HE Galeazzi fractures were associated with poorer wrist range of motion and toward delayed radiographic healing compared with LE injuries. Recognition of this association underscores the prognostic value of injury mechanism and may inform surgical planning, rehabilitation expectations, and patient counseling. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Prognostic III.

INTRODUCTION/BACKGROUND:Hounsfield units (HU) are a validated marker of bone mineral density. This study aimed to determine whether low-energy Schatzker IV, V and VI tibial plateau fractures are associated with altered bone quality. METHODS:). Fractures were classified by injury mechanism (low- vs. high-energy) and HU thresholds were defined as poor (< 110) or normal (> 160). Clinical outcomes included major complications, reoperations, range of motion, Visual Analog Scale (VAS) pain scores, and Short Musculoskeletal Function Assessment (SMFA) scores. RESULTS:Low-energy fractures (n = 96) had significantly lower HU values (113.9 vs. 150.9, p < 0.0001) across all planes. No significant differences were found in clinical outcomes. CONCLUSION/CONCLUSIONS:Low-energy Schatzker IV-VI fractures indicate poor bone quality and may represent "fragility fractures" requiring further evaluation.

OBJECTIVE:To evaluate the effect of joint preparation and patient factors on outcomes and complications in patients treated acutely with hindfoot fusion nails for ankle and pilon fractures. DESIGN/METHODS:Retrospective chart review. SETTING/METHODS:Thirteen US trauma centers and 2 UK trauma centers. PATIENT SELECTION CRITERIA/UNASSIGNED:Ankle and pilon fractures (AO-OTA types A-C) from 2010 to 2020 acutely treated definitively with hindfoot fusion nail were reviewed. Patients at least 18 years old and with minimum 6 months follow-up or earlier diagnosis of complication were included. Exclusion criteria included nonambulatory at baseline, prior internal fixation that failed and underwent revision, and prior tibiotalar or subtalar arthrodesis. OUTCOME MEASUREMENTS AND COMPARISONS/UNASSIGNED:The primary outcome was final postoperative ambulatory status. Secondary outcomes were infectious and fracture-related complications. RESULTS:One hundred forty-nine patients (75 men; 74 women; age 20-99; median 63 years) were treated for ankle (104) or pilon (45; 8A, 13B, 24C) fractures. Eighty-five patients (44%) had open fractures and 55 (37%) had diabetes. Thirty-six patients (24%) had joint preparation at the time of surgery. Forty-five (30%) were made weight bearing as tolerated postoperatively; the median time to mobilize was 1.5 days (0-210) and to full weight bearing was 35 days (0-1462). Fifty-seven patients (85%) returned to their preinjury ambulatory status, which was not affected by joint preparation (50% vs. 59%, P = 0.327). Joint preparation led to higher articular fusion rates (94% vs. 24%; P = 0.001) and fewer hardware removals (19% vs. 42%, P = 0.013), but trended toward a higher fracture nonunion rate (19% vs. 8%, P = 0.053). Forty-five patients (30%) had infectious complications, 60 (40%) had a fracture-related complication, and 67 (45%) had additional procedures. Open fractures did not lead to any differences in superficial or deep infection. Insulin-dependent diabetes was associated with higher rates of infectious complications (31% vs. 15%, P = 0.028) and amputation (17% vs. 4%, P = 0.029). CONCLUSIONS:Hindfoot fusion nails for acute ankle and pilon injuries had high complication rates. More complications occurred in patients with insulin-dependent diabetes. While 95% regained ambulation, only 57% returned to preoperative status. Joint preparation led to higher rates of articular fusion (94% vs. 24%, P < 0.001) but not fracture union (81% vs. 66%, P = 0.106). LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND/UNASSIGNED:This study aimed to compare union rates of tibia shaft fractures in two age groups: patients younger than 65 and those 65 or older. Secondary aims included comparing quality measures and functional outcomes. METHODS/UNASSIGNED:A retrospective review at a single multi-site urban academic institution was conducted. Inclusion criteria included: age ≥18, isolated OTA 42A to 42C tibia shaft fracture treated with an intramedullary nail, and follow-up ≥6 months. The primary outcome was fracture union, defined as RUST score >7. Functional outcome was measured by the Functional Ambulatory Category (FAC) score (0 = nonfunctional, 5 = independent ambulation). Patients were grouped as young (<65) or elderly (≥65). Univariate and multivariate analyses controlled for confounders. RESULTS/UNASSIGNED:Of 286 patients, 253 were young (mean age 38.9 ± 12.9 years) and 33 elderly (mean age 71.2 ± 6.4 years). Mean follow-up was 13.6 ± 7.9 months. Union rates (94.0% elderly vs. 89.3% young, p = 0.409) and time to union (6.4 vs. 6.1 months, p = 0.647) did not differ. Readmission (18.2% vs. 8.3%, p = 0.069) and complication rates (21.2% vs. 19.0%, p = 0.759) were also similar. After adjusting for baseline FAC, sex, BMI, CCI, fracture type, and injury mechanism, older age was associated with lower FAC scores at three (B = -0.460, 95% CI [-0.826, -0.094], p = 0.014), six (B = -0.371, 95% CI [-0.679, -0.063], p = 0.019), and twelve months (B = -0.317, 95% CI [-0.552, -0.082], p = 0.009). CONCLUSIONS/UNASSIGNED:Elderly patients with tibia shaft fractures treated with intramedullary nails achieve similar union rates and healing times as younger patients. However, older age independently predicts reduced ambulatory function post-injury.

BACKGROUND:The purpose of this study was to compare hospital quality and patient outcomes of hip arthroplasty for femoral neck fractures (FNFs) based on the subspecialty training of the treating surgeon: orthopaedic trauma (OT) versus adult reconstruction (AR) fellowship training. METHODS:A retrospective review was conducted on 1,008 elderly patients treated for an FNF with hemiarthroplasty or total hip arthroplasty between 2014 and 2024. Patients were grouped by their surgeon's subspecialty training (OT versus AR). Outcomes analyzed included length of stay, complications, 30-day and 90-day readmissions, dislocations, infections, and 30-day mortality. Statistical significance was set at P < 0.05. RESULTS:Baseline patient demographics were similar between groups, except for a higher proportion of women in the AR cohort (P = 0.008) and Black patients in the OT cohort (P = 0.016). Although age-unadjusted Charlson Comorbidity Index (CCI) was significantly higher in the AR group (P = 0.046), Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) scores, which take CCI and other health factors into account, were not significantly different (P = 0.59). In-hospital outcomes, including length of stay (P = 0.89) and minor and major complication rates (P = 0.38, P = 0.38), demonstrated no significant differences between groups. Post-discharge outcomes, including readmissions (30-day: P = 0.52, 90-day: P = 0.16), infections (P = 0.25), dislocations (P = 0.89), and 30-day mortality (P = 0.14), were also similar. CONCLUSION/CONCLUSIONS:No differences were identified in any of the outcomes analyzed between OT-trained and AR-trained surgeons in our study. This suggests that when FNFs are treated at high-volume academic institutions, subspecialty training may not substantially influence the short-term results of FNFs treated with hip arthroplasty. These findings highlight the importance of timely surgical intervention rather than waiting for a particularly trained surgeon to be available.

OBJECTIVES/OBJECTIVE:To evaluate factors influencing slide in statically-locked single lag screw cephalomedullary nail (CMN) constructs for reverse obliquity (RO) fractures. METHODS:Design: Retrospective comparative study. SETTING/METHODS:A multi-center academic urban hospital system (4 hospitals). PATIENT SELECTION CRITERIA/UNASSIGNED:Patients with an RO fracture (OTA/AO 31A3) treated with a CMN (Gamma or TFNA) and statically-locked single lag screw from 2014 to 2024, with at least one follow-up radiograph (minimum three months or documentation of healing). OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Lag screw sliding was measured as the difference in screw position between immediate postoperative imaging and final follow-up radiographs. Tip-to-head distance (ΔTHD) and screw protrusion ratio (ΔPR) were recorded. Patients were grouped as <5mm, 5-10mm, or >10mm slide. Comparisons included fracture subtype, nail brand, angle, and length. Bivariate analyses tested associations with slide. RESULTS:Of the 219 patients identified with a 31A3 type fracture, 85 (38.8%) met inclusion criteria. The average age was 81.0 (±9.3) years with 65 (76.5%) females. Mean radiographic follow-up was 19.9 months, with a follow-up range of 74-2,576 days. The mean slide was 7.8mm (±5.2mm). 74 patients (87.1%) had slide >2mm. ΔTHD was negligible (-0.1 ± 7.0mm), and ΔPR 0.2 (±0.1) significantly exceeded zero (p < 0.001). Neither nail length (Short: 9.4 ± 5.3mm vs. Long: 7.1 ± 5.0mm, p = 0.083), nail angle, (125°: 8.0 ± 5.4mm vs 130°: 6.5 ± 4.0mm; p = 0.286), nor nail brand had a significant effect (Gamma: 7.6 ± 5.1mm vs TFNA: 9.1 ± 6.2mm; p = 0.921). Fracture subtype (31A3.1: 9.1 ± 6.1mm vs 31A3.2: 10.4 ± 5.1mm vs 31A3.3: 6.9mm ± 4.6mm; p = 0.114) and demographic factors (p > 0.05) were not significantly associated with slide severity. CONCLUSIONS:Surgeons should expect some degree of lag screw slide and subsequent proximal fragment displacement when a Gamma nail or TFNA nail cephalomedullary nail is used for a reverse obliquity fracture, even when statically locked. LEVEL OF EVIDENCE/METHODS:Level III.

OBJECTIVES/OBJECTIVE:To determine if initial vertical fracture displacement affects postoperative outcomes following operative treatment of patella fractures. METHODS:Design: Prognostic retrospective study. SETTING/METHODS:Single multi-site urban academic institution. PATIENT SELECTION CRITERIA/UNASSIGNED:Included were patients aged ≥18 years who underwent open reduction internal fixation of a patella fracture (AO/OTA 34A-C) with minimum 6-month follow-up, and complete trauma knee x-ray series. Vertical fractures and those without significant vertical displacement (<2mm) were excluded. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Initial vertical fracture displacement was recorded. Follow-up data included knee range-of-motion and post-operative complications: nonunion, fracture related infection (FRI), hardware failure, suspected FRI, knee contracture, inferior sleeve displacement, and venous thromboembolism events. Comparisons were made between the initial amount of displacement and postoperative complications. RESULTS:229 patients with a median follow-up duration of 12 months (IQR: 6-14) were included. The mean age was 61.2 ± 15.1 years, BMI was 25.4 ± 4.7 kg/m2, and 69.0% (n = 158) were female. OTA fracture classification was: 35.4% C1, 32.3% C3, 17.9% C2, and 14.4% A1. Fixation methods included 63.8% tension band wiring, 17.9% suture repair, 13.5% plate and screws, and 4.8% screws with suture. 33 (14.4%) patients sustained complications. The mean displacement was significantly higher in patients who developed complications (21.6 mm ± 15.0 mm vs. 14.8 mm ± 10.1 mm, p=0.018), particularly for nonunion (29.8 mm ± 13.5 mm vs. 15.1 mm ± 10.6 mm, p<0.001) and hardware failure (30.8 mm ± 12.0 mm vs 15.4 mm ± 10.9 mm, p<0.001). Suture-only and screw-with-suture fixation had higher nonunion rates (p=0.004, p=0.005) than other fixation methods independent of displacement. Initial displacement predicted nonunion and hardware failure (AUROCs=0.818 and 0.838). Youden Index thresholds of >26.6mm and >21.7mm identified patients at increased risk for nonunion and hardware failure. Each millimeter increase in displacement raised nonunion and hardware failure risk by 14.9% (OR=1.1, p=0.003) and 14.6% (OR=1.1, p=0.003). CONCLUSIONS:This study supports the future use of initial vertical fracture displacement as a prognostic tool for nonunion and hardware failure after patella ORIF. Displacement >2cm placed patients at high risk for these complications. Nonunion rates were higher in both suture only and screw-with-suture fixation when compared to other fixation constructs. LEVEL OF EVIDENCE/METHODS:III.