Faculty Bibliography

INTRODUCTION/BACKGROUND:The purpose of this case series is to investigate outcomes for repair of fractures of the scapular spine and acromial process following reverse total shoulder arthroplasty (RTSA). METHODS:All adult patients who were treated operatively for a stress scapular spine or acromial fracture following a RTSA at a single center between 2013 and 2024 were identified. All patients underwent operative repair with plate and screw fixation with or without adjunctive bone grafting. Data collected included patient demographics, injury characteristics, fracture classification, surgical details, radiographic findings, and clinical outcomes, which were based on chart review of follow-up visits and revision surgeries. RESULTS:Among 2006 RTSA procedures performed during the study period, 18 patients (0.9%) developed a scapular spine or acromial stress fracture, 16 (88.9%) of which required operative fixation. Mean follow-up after fixation was 23 months. The cohort included 11 women (68.8%) and 5 men (31.2%), with a mean age of 71.9 years. All fractures were attributed to an insufficiency mechanism. Bone graft or biologic augmentation was performed in 11 patients (68.8%). Following index fracture fixation, 10 patients (62.5%) developed a postoperative complication or adverse clinical outcome, including nonunion in 6 patients (37.5%), fracture-related infection in 2 patient (12.5%), subsequent secondary acromial stress fracture in 1 patient (6.2%), and glenoid component loosening with humeral component dislocation in 1 patient (6.2%). Nine patients (56.3%) underwent at least one additional surgical procedure, including 8 patients (50.0%) who required an unplanned reoperation; hardware removal was the most common subsequent procedure (7/16, 43.8%). At final follow-up, 5 patients (31.3%) reported chronic pain, 3 patients (18.8%) had persistent nonunion, and 3 patients (18.8%) had hardware failure managed nonoperatively. The number of plates used and implant positioning did not differ significantly between patients who achieved union and those who did not (p = 0.264). CONCLUSION/CONCLUSIONS:Scapular spine and acromial stress fractures following RTSA are uncommon but clinically consequential complications of reverse total shoulder arthroplasty. Standard operative fixation demonstrated a low rate of success after a single intervention, underscoring the need for alternative treatment strategies. LEVEL OF EVIDENCE/METHODS:Level IV.

The gold standard for patella fracture fixation is tension band wiring; however, achieving stable anatomic fixation can be challenging in comminuted patterns. The "star" variable-angle locking patella plate is an alternative fixation construct that is meant to address these limitations by providing multiple fixation points and dorsal cortical stability. The purpose of this study was to analyze the outcomes of patients treated with the variable-angle locking "star" patella plate. A total of 358 patients who underwent repair of a displaced patella fracture over a 10-year period were reviewed. Patients who sustained an isolated orthopaedic trauma association (OTA) 34-C3 patella fracture and underwent open reduction internal fixation (ORIF) with the variable-angle locking star-shaped patella plating system with at least 6 months of follow-up were analyzed. Demographic and treatment characteristics, fracture union, complications, and functional outcome measures as measured by knee range of motion (ROM) were collected retrospectively at standard follow-up intervals. Thirty-seven patients (mean age 60.17 ± 16.72 [standard deviation, SD] years; mean body mass index [BMI] 25.12 ± 5.04 [SD] kg/m²) treated at one multisite, urban, academic institution were identified. All fractures were classified as OTA 34-C3. The mean operating room time (wheels-in wheels-out) was 149.43 ± 50.82 (SD) minutes. One patient (2.7%) developed a fracture-related infection (FRI), two patients (5.4%) had wound complications, and one patient (2.7%) developed a deep vein thrombosis (DVT) following surgery. All fractures healed by 6 months, and no patient underwent removal of symptomatic hardware. Three patients underwent secondary operation; one patient had repeated irrigation and debridement of a confirmed FRI, one manipulation under anesthesia for knee contracture, and one revision ORIF after loss of distal fixation. Patients displayed a mean knee ROM of 106.53 ± 21.64 degrees (SD) and 118.51 ± 16.87 degrees (SD) at the 3- and 6-month points, respectively. The novel locking "star" patella plate appears to be a reliable and safe method of treatment for the most complex patella fractures.

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:While extremes of body mass index (BMI) are known to influence surgical risks, their distinct impacts on short- and long-term outcomes following hip fracture remain poorly defined. This study compared outcomes in severely underweight, normal weight, and obese elderly patients. METHODS/UNASSIGNED:A retrospective cohort study was conducted using a prospectively collected hip fracture database (2014-2024) at a single academic medical center. Patients with BMI ≤16.5 (severely underweight) or ≥35 (class 2+ obesity) were compared to a randomly selected cohort of normal-weight controls (BMI 18.5-25.0). Outcomes included complications, discharge disposition, mortality, and functional recovery. RESULTS/UNASSIGNED:A total of 282 patients were included. Obese patients had significantly higher odds of intensive care unit (ICU) admission compared to normal weight patients (OR 5.75 [2.00-16.39], p = .001) and were less likely to be discharged home (OR 0.31 [0.14-0.66], p = .003). In contrast, underweight status was significantly associated with increased six-month mortality compared to normal weight (OR 4.95 [1.34-18.18], p = .016). No significant differences were found in healing or functionality across groups. CONCLUSION/UNASSIGNED:Obese patients were more likely to require ICU admission but did not face increased long-term mortality. Severely underweight patients demonstrated the opposite pattern, with minimal short-term morbidity but significantly higher risk of death at six months. These findings suggest that short- and long-term risks after hip fracture diverge at the extremes of BMI and highlight the need for tailored perioperative strategies based on metabolic status.

INTRODUCTION/BACKGROUND:The study aimed to investigate the efficacy of autogenous iliac crest bone graft (ICBG) compared with other graft types in achieving successful fracture nonunion repair. METHODS:An institutional review board-approved retrospective review of prospectively collected data was conducted on a consecutive series of patients surgically treated for fracture nonunions at an academic medical center between September 10, 2004, and August 20, 2023. Patients were analyzed based on which bone graft type-ICBG versus alternative graft types-used during their nonunion repair. Patient demographics, injury characteristics, and surgical history were compared. Outcomes included radiographic healing, time to union, postoperative complications, and revision rate. Cohorts were compared using an independent sample Student t-test for continuous variables and chi-square or Fisher exact tests for categorical variables. One-way analysis of variance with post hoc comparisons assessed differences across treatment strategy groups. RESULTS:Five hundred fifty-six patients were treated surgically for a fracture nonunion using standard internal fixation and a "bone graft" for biologic stimulation. 57.4% of these patients were treated with autogenous ICBG; 42.6% received alternative grafts (iliac crest aspirate, allograft, bone morphogenetic, reamer-irrigation aspirator, and/or demineralized bone matrix, without autogenous cancellous iliac crest). Compared with the alternative cohort, the ICBG cohort showed greater healing success after a single nonunion surgery (95.6% ICBG versus 86.9% alternative, P < 0.001) and faster healing times (4.8 ± 2.4 months versus 7.1 ± 4.9 months, P < 0.001). Complications at the ICBG harvest site included wound infections/hematomas and iliac wing fracture. No notable differences were found in positive cultures at the time of surgery, postoperative fracture-related infection, implant failure, or neurovascular injury. DISCUSSION/CONCLUSIONS:Using autogenous ICBG in the surgical repair of fracture nonunions was associated with higher healing rates compared with alternative graft types, supporting its continued role in enhancing bone healing outcomes, even in the face of infected nonunion.

OBJECTIVES/OBJECTIVE:To determine the rate at which abstracts accepted for the Orthopedic Trauma Association (OTA) Annual Meeting from 2019 to 2024 utilized the Fracture-related Infection (FRI) Consensus Group's definition for infection. METHODS:Data Sources: The data sources for this study included the Orthopedic Trauma Association (OTA) Annual Meeting Programs from 2019-2024 and the "abstract search" portion of OTA Website. STUDY SELECTION/METHODS:All podium and poster abstract presentations that utilized keywords for infection ("fracture-related infection," "infection," or "SSI") in the title. DATA EXTRACTION/METHODS:All abstracts were reviewed, and grouped into one of the four following categories based on the methodologic descriptors used to define infection characteristics: 1) Utilized Consensus Group Definition, 2) Utilized CDC Definition [deep, superficial, organ/space, or SSI terminology], 3) Utilized an Author Specific Definition, 4) Did Not Utilize Any Definition. DATA SYNTHESIS/RESULTS:Univariate statistics were conducted to determine yearly and overall percentages of abstracts that utilized the Consensus Group's definition as compared to the other 3 definition categories. Bivariate analysis was performed to determine if the use of Consensus Group's definition varied from 2019-2024. RESULTS:52 podium abstracts and 59 poster abstracts were included. Among the podium abstracts, 4 (7.7%) utilized the Consensus Group's definition of FRI, 37 (71.2%) utilized language from the CDC definition, 4 (7.7%) used an author specific definition, and 7 (13.5%) abstracts did not utilize any definition of descriptors of infection. Poster abstracts demonstrated similar utilization of methodical infection descriptors, as 5 (8.5%) utilized the Consensus Group's definition of FRI. The number of abstracts that utilized the Consensus Group's Definition did not vary from 2019-2024 (p=0.952 for podiums, p=0.451 for posters). CONCLUSIONS:Adoption of the FRI Consensus Group's definition among accepted OTA 2019-2024 Annual Meeting abstracts was low. LEVEL OF EVIDENCE/METHODS:IV.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the effect that associated glenohumeral dislocations have on outcomes following surgical treatment of proximal humerus fractures. METHODS:This IRB-approved study reports on 301 patients, who underwent operative treatment for proximal humerus fractures at an academic medical center from January 2006 to January 2023. Fractures were classified according to the Neer system. Patients were separated into two cohorts based on whether a glenohumeral dislocation was present at the time of initial injury. Outcomes measured included the Disabilities of the Arm, Shoulder, and Hand (DASH) score, shoulder range of motion (forward elevation, external rotation, internal rotation), readmission rates, complications, hardware removal, and need for revision surgery. Independent samples t-tests and chi-squared analysis were used for continuous and categorical variables, respectively. A binary logistic regression was performed to analyze the influence of these factors on complication rate. RESULTS:230 patients sustained an isolated fracture (PHF) and 71 sustained a fracture-dislocation (FD). Significant differences were observed between the FD and PHF groups in all measured outcomes. The FD group had a poorer DASH score (24.38 ± 19.09 vs 10.54 ± 13.67; P < 0.001) and reduced range of shoulder motion in forward elevation (114° ± 40° vs 162° ± 19°; P < 0.001), external rotation (40° ± 19° vs 66° ± 19°; P < 0.001), and internal rotation (57° ± 26° vs 82° ± 21°; P < 0.001). Readmission rates were higher in the FD group (0.28 ± 0.85 vs 0.05 ± 0.28; P < 0.001). The FD cohort also had a higher rate of complications (25.35% vs 6.52%; P < 0.001), need for removal of hardware (14.08% vs 3.04%; P = 0.002), and overall revision surgery (11.27% vs 1.30%; P < 0.001). The FD cohort demonstrated a greater incidence of AVN (12.68% vs 4.35%; P = 0.012). No significant difference was observed regarding rates of fracture healing and recurrent dislocation. Multivariate analysis in the form of binary logistic regression indicated that fracture-dislocation significantly increased the complication risk (OR = 3.310, 95% CI = 1.42-7.70; P = 0.005). CONCLUSION/CONCLUSIONS:Proximal humerus fracture-dislocations are associated with worse functional outcomes and higher complication rates compared to those without dislocations. These findings highlight the potential need for specialized treatment strategies to mitigate the impact of dislocation on recovery.

OBJECTIVES/OBJECTIVE:The purpose of this study was to systematically review available strategies for diagnosing traumatic arthrotomy. METHODS:A comprehensive literature search was conducted on October 8th, 2023 using Ovid Medline, Cochrane Central Register of Controlled Trials, Embase, and Embase Classic. Studies were included in the review if they evaluated a diagnostic strategy for traumatic arthrotomy. RESULTS:There were 26 studies included after application of the exclusion criteria. 12 studies investigated traumatic arthrotomy of the knee, 8 of the elbow, 4 of the shoulder, 4 of the wrist, and 5 of the ankle. 23 studies implemented the saline load test as a diagnostic strategy, 7 considered CT scan, 1 study used x-ray, and 1 study used ultrasound. Of the studies that considered saline load tests, 8 of them also used methylene blue. CT scans were found to have 100% sensitivity when diagnosing traumatic arthrotomy of the knee. Saline load test was shown to have 60% to 100% sensitivity when diagnosing traumatic arthrotomies of the elbow. Saline load tests had sensitivities ranging from 75% to 100% when considering a shoulder traumatic arthrotomy. The saline load test was able to diagnose traumatic arthrotomies of the wrist, and ankle with sensitivities up to 100% and 99%, respectively. CONCLUSIONS:When considering the infectious risks associated with undiagnosed traumatic arthrotomy, clinicians should seek modalities with the highest diagnostic performance. The saline load test has long been considered the gold standard for diagnosing traumatic arthrotomy, however, imaging modalities hold appeal as a less invasive and technically challenging procedure. Although diagnostic performance is joint-dependent, this review indicates that the saline load test continues to be the most reliable method for diagnosing most traumatic arthrotomies other than the knee. LEVEL OF EVIDENCE/METHODS:III.

INTRODUCTION/BACKGROUND:Tibial plateau fractures are some of the most commonly treated injuries around the knee and loss of range of motion has a significant effect on post-operative outcomes, very few studies have demonstrated the impact of flexion contractures. The purpose of this study was to determine the effect that development of a knee flexion contracture has on outcomes following operative repair of tibial plateau fractures. METHODS:Patients operatively treated for tibial plateau fractures (Schatzker II, IV, V, and VI) between 2005-2024 at a multi-center academic urban hospital system were included in this retrospective comparative study. Patients were grouped into 3 cohorts: 1. Full extension (FE), 2. 5-10 degrees of flexion contracture (Mild, ME) and 3. Greater than 10 degrees of flexion (Severe, SE) contracture at 6 months post-operatively. Patients with contracture were matched to patients who regained full extension based on age and Schatzker classification. Statistical analysis was used to evaluate outcomes including patient reported pain levels, Short Musculoskeletal Function Assessment (SMFA) scores, complication rates and reoperation rates. RESULTS:The cohort consisted of 3 groups of 30 patients (14 Schatzker II, 5 Schatzker IV, 3 Schatzker V, and 8 Schatzker VI). The average knee flexion contracture for the mild cohort was 5 degrees and the average knee flexion contracture for the severe cohort was 12.7 degrees. Patients who experienced flexion contracture had poorer SMFA scores at 6 months, and those in the severe cohort had the poorest SMFA scores (112.6) when compared to those with full extension at 6 months (77.7) (p<0.001). Flexion contractures were associated with higher rates of fracture related infection (FRI) (p =0.002). Patients with flexion contracture also had a higher rate of subsequent re-operation, with 36.7% of the ME undergoing re-operation and 40% of SE undergoing re-operation. CONCLUSIONS:Patients who developed a flexion contracture following repair of a tibial plateau fracture experienced worse outcomes, higher rates of complications, increased pain, and poorer function at long term follow up compared to those who achieved full knee extension.

METHODS:This study assessed the safety of the lateral femoral cutaneous and over the hip (LOH) block, a regional anesthetic, in anticoagulated hip fracture patients while maintaining efficacy. A retrospective review of patients diagnosed with hip fractures (AO/OTA 31A/B) who presented to a single academic medical center and level 1 trauma center actively using oral anticoagulants. Patients were grouped based on anesthesia type: LOH block (LOH) versus general anesthesia (GA) and LOH versus spinal anesthesia (SA). LOH patients were matched based on anticoagulant type, OTA/AO classification, and risk (STTGMA) score with a 3:1 ratio to GA and a 1:1 ratio to SA. Outcome comparisons included: time to surgery, operative and anesthesia time, and bleeding complications, demographics (age, sex, race, BMI, CCI, and STTGMA), postoperative complications, 90-day readmission rates, mortality within 1 year, and discharge location. RESULTS:A total of 135 patients: 27 LOH, 27 SA, and 81 GA, were analyzed. Compared to GA, LOH block patients had a shorter time to surgery (1.31 ± 0.082 vs. 0.89 ± 0.69, p = 0.014), lower rates of 90-day readmission (3.7% vs. 19.8%, p = 0.047), and a greater discharge to home with health services rate (33.3% vs. 8.6%, p = 0.024). The GA population trended-toward more major complications (p = 0.077) and mortality within 1 year (p = 0.077). Compared to SA, LOH patients were slightly underweight (25.1 ± 4.19 vs. 22.7 ± 4.16, p = 0.035) and got to surgery faster (0.89 ± 0.69 vs 1.54 ± 1.48, p = 0.039). Across all groups, there were no differences in the need for blood transfusion or other quality markers. CONCLUSION/CONCLUSIONS:The LOH block was safe and effective for use in anticoagulated hip fracture patients. This technique provided an intraoperative safety profile similar to other anesthetic choices, allowed for less delay to surgery compared to spinal anesthesia and improved discharge parameters compared to GA. LEVEL OF EVIDENCE III/METHODS:Prognostic Level III.