Faculty Bibliography

OBJECTIVES/OBJECTIVE:To determine the most common reason for 30-day readmission following hospitalization for hip fractures. METHODS:Design: A retrospective review. SETTING/METHODS:Single academic medical center that includes a Level 1 Trauma Center. PATIENT SELECTION CRITERIA/UNASSIGNED:Included were all patients operatively treated for hip fractures (OTA 31) between October 2014 and November 2023. Patients that died during their initial admission were excluded. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Patient demographics, hospital quality measures, outcomes and readmission within 30-days following discharge for each patient were reviewed. 30-day readmission reason was recorded and correlation analysis was performed. RESULTS:A total of 3,032 patients were identified with a mean age of 82.1 years and 70.5% of patients being female. The 30-day readmission cohort was 2.6 years older (p<0.001) and 8.8% more male patients (p=0.027), had 0.5 higher CCI (p<0.001), 0.3 higher ASA class (p<0.001) and were 9.2% less independent at the time of admission (p= 0.003). Hemiarthroplasty procedure (32.7% vs. 24.1%) was associated with higher 30-day readmission compared to closed percutaneous screw fixation (4.5% vs. 8.8%) and cephalomedullary nail fixation (52.2% vs. 54.4%, p<0.001). Those readmitted by 30-days developed more major (16.7% vs. 8.0%) (p<0.001) and minor (50.5% vs. 36.4%) (p<0.001) complications during their initial hospitalization and had a 1.5 day longer LOS during their first admission (p<0.001). Those discharged home were less likely to be readmitted within 30-days (20.7% vs. 27.6%, (p=0.008). Multivariate regression revealed increasing ASA class (O.R. 1.47, p=0.002) and pre-injury ambulatory status (O.R. 1.42, p=0.007) were most associated with increased 30-day readmission. The most common reason for readmission was pulmonary complications (17.1% of complications) including acute respiratory failure, COPD exacerbation and pneumonia. CONCLUSION/CONCLUSIONS:Thirty-day readmission following hip fracture was associated with older, sicker patients with decreased pre-injury ambulation status. Hemiarthroplasty for femoral neck fracture was also associated with readmission. The most common reason for 30-day readmission following hip fracture was pulmonary complications. LEVEL OF EVIDENCE/METHODS:Prognostic Level III.

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.

OBJECTIVES/OBJECTIVE:To determine which in-hospital complications following the operative treatment of hip fractures are associated with increased inpatient, 30-day and 1 year mortality. METHODS:Design: Retrospective study. SETTING/METHODS:A single academic medical center and a Level 1 Trauma Center. PATIENT SELECTION CRITERIA/UNASSIGNED:All patients who were operatively treated for hip fractures (OTA/AO 31A, 31B and Vancouver A,B, and C periprosthetic fractures) at a single center between October, 2014 and June, 2023. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Occurrence of an in-hospital complication was recorded. Cohorts were based upon mortality time points (during admission, 30-days and 1-year) and compared to patients who were alive at those time points to determine which in- hospital complications were most associated with mortality. Correlation analysis was performed between patients who died and those who were alive at each time point. RESULTS:A total of 3,134 patients (average age of 79.6 years, range 18-104 years and 66.6% female) met inclusion for this study. The overall mortality rate during admission, 30 days and 1 year were found to be 1.6%, 3.9% and 11.1%, respectively. Sepsis was the complication most associated with increased in-hospital mortality (OR: 7.79, 95% CI 3.22 - 18.82, p<0.001) compared to other in-hospital complications. Compared to other in-hospital complications, stroke was the complication most associated with 30-day mortality (OR: 7.95, 95% CI 1.82 - 34.68, p<0.001). Myocardial infarction was the complication most associated with 1-year mortality (OR: 2.86, 95% CI 1.21 - 6.77, p=0.017) compared to other in-hospital complications. CONCLUSIONS:Post-operative sepsis, stroke and myocardial infraction were the three complications most associated with mortality during admission, 30-day mortality and 1-year mortality, respectively, during the operative treatment of hip fractures. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The purpose of this study was to report on the treatment, results, and longer-term outcomes of patients who sustained a tibial plateau fracture with an associated leg compartment syndrome (CS). A total of 766 patients who sustained 766 tibial plateau fractures met inclusion criteria. Fourteen patients (1.8%) were diagnosed with CS in association with a tibial plateau fracture during their initial hospitalization, 13 at the time of presentation and 1 delayed. The treatment protocol consisted of initial external fixation and fasciotomy, followed by irrigation and debridement, and eventual closure. Fasciotomy cases included 2/14 (14.3%) single incision approaches and 12/14 (85.7%) dual incision approaches. Operative treatment of the tibial plateau fracture was performed at the time of final closure or once soft tissues were permitted. One case of CS that developed following definitive fixation was treated with fasciotomy and delayed primary closure after initial stabilization. Ten (71.4%) were available at 1-year follow-up. We compared these 10 cases to the patients with operative tibial plateau fractures without CS to assess for surgical, radiographic, clinical, and functional outcomes. We used a propensity match based on age, body mass index, sex, Charleson comorbidity index, and fracture type to reduce the presence of confounding biases. Standard statistical methods were employed. Those in the CS cohort were younger males (p < 0.05). At latest follow-up, function did not differ between those in the CS group compared with the non-CS cohort (p > 0.05). Clinically, knee flexion (130.7 vs. 126; p = 0.548), residual depression (0.5 vs. 0.2; p = 0.365), knee alignment (87.7 vs. 88.3; p = 0.470), and visual analog scale pain scores (3.0 vs. 2.4; p = 0.763) did not differ between the cohorts. Although infection was higher in the CS cohort, the overall complication rates did not differ between the CS patients and non-CS cohort (p > 0.05). Early identification and standardized treatment protocols for the management of CS that develops in association with a tibial plateau fracture lead to outcome scores that were not significantly different from patients who did not develop CS.

INTRODUCTION/BACKGROUND:Treatment options for displaced intracapsular femoral neck fractures in elderly patients include unipolar hemiarthroplasty (UHA), bipolar hemiarthroplasty (BHA), unipolar total hip arthroplasty (UTHA), and dual-mobility total hip arthroplasty (DMTHA). This network meta-analysis (NMA) of randomized controlled trials (RCTs) quantitatively compares these treatments to identify the optimal surgical technique. METHODS:Following PRISMA guidelines, a comprehensive literature search in Medline (PubMed), Cochrane, and EMBASE databases was conducted. RCTs comparing UHA, BHA, UTHA, or DMTHA were included. Interventions were ranked using the SUCRA score. RESULTS:Among 5,542 studies, 12 RCTs met inclusion criteria, involving 1,490 patients. Procedures were ranked by prosthetic dislocation, mortality, operating time, intraoperative blood loss, revision rate, Harris Hip Score (HHS). BHA ranked the best in dislocation rate, intraoperative blood loss and mortality. UHA had the shortest operating time. DMTHA had the greatest ranking for HHS. However, the differences between these treatment modalities were rarely statistically significantly different. CONCLUSION/CONCLUSIONS:A variety of arthroplasty procedures can be used to treat displaced intracapsular femoral neck fractures. Our results indicate that while BHA resulted in the best post-operative ranking amongst the compared treatment strategies in terms of dislocation rates, blood loss and mortality, the differences between the treatment options does not clearly favor a specific treatment option.

Mangled extremities are a challenging problem for the orthopaedic surgeon. The decision for salvage versus amputation is multifactorial. Several work groups have attempted to create scoring systems to guide treatment, but each case must be regarded individually. As surgical technique and prosthetics continue to improve, amputations should be seen as a viable reconstructive option, rather than failure. This article reviews scoring systems for the mangled extremity, outcomes on salvage versus amputation, amputation surgical technique, and prosthetic options.

BACKGROUND/UNASSIGNED:Significant heterogeneity in the classification and treatment of zone 3 proximal fifth metatarsal base fractures ("true Jones fractures") exists. This study compared time to clinical and radiographic healing between patients treated operatively and nonoperatively. We hypothesized that patients treated nonoperatively may demonstrate a greater time to clinical healing. METHODS/UNASSIGNED:This was a retrospective cohort study of patients presenting to a large, urban, academic medical center with "Jones" fractures between December 2012 and April 2022. Jones fractures were defined as fifth metatarsal base fractures occurring in the proximal metadiaphyseal region, distal to the articulation of the fourth and fifth metatarsals on the oblique radiographic view. Clinical healing was the time point at which the patient had returned to their baseline ambulatory status with no tenderness to palpation. Radiographic healing was the presence of bridging callus across at least 3 cortices. RESULTS/UNASSIGNED: = .331). Overall healing rate was 96% for the nonoperative group compared with 96.2% for the operative group. CONCLUSION/UNASSIGNED:In this study, nonoperative and operative treatment of true Jones fractures were associated with equivalent clinical and radiographic healing. The rate of delayed union in true Jones fractures was lower than previously described, and there was no difference in delayed union rate between nonoperative and operative management. LEVEL OF EVIDENCE/UNASSIGNED:Level III, retrospective cohort study.

BACKGROUND:The purpose of the present study was to evaluate differences in demographic features and clinical outcomes between patients who sustained a typical versus atypical subtrochanteric femoral fracture. METHODS:We reviewed the records for a cohort of consecutive patients who had undergone operative treatment of a subtrochanteric femoral fracture. Fractures were classified as either "typical" or "atypical" on the basis of the criteria of the American Society for Bone and Mineral Research (ASBMR). All patients were treated with a similar surgical algorithm and postoperative protocol. Groups were compared on the basis of demographic features, injury characteristics, operative quality measures, postoperative complications and outcomes, and radiographic time to healing. Comparative analyses were performed to compare the typical and atypical cohorts. RESULTS:Of 220 subtrochanteric fractures, 165 (75.0%) were classified as typical and 55 (25.0%) were classified as atypical. The atypical cohort was predominately female and more likely to have bisphosphonate usage (odds ratio [OR], 7.975; [95% confidence interval (CI), 3.994-15.922]; p < 0.001) and fractures with lower-energy mechanisms (p < 0.001). Patients in the atypical cohort were more likely to be treated with a 10-mm cephalomedullary nail (CMN) (OR, 2.100 [95% CI, 1.119-3.939]; p = 0.020), whereas patients in the typical cohort were treated more frequently with an 11-mm CMN (OR, 0.337 [95% CI, 0.168-0.674]; p = 0.002). There were no differences between the groups in terms of other operative parameters; however, anatomic fracture reduction in neutral lateral alignment was achieved more frequently in the typical cohort (OR, 0.438 [95% CI, 0.220-0.875]; p = 0.018). There were no differences between the groups in terms of hospital quality measures, mortality rates, readmission rates, or complication rates (including implant failure [broken screw or nail] and fracture nonunion) (p = 1.00). Interestingly, there was no significant difference between the groups in terms of time to radiographic healing (260.30 ± 187.97 days in the typical group, compared with 246.40 ± 116.33 days in the atypical group) (OR, 0.999 [95% CI, 0.997-1.002]; p = 0.606). CONCLUSIONS:Despite differences in terms of demographic and injury characteristics, patients who sustain a subtrochanteric femur fracture can expect similar outcome profiles regardless of fracture type. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE/OBJECTIVE:To compare outcomes of patients with posterior tibial plateau fractures who underwent repair indirectly with an anterior approach to those who underwent direct repair with a prone "Lobenhoffer" operative approach. METHODS:A total of 44 patients with a posterior column tibial plateau fracture that underwent repair were identified. Twenty-two patients with 22 tibial plateau fractures were fixed using a prone Lobenhoffer approach. They were compared to 22 patients treated with an indirect reduction using a supine approach for similar fracture patterns. Data collection at minimum 1 year included: patient-reported outcome scores (SMFA), patient-reported pain, knee range of motion, complications and need for reoperation. Radiographs were reviewed for knee alignment, residual depression and fracture healing. RESULTS:All demographics were similar between the groups except BMI, which was lower in the prone group (P < 0.05). Fracture type according to age, Schatzker and three-column classification was matched between cohorts. There was no difference in outcomes including: pain, radiographic knee alignment, residual articular depression, functional outcome (SMFA), complications and need for reoperations. Knee flexion at 1 year was greater in the prone group (127.8 vs. 115.8; P = 0.018). In addition, surgical time was less in the prone group (mean 73.7 min vs. 82.3 min; P = 0.015). CONCLUSION/CONCLUSIONS:The Lobenhoffer approach with direct reduction of posterior fracture fragments for complex tibial plateau fractures is an excellent option for these injuries. It allowed for faster surgery with improved ultimate knee range of motion in posterior column tibial plateau fractures.

There has been a paradigm shift towards fixing the posterior malleolus in trimalleolar ankle fractures. This study evaluated whether a surgeon's preference to intraoperatively flip or not flip patients from prone to supine for medial malleolar fixation following repair of fibular and posterior malleoli impacted surgical outcomes. A retrospective patient cohort treated at a large urban academic center and level 1 trauma center was reviewed to identify all operative trimalleolar ankle fractures initially positioned prone. One hundred and forty-seven patients with mean 12-month follow up were included and divided based on positioning for medial malleolar fixation, prone or supine (following closure, flip and re-prep and drape). Data was collected on patient demographics, injury mechanism, perioperative variables, and complication rates. Postoperative reduction films were reviewed by orthopedic traumatologists to grade the accuracy of anatomic fracture reduction. Overall, 74 (50.3%) had the medial malleolus fixed prone, while 73 (49.7%) were flipped and fixed supine. No differences in demographics, injury details, and fracture type existed between the groups. The supine group had a higher rate of initial external fixation (p=0.047), longer operative time in minutes (p<0.001), and a higher use of plate and screw constructs for medial malleolar fixation (p=0.019). There were no differences in clinical and radiographic outcomes and complication rates. This study demonstrated that intraoperative change in positioning for improved medial malleolar visualization in trimalleolar ankle fractures results in longer operative times but similar radiographic and clinical results. The decision of operative position should be based on surgeon comfort.