Faculty Bibliography

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.

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.

INTRODUCTION/BACKGROUND:Several types of fifth metatarsal (MT) fractures exist and are treated with various methods of immobilization, weight bearing restrictions, and occasionally operative procedures. This study evaluated the differences in clinical and radiographic outcomes among pseudo-Jones fractures (Zones 1 and 2), true Jones fractures (Zone 3), and fifth metatarsal shaft and neck fractures. METHODS:A retrospective review of a consecutive series of patients presenting to a single academic medical center with a fifth metatarsal fracture between 2012 and 2022 was conducted. Radiographs obtained at the initial presentation were reviewed, and fracture patterns were categorized as either Zone 1, Zone 2, Zone 3, shaft, neck, or head fractures. RESULTS:In total, 1314 patients with isolated fifth metatarsal fractures were treated (mean age = 49.6 ± 18.0 years). In total, 1217 fractures (92.5%) were initially treated nonoperatively, and 97 fractures (7.5%) were treated operatively. The overall time to clinical and radiographic healing for all fifth metatarsal fractures treated nonoperatively was 9.9 ± 8.7 weeks and 17.9 ± 15.6 weeks, respectively (P = .245, P = .088). Immediate weightbearing led to a faster time to clinical healing by (P = .035). There was no statistically significant difference in time to clinical or radiographic union among the different fracture types (P = .496, P = .400). Likewise, there was no evidence of any difference in time to clinical or radiographic union for patients treated operatively versus nonoperatively (P > .05). CONCLUSION/CONCLUSIONS:.

OBJECTIVE:To determine if the occurrence of short-term post-operative altered mental status (AMS) was lower in geriatric patients undergoing operative repair of hip fractures with Monitored Anesthesia Care and Soft-Tissue Infiltration with Local Anesthesia (MAC-STILA) when compared with general anesthesia (GA). DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Two U.S. hospitals within a single academic medical center. PATIENT SELECTION CRITERIA/UNASSIGNED:Geriatric patients with hip fractures (AO/OTA 31A and 31B) undergoing operative repair were identified. Propensity matching was performed in a 1:2 ratio to minimize selection bias (age, sex, BMI, ASA class, fracture pattern, fixation construct, pre-injury ambulatory status, and assistive device use). OUTCOME MEASURES/METHODS:Patients who underwent surgical fixation with MAC-STILA were compared with GA. Primary outcome was post-operative AMS, defined as missing ≥1 items on the alert and oriented assessment (person, place, and time) at any point from post-operative days 0-3. RESULTS:After matching, 228 patients (76 MAC-STILA: 152 GA) were included in the analysis. The average age of patients in both groups was 83 years. In the MAC-STILA group, 62% were female and 33% had baseline dementia while in the GA group 66% were female and 29% had baseline dementia. Treating patients with MAC-STILA was associated with 72% lower odds of having AMS compared with GA, controlling for baseline comorbidity and dementia (OR: 0.28. 95% CI: 0.09-0.075, p=0.016). Among patients with baseline dementia, the rate of AMS was lower in patients treated with MAC-STILA compared with GA (64.0% vs 95.3%, p = 0.001). CONCLUSION/CONCLUSIONS:Monitored Anesthesia Care and Soft-Tissue Infiltration with Local Anesthesia (MAC-STILA) was associated with lower odds of short-term postoperative altered mental status (AMS) compared to general anesthesia (GA) in hip fracture patients undergoing operative repair. Given the high rate of post-operative AMS and complications associated with geriatric hip fracture patient, MAC-STILA should be considered for use in patients with increased risk of post-operative AMS, particularly in the setting of preoperative dementia. LEVEL OF EVIDENCE/METHODS:Therapeutic III.

BACKGROUND/UNASSIGNED:The purpose of this study was to examine factors that were associated with a decline in functional ambulatory status following fractures of the tibial diaphysis. METHODS/UNASSIGNED:A retrospective review of an IRB-approved tibial diaphysis fracture database from 2012 to 2024 was conducted. Inclusion criteria were age ≥18, isolated OTA 42A-C tibia fracture treated with an intramedullary nail, and minimum 12 months follow-up. Demographics, injury, and surgical information were collected. Functional ambulatory status was measured at routine follow up intervals by the Functional Ambulatory Category (FAC) score, a six-point scale where zero represents non-ambulation and five represents normal ambulatory ability. Univariate analysis was performed using Student's T-tests and Chi-squared tests. A backwards stepwise multivariate logistic regression analysis was performed to determine factors that were independently associated with a decline in FAC score (SPSS version 29, Armonk, NY). RESULTS/UNASSIGNED:289 patients, with a mean follow up time of 15.04 ± 6.18 months, were included in the analysis with a mean age of 43.24 ± 16.22 years, body mass index of 27.19 ± 6.30, and age-unadjusted Charlson Comorbidity Index of 0.18 ± 0.54. 39.1 % of patients were female, 28.0 % patients sustained open fractures, and 52.6 % sustained high energy injuries. The logistic regression demonstrated that older age (OR = 1.04 p < .001), higher BMI (OR = 1.06 p = .024), high-energy mechanism (OR = 3.18 p = .003), nonunion (OR = 3.66, p = .005), and concomitant lower extremity fractures (OR = 4.47 p = 002), were risk factors for a decrease in final FAC score. The AUROC of the logistic regression equation was 0.787 indicating a moderate ability to discriminate between patients that will experience a loss in functional ambulatory ability and those who will not. CONCLUSION/UNASSIGNED:This study suggests that concomitant lower extremity injuries, increased age, increased BMI, high-energy mechanisms, and nonunion are risk factors that are associated with a decline in ambulatory capacity following diaphyseal tibia fractures.

PURPOSE/OBJECTIVE:The purpose of this study is to examine the effect of age on outcomes following repair of acute displaced patella fractures Methods: 248 patients who sustained a displaced patella fracture and underwent open reduction and internal fixation were identified. Patients included underwent a similar operative protocol, were prescribed a standard post-operative protocol of therapy, and were seen at standard follow-up intervals. Patients were divided into groups of < 65 years old (young) and ≥ 65 years old (older). Statistical analysis was run to determine if there was a significant difference in range of knee motion and rate of major complications. RESULTS:Of the 248 patients, 149 were young and 99 were older. The mean age of the older group was 74.5 ± 6.7 and the mean age of the young group was 50 ± 12. Fracture pattern and BMI were similar the groups, however the older group had a higher average CCI (p<0.001). Additionally, the groups had similar length of follow up (p=0.693) and similar mean time to radiographic healing (p=0.533). Older patients had limited knee extension at 6 months (compared young patients (p=0.031). Finally, older patients had a higher rate of all complications compared to young patients. Two percent of older patients developed a fracture related infection (FRI), 4% developed a symptomatic nonunion and 11% were underwent re-operation including removal of hardware, total knee replacement, irrigation and debridement and manipulation under anesthesia. CONCLUSION/CONCLUSIONS:Complication rates following patella fracture fixation in older patients were higher than young patients, despite having similar injury patterns, surgical treatment and follow up. These findings can better inform treating physicians during surgical intervention of older patients with patella fractures.

PURPOSE/OBJECTIVE:To assess the healing outcomes of patients who sustained a comminuted clavicle fracture and underwent operative fixation with or without the addition of demineralized bone matrix (DBM). METHODS:A total of 271 comminuted midshaft clavicle fractures that presented to our hospital system and underwent operative fixation with a plate and screw construct were retrospectively reviewed. Data collected include patient demographics, initial injury information, and use of demineralized bone matrix during surgery to enhance bone healing. Patients were grouped based on whether or not their fixation was augmented with DBM. Fracture-related infection (FRI), lack of fracture healing, and the need for revision fracture surgery were reviewed. Adhesive capsulitis of the shoulder and screw back out were categorized as "minor complications." Clinical healing was defined as non-tenderness about the fracture site, and radiographic healing was defined as presence of bridging callus and lack of fracture line on X-ray. Chi-square, T-test, and linear regression analysis were used to determine any significant differences between cohorts. RESULTS:Sixty-nine patients had DBM used in their repair, and 202 patients did not. Cohorts had a similar follow-up (range: 6-18 months). There were no differences in patient demographics or fracture pattern between the two groups (P > 0.05 for all). There were no differences in major and minor complications; however, the cohort treated with DBM had shorter time to radiographic healing, confirmed with regression analysis (P < 0.05). CONCLUSION/CONCLUSIONS:Augmentation of midshaft clavicle fracture constructs with DBM was associated with quicker radiographic healing.

OBJECTIVE:To develop a stratification tool to identify hip fracture patients at risk for second contralateral hip fracture and mortality within 5 years of an index fracture, and to assess the cost-effectiveness of prophylactic fixation in high-risk/low-mortality patients. METHODS:Design: Retrospective prognostic cohort study. SETTING/METHODS:Single academic system with 2 Level 1 Trauma Centers, 1 orthopedic specialty hospital, and 1 tertiary care hospital. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients who were 60 years or older with OTA 31A/B hip fractures from low-energy mechanisms between 11/1/2014 and 11/31/2023 with ≥5 years follow-up or until death were included. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:The study included four phases: (1) identifying factors associated with second hip fracture within 5 years; (2) using multivariate logistic regression to generate models predicting 5-year second hip fracture (vs. FRAX) and mortality risk; (3) creating a "risk matrix" to identify candidates for prophylactic fixation using Youden's Index which determined cutoff points encompassing the maximum sensitivity and specificity for each risk equation and were used to define a value-based target group; (4) cost analysis comparing standard vs. prophylactic care in high-risk/low-mortality patients. RESULTS:Of 426 patients (mean age 80.25 years, 73.4% female), 78 sustained second hip fractures (mean interval: 594 days). Predictors included higher FRAX score (p=0.004), dementia (p<.001), ICU stay (p=0.014), discharge to subacute care (p<.001), and 90-day readmission (p=0.011). Logistic regression predicted 5-year second fracture risk (AUC 0.742 vs. FRAX 0.617, p=0.012) and 5-year mortality (AUC 0.723). The risk matrix used cutoff points of 18.2% (mortality) and 38.2% (second fracture) to define a value-based target group (n=26; 13 experienced second fracture). Cost analysis showed prophylactic fixation of all 26 patients ($781,508) would save $353,067 compared to treating the 13 who fractured again ($1,134,575). CONCLUSIONS:A novel matrix was developed that accurately predicted 5-year second hip fracture and mortality risk. Prophylactic fixation in low-mortality, high-risk patients may reduce costs and prevent future fractures. [Tool available: https://sttgmacom.wpcomstaging.com/predicting-risk-of-second-hip-fractures/]. LEVEL OF EVIDENCE/METHODS:Level III Diagnostic.

This case presentation describes a technique for reconstruction of an acute posterior sternoclavicular joint dislocation. The patient was a 37 year-old female who sustained a left posterior sternoclavicular dislocation after a fall. A curvilinear incision was made directly over the sternoclavicular joint. After reduction, a semitendinosus allograft was used to reconstruct the sternoclavicular joint in a figure-of-8 fashion through drill holes in the manubrium and the proximal clavicle and secured with suture tape. Sternoclavicular reconstruction with semitendinosis allograft provides a reliable option with good clinical outcomes and low rates of recurrent instability.

A single-stage operative repair of terrible triad injuries through a laterally-based approach using arthroscopic instrument-assisted reduction of the coronoid fracture in cases in which the radial head is deemed appropriate for repair rather than arthroplasty is described in this technical trick. Using an arthroscopic suture lasso, adjustable drill guides, cannulated guide-pins with nitinol shuttling wires, and a suspensory cortical button allow for a more precise and facile technique of "lasso" fixation of coronoid fractures and anterior capsular injuries with intact radial heads in terrible triad injuries.