Faculty Bibliography

OBJECTIVES/OBJECTIVE:This study evaluated the impact of prolonged glucagon-like peptide-1 (GLP-1) receptor agonist use on postoperative outcomes, including radiographic post-traumatic osteoarthritis (PTOA), fracture nonunion, and final knee range of motion-following operative management of tibial plateau fractures across multiple BMI strata. METHODS:A retrospective cohort study was conducted at an urban academic institution, including patients who underwent surgical fixation for tibial plateau fractures between 2016-2024, with a ≥6 months follow-up. The GLP-1 cohort consisted of patients with documented long-term GLP-1 use pre- and postoperatively. GLP-1 users (Group A, n=24) were compared to three non-GLP-1 cohorts stratified by BMI: Group B (BMI 18.5-25, n=150), Group C (BMI 25-30, n=150), and Group D (BMI ≥30, n=100). Outcomes included Kellgren-Lawrence osteoarthritis grade, post-reduction fracture angulation, articular step-off, Charlson Comorbidity Index (CCI), fracture complications (infection, nonunion, PTOA, revision surgery), and final knee flexion range of motion (ROM). Statistical analyses used SPSS Statistics version 29.0 (IBM Corp., Armonk, NY) with ANOVA and Chi-square tests. RESULTS:Mean follow-up was 28.83 months. Baseline age, CCI, fracture angulation, and step-off were comparable between groups. Pre-injury osteoarthritis severity was higher in Group A (0.96±0.88) than in Groups B (0.68±0.86), C (0.54 ± 0.75), and D (0.78±0.74) (p<0.001). Radiographic PTOA incidence was highest in Group D (32%, p<0.01), while Group A rates were comparable to Groups B and C (p≈0.62). Final knee flexion ROM differed significantly (p<0.01), with Group D showing the lowest mobility (119.08±16.47°). Nonunion rates were significantly higher in Group A (p<0.01). CONCLUSIONS:Among obese patients, GLP-1 receptor agonist use was associated with a lower incidence of PTOA and preserved knee ROM compared to untreated obese individuals, with outcomes similar to non-obese patients. However, GLP-1 use was also linked to increased nonunion rates. These findings suggest that while GLP-1 therapy may mitigate obesity-related joint degeneration, it may also challenge fracture healing.

PURPOSE/OBJECTIVE:To characterise differences in baseline demographics, outcomes, and cost between 1st and 2nd (contralateral) hip fracture hospitalisations in the same patient that occur within 5 years of each other. METHODS:A retrospective review of operatively treated hip fractures was performed at an academic medical centre. INCLUSION CRITERIA/METHODS:age ⩾65 years, presence of a first and second, contralateral hip fracture with OTA 31A/B classification within 5 years of the hip fracture. Analysis was based on the chronological order of their fracture - 1st hip fracture versus 2nd hip fracture. Comparison of patients' demographics, postoperative complications, 90-day readmission rates, 1-year mortality, discharge location, and direct inpatient hospitalisation costs were compared. Major complications were defined as: sepsis, acute respiratory failure, myocardial infarction, stroke, pulmonary embolus, or death. RESULTS: = 0.08). There were no other differences in outcomes and hospitalisation cost. CONCLUSIONS:Patients who sustain a 2nd contralateral hip fracture within 5 years of their first hip fracture demonstrate a trend towards having more major and minor inpatient complications There are otherwise comparable hospital quality measures and cost profile during their 2nd hip fracture hospitalisation compared to their 1st hip fracture hospitalisation. Resources should be allocated to minimise the risk of complications in 2nd hip fracture patients.

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.

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.

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.

OBJECTIVES/OBJECTIVE:To evaluate the association between electronic health record (EHR)-based behavioral flag designation and postoperative outcomes in orthopedic trauma patients undergoing surgical fixation for acute fractures. DESIGN/METHODS:Retrospective cohort study with 1:1 propensity score matching. SETTING/METHODS:Level I trauma center. PATIENTS SELECTION CRITERIA/UNASSIGNED:Adult orthopedic trauma patients who underwent operative fixation for an acute fracture and received a long-term behavioral flag issued for documented disruptive, threatening, or violent behavior toward healthcare staff following institutional review either before surgery or within 1 year postoperatively were included. Those with pathologic fractures and those with inadequate follow-up were excluded. Each flagged patient was matched to an unflagged control based on age, sex, BMI, smoking status, comorbidity burden, and fracture type. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Primary outcomes included 1-year rates of major postoperative complications (e.g., fracture-related infection, nonunion, painful hardware) and reoperation. Subgroup analyses examined outcomes by timing of flag assignment. RESULTS:A total of 116 patients were included (58 flagged patients, 58 unflagged). Flagged patients had a mean age of 53.4 ± 18.1 years (range, 19-74) and were 55.2% male; unflagged controls had a mean age of 49.0 ± 13.6 years (range, 21-71) and were 55.2% male. Adequate covariate balance was achieved after 1:1 propensity score matching. Median follow-up was 12 months (range, 6 months to 9 years). Major postoperative complications occurred in 10 flagged patients (17.2%) and 2 controls (3.4%). Reoperations occurred in 9 flagged patients (15.5%) and 2 controls (3.4%). Compared with controls, patients with a behavioral flag assigned either before surgery or within 1 year postoperatively had higher odds of major complications (OR 5.57; 95% CI 1.99-18.30; p=0.002) and reoperation (OR 4.06; 95% CI 1.31-15.40; p=0.022). Among flagged patients, those with a preoperative behavioral flag had the highest odds of major complications (OR 14.74; 95% CI 2.52-282.0; p=0.014). CONCLUSIONS:EHR behavioral flag designation was associated with higher odds of major postoperative complications and reoperation after operative fixation of acute fractures. Preoperative behavioral flags demonstrated the strongest association with adverse outcomes. Behavioral flag status may serve as a useful marker of elevated perioperative risk in orthopedic trauma patients. LEVEL OF EVIDENCE/METHODS:Level III, Therapeutic.

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.

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.

INTRODUCTION/BACKGROUND:To compare outcomes of patients with geriatric hip fracture undergoing surgery <24 hours from emergency department (ED) arrival to those who underwent surgery >24 hours from arrival but within the next calendar day. METHODS:A retrospective review of a single-institution hip fracture database (2014 to 2024) was performed. The study cohort was divided into two groups based on time from ED arrival to surgery start time: <24-hour surgery (<24h) and next calendar day surgery >24 hours from arrival (>24h [next calendar day]). Univariate analysis was performed to compare baseline health, injury factors, and outcomes. Multivariate linear and logistic regression analyses were performed to adjust for procedure type and risk profile. RESULTS:There were 1,694 patients included in the study analysis, of whom 964 (56.91%) were <24h and 730 (43.09%) were >24h (next calendar day). The mean time to surgery for cohorts were <24h: 17.66 ± 5.05 vs. >24h (next calendar day): 28.78 ± 3.86 hours; P < 0.001. Univariate analysis revealed no differences between <24h and >24h (next calendar day) cohorts for in-hospital complication incidence (35.5% vs. 35.1%; P = 0.862), inpatient mortality (0.5% vs. 1.0%; P = 0.285), 30-/90-day readmission (5.6% vs. 6.2%; P = 0.625; 8.2% vs. 11.0%; P = 0.053), and 30-day/1-year mortality (2.4% vs. 2.3%; P = 0.939; 5.0% vs. 6.2%; P = 0.289). Length of stay (5.15 ± 3.15 vs. 5.58 ± 3.31; P = 0.006) and discharge location (36.4% home discharge vs. 31.0%; P = 0.019) favored the <24h cohort. After adjusting for baseline health with Score for Trauma Triage in the Geriatric and Middle-Aged and procedure type, only longer length of stay was found to be associated with the >24h (next calendar day) cohort (B = 0.407; P = 0.010). CONCLUSION/CONCLUSIONS:No notable differences were observed in key outcomes for patients undergoing <24 hours from ED arrival versus those who undergo surgery >24 hours after arrival but on the next calendar day. This study suggests that "next day hip fracture surgery" appears safe for patients with geriatric hip fracture.

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.