Faculty Bibliography

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:The purpose of this study is twofold: (1) to reliably define the concept of "extreme tibial nailing" and (2) assess the feasibility of tibial intramedullary nailing when the fracture extends into the nail's locking bolt zone. METHODS:Design: A retrospective review. SETTING/METHODS:A single academic center comprised of a specialty orthopedic hospital and a Level I Trauma Center. Patient Selection Criteria: 543 patients who sustained 555 tibia fractures between February 2014 and January 2024 were reviewed by two board-certified orthopedic surgeons. Cases were classified as "extreme nailing" based on the tibial fracture within the most proximal or distal 25% of the bone such that the fracture extended into the locking bolt section of the intramedullary nail used to treat the fracture. Patients with supplemental periarticular plating of the tibia were excluded. Outcome Measures and Comparisons: Data collected included patient demographics, hospital metrics, and outcomes. RESULTS:Twenty-five tibial fractures treated met radiographic criterion. The "extreme IMN" cohort was 45.8 years, 72% female with a mean BMI of 26.6. Over half of fractures resulted from high-energy injuries, and 40% were open. Patients were hospitalized for 92.8 h on average, and the 90-day readmission rate was 8.0%. The average time to weight-bearing allowance was 5.2 weeks post-op. Eight (32.0%) patients experienced complications: 12% developed fracture-related infection (FRI), 4% experienced hardware complications, and 20.0% developed nonunion requiring surgery. The rate of all-cause reoperation was 32.0%, and 28% of patients experienced knee or ankle pain at 6 months or later. The rate of malalignment was 8.0%, and the average time to radiographic healing was 5.7 months. CONCLUSION/CONCLUSIONS:Tibial nailing is an effective treatment for "extreme" tibial fractures that extend as far as the articular surface and interlocking cluster on either end. The majority of patients who underwent extreme tibial nailing recovered with acceptable alignment, minimal healing complications, and achieved radiographic union within 6 months. LEVEL OF EVIDENCE/METHODS:III.

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.

PURPOSE/OBJECTIVE:Evaluate healing outcomes of patients who sustained a comminuted clavicle fracture and underwent operative fixation using a bridge plate technique or interfragmentary screw/neutralization plate. METHODS:Two hundred and seventy-one comminuted clavicle fractures that underwent operative fixation with minimum 6 months follow-up were retrospectively reviewed. Patients were grouped based on fixation methods. Data collected include patient demographics and injury information. Fracture healing, total complications, fracture related infection, removal of hardware, nonunion, and revision fracture surgery were reviewed. Clinical healing was defined as non-tenderness about the fracture site, and radiographic healing was defined as bridging callus and/ or lack of fracture line on X-ray. Chi square analysis, T test, and linear regression were used for analysis. RESULTS:There were 126 comminuted fractures fixed with a bridge plate and 145 comminuted fractures fixed with a plate and at least one interfragmentary screw both with a mean follow-up of 8.2 months. The bridge plated group was more female, the result of high-energy mechanisms, and had more anteroinferior plates (p < 0.05 for all). There were no differences in time to radiographic healing as well as incidence of nonunion between cohorts. Patients fixed with the bridge plate technique underwent a higher incidence of revision surgery, higher incidence of hardware removal, and had a longer time until clinically healed. On multivariate regression analysis, fixation method was not associated with any of these outcomes (p < 0.05 for all). CONCLUSION/CONCLUSIONS:Bridge plating and lag screw/neutralization plate fixation were both associated with similar rates of healing. Complication profiles were similar.

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.

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.

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.