Faculty Bibliography

BACKGROUND/UNASSIGNED:Functional recovery following non-operative treatment of proximal humerus fractures (PHFs) varies widely, but the relative impact of patient characteristics and medical comorbidities remain unclear. This study aimed to identify factors associated with (1) patient-reported functional recovery following healing as measured by Disabilities of the Arm, Shoulder, and Hand (DASH) scores and (2) achieving functional range of shoulder motion (ROM). METHODS/UNASSIGNED:Fractures were classified using the Neer system, and all patients followed a standardized therapy protocol emphasizing early ROM. Functional outcomes were assessed using a self-reported pre-injury DASH estimate and DASH at minimum 6-month follow-up, with recovery quantified as a standardized deviation metric (absolute difference divided by the cohort SD of pre-injury estimates). Functional ROM was defined as ≥120° of forward elevation. Exploratory bivariate analyses were performed, and multivariable linear and logistic regression models were used to identify independent associations. RESULTS/UNASSIGNED:Among 166 patients, multivariable linear regression demonstrated coronary artery disease (CAD; B = 2.64; 95% CI, 0.52-4.75; p = 0.015), hypertension (HTN; B = 1.43; 95% CI, 0.06-2.80; p = 0.041), and race/ethnicity (B = 0.59; 95% CI, 0.08-1.11; p = 0.023) were independently associated with greater standardized DASH deviation; type 2 diabetes (T2DM) was not (p = 0.170). ROM data were available for 129 patients (77.7%). In multivariable logistic regression, no covariate reached statistical significance; HTN demonstrated a trend toward reduced odds of achieving functional ROM (aOR 0.29; 95% CI, 0.07-1.18; p = 0.084). CONCLUSION/UNASSIGNED:In this exploratory cohort, cardiovascular comorbidities (CAD and HTN) were independently associated with poorer patient-reported functional recovery after non-operative PHF treatment. Race/ethnicity showed an association, but subgroup sizes were small, and estimates should be interpreted cautiously. No independent predictors of functional ROM were identified.

OBJECTIVES/OBJECTIVE:To assess the concordance between blood culture isolates and intraoperative deep tissue cultures in patients with confirmed fracture-related infection (FRI). DESIGN/METHODS:Retrospective Cohort Study. SETTING/METHODS:Academic Medical Center. PATIENT SELECTION CRITERIA/UNASSIGNED:This Institutional Review Board-approved study included patients 18 years and older diagnosed with a confirmed FRI according to the FRI Consensus Group criteria who, at time of irrigation and debridement (I&D), underwent deep tissue culture (TC) as well as concurrent blood culture (BC) testing (in the Emergency Department or inpatient setting). The decision to perform BC testing was left to the discretion of the initial treating providers at the time of this presentation. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Microbiological data were reviewed from the electronic medical record. Infections were classified as monomicrobial (either gram-positive or gram-negative), polymicrobial, or culture negative. Pathogen concordance between blood and intraoperative tissue cultures was analyzed. RESULTS:84 patients were included with both intraoperative deep TC and concurrent BC. This cohort had a mean age of 56.2 ± 20.3 years and consisted of 33 females (39.3%). BC were never ordered by the orthopedic surgeon. Microbial analysis of deep tissue specimens identified 29 gram-positive infections, 18 gram-negative infections, 33 polymicrobial infections, and 4 culture-negative cases. Of the 84 BC analyzed, 69 (82.1%) were culture-negative and 15 (17.9%) were culture-positive. BC results were discordant with their respective TC isolates in 76 of 84 (90.4%) cases. This discordance in 76 cases was driven by negative BC in the setting of positive TC (69/76, 90.8%), while a smaller proportion reflected growth of different organisms in BC compared to TC (7/76, 9.2%). Concordance was observed in only 8 of 84 (9.6%) cases, in which BC identified at least one pathogen sampled from TC. BC yielded negative culture results 17 times as often as TC. McNemar's test revealed a highly significant difference in culture-positivity rates (χ2=65, p<0.0001), while Cohen's Kappa for agreement was 0.022, indicating minimal agreement between BC and TC results. CONCLUSIONS:These results suggest that blood cultures were part of some workflows for patients presenting with infections, but they did not reflect the true bony pathogens nor contribute meaningful diagnostic information in most cases of confirmed fracture-related infection (FRI) according to the FRI Consensus Group criteria. While blood culture testing is important in the evaluation of systemic infection from, it does not provide orthopedic surgeons with information that informs the management or treatment of the FRI itself. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Morbidity and mortality following geriatric hip fracture remains high. Increased time from hospital admission to hip fracture surgery is a factor that has been associated with adverse outcomes. The purpose of this study was to identify factors associated with delays to surgery greater than 1 day in geriatric hip fracture patients. The primary aim of this study was to identify and compare comorbidities between patients who underwent surgery within 1 day and those who did not using a large national data base. The null hypothesis was that patients with more acute medical comorbidities would not have a higher association with delays to surgery greater than 1 day. METHODS:Patients over the age of 65 who underwent a surgical repair for a hip fracture from 2005 to 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were grouped into those who had surgery less than 1 day after admission (n = 74,072) and those who had surgery greater than 1 day after admission (n = 21,481). Demographic data and comorbidities were collected and compared. Univariate regressions were performed to assess the effect of comorbidities on risk of surgery more than 1 day after admission. RESULTS:Hip fracture patients who did not undergo surgery within 1 day were older, more likely to be male, non-white, have lower functional status and greater ASA class. These patients had significantly greater preoperative comorbidities such as hypertension, bleeding disorder or anticoagulated status, obesity, chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). Patients who were ventilator dependent (OR: 10.09; 95% CI: [6.65, 15.79], p < 0.001), had preoperative transfusions (OR: 3.89; 95% CI: [3.64, 4.16], p < 0.001) or CHF (OR: 2.88, 95% CI: [2.68, 3.09], p < 0.001) had the greatest odds of not having surgery within 1 day. CONCLUSIONS:Hip fracture patients who did not get surgery within 1 day, had a greater preoperative comorbidity profile than those who did. Patients with certain comorbidities such as ventilator dependence, need for preoperative blood transfusion and congestive heart failure had greater odds of having surgery delayed beyond 1 day. Attention should be placed on patients who arrive with these risk factors and clinical pathways should be designed to expedite preoperative medical optimization and surgical treatment. LEVEL OF EVIDENCE/METHODS:III; Retrospective Comparative Study.

PURPOSE/OBJECTIVE:To compare clinical characteristics and outcomes of Maisonneuve fractures, as defined as syndesmotic disruption with or without proximal fibula fracture, to other pronation-external rotation (PER) stage III/IV fractures. METHODS:A retrospective review of an IRB-approved database of ankle fractures from a single orthopedic department identified patients with surgically treated PER stage III/IV fractures, including those meeting radiographic criteria for Maisonneuve fracture. Data collected included patient demographics, injury mechanism, surgical details, and Lauge-Hansen classification. Maisonneuve fractures were compared to other PER III/IV fractures requiring fibular fixation with syndesmotic stabilization. Outcomes included total complications, fracture-related infection, hardware removal, and nonunion. Patients were seen for standard follow up for 12 months post-operatively with clinical healing defined as non-tenderness about the ankle. Statistical analyses included Chi square analysis, ANOVA, and multivariable regression analysis. RESULTS:64 patients with operatively repaired Maisonneuve fractures were identified (mean follow-up of 10 months). These patients were more often male compared to other PER III/IV fractures (p < 0.05). Maisonneuve fractures were associated with a faster time to clinical healing and return to full activity, confirmed on multivariable regression analysis (p < 0.05). No significant differences in complications rates or radiographic parameters at six months or later were observed, as all values remained within accepted clinical ranges. CONCLUSION/CONCLUSIONS:Maisonneuve fracture patients experience a more rapid clinical recovery based upon painless ankle motion as well as a return to full activity faster than patients with other types of PER III/IV injuries, with comparable complication rates and radiographic outcomes.

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.