Faculty Bibliography

BACKGROUND:Alcohol and drug use (substance use) is a risk factor for crash involvement. OBJECTIVES:To assess the association between substance use and crash injury severity among older adults and how the relationship differs by rurality/urbanicity. METHODS:We pooled 2017-2021 cross-sectional data from the United States National Emergency Medical Service (EMS) Information System. We measured injury severity (low acuity, emergent, critical, and fatal) predicted by substance use, defined as self-reported or officer-reported alcohol and/or drug use. We controlled for age, sex, race/ethnicity, road user type, anatomical injured region, roadway crash, rurality/urbanicity, time of the day, and EMS response time. We performed a partial proportional ordinal logistic regression and reported the odds of worse injury outcomes (emergent, critical, and fatal injuries) compared to low acuity injuries, and the predicted probabilities by rurality/urbanicity. RESULTS:Our sample consisted of 252,790 older adults (65 years and older) road users. Approximately 67%, 25%, 6%, and 1% sustained low acuity, emergent, critical, and fatal injuries, respectively. Substance use was reported in approximately 3% of the population, and this proportion did not significantly differ by rurality/urbanicity. After controlling for patient, crash, and injury characteristics, substance use was associated with 36% increased odds of worse injury severity. Compared to urban areas, the predicted probabilities of emergent, critical, and fatal injuries were higher in rural and suburban areas. CONCLUSION:Substance use is associated with worse older adult crash injury severity and the injury severity is higher in rural and suburban areas compared to urban areas.

BACKGROUND/UNASSIGNED:Locking plate technology was developed approximately 25-years-ago and has been successfully used since. Newer designs and material properties have been used to modify the original design, but these changes have yet to be correlated to improved patient outcomes. The purpose of this study was to evaluate the outcomes of first-generation locking plate (FGLP) and screw systems at our institution over an 18 year period. METHODS/UNASSIGNED:Between 2001 to 2018, 76 patients with 82 proximal tibia and distal femur fractures (both acute fracture and nonunions) who were treated with a first-generation titanium, uniaxial locking plate with unicortical screws (FGLP), also known as a LISS plate (Synthes Paoli Pa), were identified and compared to 198 patients with 203 similar fracture patterns treated with 2nd and 3rd generation locking plates, or Later Generation Locking Plates (LGLP). Inclusion criteria was a minimum of 1-year follow-up. At latest follow-up, outcomes were assessed using radiographic analysis, Short Musculoskeletal Functional Assessment (SMFA), VAS pain scores, and knee ROM. All descriptive statistics were calculated using IBM SPSS (Armonk, NY). RESULTS/UNASSIGNED:A total of 76 patients with 82 fractures had a mean 4-year follow-up available for analysis. There were 76 patients with 82 fractures fixed with a First-generation locking plate. The mean age at time of injury for all patients was 59.2 and 61.0% were female. Mean time to union for fractures about the knee fixed with FGLP was by 5.3 months for acute fractures and 6.1 months for nonunions. At final follow-up, the mean standardized SMFA for all patients was 19.9, mean knee range of motion was 1.6°-111.9°, and mean VAS pain score was 2.7. When compared to a group of similar patients with similar fractures and nonunions treated with LGLPs there were no differences in outcomes assessed. CONCLUSION/UNASSIGNED:.

The purpose of this study was to determine if the use of peripheral nerve blocks in the operative management of tibial plateau fractures is associated with improved outcomes when compared with the use of spinal and general anesthesia. Over a period of 16 years, 132 patients who underwent operative repair for a low-energy tibial plateau fracture and had at least 12 months of follow-up met the inclusion criteria and formed the basis of this study. Patients were grouped into cohorts based on the anesthetic method used during surgery: peripheral nerve block in combination with conscious sedation or general anesthesia (BA), general anesthesia alone (GA), or spinal anesthesia alone (SA). Outcomes were assessed at 3 months, 6 months, and 12 months. Length of stay was greatest in the GA cohort (P<.05), and more patients in the BA cohort were discharged to home (P<.05). Patients in the GA cohort had the highest pain scores at 3 months and 6 months (P<.05). Patients in both the SA and BA cohorts had better Short Musculoskeletal Function Assessment scores at 6 and 12 months when compared with the GA cohort (P<.05). Although knee range of motion did not differ among the three cohorts at 3 months, it did differ at 6 months and 12 months postoperatively, with those who had a preoperative nerve blockade (SA and BA) having the greatest knee range of motion (P<.05). Regional anesthesia was safe and was associated with lower pain scores in the early postoperative period and greater knee range of motion and functional outcome scores in the late postoperative period. [Orthopedics. 2023;46(6):358-364.].

OBJECTIVES/OBJECTIVE:To (1) determine the ability of the Fracture Risk Assessment Tool (FRAX) to identify the probability of contralateral hip fractures within 2 years of index fracture and (2) identify independent risk factors for a subsequent hip fracture. DESIGN/METHODS:Retrospective. SETTING/METHODS:Urban, academic medical center. PATIENTS/METHODS:This study included a consecutive series of patients treated for unilateral hip fractures between September 2015 and July 2019. RESULTS:Eight hundred thirty-two consecutive patients were included in the analysis with a mean age of 81.2 ± 9.9 years. Thirty-one (3.7%) patients sustained a contralateral hip fracture within 2 years with these patients sustaining the second fracture at a mean 294.1 days ± 197.7 days. The average FRAX score for the entire cohort was 11.9 ± 7.4, and the area under receiving operating characteristic curve (AUROC) for FRAX score was 0.682 (95% CI, 0.596-0.767). Patients in the high-risk FRAX group had a >7% risk of contralateral hip fracture within 2 years. Independent risk factors for contralateral hip fracture risk included patient age 80 years or older and decreasing BMI. CONCLUSIONS:This study demonstrates the strong ability of the FRAX score to triage patients at risk of subsequent contralateral hip fracture within 2 years. In this high-risk FRAX group, patients age older than 80 years and who have decreasing BMI after their index fracture have a 12.5% increased risk of fracture within 2 years which is 4× higher than the current World Health Organization 10-year 3% hip fracture risk standard used to initiate pharmacologic treatment. Therefore, high-risk patients identified using this methodology should be targeted more aggressively with preventative measures including social, medical, and potentially surgical interventions. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:To investigate if any injury to the three primary branches of the popliteal artery in open tibia fractures lead to increased soft-tissue complications, particularly in the area of the affected angiosome. DESIGN/METHODS:Retrospective cohort comparative study. SETTING/METHODS:Two academic level one trauma centersPatients/Participants: Sixty-eight adult patients with open tibia fractures with a minimum one-year follow up. INTERVENTION/METHODS:N/A. MAIN OUTCOME MEASUREMENTS/METHODS:Soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture related infection (FRI) at time of final follow-up. RESULTS:Eleven (15.1%) tibia fractures had confirmed arterial injuries via CTA (7), direct intraoperative visualization (3), intraoperative angiogram (3). Ten (91.0%) were treated with ligation and 1 (9.1%) was directly repaired by vascular surgery. Ultimately, 6 (54.5%) achieved radiographic union and 4 (36.4%) required amputation performed at a mean of 2.62 ± 2.04 months, with one patient going on to nonunion diagnosed at 10 months. Patients with arterial injury had significantly higher rates of wound healing complications, FRI, nonunion, amputation rates, return to the OR, and increased time to coverage or closure. After multivariate regression, arterial injury was associated with higher odds of wound complications, FRI, and nonunion. Ten (90.9%) patients with arterial injury had open wounds in the region of the compromised angiosome, with 7 (70%) experiencing wound complications, 6 (60%) FRIs, and 3 (30%) undergoing amputation. CONCLUSIONS:Arterial injuries in open tibia fractures with or without repair, have significantly higher rates of wound healing complications, FRI, delayed time to final closure, and need for amputation. Arterial injuries appear to effect wound healing in the affected angiosome. LEVEL OF EVIDENCE/METHODS:Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION/BACKGROUND:The purpose of this study was to demonstrate a novel technology used to measure improvements in quality and value of care for treatment of hip fracture patients. METHODS:A novel value-based triaging methodology uses a risk prediction (risk M) and inpatient cost prediction (risk C) algorithm and has been demonstrated to accurately predict high-risk:high-cost episodes of care. Two hundred twenty-nine hip fracture patients from 2014 to 2016 were used to establish baseline length of stay (LOS) and total inpatient cost for each (16) risk:cost quadrants. Two hundred sixty-five patients between 2017 and 2019 with hip fractures were input into the algorithm, and historical LOS and cost for each patient were calculated. Historical values were compared with actual values to determine whether the value of the inpatient episode of care differed from the 2014 to 16 cohort. RESULTS:When evaluated without risk or cost stratification, the mean actual LOS and cost of the baseline cohort compared with the 2017 to 2019 cohort were 8.0 vs 7.5 days (P = 0.43) and $25,446 vs $29,849 (P = 0.15), respectively. This analysis demonstrates that there was only a small change in value of care provided to patients based on LOS/cost over the studied period; however, risk:cost analysis using the novel methodology demonstrated that for select risk:cost quadrants, value of care measured by LOS/cost improved, whereas for others it decreased and for others there was no change. CONCLUSION/CONCLUSIONS:Risk-cost-adjusted analysis of inpatient episodes of care rendered by a value-based triaging methodology provides a robust method of assessing improvements and/or decreases in value-based care when compared with a historical cohort. This methodology provides the tools to both track hospital interventions designed to improve quality and decrease cost as well as determine whether these interventions are effective in improving value.

PURPOSE/OBJECTIVE:The purpose of this study was to examine hospital quality measures and the long-term functional outcomes associated with lateral compression type 1 [LC1] pelvic ring injuries. METHODS:A query was performed from December 2011 to September 2020 at two institutions within one hospital system for patients with a pelvic fracture diagnosis. Chart review was performed on admitted patients to determine demographic information, medical co-morbidities (to calculate Charlson Co-morbidity Index), in-hospital complications, length of stay [LOS], discharge disposition, and 30-day readmission rates. All patients included were treated nonoperatively. An attempt was made to contact all patients for long-term follow-up to assess current functional status with a Short Musculoskeletal Function Assessment [SMFA]. RESULTS:Two-hundred and eighty-six patients were included, with 172 (65.9%) patients admitted and analyzed with respect to hospital quality measures. Patients admitted were older (83 vs 80 years, p = 0.015) with more medical co-morbidities (p = 0.001) than those discharged from the emergency department. The average LOS was 5.7 ± 3.7 days and 31 (18%) experienced in-hospital complications. The inpatient mortality rate was 1.2%, and the 30-day readmission rate was 8.1%. When comparing admitted patients without concomitant injuries, admitted patients with concomitant injuries, and non-admitted patients, admitted patients with concomitant injuries were found to have more medical co-morbidities (p = 0.001). Forty-three patients were available for long-term follow-up (average 36.6 ± 7.3 months), with an average SMFA score of 29.0 ± 25.7. CONCLUSIONS:Patients admitted for LC1 pelvic fractures are likely to be older with more medical co-morbidities, and up to 1/5th will experience inpatient complications. Although inpatient mortality remains low, this injury pattern can lead to significant functional disability that persists for several years after injury.

OBJECTIVE:To assess the effectiveness of a multimodal analgesic regimen containing "safer" opioid and non-narcotic pain medications in decreasing opioid prescriptions following surgical fixation in orthopedic trauma. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:One urban, academic medical center. SUBJECTS/METHODS:Traumatic fracture patients from 2018 (848) and 2019 (931). METHODS:In 2019 our orthopedic trauma division began a standardized protocol of post-operative pain medications that included: 50 mg of tramadol four times daily, 15 mg of meloxicam once daily, 200 mg gabapentin twice daily, and 1 g of acetaminophen every 6 hours as needed. This multimodal regimen was dubbed the "Lopioid" protocol. We compared this protocol to all patients from the prior year who followed a standard protocol that included Schedule II narcotics. RESULTS:Greater mean MME were prescribed at discharge from fracture surgery under the standard protocol compared to the Lopioid protocol (252.3 vs 150.0; p < 0.001) and there was a difference in the type of opioid medication prescribed (p < 0.001). There was a difference in the number of refills filled for patients discharged with opioids after surgical treatment between standard and Lopioid cohorts (0.31 vs 0.21; p = 0.002). There was no difference in the types of medication-related complications (p = 0.710) or the need for formal pain management consults (p = 0.199), but patients in the Lopioid cohort had lower pain scores at discharge (2.2 vs 2.7; p = 0.001). CONCLUSIONS:The Lopioid protocol was effective in decreasing the amount of Schedule II narcotics prescribed at discharge and the number of opioid refills following orthopedic surgery for fractures.

PURPOSE/OBJECTIVE:Chronic use of selective serotonin reuptake inhibitors (SSRIs) for the treatment of depression has been linked to an imbalance in bone metabolism leading to osteoporosis. More recently, the use of SSRIs in murine models has been shown to delay bone healing both in vivo and in vitro by decreasing the osteoblastic differentiation and mineralization. The purpose of this study was to evaluate whether or not chronic use of SSRI's in nonunion patients increases their time to union after surgical intervention. METHODS:We retrospectively analyzed 343 patients in a nonunion database to determine which patients were on SSRI medication. Of these patients, 139 could be contacted and of those 102 were not taking SSRIs and 37 were taking SSRIs. Patient's time to union from nonunion surgical intervention between each cohort at our institution was recorded as the primary outcome. Patient's medical comorbidities that could affect union rates such as diabetes and smoking status were also noted. Baseline Short Musculoskeletal Function Assessment (SMFA) index for bother and function were recorded from the time of nonunion surgery as well as last follow-up. RESULTS:Compared to recent census data, we found significantly more patients in the nonunion cohort using SSRIs (26.6%) than patients in the general population using any type of antidepressant (11%). There was no significant difference in the patients' baseline characteristics other than patients on SSRI treatment had a higher body mass index (BMI) and age (p = 0.048 and p = 0.043, respectively). There was no significant difference noted in the fracture types (p = 0.2063). Patients on SSRIs had a higher SMFA bother index and function index on follow-up (p = 0.0103, p = 0.0147). Patients in the SSRI group had a mean time to union from nonunion surgery of 6.1 months compared to 6.0 in patients without SSRI usage (p = 0.74). These did not reach statistical significance when subcohort analysis for long bone fractures was performed for the femur, tibia, and humerus. CONCLUSION/CONCLUSIONS:To our knowledge, this is the first clinical study to investigate the effects of SSRIs on fracture healing. While in vivo and in vitro murine models have shown that SSRIs can have a deleterious effect on osteoblastic activity, our retrospective analysis did not show a significant difference in time to union between patients with chronic SSRI use and patients who have not been on SSRIs. However, this investigation did show a higher incidence of SSRI use in the nonunion cohort when compared to the general population. In the context of the recent animal model study, this may point to a negative effect of SSRI use on the acute fracture healing process.

Introduction/UNASSIGNED:The purpose of this study was to investigate the effect of delayed closures, whether delayed primary closure (DPC) or split-thickness skin grafting (STSG), of operatively treated forearm fractures on short-term soft tissue outcomes. Methods/UNASSIGNED:In this retrospective cohort comparative study of two academic-level one trauma centers from 2010 to 2020, adult patients with diaphyseal forearm fractures who underwent open reduction and internal fixation (ORIF) were either closed primarily at index surgery, or underwent delayed closure, either with DPC or with a STSG. Primary outcome measures were soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture-related infection (FRI) at time of final follow-up. Results/UNASSIGNED:Eighty-one patients with 81 diaphyseal forearm fractures underwent ORIF with a mean follow-up of 14.3 months. Forty-one fractures (50.6%) were open injuries. Thirteen patients (16.0%) were unable to be closed primarily and underwent an average of 2.46 ± 0.7 surgeries including final coverage, with an average of 4.31 ± 2.8 days to final coverage. Four patients (30.8%) underwent DPC and 9 (69.2%) underwent STSG. Five (6.6%) patients in the delayed closure group had pre-operative compartment syndrome and underwent formal two-incision fasciotomies. There were no significant differences between delayed versus primary closure in wound healing complication rates, FRI, or radiographic union. Conclusions/UNASSIGNED:Diaphyseal forearm fractures that undergo ORIF have equivalent short-term soft tissue outcomes when closed primarily at index surgery or when closed in a delayed fashion.