Faculty Bibliography

This review demonstrates the technique for monitored anesthesia care and soft tissue infiltration with local anesthesia as the only form of anesthesia for short cephalomedullary nailing in medically complex patients. Monitored anesthesia care is defined as providing sedation and analgesia that is titrated to a level that preserves spontaneous breathing and airway reflexes. Soft tissue infiltration refers to soft tissue infiltration with local anesthesia directly into the surgical site and is performed by the surgeon before the start of the procedure.

This review describes the indications and technique for acute total hip arthroplasty in an incomplete both-column acetabular fracture in a geriatric patient.

A case of a 26-year-old man with a displaced medial malleolus fracture with extension into the posteromedial aspect of the posterior malleolus is presented. A CT scan of the ankle is obtained demonstrating a Haraguchi type 2B posterior malleolus fracture with a posteromedial and posterolateral fragment. The posteromedial fragment extends into the posterior colliculus of the medial malleolus and has a subchondral impaction fracture. There is also a 1 × 1 cm piece of the articular surface of the posterior malleolus that has flipped 90 degrees and lodged itself between the posterolateral fracture fragment. This video overview and case presentation demonstrates a posteromedial approach with fixation strategy for the posterior malleolus.

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:.

OBJECTIVES/UNASSIGNED:To document discharge locations for geriatric patients treated for a hip fracture before and during the COVID pandemic and subsequent changes in outcomes seen between each cohort. DESIGN/UNASSIGNED:Retrospective cohort study. SETTING/UNASSIGNED:Academic medical center. PATIENTS/PARTICIPANTS/UNASSIGNED:Two matched cohorts of 100 patients with hip fracture treated pre-COVID (February-May 2019) and during COVID (February-May 2020). INTERVENTION/UNASSIGNED:Discharge location and COVID status on admission. Discharge locations were home (home independently or home with health services) versus facility [subacute nursing facility (SNF) or acute rehabilitation facility]. MAIN OUTCOME MEASUREMENTS/UNASSIGNED:Readmissions, inpatient and 1-year mortality, and 1-year functional outcomes (EQ5D-3L). RESULTS/UNASSIGNED:= 0.029). COVID- patients discharged to an SNF in 2020 had a 3x increased 30-day mortality rate and 1.5x increased 1-year mortality rate compared with 2019. Patients discharged to an acute rehabilitation facility in 2020 had higher rates of 90-day readmission. There was no difference in functional outcomes. CONCLUSIONS/UNASSIGNED:All patients, including COVID- patients, discharged to all discharge locations during the onset of the pandemic experienced a higher mortality rate as compared with prepandemic. This was most pronounced in patients discharged to a skilled nursing facility in 2020 during the early stages of the pandemic. If this trend continues, it suggests that during COVID waves, discharge planning should be conducted with the understanding that no options eliminate the increased risks associated with the pandemic. LEVEL OF EVIDENCE/UNASSIGNED:III.

PURPOSE/OBJECTIVE:To determine the factors associated with discharge location in patients with hip fractures and whether home discharge was associated with a lower readmission and complication rate. METHODS:Hip fracture patients who presented to our academic medical center for operative management of a hip fracture were enrolled into an IRB-approved hip fracture database. Radiographs, demographics, and injury details were recorded at the time of presentation. Patients were grouped based upon discharge disposition: home (with or without home services), acute rehabilitation facility (ARF), or sub-acute rehabilitation facility (SAR). RESULTS:The cohorts differed in marital status, with a greater proportion of patients discharged to home being married (51.7% vs. 43.8% vs. 34.1%) (P < 0.05). Patients discharged to home were less likely to require an assistive device (P < 0.05). Patients discharged to home experienced fewer post-operative complications (P < 0.05) and had lower readmission rates (P < 0.05). Being married was associated with an increased likelihood of discharge to home (OR = 1.679, CI = 1.391-2.028, P < 0.001). Being enrolled in Medicare/Medicaid was associated with decreased odds of discharge to home (OR = 0.563, CI = 0.457-0.693, P < 0.001). Use of an assistive device was associated with decreased odds of discharge to home (OR = 0.398, CI = 0.326-0.468, P < 0.001). Increases in CCI (OR = 0.903, CI = 0.846-0.964, P = 0.002) and number of inpatient complications (OR = 0.708, CI = 0.532-0.943, P = 0.018) were associated with decreased odds of home discharge. CONCLUSION/CONCLUSIONS:Hip fracture patients discharged to home were healthier and more functional at baseline, and also less likely to have had a complicated hospital course. Those discharged to home also had lower rates of readmission and post-operative complications. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Concomitant upper extremity and hip fractures present a challenge in postoperative mobilization in the geriatric population. Operative fixation of proximal humerus fractures allows for upper extremity weight bearing. This retrospective study compared outcomes between operative and non-operative proximal humerus fracture patients with concomitant hip fractures. METHODS:A trauma database of 13,396 patients age > 55 years old was queried for concomitant hip and proximal humerus fracture patients between 2014-2021. Medical records were reviewed for demographics, hospital quality measures, Neer classification, morphine milligram equivalents (MME), and outcomes. All hip fractures were treated operatively. Patients were grouped based on operative vs. non-operative treatment of their proximal humerus fracture. Primary outcomes included comparing postoperative ambulatory status, pain, length of stay (LOS), intensive care unit (ICU) need, discharge disposition, and readmission rates. RESULTS:Forty-eight patients (0.4%) met inclusion criteria. Twelve patients (25%) underwent operative treatment for their proximal humerus fracture and 36 (75%) received non-operative treatment. Patients with operative fixations were younger (p < 0.01), had more complex Neer classifications (p = 0.031), more likely to be community ambulators (p < 0.01), and required more inpatient MMEs (p < 0.01). There were no differences in LOS (p = 0.415), need for ICU (p = 0.718), discharge location (p = 0.497), 30-day readmission (p = 0.228), or 90-day readmission (p = 0.135) between cohorts. At 6 months postoperatively, among community or household ambulators, a higher percentage of operative patients returned to their baseline ambulatory functional status, however, this was not significant (70% vs. 52%, p = 0.342). There were three deaths in the non-operative cohort and no deaths in the operative cohort. CONCLUSION/CONCLUSIONS:Patients with hip fractures and concomitant proximal humerus fractures treated operatively required more inpatient MMEs and trended toward maintaining baseline ambulatory function. There were no differences in inpatient LOS, ICU need, discharge location, or readmissions. Future larger, multicenter studies are needed to further delineate if operative repair of concomitant proximal humerus fractures provides a benefit in the geriatric population.

Introduction The presence of poorly-controlled diabetes in the setting of geriatric hip fractures has been shown to increase all-cause mortality and worsen outcomes. This study aimed to assess whether the addition of a patient's glycated hemoglobin (A1c) value to a validated geriatric inpatient risk tool improves the predictive capacity of the risk tool. Methods A cohort of 2430 patients >55 years old treated for low-energy mechanism hip fractures between October 2014 to November 2021 were reviewed for demographics (including diabetes diagnoses and their respective hemoglobin A1c values at the time of admission), injury details, hospital quality measures, and mortality. As past work demonstrated a hemoglobin A1c value above 8% to be the tipping point for worse outcomes, the baseline Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool for inpatient mortality in hip fractures (STTGMAHIP_FX_SCORE - Score for Trauma Triage in the Geriatric and Middle-Aged Hip Fracture Score) was modified to include a patient's hemoglobin A1c using an 8% cutoff (STTGMAHIP_8%A1c - Score for Trauma Triage in the Geriatric and Middle-Aged Hip 8% Hemoglobin A1c Cutoff Score). The new model's predictive ability (as measured by the area under the receiver operating curves (AUROCs)) for inpatient mortality was compared to the baseline tool using DeLong's test. Risk quartiles were generated for the new tool, and comparative analyses were conducted on hospital quality measures and outcomes.  Results Five hundred and sixty-five patients (23%) were noted to have diabetes mellitus, and 76 patients had an A1c above 8%. Patients with a hemoglobin A1c above 8% had a higher rate of inpatient complications and mortality through one year. The STTGMAHIP_8%A1c score significantly improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE (0.786 vs. 0.672, p=0.0456). Upon analysis of the risk quartiles, the highest risk cohort was found to have a longer length of stay (p<0.001), with higher rates of inpatient (p<0.001) and 30-day mortality (p<0.001) and need for admission to the intensive care unit (p<0.001) as compared to the minimal risk cohort. Patients in the lowest risk quartile were most likely to be discharged home (p<0.001). Conclusion Patients who present with a hemoglobin A1c above 8% experienced significantly worse outcomes than those below 8%. The inclusion of a patient's hemoglobin A1c as a cutoff score improves the STTGMAHIP_FX_SCORE tool to predict mortality and risk stratify patient outcomes. While diabetes presents another medical challenge to manage, providers may utilize this new variable to better highlight at-risk diabetic patients.

OBJECTIVES/OBJECTIVE:Examine the patterns and defining characteristics of middle-aged and geriatric patients who sustain orthopedic trauma in New York City. STUDY DESIGN/METHODS:Retrospective cohort study. METHODS:11,677 patients >55 years old treated for traumatic orthopedic injuries were grouped into cohorts based on their age group (cohorts of 55-64, 65-74, 75-84, 85-94, ≥95 years) and year of presentation (2014-2021). Each patient was reviewed for demographics/comorbidities, injury mechanism/type, mortality data. Comparative analyses were conducted. RESULTS:The average age of our cohort was 74 years old. The majority of patients were female (69%) and sustained their injuries via a ground level fall. The most common injuries sustained by patients occurred at the upper extremity (40%), hip (26%), and lower extremity (25%) with 820 (7%) patients sustaining polytrauma. The incidence of hip fractures and pelvic injuries increased with older age. Older patients had a higher rate of mortality through 1-year in addition to a longer length of stay. In contrast, the incidence of injury to the upper and lower extremity decreased with older age. CONCLUSIONS:The rate of mortality out through 1-year following orthopedic trauma increased as patients got older. Significantly more women experienced a traumatic injury during 2014-2021. As age increased, ground level falls were the most common mechanism of injury with injuries more likely to occur in the axial skeleton, notably the hip and pelvis. Younger patients experienced higher rates of upper and lower extremity trauma. Providers should keep these patterns in mind to optimize care for middle-aged and geriatric trauma patients.

INTRODUCTION/UNASSIGNED:Geriatric hip fracture patients are at high risk for perioperative morbidity and mortality from COVID-19. This study analyses the impact of COVID-19 vaccination on geriatric hip fracture outcomes. We hypothesise that having the COVID-19 vaccine improves outcomes for geriatric patients treated for hip fracture. METHODS/UNASSIGNED:-tests or ANOVA as appropriate. Multivariable logistic regression was used to independently assess the impact of vaccination. RESULTS/UNASSIGNED: 0.038). There were no differences in inpatient or 30-day mortality, major complications, length of stay, home discharge, or readmission within 30 or 90 days. Vaccination against COVID-19 was independently protective against the need for ICU level care. Additionally, female gender and vaccination against COVID-19 decreased the rate of minor complications. Older age and higher comorbidity burden increased the rate of minor complications. DISCUSSION/UNASSIGNED:In the hip fracture population, vaccination against COVID-19 was protective against the need for ICU level care and decreased overall minor complications. Larger studies are needed to determine if vaccination decreases mortality in this population. These findings have resource allocation implications including ICU bed availability during pandemics and patient outreach to improve vaccination status.