Faculty Bibliography

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.

BACKGROUND:Many initiatives by medical and public health communities at the national, state, and institutional level have been centered around understanding and analyzing critical determinants of population health with the goal of equitable and nondisparate care. In orthopaedic traumatology, several studies have demonstrated that race and socioeconomic status are associated with differences in care delivery and outcomes of patients with hip fractures. However, studies assessing the effectiveness of methods to address disparities in care delivery, quality metrics, and complications after hip fracture surgery are lacking. QUESTIONS/PURPOSES/OBJECTIVE:(1) Are hospital quality measures (such as delay to surgery, major inpatient complications, intensive care unit admission, and discharge disposition) and outcomes (such as mortality during inpatient stay, within 30 days or within 1 year) similar between White and non-White patients at a single institution in the setting of a standardized hip fracture pathway? (2) What factors correlate with aforementioned hospital quality measures and outcomes under the standardized care pathway? METHODS:In this retrospective, comparative study, we evaluated the records of 1824 patients 55 years of age or older with hip fractures from a low-energy mechanism who were treated at one of four hospitals in our urban academic healthcare system, which includes an orthopaedic tertiary care hospital, from the initiation of a standardized care pathway in October 2014 to March 2020. The standardized 4-day hip fracture pathway is comprised of medicine comanagement of all patients and delineated tasks for doctors, nursing, social work, care managers, and physical and occupational therapy from admission to expected discharge on postoperative day 4. Of the 1824 patients, 98% (1787 of 1824) of patients who had their race recorded in the electronic medical record chart (either by communicating it to a medical provider or by selecting their race from options including White, Black, Hispanic, and Asian in a patient portal of the electronic medical record) were potentially eligible. A total of 14% (249 of 1787) of patients were excluded because they did not have an in-state address. Of the included patients, 5% (70 of 1538) were lost to follow-up at 30 days and 22% (336 of 1538) were lost to follow-up at 1 year. Two groups were established by including all patients selecting White as primary race into the White cohort and all other patients in the non-White cohort. There were 1111 White patients who were 72% (801) female with mean age 82 ± 10 years and 427 non-White patients who were 64% (271) female with mean age 80 ± 11 years. Univariate chi-square and Mann-Whitney U tests of demographics were used to compare White and non-White patients and find factors to control for potentially relevant confounding variables. Multivariable regression analyses were used to control for important baseline between-group differences to (1) determine the correlation of White and non-White race on mortality, inpatient complications, intensive care unit (ICU) admissions, and discharge disposition and (2) assess the correlation of gender, socioeconomic status, insurance payor, and the Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) trauma risk score with these quality measures and outcomes. RESULTS:After controlling for gender, insurer, socioeconomic status and STTGMA trauma risk score, we found that non-White patients had similar or improved care in terms of mortality and rates of delayed surgery, ICU admission, major complications, and discharge location in the setting of the standardized care pathway. Non-White race was not associated with inpatient (odds ratio 1.1 [95% CI 0.40 to 2.73]; p > 0.99), 30-day (OR 1.0 [95% CI 0.48 to 1.83]; p > 0.99) or 1-year mortality (OR 0.9 [95% CI 0.57 to 1.33]; p > 0.99). Non-White race was not associated with delay to surgery beyond 2 days (OR = 1.1 [95% CI 0.79 to 1.38]; p > 0.99). Non-White race was associated with less frequent ICU admissions (OR 0.6 [95% CI 0.42 to 0.85]; p = 0.03) and fewer major complications (OR 0.5 [95% CI 0.35 to 0.83]; p = 0.047). Non-White race was not associated with discharge to skilled nursing facility (OR 1.0 [95% CI 0.78 to 1.30]; p > 0.99), acute rehabilitation facility (OR 1.0 [95% CI 0.66 to 1.41]; p > 0.99), or home (OR 0.9 [95% CI 0.68 to 1.29]; p > 0.99). Controlled factors other than White versus non-White race were associated with mortality, discharge location, ICU admission, and major complication rate. Notably, the STTGMA trauma risk score was correlated with all endpoints. CONCLUSION/CONCLUSIONS:In the context of a hip fracture care pathway that reduces variability from time of presentation through discharge, no differences in mortality, time to surgery, complications, and discharge disposition rates were observed beween White and non-White patients after controlling for baseline differences including trauma risk score. The pathway detailed in this study is one iteration that the authors encourage surgeons to customize and trial at their institutions, with the goal of providing equitable care to patients with hip fractures and reducing healthcare disparities. Future investigations should aim to elucidate the impact of standardized trauma care pathways through the use of the STTGMA trauma risk score as a controlled confounder or randomized trials in comparing standardized to individualized, surgeon-specific care. LEVEL OF EVIDENCE/METHODS:Level III, therapeutic study.

INTRODUCTION/BACKGROUND:The purpose of this study was twofold: 1. To assess how adaptive modeling, accounting for development of inpatient complications, affects the predictive capacity of the risk tool to predict inpatient mortality for a cohort of geriatric hip fracture patients. 2. To compare how risk triaging of secondary outcomes is affected by adaptive modeling. We hypothesize that adaptive modeling will improve the predictive capacity of the model and improve the ability to risk triage secondary outcomes. METHODS:and comparative analyses were conducted. RESULTS:experienced the highest rate of mortality, readmission, ICU admission, with longer lengths of stay and higher hospital costs. DISCUSSION/CONCLUSIONS:can better identify patients at risk for developing complications whose mortality and readmission risk profile increase significantly, allowing their new risk classification to inform higher levels of care. While this may increase length of stay and total costs, it may improve outcomes in both the short and long-term. LEVEL OF EVIDENCE/METHODS:III.

PURPOSE/OBJECTIVE:To determine if the DTS decreases radiation exposure (primary outcome measure), fluoroscopy time (secondary outcome measure), and time to distal screw placement (secondary outcome measure) compared to the freehand "perfect circles" method when used for locking of cephalomedullary nails in the treatment of femur fractures METHODS: Fifty-eight patients with hip or femoral shaft fractures that were treated with a long cephalomedullary nail were enrolled in this study. Cohorts were determined based on the method of distal interlocking screw placement into either the "Perfect Circles" or "Distal Targeting" cohort. Time from cephalad screw placement to placement of final distal interlocking screw (seconds), radiation exposure (mGy), and fluoroscopy time (seconds) were compared between groups. Hospital quality measures were compared between cohorts. RESULTS:Use of the DTS resulted in 77% (4.3x) lower radiation exposure (p < 0.001), 64% (2.7x) lower fluoroscopy time (p < 0.001), and 60% (1.7x) lower intraoperative time from end of cephalad screw placement to end of distal interlocking screw placement (p < 0.001) compared to the freehand "perfect circles" method. There was no difference in 30-day or 90-day complication rates between cohorts. CONCLUSION/CONCLUSIONS:The Stryker Gamma3® Distal Targeting System is a safe, effective and efficient alternative to the freehand "perfect circles" method.

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.

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/UNASSIGNED:The purpose of this study was to assess the safety and efficacy of outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol. DESIGN/UNASSIGNED:Retrospective case series. SETTING/UNASSIGNED:Tertiary referral hospital and hospital outpatient department. PATIENTS/UNASSIGNED:All consecutive nonunion surgeries performed by 1 surgeon between 2014 and 2019 were identified. Outpatient and short-stay surgeries for patients with nonunion of the tibia and femur were eligible (n = 50). INTERVENTION/UNASSIGNED:Outpatient and short-stay surgical nonunion treatment by incorporating minimally invasive surgical techniques, multimodal pain control, and a modernized postoperative protocol. MAIN OUTCOME MEASUREMENTS/UNASSIGNED:Length of stay, postoperative emergency department visits, all complications, reoperations, and time to union. RESULTS/UNASSIGNED:Fifty patients were eligible, with 32 male patients (64%) and an average age of 46.5 years. The patient cohort consisted of 28 femur (56%) and 22 tibia (44%) nonunions. The average length of stay was 0.36 days. Seven patients (14%) required reoperation, 6 patients because of deep infection and 1 patient because of painful implant removal. Four patients (8%) presented to the emergency department within 1 week of surgery. One patient requiring amputation and patients lost to follow-up were excluded from the union rate calculation. For the remaining patients (46/50), 100% (46/46) united their nonunion. The average time to radiographic union was 7.82 months. CONCLUSIONS/UNASSIGNED:An outpatient pathway is safe and effective for medically appropriate patients undergoing nonunion surgery. Outpatient nonunion surgery is a reasonable alternative that achieves similar outcomes compared with inpatient nonunion studies in the published literature. LEVEL OF EVIDENCE/UNASSIGNED:IV.

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.