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.

INTRODUCTION/BACKGROUND:Increasing age and hip fractures are considered risk factors for post-operative complications in total hip arthroplasty (THA). Consequently, older adults undergoing THA due to hip fracture may have different outcomes and require additional healthcare resources than younger patients. This study aimed to identify the influence of age on discharge disposition and 90-day outcomes of THA performed for hip fractures in patients ≥ 80 years to those aged < 80. MATERIALS AND METHODS/METHODS:A retrospective review of 344 patients who underwent primary THA for hip fracture from 2011 to 2021 was conducted. Patients ≥ 80 years old were propensity-matched to a control group < 80 years old. Patient demographics, length of stay (LOS), discharge disposition, and 90-day post-operative outcomes were collected and assessed using Chi-square and independent sample t tests. RESULTS:A total of 110 patients remained for matched comparison after propensity matching, and the average age in the younger cohort (YC, n = 55) was 67.69 ± 10.48, while the average age in the older cohort (OC, n = 55) was 85.12 ± 4.77 (p ≤ 0.001). Discharge disposition differed between the cohorts (p = 0.005), with the YC being more likely to be discharged home (52.7% vs. 27.3%) or to an acute rehabilitation center (23.6% vs. 16.4%) and less likely to be discharged to a skilled nursing facility (21.8% vs. 54.5%). 90-day revision (3.6% vs. 1.8%; p = 0.558), 90-day readmission (10.9% vs. 14.5%; p = 0.567), 90-day complications (p = 0.626), and 90-day mortality rates (1.8% vs 1.8%; p = 1.000) did not differ significantly between cohorts. CONCLUSION/CONCLUSIONS:While older patients were more likely to require a higher level of post-hospital care, outcomes and perioperative complication rates were not significantly different compared to a younger patient cohort. Payors need to consider patients' age in future payment models, as discharge disposition comprises a large percentage of post-discharge expenses. LEVEL OF EVIDENCE/METHODS:Level III, Retrospective Cohort Study.

BACKGROUND:Value is defined as outcome/cost. The purpose of this study was to analyze differences in the lengths of care, outcomes, and costs between skilled nursing facilities (SNF) and home with health services (HHS) for patients treated with arthroplasty for femoral neck fracture (FNF). METHODS:Between October 2018 and September 2020, 192 patients eligible for the Comprehensive Care for Joint Replacement (CJR) bundle program treated for a displaced FNF with total hip arthroplasty (THA) or hemiarthroplasty (HA) and discharged to SNF or HHS were analyzed for demographics, comorbidities, post-operative outcomes, costs of care, and discharge rehabilitation details. Variables were compared using chi-square or T-tests as appropriate. There were 60 (31%) patients discharged to HHS (37% THA, 63% HA) and 132 (69%) patients discharged to SNF (14% THA, 86% HA). Patients discharged to SNF were older (p<0.01), had lower Risk Assessment and Prediction Tool (RAPT) scores (p<0.01), had higher comorbidity scores (p=0.011), and had longer post-hospitalization care (p<0.01). RESULTS:There were no differences in rates of inpatient minor complications (p=0.520), inpatient major complications (p=0.119), Intensive Care Unit (ICU) admissions (p=0.193) or readmissions within 30 (p=0.690) and 90 days (p=0.176). Costs of care at a SNF was higher than HHS (p<0.01). In multivariate regressions, a lower RAPT score was associated with discharge to SNF (OR 0.69, 95% CI 0.58-0.83, p<0.001). CONCLUSION/CONCLUSIONS:Among CJR bundle patients treated for a displaced FNF with arthroplasty, discharge with HHS may be a more cost-effective option than discharge to a SNF that does not increase risk of readmission in medically appropriate 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.

OBJECTIVES/OBJECTIVE:To compare the efficacy and outcomes of dynamic tension band wiring (TBW) and plate and screw (PS) fixation of comminuted (Mayo Type IIB) olecranon fractures. DESIGN/METHODS:Retrospective cohort. SETTING/METHODS:Academic medical center. PATIENTS/PARTICIPANTS/METHODS:Forty-one patients with Mayo type IIB (OTA/AO 2U1C) olecranon fractures were involved in the study. INTERVENTION/METHODS:Patients with tensile Mayo type IIB olecranon fractures between August 2012 and November 2020 treated by a single surgeon with either TBW or PS fixation were reviewed for demographics, radiographic/surgical details, and clinical/functional outcomes. Descriptive fracture data included proximal olecranon fragment size and the presence of joint impaction at surgery. MAIN OUTCOME MEASUREMENTS/METHODS:The main outcome measurements were Mayo Elbow Performance Score, elbow range of motion, patient-reported pain, and complications. RESULTS:The mean follow-up was 38 months. Fractures healed for all patients in both groups. No differences in clinical outcomes, functional outcomes, elbow range of motion, or complications were seen between fixation groups. There was no difference in proximal fragment size between the 2 groups. Fractures with articular impaction requiring elevation and grafting demonstrated no difference in clinical or functional outcomes when compared with those that did not have any impaction. However, patients with impacted articular fractures treated with TBW had a higher rate of implant removal (25% vs. 0%, P = 0.05) when compared with those treated with PS. CONCLUSIONS:Comminuted Mayo IIB olecranon fractures are amenable to TBW or plate construct, with similar clinical and functional outcomes. The presence of articular impaction is associated with a greater need for implant removal. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:The main two forms of treatment for distal femur fractures are locked lateral plating and retrograde nailing. The goal of this trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN/METHODS:Prospective, multicenter randomized controlled trial. SETTING/METHODS:20 academic trauma centersPatients/Participants: 160 patients with distal femur fractures were enrolled. 126 patients were followed 12 months. Patients were randomized to plating in 62 cases and to intramedullary nailing in 64 cases. INTERVENTION/METHODS:Lateral locked plating or retrograde intramedullary nailing. MAIN OUTCOME MEASUREMENTS/METHODS:Functional scoring including SMFA, Bother Index, EQ Health and EQ Index. Secondary measures included alignment, operative time, range of motion, union rate, walking ability, ability to manage stairs and number and type of adverse events. RESULTS:Functional testing showed no difference between the groups. Both groups were still significantly affected by their fracture 12 months post injury. There was more coronal plane valgus in the plating group, which approached statistical significance. Range of motion, walking ability & ability to manage stairs were similar between the groups. Rate and type of adverse events were not statistically different between the groups. CONCLUSIONS:Both lateral locked plating and retrograde intramedullary nailing are reasonable surgical options for these fractures. Patients continue to improve over the course of the year following injury, but remain impaired one year post operatively. LEVEL OF EVIDENCE/METHODS:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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/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.

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.