Faculty Bibliography

OBJECTIVES:To identify factors associated with the development of fracture-related infection (FRI) in patients who have undergone operative fixation of their fracture. DESIGN:Retrospective study. SETTING:Academic medical center. PATIENTS/PARTICIPANTS:Patients with peripheral extremity long-bone fractures and shoulder and pelvic girdle fractures who underwent operative repair. This included patients who had undergone fixation inside and outside of our institution. INTERVENTION:Chi-square, Fisher exact testing, analysis of variance (ANOVA), and t tests were used for analysis of data, as appropriate. Binomial logistic regression analysis was performed to determine risk factors of FRI. MAIN OUTCOME MEASUREMENTS:Demographics, fracture location, injury mechanism, open wound status, and wound complication type. RESULTS:One hundred ninety-three patients comprised the FRI cohort. Of those with confirmed signs of FRI, 36 (18.7%) had wound breakdown to bone or implant, 120 (62.1%) had a sinus track, and 170 patients (88.1%) had the confirmed presence of microorganisms in deep tissue samples obtained during operative intervention. Factors associated with development of an FRI were as follows: higher BMI; being of Black and Hispanic race; higher American Society of Anesthesiologists class; history of tobacco, alcohol, and drug use; and fractures of the lower extremity (foot, tibia, and femur/pelvis). The results of binary logistic regression demonstrated that treatment at an urban level I trauma center and drug use positively predicted the development of FRI. CONCLUSION:Our results demonstrate that higher BMI; being of Black or Hispanic race; higher American Society of Anesthesiologists; history of tobacco, alcohol, and drug use; and fractures of the foot, tibia, and femur/pelvis are all factors associated with development of FRI. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION/BACKGROUND:The presence of diabetes has been associated with increased mortality risk after hip fracture, however, little has been published about the lab values of these diabetic patients and the role high labs play in morbidity and mortality. The purpose of this study is to quantify the severity of diabetes that is associated with worse outcomes in hip fracture patients. METHODS:A consecutive series of 2430 patients >55 years old who sustained a hip fracture between October 2014-November 2021 were reviewed for demographics, hospital quality measures, and outcomes. Each patient with a diagnosis of diabetes mellitus (DM) was reviewed for hemoglobin-A1c (HA1c) and glucose values at admission. Univariable comparisons and multivariable regression analyses were conducted to assess the impact of diabetes and elevated lab values (HA1c) on outcomes such as hospital quality measures, inpatient complications, readmission rates, and mortality rates. RESULTS:565 patients (23%) carried a diagnosis of diabetes mellitus at the time of their injury. Considerable demographic and comorbidity differences between diabetic and non-diabetic cohorts indicated that the diabetic cohort was less healthy. The diabetic cohort had longer hospitalizations, higher rates of minor complications, readmissions within 90-days, and mortality within 30-days/1-year. Stratification by HA1c levels found patients with a HA1c>8% had a significantly higher rate of major complications, and mortality at all time points (inpatient/30-day/1-year). Multivariable regression found HA1c>8% to be independently associated with a higher rate of inpatient/30-day/1-year mortality in comparison to a diagnosis of diabetes alone which was not independently significant. CONCLUSION/CONCLUSIONS:While all patients with DM experienced worse outcomes than those without, those with poorly controlled diabetes (HA1c>8%) at the time of hip fracture injury experienced poorer outcomes compared to those with well-controlled diabetes. Treating physicians must recognize these patients with poorly controlled DM at the time of arrival to adjust care planning and patient expectations accordingly.

INTRODUCTION/BACKGROUND:The purpose of this study was to assess the impact of COVID-19 on the cost of hip fracture care in the geriatric/middle-aged cohort, hypothesizing the cost of care increased during the pandemic, especially in COVID+ patients. METHODS:Between October 2014 and January 2022, 2,526 hip fracture patients older than 55 years were analyzed for demographics, injury details, COVID status on admission, hospital quality measures, and inpatient healthcare costs from the inpatient admission. Comparative analyses were conducted between: (1) All comers and high-risk patients in the prepandemic (October 2014 to January 2020) and pandemic (February 2020 to January 2022) cohorts and (2) COVID+ and COVID- patients during the pandemic. Subanalysis assessed the difference in cost breakdown for patients in the overall cohorts, the high-risk quartiles, and between the prevaccine and postvaccine pandemic cohorts. RESULTS:Although the total costs of admission for all patients, and specifically high-risk patients, were not notably higher during the pandemic, further breakdown showed higher costs for the emergency department, laboratory/pathology, radiology, and allied health services during the pandemic, which was offset by lower procedural costs. High-risk COVID+ patients had higher total costs than high-risk COVID- patients ( P < 0.001), most notably in room-and-board ( P = 0.032) and allied health ( P = 0.023) costs. Once the pandemic started, subgroup analysis demonstrated no change in the total cost in the prevaccine and postvaccine cohort. CONCLUSION/CONCLUSIONS:The overall inpatient cost of hip fracture care did not increase during the pandemic. Although individual subdivisions of cost signified increased resource utilization during the pandemic, this was offset by lower procedural costs. COVID+ patients, however, had notably higher total costs compared with COVID- patients driven primarily by increased room-and-board costs. The overall cost of care for high-risk patients did not decrease after the widespread administration of the COVID-19 vaccine. LEVEL OF EVIDENCE/METHODS:III.

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:.

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.

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.

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.

PURPOSE/OBJECTIVE:The purpose of this study is to compare medium to long term patient reported outcomes to one-year data for patients treated surgically for an aseptic fracture nonunion. METHODS:305 patients surgically treated for a fracture-nonunion were prospectively followed. Data collected included pain scores measured by the Visual Analog Scale (VAS), clinical outcomes assessed by the Short Musculoskeletal Functional Assessment (SMFA), and range of motion. 75% of patients in this study had lower extremity fracture nonunions and 25% had upper extremity fracture nonunions. Femur fracture nonunions were the most common. Data at latest follow-up was compared to one-year follow-up using the independent t-test. RESULTS:Sixty-two patients were available for follow-up data at an average of eight years. There were no differences in patient reported outcomes between one and eight years according to the standardized total SMFA (p = 0.982), functional index SMFA (p = 0.186), bothersome index SMFA (p = 0.396), activity index SMFA (p = 0.788), emotional index SMFA (p = 0.923), or mobility index SMFA (p = 0.649). There was also no difference in reported pain (p = 0.534). Range of motion data was collected for patients who followed up in clinic for an average of eight years after their surgical treatment. 58% of these patients reported a slight increase in range of motion at an average of eight years. CONCLUSION/CONCLUSIONS:Patient functional outcomes, range of motion, and reported pain all normalize after one year following surgical treatment for fracture nonunion and do not change significantly at an average of eight years. Surgeons can feel confident in counseling patients that their results will last and they do not need to follow up beyond one year, barring pain or other complications. LEVEL OF EVIDENCE/METHODS:Level IV.

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.