Faculty Bibliography

BACKGROUND:The association of tibial shaft fractures (TSFs) with posterior malleolar fractures is well described. The purpose of this study was to identify specific radiographic parameters that are predictive of any pattern of associated distal intra-articular fractures in TSFs. METHODS:All TSFs presenting over a 6-year period were identified. A radiographic review of plain radiographs and CT scans included: identification of any associated ankle fracture, classification using the OTA System, measurements of the TSF obliquity angle (FOA), relative distance from distal extent of the TSF to plafond (DFP%), and presence and level of any associated fibular fractures. Patients with and without associated ankle fractures were statistically compared. Multivariate logistic regression determined independent predictors of associated ankle fractures. RESULTS:405 TSFs in 397 patients were identified, with 145 TSFs with associated distal intra-articular fractures. There were 94 (23.2%) posterior malleolar fractures, 19 (13.1%) medial malleolar fractures, 42 (29.0%) lateral malleolar fractures involving the syndesmosis and 14 (9.7%) Chaput fragments. Multivariate regression demonstrated AO/OTA classification type 42-A1, 42-B1 or 42-C1 (OR 2.3 [95% CI 1.3-4.0]; p = 0.003), FOA greater than 45° (OR 2.7 [95% CI 1.5-4.8]; p = 0.001) and DFP% less than 33% (OR 4.1 [95% CI 2.0-9.0]; p = 0.005) were independent correlates of associated ankle fractures regardless of mechanism of injury. CONCLUSIONS:Different patterns of intra-articular fractures beyond posterior malleolar fractures can occur in TSFs. Fracture angles greater than 45° and extent into the distal 33% of the tibial shaft are independent predictors of distal intra-articular fractures in TSFs regardless of mechanism of injury. LEVEL OF EVIDENCE/METHODS:Diagnostic Level III.

OBJECTIVES/OBJECTIVE:To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip Block (LOH Block). DESIGN/METHODS:Retrospective. SETTING/METHODS:Level-I Trauma CenterPatients/Participants: 40 patients who presented between 11/2021 and 02/2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used. INTERVENTION/METHODS:Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve (FN) and accessory obturator nerve (AON). MAIN OUTCOME MEASUREMENTS/METHODS:Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates. RESULTS:A total of 120 patients (40 each: general, spinal, LOH block) were compared. The cohorts were similar in age, race, BMI, gender, CCI, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block group (p<0.05). Total OR time and anesthesia time were shortest for the LOH block cohort (p<0.05). Patients in the LOH block cohort also had lower post-operative pain scores (p<0.05). Length of hospital stay was shortest for patients in the LOH block cohort (p<0.05), and at time of discharge, patients in the LOH block cohort ambulated the furthest (p<0.05). No differences were found in regards to anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates. CONCLUSIONS:The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly requiring surgery. In addition, this block may decrease post-operative pain and length of hospital stay, and also allow for greater ambulation in the early post-operative period for hip fracture patients. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:To measure the effect of a novel augmented reality software designed to aid in lag screw placement into the femoral head for cephalomedullary nails. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Single level I trauma center. PATIENTS/METHODS:Between November 2017 and December 2020, 114 consecutive patients with a hip fracture that underwent repair with a cephalomedullary nail by one of two orthopedic trauma surgeons were reviewed. Fracture classifications included OTA/AO 31-A1, 31-A2, 31-A3, and 31-B3. INTERVENTION/METHODS:The first 57 patients underwent fracture repair without the software (control) and the subsequent 57 patients underwent repair with use of the augmented reality software (AR). MAIN OUTCOME MEASUREMENTS/METHODS:Tip apex distance (TAD) and femoral head zone (AP: superior, center, inferior; Lateral: anterior, center, posterior) were measured using standardized techniques. RESULTS:The mean TAD was lower for the AR vs. control cohort (10.7±2.9 mm vs 15.4±3.8 mm; p<0.001). TAD <10mm for AR vs. control: 25 (43.9%) vs. 3 (5.3%), p<0.001. TAD <15mm for AR vs. control: 50 (87.7%) vs. 44 (77.2%), p<0.001. On the AP view center position was achieved in 50.9% vs. 7.0% of cases for the AR vs. control cohort, respectively. On the lateral view, center position was achieved in 68.4% vs. 12.3% of cases for the AR vs. control cohort, respectively. CONCLUSION/CONCLUSIONS:This study suggests that use of the novel augmented reality software for assistance in lag screw positioning within the femoral head improves overall TAD and ability to achieve the center-center position.

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:The purpose of this study was to compare outcomes following surgical treatment of tibial plateau fractures in an elderly (≥ 65y) and non-elderly (< 65) population. METHODS:Patients with tibial plateau fractures were prospectively followed. Patients were included if they were operatively treated, had an Injury Severity Score of < 16, and had follow-up through 12 months. Clinical, radiographic, and functional outcomes were evaluated at the 3, 6, and 12-month follow-up points. RESULTS:Mean time to radiographic fracture union was by 4.68 and 5.26 months in young and elderly patients, respectively (p = 0.25). There was no difference in self-reported baseline SMFA (p = 0.617). SMFA scores were better in younger patients at 3 months (p = 0.031), however this did not hold when multivariate modeling controlled for other factors. There was no difference at 6 and 12 months (p = 0.475, 0.392). There was no difference in range of knee motion at 3 months. At 6 and 12 months, young patients had statistically but not clinically better range of knee motion (p = 0.045, 0.007). There were no differences in overall reoperation rates, conversion arthroplasty, post-traumatic osteoarthritis or wound complications. CONCLUSIONS:Age greater than 65 does not appear to portend poorer outcomes after surgical repair of a tibial plateau fracture. The complication profiles are similar. Elderly and younger patients had similar function at 12 months compared to their baseline. These data suggest that age should not be a disqualifying factor when considering whether a patient with a tibial plateau fracture should be treated operatively.

BACKGROUND:The purpose of this study is to determine the effects of energy mechanism on outcomes following repair of proximal humerus fractures (PHF) in the middle aged and geriatric population. METHODS:Two hundred sixty-nine patients who presented to our academic medical center between 2006 and 2020, and underwent operative treatment of a proximal humerus fracture were prospectively enrolled in an IRB-approved database. Patients above 55 were divided into high energy (motor vehicle accident, pedestrian struck, or fall > 2 stairs) or low energy mechanisms (fall from standing or < 2 stairs). Of 97 patients with complete documentation and follow-up, 72 were included in the low velocity (LV) group and 25 were included in the high velocity (HV) group. Demographic information, primary injury details, healing and time to union, range of motion (ROM), complications, and need for reoperation were assessed at initial presentation and subsequent follow-up appointments. RESULTS:Mean age, BMI, and gender were significantly different between the LV and HV cohorts (p = 0.01, 0.04, 0.01). OTA/AO fracture patterns were similar between the groups. (p = 0.14). Bony healing and complications occurred with similar frequency between groups (p = 1.00, 0.062). The most common complications in the LV and HV groups included avascular necrosis (9.7%, 16.0%), and screw penetration (4.2%, 12.0%), while the HV group also had rotator cuff issues including weakness and tendonitis (12.0%). There was no significant difference in need for reoperation between cohorts (p = 0.45). Time to healing, shoulder ROM, and DASH scores did not differ between each group. CONCLUSIONS:Energy and mechanism demonstrates similar outcomes in operatively treated proximal humerus fractures. These factors should not play a role in decisions for surgery in these patients and can help guide patient expectations.

BACKGROUND:The purpose of this study was to identify specific radiographic parameters that are predictive of associated PM fractures in TSFs. METHODS:All TSFs presenting over a 6-year period were identified. A review of plain radiographs and CT scans included: identification of an isolated PM fracture, AO/OTA classification, measurements of the fracture obliquity angle (FOA), absolute and relative distance from distal extent of fracture to plafond (DFP and DFP%), and presence and level of associated fibular fractures. Patients with and without PM fractures were compared. Multivariate logistic regression determined independent correlates of PM fractures and cutoff values for FOA and DFP%. RESULTS:A total of 405 TSFs in 397 patients were identified, and 94 TSFs (23.2%) had an associated PM fracture. The majority (85.1%) of TSFs with PM fractures were AO/OTA type 42-A1, 42-B1 or 42-C1 (p < 0.001). The mean FOA was 60.9 ± 12.1° in the PM group versus 40.8 ± 18.9° in the non-PM group (p < 0.001). The mean DFP was 5.9 ± 2.7 cm in the PM group versus 11.9 ± 7.9 cm in the non-PM group (p < 0.001). Multivariate regression demonstrated that AO/OTA classification type 42-A1, 42-B1 or 42-C1 (OR 4.7 [95% CI 2.4-9.8]; p < 0.001), FOA greater than 45° (OR 4.4 [95% CI 1.9-10.9]; p = 0.001) and fracture extension to the distal third of the tibia (DFP% < 33%; OR 18.3 [95% CI 3.8-330.4]; p = 0.005) were independent correlates of PMs fractures regardless of mechanism of injury or fibula fracture presence or location (AUROC 0.83 [95% CI 0.80-0.87]). Separate multivariate regression showed for every 1° increase in FOA, PM fracture odds increase 6% per degree and for every 1 cm increase in DFP odds of PM fracture decreased by 15%. CONCLUSIONS:Spiral fractures (simple, wedge or complex), fracture angles greater than 45° and extension into the distal 1/3 of the tibial shaft are independent predictors of PM fractures in TSFs regardless of mechanism of injury.

PURPOSE/OBJECTIVE:To analyze clinical, radiographic and patient-reported outcomes of distal metaphyseal femoral nonunions treated with fixed-angle plates and screws. METHODS:All patients presenting with a distal metaphyseal femoral fracture nonunion repaired with fixed-angle plating from one urban level 1 trauma center and an orthopedic specialty hospital were identified. Baseline demographic, injury information, and outcomes (healing rates, Short Musculoskeletal Function Assessment, range of motion, and post-operative pain levels) at 12 months following nonunion repair were collected. Outcomes were evaluated between patients fixed with a blade plate and with a locking plate. RESULTS:Of these 31 patients, 27 (87.1%) healed after their index nonunion surgery, 2 (6.5%) healed after one reoperation, 1 (3.2%) healed after 2 reoperations, and 1 (3.2%) had a persistent nonunion but did not want further treatment. At one-year follow-up, the group demonstrated a significant improvement in functional recovery with a mean difference of 14.5 points (p = 0.007) when compared to status before fixed-angle fixation of the nonunion. There was also a significant change in patient-reported pain levels using the VAS scale with a mean difference of 2.0 points (p = 0.009). At one-year follow-up, 11 (39.3%) had full knee range of motion (0-130), 11 (39.3%) had flexion greater than 90 and less than 120°, and 6 (21.4%) had range of motion less than 90°. CONCLUSION/CONCLUSIONS:Patients who undergo fixed angle plating and autogenous bone grafting for distal femoral metapyseal nonunions demonstrate improved functional outcomes and VAS pain score at one year follow up.

PURPOSE/OBJECTIVE:To determine if the type of approach used for treatment of lateral split-depression tibial plateau fractures affects clinical outcome and complications rate. METHODS:This is a retrospective review of 169 patients who presented between 01/2005 and 12/2020 to a Level-I trauma center for operative management of an isolated lateral Schatzker II tibial plateau fractures (AO/OTA Type 41B3.1) treated through a single anterolateral approach: a 90-degree "L" (L), longitudinal vertical (V), or "lazy S" (S). Postoperative radiographic, clinical, and functional outcomes were assessed at 3, 6, 12 months, and beyond. RESULTS:Average time to radiographic healing was longer in the S incision cohort (p < 0.05). Furthermore, patients within the S incision cohort developed more postoperative wound complications at follow-up when compared to those within the L and V incision cohorts (p < 0.05). Additionally, reoperation rates were greater in the S incision cohort (p < 0.05). Lastly, on physical examination of the knee, patients within the S incision cohort had significantly poorer knee range of motion (p < 0.05). CONCLUSIONS:Our study demonstrates that skin incision type in the anterolateral approach to the proximal tibia has an association with outcomes following operative repair of tibial plateau fractures. The information from this study can be used to inform surgeons about the potential complications and long-term outcomes that patients may experience when undergoing operative repair of a tibial plateau fracture through a specific incision type. LEVEL OF EVIDENCE/METHODS:III.

To determine if radiographic evidence of posttraumatic osteoarthritis (PTOA) following tibial plateau fracture correlates with poorer clinical and functional outcomes, patients with tibial plateau fractures were followed at 3, 6, and 12 months. All patients had baseline radiographs and computed tomography scan. Radiographs obtained at each follow-up were reviewed for healing, articular incongruence, hardware positional changes, and the development of postinjury arthritic change. Cohorts were determined based on the presence (PTOA) or absence (NPTOA) of radiographic evidence of PTOA. Demographics, fracture classification, complications, additional procedures, and functional status were compared between cohorts. Sixty patients had radiographic evidence of PTOA on follow-up radiographs at a mean final follow-up of 24.2 months. The NPTOA cohort was composed of 210 patients who were matched to the PTOA cohort based on age and Charlson comorbidity index. Mean time to fracture union for the overall cohort was 4.86 months. Cohorts did not differ in Schatzker classification, time to healing, injury mechanism, or baseline Short Musculoskeletal Function Assessment (SMFA). Patients with PTOA had a greater degree of initial depression and postoperative step-off, higher incidence of initial external fixator usage, higher rates of reoperation for any reason, and higher rates of wound complications. Associated soft tissue injury and meniscal repair did not coincide with the development of PTOA. Range of motion and SMFA scores were significantly worse at all time points in patients with PTOA. Although fracture patterns are similar, patients who required an initial external fixator, had a greater degree of initial depression or residual articular incongruity, underwent more procedures, and developed an infection were found to have increased incidence of PTOA. Radiographic evidence of osteoarthritis correlated with worse functional status in patients. The goal of surgery should be restoration of articular congruity and stability to mitigate the risk of PTOA, although this alone may not prevent degenerative changes. Patients with early loss of range of motion should be aggressively treated as this may precede the development of PTOA.