Faculty Bibliography

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

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.

OBJECTIVE:To determine if a peri-operative pain cocktail injection improves post-operative pain, ambulation distance and long-term outcomes in hip fracture patients. DESIGN/METHODS:Prospective, single-blinded, randomized controlled trial. SETTING/METHODS:Academic Medical Center. PATIENTS/PARTICIPANTS/METHODS:Patients with OTA/AO 31A1-3 and 31B1-3 fractures undergoing operative fixation, excluding arthroplasty. INTERVENTION/METHODS:Multimodal local injection of bupivacaine (Marcaine), morphine sulfate (Duramorph), ketorolac (Toradol) given at the fracture site at the time of hip fracture surgery (Hip Fracture Injection, HiFI). MAIN OUTCOME MEASUREMENTS/METHODS:Patient-reported pain, American Pain Society Patient Outcome Questionnaire (APS-POQ), narcotic usage, length of stay, post-operative ambulation, Short Musculoskeletal Function Assessment (SMFA). RESULTS:75 patients were in the treatment group and 109 in the control group. Patients in the HiFI group had a significant reduction in pain and narcotic usage compared to the control group on post-operative day (POD) 0 (p<0.01). Based on the APS-POQ, patients in the control group had a significantly harder time falling asleep, staying asleep, and experienced increased drowsiness on POD 1 (p<0.01). Patient ambulation distance was greater on POD 2 (p<0.01) and POD 3 (p<0.05) in the HiFI group. The control group experienced more major complications (p<0.05). At six-weeks post-op, patients in the treatment group reported significantly less pain, better ambulatory function, less insomnia, less depression, and better satisfaction than the control group as measured by the APS-POQ. The SMFA bothersome index was also significantly lower for patients in the HiFI group, p<0.05. CONCLUSIONS:Intraoperative HiFI not only improved early pain management and increased ambulation in patients undergoing hip fracture surgery while in the hospital, it was also associated with early improved health related quality of life following discharge. LEVEL OF EVIDENCE/METHODS:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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.

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.

BACKGROUND/UNASSIGNED:The posterolateral approach to the ankle allows for reduction and fixation of the posterior and lateral malleoli through the same surgical incision. This can be accomplished via 1 or 2 surgical "windows." The purpose of this study is to compare outcomes including wound complications following direct fixation of unstable rotational ankle fracture through the posterolateral approach using either 1 or 2 surgical windows. METHODS/UNASSIGNED:One hundred sixty-four patients with bi- or trimalleolar ankle fractures treated using the single-window posterolateral approach (between the peroneal tendons and the flexor hallucis longus [FHL]) or the 2-window technique (between the peroneal tendons and the FHL for posterior malleolus fixation; lateral to the peroneal tendons for fibula fixation) were reviewed for demographics, radiographic details, and clinical outcomes. We were able to review these 164 at the 3-month follow-up and a subset of 104 at a minimum of 12-month follow-up. RESULTS/UNASSIGNED: = .021). We did not find a significant difference in nerve complications for these 2 cohorts. CONCLUSION/UNASSIGNED:In our study, we found the single-window posterolateral approach to be associated with fewer wound complications and better postoperative range of ankle motion when compared to the 2-window approach. LEVEL OF EVIDENCE/UNASSIGNED:Level III, retrospective cohort study.

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:The purpose of this study was to compare clinical, implant related and patient reported outcomes of shoulders converted to reverse total shoulder arthroplasty (rTSA) following a previous ORIF to when rTSA is used as a primary treatment modality for an acute proximal humerus fracture (PHF) in patients ≥65 years of age. METHODS:A retrospective analysis was performed on a prospectively collected cohort of patients who underwent primary-rTSA for PHF versus a cohort who underwent conversion arthroplasty with rTSA following fracture repair between 2009-2020. Outcomes were assessed preoperatively and at the latest follow-up. Demographics and outcomes between cohorts were analyzed using conventional statistics as well as stratification by MCID and SCB thresholds where applicable. RESULTS:406 patients met criteria, 322 primary-rTSA for PHF versus 84 conversion-rTSA after failed PHF ORIF. The conversion-rTSA cohort was on average seven years younger (65±10 vs 72±9, p<0.001). Follow-up was similar between cohorts, average 47.1 months (range:24-138 months). The percentage of Neer 3-(41.9%vs45.2%) and 4-part (49.1%vs46.4%) PHFs were similar (p>0.99). The primary-rTSA cohort achieved higher forward elevation (FE), external rotation, PROMs including simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES) Score, University of California Los Angeles (UCLA) score, Constant Score, Shoulder Arthroplasty Smart (SAS) Score and Shoulder Pain and Disability Index (SPADI) score at a minimum of 24-months postop (p<0.05 for all). Patient satisfaction was higher in the primary-rTSA group compared to the conversion-rTSA cohort (p=0.002). Patient reported outcome measures uniformly favored the primary-rTSA cohort, rising to the level of statistical significance for FE, ASES and SPADI (p<0.05) relative to SCB. The AE rate and revision rate in the conversion-rTSA cohort was higher than the primary-rTSA cohort [(26.2% vs. 2.5%, p<0.001) and (8.3% vs. 1.6%, p=0.001)]. At 10-years postop revision free implant survival rates are significantly lower in the conversion cohort compared to the primary cohort, 66% vs 94% (p=0.012). Lastly, the hazard ratio of revision was 3.69 in the conversion cohort compared to only 1.0 in the primary-rTSA cohort. CONCLUSION/CONCLUSIONS:The current study demonstrates that elderly patients who undergo rTSA as a conversion procedure following previous osteosynthesis do not fare as well as those treated with rTSA for an acute displaced PHF. Conversion patients report lower patient satisfaction, have significantly restricted range of shoulder motion, higher risk of complications, higher risk of revision, poorer patient reported outcomes, and shorter implant survival at 10 years compared to those undergoing acute rTSA.