Faculty Bibliography

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.

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/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.

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: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.

INTRODUCTION/BACKGROUND:The purpose of this study is to identify optimal threshold hemoglobin (Hgb) and hematocrit (Hct) laboratory values to transfuse hip fracture patients. METHODS:A consecutive series of hip fracture patients were reviewed for demographic, clinical, and cost data. Patients receiving an allogeneic transfusion of packed red blood cells (pRBCs) were grouped based on last Hct or Hgb (H&H) value before first transfusion. Multivariate logistic regressions of H&H quantile were performed to predict "good outcomes," a composite binary variable defined as admissions satisfying (1) no major complications, (2) length of stay below top tertile, (3) cost below median, (4) no mortality within 30 days, and (5) no readmission within 30 days. Odds ratios (OR) for "good outcomes" were calculated for each H&H quantile. RESULTS:One thousand four hundred ninety-six hip fracture patients were identified, of which 598 (40.0%) were transfused with pRBCs. Patients first transfused at Hgb values from 7.55 to 7.85 g/dL (P = 0.043, OR = 2.70) or Hct values from 22.7 to 23.8% (P = 0.048, OR = 2.63) were most likely to achieve "good outcomes." DISCUSSION/CONCLUSIONS:The decision to transfuse patients should be motivated by Hgb and Hct laboratory test results, given that transfusion timing relative to surgery has been shown to not affect outcomes among patients matched by trauma risk score. Surgeons should aim to transfuse hip fracture patients at Hgb levels between 7.55 g/dL and 7.85 g/dL or Hct levels between 22.7% and 23.8%. These transfusion thresholds have the potential to lower healthcare costs without compromising quality, ultimately resulting in less costly, efficacious care for the patient. LEVEL OF EVIDENCE/METHODS:Level III.

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 extraarticular proximal tibial fractures are intramedullary nailing and locked lateral plating. The goal of this multicenter, randomized controlled trial was to determine whether there are significant differences in outcomes between these forms of treatment. DESIGN/METHODS:Multicenter, randomized controlled trial. SETTING/METHODS:Sixteen academic trauma centersPatients/Participants: 108 patients were enrolled. 99 patients were followed for 12 months. 52 patients were randomized to intramedullary nailing (IMN) and 47 patients were randomized to locked lateral plating (LLP). INTERVENTION/METHODS:Intramedullary nailing or lateral locked plating. MAIN OUTCOME MEASUREMENTS/METHODS:Functional scoring including SMFA, Bother Index, EQ-5DIndex and EQ-5DVAS. Secondary measures included alignment, operative time, range of motion, union rate, pain, walking ability, ability to manage stairs, need for ambulatory aid and number and complications. RESULTS:Functional testing demonstrated no difference between the groups, but both groups were still significantly affected 12 months post injury. Similarly, there was no difference in terms of time of surgery, alignment, nonunion, pain, walking ability, ability to manage stairs, need for ambulatory support or complications. CONCLUSIONS:Both intramedullary nailing and locked lateral plating provide for similar outcomes following these fractures. Patients continue to improve over the course of the year following injury but remain impaired even one year later.

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.