Faculty Bibliography

OBJECTIVE:To define a CT-derived zone-of-injury metric, incorporating normalized soft-tissue air extent and BMI and secondly to determine if this metric was associated with adverse outcomes following an open OTA 42A-C tibia fractures. METHODS:Design: Retrospective cohort study. SETTING/METHODS:Level I trauma center. PATIENT SELECTION CRITERIA/UNASSIGNED:A retrospective review of patients in a tibia fracture registry (2012-2024) meeting inclusion criteria (age ≥18 years old, open OTA 42A-C fractures, preoperative full length tibia CT imaging, ≥6-month follow-up) was performed.Outcome Measures and Comparisons: The CT-based ZOI was measured as the longitudinal extent of soft-tissue air (mm) normalized to tibial length (mm) (ZOIsoft/Tibial Length). The primary outcome was composite complications including fracture related infection, amputation, or nonunion. A logistic regression model using ZOIsoft/Tibial Length and BMI generated predicted probabilities for composite complications. Model discrimination was assessed via area under receiver operating characteristic (AUROC) analysis and compared to Gustilo-Anderson classification using the DeLong test. An optimal probability threshold was derived statistically (Youden Index) for dichotomizing patients into high- and low-risk cohorts. RESULTS:Fifty-five patients (58 fractures) met inclusion criteria (mean age 40.0 ± 15.1 years; 81.0% male; mean follow-up 16.9 ± 9.5 months). Soft-tissue ZOI and BMI were the significant predictors of composite complications (p = 0.006, 0.061). The CT-based ZOI model (log(p/1-p) = 0.601 + (3.343 × soft-tissue ZOI/Tibial Length) + (-0.106 × BMI) demonstrated superior discrimination (AUROC = 0.752) compared to Gustilo-Anderson (AUROC = 0.581, p = 0.042). Patients above the derived threshold (0.403) had significantly worse outcomes: composite complication rate 64.0% vs. 18.2% (p < 0.001) and nonunion (52.0% vs. 9.1%, p < 0.001). Amputation (20.0 vs 3.0%, p = 0.075) and fracture-related infection (32.0% vs. 15.2%, p = 0.203) were not significant. CONCLUSIONS:A novel CT-based ZOI metric integrating soft-tissue injury extent as measured by soft-tissue air and BMI independently predicted overall complications risk. This newly described CT-based ZOIsoft metric provided superior prognostic accuracy compared to Gustilo-Anderson classification and may enhance early risk stratification in open tibia fractures. LEVEL OF EVIDENCE/METHODS:Prognostic Level III.

BACKGROUND/UNASSIGNED:While extremes of body mass index (BMI) are known to influence surgical risks, their distinct impacts on short- and long-term outcomes following hip fracture remain poorly defined. This study compared outcomes in severely underweight, normal weight, and obese elderly patients. METHODS/UNASSIGNED:A retrospective cohort study was conducted using a prospectively collected hip fracture database (2014-2024) at a single academic medical center. Patients with BMI ≤16.5 (severely underweight) or ≥35 (class 2+ obesity) were compared to a randomly selected cohort of normal-weight controls (BMI 18.5-25.0). Outcomes included complications, discharge disposition, mortality, and functional recovery. RESULTS/UNASSIGNED:A total of 282 patients were included. Obese patients had significantly higher odds of intensive care unit (ICU) admission compared to normal weight patients (OR 5.75 [2.00-16.39], p = .001) and were less likely to be discharged home (OR 0.31 [0.14-0.66], p = .003). In contrast, underweight status was significantly associated with increased six-month mortality compared to normal weight (OR 4.95 [1.34-18.18], p = .016). No significant differences were found in healing or functionality across groups. CONCLUSION/UNASSIGNED:Obese patients were more likely to require ICU admission but did not face increased long-term mortality. Severely underweight patients demonstrated the opposite pattern, with minimal short-term morbidity but significantly higher risk of death at six months. These findings suggest that short- and long-term risks after hip fracture diverge at the extremes of BMI and highlight the need for tailored perioperative strategies based on metabolic status.

OBJECTIVES/OBJECTIVE:Altered patellar height following patella fracture repair may affect clinical outcomes, but the significance remains unclear. The purpose of this study was to evaluate the impact of immediate and final follow-up Insall-Salvati Ratio (ISR) on postoperative outcomes following patella fracture fixation. METHODS:A retrospective review at a multi-site academic urban hospital system was conducted. All patients underwent patella open reduction and internal fixation (ORIF) for displaced patella fracture (OTA 34) from 2012 to 2024. Final intraoperative and final follow-up radiographs were assessed by Insall-Salvati ratios (ISR). Patients were categorized into groups based on intraoperative ISR measurements: normal ISR, defined as .8-1.2 and abnormal ISR, outside of the 0.8-1.2 range. Follow-up radiographs were also assessed for abnormal ISR. Knee range of motion (ROM), post-operative complications, and fracture union were collected. Statistical analysis included Pearson Chi-squared tests, independent t-tests, and ANOVA tests. RESULTS:Of 191 patients, 163 (85.3%) had normal ISR and 28 (14.7%) had abnormal ISR postoperatively. Abnormal ISR was associated with higher complication rates (14.3% vs. 4.3%, p = 0.037), hardware failure (10.7% vs. 1.2%, p = 0.004), reduced knee range-of-motion at three months (105.13 ± 21.38 vs. 117.22 ± 13.75, p < .001) and six months (119.25 ± 14.26 vs. 127.37 ± 13.27, p = .020). Among patients with initially normal ISR, 12.3% developed patella baja, which was associated with higher rates of hardware removal (20% vs. 3.1%, p = 0.004) and infection (10% vs. 0.8%, p = 0.015) when compared to patients maintaining a normal ISR. CONCLUSIONS:Abnormal intraoperative Insall-Salvati ratio following patella fracture repair was associated with poorer knee ROM and increased complication rate. Progressive development of patella baja during fracture healing was associated with hardware removal and fracture related infection. Attention to intraoperative ISR optimization may improve outcomes.

OBJECTIVE:To determine if the occurrence of short-term post-operative altered mental status (AMS) was lower in geriatric patients undergoing operative repair of hip fractures with Monitored Anesthesia Care and Soft-Tissue Infiltration with Local Anesthesia (MAC-STILA) when compared with general anesthesia (GA). DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Two U.S. hospitals within a single academic medical center. PATIENT SELECTION CRITERIA/UNASSIGNED:Geriatric patients with hip fractures (AO/OTA 31A and 31B) undergoing operative repair were identified. Propensity matching was performed in a 1:2 ratio to minimize selection bias (age, sex, BMI, ASA class, fracture pattern, fixation construct, pre-injury ambulatory status, and assistive device use). OUTCOME MEASURES/METHODS:Patients who underwent surgical fixation with MAC-STILA were compared with GA. Primary outcome was post-operative AMS, defined as missing ≥1 items on the alert and oriented assessment (person, place, and time) at any point from post-operative days 0-3. RESULTS:After matching, 228 patients (76 MAC-STILA: 152 GA) were included in the analysis. The average age of patients in both groups was 83 years. In the MAC-STILA group, 62% were female and 33% had baseline dementia while in the GA group 66% were female and 29% had baseline dementia. Treating patients with MAC-STILA was associated with 72% lower odds of having AMS compared with GA, controlling for baseline comorbidity and dementia (OR: 0.28. 95% CI: 0.09-0.075, p=0.016). Among patients with baseline dementia, the rate of AMS was lower in patients treated with MAC-STILA compared with GA (64.0% vs 95.3%, p = 0.001). CONCLUSION/CONCLUSIONS:Monitored Anesthesia Care and Soft-Tissue Infiltration with Local Anesthesia (MAC-STILA) was associated with lower odds of short-term postoperative altered mental status (AMS) compared to general anesthesia (GA) in hip fracture patients undergoing operative repair. Given the high rate of post-operative AMS and complications associated with geriatric hip fracture patient, MAC-STILA should be considered for use in patients with increased risk of post-operative AMS, particularly in the setting of preoperative dementia. LEVEL OF EVIDENCE/METHODS:Therapeutic III.

OBJECTIVE:To develop a stratification tool to identify hip fracture patients at risk for second contralateral hip fracture and mortality within 5 years of an index fracture, and to assess the cost-effectiveness of prophylactic fixation in high-risk/low-mortality patients. METHODS:Design: Retrospective prognostic cohort study. SETTING/METHODS:Single academic system with 2 Level 1 Trauma Centers, 1 orthopedic specialty hospital, and 1 tertiary care hospital. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients who were 60 years or older with OTA 31A/B hip fractures from low-energy mechanisms between 11/1/2014 and 11/31/2023 with ≥5 years follow-up or until death were included. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:The study included four phases: (1) identifying factors associated with second hip fracture within 5 years; (2) using multivariate logistic regression to generate models predicting 5-year second hip fracture (vs. FRAX) and mortality risk; (3) creating a "risk matrix" to identify candidates for prophylactic fixation using Youden's Index which determined cutoff points encompassing the maximum sensitivity and specificity for each risk equation and were used to define a value-based target group; (4) cost analysis comparing standard vs. prophylactic care in high-risk/low-mortality patients. RESULTS:Of 426 patients (mean age 80.25 years, 73.4% female), 78 sustained second hip fractures (mean interval: 594 days). Predictors included higher FRAX score (p=0.004), dementia (p<.001), ICU stay (p=0.014), discharge to subacute care (p<.001), and 90-day readmission (p=0.011). Logistic regression predicted 5-year second fracture risk (AUC 0.742 vs. FRAX 0.617, p=0.012) and 5-year mortality (AUC 0.723). The risk matrix used cutoff points of 18.2% (mortality) and 38.2% (second fracture) to define a value-based target group (n=26; 13 experienced second fracture). Cost analysis showed prophylactic fixation of all 26 patients ($781,508) would save $353,067 compared to treating the 13 who fractured again ($1,134,575). CONCLUSIONS:A novel matrix was developed that accurately predicted 5-year second hip fracture and mortality risk. Prophylactic fixation in low-mortality, high-risk patients may reduce costs and prevent future fractures. [Tool available: https://sttgmacom.wpcomstaging.com/predicting-risk-of-second-hip-fractures/]. LEVEL OF EVIDENCE/METHODS:Level III Diagnostic.

OBJECTIVE:The purpose of this study was to describe our experience using superiorly applied low-profile locking plates for the operative fixation of displaced midshaft clavicle fractures (MCFs). STUDY DESIGN/METHODS:This was a retrospective analysis performed at an academic institution. RESULTS:Eighty-three patients who presented with displaced, shortened MCFs were treated operatively by a single surgeon at our institution over a 10-year period. All patients received a precontoured low-profile locking plate applied in the superior position. A displaced midshaft clavicle fracture was fixed operatively using a precountered low-profile 2.7/3.5 mm locking plate applied in the superior position. Data were analyzed to evaluate time to union, final shoulder range of motion, incidence of hardware removal, and rate of postoperative complications. The cohort was 66.2% male with an average age at initial injury of 36.5 ± 14.1 years. At a mean of 3.6 ± 1.9 months, 99% of patients had united their fracture. At an average of 7.37-month follow-up, mean range of motion was 174° forward elevation, 173° abduction, 82° external rotation, and internal rotation to T7. Using the short musculoskeletal functional assessment (SMFA), the mean functional outcome index score was 4.12, bothersome index was 1.94, activity index was 1.55, emotion index was 2.51, arm and hand index was 1.14, mobility index was 0.68, and total index was 1.56. Ninety-two percent of patients had retained their hardware. There was 1 incidence of each of the following complications: infection, nonunion, hardware failure, and deep vein thrombosis. CONCLUSION/CONCLUSIONS:Superior clavicle plating using precontoured low-profile locking plates is an acceptable treatment modality for displaced MCF. This method yields excellent results regarding time to union, shoulder range of motion, incidence of hardware removal, and the rate of postoperative complications. Patients considering operative fixation of displaced MCF should be counseled accordingly.

BACKGROUND:Acute blood loss anemia is a common complication of hip fractures. Due to this complication, the rate of allogenic blood transfusions remains high in this patient population. More recently, surgeons have utilized intraoperative tranexamic acid as a strategy to minimize blood loss. PURPOSE/OBJECTIVE:The purpose of this study was to identify risk factors and associated outcomes of blood transfusions in hip fracture patients. STUDY DESIGN/METHODS:Retrospective cohort study. METHODS:A trauma database from one academic medical center was queried for hip fracture patients (OTA/AO 31A or 31B). Demographic, clinical, quality, and cost data were obtained for each patient. A Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), a validated risk predictive and matching tool, was calculated for each patient. Patients receiving blood transfusions during their hospitalization were identified. Multivariate logistic regression analysis identified independent risk factors for transfusion during admission. Patients receiving transfusions were matched to patients not receiving a transfusion based on STTGMA. Comparative analyses of matched cohorts were performed. RESULTS:In total, 1,344 hip fracture patients (29.8% male and 70.2% female) with mean age 81.04 ± 10.18 were identified. Four hundred ninety-nine (37.1%) patients received a transfusion during their admission. Risk factors for transfusion included higher STTGMA scores (P = .006), lower hemoglobin levels on admission (P < .001), anticoagulation or antiplatelet use on admission (P = .019), and fracture repair with a long cephalomedullary nail (P = .005). Trauma risk score-matched cohort outcomes show transfusions correlated with increased mortality, complications, readmission, and longer, more costly hospital stays. CONCLUSION/CONCLUSIONS:Surgeons should be cognizant of transfusion risk factors such as repair with long cephalomedullary nail and poorer matched outcomes correlated with patients receiving transfusions. LEVEL OF EVIDENCE/METHODS:Level 3.

BACKGROUND/UNASSIGNED:Hip fracture patients may be hospice candidates if life expectancy is < 6 months. This study evaluates STTGMAHIP FX's ability to identify high-risk hip fracture patients for hospice discharge at emergency room presentation to guide end-of-life care planning. METHODS/UNASSIGNED:A retrospective analysis of a prospectively maintained registry of patients aged ≥55 with low-energy hip fractures (2014-2024) was conducted. Patients were stratified by STTGMAHIP FX percentiles: minimal (≤50th), low (50th-<80th), moderate (80th-<97.5th), and high (≥97.5th). Demographics, injury characteristics, treatment, and outcomes were recorded. The primary outcome was identification of Hospice Discharge Candidates (HDCs), defined as discharge to hospice during the index admission, inpatient mortality >48 h after surgery, or mortality <6 months post-operation. American Society of Anesthesiologists (ASA) score was compared to STTGMAHIP FX for the ability to cluster HDCs using area under receiver operating characteristic (AUROC) curve analysis and a two-proportion Z-test. RESULTS/UNASSIGNED:Among 2777 patients (mean age 81.18 ± 9.80 years), HDC incidence rose with STTGMAHIP FX risk level: 2.9% (minimal risk), 5.9% (low risk), 14.2% (moderate risk), and 29.6% (high risk) (p < 0.05). Only 17.0% of patients classified as ASA 4 were HDCs. Additionally, STTGMAHIP FX demonstrated a slightly better ability to discriminate HDCs compared to ASA, although not statistically significant (0.719 vs 0.683; p = 0.138). However, the STTGMAHIP FX high risk stratification was much more useful in identifying HDCs than ASA (29.6% vs 17.0%; p = 0.013). CONCLUSION/UNASSIGNED:STTGMAHIP FX identifies hospice-eligible hip fracture patients more effectively than ASA. High-risk patients per STTGMAHIP FX demonstrate elevated 6-month mortality and may benefit from early hospice planning at admission.

PURPOSE/OBJECTIVE:The purpose of this study was to compare fracture nonunion rates in tibial shaft fractures fixed with intramedullary nails using fixed angle locking screws (FALS) that thread into the intramedullary nail versus standard locking screws in a cohort of tibial diaphyseal fractures. Secondarily, this study evaluated whether FALS location was associated with nonunion risk in tibial diaphyseal fractures. METHODS:A retrospective review of surgically treated OTA 42 A-C tibial shaft fractures from 2014 to 2024 at a single academic institution was performed. Inclusion criteria were age > 18, isolated OTA 42 A-C tibia fracture, intramedullary nail fixation, and minimum 6-month follow-up. Patients treated with a FALS were matched to those without a FALS with a 1:1 propensity match based on OTA fracture classification and open fracture status. The Radiographic Union Score for Tibia (RUST) was used to determine healing. Statistical comparisons were performed using Pearson Chi-squared tests, independent t-tests, Mann Whitney-U tests, and multivariate logistic regression as appropriate. RESULTS:78 patients were included (39 in each cohort), with the FALS group being older and having higher age-unadjusted Charlson Comorbidity Indices (CCI). The FALS and CLS groups had comparable rates of open fractures and similar proportions of OTA/AO fractures. FALS configuration per patient was: 16 only distal, 13 only proximal, and 10 both proximal and distal. There were no differences in nonunion rates (25.6% vs. 15.4%, p = 0.262) and healed-by times (6.15 ± 2.95 [months] vs. 6.38 ± 2.73, p = 759), complication rate, or 30/90-day readmission rates (p < 0.05). Multivariate analysis demonstrated that the use of single-end FALS (used only proximally or distally) was independently associated with higher odds of nonunion compared to CLS and FALS used both proximally and distally (OR = 6.027, p = 0.025). CONCLUSION/CONCLUSIONS:The use of single-end fixed angle locking screws in only the distal or proximal segment in intramedullary nails for the treatment of OTA 42 A-C tibial diaphyseal fractures is associated with higher odds of fracture nonunion. Larger, prospective studies evaluating FALS configuration for intramedullary nail fixation of tibia shaft fractures are warranted.