Faculty Bibliography

OBJECTIVES/OBJECTIVE:Increased mortality following geriatric hip fractures is well reported. However, population-level analysis of mortality trends over time are not common. This study aimed to evaluate the 3- and 12-month mortality after geriatric hip fractures from 2010 to 2019. METHODS:The New York Statewide Planning and Research Cooperative System database from 2010 to 2020 was retrospectively queried for patients aged >65 years with a femoral neck or intertrochanteric hip fracture. Kaplan-Meier survival analysis was used to calculate mortality rates for each year. Cox proportional hazard multivariable regression controlling for sex, age, race, obesity, smoking, and Elixhauser comorbidity index was used to compare mortality hazard ratios for each year. Secondary outcomes included length of stay, discharge disposition, and 3-month readmission and emergency department visits. RESULTS:From 2010 to 2019, 142,540 patients aged ≥65 years had a diagnosis of femoral neck fracture (62%) or intertrochanteric hip fracture (38%). The mean age was 83.29 years (SD 8.22). The mean Elixhauser comorbidity index was 7.35 (SD 7.60). Kaplan-Meier survival analysis revealed that for the complete cohort 3-month mortality rate was 9.82% (95% confidence interval 9.65% to 9.98%) and 12-month mortality rate was 16.06% (95% confidence interval 15.84% to 16.27%). The 3-month mortality rate went from 10.8% in 2010 to 8.6% in 2019 and the 12-month mortality rate went from 17.7% in 2010 to 14.8% in 2018 before rising to 16.9% in 2019. Cox multivariate proportional hazard regression demonstrated statistically significant decreased hazard ratio from 2012 to 2019 compared with reference hazard in 2010 (all P < 0.05). Reductions were also observed for length of stay (7.8 to 6.4 days, P < 0.001), 3-month readmissions rate (34% to 22%, P < 0.001), and 3-month emergency department visit rate (45% to 34%, P < 0.001). CONCLUSION/CONCLUSIONS:Mortality after geriatric hip fractures has demonstrated a reduction in the past decade with 3-month mortality continuously decreasing from 2010 to 2019 and 12-month mortality decreasing from 2010 to 2018 before increasing in 2019.

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.

INTRODUCTION/BACKGROUND:The study aimed to investigate the efficacy of autogenous iliac crest bone graft (ICBG) compared with other graft types in achieving successful fracture nonunion repair. METHODS:An institutional review board-approved retrospective review of prospectively collected data was conducted on a consecutive series of patients surgically treated for fracture nonunions at an academic medical center between September 10, 2004, and August 20, 2023. Patients were analyzed based on which bone graft type-ICBG versus alternative graft types-used during their nonunion repair. Patient demographics, injury characteristics, and surgical history were compared. Outcomes included radiographic healing, time to union, postoperative complications, and revision rate. Cohorts were compared using an independent sample Student t-test for continuous variables and chi-square or Fisher exact tests for categorical variables. One-way analysis of variance with post hoc comparisons assessed differences across treatment strategy groups. RESULTS:Five hundred fifty-six patients were treated surgically for a fracture nonunion using standard internal fixation and a "bone graft" for biologic stimulation. 57.4% of these patients were treated with autogenous ICBG; 42.6% received alternative grafts (iliac crest aspirate, allograft, bone morphogenetic, reamer-irrigation aspirator, and/or demineralized bone matrix, without autogenous cancellous iliac crest). Compared with the alternative cohort, the ICBG cohort showed greater healing success after a single nonunion surgery (95.6% ICBG versus 86.9% alternative, P < 0.001) and faster healing times (4.8 ± 2.4 months versus 7.1 ± 4.9 months, P < 0.001). Complications at the ICBG harvest site included wound infections/hematomas and iliac wing fracture. No notable differences were found in positive cultures at the time of surgery, postoperative fracture-related infection, implant failure, or neurovascular injury. DISCUSSION/CONCLUSIONS:Using autogenous ICBG in the surgical repair of fracture nonunions was associated with higher healing rates compared with alternative graft types, supporting its continued role in enhancing bone healing outcomes, even in the face of infected nonunion.

OBJECTIVE:To evaluate revision and removal rates of radial head arthroplasty (RHA) for elbow trauma using modern press-fit modular implants. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Urban academic medical center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients who underwent RHA (2012-2024) for isolated comminuted radial head fractures, combined head-neck fractures, terrible triad injuries, or Monteggia variants (OTA 2R1) were study eligible. Inclusion criteria consisted of treatment with press-fit modular implants and ≥1 year of clinical follow-up. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Demographics, injury patterns, elbow range of motion, and postoperative complications-including fracture-related infection, nerve injury, periprosthetic fracture, implant resection, and non-resection procedures-were assessed. Implant survivorship was evaluated via Kaplan-Meier analysis. RESULTS:250 patients were included (mean age 52.2 ± 17.8 years, range 18.1-88.3 years; mean length of follow up 43.8 ± 35.2 months, range 12.0-128.0 months, BMI 28.7 ± 6.3 kg/m2, 56.8% female). Common indications for RHA included Monteggia fractures (38.0%), isolated radial head fractures (23.6%), and terrible triad injuries (19.2%).Post-index surgery iatrogenic nerve injury occurred in 7.2%, most commonly involving the ulnar nerve. Fracture related infection occurred in 2.8% post index surgery, and one nonoperative periprosthetic fracture (0.4%) was observed.The resection rate was 7.2% (18/250), with 33.3% (6/18) of implant resection surgeries occurring within one year (mean length of follow up 43.8 ± 35.2 months, range 12.0-128.0 months). Common resection indications included postoperative stiffness (n=5), infection (n=4), and neuropathy (n=3). One-year implant survival was 97.6%, with mean survivorship of 8.5 ± 1.0 years (95% CI, 7.1-9.8).In total, 24 patients (9.6%) underwent additional non-resection procedures including nerve decompressions, elbow contracture releases with excision of heterotopic ossification, and manipulations under anesthesia.At final follow-up (mean 43.8 ± 35.2 months), mean range of motion was 125.4° flexion, -14.9° extension, 73.5° pronation, and 79.3° supination. No significant difference in length of follow-up was observed between patients with post-operative nerve injury (52.4 ± 38.2 months) and those without (42.5 ± 34.8 months, p = 0.16). CONCLUSION/CONCLUSIONS:With a 7.2% resection rate and one-year implant survival of 97.6%, contemporary press-fit modular RHA demonstrated durable elbow trauma outcomes.

OBJECTIVES/OBJECTIVE:To evaluate factors influencing slide in statically-locked single lag screw cephalomedullary nail (CMN) constructs for reverse obliquity (RO) fractures. METHODS:Design: Retrospective comparative study. SETTING/METHODS:A multi-center academic urban hospital system (4 hospitals). PATIENT SELECTION CRITERIA/UNASSIGNED:Patients with an RO fracture (OTA/AO 31A3) treated with a CMN (Gamma or TFNA) and statically-locked single lag screw from 2014 to 2024, with at least one follow-up radiograph (minimum three months or documentation of healing). OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Lag screw sliding was measured as the difference in screw position between immediate postoperative imaging and final follow-up radiographs. Tip-to-head distance (ΔTHD) and screw protrusion ratio (ΔPR) were recorded. Patients were grouped as <5mm, 5-10mm, or >10mm slide. Comparisons included fracture subtype, nail brand, angle, and length. Bivariate analyses tested associations with slide. RESULTS:Of the 219 patients identified with a 31A3 type fracture, 85 (38.8%) met inclusion criteria. The average age was 81.0 (±9.3) years with 65 (76.5%) females. Mean radiographic follow-up was 19.9 months, with a follow-up range of 74-2,576 days. The mean slide was 7.8mm (±5.2mm). 74 patients (87.1%) had slide >2mm. ΔTHD was negligible (-0.1 ± 7.0mm), and ΔPR 0.2 (±0.1) significantly exceeded zero (p < 0.001). Neither nail length (Short: 9.4 ± 5.3mm vs. Long: 7.1 ± 5.0mm, p = 0.083), nail angle, (125°: 8.0 ± 5.4mm vs 130°: 6.5 ± 4.0mm; p = 0.286), nor nail brand had a significant effect (Gamma: 7.6 ± 5.1mm vs TFNA: 9.1 ± 6.2mm; p = 0.921). Fracture subtype (31A3.1: 9.1 ± 6.1mm vs 31A3.2: 10.4 ± 5.1mm vs 31A3.3: 6.9mm ± 4.6mm; p = 0.114) and demographic factors (p > 0.05) were not significantly associated with slide severity. CONCLUSIONS:Surgeons should expect some degree of lag screw slide and subsequent proximal fragment displacement when a Gamma nail or TFNA nail cephalomedullary nail is used for a reverse obliquity fracture, even when statically locked. LEVEL OF EVIDENCE/METHODS:Level III.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the effect that associated glenohumeral dislocations have on outcomes following surgical treatment of proximal humerus fractures. METHODS:This IRB-approved study reports on 301 patients, who underwent operative treatment for proximal humerus fractures at an academic medical center from January 2006 to January 2023. Fractures were classified according to the Neer system. Patients were separated into two cohorts based on whether a glenohumeral dislocation was present at the time of initial injury. Outcomes measured included the Disabilities of the Arm, Shoulder, and Hand (DASH) score, shoulder range of motion (forward elevation, external rotation, internal rotation), readmission rates, complications, hardware removal, and need for revision surgery. Independent samples t-tests and chi-squared analysis were used for continuous and categorical variables, respectively. A binary logistic regression was performed to analyze the influence of these factors on complication rate. RESULTS:230 patients sustained an isolated fracture (PHF) and 71 sustained a fracture-dislocation (FD). Significant differences were observed between the FD and PHF groups in all measured outcomes. The FD group had a poorer DASH score (24.38 ± 19.09 vs 10.54 ± 13.67; P < 0.001) and reduced range of shoulder motion in forward elevation (114° ± 40° vs 162° ± 19°; P < 0.001), external rotation (40° ± 19° vs 66° ± 19°; P < 0.001), and internal rotation (57° ± 26° vs 82° ± 21°; P < 0.001). Readmission rates were higher in the FD group (0.28 ± 0.85 vs 0.05 ± 0.28; P < 0.001). The FD cohort also had a higher rate of complications (25.35% vs 6.52%; P < 0.001), need for removal of hardware (14.08% vs 3.04%; P = 0.002), and overall revision surgery (11.27% vs 1.30%; P < 0.001). The FD cohort demonstrated a greater incidence of AVN (12.68% vs 4.35%; P = 0.012). No significant difference was observed regarding rates of fracture healing and recurrent dislocation. Multivariate analysis in the form of binary logistic regression indicated that fracture-dislocation significantly increased the complication risk (OR = 3.310, 95% CI = 1.42-7.70; P = 0.005). CONCLUSION/CONCLUSIONS:Proximal humerus fracture-dislocations are associated with worse functional outcomes and higher complication rates compared to those without dislocations. These findings highlight the potential need for specialized treatment strategies to mitigate the impact of dislocation on recovery.

BACKGROUND:The purpose of this study was to compare hospital quality and patient outcomes of hip arthroplasty for femoral neck fractures (FNFs) based on the subspecialty training of the treating surgeon: orthopaedic trauma (OT) versus adult reconstruction (AR) fellowship training. METHODS:A retrospective review was conducted on 1,008 elderly patients treated for an FNF with hemiarthroplasty or total hip arthroplasty between 2014 and 2024. Patients were grouped by their surgeon's subspecialty training (OT versus AR). Outcomes analyzed included length of stay, complications, 30-day and 90-day readmissions, dislocations, infections, and 30-day mortality. Statistical significance was set at P < 0.05. RESULTS:Baseline patient demographics were similar between groups, except for a higher proportion of women in the AR cohort (P = 0.008) and Black patients in the OT cohort (P = 0.016). Although age-unadjusted Charlson Comorbidity Index (CCI) was significantly higher in the AR group (P = 0.046), Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) scores, which take CCI and other health factors into account, were not significantly different (P = 0.59). In-hospital outcomes, including length of stay (P = 0.89) and minor and major complication rates (P = 0.38, P = 0.38), demonstrated no significant differences between groups. Post-discharge outcomes, including readmissions (30-day: P = 0.52, 90-day: P = 0.16), infections (P = 0.25), dislocations (P = 0.89), and 30-day mortality (P = 0.14), were also similar. CONCLUSION/CONCLUSIONS:No differences were identified in any of the outcomes analyzed between OT-trained and AR-trained surgeons in our study. This suggests that when FNFs are treated at high-volume academic institutions, subspecialty training may not substantially influence the short-term results of FNFs treated with hip arthroplasty. These findings highlight the importance of timely surgical intervention rather than waiting for a particularly trained surgeon to be available.

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.

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.