Faculty Bibliography

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.

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.

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.

INTRODUCTION/BACKGROUND:To compare outcomes of patients with geriatric hip fracture undergoing surgery <24 hours from emergency department (ED) arrival to those who underwent surgery >24 hours from arrival but within the next calendar day. METHODS:A retrospective review of a single-institution hip fracture database (2014 to 2024) was performed. The study cohort was divided into two groups based on time from ED arrival to surgery start time: <24-hour surgery (<24h) and next calendar day surgery >24 hours from arrival (>24h [next calendar day]). Univariate analysis was performed to compare baseline health, injury factors, and outcomes. Multivariate linear and logistic regression analyses were performed to adjust for procedure type and risk profile. RESULTS:There were 1,694 patients included in the study analysis, of whom 964 (56.91%) were <24h and 730 (43.09%) were >24h (next calendar day). The mean time to surgery for cohorts were <24h: 17.66 ± 5.05 vs. >24h (next calendar day): 28.78 ± 3.86 hours; P < 0.001. Univariate analysis revealed no differences between <24h and >24h (next calendar day) cohorts for in-hospital complication incidence (35.5% vs. 35.1%; P = 0.862), inpatient mortality (0.5% vs. 1.0%; P = 0.285), 30-/90-day readmission (5.6% vs. 6.2%; P = 0.625; 8.2% vs. 11.0%; P = 0.053), and 30-day/1-year mortality (2.4% vs. 2.3%; P = 0.939; 5.0% vs. 6.2%; P = 0.289). Length of stay (5.15 ± 3.15 vs. 5.58 ± 3.31; P = 0.006) and discharge location (36.4% home discharge vs. 31.0%; P = 0.019) favored the <24h cohort. After adjusting for baseline health with Score for Trauma Triage in the Geriatric and Middle-Aged and procedure type, only longer length of stay was found to be associated with the >24h (next calendar day) cohort (B = 0.407; P = 0.010). CONCLUSION/CONCLUSIONS:No notable differences were observed in key outcomes for patients undergoing <24 hours from ED arrival versus those who undergo surgery >24 hours after arrival but on the next calendar day. This study suggests that "next day hip fracture surgery" appears safe for patients with geriatric hip fracture.

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.

INTRODUCTION/BACKGROUND:Tibial plateau fractures are some of the most commonly treated injuries around the knee and loss of range of motion has a significant effect on post-operative outcomes, very few studies have demonstrated the impact of flexion contractures. The purpose of this study was to determine the effect that development of a knee flexion contracture has on outcomes following operative repair of tibial plateau fractures. METHODS:Patients operatively treated for tibial plateau fractures (Schatzker II, IV, V, and VI) between 2005-2024 at a multi-center academic urban hospital system were included in this retrospective comparative study. Patients were grouped into 3 cohorts: 1. Full extension (FE), 2. 5-10 degrees of flexion contracture (Mild, ME) and 3. Greater than 10 degrees of flexion (Severe, SE) contracture at 6 months post-operatively. Patients with contracture were matched to patients who regained full extension based on age and Schatzker classification. Statistical analysis was used to evaluate outcomes including patient reported pain levels, Short Musculoskeletal Function Assessment (SMFA) scores, complication rates and reoperation rates. RESULTS:The cohort consisted of 3 groups of 30 patients (14 Schatzker II, 5 Schatzker IV, 3 Schatzker V, and 8 Schatzker VI). The average knee flexion contracture for the mild cohort was 5 degrees and the average knee flexion contracture for the severe cohort was 12.7 degrees. Patients who experienced flexion contracture had poorer SMFA scores at 6 months, and those in the severe cohort had the poorest SMFA scores (112.6) when compared to those with full extension at 6 months (77.7) (p<0.001). Flexion contractures were associated with higher rates of fracture related infection (FRI) (p =0.002). Patients with flexion contracture also had a higher rate of subsequent re-operation, with 36.7% of the ME undergoing re-operation and 40% of SE undergoing re-operation. CONCLUSIONS:Patients who developed a flexion contracture following repair of a tibial plateau fracture experienced worse outcomes, higher rates of complications, increased pain, and poorer function at long term follow up compared to those who achieved full knee extension.

PURPOSE/OBJECTIVE:The purpose of this study is to compare the quality and clinical outcomes of patients who underwent open reduction internal fixation for a proximal humerus fracture in a "timely manner" which was defined to be within 5 days of injury compared to those with "delayed intervention" (>5 Days) to determine the effect this had. METHODS:This IRB-approved study evaluated patients who sustained a proximal humerus fracture treated with plate and screw fixation (ORIF) between January 2004 and October 2022 and had time from injury to surgery documented. Patients were grouped based on the time to surgery (TTS) - Less than 5 Days (L5) vs. More than 5 Days (M5). TTS was also evaluated as a continuous variable. Univariable and multivariable analysis compared patient demographics, injury/surgical characteristics, postoperative complications, and clinical outcomes to determine effect of TTS. Clinical outcomes included shoulder range of motion (ROM) and Disabilities of the Arm, Shoulder, and Hand (DASH) score at least 1 year following the date of injury. Standard statistical tests were used (p<0.05 considered significant). RESULTS:, p=0.03, β= -0.27, 95% CI = -41.71- -2.89) surgery was associated with less passive forward elevation. CONCLUSION/CONCLUSIONS:Timing of surgery did not impact outcomes of patients who underwent open reduction internal fixation for proximal humerus fractures. Surgical intervention after 14 days was associated with diminished passive forward elevation only.

INTRODUCTION/BACKGROUND:The purpose of this study was to assess the effect of an acute traumatic meniscus tear that required repair in association with a tibial plateau fracture repair on outcomes. METHODS:Over a 17-year period, 843 patients presented with a tibial plateau fracture and were followed prospectively. 721 patients with Schatzker I-VI fractures were treated operatively via a standardized algorithm. 161 tibial plateau fractures (22.3 %) had an associated meniscus tear that underwent acute repair at the time of bony fixation. These patients were compared to operatively repaired tibial plateau fracture patients with no meniscus injury (NMR). Demographics were collected and outcomes including: radiographic healing, knee range of motion (ROM), and complication rates, were recorded. In addition, re-operation rates were compared and any reoperation for meniscus repair failure identified. All patients had a minimum of 1 year follow up. RESULTS:A total of 524 patients with a mean of 21.4 (range: 12-120) months follow up met inclusion criteria. Patients in the meniscus repair (MR) cohort had poorer knee extension (1.01 degrees, range: 0-30 degrees) compared to the NMR cohort (0.07 degrees, range: 0-10 degrees) (p < 0.001), in addition to poorer knee flexion (123 degrees, range: 0-145 degrees, p = 0.024). Additionally, MR patients reported higher pain scores (mean: 3 and range: 0-8, p = 0.005) at latest follow up. Finally, MR patients had higher rates of infection (8.1 % vs. 3.3 %, p = 0.025) and lateral collapse of the joint (p = 0.032). CONCLUSION/CONCLUSIONS:Patients who had a meniscus repair at the time of tibial plateau fracture repair were found to have poorer knee ROM, more patient reported pain at minimum 12 (mean 24) months post-operation. Additionally, these patients developed more post-operative complications than those patients who did not undergo a meniscus repair.

OBJECTIVES/OBJECTIVE:The purpose of this study is twofold: (1) to reliably define the concept of "extreme tibial nailing" and (2) assess the feasibility of tibial intramedullary nailing when the fracture extends into the nail's locking bolt zone. METHODS:Design: A retrospective review. SETTING/METHODS:A single academic center comprised of a specialty orthopedic hospital and a Level I Trauma Center. Patient Selection Criteria: 543 patients who sustained 555 tibia fractures between February 2014 and January 2024 were reviewed by two board-certified orthopedic surgeons. Cases were classified as "extreme nailing" based on the tibial fracture within the most proximal or distal 25% of the bone such that the fracture extended into the locking bolt section of the intramedullary nail used to treat the fracture. Patients with supplemental periarticular plating of the tibia were excluded. Outcome Measures and Comparisons: Data collected included patient demographics, hospital metrics, and outcomes. RESULTS:Twenty-five tibial fractures treated met radiographic criterion. The "extreme IMN" cohort was 45.8 years, 72% female with a mean BMI of 26.6. Over half of fractures resulted from high-energy injuries, and 40% were open. Patients were hospitalized for 92.8 h on average, and the 90-day readmission rate was 8.0%. The average time to weight-bearing allowance was 5.2 weeks post-op. Eight (32.0%) patients experienced complications: 12% developed fracture-related infection (FRI), 4% experienced hardware complications, and 20.0% developed nonunion requiring surgery. The rate of all-cause reoperation was 32.0%, and 28% of patients experienced knee or ankle pain at 6 months or later. The rate of malalignment was 8.0%, and the average time to radiographic healing was 5.7 months. CONCLUSION/CONCLUSIONS:Tibial nailing is an effective treatment for "extreme" tibial fractures that extend as far as the articular surface and interlocking cluster on either end. The majority of patients who underwent extreme tibial nailing recovered with acceptable alignment, minimal healing complications, and achieved radiographic union within 6 months. LEVEL OF EVIDENCE/METHODS:III.

PURPOSE/OBJECTIVE:Evaluate healing outcomes of patients who sustained a comminuted clavicle fracture and underwent operative fixation using a bridge plate technique or interfragmentary screw/neutralization plate. METHODS:Two hundred and seventy-one comminuted clavicle fractures that underwent operative fixation with minimum 6 months follow-up were retrospectively reviewed. Patients were grouped based on fixation methods. Data collected include patient demographics and injury information. Fracture healing, total complications, fracture related infection, removal of hardware, nonunion, and revision fracture surgery were reviewed. Clinical healing was defined as non-tenderness about the fracture site, and radiographic healing was defined as bridging callus and/ or lack of fracture line on X-ray. Chi square analysis, T test, and linear regression were used for analysis. RESULTS:There were 126 comminuted fractures fixed with a bridge plate and 145 comminuted fractures fixed with a plate and at least one interfragmentary screw both with a mean follow-up of 8.2 months. The bridge plated group was more female, the result of high-energy mechanisms, and had more anteroinferior plates (p < 0.05 for all). There were no differences in time to radiographic healing as well as incidence of nonunion between cohorts. Patients fixed with the bridge plate technique underwent a higher incidence of revision surgery, higher incidence of hardware removal, and had a longer time until clinically healed. On multivariate regression analysis, fixation method was not associated with any of these outcomes (p < 0.05 for all). CONCLUSION/CONCLUSIONS:Bridge plating and lag screw/neutralization plate fixation were both associated with similar rates of healing. Complication profiles were similar.