Faculty Bibliography

OBJECTIVES/OBJECTIVE:To determine if initial vertical fracture displacement affects postoperative outcomes following operative treatment of patella fractures. METHODS:Design: Prognostic retrospective study. SETTING/METHODS:Single multi-site urban academic institution. PATIENT SELECTION CRITERIA/UNASSIGNED:Included were patients aged ≥18 years who underwent open reduction internal fixation of a patella fracture (AO/OTA 34A-C) with minimum 6-month follow-up, and complete trauma knee x-ray series. Vertical fractures and those without significant vertical displacement (<2mm) were excluded. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Initial vertical fracture displacement was recorded. Follow-up data included knee range-of-motion and post-operative complications: nonunion, fracture related infection (FRI), hardware failure, suspected FRI, knee contracture, inferior sleeve displacement, and venous thromboembolism events. Comparisons were made between the initial amount of displacement and postoperative complications. RESULTS:229 patients with a median follow-up duration of 12 months (IQR: 6-14) were included. The mean age was 61.2 ± 15.1 years, BMI was 25.4 ± 4.7 kg/m2, and 69.0% (n = 158) were female. OTA fracture classification was: 35.4% C1, 32.3% C3, 17.9% C2, and 14.4% A1. Fixation methods included 63.8% tension band wiring, 17.9% suture repair, 13.5% plate and screws, and 4.8% screws with suture. 33 (14.4%) patients sustained complications. The mean displacement was significantly higher in patients who developed complications (21.6 mm ± 15.0 mm vs. 14.8 mm ± 10.1 mm, p=0.018), particularly for nonunion (29.8 mm ± 13.5 mm vs. 15.1 mm ± 10.6 mm, p<0.001) and hardware failure (30.8 mm ± 12.0 mm vs 15.4 mm ± 10.9 mm, p<0.001). Suture-only and screw-with-suture fixation had higher nonunion rates (p=0.004, p=0.005) than other fixation methods independent of displacement. Initial displacement predicted nonunion and hardware failure (AUROCs=0.818 and 0.838). Youden Index thresholds of >26.6mm and >21.7mm identified patients at increased risk for nonunion and hardware failure. Each millimeter increase in displacement raised nonunion and hardware failure risk by 14.9% (OR=1.1, p=0.003) and 14.6% (OR=1.1, p=0.003). CONCLUSIONS:This study supports the future use of initial vertical fracture displacement as a prognostic tool for nonunion and hardware failure after patella ORIF. Displacement >2cm placed patients at high risk for these complications. Nonunion rates were higher in both suture only and screw-with-suture fixation when compared to other fixation constructs. LEVEL OF EVIDENCE/METHODS:III.

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.

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.

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.

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.

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.

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.