Faculty Bibliography

Purpose/UNASSIGNED:To assess risk factors and associated outcomes of acute kidney injury (AKI) in hip fracture patients. Methods/UNASSIGNED:Risk factors for AKI were identified by multivariate logistic regression. AKI patients were matched to patients who did not experience AKI using a validated trauma triage score. Comparative analyses between matched groups were performed. Results/UNASSIGNED:Risk factors of AKI included increasing Charlson Comorbidity Index and use of anticoagulation medications. AKI was associated with increased likelihood of medical complications and longer, more costly hospital stays. Discussion/UNASSIGNED:

Introduction/UNASSIGNED:The purpose of this study is to determine if the risk of receiving a blood transfusion during hip fracture hospitalization can be predicted by a validated risk profiling score (Score for Trauma Triage in Geriatric and Middle Aged (STTGMA)). Materials and Methods/UNASSIGNED:A consecutive series of 1449 patients 55 years and older admitted for a hip fracture at one academic medical center were identified from a trauma database. The STTGMA risk score was calculated for each patient. Patients were stratified into risk groups based on their STTGMA score quantile: minimal risk (0-50%), low risk (50-80%), moderate risk (80-95%), and high risk (95-100%). Incidence and volume of blood transfusions were compared between risk groups. Results/UNASSIGNED:< 0.001). STTGMA was predictive of first transfusion incidence in both the preoperative and postoperative periods. There was no difference in mean total transfusion volume between the four risk groups. Conclusion/UNASSIGNED:The STTGMA model is capable of risk stratifying hip fracture patients more likely to receive blood transfusions during hospitalization. Surgeons can use this tool to anticipate transfusion requirements.

CASE:A 41-year-old man presented with a transverse patella fracture and proximal patellar tendon avulsion after a fall from standing. Disruption of the extensor mechanism of the knee at multiple points is rare. He was treated operatively for his patella fracture and patellar tendon avulsion but experienced early failure of the patellar tendon fixation requiring reoperation. Both components of injury ultimately healed, and he returned to function. CONCLUSION:This case describes a rare presentation of an uncommon injury pattern affecting the extensor mechanism. This is the first report to describe multifocal failure of the extensor chain from a low-energy mechanism.

OBJECTIVES/OBJECTIVE:To examine the feasibility of a novel anesthetic option for hip fracture fixation with short cephalomedullary nails. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:An urban, academic level 1 trauma center, a tertiary care academic medical center, and an orthopedic specialty hospitalPatients/Participants: 20 recent and 40 risk-matched (1:1:1 by anesthesia type) historical hip fracture patients. INTERVENTION/METHODS:All patients with an OTA 31.A1-3 IT hip fracture presenting from October 1st 2019 - March 31st, 2020 treated with a short cephalomedullary nail (CMN) underwent a new intraoperative anesthesia protocol using monitored anesthesia care (MAC) and soft-tissue infiltration with local anesthesia (STILA). MAIN OUTCOME MEASUREMENTS/METHODS:Intraoperative measures, postoperative pain scores, narcotic and acetaminophen use, hospital quality measures, and inpatient cost. RESULTS:A total of 60 patients (20 each: MAC, general, spinal) were identified. There were differences among the groups regarding mean minimum and maximum intraoperative heart rate with MAC-STILA protocol demonstrating the best maintenance of normal heart rate parameters (60-100 bpm). For the first 3 hours post-operatively, MAC-STILA patients reported consistently lower pain scores (VAS <1) than spinal or general patients (VAS>1). Through 48 hours postoperatively, MAC-STILA narcotic usage was similar to that of the spinal cohort and approximately five times less than the general cohort. There were no differences in procedural time, length of stay, minor or major complications, inpatient and 30-day mortality, or 30-day readmissions, or post-operative ambulatory distance. There was no difference in inpatient cost among cohorts. CONCLUSIONS:This feasibility study demonstrates safety for the MAC-STILA protocol with comparison to spinal and general anesthesia. The MAC-STILA protocol is a viable option for treatment of OTA 13.A1-3 IT fractures with a short CMN, and may be the preferred method for patients with severe medical co-morbidities or relative contraindications to general and/or spinal anesthesia. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Introduction/UNASSIGNED:Operative hip fractures are known to cause a loss in functional status in the elderly. While several studies exist demonstrating the association between age, pre-injury functioning, and comorbidities related to this loss of function, no studies have predicted this using a validated risk stratification tool. We attempt to use the Score for Trauma Triage for Geriatric and Middle-Aged (STTGMA) tool to predict loss of ambulatory function and need for assistive device use. Materials and Methods/UNASSIGNED:Five hundred and fifty-six patients ≥55 years of age who underwent operative hip fracture fixation were enrolled in a trauma registry. Demographics, functional status, injury severity, and hospital course were used to determine a STTGMA score and patients were stratified into risk quartiles. At least 1 year after hospitalization, patients completed the EQ-5D questionnaire for functional outcomes. Results/UNASSIGNED:Two hundred and sixty-eight (48.2%) patients or their family members responded to the questionnaire. Of the 184 patients alive, 65 (35.3%) reported a return to baseline function. Eighty-nine (48.4%) patients reported a loss in ambulatory status. Patients with higher STTGMA scores were older, had more comorbidities, reported greater need for help with daily activities, increased difficulty with self-care, and a reduction in return to activities of daily living (all p ≤ 0.001). Patients with lower STTGMA scores were more likely to never require an assistive device while those with higher scores were more likely to continue needing one (p = 0.004 and p < 0.001). Patients in the highest STTGMA risk groups were 1.5x more likely to have an impairment in ambulatory status (need for ambulatory assistive device or decreased ambulatory capacity) (p = 0.004). Discussion/UNASSIGNED:Patients in higher STTGMA risk quartiles were more likely to experience impairment after hip fracture surgery. The STTGMA tool can predict loss of ambulatory independence following hip fracture. At-risk populations can be targeted for enhanced physiotherapy and rehabilitation services for optimal return to prior functioning.

Introduction/UNASSIGNED:Distal radius fractures are the second most common fracture in the elderly population. The incidence of these fractures has increased over time, and is projected to continue to do so. The aim of this study is to utilize a validated trauma risk prediction tool to stratify middle-aged and geriatric patients with operative distal radius fractures as well as compare hospital quality metrics and inpatient hospitalization costs among the risk groups. Materials and Methods/UNASSIGNED:Patients were prospectively enrolled in an orthopedic trauma registry. The Score for Trauma Triage in Geriatric and Middle Aged (STTGMA) was calculated using patient demographics, injury severity, and functional status. Patients were then stratified into minimal-risk, moderate-risk, and high-risk cohorts based on their scores. Length of stay, need for escalation of care, complications, mortality, discharge location, 1-year patient reported outcomes, and index admission costs were evaluated. Results/UNASSIGNED:= .019). There were no complications or mortality in any of the risk groups. No patients required intensive care and all patients were discharged home. There was no difference in readmission rates, inpatient cost, or 1-year patient reported outcomes among the risk cohorts. Discussion/Conclusions/UNASSIGNED:The Score for Trauma Triage in Geriatric and Middle-Aged is able to risk-stratify patients that undergo operative intervention of distal radius fractures. Middle aged and elderly patients with isolated closed distal radius fractures can be safely managed on an outpatient basis regardless of risk. Standardized pathways can be created in the management of these injuries, thereby optimizing value-based care. Level of evidence/UNASSIGNED:Prognostic Level III.

PURPOSE/OBJECTIVE:This study sought to compare postoperative outcomes and complications between patients with distal humerus fractures treated with open reduction and internal fixation (ORIF) of their non-dominant versus dominant arm. METHODS:A retrospective review of all patients who sustained a distal humerus fracture treated operatively with ORIF at one academic institution between 2011 and 2015 was performed. Measured outcomes included complications, time to fracture union, painful hardware, removal of hardware, Mayo Elbow Performance Index (MEPI), and elbow range of motion. Differences in outcomes between patients who underwent surgery of their dominant upper extremity and those who underwent surgery of their non-dominant extremity were assessed. RESULTS:Sixty-nine patients met inclusion criteria. Forty (58.0%) underwent ORIF of a distal humerus fracture on their non-dominant arm and 29 (42.0%) on their dominant arm. Groups did not differ with respect to demographics, injury information, or surgical management. Mean overall follow-up was 14.1 ± 10.5 months, with all patients achieving at least 6 months follow-up. The non-dominant cohort experienced a higher proportion of postoperative complications (P = 0.048), painful hardware (P = 0.018), and removal of hardware (P = 0.002). At latest follow-up, the non-dominant cohort had lower MEPI scores (P = 0.037) but no difference in elbow arc of motion (P = 0.314). CONCLUSION/CONCLUSIONS:Patients who sustained a distal humerus fracture of their non-dominant arm treated with ORIF experienced more postoperative complications, reported a greater incidence of painful hardware, underwent removal of hardware more often, and had worse functional recovery in this study. Physicians should emphasize the importance of physical therapy and maintaining arm movement especially when the non-dominant arm is involved following distal humerus fracture repair. LEVEL OF EVIDENCE/METHODS:Level III.

Introduction/UNASSIGNED:This study sought to investigate whether a validated trauma triage tool can stratify hospital quality measures and inpatient cost for middle-aged and geriatric trauma patients with isolated proximal and midshaft humerus fractures. Materials and Methods/UNASSIGNED:Patients aged 55 and older who sustained a proximal or midshaft humerus fracture and required inpatient treatment were included. Patient demographic, comorbidity, and injury severity information was used to calculate each patient's Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA). Based on scores, patients were stratified to create minimal, low, moderate, and high risk groups. Outcomes included length of stay, complications, operative management, ICU/SDU-level care, discharge disposition, unplanned readmission, and index admission costs. Results/UNASSIGNED:Seventy-four patients with 74 humerus fractures met final inclusion criteria. Fifty-eight (78.4%) patients presented with proximal humerus and 16 (21.6%) with midshaft humerus fractures. Mean length of stay was 5.5 ± 3.4 days with a significant difference among risk groups (P = 0.029). Lower risk patients were more likely to undergo surgical management (P = 0.015) while higher risk patients required more ICU/SDU-level care (P < 0.001). Twenty-six (70.3%) minimal risk patients were discharged home compared to zero high risk patients (P = 0.001). Higher risk patients experienced higher total inpatient costs across operative and nonoperative treatment groups. Conclusion/UNASSIGNED:The STTGMA tool is able to reliably predict hospital quality measures and cost outcomes that may allow hospitals and providers to improve value-based care and clinical decision-making for patients presenting with proximal and midshaft humerus fractures. Level of Evidence/UNASSIGNED:Prognostic Level III.

Introduction/UNASSIGNED:Despite the recommendation for postoperative orthopedic follow-up after a hip fracture in elderly patients, many patients do not return for these visits. In this study, we attempt to determine if early follow-up (<4 weeks post-discharge) changes orthopedic post-operative management. Materials and Methods/UNASSIGNED:1232 patients aged > 55 years old who underwent operative fixation for hip fractures were enrolled into an orthopedic trauma registry and followed from hospitalization through one year. Demographics, comorbidities, injury severity, and hospital course data were collected. Need for readmission and orthopedic follow-up were ascertained through chart review. Results/UNASSIGNED:417 patients (33.8%) patients did not return for any follow-up and 30 (2.4%) patients died <30 days from discharge. 370 (45.5%) patients had early orthopedic follow-up ≤28 days after discharge. 317 (38.9%) patients were seen ≥29 days after discharge (late follow-up). 127 (15.6%) patients returned for isolated non-orthopedic care. There were 23 (6.2%) readmissions in the early group, 17 (5.4%) in the late group, and 24 (18.9%) in the no follow-up group (p < 0.001). Patients discharged home were more likely to present for early follow-up compared to those with late and non-orthopedic follow-up (p = 0.002), however there was no difference in readmission rates between those discharged home vs. SNFs/SARs. Discussion/UNASSIGNED:Patients who received isolated non-orthopedic follow-up within 4 weeks of surgery experienced more hospital readmissions than those with follow-up in that time period; however, these readmissions were primarily due to medical issues. There was no difference in orthopedic-related readmissions and changes in orthopedic management between groups. Patients discharged to SNFs/SARs did not present for early orthopedic as often as those discharged home. Conclusion/UNASSIGNED:Early orthopedic follow up after hip fracture care does not change post-operative management in these patients and has implications for value-based care. Level of Evidence/UNASSIGNED:Prognostic Level III.

Introduction/UNASSIGNED:The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a validated mortality risk score that evaluates 4 major physiologic criteria: age, comorbidities, vital signs, and anatomic injuries. The aim of this study was to investigate whether the addition of ASA physical status classification system to the STTGMA tool would improve risk stratification of a middle-aged and elderly trauma population. Methods/UNASSIGNED:A total of 1332 patients aged 55 years and older who sustained a hip fracture through a low-energy mechanism between October 2014 and February 2020 were included. The STTGMA and STTGMAASA mortality risk scores were calculated. The ability of the models to predict inpatient mortality was compared using area under the receiver operating characteristic curves (AUROCs) by DeLong's test. Patients were stratified into minimal, low, moderate, and high risk cohorts based on their risk scores. Comparative analyses between risk score stratification distribution of mortality, complications, length of stay, ICU admission, and readmission were performed using Fisher's exact test. Total cost of admission was fitted by univariate linear regression with STTGMA and STTGMAASA. Results/UNASSIGNED:There were 27 inpatient mortalities (2.0%). When STTGMA was used, the AUROC was 0.742. When STTGMAASA was used, the AUROC was 0.823. DeLong's test resulted in significant difference in predictive capacity for inpatient mortality between STTGMA and STTGMAASA (p = 0.04). Risk score stratification yielded significantly different distribution of all outcomes between risk cohorts (p < 0.01). STTGMAASA stratification produced a larger percentage of all negative outcomes with increasing risk cohort. Total hospital cost was statistically correlated with both STTGMAASA (p < 0.01) and STTGMA (p = 0.02). Conclusion/UNASSIGNED:Including ASA physical status as a variable in STTGMA improves the model's ability to predict inpatient mortality and risk stratify middle-aged and geriatric hip fracture patients.