Faculty Bibliography

SUMMARY/CONCLUSIONS:Anteromedial coronoid facet fractures typically occur with varus, pronation, and axial forces applied to the elbow. Due in part to the high rate of concomitant lateral collateral ligament (LCL) injuries, untreated anteromedial facet fractures can result in varus and posteromedial rotatory elbow instability. Although small fractures that are not amenable to open reduction and internal fixation can be treated with isolated LCL repair, larger fragments are treated with buttress plating on the anteromedial surface of the coronoid with or without LCL repair. The "over-the-top" approach via a split in the flexor pronator mass is the preferred method of accessing the anteromedial facet. Although data regarding the functional outcomes after operative fixation of the anteromedial facet are limited, observational studies have demonstrated good restoration of elbow stability and motion.

OBJECTIVES/OBJECTIVE:This study compares demographics, outcomes, and costs of patients with similar multifragmentary pertrochanteric (MP) fracture patterns treated with either a short or long cephalomedullary nail (CMN) to determine treatment efficacy and value during hospital admission. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Level-1 trauma center. PATIENTS/METHODS:384 patients who presented with a MP fracture [AO/OTA 31A2.2 and 31A2.3] at 1 of 3 hospitals within a single academic medical center. INTERVENTION/METHODS:Surgical treatment with either short or long CMN Main outcome measurements: Operative time, in-hospital complications, discharge disposition, procedural and total costs of admission. RESULTS:Sixty-nine (18.0%) patients were treated with long CMNs compared to 315 patients treated with short CMNs. Patients treated with long CMNs had increased rates of transfusions of allogenic packed red blood cells (52.2% vs 34.0%, p = 0.005), discharge to rehabilitation facilities (91.3% vs 80.3%, p = 0.030), and had costlier hospital stays ($28,632.50 vs $23,024.86, p = 0.014) with longer (74.9 vs 52.3 min, p <0.001), costlier procedures and implants ($12,090.31 vs $9,647.41, p = 0.014) compared to patients treated with short CMNs. There were no differences in timing of radiographic healing, rates of readmission, nonunion, screw cut out, fixation failure, or peri‑implant fracture. CONCLUSIONS:Short and long CMNs are equally suitable implants for the most unstable intertrochanteric fracture patterns. Short CMNs correlate with reduced operative time and costs with non-inferior in-hospital complication rates, hospital quality measures, and less frequent rehabilitation facility discharges. Given the similar long-term outcomes demonstrated here and in the literature, this data suggests nail length selection should be driven more by cost and discharge considerations for MP fractures. LEVEL OF EVIDENCE/METHODS:level III.

Introduction/UNASSIGNED:The purpose of this study was to assess the hospital quality measures and outcomes of operative hip fracture patients before and after implementation of an anesthesiology department protocol assigning decision for a preoperative transthoracic echocardiogram (TTE) to the hospitalist co-managing physician. Materials and Methods/UNASSIGNED:Demographics, injury details, hospital quality measures, and outcomes were reviewed for a consecutive series of patients presenting to our institution with an operative hip fracture. In May of 2019, a new protocol assigning the responsibility to indicate a patient for preoperative TTE was mandated to the co-managing hospitalist at the institution. Patients were split into pre-protocol and post-protocol cohorts. Linear regression modeling and comparative analyses were conducted with a Bonferroni adjusted alpha as appropriate. Results/UNASSIGNED:Between September 2015 and June 2021, 1002 patients presented to our institution and were diagnosed with a hip fracture. Patients in the post-protocol cohort were less likely to undergo a preoperative echocardiogram, experienced a shorter time (days) to surgery, shorter length of stay, an increase in amount of home discharges, and lower complication risks for urinary tract infection and acute blood loss anemia as compared to those in the pre-protocol cohort. There were no differences seen in inpatient or 30-day mortality. Multivariable linear regression demonstrated a patient's comorbidity profile (Charlson Comorbidity Index (CCI)) and their date of presentation (pre- or post-protocol), were both associated with (P<0.01) a patients' time to surgery. Conclusion/UNASSIGNED:A standardized preoperative work flow protocol regarding which physician evaluates and determines which patients require a preoperative TTE allows for a streamlined perioperative course for hip fracture patients. This allows for a shortened time to surgery and length of stay with an increase in home discharges and was associated with a reduced risk of common index hospitalization complications including UTI and anemia.

OBJECTIVES/OBJECTIVE:To investigate if any injury to the three primary branches of the popliteal artery in open tibia fractures lead to increased soft-tissue complications, particularly in the area of the affected angiosome. DESIGN/METHODS:Retrospective cohort comparative study. SETTING/METHODS:Two academic level one trauma centersPatients/Participants: Sixty-eight adult patients with open tibia fractures with a minimum one-year follow up. INTERVENTION/METHODS:N/A. MAIN OUTCOME MEASUREMENTS/METHODS:Soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture related infection (FRI) at time of final follow-up. RESULTS:Eleven (15.1%) tibia fractures had confirmed arterial injuries via CTA (7), direct intraoperative visualization (3), intraoperative angiogram (3). Ten (91.0%) were treated with ligation and 1 (9.1%) was directly repaired by vascular surgery. Ultimately, 6 (54.5%) achieved radiographic union and 4 (36.4%) required amputation performed at a mean of 2.62 ± 2.04 months, with one patient going on to nonunion diagnosed at 10 months. Patients with arterial injury had significantly higher rates of wound healing complications, FRI, nonunion, amputation rates, return to the OR, and increased time to coverage or closure. After multivariate regression, arterial injury was associated with higher odds of wound complications, FRI, and nonunion. Ten (90.9%) patients with arterial injury had open wounds in the region of the compromised angiosome, with 7 (70%) experiencing wound complications, 6 (60%) FRIs, and 3 (30%) undergoing amputation. CONCLUSIONS:Arterial injuries in open tibia fractures with or without repair, have significantly higher rates of wound healing complications, FRI, delayed time to final closure, and need for amputation. Arterial injuries appear to effect wound healing in the affected angiosome. LEVEL OF EVIDENCE/METHODS:Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The advent of value-based care as a component of the United States health care system is part of a broader paradigm shifting away from fee-for-service payment models in favor of alternative reimbursement incentives tied to quality and outcome metrics. Bundled care models, gainsharing agreements, and other cost containment measures, although promising, may induce unintended systemwide consequences for orthopedic trauma surgeons who often specialize in tending to costly multiply injured patients and marginalized populations. This article reviews facets of value-based care applicable to orthopedic trauma surgery with an emphasis on public health and ethical considerations for policymakers and orthopedic surgeons.

Background/UNASSIGNED:Nearly 20% of Americans consider themselves disabled. A common cause of disability is unexpected orthopaedic trauma. The purpose of this current study, assessing common lower extremity trauma, is the following: to assess the prevalence of self-reported feelings of disability following these injuries, to determine if self-reported feelings of disability impact functional outcomes, and to understand patient characteristics associated with self-reported feelings of disability. Methods/UNASSIGNED:The functional statuses of patients with tibial plateau fractures and ankle fractures were prospectively assessed. Patient reported feelings of disability (acquired from validated functional outcome surveys), which were compared with overall patient-reported functional outcome and emotional status at each follow-up visit. Additionally, patient demographics were analyzed, to assess associations with feelings of disability. Results/UNASSIGNED: = 0.252). Self-reported feelings of disability declined at each follow-up visit, from 48.1% at short-term follow-up to 22.1% at long-term follow-up. Conclusion/UNASSIGNED:Self-reported feelings of disability, following lower extremity trauma, had strong positive correlations with worse outcomes. Orthopaedic trauma surgeons should be aware of the percentage of patients who feel disabled following lower extremity fractures, and know that this is associated with sub-optimal outcomes. Level of Evidence/UNASSIGNED:III.

BACKGROUND:Women have long been underrepresented in orthopaedic surgery; however, there is a lack of quantitative data on the representation of women in orthopaedic academic program leadership. QUESTIONS/PURPOSES:(1) What is the proportion of women in leadership roles in orthopaedic surgery departments and residency programs in the United States (specifically, chairs, vice chairs, program directors, assistant program directors, and subspecialty division chiefs)? (2) How do women and men leaders compare in terms of years in position in those roles, years in practice, academic rank, research productivity as represented by publications, and subspecialty breakdown? (3) Is there a difference between men and women in the chair or program director role in terms of whether they are working in that role at institutions where they attended medical school or completed their residency or fellowship? METHODS:We identified 161 academic orthopaedic residency programs from the Accreditation Council for Graduate Medical Education (ACGME) website. Data (gender, length of time in position, length of time in practice, professorship appointment, research productivity as indirectly measured via PubMed publications, and subspecialty) were collected for chairs, vice chairs, program directors, assistant program directors, and subspecialty division chiefs in July 2020 to control for changes in leadership. Information not provided by the ACGME and PubMed was found using orthopaedic program websites and the specific leader's curriculum vitae. Complete data were obtained for chairs and program directors, but there were missing data points for vice chairs, assistant program directors, and division chiefs. All statistical analysis was performed using SPSS using independent t-tests for continuous variables and the Pearson chi-square test for categorical variables, with p < 0.05 considered significant. RESULTS:Three percent (4 of 153) of chairs, 8% (5 of 61) of vice chairs, 11% (18 of 161) of program directors, 27% (20 of 75) of assistant program directors, and 9% (45 of 514) of division chiefs were women. There were varying degrees of missing data points for vice chairs, assistant program directors, and division chiefs as not all programs reported or have those positions. Women chairs had fewer years in their position than men (2 ± 1 versus 9 ± 7 [95% confidence interval -9.3 to -5.9]; p < 0.001). Women vice chairs more commonly specialized in hand or tumor compared with men (40% [2 of 5] and 40% [2 of 5] versus 11% [6 of 56] and 4% [2 of 56], respectively; X2(9) = 16; p = 0.04). Women program directors more commonly specialized in tumor or hand compared with men (33% [6 of 18] and 17% [3 of 18] versus 6% [9 of 143] and 11% [16 of 143], respectively; X2(9) = 20; p = 0.02). Women assistant program directors had fewer years in practice (9 ± 4 years versus 14 ± 11 years [95% CI -10.5 to 1.6]; p = 0.045) and fewer publications (11 ± 7 versus 30 ± 48 [95% CI -32.9 to -5.8]; p = 0.01) than men. Women division chiefs had fewer years in practice and publications than men and were most prevalent in tumor and pediatrics (21% [10 of 48] and 16% [9 of 55], respectively) and least prevalent in spine and adult reconstruction (2% [1 of 60] and 1% [1 of 70], respectively) (X2(9) = 26; p = 0.001). Women program directors were more likely than men to stay at the same institution they studied at for medical school (39% [7 of 18] versus 14% [20 of 143]; odds ratio 3.9 [95% CI 1.4 to 11.3]; p = 0.02) and trained at for residency (61% [11 of 18] versus 42% [60 of 143]; OR 2.2 [95% CI 0.8 to 5.9]; p = 0.01). CONCLUSION:The higher percentage of women in junior leadership positions in orthopaedic surgery, with the data available, is a promising finding. Hand, tumor, and pediatrics appear to be orthopaedic subspecialties with a higher percentage of women. However, more improvement is needed to achieve gender parity in orthopaedics overall, and more information is needed in terms of publicly available information on gender representation in orthopaedic leadership. CLINICAL RELEVANCE:Proportional representation of women in orthopaedics is essential for quality musculoskeletal care, and proportional representation in leadership may help encourage women to apply to the specialty. Our findings suggest movement in an improving direction in this regard, though more progress is needed.

The dataset presented was collected via retrospective review from an orthopedic trauma database approved by the institutional review board at the author's institution from patients treated at any of the four hospitals serviced by the academic orthopedic surgery department. Femoral neck and intertrochanteric hip fracture patients from low energy mechanisms admitted between October 2014 and February 2020, were selected if they were age 55 or older and had recorded sex, body mass index (BMI), Charlson Comorbidity Index (CCI), American Society of Anaesthesiologists (ASA) physical status classification, Glasgow Coma Score, Abbreviated Injury Severity score for the chest, head and neck, and extremities, and ambulation status prior to injury. The resultant 1,590 subject dataset may be analysed via the supplied R statistical code to determine the frequency of equipoise in baseline and outcome variables from propensity matching via three matching schemes. The code implements three matching schemes including matching by (1) The Score for Trauma Triage in Geriatric and Middle-Aged (STTGMA) (2) CCI alone, or (3) a combination of sex, age, CCI and BMI. The code selects a subset of ten percent of hip fracture patients by a pseudorandom number generator (PRNG). The code matches the remaining patients 1:1 to the selected patients by propensity score generated by logistic regression of STTGMA, CCI, or a combination of sex, age, CCI and BMI using greedy nearest neighbor matching without replacement by the MatchIt package for R software. The code then compares matched cohorts by Chi-square, Fisher, or Mann-Whitney U test with significance level of 0.05 representing a 5% chance of significant differences due to random sampling of subjects. The supplied code repeats the random selection, matching and testing process 100,000 times for each matching method. The resultant code output is the frequency of significantly different demographic or outcome parameters among matched cohorts by matching method. This data and statistical code have reuse potential to explore alternative matching schemes. The supplied baseline variables should be robust enough to derive alternative risk scores for each patient which may be included as a matching variable for comparison. The authors also look forward to unexpected ways that this data may be used by readers.

In this study, we evaluated risk factors for gram-negative fracture-related infection in a mixed cohort of gram-positive and gram-negative fracture-related infections to guide perioperative antibiotic prophylaxis for surgical fixation of fractures. We performed a retrospective review of all patients with fracture who were treated at an urban academic level I trauma center between February 1, 2012, and June 30, 2017. Inclusion criteria were as follows: (1) open or closed fracture with internal fixation; (2) deep, acute to subacute (<6 weeks), culture-positive fracture-related infection; and (3) age 18 years or older. Infections were classified as gram positive, gram negative, or polymicrobial. Demographic, surgical, and postoperative characteristics were compared among groups. Of 3360 patients, 43 (1.3%) had a fracture-related infection (15 gram negative, 14 gram positive, and 14 polymicrobial). Risk factors for gram-negative infection included initial external fixation (P=.038), the need for soft tissue coverage of an open fracture site (P=.039), lower albumin level at the time of infection (P=.005), and hospitalization for longer than 10 days (P=.018). Perioperative gram-negative antibiotic prophylaxis for fracture fixation surgery should be considered for those who have been staged with external fixation, require soft tissue coverage, are at risk for malnutrition in the postoperative period, and have prolonged inpatient hospitalization. [Orthopedics. 20XX;XX(X):xx-xx.].