Faculty Bibliography

Purpose/UNASSIGNED:The purpose of this study was 2-fold: 1) to investigate the age-related frequency, demographics and distribution of the middle-aged and geriatric orthopedic trauma population and 2) to describe the age-related frequency and distribution of hospital quality measure outcomes and inpatient cost. Methods/UNASSIGNED:All patients > 55 years of age who required orthopedic, trauma, or neurosurgery consults at 3 hospitals within an academic medical center from 2014 to 2017 were prospectively followed. On initial evaluation, each patient's demographics, injury severity, and functional status were collected. Patients were grouped into low and high-energy mechanism cohorts and divided into 5 groups based on age. Hospital quality measures including length of stay, complications, discharge location, and cost of care was compared between age groups. Data were analyzed using ANOVA and Chi-square tests. Results/UNASSIGNED:A total of 3965 patients were included in this study of which 3268 (82%) sustained low-energy trauma and 697 (18%) sustained high-energy trauma. With increasing age, more patients had more comorbidities, were less likely to be community ambulators, and more likely to use assistive devices (p < 0.05). Patients in older age groups had longer lengths of stay, more complications, were more likely to need ICU level care, and were less likely to be discharged home (p < 0.05). Rates of mortality were also greater in patients of more advanced age in both low and high-energy cohorts, and the calculated risk triage tool (STTGMA) score increased with each age bracket (p < 0.05). Total cost of care differed between age groups in the low-energy cohort (p = 0.003). Conclusion/UNASSIGNED:This epidemiological study provides a clear picture of the frequency and distribution of demographic, physiologic characteristics, outcomes, and cost of care in a middle-aged and geriatric orthopedic trauma population as evaluated by the STTGMA risk tool. Risk profiling of geriatric trauma patients allows for the establishment of baseline norms.

INTRODUCTION/BACKGROUND:Nonunion of a femoral periprosthetic fracture is a rare occurrence in orthopedic practice. Failure of a periprosthetic fracture to heal can lead to substantial disability and pain for patients as well as the potential need for component revision. Relatively little literature exists describing their management and outcome. METHODS:Eleven patients with femoral periprosthetic fracture nonunion who presented for tertiary care were enrolled in a prospective data registry. Patients were considered to have developed nonunion following failure of progression in radiographic and clinical healing for a 6-month period. All patients were seen at standard postoperative intervals, and outcomes were recorded using the Short Musculoskeletal Function Assessment (SMFA), visual analog scale (VAS) for pain, physical examination, and radiographic examination. Preoperative radiographs were reviewed for classification. RESULTS:Eleven patients had periprosthetic femoral fracture nonunion associated with prior hip (five patients) or knee (six patients) arthroplasty and were included in our study. Mean follow-up time was 30 months. Mean age at time of nonunion surgery was 64.5 years (range: 41.8 to 78.2 years). All patients underwent removal of previous fracture hardware at time of nonunion surgery. Ten (91%) of 11 received autogenous iliac crest bone grafting at time of nonunion surgery. Ten (91%) of the 11 patients went on to union without further intervention. Mean time to union was 7.9 months (SD: 8.0). The one patient that developed a persistent nonunion was complicated by infection requiring multiple irrigation and debridement procedures and total hip explant. The mean improvement in total SMFA score from baseline to final follow-up was 22.6 (p = 0.030). The greatest functional improvement was in the bothersome index at 28.0 (p = 0.028). The mean improvement in VAS pain score from baseline to final follow-up was 4.5 (p = 0.013). DISCUSSION/CONCLUSIONS:Periprosthetic fracture nonunions can be successfully treated with operative intervention aimed at compression plating with bone graft and retention of primary components. In addition, successful periprosthetic nonunion repair improves function and pain in these patients.

OBJECTIVES:(1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING:One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS:One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION:The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS:Inpatient and 30-day mortality, major, and minor complications. RESULTS:Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION:The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Introduction/UNASSIGNED:This study sought to investigate whether a validated trauma triage risk assessment tool can predict time to surgery and delay to surgery. Materials and Methods/UNASSIGNED:Patients aged 55 and older who were admitted for operative repair or arthroplasty of a hip fracture over a 3-year period at a single academic institution were included. Risk quartiles were constructed using Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) calculations. Negative binomial and multivariable logistic regression were used to evaluate time to surgery and delay to surgery, respectively. Pairwise comparisons were performed to evaluate 30-day mortality rates and demonstrate the effectiveness of the STTGMA tool in triaging mortality risk. Results/UNASSIGNED:= .046). Discussion/UNASSIGNED:Patients in higher STTGMA quartiles encountered longer time to surgery, greater operative delays, and higher 30-day mortality. Conclusion/UNASSIGNED:Score for Trauma Triage in the Geriatric and Middle-Aged can quickly identify hip fracture patients at risk for a delay to surgery and may allow treatment teams to optimize surgical timing by proactively targeting these patients. Level of Evidence/UNASSIGNED:Prognostic Level III.

BACKGROUND:The number of individuals turning to cycling for physical activity and commuting has been expanding across the US. However, studies have demonstrated that when compared to motor vehicle accidents, cyclists in major cities have a significantly increased risk of injuries requiring hospitalizations. The purpose of this study was to assess if a correlation exists between the growing cyclist volume in a densely populated metropolitan city and prevalence of clavicle fractures requiring inpatient hospital admissions. HYPOTHESIS/OBJECTIVE:A correlation exists between the increased number of cyclists and the increasing number of clavicle fractures requiring inpatient hospital admissions. METHODS:Patients who sustained a clavicle fracture that required an inpatient admission were identified using the New York Statewide Planning and Research Cooperative System (SPARCS). The location of hospital admission was screened using New York City (NYC) hospital county codes, as only clavicle fractures presenting to NYC hospitals were included in the analysis. This study was exempt from Institutional Review Board (IRB) approval. Public transportation data was available through the Department of Transportation (DOT) and The Decennial Census. These databases are publicly available and are performed to assess if New Yorkers are using cycling as a mode of transportation. The cycling data included the following information in a given year: the number of people in NYC who use a bicycle as their primary mode of commuting to work, the number of daily cycling trips, total bicycle protected bike lane mileage, midtown Manhattan cycling counts and East River Bridge cycling counts. Spearman's correlation analysis was conducted between the numbers of patients with clavicle fractures per year and the described data for that specific year. Additionally, the number of bicycle-share program miles traveled per month and total number of cycling trips that month were obtained from the public bicycle-sharing program database from June 2013 through June 2015. Spearman's correlation analysis was conducted between the numbers of patients with clavicle fractures per month and total bicycle-sharing miles and trips traveled per month. RESULTS:The increasing daily cycling trips in NYC has a strong correlation with the increasing number of clavicle fractures in NYC (rs = .979, p < 0.001). The increasing use of a bicycle as transportation to work has a strong positive correlation with the increasing number of clavicle fractures in NYC (rs = .988, p < 0.001). There was a strong positive correlation between the mileage of bicycle lanes in NYC and the number of clavicle fractures (rs = .867, p = 0.001). A strong positive correlation exists between NYC clavicle fracture number and public bicycle-sharing miles (rs = .819, p < 0.001) and trips (rs = .811, p < 0.001). CONCLUSION/CONCLUSIONS:There are many physical benefits to cycling. Cycling, as a means of transportation, has been encouraged to decrease CO2 emissions from vehicular transportation. These benefits do not come without risks, as this study shows a correlation between increased cycling and clavicle fractures. CLINICAL RELEVANCE/CONCLUSIONS:Physicians and public health officials should be aware of the dangers of cycling in major cities in order to create safer routes for this environmentally beneficial route of transportation.

BACKGROUND/UNASSIGNED:The purpose of this study was to identify characteristic patterns of syndesmotic screw (SS) failure, and any effects on clinical outcome. METHODS/UNASSIGNED:A retrospective study was performed using a consecutive series of patients treated with open reduction and internal fixation with trans-syndesmotic screws for unstable ankle fractures with syndesmotic injury between 2015 and 2017. Patient demographics, fracture characteristics and classification, rates and patterns of trans-syndesmotic screw breakage, and backout were analyzed. Functional outcome was assessed using passive range of motion (ROM) and Maryland Foot Score (MFS). RESULTS/UNASSIGNED:> .07). CONCLUSION/UNASSIGNED:Syndesmotic screw breakage was common in younger, male patients. Despite similarities in ankle range of motion and clinical outcome scores to patients with intact screws, there was a trend towards more frequent screw removal. This information can be used to counsel patients pre- and postoperatively regarding the potential for screw failure and subsequent implant removal. LEVEL OF EVIDENCE/UNASSIGNED:Level III, retrospective case-control study.

OBJECTIVES/OBJECTIVE:To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN/METHODS:Prospective cohort study SETTING:: Seven musculoskeletal care centers with New York City and Long Island. PATIENTS/PARTICIPANTS/METHODS:138 recent and 115 historical hip fracture patients. INTERVENTION/METHODS:Patients with hip fractures occurring between February 1, 2020 and April 15, 2020 or between February 1, 2019 and April 15, 2019 were prospectively enrolled in an orthopedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs) or COVID negative (C-). MAIN OUTCOME MEASUREMENTS/METHODS:Hospital quality measures, inpatient complications and mortality rates. RESULTS:Seventeen (12.2%) patients were confirmed C+ by testing and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared to Cs and C- cohorts, had: an increased mortality rate (35.3% vs 7.1% vs 0.9%), increased length of hospital stay, a greater major complication rate and a greater incidence of ventilator need postoperatively. CONCLUSIONS:COVID-19 had a devastating effect on the care of hip fracture patients during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in hip fracture patients complicated by COVID-19. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

OBJECTIVES/OBJECTIVE:To develop a tool that can be used preoperatively to identify patients at risk of poor functional outcome following operative repair of fracture nonunion. DESIGN/METHODS:Retrospective analysis of prospectively collected data. SETTING/METHODS:Academic medical center. PATIENTS/PARTICIPANTS/METHODS:Three hundred twenty-eight patients who underwent operative repair of a fracture nonunion were prospectively followed for a minimum of 12 months post-operatively. INTERVENTION/METHODS:After randomization, 223 (68%) patients comprised an experimental cohort and 105 (32%) patients comprised a separate validation cohort. Within the experimental cohort, forward stepwise multivariate logistic regression was applied to 17 independent variables to generate a predictive model identifying patients at risk of having a poor functional outcome [Predicting Risk of Function in Trauma-Nonunion (PRoFiT-NU) Score]. MAIN OUTCOME MEASUREMENTS/METHODS:Functional outcomes were assessed using the Short Musculoskeletal Function Assessment (SMFA). Poor outcome was defined as an SMFA function index greater than 10 points above the mean at 12 months post-operatively. RESULTS:Significant predictors of poor outcome were lower extremity nonunion [odds ratio (OR) = 3.082; P = 0.021], tobacco use (OR = 2.994; P = 0.009), worker's compensation insurance (OR = 3.986; P = 0.005), radiographic bone loss (OR = 2.397; P = 0.040), and preoperative SMFA function index (OR = 1.027; P = 0.001). The PRoFiT-NU model was significant and a good predictor of poor functional outcome (χ(5) = 51.98, P < 0.0005; area under the receiver operating curve = 0.79). Within the separate validation cohort, 16% of patients had a poor outcome at a PRoFiT-NU score below 25% (low risk), 39% of patients had a poor outcome at a PRoFiT-NU score between 25% and 50% (intermediate risk), and 63% of patients had a poor outcome at a PRoFiT-NU score above 50% (high risk). CONCLUSIONS:The PRoFiT-NU score is an accurate predictor of poor functional outcome following fracture nonunion repair. LEVEL OF EVIDENCE/METHODS:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence description of levels of evidence.

AIMS/OBJECTIVE:Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients' long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques. METHODS:-test. RESULTS:Patient-reported functional outcomes as assessed by overall SMFA were statistically significantly improved at five years (p < 0.001) compared with one-year data from the same patients. Patients additionally reported an improvement in the Standardized Mobility Index (p < 0.001), Standardized Emotional Index (p < 0.001), as well as improvement in Standardized Bothersome Index (p = 0.003) between the first year and latest follow-up. Patient-reported pain and knee ROM were similar at five years to their one-year follow-up. In total, 15 of the patients had undergone subsequent orthopaedic surgery for their knees at the time of most recent follow-up. Of note, only one patient had undergone knee arthroplasty following plateau fixation related to post-traumatic osteoarthritis (OA). CONCLUSION/CONCLUSIONS:2020;102-B(5):632-637.