Faculty Bibliography

OBJECTIVES/OBJECTIVE:To evaluate the clinical and functional outcomes after operative repair of nonunited lower extremity fractures initially repaired outside the developed Western world. DESIGN/METHODS:Retrospective analysis of prospectively collected data. SETTING/METHODS:Academic medical center. PATIENTS/PARTICIPANTS/METHODS:From September 2004 through February 2017, 227 patients who underwent operative repair of a lower extremity fracture nonunion were prospectively enrolled in a research registry. All patients underwent previous fracture surgery and had at least 12 months of postoperative follow-up. INTERVENTION/METHODS:Repair of lower extremity fracture nonunion. MAIN OUTCOME MEASUREMENTS/METHODS:Postoperative complications, reoperation rate, time to union, and functional outcomes were assessed using the Short Musculoskeletal Function Assessment and Visual Analog Scale pain scores. Univariate and multivariate analyses were performed to evaluate the differences in patients who underwent initial fracture repair outside the developed Western world as opposed to within the United States. RESULTS:Twenty-one patients (9.3%) underwent initial fracture repair outside the developed Western world. These patients had a greater incidence of infected nonunions (47.6% vs. 23.3%; P = 0.015) and failure of a previous implant at the time of presentation (52.4% vs. 22.8%; P = 0.003) than those initially managed within the United States. This cohort also experienced a greater rate of postoperative complications after nonunion repair (23.8% vs. 6.3%; P = 0.016). The geographic location of initial fracture repair was not associated with postoperative Short Musculoskeletal Function Assessment scores or Visual Analog Scale pain scores after controlling for possible confounding variables. CONCLUSIONS:Patients who present with a nonunited lower extremity fracture initially repaired outside the developed Western world experience a high rate of postoperative complications after fracture nonunion repair but can expect good short- and long-term functional outcomes. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:To investigate the ability of a validated geriatric trauma risk prediction tool to stratify hospital quality metrics and inpatient cost for middle-aged and geriatric patients admitted from the ED for operative treatment of an ankle fracture. DESIGN/METHODS:Prospective cohort study SETTING:: Single Academic Medical Center PATIENTS:: Patients aged 55 and older who sustained a rotational ankle fracture and were treated operatively during their index hospitalization INTERVENTION:: Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), using patient's demographic, injury severity, and functional status. Patients were stratified into groups based on scores to create a minimal-, low-, moderate-, and high-risk cohort. MAIN OUTCOME MEASUREMENTS/METHODS:length of stay, complications, need for ICU/SDU level care, discharge location, and index admission costs RESULTS:: Fifty ankle fracture patients met inclusion criteria. Mean length of stay was 7.8 ± 5.2 days with a significant difference among the four risk groups (4.6 day difference between low and high risk). 73.1% of minimal risk patients were discharged home compared to 0% of high-risk patients. There was no difference in complication rate or in need for ICU level care between groups. However, high-risk patients had a mean total inpatient cost two times greater than that of minimal risk patients. CONCLUSION/CONCLUSIONS:The STTGMA tool is able to meaningfully stratify older ankle fracture patients requiring operative fixation with regards to hospital quality metrics and cost. This information may allow for efficient targeted reductions in costs while optimizing outcomes. LEVEL OF EVIDENCE/METHODS:Prognostic, Level III.

Background/UNASSIGNED:The purpose of this study is to evaluate the ability of preoperative and postoperative radiographic union scores for tibia fractures (RUST) to predict treatment success of tibia fracture nonunion. Materials and methods/UNASSIGNED:Patients presenting for operative treatment of tibia fracture nonunion were enrolled in a prospective data registry. Enrolled patients were followed at regular intervals for 12 months. Preoperative and 12 week postoperative radiographs were reviewed and scored using the RUST criteria. Postoperative time to union was determined by clinical and radiographic measures. Multivariate regressions were conducted to predict time to union using preoperative and postoperative RUST while controlling for treatment method. Receiver operating characteristic (ROC) curve was conducted to determine the accuracy of preoperative RUST in predicting failure of treatment. Results/UNASSIGNED:Sixty-eight patients with aseptic tibia fracture nonunion treated operatively were identified. Sixty-one patients achieved union. Mean preoperative RUST was 7.5 (SD 1.4). Mean postoperative RUST was 9.2 (SD 1.4). Multivariate linear regressions demonstrated that preoperative (p = 0.043) and postoperative (p = 0.007) RUST are significant predictors of time to union after tibia fracture nonunion surgery. ROC curve demonstrated preoperative RUST below 7 was a good predictor of developing persistent tibia fracture nonunion (AUC = 0.83, Sensitivity = 1.000, Specificity = 0.745). Conclusions/UNASSIGNED:RUST preoperatively and postoperatively predicts outcome after nonunion surgery. RUST can be used as part of the complete clinical picture to shape patient expectations and guide treatment.

CASE/METHODS:An 65-year-old immunocompetent female developed a Leclercia adecarboxylata infection following the repair of closed olecranon fracture. L. adecarboxylata is associated with polymicrobial infections, infections in immunocompromised patients and penetrating or open wounds. Following speciation, intravenous ceftriaxone was started. Two weeks later, the patient presented with leukopenia and neutropenia. Per infectious disease recommendations, the patient was switched to intravenous ertapenem with resolution of both infection and neutropenia. The olecranon fracture went on to heal fully. CONCLUSIONS:This case describes a rare postoperative monomicrobial infection with L. adecarboxylata in an immunocompetent host following musculoskeletal trauma and identifies L. adecarboxylata as a potential emerging hospital-acquired pathogen following orthopedic surgery.

BACKGROUND/UNASSIGNED:The purpose of this study was to determine the efficacy of medial malleolar fixation with 1 vs 2 screws. METHODS/UNASSIGNED:Between April 2013 and February 2017, 196 patients who presented at 2 hospitals within one academic institution with an unstable rotational ankle fracture with a medial fracture and were treated operatively by a trained orthopedic surgeon were identified. These patients' charts were reviewed and their injury, radiographic, surgical, and follow-up data recorded. Medial malleolus fragment size was assessed on the anteroposterior (AP) and lateral views of the initial injury radiograph. Functional outcome was assessed using Maryland Foot Score (MFS). Patients were grouped based upon the number of screws utilized to fox the medial malleolar fragment. Data were assessed using Fisher exact tests and independent t tests with SPSS, version 23. RESULTS/UNASSIGNED:Out of the 196 patients who met inclusion criteria, 47 patients (24%) were fixed with 1 medial malleolar screw and 149 patients (76%) were fixed with 2 screws. There were no differences among patients who received 1 vs 2 screws with regard to age, gender, body mass index, American Society of Anesthesiologists grade, or smoking status. The average malleolar fragment size was smaller in those treated with 1 screw on both the AP and lateral radiographic views than those with 2 screws ( P = .009, P = .001, respectively). There was no difference between groups in ankle dorsiflexion or plantarflexion at 1 year postoperation ( P = .451, P = .581). Patients who received 1 screw did not differ from those who received 2 screws with respect to Maryland Foot Scores ( P = .924). There was no difference in rate of revision surgery or need for hardware removal between groups ( P = .093). Furthermore, time to healing and postoperative complication rate did not differ between groups. CONCLUSION/UNASSIGNED:The use of a single screw for medial malleolar fixation provided stable fixation to allow ankle fracture healing, without an increase in complications. This information is especially important in situations when the fragment is too small to accommodate multiple fixation points. LEVEL OF EVIDENCE/UNASSIGNED:Level III, retrospective case-control study.

BACKGROUND:Little evidence regarding the extent of recovery of radial nerve lesions with associated humerus trauma exists. The aim of this study is to examine the incidence and resolution of types of radial nerve palsy (RNP) in operative and nonoperative humeral shaft fracture populations. MATERIALS AND METHODS/METHODS:Radial nerve lesions were identified as complete (RNPc), which included motor and sensory loss, and incomplete (RNPi), which included sensory-only lesions. Charts were reviewed for treatment type, radial nerve status, RNP resolution time, and follow-up time. Descriptive statistics were used to document incidence of RNP and time to resolution. Independent-samples t-test was used to determine significant differences between RNP resolution time in operative and nonoperative cohorts. RESULTS:A total of 175 patients (77 operative, 98 nonoperative) with diaphyseal humeral shaft injury between 2007 and 2016 were identified and treated. Seventeen out of 77 (22.1%) patients treated operatively were diagnosed preoperatively with a radial nerve lesion. Two (2.6%) patients developed secondary RNPc postoperatively. Eight out of 98 (8.2%) patients presented with RNP postinjury for nonoperatively treated humeral shaft fracture. All patients who presented with either RNPc, RNPi, or iatrogenic RNP had complete resolution of their RNP. No statistically significant difference was found in recovery time when comparing the operative versus nonoperative RNPc, operative versus nonoperative RNPi, or RNPc versus RNPi patient groups. CONCLUSIONS:All 27 (100%) patients presenting with or developing radial nerve palsy in our study recovered. No patient required further surgery for radial nerve palsy. Radial nerve exploration in conjunction with open reduction and internal fixation (ORIF) appears to facilitate speedier resolution of RNP when directly compared with observation in nonoperative cases, although not statistically significantly so. These findings provide surgeons valuable information they can share with patients who sustain radial nerve injury with associated humerus shaft fracture or nonunion. LEVEL OF EVIDENCE/METHODS:Level III treatment study.

The purpose of this study was to evaluate whether patients with hip fractures receiving antiplatelet and direct oral anticoagulants treated within 48 hours of admission had worse surgical and clinical outcomes than those whose surgery was delayed more than 48 hours. Consecutive patients 55 years and older with an operatively treated hip fracture were analyzed. Patients receiving the following anticoagulants were included: antiplatelet drugs, factor Xa inhibitors, and direct thrombin inhibitors. Outcomes included surgical blood loss, procedure time, transfusion requirement, length of stay, complication rate, and need for intensive care unit or step-down unit level care. Patients who underwent surgery within 48 hours of presentation were compared with patients whose surgery was delayed more than 48 hours. Of 551 consecutive operative hip fracture patients, 78 (14.2%) were receiving the anticoagulant medications included in this study. Of these 78 patients, 58 had surgery within 48 hours and 20 had surgery after 48 hours. When comparing the early and delayed fixation cohorts, there was no difference in transfusion requirement, length of surgery, or blood loss. Type of anticoagulant made no difference in transfusion requirement, blood loss, or length of surgery. There was also no difference in the mean number of complications or in the need for intensive care unit or step-down unit level care. In this study, patients receiving antiplatelet therapy, factor Xa inhibitors, or direct thrombin inhibitors who underwent surgical fixation of their hip fracture within 48 hours of admission were at no higher risk for transfusion, increased surgical blood loss, longer operative time, or inpatient mortality. [Orthopedics. 201x; xx(x):xx-xx.].

OBJECTIVES/OBJECTIVE:Analyze the effectiveness of a BPCI (Bundle Payments for Care Improvement) initiative at a large urban medical center for hip fracture patients included in the bundle payment program with respect to improving patient outcomes and reducing cost DESIGN:: Retrospective cohort SETTING:: Single Academic Institution PATIENTS/PARTICIPANTS:: Patients discharged with the DRG codes 469-470 performed for hip fractures between July 2011 and September 2014 were evaluated. A BPCI initiative focused on optimizing care coordination, patient education, expectations, and minimizing post-acute facility and resource utilization was initiated in October 2013. Patient outcomes prior to the introduction of the BPCI initiative were compared to those who participated in the initiative. INTERVENTION/METHODS:Application of BPCI principles MAIN OUTCOME MEASURES:: length of stay, location of discharge, readmission within 90 days, and 90-day episode of care costs RESULTS:: Sixty-one patients received care prior to the initiative, and forty-four patients were treated with the initiative. The mean length of stay decreased from 6.8 to 5.3 days and the percentage of patients discharged home increased by nearly 10% with the introduction of the BPCI initiative (6.6% vs. 15.9%). There was a 13.1% reduction in total 90-day episode of care cost ($57,546 vs. $49,993, p=0.210) upon introduction of the initiative. There was no significant difference in readmission rate between the two cohorts. CONCLUSION/CONCLUSIONS:This study demonstrates the success of one such program for hip fracture arthroplasty patients aimed at care coordination and minimizing post-acute hospitalization facility care both with respect to improved patient outcomes and substantial cost reduction. LEVEL OF EVIDENCE/METHODS:Therapeutic Level IV.

PURPOSE/OBJECTIVE:The purpose of this study was to determine the effect of regional anaesthesia as compared to general anaesthesia on clinical, functional, and radiographic outcomes following long bone fracture nonunion repair. METHODS:262 patients who underwent operative repair of a long bone fracture nonunion and had at least 12 months of post-operative follow up were included in this study. Functional outcomes were assessed prospectively using the Short Musculoskeletal Function Assessment (SMFA) and Visual Analog Scale (VAS) pain scores prior to nonunion repair and at routine intervals post-operatively. Patients were divided into two matched groups based upon the type of anaesthetic method used in surgery. The regional anaesthesia cohort was composed of all patients who received regional anaesthesia (spinal anaesthesia or peripheral nerve block) alone or in addition to general anaesthesia, while patients who received general anaesthesia alone made up the general anaesthesia cohort. Univariate and multivariate analyses were performed to examine the effect of anaesthesia type on functional outcome scores, post-operative pain, bony healing, and complication rate. RESULTS:The regional anaesthesia and general anaesthesia cohorts each consisted of 131 patients. Multiple linear regression demonstrated there to be no significant association between anaesthetic method and total SMFA scores at all post-operative time points. Additionally, anaesthetic method was not associated with post-operative VAS pain scores, time to union, or the rate of post-operative complications. CONCLUSION/CONCLUSIONS:In this cohort, the use of regional anaesthesia during operative repair of long bone fracture nonunion was associated with no significant difference in functional outcome scores or pain levels at all post-operative time points. Furthermore, the use of regional anaesthesia had no effect on the rate of post-operative complications. Either type of anaesthetic appears to be safe and effective in performing these surgeries.

BACKGROUND:Socioeconomic disparities are an inherent and currently unavoidable aspect of medicine. Knowledge of these disparities is an essential component towards medical decision making, particularly among an increasingly diverse population. While healthcare disparities have been elucidated in a wide variety of orthopaedic conditions and management options, they have not been established among patients who present for treatment of an ununited fracture. The purpose of this study is to answer the following questions: 1) Following surgical management of (fracture) non-unions, are there differences in outcomes between differing ethnic groups? 2) Following surgical management of (fracture) non-unions, are there differences in outcomes between patients with differing education levels? 3) Following surgical management of (fracture) non-unions, are there differences in outcome between patients with differing incomes? METHODS:Between September 2004 and December 2017, operatively treated patients who presented with a long bone fracture non-union were prospectively followed. These patients presented with a variety of fracture non-unions that underwent surgical intervention. Sociodemographic factors were recorded at presentation. Long-term outcomes were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, post-operative complications and physical exam at latest follow up. The SMFA is a 46-item questionnaire, assessing patient functional and emotional response to musculoskeletal ailments. RESULTS:Three-hundred-twenty-nine patients met inclusion criteria. Patients with a lower education had worse long-term functional outcomes (P < 0.001) and increased pain scores (P = 0.002) at latest follow-up. Patients who made less than $50,000 annually had worse long-term functional outcomes (P = 0.002) and reported higher pain scores (P = 0.003) following surgical management of (fracture) non-unions. Multiple linear regression demonstrated education level to be an independent predictor of long-term functional outcomes following surgical management of (fracture) non-unions (B= -0.154, 95% Confidence Interval [CI]=-10.96 to -1.26, P = 0.014). No differences existed in outcomes or pain scores between those of different ethnic groups. No differences existed regarding post-operative complications and time to union between patients of different ethnic groups, educational levels and income status. CONCLUSION/CONCLUSIONS:Patients with lower education levels and individuals who make less than $50,000 annually have worse functional outcomes following surgical management of (fracture) non-unions. Orthopaedic trauma surgeons should therefore be aware of these disparities, and consider early interventions aimed at optimizing patient recovery in these subsets.