Faculty Bibliography

OBJECTIVES/OBJECTIVE:To identify factors associated with the need for reoperations in patients treated surgically for fracture nonunion. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:One urban Level 1 trauma center and an orthopaedic specialty hospital. PATIENTS/PARTICIPANTS/METHODS:This study included 365 patients who did not and 95 patients who did undergo a reoperation after nonunion repair. INTERVENTION/METHODS:All patients who underwent fracture nonunion repair were identified. Baseline demographic, injury, and surgical information were collected. These factors were compared between patients who did and did not require an unplanned reoperation. MAIN OUTCOME MEASUREMENTS/METHODS:An unplanned reoperation after index fracture nonunion surgery. RESULTS:When compared with patients who did not undergo a reoperation after their index fracture nonunion surgery, patients who underwent at least 1 reoperation had a greater proportion of those who sustained an open fracture, a high-energy injury, initial neurologic or vascular injuries, the need for a flap or soft tissue graft at initial treatment, and lower extremity injuries with univariate analysis. Unplanned reoperation was also associated with diagnosis of "infected" nonunion at initial nonunion surgery. Multivariate analysis confirmed initial nerve or vascular injuries and positive infection status were statistically significant predictors of a reoperation. CONCLUSIONS:Initial injury characteristics such as nerve or vascular injury at initial injury and positive infection status at the index nonunion surgery were associated with the need for a secondary surgery after nonunion repair. Appropriate care of these patients should be aimed at adjusting expectations of unplanned reoperation in the future and potentially enhanced treatment strategies. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background/UNASSIGNED:Inaccuracy of ankle syndesmotic repair via reduction and trans-syndesmotic fixation can occur during ankle fracture repair. The goal of this study was to determine whether reduction and fixation of the posterior malleolar fracture (PM) fragment in rotational ankle fractures reduces the need for independent syndesmotic screw fixation. Methods/UNASSIGNED:A retrospective study was conducted using a consecutive series of patients treated operatively for a rotationally unstable ankle fracture with a PM fragment between 2011-2017. All ankle fractures underwent open reduction and internal fixation and divided into two groups: PM fixed or not fixed. An intraoperative stress evaluation of the ankle following bony fixation was performed in all cases to evaluate syndesmotic instability. Patient and fracture characteristics, and intraoperative instability and trans-syndesmotic fixation were compared between both groups. Results/UNASSIGNED:Eighty-five unstable ankle fractures that had a PM fragment were identified. Forty-three fractures underwent PM fixation and 42 did not. There were no differences between the PM fixation groups with regard to age, gender, body mass index or fracture pattern (p>0.183 for all). On average, PM fragments in the fixed group were larger than those not fixed (p<0.001). There were significantly lower odds of needing syndesmotic fixation if the PM fragment was reduced and fixed (p<0.001). Only 2 out of 43 ankles with a fixed PM fragment underwent syndesmotic fixation compared with 34 out of 42 non-fixed PM fragments. Conclusion/UNASSIGNED:.

INTRODUCTION/BACKGROUND:The purpose of this study is to evaluate the relationship between patients' own health expectations and treatment outcomes following surgical repair of proximal humerus fractures. HYPOTHESIS/OBJECTIVE:Patients' health expectations will correlate with treatment outcomes following surgical repair of proximal humerus fractures. MATERIAL AND METHODS/METHODS:Over a 14-year period, 247 patients with a displaced proximal humerus fracture who underwent ORIF with locking compression plates were prospectively followed at one academic institution. Minimum follow-up period was 12 months. Patient-reported functional outcome data for the latest follow up visit (12 months and greater) was obtained from Disabilities of Arm, Shoulder, and Hand (DASH) questionnaires. Survey responses regarding health expectations were recorded at 3-month follow-up and converted to dichotomous variables. Two groups were identified: the high expectations and the low expectations groups. Statistical analysis comparing the two groups and their functional and clinical outcomes was performed using the independent t-test, using p<0.05 for significance. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to further statistically characterize the relationship between health expectations at 3 months and long-term outcomes. RESULTS:One hundred and eighty-five (75.0%) patients available for analysis with a mean follow-up length of 24.8 months. The cohort included 124 (67%) females and 61 (33%) males and the average age at time of injury was 59.5 years. Eighty-six (46.5%) patients had low expectations for their overall health and 99 (53.5%) patients had high expectations for their health. No significant differences were seen between groups in regards to age, gender, follow-up length, Charlson Comorbidity Index (CCI), smoking and tobacco use, fracture pattern (OTA and Neer classifications), early complications (p>0.05), fracture healing, and avascular necrosis. The mean DASH score at the latest follow up for patients with low expectations was 31.42±22.8 whereas the mean for those with high expectations was 16.76±20.2 (p<0.0005). The mean forward flexion of the shoulder for patients with low expectations was 137.8±31.5 degrees as compared to 148.5±26.3 degrees (p<0.05). The positive predictive value of good expectations correlating with good outcomes was 71.7%. DISCUSSION/CONCLUSIONS:Patients with high expectations for their health early following injury had better outcomes in the long term. These high expectations also appeared to have an optimal influence on range of shoulder motion. This data suggests attitudinal and psychological factors that affect patient health expectations early on in the course of treatment may also influence patients' functional and clinical outcomes. LEVEL OF EVIDENCE/METHODS:II; Retrospective Study.

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.

»:Tranexamic acid (TXA) is a drug used to control hemorrhage by preventing the breakdown of fibrin. »:TXA is a cost-effective treatment for trauma patients across a variety of economic settings. »:Concerns of TXA causing thromboembolic events (TEEs) in orthopaedic trauma patients are not supported by evidence. »:TXA has been shown to reduce blood loss in hip fracture surgery.

SUMMARY:High-energy tibial plateau fractures are associated with knee fracture dislocations and concomitant ligamentous injury. Both bony and ligamentous injuries can require surgical fixation, often requiring a multidisciplinary team and staged treatment. This article and accompanying video describe the workup and treatment of a Moore type 4 tibial plateau rim compression fracture with posterolateral corner and anterior cruciate ligament rupture that underwent open reduction internal fixation of the tibial plateau with posterolateral corner reconstruction and then staged anterior cruciate ligament reconstruction with quad tendon autograft.

SUMMARY:There are a variety of treatment options available for proximal humerus fractures, including nonoperative management, open reduction internal fixation with screws, locking plates, intramedullary nailing, or suture fixation, and arthroplasty, including hemiarthroplasty and total shoulder replacements. Fracture characteristics, including the number of fracture parts and involvement of the humeral head and glenoid and the patient's functional status and postoperative goals help dictate the optimal choice. Although the indications for hemiarthroplasty as treatment for severe proximal humerus fractures have narrowed, the authors believe that there is a still a place for this technique in practice.

SUMMARY:A 58-year-old woman with a proximal 1/3 humeral shaft nonunion presented 2 years after initial injury. We present a technique for nonunion repair, including nonunion site preparation, direct compression of the fracture site using plate osteosynthesis, and iliac crest bone graft harvest and utilization. The purpose of this video is to review humeral shaft nonunion literature and describe our management technique.