Faculty Bibliography

INTRODUCTION:Urinary tract infection (UTI) complications are often attributed to the inappropriate use of urinary catheters. PURPOSE:We sought to examine the effectiveness of a hospital-wide policy aimed at reducing the use of indwelling Foley catheters. METHODS:We completed a retrospective review of prospectively collected data on 577 hip and femur fracture patients aged 55 years and older who were operatively treated at a Level 1 trauma center between October 2014 and March 2019. New standard-of-care guidelines restricting the use of indwelling Foley catheters were implemented starting January 2018, and we compared perioperative outcomes between cohorts. RESULTS:Over a 50% absolute reduction in indwelling Foley catheter use and a near 30% relative reduction in hospital-acquired UTI were achieved. Postpolicy cohort patients without indwelling Foley catheters experienced lower odds of hospital-acquired UTI, higher odds of home discharge, as well as decreased time to surgery, shorter length of stay, and lower total inpatient cost compared with those with indwelling Foley catheters. CONCLUSIONS:The policy of restricting indwelling Foley catheter placement was safe and effective. A decrease in indwelling Foley catheter use led to a decrease in the rate of hospital-acquired UTI and positively affected other perioperative outcomes.

The purpose of this study was to compare the functional outcomes of diabetic patients who were treated for a fracture nonunion against matched controls. Sixty-one diabetic patients (type 1 or type 2) were identified from a prospective database. This cohort was paired with matched controls and univariate analysis was performed to evaluate for differences in complication rates, time to bony union and functional outcomes at 3, 6, 12, and greater than 24 months post-operatively.The diabetic group was composed of 29 females and 32 males, with an average age of 58 years, and 17 upper extremity nonunions and 43 lower extremity nonunions. Time to bony union, complication rate or functional outcomes at any follow-up time point did not significantly differ between groups. The comorbidity of diabetes mellitus does not lead to worse functional outcomes or increased complications following surgical treatment for a fracture nonunion.

Background/UNASSIGNED:Orthopedic surgeons use radiographs to determine degrees of fracture healing, guide progression of clinical care, and assist in determining weight bearing and removal of immobilization. However, no gold standard exists to determine the progression of healing of humeral shaft fractures treated non-operatively. Purpose/UNASSIGNED:The purpose of this study was to determine whether a scale comparable to the modified Radiographic Union Score for Tibial (RUST) fractures applied to non-operatively treated humeral shaft fractures can increase interobserver reliability in determining fracture healing. Methods/UNASSIGNED:A retrospective review was undertaken by three orthopedic traumatologists and one musculoskeletal radiologist, who evaluated 50 sets of anteroposterior and lateral radiographs, presented at random, of non-operatively treated humeral shaft fractures at various stages of healing from 17 patients. The radiographs were scored using a modified RUST scale called the Radiographic Humerus Union Measurement (RHUM). Observers were blinded to the time from injury. After a 4-week washout period, observers again scored the same radiographs. Observers classified each fracture as either healed or not healed based on the combination of radiographs. Inter- and intraobserver reliability of the RHUM were determined using an intraclass correlation coefficient (ICC). Interobserver reliability of determining a healed fracture was calculated using Cohen's kappa (κ) statistics. A receiver operator characteristic curve was conducted to determine the RHUM score predictive of a fracture being considered healed. Results/UNASSIGNED:ICC demonstrated almost perfect interobserver reliability (ICC, 0.838; ICC 95% CI, 0.765 to 0.896) and intraobserver reliability (ICC range, 0.822 to 0.948) of the RHUM. κ demonstrated substantial agreement between observers in considering a fracture healed (κ = 0.647). Receiver operating characteristic (ROC) curve demonstrated that a RHUM of 10 or higher is an excellent predictor of the observer considering the fracture healed (area under the ROC curve = 0.946, specificity = 0.957, 95% CI specificity, 0.916 to 0.979). Conclusions/UNASSIGNED:This cortical scoring system has excellent interobserver reliability in humeral shaft fractures treated non-operatively. Consistent with previous cortical scoring systems, a RHUM score of 10 or above can be considered radiographically healed.

BACKGROUND:The purpose of this study was to compare the long-term functional status of patients treated surgically for a clavicular nonunion using patients treated either op-eratively or non-operatively for an acute clavicle fracture as a comparison group. METHODS:Twenty consecutive patients treated by a single surgeon for a clavicle fracture nonunion were identified. For comparison of outcomes, acute clavicle fractures were identified from an electronic medical record (EMR) query of the same orthopedic surgeon. Ninety acute clavicle fracture patients were identified and 27 (30%) patients were available for long-term follow-up. Clavicular nonunions were compared to acute clavicle fracture patients in a univariate analysis then a multivariate analysis to analyze clavicle nonunion patients against operative and non-operative acute clavicle fracture patients. The main outcome measures were time to bony union, postoperative complications, visual analog scale (VAS) pain scores, and Short Musculoskeletal Functional Assessment (SMFA) scores at long-term follow-up. RESULTS:There was no difference in time to healing or functional outcomes as assessed by SMFA and VAS pain scores between clavicle nonunion and acute fracture patients. Postoperative complications also did not differ between the groups. CONCLUSIONS:Patients who are treated surgically for clavicular nonunions ultimately regain a similar functional status as patients who are treated either operatively or non-operatively for an acute clavicle fracture and heal acutely.

Olecranon osteotomy allows for improved visualization of the distal humeral articular surface. This study compared the clinical outcomes of 2 methods of olecranon repair following olecranon osteotomy as part of distal humerus fracture repair. This was a retrospective review of distal humerus fractures treated via a transolecranon approach during a 9-year period. In each case, the olecranon osteotomy was fixed with either tension band wiring (TBW) or plate fixation (PF). Patient demographics, injury information, and surgical management were recorded. Measured outcomes included elbow motion, time to osteotomy union, and postoperative complications. Mayo Elbow Performance Index (MEPI) scores were obtained for all patients. Forty-eight patients were included. All patients had intra-articular AO type 13-C2 or 13-C3 distal humerus fractures and underwent open reduction and internal fixation (ORIF) with olecranon osteotomy. Mean documented follow-up was 20.5 months. Twenty-seven patients had fixation of the olecranon osteotomy with TBW, and 21 with PF. Clinically, there were no differences in osteotomy time to union, elbow motion, or MEPI score at final follow-up. However, patients fixed with TBW had greater elbow extension at both 6-month and final follow-up. Complication rates did not differ. Patients undergoing TBW or PF for repair of an olecranon osteotomy following ORIF of intra-articular distal humerus fractures have similar outcomes. Patients undergoing osteotomy PF may experience less terminal elbow extension when compared with those fixed with TBW. Given their similar clinical outcomes, either modality may be considered when selecting a construct for olecranon osteotomy repair as part of comminuted distal humerus fracture repair. [Orthopedics. 2021;44(x):xx-xx.].

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.

CASE/METHODS:Two patients who developed radial nerve palsy at least 6 weeks after injury during nonoperative treatment of humeral shaft fractures. This complication was associated with external bracing, progressive varus angulation during treatment, and excess callus formation. CONCLUSION/CONCLUSIONS:Delayed radial nerve palsy may develop during nonoperative treatment of humeral shaft fractures when functional bracing fails to maintain alignment and stability at the fracture site.

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.