Faculty Bibliography

To determine the functional outcome and complications following dorsal plating for unstable fractures of the distal radius. We searched our IRB-approved Distal Radius Fracture Databases and identified all patients who were treated with a dorsally applied plate. Thirty-four distal radius fractures in 33 patients with a mean age of 50 years and average follow-up of 14 months were treated with a dorsal locking plate from 2007 to 2015. Fifteen and six patients had dorsal shearing fracture pattern and delayed presentation, respectively. There were no loss of reduction, malunion, or nonunion. Average VAS pain score was 2.1/10. Eight patients (23%) required hardware removal, one of which was due to extensor tendon rupture (3%) and five due to extensor tendon irritation (15%). Dorsal locked plating of distal radius fractures with newer low-profile implants is a viable option for particular fractures types, such as the dorsal rim shear type fractures.

OBJECTIVES/OBJECTIVE:To evaluate the causes of 30-day readmissions following orthopedic trauma surgery and classify them based on their relation to the index admission. DESIGN/METHODS:Retrospective chart review. SETTING/METHODS:One large, academic medical center. PARTICIPANTS/METHODS:Patients admitted to a large, academic medical center for a traumatic fracture injury over a nine-year period. INTERVENTION/METHODS:Assignment of readmission classification. MAIN OUTCOME MEASUREMENTS/METHODS:Readmissions within 30 days of discharge were identified and classified into: orthopedic complications; medical complications; and non-complications. A chi-square test was performed to assess any difference in the proportion of readmissions between the hospital-reported readmission rate and the orthopedic complication readmission rate. RESULTS:1,955 patients who were admitted between 2011-2018 for an acute orthopedic trauma fracture injury were identified. Eighty-nine patients were readmitted within 30 days of discharge with an overall readmission rate of 4.55%. Within the 30-day readmission cohort, 30 (33.7%) were the direct result of orthopedic treatment complications, 36 (40.4%) were unrelated medical conditions, and 23 (25.8%) were non-complications. Thus, the readmission rate directly due to orthopedic treatment complications was 1.53%. A chi-square test of homogeneity revealed a statistically significant difference between the hospital-reported readmission rate and the orthopedic-treatment complication readmission rate, p < .0005. CONCLUSION/CONCLUSIONS:The use of 30-day readmissions as a measure of hospital quality of care overreports the number of preventable readmissions and penalizes surgeons and hospitals for caring for patients with less optimal health. LEVEL OF EVIDENCE/METHODS:Diagnostic Level III.

INTRODUCTION/BACKGROUND:Total hip arthroplasty (THA) is often used for displaced femoral neck fracture. In this study, institutional hip arthroplasty data were compared with the National American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data for any differences in outcomes between our hospital, with an integrated hip fracture care pathway, and those of the country as a whole. METHODS:Elective THA was compared with arthroplasty performed for acute fracture. Outcomes for both groups included thromboembolic event (VTE), death, and deep prosthetic infection. RESULTS:Institutional data revealed no increased rate of infection after THA for fracture compared with elective. National Surgical Quality Improvement Program analysis revealed higher infection rates in fracture arthroplasty. There was an increased VTE rate in fracture performed for arthroplasty compared with elective in both institutional and NSQIP data. CONCLUSIONS:When performed at an academic medical center with an integrated care program, THA for fracture can have similar infection rates to elective THA. By contrast, national data showed significantly higher rates of infection and VTE for arthroplasty for fracture compared with elective. The contrast in complication rates may be related to well-functioning comprehensive interdisciplinary pathways. Patient-centered care pathways may be optimal for hip fracture patients.

Fracture-related infection (FRI) remains a challenging complication that imposes a heavy burden on orthopaedic trauma patients. The surgical management eradicates the local infectious focus and if necessary facilitates bone healing. Treatment success is associated with debridement of all dead and poorly vascularized tissue. Debridement is, however, often associated with formation of a dead space, which provides an ideal environment for bacteria and is a potential site for recurrent infection. Dead space management is therefore of critical importance. For this reason, the use of locally delivered antimicrobials has gained attention, not only for local antimicrobial activity, but also for dead space management. Local antimicrobial therapy has been widely studied in periprosthetic joint infection, without addressing the specific problems of FRI. Furthermore, the literature presents a wide array of methods and guidelines with respect to the use of local antimicrobials. The present review describes the scientific evidence related to dead space management with a focus on the currently available local antimicrobial strategies in the management of FRI. LEVEL OF EVIDENCE:: Level V.

CASE/METHODS:This report reviews 2 cases of chronic lower extremity pain after traumatic tibial shaft fractures treated with intramedullary nail fixation. After examination and radiographic evaluation, clinical suspicion and pressure manometry were used to identify fascial herniation and indicate patients for fasciotomy, which ultimately relieved pain. CONCLUSIONS:Lower extremity fascial hernias typically present with nonspecific chronic pain. Ultrasonography and magnetic resonance imaging (MRI) can be used to confirm diagnosis. However, in patients with implanted hardware, MRI may be ineffective in detecting hernias because of artifact. Clinical suspicion and pressure manometry are effective ways of identifying patients with this etiology of chronic pain.

Introduction/UNASSIGNED:Rising costs of post-acute care facilities for both the patient and payers make discharge home after hospital stay, with or without home help, a favorable alternative for all parties. Our objectives were to assess the effect of marital status, a large source of social support for many, on disposition following hospital stay. Methods/UNASSIGNED:Patients were prospectively entered into an institutional review board-approved, trauma database at a large, academic medical center. Patients aged 55 years or older with any fracture injury between 2014 and 2017 were included. Retrospectively, their relationship status was recorded through review of patient records. A status of "married" was separated from those with a status self-reported as "single," "divorced," or "widowed." Multinomial logistic regression was used to assess whether discharge location differs by marital status while controlling for demographics and injury characteristics. Results/UNASSIGNED:Of 1931 patients, 8.3% were divorced, 29.9% were single, 20.0% were widowed, and 41.8% were married. There was a significant correlation between discharge disposition and marital status. Single patients had 1.71 times, and widowed patients had 1.80 times, the odds of being discharged to a nursing home, long-term care facility, or skilled nursing facility compared to married patients after controlling for age, gender, Score for Trauma Triage in the Geriatric and Middle-Aged score, and insurance type. Additionally, single and widowed patients experienced 1.36 and 1.30 times longer length of hospital stay than their married counterparts, respectively. Discussion/UNASSIGNED:Patients who are identified as "single" or "widowed" should have early social work intervention to establish clear discharge expectations. Early intervention in this way would allow time for contact with close, living relatives or friends who may be able to provide sufficient support so that patients can return home. Increasing home discharge rates for these patients would reduce lengths of hospital stay and reduce post-acute care costs for both patient and payers without materially altering unplanned readmission rates.

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/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.