Faculty Bibliography

INTRODUCTION/BACKGROUND:The study aimed to investigate the efficacy of autogenous iliac crest bone graft (ICBG) compared with other graft types in achieving successful fracture nonunion repair. METHODS:An institutional review board-approved retrospective review of prospectively collected data was conducted on a consecutive series of patients surgically treated for fracture nonunions at an academic medical center between September 10, 2004, and August 20, 2023. Patients were analyzed based on which bone graft type-ICBG versus alternative graft types-used during their nonunion repair. Patient demographics, injury characteristics, and surgical history were compared. Outcomes included radiographic healing, time to union, postoperative complications, and revision rate. Cohorts were compared using an independent sample Student t-test for continuous variables and chi-square or Fisher exact tests for categorical variables. One-way analysis of variance with post hoc comparisons assessed differences across treatment strategy groups. RESULTS:Five hundred fifty-six patients were treated surgically for a fracture nonunion using standard internal fixation and a "bone graft" for biologic stimulation. 57.4% of these patients were treated with autogenous ICBG; 42.6% received alternative grafts (iliac crest aspirate, allograft, bone morphogenetic, reamer-irrigation aspirator, and/or demineralized bone matrix, without autogenous cancellous iliac crest). Compared with the alternative cohort, the ICBG cohort showed greater healing success after a single nonunion surgery (95.6% ICBG versus 86.9% alternative, P < 0.001) and faster healing times (4.8 ± 2.4 months versus 7.1 ± 4.9 months, P < 0.001). Complications at the ICBG harvest site included wound infections/hematomas and iliac wing fracture. No notable differences were found in positive cultures at the time of surgery, postoperative fracture-related infection, implant failure, or neurovascular injury. DISCUSSION/CONCLUSIONS:Using autogenous ICBG in the surgical repair of fracture nonunions was associated with higher healing rates compared with alternative graft types, supporting its continued role in enhancing bone healing outcomes, even in the face of infected nonunion.

OBJECTIVES/OBJECTIVE:The purpose of this study is twofold: (1) to reliably define the concept of "extreme tibial nailing" and (2) assess the feasibility of tibial intramedullary nailing when the fracture extends into the nail's locking bolt zone. METHODS:Design: A retrospective review. SETTING/METHODS:A single academic center comprised of a specialty orthopedic hospital and a Level I Trauma Center. Patient Selection Criteria: 543 patients who sustained 555 tibia fractures between February 2014 and January 2024 were reviewed by two board-certified orthopedic surgeons. Cases were classified as "extreme nailing" based on the tibial fracture within the most proximal or distal 25% of the bone such that the fracture extended into the locking bolt section of the intramedullary nail used to treat the fracture. Patients with supplemental periarticular plating of the tibia were excluded. Outcome Measures and Comparisons: Data collected included patient demographics, hospital metrics, and outcomes. RESULTS:Twenty-five tibial fractures treated met radiographic criterion. The "extreme IMN" cohort was 45.8 years, 72% female with a mean BMI of 26.6. Over half of fractures resulted from high-energy injuries, and 40% were open. Patients were hospitalized for 92.8 h on average, and the 90-day readmission rate was 8.0%. The average time to weight-bearing allowance was 5.2 weeks post-op. Eight (32.0%) patients experienced complications: 12% developed fracture-related infection (FRI), 4% experienced hardware complications, and 20.0% developed nonunion requiring surgery. The rate of all-cause reoperation was 32.0%, and 28% of patients experienced knee or ankle pain at 6 months or later. The rate of malalignment was 8.0%, and the average time to radiographic healing was 5.7 months. CONCLUSION/CONCLUSIONS:Tibial nailing is an effective treatment for "extreme" tibial fractures that extend as far as the articular surface and interlocking cluster on either end. The majority of patients who underwent extreme tibial nailing recovered with acceptable alignment, minimal healing complications, and achieved radiographic union within 6 months. LEVEL OF EVIDENCE/METHODS:III.

PURPOSE/OBJECTIVE:Evaluate healing outcomes of patients who sustained a comminuted clavicle fracture and underwent operative fixation using a bridge plate technique or interfragmentary screw/neutralization plate. METHODS:Two hundred and seventy-one comminuted clavicle fractures that underwent operative fixation with minimum 6 months follow-up were retrospectively reviewed. Patients were grouped based on fixation methods. Data collected include patient demographics and injury information. Fracture healing, total complications, fracture related infection, removal of hardware, nonunion, and revision fracture surgery were reviewed. Clinical healing was defined as non-tenderness about the fracture site, and radiographic healing was defined as bridging callus and/ or lack of fracture line on X-ray. Chi square analysis, T test, and linear regression were used for analysis. RESULTS:There were 126 comminuted fractures fixed with a bridge plate and 145 comminuted fractures fixed with a plate and at least one interfragmentary screw both with a mean follow-up of 8.2 months. The bridge plated group was more female, the result of high-energy mechanisms, and had more anteroinferior plates (p < 0.05 for all). There were no differences in time to radiographic healing as well as incidence of nonunion between cohorts. Patients fixed with the bridge plate technique underwent a higher incidence of revision surgery, higher incidence of hardware removal, and had a longer time until clinically healed. On multivariate regression analysis, fixation method was not associated with any of these outcomes (p < 0.05 for all). CONCLUSION/CONCLUSIONS:Bridge plating and lag screw/neutralization plate fixation were both associated with similar rates of healing. Complication profiles were similar.

METHODS:This study assessed the safety of the lateral femoral cutaneous and over the hip (LOH) block, a regional anesthetic, in anticoagulated hip fracture patients while maintaining efficacy. A retrospective review of patients diagnosed with hip fractures (AO/OTA 31A/B) who presented to a single academic medical center and level 1 trauma center actively using oral anticoagulants. Patients were grouped based on anesthesia type: LOH block (LOH) versus general anesthesia (GA) and LOH versus spinal anesthesia (SA). LOH patients were matched based on anticoagulant type, OTA/AO classification, and risk (STTGMA) score with a 3:1 ratio to GA and a 1:1 ratio to SA. Outcome comparisons included: time to surgery, operative and anesthesia time, and bleeding complications, demographics (age, sex, race, BMI, CCI, and STTGMA), postoperative complications, 90-day readmission rates, mortality within 1 year, and discharge location. RESULTS:A total of 135 patients: 27 LOH, 27 SA, and 81 GA, were analyzed. Compared to GA, LOH block patients had a shorter time to surgery (1.31 ± 0.082 vs. 0.89 ± 0.69, p = 0.014), lower rates of 90-day readmission (3.7% vs. 19.8%, p = 0.047), and a greater discharge to home with health services rate (33.3% vs. 8.6%, p = 0.024). The GA population trended-toward more major complications (p = 0.077) and mortality within 1 year (p = 0.077). Compared to SA, LOH patients were slightly underweight (25.1 ± 4.19 vs. 22.7 ± 4.16, p = 0.035) and got to surgery faster (0.89 ± 0.69 vs 1.54 ± 1.48, p = 0.039). Across all groups, there were no differences in the need for blood transfusion or other quality markers. CONCLUSION/CONCLUSIONS:The LOH block was safe and effective for use in anticoagulated hip fracture patients. This technique provided an intraoperative safety profile similar to other anesthetic choices, allowed for less delay to surgery compared to spinal anesthesia and improved discharge parameters compared to GA. LEVEL OF EVIDENCE III/METHODS:Prognostic Level III.

INTRODUCTION/BACKGROUND:Several types of fifth metatarsal (MT) fractures exist and are treated with various methods of immobilization, weight bearing restrictions, and occasionally operative procedures. This study evaluated the differences in clinical and radiographic outcomes among pseudo-Jones fractures (Zones 1 and 2), true Jones fractures (Zone 3), and fifth metatarsal shaft and neck fractures. METHODS:A retrospective review of a consecutive series of patients presenting to a single academic medical center with a fifth metatarsal fracture between 2012 and 2022 was conducted. Radiographs obtained at the initial presentation were reviewed, and fracture patterns were categorized as either Zone 1, Zone 2, Zone 3, shaft, neck, or head fractures. RESULTS:In total, 1314 patients with isolated fifth metatarsal fractures were treated (mean age = 49.6 ± 18.0 years). In total, 1217 fractures (92.5%) were initially treated nonoperatively, and 97 fractures (7.5%) were treated operatively. The overall time to clinical and radiographic healing for all fifth metatarsal fractures treated nonoperatively was 9.9 ± 8.7 weeks and 17.9 ± 15.6 weeks, respectively (P = .245, P = .088). Immediate weightbearing led to a faster time to clinical healing by (P = .035). There was no statistically significant difference in time to clinical or radiographic union among the different fracture types (P = .496, P = .400). Likewise, there was no evidence of any difference in time to clinical or radiographic union for patients treated operatively versus nonoperatively (P > .05). CONCLUSION/CONCLUSIONS:.

INTRODUCTION/BACKGROUND:To evaluate the impact of prolonged GLP-1 usage on mortality, readmission, incidence of in-hospital complications, and incidence of implant failure following hip fracture surgery across various BMI strata. METHODS:A prospective hip fracture registry (2014-2024) at a single institution was used to identify 58 obese patients on prolonged GLP-1 therapy at the time of injury. These patients (Group A) were matched by age, fracture pattern, and comorbidity burden to BMI-based control cohorts: normal (Group B), overweight (Group C), and obese (Group D). Postoperative complication rates, readmissions, and implant failures were compared. Major complications were defined as events needing further procedures, extended hospitalization, or causing significant functional impairment. Minor complications were those managed with minimal treatment. Statistical analysis included ANOVA, chi-square, and post hoc residual testing. Data were analyzed using IBM SPSS Statistics (Version 21.0, Chicago, IL). RESULTS: ≈ 17.33, p < 0.001): 22.41% in Group A, 55.17% in Group B, 51.72% in Group C, and 60.34% in Group D. Group D exhibited significantly higher 30-day (17.24%, p < 0.001) and 90-day (24.14%, p < 0.05) readmission rates. No significant differences were observed in major complications, hardware failure incidence, or 30-day or 1-year. CONCLUSIONS: ≥ 6 months of continuous GLP-1 receptor agonist therapy was associated with a reduction in 30-day and 90-day readmission rates and overall and minor in-hospital complications in obese patients undergoing hip fracture surgery. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND/UNASSIGNED:The purpose of this study was to examine factors that were associated with a decline in functional ambulatory status following fractures of the tibial diaphysis. METHODS/UNASSIGNED:A retrospective review of an IRB-approved tibial diaphysis fracture database from 2012 to 2024 was conducted. Inclusion criteria were age ≥18, isolated OTA 42A-C tibia fracture treated with an intramedullary nail, and minimum 12 months follow-up. Demographics, injury, and surgical information were collected. Functional ambulatory status was measured at routine follow up intervals by the Functional Ambulatory Category (FAC) score, a six-point scale where zero represents non-ambulation and five represents normal ambulatory ability. Univariate analysis was performed using Student's T-tests and Chi-squared tests. A backwards stepwise multivariate logistic regression analysis was performed to determine factors that were independently associated with a decline in FAC score (SPSS version 29, Armonk, NY). RESULTS/UNASSIGNED:289 patients, with a mean follow up time of 15.04 ± 6.18 months, were included in the analysis with a mean age of 43.24 ± 16.22 years, body mass index of 27.19 ± 6.30, and age-unadjusted Charlson Comorbidity Index of 0.18 ± 0.54. 39.1 % of patients were female, 28.0 % patients sustained open fractures, and 52.6 % sustained high energy injuries. The logistic regression demonstrated that older age (OR = 1.04 p < .001), higher BMI (OR = 1.06 p = .024), high-energy mechanism (OR = 3.18 p = .003), nonunion (OR = 3.66, p = .005), and concomitant lower extremity fractures (OR = 4.47 p = 002), were risk factors for a decrease in final FAC score. The AUROC of the logistic regression equation was 0.787 indicating a moderate ability to discriminate between patients that will experience a loss in functional ambulatory ability and those who will not. CONCLUSION/UNASSIGNED:This study suggests that concomitant lower extremity injuries, increased age, increased BMI, high-energy mechanisms, and nonunion are risk factors that are associated with a decline in ambulatory capacity following diaphyseal tibia fractures.

PURPOSE/OBJECTIVE:The purpose of this study is to examine the effect of age on outcomes following repair of acute displaced patella fractures Methods: 248 patients who sustained a displaced patella fracture and underwent open reduction and internal fixation were identified. Patients included underwent a similar operative protocol, were prescribed a standard post-operative protocol of therapy, and were seen at standard follow-up intervals. Patients were divided into groups of < 65 years old (young) and ≥ 65 years old (older). Statistical analysis was run to determine if there was a significant difference in range of knee motion and rate of major complications. RESULTS:Of the 248 patients, 149 were young and 99 were older. The mean age of the older group was 74.5 ± 6.7 and the mean age of the young group was 50 ± 12. Fracture pattern and BMI were similar the groups, however the older group had a higher average CCI (p<0.001). Additionally, the groups had similar length of follow up (p=0.693) and similar mean time to radiographic healing (p=0.533). Older patients had limited knee extension at 6 months (compared young patients (p=0.031). Finally, older patients had a higher rate of all complications compared to young patients. Two percent of older patients developed a fracture related infection (FRI), 4% developed a symptomatic nonunion and 11% were underwent re-operation including removal of hardware, total knee replacement, irrigation and debridement and manipulation under anesthesia. CONCLUSION/CONCLUSIONS:Complication rates following patella fracture fixation in older patients were higher than young patients, despite having similar injury patterns, surgical treatment and follow up. These findings can better inform treating physicians during surgical intervention of older patients with patella fractures.

PURPOSE/OBJECTIVE:To assess the healing outcomes of patients who sustained a comminuted clavicle fracture and underwent operative fixation with or without the addition of demineralized bone matrix (DBM). METHODS:A total of 271 comminuted midshaft clavicle fractures that presented to our hospital system and underwent operative fixation with a plate and screw construct were retrospectively reviewed. Data collected include patient demographics, initial injury information, and use of demineralized bone matrix during surgery to enhance bone healing. Patients were grouped based on whether or not their fixation was augmented with DBM. Fracture-related infection (FRI), lack of fracture healing, and the need for revision fracture surgery were reviewed. Adhesive capsulitis of the shoulder and screw back out were categorized as "minor complications." Clinical healing was defined as non-tenderness about the fracture site, and radiographic healing was defined as presence of bridging callus and lack of fracture line on X-ray. Chi-square, T-test, and linear regression analysis were used to determine any significant differences between cohorts. RESULTS:Sixty-nine patients had DBM used in their repair, and 202 patients did not. Cohorts had a similar follow-up (range: 6-18 months). There were no differences in patient demographics or fracture pattern between the two groups (P > 0.05 for all). There were no differences in major and minor complications; however, the cohort treated with DBM had shorter time to radiographic healing, confirmed with regression analysis (P < 0.05). CONCLUSION/CONCLUSIONS:Augmentation of midshaft clavicle fracture constructs with DBM was associated with quicker radiographic healing.

A single-stage operative repair of terrible triad injuries through a laterally-based approach using arthroscopic instrument-assisted reduction of the coronoid fracture in cases in which the radial head is deemed appropriate for repair rather than arthroplasty is described in this technical trick. Using an arthroscopic suture lasso, adjustable drill guides, cannulated guide-pins with nitinol shuttling wires, and a suspensory cortical button allow for a more precise and facile technique of "lasso" fixation of coronoid fractures and anterior capsular injuries with intact radial heads in terrible triad injuries.