Faculty Bibliography

OBJECTIVES/OBJECTIVE:To develop a tool that can be used preoperatively to identify patients at risk of poor functional outcome following operative repair of fracture nonunion. DESIGN/METHODS:Retrospective analysis of prospectively collected data. SETTING/METHODS:Academic medical center. PATIENTS/PARTICIPANTS/METHODS:Three hundred twenty-eight patients who underwent operative repair of a fracture nonunion were prospectively followed for a minimum of 12 months post-operatively. INTERVENTION/METHODS:After randomization, 223 (68%) patients comprised an experimental cohort and 105 (32%) patients comprised a separate validation cohort. Within the experimental cohort, forward stepwise multivariate logistic regression was applied to 17 independent variables to generate a predictive model identifying patients at risk of having a poor functional outcome [Predicting Risk of Function in Trauma-Nonunion (PRoFiT-NU) Score]. MAIN OUTCOME MEASUREMENTS/METHODS:Functional outcomes were assessed using the Short Musculoskeletal Function Assessment (SMFA). Poor outcome was defined as an SMFA function index greater than 10 points above the mean at 12 months post-operatively. RESULTS:Significant predictors of poor outcome were lower extremity nonunion [odds ratio (OR) = 3.082; P = 0.021], tobacco use (OR = 2.994; P = 0.009), worker's compensation insurance (OR = 3.986; P = 0.005), radiographic bone loss (OR = 2.397; P = 0.040), and preoperative SMFA function index (OR = 1.027; P = 0.001). The PRoFiT-NU model was significant and a good predictor of poor functional outcome (χ(5) = 51.98, P < 0.0005; area under the receiver operating curve = 0.79). Within the separate validation cohort, 16% of patients had a poor outcome at a PRoFiT-NU score below 25% (low risk), 39% of patients had a poor outcome at a PRoFiT-NU score between 25% and 50% (intermediate risk), and 63% of patients had a poor outcome at a PRoFiT-NU score above 50% (high risk). CONCLUSIONS:The PRoFiT-NU score is an accurate predictor of poor functional outcome following fracture nonunion repair. LEVEL OF EVIDENCE/METHODS:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence description of levels of evidence.

AIMS/OBJECTIVE:Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients' long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques. METHODS:-test. RESULTS:Patient-reported functional outcomes as assessed by overall SMFA were statistically significantly improved at five years (p < 0.001) compared with one-year data from the same patients. Patients additionally reported an improvement in the Standardized Mobility Index (p < 0.001), Standardized Emotional Index (p < 0.001), as well as improvement in Standardized Bothersome Index (p = 0.003) between the first year and latest follow-up. Patient-reported pain and knee ROM were similar at five years to their one-year follow-up. In total, 15 of the patients had undergone subsequent orthopaedic surgery for their knees at the time of most recent follow-up. Of note, only one patient had undergone knee arthroplasty following plateau fixation related to post-traumatic osteoarthritis (OA). CONCLUSION/CONCLUSIONS:2020;102-B(5):632-637.

OBJECTIVES/OBJECTIVE:To determine whether a validated trauma triage tool can identify which middle-aged and geriatric trauma patients with tibial shaft and plateau fractures are at risk for costly admissions and poorer hospital quality measures. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Level 1 trauma center. PATIENTS/PARTICIPANTS/METHODS:64 patients over the age of 55 hospitalized with isolated tibial shaft or plateau fractures. INTERVENTION/METHODS:Patients with either isolated tibial plateau fractures or tibial shaft fractures over a three year period were prospectively enrolled in an orthopedic trauma registry. Demographic information, injury severity, and comorbidities were assessed and incorporated into the STTGMA score, a validated trauma triage score that calculates inpatient mortality risk upon admission. Patients were then grouped into tertiles based on their STTGMA score. MAIN OUTCOME MEASUREMENTS/METHODS:Length of stay, complications, discharge location, and direct variable costs. RESULTS:64 patients met inclusion criteria. 33 (51.6%) patients presented with tibial plateau fractures and 31 (48.4%) with tibial shaft fractures. The mean age was 66.7 ± 10.2 years. Mean length of stay was significantly different between risk groups with a mean of 6.8 ± 4 days (p<0.001). While 19 (90.5%) of minimal risk patients were discharged home, only 7 (33.3%) and 5 (22.7%) of moderate and high-risk patients were discharged home, respectively (p<0.001). Higher risk patients experienced a significantly greater number of complications during hospitalization but had no differences in the need for ICU level care (p=0.027 and p=0.344, respectively). The total cost difference between the lowest and highest risk group was nearly 50% ($14070 ± 8056 vs $25147 ± 14471, mean difference $11077; p=0.022). CONCLUSION/CONCLUSIONS:Application of the STTGMA triage tool allows for prediction of key hospital quality measures and cost of hospitalization that can improve clinical decision-making. LEVEL OF EVIDENCE/METHODS:Prognostic Level III.

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/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 infections (FRIs) are among the most common complications following fracture fixation, and they have a huge economic and functional impact on patients. Because consensus guidelines with respect to prevention, diagnosis, and treatment of this major complication are scarce, delegates from different countries gathered in Philadelphia in July 2018 as part of the Second International Consensus Meeting (ICM) on Musculoskeletal Infection. This paper summarizes the discussion and recommendations from that consensus meeting, using the Delphi technique, with a focus on FRIs. A standardized definition that was based on diagnostic criteria was endorsed, which will hopefully improve reporting and research on FRIs in the future. Furthermore, this paper provides a grade of evidence (strong, moderate, limited, or consensus) for strategies and practices that prevent and treat infection. The grade of evidence is based on the quality of evidence as utilized by the American Academy of Orthopaedic Surgeons. The guidelines presented herein focus not only on the appropriate use of antibiotics, but also on practices for the timing of fracture fixation, soft-tissue coverage, and bone defect and hardware management. We hope that this summary as well as the full document by the International Consensus Group are utilized by those who are charged with musculoskeletal care internationally to optimize their management strategies for the prevention and treatment of FRIs.

INTRODUCTION/BACKGROUND:Burnout is an occupational hazard for physicians at all stages of training and medical practice. The purpose of the current study was to determine whether residency factors, with the use of an activity monitor, including the amount of exercise, have any impact on burnout among orthopaedic surgery residents in varying years of training. METHODS:Orthopaedic residents at a single institution were recruited immediately before beginning a new clinical rotation and followed for four weeks. On enrollment, the participants were given a wrist-worn activity monitor (Fitbit Flex) and instructed on its use for tracking physical activity. REDCap was used to collect burnout levels (as assessed by using the Maslach Burnout Inventory and the Patient Health Questionnaire-9), which were completed a total of five times, once at enrollment and weekly during the study period. RESULTS:Twenty-seven residents were enrolled, including 13 junior residents (interns and second years) and 14 senior residents (third, fourth, and fifth years). Seven residents were on fracture rotations, whereas 20 were not. As measured by using the Maslach Burnout Inventory, juniors were more emotionally exhausted (P = 0.01) and depersonalized (P = 0.027). No difference in the objective physical activity data as measured by using the Fitbit Flex and no difference in the self-reported hours of sleep were observed. Residents on orthopaedic trauma rotations also reported significantly higher rates of emotional exhaustion and depersonalization (P < 0.001) than other residents and were more physically active on average (P < 0.030). DISCUSSION/CONCLUSIONS:Although depersonalization and depression are common symptoms seen among orthopaedic surgery residents, this study demonstrated that quality of life improves markedly as they progress through their residency training. Residents on orthopedic trauma rotations have greater levels of emotional exhaustion and depersonalization. This pilot study suggests that burnout prevention programs should begin at the start of training to provide residents with strategies to combat and then reinforced while on orthopaedic trauma rotations. LEVEL OF EVIDENCE/METHODS:Level III Diagnostic Study.

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/OBJECTIVE:The purpose of this study is to determine if the radiographic humerus union measurement (RHUM) is predictive of union in humeral shaft fractures treated nonoperatively. METHODS:All patients with long bone fracture nonunion presenting to a single surgeon were enrolled in a prospective registry. This registry was queried to identify patients with humeral shaft fractures treated nonoperatively and developed nonunion. The nonunion cohort was matched to a three to one gender- and age-matched control group that were treated nonoperatively for a humeral shaft fracture and achieved union. Two fellowship-trained orthopedic traumatologists blinded to eventual union scored radiographs obtained 12 weeks after injury using the RHUM. A binomial logistic regression determined the effect of the RHUM on the likelihood of developing union. RESULTS:Nine patients with humeral shaft fractures treated nonoperatively with radiographs 12 weeks after injury that developed nonunion were identified. These patients were matched to 27 controls. Logistic regression demonstrated the RHUM was a significant predictor of healing 12 weeks after humeral shaft fracture treated nonoperatively (p = 0.014, odds ratio 9.434, 95% CI for OR 1.586-56.098). All patients with RHUM below 7 went on to nonunion. All patients with RHUM above 8 healed. Three of seven patients (43%) with RHUM of 7 or 8 healed. CONCLUSION/CONCLUSIONS:The RHUM demonstrated an increased likelihood of achieving union 12 weeks after injury. Orthopedic surgeons can counsel patients that fractures with RHUM scores of 6 or below are in danger of developing nonunion and can target interventions appropriately.