Faculty Bibliography

BACKGROUND: Operation choice is a complex decision in the surgical management of proximal humerus fractures. Recently, there has been an increase in the use of total shoulder arthroplasty (TSA) for complex fracture patterns. HYPOTHESIS: Patients with proximal humerus fractures who receive TSA are more likely to have higher hospital charges and a prolonged length of stay relative to patients receiving hemiarthroplasty (HA), open reduction with internal fixation (ORIF) or closed reduction with internal fixation (CRIF). MATERIALS AND METHODS: A statewide electronic database was used to identify 13,316 hospital admissions from 2000-2011 were a proximal humerus fracture was surgically managed in an effort to determine the effect of operation choice on cost and length of stay. A univariate analysis was preformed to examine overall trends in surgical management. Additionally, a periodic, multivariate logistic regression analysis was used to determine how operation choice affected the odds of a high cost hospital stay or a prolonged length of stay after controlling for age, comorbidity burden, gender, and insurance type. RESULTS: After controlling for confounding factors, patients receiving total shoulder arthroplasty (TSA) were 2.25 times more likely to have high total hospital charges than patients receiving HA and 3.21 times more likely than patients receiving ORIF. Additionally, TSA was found to be a significant negative predictor of prolonged length of stay (pLOS). HA, ORIF and CRIF did not significantly predict pLOS. DISCUSSION: The use of TSA for acute proximal humerus fractures is associated with increased hospital costs despite a shorter length of stay when compared to other operative choices. As reverse total shoulder arthroplasty becomes more popular for treatment of this injury, it is important that functional outcomes be interpreted in the context of relative cost trade-offs. LEVEL OF EVIDENCE: Level IV.

BACKGROUND: Although most humeral nonunions are successfully treated with a single procedure, some humeral nonunions are more difficult to heal and require multiple procedures. Current literature does not provide evidence describing how the prognosis for surgical repair in patients who develop humeral diaphyseal nonunions may be affected by initial operative versus nonoperative treatment. QUESTIONS/PURPOSES: The purpose of this study was to assess whether operative versus nonoperative treatment of acute humeral shaft fractures impacts outcome of subsequent repairs of humeral nonunions (NU) including the need for additional surgery and a comparison of pain relief (Visual Analogue Scale for pain) and functional outcome (Short Musculoskeletal Functional Assessment). METHODS: Thirty-four patients with humeral shaft nonunion were evaluated of which 15 patients had been treated operatively (OF), and 19 patients had been treated nonoperatively (NO) for their initial humerus shaft fracture. All patients underwent plating with autogenous bone graft or allograft +/- bone morphogenic protein (BMP) 2 or 7 as their final NU repair surgery prior to healing. We compared functional outcome and pain for both cohorts and determined risk factors for requiring more than 1 nonunion repair surgery. RESULTS: The mean time of final follow-up was 14.7 +/- 10.4 months. Thirty-three of 34 NUs (97.1%) healed. Patients who underwent OF of their original fracture were more likely to require more than 1 NU repair surgery (66.7 vs. 0%, p < 0.01). Of the 15 patients who underwent initial OF, 33.0% required 1 NU surgery, 33.0% required 2 NU surgeries, and 33.0% required 3 NU surgeries. Patients who underwent initial OF were more likely to require >6 months to achieve union (40.0 vs. 10.5%, p = 0.04). At final follow-up, there was no difference in functional outcome or pain scores. Initial OF was the only independent predictor of needing more than 1 NU repair surgery (OR 70.1 CI 2.8-1762.3) to achieve healing. CONCLUSION: Humeral shaft nonunions following initial operative fixation of the index fracture is more resistant to achieving union when compared to nonunions forming after initial nonoperative treatment. When final healing is achieved, there is no difference in function or pain.

Background Displaced tibial plateau fractures often require surgical treatment and plate and screw constructs are the most common method of fixation. There has been increased usage of locking plate technology for both complex and simple fracture patterns without any evidence demonstrating their advantage. Purpose The purpose of this study was to compare the clinical use of locked versus nonlocked plating for repair of displaced Schatzker type-II (OTA Type 41B) tibial plateau fractures. Methods Seventy-seven consecutive patients treated operatively with one of two types of plate and screw constructs in a nonrandomized fashion for Schatzker type II tibial plateau fractures and they were prospectively followed over a 5-year period. A total of 35 (45.5%) patients were treated using a locked plate and screw construct and 42 (54.5%) patients were treated with a nonlocked plate and screw construct. All patients received the same pre- and postoperative care and there was no difference in plate morphology and length between cohorts. Clinical outcomes were assessed using Short Musculoskeletal Functional Assessment (SMFA) scores, Visual Analogue Score for pain, and knee ranges of motion. Radiographic outcome was assessed with plain radiographs at all follow-up points. Implant costs for both types of constructs were calculated from hospital purchasing records. Results Patients were assessed at a mean period of 18.5 months (range: 12-72 months). There was no difference in demographic factors, physical examination parameters, radiographic outcomes, and SMFA scores between cohorts. In terms of cost, the cost of locked construct was $905 more than the nonlocked construct. Conclusion Based on clinical outcomes and cost per implant, we found no evidence to support the routine use of locked plating for simple split depression fractures of the lateral tibial plateau. The use of standard nonlocked, precontoured implants provides adequate fixation for these fracture patterns.

OBJECTIVE: To investigate the impact of post-traumatic humeral shaft malalignment on the ability to position the hand in space. METHODS: Two unique models were created: a cadaver model and a computerized 3-dimensional model. In the cadaveric model, a midshaft transverse osteotomy of the humerus was created to simulate fracture. The osteotomy was fixed in varying degrees of coronal and sagittal malalignment. The hand's ability to reach six different bony landmarks was assessed as a surrogate measure of function. Subsequently, a healthy male volunteer underwent full body magnetic resonance imaging with subsequent 3D skeletal recreation. A 'virtual' midshaft transverse osteotomy was created. The osteotomy was angulated in various degrees of coronal and sagittal malalignment and the hand's ability to reach the same six bony landmarks was measured. RESULTS: In the cadaver model, varus angulation was better tolerated than valgus and sagittal deformity. Varus deformity less than 25 degrees did not have a negative influence. Valgus angulation of 20 degrees resulted in a more severe deficit. Estimated function of the upper extremity was most sensitive to sagittal deformity. These trends were confirmed in the 3D model. CONCLUSIONS: The direction and magnitude of post-traumatic humeral shaft malalignment independently affect the ability to position the hand in space, a surrogate measure of function. Upper extremity function may be more sensitive to post-traumatic humeral shaft malalignment than previously reported. Clinical studies investigating the impact of humeral shaft malalignment on functional use of the upper extremity are warranted to clinically confirm these findings.

BACKGROUND: To compare 30-day outcomes in patients treated for a distal femur (DF) fracture with plate fixation (PF) or intramedullary nail (IMN). METHODS: Differences in rates of any adverse events (AAE), serious adverse events (SAE), infectious complications, and mortality were explored between groups in the ACS-NSQIP database. RESULTS: There were 511 PF and 44 IMN patients. The PF group and IMN groups had similar rates of AAEs (p = 0.35), SAEs (p = 0.46), infectious complications (p = 1.00), and mortality (p = 0.39). CONCLUSIONS: DF fractures treated with IMN have equivalent short-term outcomes compared to those treated with PF.

OBJECTIVE: There continues to be controversy over whether operative delay is necessary for patients on antiplatelet therapy, particularly for elderly patients with hip fractures. This study sought to assess current clinical practices of orthopedic surgeons regarding perioperative management of these patients. METHODS: A 12-question, Web-based survey was distributed to orthopedic surgeons via e-mail. Questions regarding timing of surgery assumed patients were on antiplatelet therapy and assessed attitudes toward emergent and nonemergent orthopedic cases as well as operative delay for specific closed fracture types. Responses were compared using unpaired, 2-tailed Student t tests for continuous variables and Pearson chi-square tests with odds ratios (ORs) and 95% confidence intervals (CIs) for categorical variables. Statistical significance was defined as a P value <.05. RESULTS: Overall 67 orthopedic surgeons responded. Fifty-two percent (n = 35) of the respondents described their practice as academic. Thirty-nine percent (n = 25) of the surgeons indicated that no delay was acceptable for urgent but nonemergent surgery, and 78% (n = 50) reported no delay for emergent surgery was acceptable. Sixty-eight percent (n = 46) of respondents felt patients on antiplatelet therapy with closed hip fractures did not require operative delay. Surgeons who opted for surgical delay in hip fractures were more likely to delay surgery in other lower extremity fracture types (OR = 16.4, 95% CI 4.48-60.61, P < .001). Sixty-four percent (n = 41) of the surgeons indicated there was no protocol in place at their institution. CONCLUSIONS: There continues to be wide variability among orthopedic surgeons with regard to management of patients with fracture on antiplatelet therapy. Over a quarter of surgeons continue to opt for surgical delay in patients with hip fracture. This survey highlights the need to formulate and better disseminate practice management guidelines for patients with fracture on antiplatelet therapy, particularly given the aging population in the United States.

PURPOSE: To compare and contrast postoperative complications in the geriatric population following open reduction and internal fixation (ORIF) for (DF) fractures relative to femoral neck (FN) fractures. METHODS: Patients aged 65 years and older in the American College of Surgeons National Surgical Quality Improvement Program database who underwent ORIF for FN fractures or DF fractures from 2005 to 2012 were identified. Differences in rates of any adverse events (AAEs), serious adverse events (SAEs), infectious complications, and mortality between groups were explored using univariate and multivariate analyses. RESULTS: The DF cohort had a higher proportion of females (81.95% vs 71.35%, P < .001), were younger (79.41 +/- 7.93 vs 82.11 +/- 7.26 years old, P < .001), and had a lower age adjusted modified Charlson comorbidity index score (4.22 +/- 1.32 vs 4.49 +/- 1.35, P = .02). Cases with DF and FN did not differ in AAE (20.05% vs 20.20%, P = .94), SAE (12.03% vs 13.19%, P = .51), infectious complication (4.26% vs 4.22%, P = .97), hospital length of stay (7.32 +/- 6.73 days vs 7.02 +/- 10.67 days, P = .59), or mortality rates (4.51% vs 5.99%, P = .23). Multivariate analyses revealed that fracture type did not impact AAE (P = .28), SAE (P = .58), infectious complications (P = .83), or mortality (P = .85) rates. CONCLUSION: Postoperative morbidity and mortality of geriatric patients who sustain DF and FN fractures treated operatively were comparable. This information can be used when risk stratifying and prognosticating for elderly patients undergoing these procedures.

OBJECTIVES: To evaluate the impact of diabetes mellitus (DM) and associated complications on cost, length of stay, and inpatient mortality after open reduction internal fixation (ORIF) of an ankle fracture, and the implications of these variables during a time of health care payment reform. DESIGN: Retrospective study. SETTING: The Statewide Planning and Research Cooperative System database, which includes all admissions to New York State hospitals from 2000 to 2011. PATIENTS/PARTICIPANTS: A total of 58,748 patients were identified as having undergone the primary procedure of ORIF of the ankle (ICD-9-CM procedure code 79.36). INTERVENTION: ORIF of the ankle. MAIN OUTCOME MEASURE: Cost, length of stay, and inpatient mortality. RESULTS: Of the 58,748 patients evaluated, 7501 (12.8%) had DM. Mean length of stay and total hospital charges were significantly greater for the DM cohort compared to the without DM cohort (P < 0.01). Patients with DM had greater Charlson Comorbidity Index scores and greater in-hospital mortality than patients without DM (both P < 0.01). Of the patients with diabetes, 1098/7501 had complicated diabetes mellitus (C-DM). Patients with C-DM stayed 2.4 days longer and were $6895 more costly than those with diabetes alone (both P < 0.01). Patients with C-DM also had a significantly higher in-hospital mortality rate than those with diabetes alone. CONCLUSIONS: Patients with diabetes admitted to the hospital for ankle ORIF have more expensive hospital stays and higher in-hospital mortality rates than patients without diabetes. The presence of diabetic complications further increases these risks. These data will help provide risk-adjustment for future health care payment reform initiatives. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES: To evaluate the relationship between mechanism of injury and mortality in geriatric trauma patients and the ability of existing injury severity indices (ISIs) to assess mortality. DESIGN: Retrospective review. SETTING: Urban level 1 trauma center. PARTICIPANTS: Four thousand five hundred forty-five trauma patients age >/=55 presenting between 2008 and 2011. INTERVENTION: Low-energy (LE-GTP) and high-energy (HE-GTP) geriatric trauma patient cohorts were created based on ICD-9 injury codes. Existing ISIs were evaluated for their ability to predict in-hospital mortality using the area under the receiver-operating characteristic curve (AUROC). MAIN OUTCOME MEASURES: Mortality. RESULTS: The Trauma Score-Injury Severity Score (TRISS) was the most predictive ISI for both cohorts and was deemed to have moderate predictive capacity (AUROC: 0.82) in LE-GTP and excellent predictive capacity (AUROC: 0.91) in the HE-GTP. For, HE-GTP each 1-year increase in age was associated with a 12% increase risk of mortality versus 6% for LE-GTP. Preexisting conditions (PECs) were distributed differently between the cohorts with significantly more PECs in the LE-GTP (P < 0.01). CONCLUSIONS: Existing ISIs have fair-to-moderate predictive capacity for in-hospital morality in LE-GTPs and moderate-to-excellent predictive capacity in HE-GTPs. LE-GTPs and HE-GTPs are distinct cohorts that should be evaluated separately. Combining the cohorts underestimates both the effect of age on HE-GTPs and the effect of PECs on LE-GTPs while overestimating the effect of PECs on HE-GTPs. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES:: To quantify the impact of compartment syndrome in the setting of tibial shaft fracture on hospital length of stay and total hospital charges. DESIGN:: Retrospective case-control study. SETTING:: All New York State hospital admissions from 2001-2011, as recorded by the New York Statewide Planning and Research Cooperative System (SPARCS) database. PATIENTS:: 33,629 inpatients with isolated open or closed fractures of the tibia and/or fibula (AO/OTA 41-43). 692 patients developed a compartment syndrome in the setting of tibia fracture. All patients were filtered to ensure none had other complications or medical comorbidities that would increase length of stay or total hospital charges. INTERVENTION:: Fasciotomy and delayed closure in patients who developed a compartment syndrome. MAIN OUTCOME MEASURE:: Hospital length of stay (days) and total inflation-adjusted hospital charges RESULTS:: A total of 33,629 patients with tibial shaft fracture were included in the study. There were 32,937 patients who did not develop a compartment syndrome. For this group, the mean length of stay was 6 days and the mean inflation-adjusted hospital charges were $34,000. Patients who developed compartment syndrome remained in-house for an average of 14 days with average charges totaling $79,000. These differences were highly significant for both lengths of stay and hospital charges (p < 0.001). CONCLUSION:: Besides the obvious physical detriment experienced by patients with compartment syndrome, there is also a significant economic impact to the healthcare system. Compartment syndrome following a tibial fracture more than doubles length of stay and total hospital charges. These findings highlight the need for a standardized care algorithm aimed towards efficiently and adequately treating acute compartment syndrome. Such an algorithm would optimize cost of care and presumably decrease length of stay. LEVEL OF EVIDENCE:: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.