Faculty Bibliography

BACKGROUND/UNASSIGNED:The purpose of this study is to determine differences in outcomes between "extreme" tibial metaphyseal fractures treated with intramedullary nailing (IMN) or plate osteosynthesis. METHODS/UNASSIGNED:545 prospectively collected patients were reviewed by two board-certified orthopedic trauma surgeons to identify extreme tibial shaft fractures (defined as most proximal or distal segments that involved or would have involved the area encompassed by the nail locking bolts). Fifty-one patients were identified. Twenty-five patients treated with an intramedullary nail were compared to 24 patients treated with plate and screws for similar patterns. Data collected included patient demographics, surgical details, and outcomes. Cohorts were compared using fisher's exact test, independent T tests, and multivariable linear regression. RESULTS/UNASSIGNED:The mean age of all patients was 46.73 years. There were no differences in ASA, CCI, age, male/female composition, or BMI between cohorts. There were no differences in low vs. high-energy mechanism of injury between cohorts, however the IMN cohort had a greater proportion of open fractures (p = 0.018). When controlling for covariates, patients who underwent IMN were allowed earlier weight bearing on the operative extremity. There were no differences in ankle or knee range of motion at latest follow up. There was a greater incidence of total complications among IMN (p = 0.033). Single variable analysis revealed an association between IMN and nonunion (p = 0.050). IMN trended towards greater need for reoperation (p = 0.086). CONCLUSION/UNASSIGNED:Intramedullary nailing of "extreme tibia fractures" was associated with higher rates of total complications compared to plate osteosynthesis and trended with greater need for reoperation. However, it should be noted that there was a higher incidence of open fractures in this cohort. There were no differences in the rate of malalignment, range of motion, or time to healing between cohorts.

OBJECTIVES/OBJECTIVE:To examine the efficacy of regional only anesthesia for arthroplasty surgery following displaced femoral neck fractures. METHODS:Design: Retrospective study. SETTING/METHODS:A single academic medical center and Level 1 Trauma Center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients with displaced femoral neck fracture (AO/OTA 31B1.3) treated with either hemi- or total hip arthroplasty were identified. Patients who had general (GA) and Spinal (SA) anesthesia were each matched 2:1 to those who underwent Lateral Femoral Cutaneous and Over the Hip (LOH),based on the Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) risk score and arthroplasty type. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Patient demographics, injury characteristics, and surgical history were compared. Outcomes included postoperative complications, 90-day readmission rates, 1-year mortality and discharge location. Significance was p>0.05. RESULTS:145 patients were analyzed: 58 GA, 58 SA, and 29 Regional. Cohorts were similar in demographics: mean age was 79.9 +9.9 for LOH, 79.8+11.00 for GA and 82.2+8.6 for SA (p=0.3), with 72% female patients in the LOH, 67% female in the GA and 76% female in SA (p=0.585). GA patients had the highest BMI (25.3±5.3 kg/m2, p=0.004). SA patients had the highest ASA score (2.9±0.7, p=0.036). GA patients had the longest anesthesia (2:55 hours, p=0.013) and operating room time (3:35, p=0.009). Regional anesthesia had the shortest anesthesia (2:26, p=0.013) and operating room time (2:54, p=0.009). GA had a higher complication rate (56.9%, p=0.039), including major complications (20.7%, p=0.025) and post-operative anemia (34.5%, p=0.049). GA had a longer length of stay (6.4±2.9 days, p=0.022). Patients operated on under regional only were discharged to home (62%, p=0.003) while more GA (79%) and SA (71%) patients were discharged to SNF (p<0.001). LOH patients ambulated sooner following surgery (1.03±0.2 days, p=0.001). No post-operative complications, blood transfusions (p=0.321), mortality (p=0.089), 30-day readmission (p=0.819), and post-operative delirium (p=0.514) were significantly different. CONCLUSION/CONCLUSIONS:Regional only anesthesia (LOH Block) was safe and effective for hemi and total hip arthroplasty for a displaced femoral neck fracture as compared to spinal and general anesthesia. This anesthetic approach allowed for successful procedures and yielded lower associated rates of post-operative complications and operative time in addition to improved quality measures. LEVEL OF EVIDENCE/METHODS:Prognostic Level III.

INTRODUCTION/BACKGROUND:The purpose of this study was to assess the demographic characteristics of hip fracture patients who followed up versus those who did not and secondarily to evaluate if follow-up duration correlated with long-term functional outcomes. METHODS:This was a retrospective review that queried a trauma database for all patients aged >55 years with hip fractures because of low-energy mechanisms between February 2019 and May 2020. Demographic characteristics, hospital quality measures, clinical outcomes, follow-up attendance, and 1-year functional outcomes were collected from the electronic medical record or through phone. Comparative analyses were conducted between patients who attended >50% of their follow-up appointments and those who attended <50% of their follow-up appointments. Patients were stratified based on the number of follow-up appointments attended and were compared. Multivariable regression analyses were conducted to identify factors influencing follow-up attendance and its association with functional outcomes. RESULTS:Four hundred fifty-two patients were included for analysis. Patients attending follow-up were younger, more likely to be community ambulators, White, and female. Multivariable regression revealed that younger age, White ethnicity, and female sex were independently associated with higher 1-year follow-up attendance. A positive linear relationship was observed between follow-up attendance and improved functional outcomes. Patients attending >50% of their appointments had better outcome scores. Overall, 218 patients were contacted through phone for 1-year follow-up and thus the 1-year follow-up rate increased to 69%. CONCLUSION/CONCLUSIONS:Consistent follow-up is associated with better 1-year outcomes in geriatric hip fracture patients. Recognizing the demographic factors associated with follow-up attendance can assist in patient education and engagement.

OBJECTIVE:This study assesses the impact of a structured summer externship program (SEP) in orthopedic surgery on participants' career trajectories and diversity within the field. Specifically, we evaluated the proportion of SEP participants who chose a career in orthopedic surgery and analyzed trends in gender and racial/ethnic diversity among the cohort over a 20-year period. DESIGN/METHODS:A retrospective cohort analysis was conducted using data from participants in 1 academic department's SEP between 2004 and 2023. Participant demographic data, ultimate specialty match information, and residency outcomes were collected and statistically analyzed to assess trends in specialty selection, gender, and racial/ethnic diversity among the SEP alumni. SETTING/METHODS:This study took place in the Department of Orthopedic Surgery at a large academic tertiary medical center. PARTICIPANTS/METHODS:The study included 564 medical students who participated in the SEP between 2004 and 2023. Of these, 441 (78.2%) have graduated from medical school to date, 114 (20.2%) are still enrolled, and 5 (0.89%) have left medicine for careers in other sectors. Data for 9 participants (1.6%) was unavailable. RESULTS:Among the 436 graduates, 161 (36.9%) eventually matched into orthopedic surgery. An additional 13.5% entered internal medicine, 7.3% matched into radiology, 6.6% into emergency medicine, 5.5% into anesthesiology, and 30.3% into various other specialties. Female representation in the SEP increased from 16.6% in 2004 to 51.1% in 2023 (χ² = 4.95, p = 0.026), while non-white participant representation grew from 16.6% to 45% over the same period (χ² =3.18, p = 0.075). CONCLUSIONS:The SEP is one way of providing resources and opportunity for engagement for students interested in orthopedic surgery careers while promoting diversity within the field. This program serves as a valuable pathway, offering early exposure to orthopedic surgery, research opportunities, and professional networking, all of which may play an increasingly critical role as residency selection criteria evolve. The SEP's advantages to participants underscore the importance of targeted programs in fostering opportunity for previously underrepresented groups in the field of orthopedic surgery.

OBJECTIVES/OBJECTIVE:To determine the most common reason for 30-day readmission following hospitalization for hip fractures. METHODS:Design: A retrospective review. SETTING/METHODS:Single academic medical center that includes a Level 1 Trauma Center. PATIENT SELECTION CRITERIA/UNASSIGNED:Included were all patients operatively treated for hip fractures (OTA 31) between October 2014 and November 2023. Patients that died during their initial admission were excluded. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Patient demographics, hospital quality measures, outcomes and readmission within 30-days following discharge for each patient were reviewed. 30-day readmission reason was recorded and correlation analysis was performed. RESULTS:A total of 3,032 patients were identified with a mean age of 82.1 years and 70.5% of patients being female. The 30-day readmission cohort was 2.6 years older (p<0.001) and 8.8% more male patients (p=0.027), had 0.5 higher CCI (p<0.001), 0.3 higher ASA class (p<0.001) and were 9.2% less independent at the time of admission (p= 0.003). Hemiarthroplasty procedure (32.7% vs. 24.1%) was associated with higher 30-day readmission compared to closed percutaneous screw fixation (4.5% vs. 8.8%) and cephalomedullary nail fixation (52.2% vs. 54.4%, p<0.001). Those readmitted by 30-days developed more major (16.7% vs. 8.0%) (p<0.001) and minor (50.5% vs. 36.4%) (p<0.001) complications during their initial hospitalization and had a 1.5 day longer LOS during their first admission (p<0.001). Those discharged home were less likely to be readmitted within 30-days (20.7% vs. 27.6%, (p=0.008). Multivariate regression revealed increasing ASA class (O.R. 1.47, p=0.002) and pre-injury ambulatory status (O.R. 1.42, p=0.007) were most associated with increased 30-day readmission. The most common reason for readmission was pulmonary complications (17.1% of complications) including acute respiratory failure, COPD exacerbation and pneumonia. CONCLUSION/CONCLUSIONS:Thirty-day readmission following hip fracture was associated with older, sicker patients with decreased pre-injury ambulation status. Hemiarthroplasty for femoral neck fracture was also associated with readmission. The most common reason for 30-day readmission following hip fracture was pulmonary complications. LEVEL OF EVIDENCE/METHODS:Prognostic Level III.

This study aims to identify if there are significant differences in hospital quality measures between hip fracture patients who were treated under the management of a dedicated Hip Fracture Care Coordinator (HFCC) and those who were not. An institutional review board-approved hip fracture registry was queried for patients who were admitted at an orthopedic hospital under the care of HFCC from October 2021 to April 2023 (2.5 years). A comparison cohort of patients was obtained from reviewing patients in the 2.5 years (April 2019-October 2021) before the hiring of the HFCC. Univariable comparisons and multivariable regression analyses were conducted to assess the impact of the HFCC on outcomes such as hospital quality measures, inpatient complications, discharge location, and readmission and mortality rates. One thousand fifty-six hip fracture patients were identified: 532 (50.4%) without-HFCC and 524 (49.6%) HFCC. When controlling for covariates using binary logistic regression, the presence of an HFCC was associated with a higher likelihood of home discharge (odds ratio = 2.481, p < .001). Regression analyses demonstrated similar benefits of the HFCC with outcome variables such as intensive care unit stay (p < .001) and time to surgery (p < .001). This study demonstrates an association between the HFCC and improved outcomes for both patients and the hospital system.

OBJECTIVES/OBJECTIVE:To determine if there is a correlation between time to surgery (TTS) and outcomes following repair of elbow fractures. METHODS:Design: Retrospective comparative study. SETTING/METHODS:A single, urban hospital system. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients from March 2011 to September 2022 who sustained an isolated fracture about the elbow joint (AO/OTA 13-A, B, and C and 21-A, B, and C), underwent surgical repair, and had at least 6 months of post-operative follow up identified from an Institutional Review Board-approved database. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Time to surgery, in days, was recorded. Radiographic and clinical follow up was obtained at all visits and a Mayo Elbow Performance Index (MEPI) was calculated based on the latest follow up. Complications recorded: elbow contracture, infection, early hardware failure, reoperation, and fracture nonunion. Multivariable regression and Spearman correlation analysis were used to determine any significant outcome differences based on time to surgery. RESULTS:351 patients included with a mean age of 54.8 (range: 18 - 86) years with 217 females (61.8%) and 134 males (38.2%). Eighty-two patients (23.4%) developed at least one complication while 269 patients (76.6%) did not. As a continuous variable, TTS was not correlated with arc of motion at any follow up visit nor with the latest recorded MEPI score (p > 0.05). Mean TTS for patients who did and did not experience a complication was 6 (range: 0-24) and 10 (range: 0-38) days, respectively, and this was not significantly different (p = 0.217). Complication rate and any of the individual complications were not associated with TTS following a multivariable analysis controlling for age, sex, injury mechanism, open fracture, Charlson Comorbidity Index, and AO/OTA classification (p > 0.05 for all). CONCLUSIONS:Timing of surgery following OTA 13 A-C and 21 A-C elbow fractures was not associated with differences in post-operative complications or range of elbow motion. LEVEL OF EVIDENCE/METHODS:Level III.

INTRODUCTION/BACKGROUND:Patient-reported outcome measures (PROMs) are an important component of evaluating patient health and are increasingly utilized in orthopedics. However, their use remains inconsistent among orthopedic subspecialties, with only 21% of orthopedic trauma surgeons reporting regular use of PROMs in their practice. While tools for quantifying patient distress in response to pain have been developed, they are often difficult to apply due to extensive questioning and the need for prospective implementation. The purpose of this study was to propose a novel retrospective technique to measure the Pain Distress Index (PDI) using two common PROMs: the visual analog scale (VAS) and the short musculoskeletal functional assessment (SMFA). METHODS:A total of 797 patients who underwent operative repair of a tibial plateau fracture or revision of long bone nonunion were included. To quantify PDI, a linear trend line was calculated from a scatter plot of SMFA Bothersome Index (BI) vs. VAS pain scores at three months postoperatively. Reported SMFA BI was compared to predicted SMFA BI, and patients were stratified into three cohorts: "limited," "adequate," and "excellent" PDI. RESULTS:In both cohorts, SMFA Function Index scores at 6 and 12 months postoperatively differed significantly among the limited, adequate, and excellent PDI levels (p < 0.0005, p < 0.0005). Worse PDI (indicating greater distress from pain) was associated with poorer SMFA Function Index scores. CONCLUSIONS:The combination of SMFA BI and VAS scores may serve as a useful tool to quantify PDI without requiring an additional questionnaire. "Limited" PDI was associated with poorer functional outcomes at 6 and 12 months postoperatively. This method may help predict which patients are at risk for worse functional outcomes and could serve as a retrospective proxy for resilience in future research.

OBJECTIVES/OBJECTIVE:To identify which hip fracture patients benefit the most from operative repair within 24 hours of Emergency Department presentation based on patient risk stratification. DESIGN/METHODS:Retrospective Cohort. SETTING/METHODS:Academic Medical Center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients operatively treated for an AO/OTA 31 A, 31 B, or 32 A hip fracture. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Each patient was placed into an "individualized risk quartile" (Individual Risk Quartile) using a validated risk stratification tool (The Score for Trauma Triage in the Geriatric and Middle-Aged [Score for Trauma Triage and Geriatric Middle Aged], a tool proven to predict inpatient mortality in trauma patients). Patients were risk stratified into minimal-, low-, moderate-, and high-risk IRQs. In each cohort, patients were separated into 3 groups based on their time from Emergency Department arrival to surgery (<24 hours, >24 hours and <48 hours, and >48 hours). Each of these 12 groups was analyzed for complications (minor inpatient complications included acute kidney injury, urinary tract infection, decubitus ulcer, and acute blood loss anemia, while major inpatient complications included sepsis or septic shock, pneumonia, acute respiratory failure, stroke, myocardial infarction, cardiac arrest, and deep vein thrombosis or pulmonary embolism), mortality rates, and hospital quality measures (length of stay and readmission rates). The results were compared across cohorts. RESULTS:A total of 2472 patients were identified: the mean age of the cohort was 80.6 ± 10.3 and was predominantly female (69%) and white (71%). The data demonstrated improved outcomes (complications, mortality rates, hospital quality measures) across all patients (nonrisk stratified) for surgery within 24 hours compared with surgery between 24 hours and 48 hours and surgery greater than 48 hours (all outcomes P < 0.050). However, these effects were not evenly distributed among the IRQs. In the IRQ4 cohort, major complication rates progressed from 20% to 25% to 34% as a function of time to surgery ( P = 0.007). IRQ1 did not demonstrate similar results ( P = 0.756), with the rates essentially static across surgery time points (3%-2% to 4%). A similar trend was seen when analyzing mortality at 1 year for highest risk patients, with similar 1-year mortality rates across operating room windows of IRQs 1-3 (IRQ1: P = 0.061, IRQ2: P = 0.259, IRQ3: P = 0.524) but increased in IRQ4 with increasing time to surgery (21% vs. 33% vs. 33%, P = 0.006). CONCLUSIONS:This study demonstrates a differential impact of expedited time to surgery on patients when stratified by the risk profile. The lowest risk hip fracture patients do not fare worse if operated on within 48 hours as compared to 24 hours. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION/BACKGROUND:The purpose was to determine whether computed tomography (CT) Hounsfield units (HU) as a proxy for bone quality can predict postoperative complications following surgical treatment of proximal humerus fractures. METHODS:Sixty-six patients with 2-, 3-, or 4-part proximal humerus fractures who underwent surgical fixation at single institution and had complete radiographic data available were included. Radiographic measurements included the deltoid tuberosity index (DTI) on preoperative anterior-posterior shoulder radiographs, and the HU value from the surgical proximal humerus was determined by measuring the humeral head at the midaxial/coronal/sagittal CT image using a circle-type region of interest (≥35 mm2). Postoperative complications recorded were implant failure, development of osteonecrosis, nonunion, and acute periprosthetic fracture. Patients with and without complications were statistically compared, and binary logistic regression was performed to determine whether preoperative proximal humerus CT HU were predictive of complications. RESULTS:Eight patients (12.1%) developed 11 overall complications, with three patients experiencing multiple complications each. Complications included osteonecrosis (4), implant failure (5), nonunion (1), and acute periprosthetic fracture (1). No difference was observed in demographics or Neer or AO/OTA classification between those with and without complications. Patients with complications had markedly lower DTI and overall HU as well as HU in the coronal and sagittal planes. Regression analysis for average DTI demonstrated a higher DTI and had a 10 times decreased risk of complication (P = 0.040, odds ratio = -10.5, 95% confidence interval, 0.000 to 0.616). Regression analysis for average total HU also found a higher HU associated with a decreased risk of complications (P = 0.034, odds ratio = -0.020, 95% confidence interval, 0.980 to 0.962). Logistic regression analysis, including age, age-adjusted Charlson Comorbidity Index, mean DTI, and mean total HU, only found mean total HU to be notable within the model. DISCUSSION/CONCLUSIONS:CT HU may identify patients with poorer bone quality and thus help predict postoperative complications. LEVEL OF EVIDENCE/METHODS:Diagnostic Level III.