Faculty Bibliography

INTRODUCTION/BACKGROUND:Delays in time to surgery (TTS) for patients with a hip fracture negatively affect patient outcomes, including mortality. Surgery within 24 to 48 hours of admission for a hip fracture markedly reduces these risks; however, attempts at improving TTS after hip fracture have had mixed results. Drivers of delays in TTS across different settings in the United States are not well described. Therefore, the aim of this study was to identify drivers of delays in TTS for patients with a hip fracture from different settings to inform where patient- and context-specific improvements in TTS may be implemented. METHODS:Semistructured interviews were completed using the Consolidated Framework for Implementation Research and Theoretical Domains Framework. Interviews were completed with stakeholders involved in hip fracture care between June 2023 and October 2023. Transcripts were analyzed iteratively through a combined inductive and deductive approach. The data were analyzed to synthesize overarching themes related to drivers of delays of TTS. RESULTS:A total of 25 stakeholders, 24 orthopaedic surgeons, and 1 nurse practitioner, from 22 different hospital systems across the United States participated in semistructured interviews. Eight themes of drivers of delayed TTS emerged: (1) patient health; (2) structural drivers of health; (3) care coordination; (4) prioritization; (5) improvement climate; (6) availability; (7) incentive structure; and (8) empowerment. CONCLUSION/CONCLUSIONS:Eight major themes related to drivers in TTS for patients with a hip fracture were identified across hospital systems. These findings inform the process of identifying site-specific drivers of delayed TTS at individual health systems and implementing targeted improvement programs for TTS for patients with a hip fracture.

BACKGROUND:The purpose of this study was to compare hospital quality and patient outcomes of hip arthroplasty for femoral neck fractures (FNFs) based on the subspecialty training of the treating surgeon: orthopaedic trauma (OT) versus adult reconstruction (AR) fellowship training. METHODS:A retrospective review was conducted on 1,008 elderly patients treated for an FNF with hemiarthroplasty or total hip arthroplasty between 2014 and 2024. Patients were grouped by their surgeon's subspecialty training (OT versus AR). Outcomes analyzed included length of stay, complications, 30-day and 90-day readmissions, dislocations, infections, and 30-day mortality. Statistical significance was set at P < 0.05. RESULTS:Baseline patient demographics were similar between groups, except for a higher proportion of women in the AR cohort (P = 0.008) and Black patients in the OT cohort (P = 0.016). Although age-unadjusted Charlson Comorbidity Index (CCI) was significantly higher in the AR group (P = 0.046), Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) scores, which take CCI and other health factors into account, were not significantly different (P = 0.59). In-hospital outcomes, including length of stay (P = 0.89) and minor and major complication rates (P = 0.38, P = 0.38), demonstrated no significant differences between groups. Post-discharge outcomes, including readmissions (30-day: P = 0.52, 90-day: P = 0.16), infections (P = 0.25), dislocations (P = 0.89), and 30-day mortality (P = 0.14), were also similar. CONCLUSION/CONCLUSIONS:No differences were identified in any of the outcomes analyzed between OT-trained and AR-trained surgeons in our study. This suggests that when FNFs are treated at high-volume academic institutions, subspecialty training may not substantially influence the short-term results of FNFs treated with hip arthroplasty. These findings highlight the importance of timely surgical intervention rather than waiting for a particularly trained surgeon to be available.

In January 2024, New York University Langone Orthopedic Surgery achieved a significant milestone with the first all-women team, from chief residents to interns, at Bellevue Hospital. In a field still dominated by men, only 16% of orthopaedic resident physicians and 6% of practicing orthopaedic surgeons are female, this was no small feat. Although there are many factors that made this historic team possible, it is clear that the earliest female pioneers of orthopaedic surgery were absolutely critical. This paper aims to discuss 5 pioneering women who not only created a path for the now thousands of female orthopaedic surgeons but also left a legacy of significant contributions to the practice of orthopaedics. These trailblazers are as follows: Dr. Marian Frauenthal Sloane, Dr. Ruth Jackson, Dr. Jacquelin Perry, Dr. Claudia Thomas, and Dr. Ericka Lawler.

OBJECTIVE:The purpose of this study was to describe our experience using superiorly applied low-profile locking plates for the operative fixation of displaced midshaft clavicle fractures (MCFs). STUDY DESIGN/METHODS:This was a retrospective analysis performed at an academic institution. RESULTS:Eighty-three patients who presented with displaced, shortened MCFs were treated operatively by a single surgeon at our institution over a 10-year period. All patients received a precontoured low-profile locking plate applied in the superior position. A displaced midshaft clavicle fracture was fixed operatively using a precountered low-profile 2.7/3.5 mm locking plate applied in the superior position. Data were analyzed to evaluate time to union, final shoulder range of motion, incidence of hardware removal, and rate of postoperative complications. The cohort was 66.2% male with an average age at initial injury of 36.5 ± 14.1 years. At a mean of 3.6 ± 1.9 months, 99% of patients had united their fracture. At an average of 7.37-month follow-up, mean range of motion was 174° forward elevation, 173° abduction, 82° external rotation, and internal rotation to T7. Using the short musculoskeletal functional assessment (SMFA), the mean functional outcome index score was 4.12, bothersome index was 1.94, activity index was 1.55, emotion index was 2.51, arm and hand index was 1.14, mobility index was 0.68, and total index was 1.56. Ninety-two percent of patients had retained their hardware. There was 1 incidence of each of the following complications: infection, nonunion, hardware failure, and deep vein thrombosis. CONCLUSION/CONCLUSIONS:Superior clavicle plating using precontoured low-profile locking plates is an acceptable treatment modality for displaced MCF. This method yields excellent results regarding time to union, shoulder range of motion, incidence of hardware removal, and the rate of postoperative complications. Patients considering operative fixation of displaced MCF should be counseled accordingly.

INTRODUCTION/BACKGROUND:The purpose of this study was to assess whether language affects patient time to surgery following hip fractures. METHODS:Patients >55 years who underwent operative hip fracture repair between 2014 and 2021 were reviewed for demographics, language, hospital quality measures, and outcomes. Patients were split into English (E) or non-English (NE) cohorts based on their primary language. RESULTS:A total of 1880 patients (1477 E, 403 NE) were included. The E cohort was younger, had lower body mass index, and lower American Society of Anesthesiology Score (P < .01). The E cohort had more White patients (P < .01), whereas the NE cohort had more Hispanic, Asian, and patients with unknown backgrounds (P < .01 for all). At baseline, the E cohort patients were more likely to be community ambulators (P < .01). There were no differences in time to surgery or length of stay (P > .05). CONCLUSION/CONCLUSIONS:Despite poorer baseline medical conditions, NE speaking patients received similar care to English speakers highlighting the importance of an effective standardized protocol with readily available translation services. LEVEL OF EVIDENCE/METHODS:Level III, Retrospective cohort study.

BACKGROUND:Acute blood loss anemia is a common complication of hip fractures. Due to this complication, the rate of allogenic blood transfusions remains high in this patient population. More recently, surgeons have utilized intraoperative tranexamic acid as a strategy to minimize blood loss. PURPOSE/OBJECTIVE:The purpose of this study was to identify risk factors and associated outcomes of blood transfusions in hip fracture patients. STUDY DESIGN/METHODS:Retrospective cohort study. METHODS:A trauma database from one academic medical center was queried for hip fracture patients (OTA/AO 31A or 31B). Demographic, clinical, quality, and cost data were obtained for each patient. A Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), a validated risk predictive and matching tool, was calculated for each patient. Patients receiving blood transfusions during their hospitalization were identified. Multivariate logistic regression analysis identified independent risk factors for transfusion during admission. Patients receiving transfusions were matched to patients not receiving a transfusion based on STTGMA. Comparative analyses of matched cohorts were performed. RESULTS:In total, 1,344 hip fracture patients (29.8% male and 70.2% female) with mean age 81.04 ± 10.18 were identified. Four hundred ninety-nine (37.1%) patients received a transfusion during their admission. Risk factors for transfusion included higher STTGMA scores (P = .006), lower hemoglobin levels on admission (P < .001), anticoagulation or antiplatelet use on admission (P = .019), and fracture repair with a long cephalomedullary nail (P = .005). Trauma risk score-matched cohort outcomes show transfusions correlated with increased mortality, complications, readmission, and longer, more costly hospital stays. CONCLUSION/CONCLUSIONS:Surgeons should be cognizant of transfusion risk factors such as repair with long cephalomedullary nail and poorer matched outcomes correlated with patients receiving transfusions. LEVEL OF EVIDENCE/METHODS:Level 3.

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.

OBJECTIVES/OBJECTIVE:Altered patellar height following patella fracture repair may affect clinical outcomes, but the significance remains unclear. The purpose of this study was to evaluate the impact of immediate and final follow-up Insall-Salvati Ratio (ISR) on postoperative outcomes following patella fracture fixation. METHODS:A retrospective review at a multi-site academic urban hospital system was conducted. All patients underwent patella open reduction and internal fixation (ORIF) for displaced patella fracture (OTA 34) from 2012 to 2024. Final intraoperative and final follow-up radiographs were assessed by Insall-Salvati ratios (ISR). Patients were categorized into groups based on intraoperative ISR measurements: normal ISR, defined as .8-1.2 and abnormal ISR, outside of the 0.8-1.2 range. Follow-up radiographs were also assessed for abnormal ISR. Knee range of motion (ROM), post-operative complications, and fracture union were collected. Statistical analysis included Pearson Chi-squared tests, independent t-tests, and ANOVA tests. RESULTS:Of 191 patients, 163 (85.3%) had normal ISR and 28 (14.7%) had abnormal ISR postoperatively. Abnormal ISR was associated with higher complication rates (14.3% vs. 4.3%, p = 0.037), hardware failure (10.7% vs. 1.2%, p = 0.004), reduced knee range-of-motion at three months (105.13 ± 21.38 vs. 117.22 ± 13.75, p < .001) and six months (119.25 ± 14.26 vs. 127.37 ± 13.27, p = .020). Among patients with initially normal ISR, 12.3% developed patella baja, which was associated with higher rates of hardware removal (20% vs. 3.1%, p = 0.004) and infection (10% vs. 0.8%, p = 0.015) when compared to patients maintaining a normal ISR. CONCLUSIONS:Abnormal intraoperative Insall-Salvati ratio following patella fracture repair was associated with poorer knee ROM and increased complication rate. Progressive development of patella baja during fracture healing was associated with hardware removal and fracture related infection. Attention to intraoperative ISR optimization may improve outcomes.

Most surgically repaired proximal femoral fractures heal uneventfully, however a small percentage of surgical interventions lead to failures. Salvage of failed treatment is challenging and dependent on the type and location of the complication. Potential complications of intracapsular hip fractures and their treatment include fixation failure, nonunion, and osteonecrosis of the femoral head. Factors guiding the choice of salvage option include patient age and quality of remaining bone. This article aims to present several potential complications and corresponding potential solutions using supporting literature, when available. This narrative review focuses on salvage treatment options of failed fixation of femoral neck fractures. Total hip arthroplasty is always the last resort salvage option.

PURPOSE/OBJECTIVE:The purpose of this study was to compare fracture nonunion rates in tibial shaft fractures fixed with intramedullary nails using fixed angle locking screws (FALS) that thread into the intramedullary nail versus standard locking screws in a cohort of tibial diaphyseal fractures. Secondarily, this study evaluated whether FALS location was associated with nonunion risk in tibial diaphyseal fractures. METHODS:A retrospective review of surgically treated OTA 42 A-C tibial shaft fractures from 2014 to 2024 at a single academic institution was performed. Inclusion criteria were age > 18, isolated OTA 42 A-C tibia fracture, intramedullary nail fixation, and minimum 6-month follow-up. Patients treated with a FALS were matched to those without a FALS with a 1:1 propensity match based on OTA fracture classification and open fracture status. The Radiographic Union Score for Tibia (RUST) was used to determine healing. Statistical comparisons were performed using Pearson Chi-squared tests, independent t-tests, Mann Whitney-U tests, and multivariate logistic regression as appropriate. RESULTS:78 patients were included (39 in each cohort), with the FALS group being older and having higher age-unadjusted Charlson Comorbidity Indices (CCI). The FALS and CLS groups had comparable rates of open fractures and similar proportions of OTA/AO fractures. FALS configuration per patient was: 16 only distal, 13 only proximal, and 10 both proximal and distal. There were no differences in nonunion rates (25.6% vs. 15.4%, p = 0.262) and healed-by times (6.15 ± 2.95 [months] vs. 6.38 ± 2.73, p = 759), complication rate, or 30/90-day readmission rates (p < 0.05). Multivariate analysis demonstrated that the use of single-end FALS (used only proximally or distally) was independently associated with higher odds of nonunion compared to CLS and FALS used both proximally and distally (OR = 6.027, p = 0.025). CONCLUSION/CONCLUSIONS:The use of single-end fixed angle locking screws in only the distal or proximal segment in intramedullary nails for the treatment of OTA 42 A-C tibial diaphyseal fractures is associated with higher odds of fracture nonunion. Larger, prospective studies evaluating FALS configuration for intramedullary nail fixation of tibia shaft fractures are warranted.