Faculty Bibliography

Purpose: This study aims to compare patients in whom fixation failure occurred via cut-out (CO) or cut-through (CT) in order to determine patient factors and radiographic parameters that may be predictive of each mechanism. Materials and Methods: This retrospective cohort study includes 18 patients with intertrochanteric (IT) hip fractures (AO/OTA classification 31A1.3) who underwent treatment using a single lag screw design intramedullary nail in whom fixation failure occurred within one year. All patients were reviewed for demographics and radi¬ographic parameters including tip-to-apex distance (TAD), posteromedial calcar continuity, neck-shaft angle, lat¬eral wall thickness, and others. Patients were grouped into cohorts based on the mechanism of failure, either lag screw CO or CT, and a comparison was performed. Results: No differences in demographics, injury details, fracture classifications, or radiographic parameters were observed between CO/CT cohorts. Of note, a similar rate of post-reduction TAD>25 mm (P=0.936) was observed between groups. A higher rate of DEXA (dual energy X-ray absorptiometry) confirmed osteoporosis (25.0% vs. 60.0%) was observed in the CT group, but without significance. Conclusion: The mechanism of CT failure during intramedullary nail fixation of an IT fracture did not show an association with clinical data including patient demographics, reduction accuracy, or radiographic parameters. As reported in previous biomechanical studies, the main predictive factor for patients in whom early failure might occur via the CT effect mechanism may be related to bone quality; however, conduct of larger studies will be required in order to determine whether there is a difference in bone quality.

OBJECTIVES:To identify factors associated with the development of fracture-related infection (FRI) in patients who have undergone operative fixation of their fracture. DESIGN:Retrospective study. SETTING:Academic medical center. PATIENTS/PARTICIPANTS:Patients with peripheral extremity long-bone fractures and shoulder and pelvic girdle fractures who underwent operative repair. This included patients who had undergone fixation inside and outside of our institution. INTERVENTION:Chi-square, Fisher exact testing, analysis of variance (ANOVA), and t tests were used for analysis of data, as appropriate. Binomial logistic regression analysis was performed to determine risk factors of FRI. MAIN OUTCOME MEASUREMENTS:Demographics, fracture location, injury mechanism, open wound status, and wound complication type. RESULTS:One hundred ninety-three patients comprised the FRI cohort. Of those with confirmed signs of FRI, 36 (18.7%) had wound breakdown to bone or implant, 120 (62.1%) had a sinus track, and 170 patients (88.1%) had the confirmed presence of microorganisms in deep tissue samples obtained during operative intervention. Factors associated with development of an FRI were as follows: higher BMI; being of Black and Hispanic race; higher American Society of Anesthesiologists class; history of tobacco, alcohol, and drug use; and fractures of the lower extremity (foot, tibia, and femur/pelvis). The results of binary logistic regression demonstrated that treatment at an urban level I trauma center and drug use positively predicted the development of FRI. CONCLUSION:Our results demonstrate that higher BMI; being of Black or Hispanic race; higher American Society of Anesthesiologists; history of tobacco, alcohol, and drug use; and fractures of the foot, tibia, and femur/pelvis are all factors associated with development of FRI. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE/UNASSIGNED:This study aims to compare patients in whom fixation failure occurred via cut-out (CO) or cut-through (CT) in order to determine patient factors and radiographic parameters that may be predictive of each mechanism. MATERIALS AND METHODS/UNASSIGNED:This retrospective cohort study includes 18 patients with intertrochanteric (IT) hip fractures (AO/OTA classification 31A1.3) who underwent treatment using a single lag screw design intramedullary nail in whom fixation failure occurred within one year. All patients were reviewed for demographics and radiographic parameters including tip-to-apex distance (TAD), posteromedial calcar continuity, neck-shaft angle, lateral wall thickness, and others. Patients were grouped into cohorts based on the mechanism of failure, either lag screw CO or CT, and a comparison was performed. RESULTS/UNASSIGNED:=0.936) was observed between groups. A higher rate of DEXA (dual energy X-ray absorptiometry) confirmed osteoporosis (25.0% vs. 60.0%) was observed in the CT group, but without significance. CONCLUSION/UNASSIGNED:The mechanism of CT failure during intramedullary nail fixation of an IT fracture did not show an association with clinical data including patient demographics, reduction accuracy, or radiographic parameters. As reported in previous biomechanical studies, the main predictive factor for patients in whom early failure might occur via the CT effect mechanism may be related to bone quality; however, conduct of larger studies will be required in order to determine whether there is a difference in bone quality.

This review demonstrates the technique for monitored anesthesia care and soft tissue infiltration with local anesthesia as the only form of anesthesia for short cephalomedullary nailing in medically complex patients. Monitored anesthesia care is defined as providing sedation and analgesia that is titrated to a level that preserves spontaneous breathing and airway reflexes. Soft tissue infiltration refers to soft tissue infiltration with local anesthesia directly into the surgical site and is performed by the surgeon before the start of the procedure.

A case of a 26-year-old man with a displaced medial malleolus fracture with extension into the posteromedial aspect of the posterior malleolus is presented. A CT scan of the ankle is obtained demonstrating a Haraguchi type 2B posterior malleolus fracture with a posteromedial and posterolateral fragment. The posteromedial fragment extends into the posterior colliculus of the medial malleolus and has a subchondral impaction fracture. There is also a 1 × 1 cm piece of the articular surface of the posterior malleolus that has flipped 90 degrees and lodged itself between the posterolateral fracture fragment. This video overview and case presentation demonstrates a posteromedial approach with fixation strategy for the posterior malleolus.

This review describes the indications and technique for acute total hip arthroplasty in an incomplete both-column acetabular fracture in a geriatric patient.

BACKGROUND:The association of tibial shaft fractures (TSFs) with posterior malleolar fractures is well described. The purpose of this study was to identify specific radiographic parameters that are predictive of any pattern of associated distal intra-articular fractures in TSFs. METHODS:All TSFs presenting over a 6-year period were identified. A radiographic review of plain radiographs and CT scans included: identification of any associated ankle fracture, classification using the OTA System, measurements of the TSF obliquity angle (FOA), relative distance from distal extent of the TSF to plafond (DFP%), and presence and level of any associated fibular fractures. Patients with and without associated ankle fractures were statistically compared. Multivariate logistic regression determined independent predictors of associated ankle fractures. RESULTS:405 TSFs in 397 patients were identified, with 145 TSFs with associated distal intra-articular fractures. There were 94 (23.2%) posterior malleolar fractures, 19 (13.1%) medial malleolar fractures, 42 (29.0%) lateral malleolar fractures involving the syndesmosis and 14 (9.7%) Chaput fragments. Multivariate regression demonstrated AO/OTA classification type 42-A1, 42-B1 or 42-C1 (OR 2.3 [95% CI 1.3-4.0]; p = 0.003), FOA greater than 45° (OR 2.7 [95% CI 1.5-4.8]; p = 0.001) and DFP% less than 33% (OR 4.1 [95% CI 2.0-9.0]; p = 0.005) were independent correlates of associated ankle fractures regardless of mechanism of injury. CONCLUSIONS:Different patterns of intra-articular fractures beyond posterior malleolar fractures can occur in TSFs. Fracture angles greater than 45° and extent into the distal 33% of the tibial shaft are independent predictors of distal intra-articular fractures in TSFs regardless of mechanism of injury. LEVEL OF EVIDENCE/METHODS:Diagnostic Level III.

INTRODUCTION/BACKGROUND:The presence of diabetes has been associated with increased mortality risk after hip fracture, however, little has been published about the lab values of these diabetic patients and the role high labs play in morbidity and mortality. The purpose of this study is to quantify the severity of diabetes that is associated with worse outcomes in hip fracture patients. METHODS:A consecutive series of 2430 patients >55 years old who sustained a hip fracture between October 2014-November 2021 were reviewed for demographics, hospital quality measures, and outcomes. Each patient with a diagnosis of diabetes mellitus (DM) was reviewed for hemoglobin-A1c (HA1c) and glucose values at admission. Univariable comparisons and multivariable regression analyses were conducted to assess the impact of diabetes and elevated lab values (HA1c) on outcomes such as hospital quality measures, inpatient complications, readmission rates, and mortality rates. RESULTS:565 patients (23%) carried a diagnosis of diabetes mellitus at the time of their injury. Considerable demographic and comorbidity differences between diabetic and non-diabetic cohorts indicated that the diabetic cohort was less healthy. The diabetic cohort had longer hospitalizations, higher rates of minor complications, readmissions within 90-days, and mortality within 30-days/1-year. Stratification by HA1c levels found patients with a HA1c>8% had a significantly higher rate of major complications, and mortality at all time points (inpatient/30-day/1-year). Multivariable regression found HA1c>8% to be independently associated with a higher rate of inpatient/30-day/1-year mortality in comparison to a diagnosis of diabetes alone which was not independently significant. CONCLUSION/CONCLUSIONS:While all patients with DM experienced worse outcomes than those without, those with poorly controlled diabetes (HA1c>8%) at the time of hip fracture injury experienced poorer outcomes compared to those with well-controlled diabetes. Treating physicians must recognize these patients with poorly controlled DM at the time of arrival to adjust care planning and patient expectations accordingly.

PURPOSE/OBJECTIVE:To analyze clinical, radiographic and patient-reported outcomes of distal metaphyseal femoral nonunions treated with fixed-angle plates and screws. METHODS:All patients presenting with a distal metaphyseal femoral fracture nonunion repaired with fixed-angle plating from one urban level 1 trauma center and an orthopedic specialty hospital were identified. Baseline demographic, injury information, and outcomes (healing rates, Short Musculoskeletal Function Assessment, range of motion, and post-operative pain levels) at 12 months following nonunion repair were collected. Outcomes were evaluated between patients fixed with a blade plate and with a locking plate. RESULTS:Of these 31 patients, 27 (87.1%) healed after their index nonunion surgery, 2 (6.5%) healed after one reoperation, 1 (3.2%) healed after 2 reoperations, and 1 (3.2%) had a persistent nonunion but did not want further treatment. At one-year follow-up, the group demonstrated a significant improvement in functional recovery with a mean difference of 14.5 points (p = 0.007) when compared to status before fixed-angle fixation of the nonunion. There was also a significant change in patient-reported pain levels using the VAS scale with a mean difference of 2.0 points (p = 0.009). At one-year follow-up, 11 (39.3%) had full knee range of motion (0-130), 11 (39.3%) had flexion greater than 90 and less than 120°, and 6 (21.4%) had range of motion less than 90°. CONCLUSION/CONCLUSIONS:Patients who undergo fixed angle plating and autogenous bone grafting for distal femoral metapyseal nonunions demonstrate improved functional outcomes and VAS pain score at one year follow up.

INTRODUCTION/BACKGROUND:The purpose of this epidemiologic study was to analyze the care provided by our institution to middle-aged and geriatric hip fracture patients throughout the pandemic to examine for any differences compared to pre-pandemic care and across the pandemic stages. METHODS:Consecutive patients >55 years old treated for hip fractures at our institution between October 2014 and January 2022 were analyzed for demographics, coronavirus disease 2019 (COVID-19) and vaccination status at admission, injury characteristics, hospital quality measures, and outcomes. Patients were divided into three separate cohorts: Pre-COVID-19 (PRECOV), COVID-19 Pre-Vaccine (PREVAX), and COVID-19 Post-Vaccine (POSTVAX). A sub-analysis removed COVID-19-positive patients across the study period. Comparative analyses were conducted. RESULTS:A total of 2,633 hip fracture patients were included. For the overall cohort, there was no difference in the rate of inpatient deaths between the PRECOV, PREVAX, and POSTVAX cohorts (p=0.278). PRECOV had a significantly lower 30-day mortality rate compared to PREVAX or POSTVAX (p=0.012). Differences in complication rates for surgical site infection, urinary tract infection, and anemia (p<0.01 for all) were seen between cohorts. PRECOV had the longest length of hospital stay (p<0.01). PREVAX patients required more ICU level of care (p<0.01). When removing COVID-19-positive patients, all three cohorts had similar inpatient (p=0.872) and 30-day mortality rates (p=0.130). CONCLUSION/CONCLUSIONS:The care of patients treated for hip fractures did not change throughout the pandemic at our institution. The elevated mortality rate due to the effects of COVID-19 seen in the pre-vaccine cohort decreased over time as the understanding of COVID-19 improved and the vaccine was introduced. We recommend continuation of the same hip fracture care protocols as used pre-pandemic.