Faculty Bibliography

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.

PURPOSE/OBJECTIVE:The purpose of this study is to examine the effect of age on outcomes following repair of acute displaced patella fractures Methods: 248 patients who sustained a displaced patella fracture and underwent open reduction and internal fixation were identified. Patients included underwent a similar operative protocol, were prescribed a standard post-operative protocol of therapy, and were seen at standard follow-up intervals. Patients were divided into groups of < 65 years old (young) and ≥ 65 years old (older). Statistical analysis was run to determine if there was a significant difference in range of knee motion and rate of major complications. RESULTS:Of the 248 patients, 149 were young and 99 were older. The mean age of the older group was 74.5 ± 6.7 and the mean age of the young group was 50 ± 12. Fracture pattern and BMI were similar the groups, however the older group had a higher average CCI (p<0.001). Additionally, the groups had similar length of follow up (p=0.693) and similar mean time to radiographic healing (p=0.533). Older patients had limited knee extension at 6 months (compared young patients (p=0.031). Finally, older patients had a higher rate of all complications compared to young patients. Two percent of older patients developed a fracture related infection (FRI), 4% developed a symptomatic nonunion and 11% were underwent re-operation including removal of hardware, total knee replacement, irrigation and debridement and manipulation under anesthesia. CONCLUSION/CONCLUSIONS:Complication rates following patella fracture fixation in older patients were higher than young patients, despite having similar injury patterns, surgical treatment and follow up. These findings can better inform treating physicians during surgical intervention of older patients with patella fractures.

BACKGROUND/UNASSIGNED:Septic arthritis (SA) is an orthopedic urgency with significant morbidity and potential mortality. Differentiating SA and crystalline arthritis (CA) is difficult as concurrent disease may exist. This study sought to identify the prevalence of and define diagnostic laboratory markers for SA in the setting of CA. METHODS/UNASSIGNED:A retrospective review was conducted of adult patients presenting to a single medical center between January 2012 and March 2023 with monosodium urate (MU) or calcium pyrophosphate (CPP) in synovial knee joint fluid of a native knee. Categorical variables were assessed using chi-square and Fisher exact tests. Receiver operating characteristic curves were computed, and diagnostic accuracy was determined from associated area under the ROC curve (AUC). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated and optimal diagnostic thresholds determined by Youden index. RESULTS/UNASSIGNED:225 knee aspirations were analyzed, 56.4 % CPP and 43.6 % MSU. There were 12 cases of superimposed SA (5.3 %), 11 culture confirmed and 1 suspected. Immunosuppression was associated with a higher incidence of SA (41.7 % versus 14.6 %, p = 0.0271). SA had a significantly higher mean synovial WBC (135,796 vs 22,510; p = 0.0007). There was no difference in percentage of PMNs between the septic and aseptic groups (90.6 % vs 69.7 %; p = 3.327). Of the 12 cases of concomitant SA, 10 (83.3 %) had a synovial WBC ≥50,000/mm3, compared to 21 (9.9 %) of the aseptic aspirations (p < 0.0001). Nine (75 %) aspirations in the septic group had ≥90 % PMNs, compared to 78 (36.6 %) in the aseptic group (p = 0.0123). The optimal diagnostic threshold for synovial WBC was 50,000/mm3 (91.7 % sensitivity, 90.1 % specificity, AUC = 0.960). The optimal synovial percentage of PMNs was 64 % (100 % sensitivity, 6.7 % specificity, AUC = 0.731). CONCLUSION/UNASSIGNED:In the setting of CA, synovial WBC may provide a useful diagnostic marker for SA with an optimal threshold of 50,000 cells/mm3.

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.

PURPOSE/OBJECTIVE:The purpose of this study is to compare the quality and clinical outcomes of patients who underwent open reduction internal fixation for a proximal humerus fracture in a "timely manner" which was defined to be within 5 days of injury compared to those with "delayed intervention" (>5 Days) to determine the effect this had. METHODS:This IRB-approved study evaluated patients who sustained a proximal humerus fracture treated with plate and screw fixation (ORIF) between January 2004 and October 2022 and had time from injury to surgery documented. Patients were grouped based on the time to surgery (TTS) - Less than 5 Days (L5) vs. More than 5 Days (M5). TTS was also evaluated as a continuous variable. Univariable and multivariable analysis compared patient demographics, injury/surgical characteristics, postoperative complications, and clinical outcomes to determine effect of TTS. Clinical outcomes included shoulder range of motion (ROM) and Disabilities of the Arm, Shoulder, and Hand (DASH) score at least 1 year following the date of injury. Standard statistical tests were used (p<0.05 considered significant). RESULTS:, p=0.03, β= -0.27, 95% CI = -41.71- -2.89) surgery was associated with less passive forward elevation. CONCLUSION/CONCLUSIONS:Timing of surgery did not impact outcomes of patients who underwent open reduction internal fixation for proximal humerus fractures. Surgical intervention after 14 days was associated with diminished passive forward elevation only.

INTRODUCTION/UNASSIGNED:There is scarce data in literature on the demographics, treatment, and outcomes of subtrochanteric femur fracture patients. This study evaluated the effect of age on injury details, perioperative and hospital parameters, and outcomes following subtrochanteric fracture fixation. METHODS/UNASSIGNED:An IRB-approved review of a consecutive series of subtrochanteric femoral fractures was performed. Patient charts and radiographs were examined to confirm patients were operatively treated for an AO/OTA Type 32A, B or C subtrochanteric femur fracture, as well as for demographics, injury information, perioperative details, radiographic parameters, hospital quality measures, and outcomes. Patients were divided into younger (Y) (< 65 years old) and older (O) (≥ 65 years old) cohorts. Comparative analyses were conducted between cohorts. RESULTS/UNASSIGNED: < 0.001). There were no differences in post-op complications, readmission or mortality rates, nonunion, fixation failure, or radiographic time to healing between cohorts. CONCLUSION/UNASSIGNED:Younger patients present with different subtrochanteric fracture patterns and discharge profiles than older patients and are treated with different implants. However, despite these differences, younger and older patients have similar radiographic and clinical outcomes. LEVEL OF EVIDENCE/UNASSIGNED:III.

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/UNASSIGNED:This report describes the use of a combination of a retrograde femoral nail and distal femur locking plate for the treatment of an open intra-articular distal femur fracture in a 99-year-old female. The purpose of this report is to highlight that nail-plate fixation constructs can be performed percutaneously and expeditiously even in extremely old patients; therefore, patient age should not be a limiting factor in choosing this construct to allow for immediate weight-bearing. CASE REPORT/UNASSIGNED:The patient was a 99-year-old female who presented to the emergency room after a fall. Plain radiographs demonstrated a comminuted supracondylar distal femur fracture with a sagittal intercondylar split (OTA classification 33A3.3). She was indicated for operative repair and was fixed with a combination of a retrograde Stryker T2 alpha nail and Stryker distal femur locking plate. This method was chosen to allow the patient to be weight-bearing as tolerated after surgery so she could immediately start work with physical therapy to work towards getting back to her pre-injury ambulatory status. At 3 months post-operatively, she had minimal pain, no difficulties with activities of daily living, and was ambulating with the assistance of a cane. At 9 months post-operatively, she was ambulating with a cane (pre-injury status). She did not report any pain, and her radiographs illustrated fracture site consolidation. Furthermore, her short musculoskeletal functional assessment score was the same as it was pre-injury (81). CONCLUSION/UNASSIGNED:This case supports the idea of using a nail-plate combination for repair of intra-articular distal femur fractures, even in the very elderly as the patient's functional outcome data reached pre-injury levels. In addition, it allows even elderly patients to begin early weight-bearing and decreases complications related to lack of extremity use.

BACKGROUND:The purpose of this study is to stratify the age at which older adults are most likely to sustain injuries and major complications resulting from low-energy falls so that fall prevention strategies may be targeted to more susceptible age groups. METHODS:A consecutive series of 12 709 patients older than 55 years enrolled in an orthopedic trauma registry from October 2014 to April 2021 were reviewed for demographic factors, hospital quality measures, and outcomes. Patients were grouped by age brackets in 5-year intervals. Comparative analyses were conducted across age groups with an additional post hoc analysis comparing the 75- to 79-year-old cohort with others. All statistical analyses were conducted utilizing a Bonferroni-adjusted alpha. RESULTS:Of the 12 709 patients, 9924 patients (78%) sustained a low-energy fall. The mean age of the cohort was 75.3 (range: 55-106) years and the median number of complications per person was 1.0 (range: 0-7). The proportion of females increased across each age group. The mean Charlson Comorbidity Index increased across each age group, except in the cohort of 90+ years of age. There was a varied distribution of fractures among age groups with the incidence of hip fractures most prominently increasing with age. Complication rates varied significantly between all age groups. Between the ages of 70 to 74 years and 80 to 84 years, there was a 2-fold increase in complication rate, and between the ages of 70 to 74 years and 75 to 79 years, there was a near 2×/1.5×/1.4× increase in inpatient, 30-day, and 1-year mortality rate, respectively. When controlling for confounding demographic variables between age groups, the rates of complications and mortality still differed. CONCLUSIONS:Fall prevention interventions, while applicable to all older adult patients, could improve outcomes by offering additional resources particularly for individuals between 70 and 80 years of age. These additional resources can help minimize excessive hospitalizations, prolonged lengths of stay, and the detrimental complications that frequently coincide with falls. Although hip fractures are the most common fracture as patients get older, other fractures still occur with frequency, and fall prevention strategies should account for prevention of these injuries as well.

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.