Faculty Bibliography

BACKGROUND/UNASSIGNED:Operative management is often required for fractures of the elbow, with treatment goals aiming to restore stability, reduction, and early range of motion. The purpose of this study was to determine risk factors for necessitating the application of an external fixator, and to compare range of motion and functional outcomes between patients who required an elbow external fixator to those who did not. HYPOTHESIS/UNASSIGNED:We hypothesize that patients who require an external fixator will have worse elbow range of motion and functional outcomes when compared to those who did not. PATIENTS AND METHODS/UNASSIGNED:This is a retrospective study of 391 patients who presented at a Level-I trauma center between March 2011 and January 2021 for operative management of a fracture/fracture-dislocation of the distal humerus (AO/OTA 13A-C) and/or proximal ulna and/or radius (AO/OTA 21A-C). A primary analysis was performed to determine risk factors for necessitating the application of an external fixator. A secondary analysis was performed comparing elbow range-of-motion and functional outcomes between cases and controls. RESULTS/UNASSIGNED:391 patients were identified; 26 required external fixation (cases) and 365 did not (controls). Significant risk factors for necessitating placement of an external fixator included large BMI (OR = 1.087, 95 % CI = 1.007-1.173, p = 0.033), elbow dislocation (OR = 7.549, 95 % CI = 2.387-23.870, p = 0.001), open wound status (OR = 9.584, 95 % CI = 2.794-32.878, p < 0.001), and additional non-contiguous orthopaedic injury (OR = 9.225, 95 % CI = 2.219-38.360, p = 0.002). Elbow ROM was poorer in the external fixator group with regards to extension (-15°), flexion (+19.4°), and pronation (+14.3°) (p < 0.05). In addition, those who did not need external fixation had better functional scores (+20.4 points MEPI) (p < 0.05). DISCUSSION/UNASSIGNED:The use of external fixation about the elbow is associated with significantly worse initial injuries and results in poorer outcomes. These results can be used to inform the surgeon-patient discussion regarding treatment options and expected functional outcomes. LEVEL OF EVIDENCE/UNASSIGNED:III.

There has been a paradigm shift towards fixing the posterior malleolus in trimalleolar ankle fractures. This study evaluated whether a surgeon's preference to intraoperatively flip or not flip patients from prone to supine for medial malleolar fixation following repair of fibular and posterior malleoli impacted surgical outcomes. A retrospective patient cohort treated at a large urban academic center and level 1 trauma center was reviewed to identify all operative trimalleolar ankle fractures initially positioned prone. One hundred and forty-seven patients with mean 12-month follow up were included and divided based on positioning for medial malleolar fixation, prone or supine (following closure, flip and re-prep and drape). Data was collected on patient demographics, injury mechanism, perioperative variables, and complication rates. Postoperative reduction films were reviewed by orthopedic traumatologists to grade the accuracy of anatomic fracture reduction. Overall, 74 (50.3%) had the medial malleolus fixed prone, while 73 (49.7%) were flipped and fixed supine. No differences in demographics, injury details, and fracture type existed between the groups. The supine group had a higher rate of initial external fixation (p=0.047), longer operative time in minutes (p<0.001), and a higher use of plate and screw constructs for medial malleolar fixation (p=0.019). There were no differences in clinical and radiographic outcomes and complication rates. This study demonstrated that intraoperative change in positioning for improved medial malleolar visualization in trimalleolar ankle fractures results in longer operative times but similar radiographic and clinical results. The decision of operative position should be based on surgeon comfort.

BACKGROUND/UNASSIGNED:Previous studies show the "off-hour" effect impacts outcomes after surgery in non-orthopedic settings. This study assessed if the off-hour effect impacts surgical precision and outcomes in middle-aged patients and patients 65 years and older with hip fractures. MATERIALS AND METHODS/UNASSIGNED:All operative patients in an academic medical center's institutional review board-approved hip fracture registry were reviewed for demographics, hospital quality measures, operative details, radiographic parameters, and outcomes. Patients were grouped into standard (7 am to 4:59 pm) and off-hour (5 pm to 6:59 am) cohorts depending on surgical start time and comparative analyses were conducted. Two subanalyses were conducted: one comparing the quality of reduction for patients with intertrochanteric hip fractures and another comparing the rates of inpatient transfusion and postoperative dislocation for patients treated with arthroplasty. RESULTS/UNASSIGNED:A total of 2334 patients underwent operative treatment. The off-hour cohort had hospital quality measures and outcomes similar to the standard cohort, including length of stay, rates of inpatient complication, mortality, and readmission. Sub-analysis of 814 intertrochanteric hip fractures demonstrated similar tip-apex distance, residual calcar step-off, and post-fixation neck-shaft angle, while subanalysis of 713 patients undergoing arthroplasty showed similar rates of transfusion and dislocation between cohorts. CONCLUSION/UNASSIGNED:. 2024;47(3):185-191.].

We sought to determine what effect the size of a displaced coronoid fracture fragment in Monteggia injuries has on clinical outcome. Sixty-seven patients presented to an academic medical center for operative fixation of a Monteggia fracture. Radiographs were assessed for length and height of the displaced coronoid fragment using measuring tools in our center's imaging archive system. Data were analyzed using binary logistic or linear regression, as appropriate, controlling for sex, age, and Charlson Comorbidity Index. Outcome measurements included radiographic healing, range of motion, postoperative complications, and reoperation. The cohort had a mean follow-up of 16.7 months. Mean coronoid fragment area was 362.4±155.9 mm². Elbow range of motion decreased by 3.8° of elbow flexion (P<.001), 3.3° of elbow extension (P<.001), and 3.8° of forearm supination (P=.007) for every 1-cm² increase in coronoid fragment area. Complications (P=.012) and reoperation (P=.036) were associated with increasing coronoid fragment area. Nonunion rate, nerve injury, and pronation range of motion were not correlated to increasing coronoid fracture fragment area (P=.777, P=.123, and P=.351, respectively). As displaced coronoid fragment size increases in Monteggia fracture patterns, elbow range of motion decreases linearly. Coronoid displacement was also associated with increased rates of postoperative complication and need for reoperation. [Orthopedics. 2024;47(1):15-21.].

BACKGROUND/UNASSIGNED:Fifth Edition, psychiatric diagnosis is associated with worse outcomes for patients who develop a confirmed fracture-related infection (FRI). MATERIALS AND METHODS/UNASSIGNED:Included patients had open or closed fractures managed with internal fixation and had confirmed FRIs. Baseline demographics, injury information, and outcomes were collected via chart review. All patients who had a diagnosis of psychiatric illness, which included depression, bipolar disorder, anxiety disorder, and schizophrenia, were identified. Patients with and without a psychiatric diagnosis were statistically compared. RESULTS/UNASSIGNED:=.270). CONCLUSION/UNASSIGNED:. 2024;47(4):198-204.].

BACKGROUND:The purpose of this study is to characterize the effects of head injuries amongst the middle-aged and geriatric populations on hospital quality measures, costs, and outcomes in an orthopedic trauma setting. METHODS:Patients with head and orthopedic injuries aged >55 treated at an academic medical center from October 2014-April 2021 were reviewed for their Abbreviated Injury Score for Head and Neck (AIS-H), baseline demographics, injury characteristics, hospital quality measures and outcomes. Univariate comparative analyses were conducted across AIS-H groups with additional regression analyses controlling for confounding variables. All statistical analyses were conducted with a Bonferroni adjusted alpha. RESULTS:A total of 1,051 patients were included. The mean age was 74 years, and median AIS-H score was 2 (range 1-6). While outcomes worsened and costs increased as AIS-H scores increased, the most drastic (and clinically relevant) rise occurs between scores 2-3. Patients who sustained a head injury warranting an AIS-H score of 3 experienced a significantly higher rate of major complications, need for ICU admission, inpatient and 1-year mortality with longer lengths of stay and higher total costs despite no differences in demographics or injury characteristics. Regression analysis found a higher AIS-H score was independently associated with greater mortality risk. CONCLUSION/CONCLUSIONS:AIS-H scores >2 correlate with significantly worse outcomes and higher hospital costs. Concomitant head injuries impact both outcomes and direct variable costs for middle-aged and geriatric orthopedic trauma patients. Clinicians, hospitals, and payers should consider the significant effect of head injuries on the hospitalization of these patients.

OBJECTIVE:To report on demographics, injury patterns, management strategies and outcomes of patients who sustained fractures of the tibial plateau seen at a single center over a 16-year period. DESIGN/METHODS:Prospective collection of data.Patients/ Participants: 716 patients with 725 tibia plateau fractures, were treated by one of 5 surgeons. INTERVENTION/METHODS:Treatment of tibial plateau fractures. MAIN OUTCOME MEASUREMENTS/METHODS:Outcomes were obtained at standard timepoints. Complications were recorded. Patients were stratified into 3 groups: those treated in the first 5 years, those treated in the second 5 years and those treated in the most recent 6 years. RESULTS:608 fractures were followed for a mean 13.4 months (6-120) and 82% had a minimum 1-year follow up. Patients returned to self-reported baseline function at a consistent proportion during the 3 time periods. The average knee arc was 125 degrees (75 - 135 degrees) at latest follow up and did not differ over time. The overall complication rate following surgery was 12% and did not differ between time periods. Radiographs demonstrated excellent rates of healing and low rates of PTOA and improved articular reductions at healing (0.58 mm in group 3 compared to 0.94 mm in Group 1 and 1.12 mm in Group 2) (P<0.05). CONCLUSION/CONCLUSIONS:The majority of patients regained their baseline functional status following surgical intervention and healing. Over time the ability of surgeons to achieve a more anatomic joint reduction was seen, however this did not correlate with improved functional outcomes. LEVEL OF EVIDENCE/METHODS:Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE/OBJECTIVE:To determine the factors associated with discharge location in patients with hip fractures and whether home discharge was associated with a lower readmission and complication rate. METHODS:Hip fracture patients who presented to our academic medical center for operative management of a hip fracture were enrolled into an IRB-approved hip fracture database. Radiographs, demographics, and injury details were recorded at the time of presentation. Patients were grouped based upon discharge disposition: home (with or without home services), acute rehabilitation facility (ARF), or sub-acute rehabilitation facility (SAR). RESULTS:The cohorts differed in marital status, with a greater proportion of patients discharged to home being married (51.7% vs. 43.8% vs. 34.1%) (P < 0.05). Patients discharged to home were less likely to require an assistive device (P < 0.05). Patients discharged to home experienced fewer post-operative complications (P < 0.05) and had lower readmission rates (P < 0.05). Being married was associated with an increased likelihood of discharge to home (OR = 1.679, CI = 1.391-2.028, P < 0.001). Being enrolled in Medicare/Medicaid was associated with decreased odds of discharge to home (OR = 0.563, CI = 0.457-0.693, P < 0.001). Use of an assistive device was associated with decreased odds of discharge to home (OR = 0.398, CI = 0.326-0.468, P < 0.001). Increases in CCI (OR = 0.903, CI = 0.846-0.964, P = 0.002) and number of inpatient complications (OR = 0.708, CI = 0.532-0.943, P = 0.018) were associated with decreased odds of home discharge. CONCLUSION/CONCLUSIONS:Hip fracture patients discharged to home were healthier and more functional at baseline, and also less likely to have had a complicated hospital course. Those discharged to home also had lower rates of readmission and post-operative complications. LEVEL OF EVIDENCE/METHODS:III.