Faculty Bibliography

BACKGROUND:The purpose of this study was to identify specific radiographic parameters that are predictive of associated PM fractures in TSFs. METHODS:All TSFs presenting over a 6-year period were identified. A review of plain radiographs and CT scans included: identification of an isolated PM fracture, AO/OTA classification, measurements of the fracture obliquity angle (FOA), absolute and relative distance from distal extent of fracture to plafond (DFP and DFP%), and presence and level of associated fibular fractures. Patients with and without PM fractures were compared. Multivariate logistic regression determined independent correlates of PM fractures and cutoff values for FOA and DFP%. RESULTS:A total of 405 TSFs in 397 patients were identified, and 94 TSFs (23.2%) had an associated PM fracture. The majority (85.1%) of TSFs with PM fractures were AO/OTA type 42-A1, 42-B1 or 42-C1 (p < 0.001). The mean FOA was 60.9 ± 12.1° in the PM group versus 40.8 ± 18.9° in the non-PM group (p < 0.001). The mean DFP was 5.9 ± 2.7 cm in the PM group versus 11.9 ± 7.9 cm in the non-PM group (p < 0.001). Multivariate regression demonstrated that AO/OTA classification type 42-A1, 42-B1 or 42-C1 (OR 4.7 [95% CI 2.4-9.8]; p < 0.001), FOA greater than 45° (OR 4.4 [95% CI 1.9-10.9]; p = 0.001) and fracture extension to the distal third of the tibia (DFP% < 33%; OR 18.3 [95% CI 3.8-330.4]; p = 0.005) were independent correlates of PMs fractures regardless of mechanism of injury or fibula fracture presence or location (AUROC 0.83 [95% CI 0.80-0.87]). Separate multivariate regression showed for every 1° increase in FOA, PM fracture odds increase 6% per degree and for every 1 cm increase in DFP odds of PM fracture decreased by 15%. CONCLUSIONS:Spiral fractures (simple, wedge or complex), fracture angles greater than 45° and extension into the distal 1/3 of the tibial shaft are independent predictors of PM fractures in TSFs regardless of mechanism of injury.

OBJECTIVES/UNASSIGNED:To document discharge locations for geriatric patients treated for a hip fracture before and during the COVID pandemic and subsequent changes in outcomes seen between each cohort. DESIGN/UNASSIGNED:Retrospective cohort study. SETTING/UNASSIGNED:Academic medical center. PATIENTS/PARTICIPANTS/UNASSIGNED:Two matched cohorts of 100 patients with hip fracture treated pre-COVID (February-May 2019) and during COVID (February-May 2020). INTERVENTION/UNASSIGNED:Discharge location and COVID status on admission. Discharge locations were home (home independently or home with health services) versus facility [subacute nursing facility (SNF) or acute rehabilitation facility]. MAIN OUTCOME MEASUREMENTS/UNASSIGNED:Readmissions, inpatient and 1-year mortality, and 1-year functional outcomes (EQ5D-3L). RESULTS/UNASSIGNED:= 0.029). COVID- patients discharged to an SNF in 2020 had a 3x increased 30-day mortality rate and 1.5x increased 1-year mortality rate compared with 2019. Patients discharged to an acute rehabilitation facility in 2020 had higher rates of 90-day readmission. There was no difference in functional outcomes. CONCLUSIONS/UNASSIGNED:All patients, including COVID- patients, discharged to all discharge locations during the onset of the pandemic experienced a higher mortality rate as compared with prepandemic. This was most pronounced in patients discharged to a skilled nursing facility in 2020 during the early stages of the pandemic. If this trend continues, it suggests that during COVID waves, discharge planning should be conducted with the understanding that no options eliminate the increased risks associated with the pandemic. LEVEL OF EVIDENCE/UNASSIGNED:III.

The aim of this study was to compare outcomes of tibial plateau fracture dislocations (FD) with tibial plateau fractures alone. This study was an analysis of a series of tibial plateau fractures, in which FD was defined as a fracture of the tibial plateau with an associated loss of congruent joint reduction and stability of the knee, and classified by the Moore system. Patient data collected included demographics, injury information, and functional outcomes (short musculoskeletal function assessment [SMFA] score and Pain by the visual analog scale). Clinical outcomes at follow-up were recorded including knee range of motion, knee stability and development of complications. There were a total of 325 tibial plateau fracture patients treated operatively, of which 22.2% were identified as FD (n = 72). At injury presentation there was no difference with regard to nerve injury or compartment syndrome (both p > 0.05). FD patients had a higher incidence of arterial injury and acute ligament repair (both p < 0.005). At a mean follow-up of 17.5 months, FD patients were similar with regard to pain, total SMFA scores, and return to sports than their non-FD counterparts (p = 0.884, p = 0.531, p = 0.802). FD patients were found to have decreased knee flexion compared with non-FD patients by 5 degrees (mean: 120 and 125 degrees) (p < 0.05). FD patients also had a higher incidence of late knee instability and subsequent surgery for ligament reconstruction (p < 0.005 & p < 0.05). However, there was no difference in neurological function between groups at follow-up (p = 0.102). Despite the higher incidence of ligamentous instability and decreased range of motion, FD patients appear to have similar long-term functional outcomes compared with non-FD of the tibial plateau. While FD patients initially presented with a higher incidence of arterial injury, neurovascular outcomes at final follow-up were similar to those without a dislocation.

BACKGROUND:The purpose of this study was to (1) assess the effect of preoperative echocardiogram on time to surgery and (2) assess the outcomes of patients with a previous percutaneous coronary intervention (PCI). METHODS:Demographic, clinical, quality and cost data were obtained and a validated risk predictive tool (STTGMA) was calculated for each of a consecutive series of hip fracture patients. Comparative analyses of patients who had an echocardiogram prior to surgery or a PCI prior to hospitalization were performed. RESULTS:Between 2014 and 2020, 2625 patients presented to our institution with a hip fracture. From this cohort 471 patients underwent a preoperative transthoracic echocardiogram (TTE), 30 who had a history of a PCI, and an additional 26 who had a history of PCI but did not undergo a preoperative TTE. Those undergoing a preoperative TTE had similar time (days) to surgery (1.73 vs 1.77, p = 0.86) and 30-day mortality (4% vs 7%, p = 0.545) regardless of PCI history. PCI patients who underwent a preoperative TTE experienced increased rates of 1-year mortality (27% vs 10%, p = 0.007) and major complications (23% vs 12%, p = 0.08) compared to those without a PCI history. PCI patients undergoing a preoperative TTE had a similar time (days) to surgery (1.77 vs 1.48, .p = 0.397) compared to PCI patients without a preoperative TTE. Patients who underwent a preoperative TTE had higher rates of 90-day readmission (31.0% vs 8.0%, p = 0.047) and 1-year mortality (26.7% vs 3.8%, p = 0.029). CONCLUSIONS:Having a preoperative TTE does not affect surgical wait times in hip fracture patients regardless of PCI history, but it may not improve mortality outcomes or reduce postoperative complications in patients with a history of a PCI.

OBJECTIVES/OBJECTIVE:Examine the patterns and defining characteristics of middle-aged and geriatric patients who sustain orthopedic trauma in New York City. STUDY DESIGN/METHODS:Retrospective cohort study. METHODS:11,677 patients >55 years old treated for traumatic orthopedic injuries were grouped into cohorts based on their age group (cohorts of 55-64, 65-74, 75-84, 85-94, ≥95 years) and year of presentation (2014-2021). Each patient was reviewed for demographics/comorbidities, injury mechanism/type, mortality data. Comparative analyses were conducted. RESULTS:The average age of our cohort was 74 years old. The majority of patients were female (69%) and sustained their injuries via a ground level fall. The most common injuries sustained by patients occurred at the upper extremity (40%), hip (26%), and lower extremity (25%) with 820 (7%) patients sustaining polytrauma. The incidence of hip fractures and pelvic injuries increased with older age. Older patients had a higher rate of mortality through 1-year in addition to a longer length of stay. In contrast, the incidence of injury to the upper and lower extremity decreased with older age. CONCLUSIONS:The rate of mortality out through 1-year following orthopedic trauma increased as patients got older. Significantly more women experienced a traumatic injury during 2014-2021. As age increased, ground level falls were the most common mechanism of injury with injuries more likely to occur in the axial skeleton, notably the hip and pelvis. Younger patients experienced higher rates of upper and lower extremity trauma. Providers should keep these patterns in mind to optimize care for middle-aged and geriatric trauma patients.

The American Society of Anesthesiologists Physical Status (ASA-PS) grade better risk stratifies geriatric trauma patients, but it is only reported in patients scheduled for surgery. The Charlson Comorbidity Index (CCI), however, is available for all patients. This study aims to create a crosswalk from the CCI to ASA-PS. Geriatric trauma cases, aged 55 years and older with both ASA-PS and CCI values (N = 4223), were used for the analysis. We assessed the relationship between CCI and ASA-PS, adjusting for age, sex, marital status, and body mass index. We reported the predicted probabilities and the receiver operating characteristics. A CCI of zero was highly predictive of ASA-PS grade 1 or 2, and a CCI of 1 or higher was highly predictive of ASA-PS grade 3 or 4. Additionally, while a CCI of 3 predicted ASA-PS grade 4, a CCI of 4 and higher exhibited greater accuracy in predicting ASA-PS grade 4. We created a formula that may accurately situate a geriatric trauma patient in the appropriate ASA-PS grade after adjusting for age, sex, marital status, and body mass index. In conclusion, ASA-PS grades can be predicted from CCI, and this may aid in generating more predictive trauma models.

INTRODUCTION/BACKGROUND:The purpose of this study is to identify optimal threshold hemoglobin (Hgb) and hematocrit (Hct) laboratory values to transfuse hip fracture patients. METHODS:A consecutive series of hip fracture patients were reviewed for demographic, clinical, and cost data. Patients receiving an allogeneic transfusion of packed red blood cells (pRBCs) were grouped based on last Hct or Hgb (H&H) value before first transfusion. Multivariate logistic regressions of H&H quantile were performed to predict "good outcomes," a composite binary variable defined as admissions satisfying (1) no major complications, (2) length of stay below top tertile, (3) cost below median, (4) no mortality within 30 days, and (5) no readmission within 30 days. Odds ratios (OR) for "good outcomes" were calculated for each H&H quantile. RESULTS:One thousand four hundred ninety-six hip fracture patients were identified, of which 598 (40.0%) were transfused with pRBCs. Patients first transfused at Hgb values from 7.55 to 7.85 g/dL (P = 0.043, OR = 2.70) or Hct values from 22.7 to 23.8% (P = 0.048, OR = 2.63) were most likely to achieve "good outcomes." DISCUSSION/CONCLUSIONS:The decision to transfuse patients should be motivated by Hgb and Hct laboratory test results, given that transfusion timing relative to surgery has been shown to not affect outcomes among patients matched by trauma risk score. Surgeons should aim to transfuse hip fracture patients at Hgb levels between 7.55 g/dL and 7.85 g/dL or Hct levels between 22.7% and 23.8%. These transfusion thresholds have the potential to lower healthcare costs without compromising quality, ultimately resulting in less costly, efficacious care for the patient. LEVEL OF EVIDENCE/METHODS:Level III.

INTRODUCTION/BACKGROUND:Humeral shaft fractures make up 1-3% of all fractures and are most often treated nonoperatively; rates of union have been suggested to be greater than 85%. It has been postulated that proximal third fractures are more susceptible to nonunion development; however, current evidence is conflicting and presented in small cohorts. It is our hypothesis that anatomic site of fracture and fracture pattern are not associated with development of nonunion. MATERIALS AND METHODS/METHODS:In a retrospective cohort study, 147 consecutive patients treated nonoperatively for a humeral shaft fracture were assessed for development of nonunion during their treatment course. Their charts were reviewed for demographic and radiographic parameters such as age, sex, current tobacco use, diabetic comorbidity, fracture location, fracture pattern, AO/OTA classification, and need for intervention for nonunion. RESULTS:One hundred and forty-seven patients with 147 nonoperatively treated humeral shaft fractures were eligible for this study and included: 39 distal, 65 middle, and 43 proximal third fractures. One hundred and twenty-six patients healed their fractures by a mean 16 ± 6.4 weeks. Of the 21 patients who developed a nonunion, two were of the distal third, 10 of the middle third, and nine were of the proximal third. In a binomial logistic regression analysis, there were no differences in age, sex, tobacco use, diabetic comorbidity, fracture pattern, anatomic location, and OTA fracture classification between patients in the union and nonunion cohorts. CONCLUSIONS:Fracture pattern and anatomic location of nonoperatively treated humeral shaft fractures were not related to development of fracture nonunion.

OBJECTIVES/OBJECTIVE:To measure the effect of a novel augmented reality software designed to aid in lag screw placement into the femoral head for cephalomedullary nails. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Single level I trauma center. PATIENTS/METHODS:Between November 2017 and December 2020, 114 consecutive patients with a hip fracture that underwent repair with a cephalomedullary nail by one of two orthopedic trauma surgeons were reviewed. Fracture classifications included OTA/AO 31-A1, 31-A2, 31-A3, and 31-B3. INTERVENTION/METHODS:The first 57 patients underwent fracture repair without the software (control) and the subsequent 57 patients underwent repair with use of the augmented reality software (AR). MAIN OUTCOME MEASUREMENTS/METHODS:Tip apex distance (TAD) and femoral head zone (AP: superior, center, inferior; Lateral: anterior, center, posterior) were measured using standardized techniques. RESULTS:The mean TAD was lower for the AR vs. control cohort (10.7±2.9 mm vs 15.4±3.8 mm; p<0.001). TAD <10mm for AR vs. control: 25 (43.9%) vs. 3 (5.3%), p<0.001. TAD <15mm for AR vs. control: 50 (87.7%) vs. 44 (77.2%), p<0.001. On the AP view center position was achieved in 50.9% vs. 7.0% of cases for the AR vs. control cohort, respectively. On the lateral view, center position was achieved in 68.4% vs. 12.3% of cases for the AR vs. control cohort, respectively. CONCLUSION/CONCLUSIONS:This study suggests that use of the novel augmented reality software for assistance in lag screw positioning within the femoral head improves overall TAD and ability to achieve the center-center position.