Faculty Bibliography

BACKGROUND:Periprosthetic femoral fractures (PFF) carry significant morbidity following arthroplasty for femoral neck fracture (FNF). This study assessed fracture complications following arthroplasty for FNF and the effect of cement fixation of the femoral component on intraoperative and post-operative PFF. METHODS:Between February 2014 and September 2021, 740 patients with a FNF who underwent arthroplasty were analyzed for demographics, surgical management, use of cement for fixation of the femoral component, and subsequent PFF. Variables were compared with Mann-Whitney or Chi-square as appropriate. Multivariate logistic regression was used to assess independent risk factors associated with intraoperative or post-operative PFF. RESULTS:There were 163 THAs (41% cemented) and 577 HAs (95% cemented). There were 28 PFFs (3.8%): 18 post-operative and 10 intraoperative. Fewer post-operative PFFs occurred with cemented stems (1.63% vs. 6.30%, p = 0.002). Mean time from surgery to presentation with post-operative PFF was 14 months (0-45 months). Mean follow-up time was 10.3 months (range: 0-75.7 months). In multivariate regression, use of cement and THA was independently associated with decreased post-operative PFF (cement: OR 0.112, 95% CI 0.036-0.352, p < 0.001 and THA: OR 0.249, 95% CI 0.064-0.961, p = 0.044). More intraoperative fractures occurred during THA (3.68% vs. 0.69%, p = 0.004) and non-cemented procedures (5.51% vs. 0.49%, p < 0.001). In multivariate regression, use of cement was protective against intraoperative fracture (OR 0.100, CI 0.017-0.571, p = 0.010). CONCLUSIONS:In patients with a FNF treated with arthroplasty, cementing the femoral component is associated with a lower risk of intraoperative and post-operative PFF. Choice of procedure may be based on patient factors and surgeon preference.

OBJECTIVES/OBJECTIVE:To evaluate whether retention of antibiotic cement delivery devices after resolution of orthopaedic infection is associated with recurrence. DESIGN/UNASSIGNED:Retrospective cohort. SETTING/UNASSIGNED:Academic medical center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients with a fracture definitively treated with internal fixation that went on to unite and develop a confirmed fracture-related infection or osteomyelitis after a remote fracture surgery and had implantation of antibiotic-impregnated cement for infection management. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Patients were divided into whom the antibiotic implants were retained (Retained Cohort) and whom the antibiotic implants were removed (Removed Cohort). Outcome measures included clinical infection resolution, infection recurrence, time to resolution of infection signs, symptoms and laboratory values, reoperation and readmission rates, and need for soft tissue coverage (local flap vs. free tissue transfer) because of recurrence. RESULTS:Of 98 patients treated for fracture-related infection in united fractures or osteomyelitis after a remote fracture surgery, 39 (39.8%) underwent implantation of antibiotic-impregnated cement delivery devices: 21 (21.4%) beads, 7 (7.1%) rods, and 11 (11.2%) blocks. Twenty patients (51.3%) comprised the Retained Cohort and 19 patients (48.7%) comprised the Removed Cohort. There were few differences in demographics ([American Society of Anesthesiology Score, P = 0.026] and [diabetes, P = 0.047]), infection location, and pathogenic profiles. The cohorts demonstrated no difference in eventual resolution of infection (100% in the Retained Cohort, 95% in the Removed Cohort, P = 0.487) and experienced similar time to clinical infection resolution, based on signs, symptoms, and laboratory values ( P = 0.360). There was no difference in incidence of subsequent infection recurrence after clinical infection resolution (1 recurrence Retained vs. 2 recurrences Removed, P = 0.605) for those considered "cured." Compared with the Retained Cohort, the Removed Cohort underwent more reoperations (0.40 vs. 1.84 reoperations, P < 0.001) and admissions after implantation ( P < 0.001). CONCLUSIONS:Retention of antibiotic-impregnated cement delivery devices in patients with orthopaedic infection after fractured bones that have healed was not associated with infection recurrence. Additional surgical intervention with the sole purpose of removing antibiotic delivery devices may not be warranted. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:To quantify the rate of union and time to clinical and radiographic healing in Zone 2 proximal fifth metatarsal (MT) fractures and compare these outcomes between Zone 2 fractures treated operatively and nonoperatively. DESIGN/UNASSIGNED:Retrospective cohort study. SETTING/UNASSIGNED:Academic Level I Trauma Center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients with fifth MT fractures who presented between December 2012 and April 2022 and confirmed to have Zone 2 fractures (defined as fractures entering the proximal 4-5 MT articulation on the oblique radiographic view) were included in the study analysis in either the operative or nonoperative cohort. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Nonunion, time to clinical healing by, and time to radiographic healing between operative and nonoperative treatment. RESULTS:Among the 499 included patients, 475 patients (95.2%) were initially treated nonoperatively and 24 patients (4.8%) were treated operatively. Both groups were similar in demographics. There was no difference in the proportion of patients with nonunions between groups (6.1% in the nonoperative group vs. 3.8% in the operative group, P = 1.000). In addition, there was no statistically significant difference between groups with respect to the time to clinical healing (9.9 ± 8.3 weeks for the nonoperative group vs. 15.4 ± 15.0 weeks for the operative group, P = 0.117) or the time to radiographic healing (18.7 ± 12 weeks for the nonoperative group vs. 18.5 ± 16.6 weeks for the operative group, P = 0.970). CONCLUSIONS:Zone 2 fifth MT base fractures were successfully treated with nonoperative management. There was no evidence in this study that operative treatment leads to significantly faster clinical or radiographic healing. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION/BACKGROUND:The purpose of this study was to evaluate outcomes following reverse obliquity (RO) intertrochanteric hip fractures based on the use of short cephalomedullary nails (CMNs) compared to long CMNs for fixation. METHODS:An IRB-approved prospectively collected hip fracture registry at an urban academic medical center was queried for all AO/OTA 31A3.1-3 reverse obliquity intertrochanteric (RO) fractures. One hundred and seventy patients with age > 55 years old and minimum 6-month follow-up were identified for analysis. Data was collected for patient demographics, injury details, intraoperative radiographic parameters, perioperative physiologic parameters, hospital quality measures, and outcomes including radiographic time to healing, need for reoperation, nonunion, and mortality. Comparative analyses were conducted between cohorts. Additional multivariable binary logistic and linear regression analyses were performed to evaluate for factors independently associated with short and long nail usage. RESULTS:The mean age of the entire cohort was 80.91±10.09 years: 103 patients had a long CMN implanted, and 67 patients had a short CMN implanted. There were no demographic differences or differences in radiographic time to healing, rates of mortality, readmission, nonunion, and need for reoperation. Univariable analysis revealed that short CMN had lower intraoperative blood loss (111.19±83.97 mL vs 176.72±161.45 mL, p = 0.002), decreased need for transfusion (37% vs. 55 %, p = 0.022), and shorter procedures (118.67±57.87 min vs. 148.95±77.83 min, p = 0.002. Multivariable analysis revealed that short nail usage was associated with decreased intraoperative blood loss, decreased need for transfusion, and shorter operative times. CONCLUSION/CONCLUSIONS:Nail length does not affect healing or hospital quality outcomes in the treatment of RO hip fractures. The use of short CMNs for these fractures did correlate with lower intraoperative blood loss, operative time, and need for blood transfusion, with non-inferior outcomes and similar hospital quality measures when compared to long CMNs.

BACKGROUND/UNASSIGNED:Significant heterogeneity in the classification and treatment of zone 3 proximal fifth metatarsal base fractures ("true Jones fractures") exists. This study compared time to clinical and radiographic healing between patients treated operatively and nonoperatively. We hypothesized that patients treated nonoperatively may demonstrate a greater time to clinical healing. METHODS/UNASSIGNED:This was a retrospective cohort study of patients presenting to a large, urban, academic medical center with "Jones" fractures between December 2012 and April 2022. Jones fractures were defined as fifth metatarsal base fractures occurring in the proximal metadiaphyseal region, distal to the articulation of the fourth and fifth metatarsals on the oblique radiographic view. Clinical healing was the time point at which the patient had returned to their baseline ambulatory status with no tenderness to palpation. Radiographic healing was the presence of bridging callus across at least 3 cortices. RESULTS/UNASSIGNED: = .331). Overall healing rate was 96% for the nonoperative group compared with 96.2% for the operative group. CONCLUSION/UNASSIGNED:In this study, nonoperative and operative treatment of true Jones fractures were associated with equivalent clinical and radiographic healing. The rate of delayed union in true Jones fractures was lower than previously described, and there was no difference in delayed union rate between nonoperative and operative management. LEVEL OF EVIDENCE/UNASSIGNED:Level III, retrospective cohort study.

OBJECTIVES/OBJECTIVE:The authors report no conflict of interest.To determine if short-term immobilization with a rigid long arm plaster elbow splint after surgery of the arm, elbow, or forearm results in superior outcomes compared with a soft dressing with early motion. DESIGN/METHODS:Prospective Randomized Control Trial. SETTING/METHODS:Academic Medical Center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients undergoing operative treatment for a mid-diaphysis or distal humerus, elbow, or forearm fracture were consented and randomized according to the study protocol for postoperative application of a rigid elbow splint (10-14 days in a plaster Sugar Tong Splint for forearm fracture or a Long Arm plaster Splint for 10-14 for all others) or soft dressing and allowing immediate free range of elbow and wrist motion (range of motion [ROM]). OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Self-reported pain (visual analog score or VAS), Healthscale (0-100, 100 denoting excellent health), and physical function (EuroQol 5 Dimension or EQ-5D) surveyed on postoperative days 1-5 and 14 were compared between groups. Patient-reported pain score (0-10, 10 denoting highest satisfaction) at week 6, time to fracture union, ultimate disabilities of the arm, shoulder, and hand score, and elbow ROM were also collected for analysis. Incidence of complications were assessed. RESULTS:Hundred patients (38 men to 62 women with a mean age of 55.7 years) were included. Over the first 5 days and again at postop day 14, the splint cohort reported a higher "Healthscale" from 0 to 100 than the nonsplint group on all study days ( P = 0.041). There was no difference in reported pain between the 2 study groups over the same interval ( P = 0.161 and 0.338 for least and worst pain, respectively), and both groups reported similar rates of treatment satisfaction ( P = 0.30). Physical function ( P = 0.67) and rates of wound problems ( P = 0.27) were similar. Additionally, the mean time to fracture healing was similar for the splint and control groups (4.6 ± 2.8 vs. 4.0 ± 2.2 months, P = 0.34). Ultimate elbow ROM was similar between the study groups ( P = 0.48, P = 0.49, P = 0.61, and P = 0.51 for elbow extension, flexion, pronation, and supination, respectively). CONCLUSIONS:Free range of elbow motion without splinting produced similar results compared with elbow immobilization after surgical intervention for a fracture to the humerus, elbow, and forearm. There was no difference in patient-reported pain outcomes, wound problems, or elbow ROM. Immobilized patients reported slightly higher "healthscale" ratings than nonsplinted patients and, however, reported similar rates of satisfaction. Both treatment strategies are acceptable after upper extremity fracture surgery. LEVEL OF EVIDENCE/METHODS:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE/UNASSIGNED:This study sought to examine the utilization of bone health evaluations in geriatric hip fracture patients and identify risk factors for the development of future fragility fractures. MATERIALS AND METHODS/UNASSIGNED:A consecutive series of patients ≥55 years who underwent surgical management of a hip fracture between September 2015 and July 2019 were identified. Chart review was performed to evaluate post-injury follow-up, performance of a bone health evaluation, and use of osteoporosis-related diagnostic and pharmacologic treatment. RESULTS/UNASSIGNED:A total of 832 patients were included. The mean age of the patients was 81.2±9.9 years. Approximately 21% of patients underwent a comprehensive bone health evaluation. Of this cohort, 64.7% were started on pharmacologic therapy, and 73 patients underwent bone mineral density testing. Following discharge from the hospital, 70.3% of the patients followed-up on an outpatient basis with 95.7% seeing orthopedic surgery for post-fracture care. Overall, 102 patients (12.3%) sustained additional fragility fractures within two years, and 31 of these patients (3.7%) sustained a second hip fracture. There was no difference in the rate of second hip fractures or other additional fragility fractures based on the use of osteoporosis medications. CONCLUSION/UNASSIGNED:Management of osteoporosis in geriatric hip fracture patients could be improved. Outpatient follow-up post-hip fracture is almost 70%, yet a minority of patients were started on osteoporosis medications and many sustained additional fragility fractures. The findings of this study indicate that orthopedic surgeons have an opportunity to lead the charge in treatment of osteoporosis in the post-fracture setting.

OBJECTIVES/OBJECTIVE:The objective of this study was to ascertain outcome differences after fixation of unstable rotational ankle fractures allowed to weight-bear 2 weeks postoperatively compared with 6 weeks. DESIGN/METHODS:Prospective case-control study. SETTING/METHODS:Academic medical center; Level 1 trauma center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients with unstable ankle fractures (OTA/AO:44A-C) undergoing open reduction internal fixation (ORIF) were enrolled. Patients requiring trans-syndesmotic fixation were excluded. Two surgeons allowed weight-bearing at 2 weeks postoperatively (early weight-bearing [EWB] cohort). Two other surgeons instructed standard non-weight-bearing until 6 weeks postoperatively (non-weight-bearing cohort). OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:The main outcome measures included the Olerud-Molander questionnaire, the SF-36 questionnaire, and visual analog scale at 6 weeks, 3 months, 6 months, and 12 months postoperatively and complications, return to work, range of ankle motion, and reoperations at 12 months were compared between the 2 cohorts. RESULTS:One hundred seven patients were included. The 2 cohorts did not differ in demographics or preinjury scores ( P > 0.05). Six weeks postoperatively, EWB patients had improved functional outcomes as measured by the Olerud-Molander and SF-36 questionnaires. Early weight-bearing patients also had better visual analog scale scores (standardized mean difference -0.98, 95% confidence interval [CI] -1.27 to -0.70, P < 0.05) and a greater proportion returning to full capacity work at 6 weeks (odds ratio = 3.42, 95% CI, 1.08-13.07, P < 0.05). One year postoperatively, EWB patients had improved pain measured by SF-36 (standardized mean difference 6.25, 95% CI, 5.59-6.92, P < 0.01) and visual analog scale scores (standardized mean difference -0.05, 95% CI, -0.32 to 0.23, P < 0.01). There were no differences in complications or reoperation at 12 months ( P > 0.05). CONCLUSIONS:EWB patients had improved early function, final pain scores, and earlier return to work, without an increased complication rate compared with those kept non-weight-bearing for 6 weeks. LEVEL OF EVIDENCE/METHODS:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

This study's purpose is to determine if patients treated for hip fracture at highest risk for poor functional outcomes, shorter time to death, and death within 1-year can be predicted at the time of admission. We hypothesized that the Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool can be used to predict risk of these variables. Between February 2019-July 2020, 544 patients ≥ 55-years-old were treated for hip fracture [AO/OTA 31A/B, 32A/C]. Each patient's demographics, functional status, and injury details were used to calculate their respective risk (STTGMA) score at time of admission. Patients were divided into risk quartiles by STTGMA score. Patients were contacted by phone to complete EuroQol-5 Dimension (EQ5D-3L) questionnaires on functional status. Comparative analyses were conducted on outcomes and EQ5D-3L questionnaire results. 439 patients (80.7%) had at least 1-year follow-up. 82 patients (18.7%) died within 1-year after hospitalization. Mean STTGMA score was 1.67% ± 4.49%. The highest-risk cohort experienced a 42x (p < 0.01) and 2.5x (p = 0.01) increased rate of 1-year mortality compared to the minimal- and low-risk groups respectively. The highest-risk cohort had the shortest time to death (p = 0.015). The highest-risk cohort had the lowest EQ5D index (p < 0.01) and VAS scores (p < 0.01) along with the highest rate of 30 day readmission (p < 0.01) and the longest length of stay (p < 0.01). The STTGMA tool provides important prognostic information for middle-aged and geriatric hip fracture patients that can help modulate care levels. This information is useful when counseling patients, their families, and caregivers on expected outcomes.