Faculty Bibliography

BACKGROUND/UNASSIGNED:To compare functional outcomes between obese and non-obese patients after intramedullary nail (IMN) fixation of OTA 42A-C tibial fractures. Secondarily, to compare clinical outcomes and union rates between cohorts. METHODS/UNASSIGNED:). Univariate comparisons between cohorts were performed, and multivariable regression was used to adjust for confounders. RESULTS/UNASSIGNED:286 patients met inclusion criteria: 60 (21.0%) were obese and 226 (79.0%) were non-obese. The mean follow-up time was 13.60 ± 7.90 months. There were no differences in injury or demographic characteristics, besides a higher rate of diabetes in the obese group (20% vs. 5.3%, p < 0.001). Obesity was associated with lower 3-month (B = -0.352, p = 0.009), 6-month (B = -0.283 p = 0.013) and 12-month (B = -0.181 p = 0.039) FAC scores when controlling for baseline FAC score, age, fracture pattern, diabetes, and open fractures. The obese group was not associated with fracture nonunion (81.7% vs. 90.3%, p = 0.064) and showed no difference in healed-by times (6.28 ± 2.45 [months] vs. 6.13 ± 2.83, p = 0.751). The obese group had a higher rate of amputation (5% vs. 0%, p < 0.001) but no difference in overall complication rate (28.3% vs. 18.0%, p = 0.081). CONCLUSIONS/UNASSIGNED:Obese patients who undergo intramedullary nail fixation of OTA 42A-C tibial diaphyseal fractures have worse functional ambulatory outcomes compared to their non-obese counterparts.

The gold standard for patella fracture fixation is tension band wiring; however, achieving stable anatomic fixation can be challenging in comminuted patterns. The "star" variable-angle locking patella plate is an alternative fixation construct that is meant to address these limitations by providing multiple fixation points and dorsal cortical stability. The purpose of this study was to analyze the outcomes of patients treated with the variable-angle locking "star" patella plate. A total of 358 patients who underwent repair of a displaced patella fracture over a 10-year period were reviewed. Patients who sustained an isolated orthopaedic trauma association (OTA) 34-C3 patella fracture and underwent open reduction internal fixation (ORIF) with the variable-angle locking star-shaped patella plating system with at least 6 months of follow-up were analyzed. Demographic and treatment characteristics, fracture union, complications, and functional outcome measures as measured by knee range of motion (ROM) were collected retrospectively at standard follow-up intervals. Thirty-seven patients (mean age 60.17 ± 16.72 [standard deviation, SD] years; mean body mass index [BMI] 25.12 ± 5.04 [SD] kg/m²) treated at one multisite, urban, academic institution were identified. All fractures were classified as OTA 34-C3. The mean operating room time (wheels-in wheels-out) was 149.43 ± 50.82 (SD) minutes. One patient (2.7%) developed a fracture-related infection (FRI), two patients (5.4%) had wound complications, and one patient (2.7%) developed a deep vein thrombosis (DVT) following surgery. All fractures healed by 6 months, and no patient underwent removal of symptomatic hardware. Three patients underwent secondary operation; one patient had repeated irrigation and debridement of a confirmed FRI, one manipulation under anesthesia for knee contracture, and one revision ORIF after loss of distal fixation. Patients displayed a mean knee ROM of 106.53 ± 21.64 degrees (SD) and 118.51 ± 16.87 degrees (SD) at the 3- and 6-month points, respectively. The novel locking "star" patella plate appears to be a reliable and safe method of treatment for the most complex patella fractures.

BACKGROUND/UNASSIGNED:Functional recovery following non-operative treatment of proximal humerus fractures (PHFs) varies widely, but the relative impact of patient characteristics and medical comorbidities remain unclear. This study aimed to identify factors associated with (1) patient-reported functional recovery following healing as measured by Disabilities of the Arm, Shoulder, and Hand (DASH) scores and (2) achieving functional range of shoulder motion (ROM). METHODS/UNASSIGNED:Fractures were classified using the Neer system, and all patients followed a standardized therapy protocol emphasizing early ROM. Functional outcomes were assessed using a self-reported pre-injury DASH estimate and DASH at minimum 6-month follow-up, with recovery quantified as a standardized deviation metric (absolute difference divided by the cohort SD of pre-injury estimates). Functional ROM was defined as ≥120° of forward elevation. Exploratory bivariate analyses were performed, and multivariable linear and logistic regression models were used to identify independent associations. RESULTS/UNASSIGNED:Among 166 patients, multivariable linear regression demonstrated coronary artery disease (CAD; B = 2.64; 95% CI, 0.52-4.75; p = 0.015), hypertension (HTN; B = 1.43; 95% CI, 0.06-2.80; p = 0.041), and race/ethnicity (B = 0.59; 95% CI, 0.08-1.11; p = 0.023) were independently associated with greater standardized DASH deviation; type 2 diabetes (T2DM) was not (p = 0.170). ROM data were available for 129 patients (77.7%). In multivariable logistic regression, no covariate reached statistical significance; HTN demonstrated a trend toward reduced odds of achieving functional ROM (aOR 0.29; 95% CI, 0.07-1.18; p = 0.084). CONCLUSION/UNASSIGNED:In this exploratory cohort, cardiovascular comorbidities (CAD and HTN) were independently associated with poorer patient-reported functional recovery after non-operative PHF treatment. Race/ethnicity showed an association, but subgroup sizes were small, and estimates should be interpreted cautiously. No independent predictors of functional ROM were identified.

The purpose of this study was to compare outcomes in patients who sustained isolated lateral column tibial plateau fractures and combined lateral and posterolateral column tibial plateau fractures (AO/OTA 41B3 lateral split-depression fractures). Fractures were classified according to the three-column classification system of tibial plateau fractures. The primary outcome was the difference in Short Musculoskeletal Function Assessment (SMFA) function index at 12 months postoperatively between patients with lateral column plateau fractures and patients with combined lateral and posterolateral column plateau fractures. Seventy-eight patients were included (mean age: 48.8 ± 14.1 years). Thirty-two patients (41.0%) were in the isolated lateral column group (L), and 46 patients (59.0%) were in the lateral column plus posterolateral column group (L + PL). At 1 year following injury and fixation, the L + PL group demonstrated significantly worse SMFA function index than the L group (19.1 ± 17.7 vs. 9.1 ± 12.5, p = 0.005). Similarly, the L + PL group was significantly more bothered by the sequelae of their injury compared to the L group at 1 year based on the SMFA bothersome index (20.7 ± 23.7 vs. 8.6 ± 12.3, p = 0.005). Patients with combined lateral and posterolateral column tibial plateau fractures demonstrate worse outcomes compared to isolated lateral column fractures 1 year after fixation. The study provides level III evidence.

OBJECTIVES/OBJECTIVE:To assess the concordance between blood culture isolates and intraoperative deep tissue cultures in patients with confirmed fracture-related infection (FRI). DESIGN/METHODS:Retrospective Cohort Study. SETTING/METHODS:Academic Medical Center. PATIENT SELECTION CRITERIA/UNASSIGNED:This Institutional Review Board-approved study included patients 18 years and older diagnosed with a confirmed FRI according to the FRI Consensus Group criteria who, at time of irrigation and debridement (I&D), underwent deep tissue culture (TC) as well as concurrent blood culture (BC) testing (in the Emergency Department or inpatient setting). The decision to perform BC testing was left to the discretion of the initial treating providers at the time of this presentation. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Microbiological data were reviewed from the electronic medical record. Infections were classified as monomicrobial (either gram-positive or gram-negative), polymicrobial, or culture negative. Pathogen concordance between blood and intraoperative tissue cultures was analyzed. RESULTS:84 patients were included with both intraoperative deep TC and concurrent BC. This cohort had a mean age of 56.2 ± 20.3 years and consisted of 33 females (39.3%). BC were never ordered by the orthopedic surgeon. Microbial analysis of deep tissue specimens identified 29 gram-positive infections, 18 gram-negative infections, 33 polymicrobial infections, and 4 culture-negative cases. Of the 84 BC analyzed, 69 (82.1%) were culture-negative and 15 (17.9%) were culture-positive. BC results were discordant with their respective TC isolates in 76 of 84 (90.4%) cases. This discordance in 76 cases was driven by negative BC in the setting of positive TC (69/76, 90.8%), while a smaller proportion reflected growth of different organisms in BC compared to TC (7/76, 9.2%). Concordance was observed in only 8 of 84 (9.6%) cases, in which BC identified at least one pathogen sampled from TC. BC yielded negative culture results 17 times as often as TC. McNemar's test revealed a highly significant difference in culture-positivity rates (χ2=65, p<0.0001), while Cohen's Kappa for agreement was 0.022, indicating minimal agreement between BC and TC results. CONCLUSIONS:These results suggest that blood cultures were part of some workflows for patients presenting with infections, but they did not reflect the true bony pathogens nor contribute meaningful diagnostic information in most cases of confirmed fracture-related infection (FRI) according to the FRI Consensus Group criteria. While blood culture testing is important in the evaluation of systemic infection from, it does not provide orthopedic surgeons with information that informs the management or treatment of the FRI itself. LEVEL OF EVIDENCE/METHODS:III.

PURPOSE/OBJECTIVE:To compare clinical characteristics and outcomes of Maisonneuve fractures, as defined as syndesmotic disruption with or without proximal fibula fracture, to other pronation-external rotation (PER) stage III/IV fractures. METHODS:A retrospective review of an IRB-approved database of ankle fractures from a single orthopedic department identified patients with surgically treated PER stage III/IV fractures, including those meeting radiographic criteria for Maisonneuve fracture. Data collected included patient demographics, injury mechanism, surgical details, and Lauge-Hansen classification. Maisonneuve fractures were compared to other PER III/IV fractures requiring fibular fixation with syndesmotic stabilization. Outcomes included total complications, fracture-related infection, hardware removal, and nonunion. Patients were seen for standard follow up for 12 months post-operatively with clinical healing defined as non-tenderness about the ankle. Statistical analyses included Chi square analysis, ANOVA, and multivariable regression analysis. RESULTS:64 patients with operatively repaired Maisonneuve fractures were identified (mean follow-up of 10 months). These patients were more often male compared to other PER III/IV fractures (p < 0.05). Maisonneuve fractures were associated with a faster time to clinical healing and return to full activity, confirmed on multivariable regression analysis (p < 0.05). No significant differences in complications rates or radiographic parameters at six months or later were observed, as all values remained within accepted clinical ranges. CONCLUSION/CONCLUSIONS:Maisonneuve fracture patients experience a more rapid clinical recovery based upon painless ankle motion as well as a return to full activity faster than patients with other types of PER III/IV injuries, with comparable complication rates and radiographic outcomes.

OBJECTIVES/OBJECTIVE:This study evaluated the impact of prolonged glucagon-like peptide-1 (GLP-1) receptor agonist use on postoperative outcomes, including radiographic post-traumatic osteoarthritis (PTOA), fracture nonunion, and final knee range of motion-following operative management of tibial plateau fractures across multiple BMI strata. METHODS:A retrospective cohort study was conducted at an urban academic institution, including patients who underwent surgical fixation for tibial plateau fractures between 2016-2024, with a ≥6 months follow-up. The GLP-1 cohort consisted of patients with documented long-term GLP-1 use pre- and postoperatively. GLP-1 users (Group A, n=24) were compared to three non-GLP-1 cohorts stratified by BMI: Group B (BMI 18.5-25, n=150), Group C (BMI 25-30, n=150), and Group D (BMI ≥30, n=100). Outcomes included Kellgren-Lawrence osteoarthritis grade, post-reduction fracture angulation, articular step-off, Charlson Comorbidity Index (CCI), fracture complications (infection, nonunion, PTOA, revision surgery), and final knee flexion range of motion (ROM). Statistical analyses used SPSS Statistics version 29.0 (IBM Corp., Armonk, NY) with ANOVA and Chi-square tests. RESULTS:Mean follow-up was 28.83 months. Baseline age, CCI, fracture angulation, and step-off were comparable between groups. Pre-injury osteoarthritis severity was higher in Group A (0.96±0.88) than in Groups B (0.68±0.86), C (0.54 ± 0.75), and D (0.78±0.74) (p<0.001). Radiographic PTOA incidence was highest in Group D (32%, p<0.01), while Group A rates were comparable to Groups B and C (p≈0.62). Final knee flexion ROM differed significantly (p<0.01), with Group D showing the lowest mobility (119.08±16.47°). Nonunion rates were significantly higher in Group A (p<0.01). CONCLUSIONS:Among obese patients, GLP-1 receptor agonist use was associated with a lower incidence of PTOA and preserved knee ROM compared to untreated obese individuals, with outcomes similar to non-obese patients. However, GLP-1 use was also linked to increased nonunion rates. These findings suggest that while GLP-1 therapy may mitigate obesity-related joint degeneration, it may also challenge fracture healing.

PURPOSE/OBJECTIVE:To characterise differences in baseline demographics, outcomes, and cost between 1st and 2nd (contralateral) hip fracture hospitalisations in the same patient that occur within 5 years of each other. METHODS:A retrospective review of operatively treated hip fractures was performed at an academic medical centre. INCLUSION CRITERIA/METHODS:age ⩾65 years, presence of a first and second, contralateral hip fracture with OTA 31A/B classification within 5 years of the hip fracture. Analysis was based on the chronological order of their fracture - 1st hip fracture versus 2nd hip fracture. Comparison of patients' demographics, postoperative complications, 90-day readmission rates, 1-year mortality, discharge location, and direct inpatient hospitalisation costs were compared. Major complications were defined as: sepsis, acute respiratory failure, myocardial infarction, stroke, pulmonary embolus, or death. RESULTS: = 0.08). There were no other differences in outcomes and hospitalisation cost. CONCLUSIONS:Patients who sustain a 2nd contralateral hip fracture within 5 years of their first hip fracture demonstrate a trend towards having more major and minor inpatient complications There are otherwise comparable hospital quality measures and cost profile during their 2nd hip fracture hospitalisation compared to their 1st hip fracture hospitalisation. Resources should be allocated to minimise the risk of complications in 2nd hip fracture patients.

OBJECTIVE:To examine factors associated with lag screw slide following fixation of intertrochanteric hip fractures with 1 type of cephalomedullary nail. METHODS:Retrospective review of patients operatively treated for intertrochanteric hip fractures (OTA/AO 31A1 and 31A2) with a single cephalomedullary nail (CMN) at a single academic medical centre between November 2014 and November 2023. CMN lag screw was placed in "dynamic" mode to allow for controlled collapse, or screw "slide." Screw slide was defined as the difference in lateral prominence of the lag screw at latest follow up compared to its initial position. Patients were grouped based on the amount of screw slide (<5 mm, 5-15 mm, >15 mm) and correlation analysis was performed. RESULTS: = 0.002) was associated with >15 mm screw slide. CONCLUSIONS:Excessive lag screw slide (>15 mm) was associated with higher patient BMI. Patients with higher BMIs should be monitored to identify excessive slide. Surgeons should attempt to keep the lag screw as close to the lateral cortex as possible. While the use of anti-osteoporotic therapy was associated with more slide, this was almost exclusively seen in patients only prescribed vitamin D and calcium.