Faculty Bibliography

This review details an open reduction internal fixation technique of a comminuted, intraarticular Y-type bicolumnar distal humerus fracture using supplemental minifragment plating in addition to dual locking plates. Owing to significant articular comminution, an olecranon osteotomy with an anconeus pedicle flap was used to facilitate exposure to achieve an accurate articular reduction to restore elbow function.

This abstract describes an open reduction and internal fixation technique used for a supination adduction ankle injury. This technique demonstrates medial plafond articular disimpaction with backfilling of the bony void with cancellous allograft. The medial malleolus was then fixed with a mini fragment plate in antiglide fashion with subchondral rafting screws. The lateral malleolus fracture was addressed with use of a retrograde screw rather than a fibular plate. This technique emphasizes the importance of both recognizing and addressing the anteromedial plafond impaction of supination adduction ankle fractures.

OBJECTIVES/OBJECTIVE:To compare 2 methods of initial immobilization of closed humeral shaft fractures-coaptation splinting followed by delayed functional bracing and immediate functional bracing-with respect to pain, satisfaction, and skin-related complications during the initial 10-day post-injury period. DESIGN/METHODS:Multicenter, randomized, two-arm, parallel clinical trial. SETTING/METHODS:One academic medical center with 2 Level 1 academic trauma centers and 1 tertiary care orthopaedic center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients with acute, closed humeral shaft fractures (AO/OTA 12A, 12B, 12C) were randomized to either initial coaptation splinting followed by delayed transition to Sarmiento bracing or immediate Sarmiento bracing. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Pain intensity over time measured by a patient-reported Likert scale (numerical rating scale, 0-10) once daily at the same time during the first 10 days post-injury, skin-related complications (skin damage ranging from abrasion or blistering to full-thickness skin loss secondary to pressure from the splint or brace), analgesic consumption in morphine milligram equivalent (MME), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function scores, and patient satisfaction. RESULTS:Fifty-eight patients were included in the analysis with a mean age of 48.8 ± 23.9 years (mean 50.5 years [range 18.4-92.2 years] in the coaptation splint group vs. mean 47.3 years [range 19.7-85.9 years] in the immediate Sarmiento brace group). Patients in the immediate Sarmiento bracing group reported significantly higher pain scores compared with coaptation splinting during the first 10 days postinjury (mean treatment effect = 0.97 points, 95% CI [0.26-1.69], P = 0.010; Figure 3). Cumulative opioid consumption over the 10-day period was similar between groups (median 20.0 MME for the coaptation splint group vs. 32.5 MME for the Sarmiento brace group, P = 0.308). PROMIS Physical Function scores were not significantly different between groups on postinjury day 7 (median 53.0 [IQR 44.5-68.5] for the splint group vs. 51.1 [IQR 45.0-60.5] for the brace group, P = 0.756). The rate of skin-related complications was higher in the Sarmiento brace group (33.3% vs. 7.1%, P = 0.022). Patient satisfaction scores at day 7 were not significantly different between groups (6.3 ± 2.7 for the coaptation splint group vs. 5.8 ± 3.1 for the Sarmiento brace group, P = 0.520). CONCLUSIONS:Immediate Sarmiento bracing was associated with increased patient-reported pain (roughly 1 point on the 0-10 numeric rating scale) and higher skin complication rates during the initial 10-day period after injury compared with initial coaptation splinting for acute humeral shaft fractures, without demonstrable benefits in function, analgesic requirements, or patient satisfaction. These findings support the traditional approach of initial coaptation splinting followed by delayed transition to functional bracing once acute swelling subsides. LEVEL OF EVIDENCE/METHODS:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

PURPOSE/OBJECTIVE:To determine whether cephalomedullary nail (CMN) angle was associated with malreduction after intertrochanteric (IT) fracture fixation. Secondarily, to explore if CMN angle was associated with fixation failure (FF). METHODS:A retrospective comparative review was conducted of patients ≥ 65 years old with low energy falls and OTA/AO 31-A fractures treated with a CMN from 12/01/2016-06/30/2024 at a single academic institution (four hospitals). The primary outcome was immediate postoperative malreduction (IPM)-the absolute difference between post-fixation neck-shaft angle (NSA) and native contralateral NSA being ≥ 3°. The secondary outcome was FF. Univariate analyses compared IPM between 125° and 130° CMNs. Multivariable regression was performed to determine if CMN angle was associated with IPM, and as an exploratory analysis, FF. RESULTS:A total of 277 patients were included with follow-up of 18.2 ± 15.1 months. The 125° CMN group had significantly greater age, body mass index (BMI), and American Society of Anesthesiologists score (ASA). There was a higher incidence of IPM with 125° CMNs (p = 0.02). Among patients with native NSA ≥ 130°, those treated with a 125° nail had significantly higher IPM incidence (p = 0.01). Mean IPM did not differ by CMN angle. Logistic regression found that BMI (OR 1.06, p = 0.04) and 125° CMN angle (OR 1.82, p = 0.05) were associated with IPM. FF rates were similar between CMN angle groups, but failures had greater varus IPM than non-failures (p = 0.02). In the exploratory FF regression model, CMN angle and varus IPM were not associated with failure, while larger native NSA was associated with FF (OR 1.16, p < 0.001). CONCLUSION/CONCLUSIONS:125° and 130° nails achieved similar mean fracture alignment, yet 125° nails were more frequently associated with varus malreduction, especially with native valgus neck-shaft angles. After adjusting for confounders, higher BMI and 125° nails were associated with malreduction but not with fixation failure.

PURPOSE/OBJECTIVE:To evaluate the effect of baseline dementia on postoperative outcomes in hip fracture patients undergoing hemiarthroplasty. METHODS:A retrospective review was conducted of patients aged 55 years or older who underwent hemiarthroplasty for displaced femoral neck fracture (AO/OTA 31B) between 2012 and 2024 at a large urban academic institution. Dementia was identified by ICD-10 codes and confirmed by chart review. A 3:1 propensity score matched cohort was created using the Score for Trauma Triage in Geriatric and Middle-aged (STTGMA). Demographics and baseline characteristics were compared to ensure similarity. Outcomes included total complications, major and minor complications, periprosthetic dislocation, length of stay, ICU admission, discharge location, 30- and 90-day readmission, revision surgery, inpatient, and 30-day and 1-year mortality. RESULTS:A total of 1,030 patients were included, with 241 patients with dementia and 839 controls. After 3:1 STTGMA propensity matching, baseline characteristics were comparable (mean age 82.75 vs. 83.0 years, P = 0.065; Charlson Comorbidity Index 1.96 vs. 1.92, P = 0.42; STTGMA 0.022 vs. 0.020, P = 0.50). Patients with dementia had increased major complications (17.92% vs. 10.93%, P = 0.013), including sepsis (5.00% vs. 2.21%, P = 0.027), urinary tract infections (13.33% vs. 6.78%, P = 0.002), and hip hemiarthroplasty dislocations (6.25% vs. 2.21%, P = 0.002). Patients with dementia also had longer length of stay (7.84 ± 5.83 vs. 6.80 ± 2.24 days, P = 0.030), increased 30-day readmissions (15.83% vs. 8.85%, P < 0.001), increased 90-day readmission (20.00% vs. 11.76%, P < 0.001), and higher 1-year mortality (16.25% vs. 8.02%, P < 0.001). No differences were observed in pneumonia, stroke, myocardial infarction, cardiac arrest, venothromboembolism, acute kidney injury, anemia, and revision surgery. CONCLUSION/CONCLUSIONS:Dementia was associated with increased major complications, hip hemiarthroplasty dislocations, higher readmission, and mortality after hemiarthroplasty. These findings highlight the need for targeted perioperative planning and multidisciplinary care pathways in cognitively impaired patients.

IntroductionTourniquet use for ankle fracture fixation surgery is a common but not universally accepted practice due to concerns regarding soft tissue complications. Although prior literature has demonstrated increased short-term postoperative pain, tourniquet use's association with other complications remains under-investigated.MethodsA retrospective cohort study was performed of adult patients undergoing open reduction and internal fixation of a closed rotational ankle fracture (OTA Type 44) between 2012 and 2024 at an urban academic health system. Patients were stratified by tourniquet use. Demographic information, injury characteristics, and operative variables were collected. The primary outcome was the development of postoperative complications-wound dehiscence, fracture-related infection, superficial wound infection, delayed wound healing, peripheral nerve injury, venous thromboembolism, and nonunion. Secondary outcomes were operative time and estimated blood loss. Multivariable logistic regression was used to evaluate the association between tourniquet use and postoperative complications.ResultsA total of 617 patients met the inclusion criteria, including 446 who had a tourniquet inflated during surgery and 171 who did not. No significant differences in baseline patient demographics or comorbidity were observed. After multivariable logistic regression, tourniquet use was not associated with higher odds of any wound complication, fracture-related infection, delayed wound healing, or peripheral nerve injury. Among patients in the tourniquet cohort, 4 developed venous thromboembolism and 7 developed a fracture nonunion. No such complications were observed among patients treated without a tourniquet. Tourniquet use was associated with a modest decrease in estimated blood loss (47.3 ± 44.2 vs 33.9 ± 36.0 mL, P < .001) with no significant increase in operative time.ConclusionTourniquet use during operative fixation of closed rotational ankle fractures was not associated with increased soft tissue or bony complications. The findings support the safety of continued tourniquet use per surgeon preference, provided that appropriate patient selection is employed.

PURPOSE/OBJECTIVE:To evaluate whether incorporation of arterial injury into CT-based zone-of-injury (ZOI) models improves complication prediction after open tibial shaft fractures. METHODS:A retrospective cohort study was conducted at an urban multicenter academic hospital (2012-2024). Patients ≥ 18 years with open OTA 42A-C tibia fractures, preoperative CT, and ≥ 6 months follow-up were included. Arterial injury and wound location within the anterior tibial, posterior tibial, or peroneal angiosomes were identified on CT angiography. Soft-tissue ZOI (longitudinal extent of soft-tissue air) and fracture ZOI (fracture span) were normalized to tibial length. The primary outcome was a composite complication of fracture-related infection, nonunion, or amputation. Logistic regression identified predictors, and ROC analysis compared discrimination of (1) an angiosome-augmented ZOI model, (2) a standard ZOI model, and (3) Gustilo-Anderson classification. RESULTS:Eighty-two patients were included: 32 (39.0%) developed major complications. Arterial injury was present in 11 patients and significantly associated with complications (72.7% vs 33.8%, p = 0.020). The augmented ZOI model included arterial injury, anterior angiosome involvement, number of angiosomes affected, normalized soft-tissue ZOI, and BMI (AUROC 0.777), outperforming the standard ZOI model (AUROC 0.707) and Gustilo-Anderson classification (AUROC 0.592). DeLong testing showed no significant difference between ZOI and the augmented model. CONCLUSION/CONCLUSIONS:The original CT-based ZOI model, which incorporates soft-tissue injury measurements normalized to tibial length and BMI, remains a robust objective predictor of complications following open tibial shaft fractures, consistent with prior published work. While arterial injury is associated with adverse outcomes, its addition to ZOI-based models does not significantly improve predictive performance. Notably, only the arterial-augmented ZOI model demonstrated a statistically significant improvement in discrimination over the Gustilo-Anderson classification, whereas the standard ZOI model did not reach significance in this cohort, suggesting that augmentation may be necessary to meaningfully surpass subjective wound grading. LEVEL OF EVIDENCE/METHODS:III.

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.