Faculty Bibliography

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.

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.