Faculty Bibliography

BACKGROUND:The purpose of this study was to compare hospital quality and patient outcomes of hip arthroplasty for femoral neck fractures (FNFs) based on the subspecialty training of the treating surgeon: orthopaedic trauma (OT) versus adult reconstruction (AR) fellowship training. METHODS:A retrospective review was conducted on 1,008 elderly patients treated for an FNF with hemiarthroplasty or total hip arthroplasty between 2014 and 2024. Patients were grouped by their surgeon's subspecialty training (OT versus AR). Outcomes analyzed included length of stay, complications, 30-day and 90-day readmissions, dislocations, infections, and 30-day mortality. Statistical significance was set at P < 0.05. RESULTS:Baseline patient demographics were similar between groups, except for a higher proportion of women in the AR cohort (P = 0.008) and Black patients in the OT cohort (P = 0.016). Although age-unadjusted Charlson Comorbidity Index (CCI) was significantly higher in the AR group (P = 0.046), Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) scores, which take CCI and other health factors into account, were not significantly different (P = 0.59). In-hospital outcomes, including length of stay (P = 0.89) and minor and major complication rates (P = 0.38, P = 0.38), demonstrated no significant differences between groups. Post-discharge outcomes, including readmissions (30-day: P = 0.52, 90-day: P = 0.16), infections (P = 0.25), dislocations (P = 0.89), and 30-day mortality (P = 0.14), were also similar. CONCLUSION/CONCLUSIONS:No differences were identified in any of the outcomes analyzed between OT-trained and AR-trained surgeons in our study. This suggests that when FNFs are treated at high-volume academic institutions, subspecialty training may not substantially influence the short-term results of FNFs treated with hip arthroplasty. These findings highlight the importance of timely surgical intervention rather than waiting for a particularly trained surgeon to be available.

OBJECTIVES/OBJECTIVE:To evaluate factors influencing slide in statically-locked single lag screw cephalomedullary nail (CMN) constructs for reverse obliquity (RO) fractures. METHODS:Design: Retrospective comparative study. SETTING/METHODS:A multi-center academic urban hospital system (4 hospitals). PATIENT SELECTION CRITERIA/UNASSIGNED:Patients with an RO fracture (OTA/AO 31A3) treated with a CMN (Gamma or TFNA) and statically-locked single lag screw from 2014 to 2024, with at least one follow-up radiograph (minimum three months or documentation of healing). OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Lag screw sliding was measured as the difference in screw position between immediate postoperative imaging and final follow-up radiographs. Tip-to-head distance (ΔTHD) and screw protrusion ratio (ΔPR) were recorded. Patients were grouped as <5mm, 5-10mm, or >10mm slide. Comparisons included fracture subtype, nail brand, angle, and length. Bivariate analyses tested associations with slide. RESULTS:Of the 219 patients identified with a 31A3 type fracture, 85 (38.8%) met inclusion criteria. The average age was 81.0 (±9.3) years with 65 (76.5%) females. Mean radiographic follow-up was 19.9 months, with a follow-up range of 74-2,576 days. The mean slide was 7.8mm (±5.2mm). 74 patients (87.1%) had slide >2mm. ΔTHD was negligible (-0.1 ± 7.0mm), and ΔPR 0.2 (±0.1) significantly exceeded zero (p < 0.001). Neither nail length (Short: 9.4 ± 5.3mm vs. Long: 7.1 ± 5.0mm, p = 0.083), nail angle, (125°: 8.0 ± 5.4mm vs 130°: 6.5 ± 4.0mm; p = 0.286), nor nail brand had a significant effect (Gamma: 7.6 ± 5.1mm vs TFNA: 9.1 ± 6.2mm; p = 0.921). Fracture subtype (31A3.1: 9.1 ± 6.1mm vs 31A3.2: 10.4 ± 5.1mm vs 31A3.3: 6.9mm ± 4.6mm; p = 0.114) and demographic factors (p > 0.05) were not significantly associated with slide severity. CONCLUSIONS:Surgeons should expect some degree of lag screw slide and subsequent proximal fragment displacement when a Gamma nail or TFNA nail cephalomedullary nail is used for a reverse obliquity fracture, even when statically locked. LEVEL OF EVIDENCE/METHODS:Level III.

OBJECTIVES/OBJECTIVE:To determine if initial vertical fracture displacement affects postoperative outcomes following operative treatment of patella fractures. METHODS:Design: Prognostic retrospective study. SETTING/METHODS:Single multi-site urban academic institution. PATIENT SELECTION CRITERIA/UNASSIGNED:Included were patients aged ≥18 years who underwent open reduction internal fixation of a patella fracture (AO/OTA 34A-C) with minimum 6-month follow-up, and complete trauma knee x-ray series. Vertical fractures and those without significant vertical displacement (<2mm) were excluded. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Initial vertical fracture displacement was recorded. Follow-up data included knee range-of-motion and post-operative complications: nonunion, fracture related infection (FRI), hardware failure, suspected FRI, knee contracture, inferior sleeve displacement, and venous thromboembolism events. Comparisons were made between the initial amount of displacement and postoperative complications. RESULTS:229 patients with a median follow-up duration of 12 months (IQR: 6-14) were included. The mean age was 61.2 ± 15.1 years, BMI was 25.4 ± 4.7 kg/m2, and 69.0% (n = 158) were female. OTA fracture classification was: 35.4% C1, 32.3% C3, 17.9% C2, and 14.4% A1. Fixation methods included 63.8% tension band wiring, 17.9% suture repair, 13.5% plate and screws, and 4.8% screws with suture. 33 (14.4%) patients sustained complications. The mean displacement was significantly higher in patients who developed complications (21.6 mm ± 15.0 mm vs. 14.8 mm ± 10.1 mm, p=0.018), particularly for nonunion (29.8 mm ± 13.5 mm vs. 15.1 mm ± 10.6 mm, p<0.001) and hardware failure (30.8 mm ± 12.0 mm vs 15.4 mm ± 10.9 mm, p<0.001). Suture-only and screw-with-suture fixation had higher nonunion rates (p=0.004, p=0.005) than other fixation methods independent of displacement. Initial displacement predicted nonunion and hardware failure (AUROCs=0.818 and 0.838). Youden Index thresholds of >26.6mm and >21.7mm identified patients at increased risk for nonunion and hardware failure. Each millimeter increase in displacement raised nonunion and hardware failure risk by 14.9% (OR=1.1, p=0.003) and 14.6% (OR=1.1, p=0.003). CONCLUSIONS:This study supports the future use of initial vertical fracture displacement as a prognostic tool for nonunion and hardware failure after patella ORIF. Displacement >2cm placed patients at high risk for these complications. Nonunion rates were higher in both suture only and screw-with-suture fixation when compared to other fixation constructs. LEVEL OF EVIDENCE/METHODS:III.

OBJECTIVE:To define a CT-derived zone-of-injury metric, incorporating normalized soft-tissue air extent and BMI and secondly to determine if this metric was associated with adverse outcomes following an open OTA 42A-C tibia fractures. METHODS:Design: Retrospective cohort study. SETTING/METHODS:Level I trauma center. PATIENT SELECTION CRITERIA/UNASSIGNED:A retrospective review of patients in a tibia fracture registry (2012-2024) meeting inclusion criteria (age ≥18 years old, open OTA 42A-C fractures, preoperative full length tibia CT imaging, ≥6-month follow-up) was performed.Outcome Measures and Comparisons: The CT-based ZOI was measured as the longitudinal extent of soft-tissue air (mm) normalized to tibial length (mm) (ZOIsoft/Tibial Length). The primary outcome was composite complications including fracture related infection, amputation, or nonunion. A logistic regression model using ZOIsoft/Tibial Length and BMI generated predicted probabilities for composite complications. Model discrimination was assessed via area under receiver operating characteristic (AUROC) analysis and compared to Gustilo-Anderson classification using the DeLong test. An optimal probability threshold was derived statistically (Youden Index) for dichotomizing patients into high- and low-risk cohorts. RESULTS:Fifty-five patients (58 fractures) met inclusion criteria (mean age 40.0 ± 15.1 years; 81.0% male; mean follow-up 16.9 ± 9.5 months). Soft-tissue ZOI and BMI were the significant predictors of composite complications (p = 0.006, 0.061). The CT-based ZOI model (log(p/1-p) = 0.601 + (3.343 × soft-tissue ZOI/Tibial Length) + (-0.106 × BMI) demonstrated superior discrimination (AUROC = 0.752) compared to Gustilo-Anderson (AUROC = 0.581, p = 0.042). Patients above the derived threshold (0.403) had significantly worse outcomes: composite complication rate 64.0% vs. 18.2% (p < 0.001) and nonunion (52.0% vs. 9.1%, p < 0.001). Amputation (20.0 vs 3.0%, p = 0.075) and fracture-related infection (32.0% vs. 15.2%, p = 0.203) were not significant. CONCLUSIONS:A novel CT-based ZOI metric integrating soft-tissue injury extent as measured by soft-tissue air and BMI independently predicted overall complications risk. This newly described CT-based ZOIsoft metric provided superior prognostic accuracy compared to Gustilo-Anderson classification and may enhance early risk stratification in open tibia fractures. LEVEL OF EVIDENCE/METHODS:Prognostic Level III.

BACKGROUND/UNASSIGNED:While extremes of body mass index (BMI) are known to influence surgical risks, their distinct impacts on short- and long-term outcomes following hip fracture remain poorly defined. This study compared outcomes in severely underweight, normal weight, and obese elderly patients. METHODS/UNASSIGNED:A retrospective cohort study was conducted using a prospectively collected hip fracture database (2014-2024) at a single academic medical center. Patients with BMI ≤16.5 (severely underweight) or ≥35 (class 2+ obesity) were compared to a randomly selected cohort of normal-weight controls (BMI 18.5-25.0). Outcomes included complications, discharge disposition, mortality, and functional recovery. RESULTS/UNASSIGNED:A total of 282 patients were included. Obese patients had significantly higher odds of intensive care unit (ICU) admission compared to normal weight patients (OR 5.75 [2.00-16.39], p = .001) and were less likely to be discharged home (OR 0.31 [0.14-0.66], p = .003). In contrast, underweight status was significantly associated with increased six-month mortality compared to normal weight (OR 4.95 [1.34-18.18], p = .016). No significant differences were found in healing or functionality across groups. CONCLUSION/UNASSIGNED:Obese patients were more likely to require ICU admission but did not face increased long-term mortality. Severely underweight patients demonstrated the opposite pattern, with minimal short-term morbidity but significantly higher risk of death at six months. These findings suggest that short- and long-term risks after hip fracture diverge at the extremes of BMI and highlight the need for tailored perioperative strategies based on metabolic status.

OBJECTIVES/OBJECTIVE:Altered patellar height following patella fracture repair may affect clinical outcomes, but the significance remains unclear. The purpose of this study was to evaluate the impact of immediate and final follow-up Insall-Salvati Ratio (ISR) on postoperative outcomes following patella fracture fixation. METHODS:A retrospective review at a multi-site academic urban hospital system was conducted. All patients underwent patella open reduction and internal fixation (ORIF) for displaced patella fracture (OTA 34) from 2012 to 2024. Final intraoperative and final follow-up radiographs were assessed by Insall-Salvati ratios (ISR). Patients were categorized into groups based on intraoperative ISR measurements: normal ISR, defined as .8-1.2 and abnormal ISR, outside of the 0.8-1.2 range. Follow-up radiographs were also assessed for abnormal ISR. Knee range of motion (ROM), post-operative complications, and fracture union were collected. Statistical analysis included Pearson Chi-squared tests, independent t-tests, and ANOVA tests. RESULTS:Of 191 patients, 163 (85.3%) had normal ISR and 28 (14.7%) had abnormal ISR postoperatively. Abnormal ISR was associated with higher complication rates (14.3% vs. 4.3%, p = 0.037), hardware failure (10.7% vs. 1.2%, p = 0.004), reduced knee range-of-motion at three months (105.13 ± 21.38 vs. 117.22 ± 13.75, p < .001) and six months (119.25 ± 14.26 vs. 127.37 ± 13.27, p = .020). Among patients with initially normal ISR, 12.3% developed patella baja, which was associated with higher rates of hardware removal (20% vs. 3.1%, p = 0.004) and infection (10% vs. 0.8%, p = 0.015) when compared to patients maintaining a normal ISR. CONCLUSIONS:Abnormal intraoperative Insall-Salvati ratio following patella fracture repair was associated with poorer knee ROM and increased complication rate. Progressive development of patella baja during fracture healing was associated with hardware removal and fracture related infection. Attention to intraoperative ISR optimization may improve outcomes.

OBJECTIVES/OBJECTIVE:Increased mortality following geriatric hip fractures is well reported. However, population-level analysis of mortality trends over time are not common. This study aimed to evaluate the 3- and 12-month mortality after geriatric hip fractures from 2010 to 2019. METHODS:The New York Statewide Planning and Research Cooperative System database from 2010 to 2020 was retrospectively queried for patients aged >65 years with a femoral neck or intertrochanteric hip fracture. Kaplan-Meier survival analysis was used to calculate mortality rates for each year. Cox proportional hazard multivariable regression controlling for sex, age, race, obesity, smoking, and Elixhauser comorbidity index was used to compare mortality hazard ratios for each year. Secondary outcomes included length of stay, discharge disposition, and 3-month readmission and emergency department visits. RESULTS:From 2010 to 2019, 142,540 patients aged ≥65 years had a diagnosis of femoral neck fracture (62%) or intertrochanteric hip fracture (38%). The mean age was 83.29 years (SD 8.22). The mean Elixhauser comorbidity index was 7.35 (SD 7.60). Kaplan-Meier survival analysis revealed that for the complete cohort 3-month mortality rate was 9.82% (95% confidence interval 9.65% to 9.98%) and 12-month mortality rate was 16.06% (95% confidence interval 15.84% to 16.27%). The 3-month mortality rate went from 10.8% in 2010 to 8.6% in 2019 and the 12-month mortality rate went from 17.7% in 2010 to 14.8% in 2018 before rising to 16.9% in 2019. Cox multivariate proportional hazard regression demonstrated statistically significant decreased hazard ratio from 2012 to 2019 compared with reference hazard in 2010 (all P < 0.05). Reductions were also observed for length of stay (7.8 to 6.4 days, P < 0.001), 3-month readmissions rate (34% to 22%, P < 0.001), and 3-month emergency department visit rate (45% to 34%, P < 0.001). CONCLUSION/CONCLUSIONS:Mortality after geriatric hip fractures has demonstrated a reduction in the past decade with 3-month mortality continuously decreasing from 2010 to 2019 and 12-month mortality decreasing from 2010 to 2018 before increasing in 2019.

OBJECTIVE:To develop a stratification tool to identify hip fracture patients at risk for second contralateral hip fracture and mortality within 5 years of an index fracture, and to assess the cost-effectiveness of prophylactic fixation in high-risk/low-mortality patients. METHODS:Design: Retrospective prognostic cohort study. SETTING/METHODS:Single academic system with 2 Level 1 Trauma Centers, 1 orthopedic specialty hospital, and 1 tertiary care hospital. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients who were 60 years or older with OTA 31A/B hip fractures from low-energy mechanisms between 11/1/2014 and 11/31/2023 with ≥5 years follow-up or until death were included. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:The study included four phases: (1) identifying factors associated with second hip fracture within 5 years; (2) using multivariate logistic regression to generate models predicting 5-year second hip fracture (vs. FRAX) and mortality risk; (3) creating a "risk matrix" to identify candidates for prophylactic fixation using Youden's Index which determined cutoff points encompassing the maximum sensitivity and specificity for each risk equation and were used to define a value-based target group; (4) cost analysis comparing standard vs. prophylactic care in high-risk/low-mortality patients. RESULTS:Of 426 patients (mean age 80.25 years, 73.4% female), 78 sustained second hip fractures (mean interval: 594 days). Predictors included higher FRAX score (p=0.004), dementia (p<.001), ICU stay (p=0.014), discharge to subacute care (p<.001), and 90-day readmission (p=0.011). Logistic regression predicted 5-year second fracture risk (AUC 0.742 vs. FRAX 0.617, p=0.012) and 5-year mortality (AUC 0.723). The risk matrix used cutoff points of 18.2% (mortality) and 38.2% (second fracture) to define a value-based target group (n=26; 13 experienced second fracture). Cost analysis showed prophylactic fixation of all 26 patients ($781,508) would save $353,067 compared to treating the 13 who fractured again ($1,134,575). CONCLUSIONS:A novel matrix was developed that accurately predicted 5-year second hip fracture and mortality risk. Prophylactic fixation in low-mortality, high-risk patients may reduce costs and prevent future fractures. [Tool available: https://sttgmacom.wpcomstaging.com/predicting-risk-of-second-hip-fractures/]. LEVEL OF EVIDENCE/METHODS:Level III Diagnostic.