Faculty Bibliography

BACKGROUND/UNASSIGNED:Hip fracture patients may be hospice candidates if life expectancy is < 6 months. This study evaluates STTGMAHIP FX's ability to identify high-risk hip fracture patients for hospice discharge at emergency room presentation to guide end-of-life care planning. METHODS/UNASSIGNED:A retrospective analysis of a prospectively maintained registry of patients aged ≥55 with low-energy hip fractures (2014-2024) was conducted. Patients were stratified by STTGMAHIP FX percentiles: minimal (≤50th), low (50th-<80th), moderate (80th-<97.5th), and high (≥97.5th). Demographics, injury characteristics, treatment, and outcomes were recorded. The primary outcome was identification of Hospice Discharge Candidates (HDCs), defined as discharge to hospice during the index admission, inpatient mortality >48 h after surgery, or mortality <6 months post-operation. American Society of Anesthesiologists (ASA) score was compared to STTGMAHIP FX for the ability to cluster HDCs using area under receiver operating characteristic (AUROC) curve analysis and a two-proportion Z-test. RESULTS/UNASSIGNED:Among 2777 patients (mean age 81.18 ± 9.80 years), HDC incidence rose with STTGMAHIP FX risk level: 2.9% (minimal risk), 5.9% (low risk), 14.2% (moderate risk), and 29.6% (high risk) (p < 0.05). Only 17.0% of patients classified as ASA 4 were HDCs. Additionally, STTGMAHIP FX demonstrated a slightly better ability to discriminate HDCs compared to ASA, although not statistically significant (0.719 vs 0.683; p = 0.138). However, the STTGMAHIP FX high risk stratification was much more useful in identifying HDCs than ASA (29.6% vs 17.0%; p = 0.013). CONCLUSION/UNASSIGNED:STTGMAHIP FX identifies hospice-eligible hip fracture patients more effectively than ASA. High-risk patients per STTGMAHIP FX demonstrate elevated 6-month mortality and may benefit from early hospice planning at admission.

BACKGROUND/UNASSIGNED:This study compares outcomes and complications of patients with Bado II Monteggia fracture-dislocations that required radial head fixation or replacement based upon approach to the radial head. METHODS/UNASSIGNED:A retrospective review was performed of 159 consecutive patients with proximal ulna fractures and a radial head dislocation or fracture (Monteggia Variant). Injuries were classified by Bado type. Forty-one patients with Bado II Monteggia injuries treated with either a radial head replacement or fixation with complete follow up were included. Demographics, injury information, surgical details, and follow up information including elbow range of motion (ROM) and complications were collected. A trans-osseous posterior (TOP) approach working through the ulna fracture to address the radial head first was used in 19 patients, while 22 patients had their radial head treated via a separate lateral (Kocher) interval after ulnar fixation. Ulnar plate fixation was performed for all patients. Comparisons were made using independent t-tests. RESULTS/UNASSIGNED:Forty-one Monteggia lesions treated through TOP (19, 46 %) or Kocher (22, 64 %) approaches underwent a radial head replacement (33, 80.5 %) or fracture repair (8, 19.5 %) with a mean final follow-up of 15.3 months. At all post-operative visits, groups displayed similar rates of functional elbow ROM. At latest follow-up rates of patient-reported pain, ultimate elbow ROM, time to radiographic healing were equivalent. No significant differences were observed in ulna non-union, joint malalignment, post-operative nerve injury, post-operative infection, heterotopic ossification, incidence of hardware failure, patient-reported pain, and rate of removal of symptomatic hardware. Sub-analysis of radial head replacement versus fixation revealed equivalent percentage of patients with full ROM at each post-operative time point. CONCLUSION/UNASSIGNED:For Bado II Monteggia fracture-dislocations, the surgical approach to the radial head-TOP versus Kocher-does not influence ultimate patient outcomes or complication rates. Radial head replacement and fixation provide comparable results. LEVEL OF EVIDENCE/UNASSIGNED:III.

Most surgically repaired proximal femoral fractures heal uneventfully, however a small percentage of surgical interventions lead to failures. Salvage of failed treatment is challenging and dependent on the type and location of the complication. Potential complications of intracapsular hip fractures and their treatment include fixation failure, nonunion, and osteonecrosis of the femoral head. Factors guiding the choice of salvage option include patient age and quality of remaining bone. This article aims to present several potential complications and corresponding potential solutions using supporting literature, when available. This narrative review focuses on salvage treatment options of failed fixation of femoral neck fractures. Total hip arthroplasty is always the last resort salvage option.

PURPOSE/OBJECTIVE:The purpose of this study was to compare fracture nonunion rates in tibial shaft fractures fixed with intramedullary nails using fixed angle locking screws (FALS) that thread into the intramedullary nail versus standard locking screws in a cohort of tibial diaphyseal fractures. Secondarily, this study evaluated whether FALS location was associated with nonunion risk in tibial diaphyseal fractures. METHODS:A retrospective review of surgically treated OTA 42 A-C tibial shaft fractures from 2014 to 2024 at a single academic institution was performed. Inclusion criteria were age > 18, isolated OTA 42 A-C tibia fracture, intramedullary nail fixation, and minimum 6-month follow-up. Patients treated with a FALS were matched to those without a FALS with a 1:1 propensity match based on OTA fracture classification and open fracture status. The Radiographic Union Score for Tibia (RUST) was used to determine healing. Statistical comparisons were performed using Pearson Chi-squared tests, independent t-tests, Mann Whitney-U tests, and multivariate logistic regression as appropriate. RESULTS:78 patients were included (39 in each cohort), with the FALS group being older and having higher age-unadjusted Charlson Comorbidity Indices (CCI). The FALS and CLS groups had comparable rates of open fractures and similar proportions of OTA/AO fractures. FALS configuration per patient was: 16 only distal, 13 only proximal, and 10 both proximal and distal. There were no differences in nonunion rates (25.6% vs. 15.4%, p = 0.262) and healed-by times (6.15 ± 2.95 [months] vs. 6.38 ± 2.73, p = 759), complication rate, or 30/90-day readmission rates (p < 0.05). Multivariate analysis demonstrated that the use of single-end FALS (used only proximally or distally) was independently associated with higher odds of nonunion compared to CLS and FALS used both proximally and distally (OR = 6.027, p = 0.025). CONCLUSION/CONCLUSIONS:The use of single-end fixed angle locking screws in only the distal or proximal segment in intramedullary nails for the treatment of OTA 42 A-C tibial diaphyseal fractures is associated with higher odds of fracture nonunion. Larger, prospective studies evaluating FALS configuration for intramedullary nail fixation of tibia shaft fractures are warranted.

INTRODUCTION/BACKGROUND:Tibial plateau fractures are some of the most commonly treated injuries around the knee and loss of range of motion has a significant effect on post-operative outcomes, very few studies have demonstrated the impact of flexion contractures. The purpose of this study was to determine the effect that development of a knee flexion contracture has on outcomes following operative repair of tibial plateau fractures. METHODS:Patients operatively treated for tibial plateau fractures (Schatzker II, IV, V, and VI) between 2005-2024 at a multi-center academic urban hospital system were included in this retrospective comparative study. Patients were grouped into 3 cohorts: 1. Full extension (FE), 2. 5-10 degrees of flexion contracture (Mild, ME) and 3. Greater than 10 degrees of flexion (Severe, SE) contracture at 6 months post-operatively. Patients with contracture were matched to patients who regained full extension based on age and Schatzker classification. Statistical analysis was used to evaluate outcomes including patient reported pain levels, Short Musculoskeletal Function Assessment (SMFA) scores, complication rates and reoperation rates. RESULTS:The cohort consisted of 3 groups of 30 patients (14 Schatzker II, 5 Schatzker IV, 3 Schatzker V, and 8 Schatzker VI). The average knee flexion contracture for the mild cohort was 5 degrees and the average knee flexion contracture for the severe cohort was 12.7 degrees. Patients who experienced flexion contracture had poorer SMFA scores at 6 months, and those in the severe cohort had the poorest SMFA scores (112.6) when compared to those with full extension at 6 months (77.7) (p<0.001). Flexion contractures were associated with higher rates of fracture related infection (FRI) (p =0.002). Patients with flexion contracture also had a higher rate of subsequent re-operation, with 36.7% of the ME undergoing re-operation and 40% of SE undergoing re-operation. CONCLUSIONS:Patients who developed a flexion contracture following repair of a tibial plateau fracture experienced worse outcomes, higher rates of complications, increased pain, and poorer function at long term follow up compared to those who achieved full knee extension.

PURPOSE/OBJECTIVE:The purpose of this study is to compare the quality and clinical outcomes of patients who underwent open reduction internal fixation for a proximal humerus fracture in a "timely manner" which was defined to be within 5 days of injury compared to those with "delayed intervention" (>5 Days) to determine the effect this had. METHODS:This IRB-approved study evaluated patients who sustained a proximal humerus fracture treated with plate and screw fixation (ORIF) between January 2004 and October 2022 and had time from injury to surgery documented. Patients were grouped based on the time to surgery (TTS) - Less than 5 Days (L5) vs. More than 5 Days (M5). TTS was also evaluated as a continuous variable. Univariable and multivariable analysis compared patient demographics, injury/surgical characteristics, postoperative complications, and clinical outcomes to determine effect of TTS. Clinical outcomes included shoulder range of motion (ROM) and Disabilities of the Arm, Shoulder, and Hand (DASH) score at least 1 year following the date of injury. Standard statistical tests were used (p<0.05 considered significant). RESULTS:, p=0.03, β= -0.27, 95% CI = -41.71- -2.89) surgery was associated with less passive forward elevation. CONCLUSION/CONCLUSIONS:Timing of surgery did not impact outcomes of patients who underwent open reduction internal fixation for proximal humerus fractures. Surgical intervention after 14 days was associated with diminished passive forward elevation only.

INTRODUCTION/BACKGROUND:The purpose of this study was to assess the effect of an acute traumatic meniscus tear that required repair in association with a tibial plateau fracture repair on outcomes. METHODS:Over a 17-year period, 843 patients presented with a tibial plateau fracture and were followed prospectively. 721 patients with Schatzker I-VI fractures were treated operatively via a standardized algorithm. 161 tibial plateau fractures (22.3 %) had an associated meniscus tear that underwent acute repair at the time of bony fixation. These patients were compared to operatively repaired tibial plateau fracture patients with no meniscus injury (NMR). Demographics were collected and outcomes including: radiographic healing, knee range of motion (ROM), and complication rates, were recorded. In addition, re-operation rates were compared and any reoperation for meniscus repair failure identified. All patients had a minimum of 1 year follow up. RESULTS:A total of 524 patients with a mean of 21.4 (range: 12-120) months follow up met inclusion criteria. Patients in the meniscus repair (MR) cohort had poorer knee extension (1.01 degrees, range: 0-30 degrees) compared to the NMR cohort (0.07 degrees, range: 0-10 degrees) (p < 0.001), in addition to poorer knee flexion (123 degrees, range: 0-145 degrees, p = 0.024). Additionally, MR patients reported higher pain scores (mean: 3 and range: 0-8, p = 0.005) at latest follow up. Finally, MR patients had higher rates of infection (8.1 % vs. 3.3 %, p = 0.025) and lateral collapse of the joint (p = 0.032). CONCLUSION/CONCLUSIONS:Patients who had a meniscus repair at the time of tibial plateau fracture repair were found to have poorer knee ROM, more patient reported pain at minimum 12 (mean 24) months post-operation. Additionally, these patients developed more post-operative complications than those patients who did not undergo a meniscus repair.

OBJECTIVE:To evaluate revision and removal rates of radial head arthroplasty (RHA) for elbow trauma using modern press-fit modular implants. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Urban academic medical center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients who underwent RHA (2012-2024) for isolated comminuted radial head fractures, combined head-neck fractures, terrible triad injuries, or Monteggia variants (OTA 2R1) were study eligible. Inclusion criteria consisted of treatment with press-fit modular implants and ≥1 year of clinical follow-up. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Demographics, injury patterns, elbow range of motion, and postoperative complications-including fracture-related infection, nerve injury, periprosthetic fracture, implant resection, and non-resection procedures-were assessed. Implant survivorship was evaluated via Kaplan-Meier analysis. RESULTS:250 patients were included (mean age 52.2 ± 17.8 years, range 18.1-88.3 years; mean length of follow up 43.8 ± 35.2 months, range 12.0-128.0 months, BMI 28.7 ± 6.3 kg/m2, 56.8% female). Common indications for RHA included Monteggia fractures (38.0%), isolated radial head fractures (23.6%), and terrible triad injuries (19.2%).Post-index surgery iatrogenic nerve injury occurred in 7.2%, most commonly involving the ulnar nerve. Fracture related infection occurred in 2.8% post index surgery, and one nonoperative periprosthetic fracture (0.4%) was observed.The resection rate was 7.2% (18/250), with 33.3% (6/18) of implant resection surgeries occurring within one year (mean length of follow up 43.8 ± 35.2 months, range 12.0-128.0 months). Common resection indications included postoperative stiffness (n=5), infection (n=4), and neuropathy (n=3). One-year implant survival was 97.6%, with mean survivorship of 8.5 ± 1.0 years (95% CI, 7.1-9.8).In total, 24 patients (9.6%) underwent additional non-resection procedures including nerve decompressions, elbow contracture releases with excision of heterotopic ossification, and manipulations under anesthesia.At final follow-up (mean 43.8 ± 35.2 months), mean range of motion was 125.4° flexion, -14.9° extension, 73.5° pronation, and 79.3° supination. No significant difference in length of follow-up was observed between patients with post-operative nerve injury (52.4 ± 38.2 months) and those without (42.5 ± 34.8 months, p = 0.16). CONCLUSION/CONCLUSIONS:With a 7.2% resection rate and one-year implant survival of 97.6%, contemporary press-fit modular RHA demonstrated durable elbow trauma outcomes.

INTRODUCTION/BACKGROUND:The study aimed to investigate the efficacy of autogenous iliac crest bone graft (ICBG) compared with other graft types in achieving successful fracture nonunion repair. METHODS:An institutional review board-approved retrospective review of prospectively collected data was conducted on a consecutive series of patients surgically treated for fracture nonunions at an academic medical center between September 10, 2004, and August 20, 2023. Patients were analyzed based on which bone graft type-ICBG versus alternative graft types-used during their nonunion repair. Patient demographics, injury characteristics, and surgical history were compared. Outcomes included radiographic healing, time to union, postoperative complications, and revision rate. Cohorts were compared using an independent sample Student t-test for continuous variables and chi-square or Fisher exact tests for categorical variables. One-way analysis of variance with post hoc comparisons assessed differences across treatment strategy groups. RESULTS:Five hundred fifty-six patients were treated surgically for a fracture nonunion using standard internal fixation and a "bone graft" for biologic stimulation. 57.4% of these patients were treated with autogenous ICBG; 42.6% received alternative grafts (iliac crest aspirate, allograft, bone morphogenetic, reamer-irrigation aspirator, and/or demineralized bone matrix, without autogenous cancellous iliac crest). Compared with the alternative cohort, the ICBG cohort showed greater healing success after a single nonunion surgery (95.6% ICBG versus 86.9% alternative, P < 0.001) and faster healing times (4.8 ± 2.4 months versus 7.1 ± 4.9 months, P < 0.001). Complications at the ICBG harvest site included wound infections/hematomas and iliac wing fracture. No notable differences were found in positive cultures at the time of surgery, postoperative fracture-related infection, implant failure, or neurovascular injury. DISCUSSION/CONCLUSIONS:Using autogenous ICBG in the surgical repair of fracture nonunions was associated with higher healing rates compared with alternative graft types, supporting its continued role in enhancing bone healing outcomes, even in the face of infected nonunion.

OBJECTIVES/OBJECTIVE:The purpose of this study is twofold: (1) to reliably define the concept of "extreme tibial nailing" and (2) assess the feasibility of tibial intramedullary nailing when the fracture extends into the nail's locking bolt zone. METHODS:Design: A retrospective review. SETTING/METHODS:A single academic center comprised of a specialty orthopedic hospital and a Level I Trauma Center. Patient Selection Criteria: 543 patients who sustained 555 tibia fractures between February 2014 and January 2024 were reviewed by two board-certified orthopedic surgeons. Cases were classified as "extreme nailing" based on the tibial fracture within the most proximal or distal 25% of the bone such that the fracture extended into the locking bolt section of the intramedullary nail used to treat the fracture. Patients with supplemental periarticular plating of the tibia were excluded. Outcome Measures and Comparisons: Data collected included patient demographics, hospital metrics, and outcomes. RESULTS:Twenty-five tibial fractures treated met radiographic criterion. The "extreme IMN" cohort was 45.8 years, 72% female with a mean BMI of 26.6. Over half of fractures resulted from high-energy injuries, and 40% were open. Patients were hospitalized for 92.8 h on average, and the 90-day readmission rate was 8.0%. The average time to weight-bearing allowance was 5.2 weeks post-op. Eight (32.0%) patients experienced complications: 12% developed fracture-related infection (FRI), 4% experienced hardware complications, and 20.0% developed nonunion requiring surgery. The rate of all-cause reoperation was 32.0%, and 28% of patients experienced knee or ankle pain at 6 months or later. The rate of malalignment was 8.0%, and the average time to radiographic healing was 5.7 months. CONCLUSION/CONCLUSIONS:Tibial nailing is an effective treatment for "extreme" tibial fractures that extend as far as the articular surface and interlocking cluster on either end. The majority of patients who underwent extreme tibial nailing recovered with acceptable alignment, minimal healing complications, and achieved radiographic union within 6 months. LEVEL OF EVIDENCE/METHODS:III.