Faculty Bibliography

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.

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.

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.

INTRODUCTION/BACKGROUND:To compare outcomes of patients with geriatric hip fracture undergoing surgery <24 hours from emergency department (ED) arrival to those who underwent surgery >24 hours from arrival but within the next calendar day. METHODS:A retrospective review of a single-institution hip fracture database (2014 to 2024) was performed. The study cohort was divided into two groups based on time from ED arrival to surgery start time: <24-hour surgery (<24h) and next calendar day surgery >24 hours from arrival (>24h [next calendar day]). Univariate analysis was performed to compare baseline health, injury factors, and outcomes. Multivariate linear and logistic regression analyses were performed to adjust for procedure type and risk profile. RESULTS:There were 1,694 patients included in the study analysis, of whom 964 (56.91%) were <24h and 730 (43.09%) were >24h (next calendar day). The mean time to surgery for cohorts were <24h: 17.66 ± 5.05 vs. >24h (next calendar day): 28.78 ± 3.86 hours; P < 0.001. Univariate analysis revealed no differences between <24h and >24h (next calendar day) cohorts for in-hospital complication incidence (35.5% vs. 35.1%; P = 0.862), inpatient mortality (0.5% vs. 1.0%; P = 0.285), 30-/90-day readmission (5.6% vs. 6.2%; P = 0.625; 8.2% vs. 11.0%; P = 0.053), and 30-day/1-year mortality (2.4% vs. 2.3%; P = 0.939; 5.0% vs. 6.2%; P = 0.289). Length of stay (5.15 ± 3.15 vs. 5.58 ± 3.31; P = 0.006) and discharge location (36.4% home discharge vs. 31.0%; P = 0.019) favored the <24h cohort. After adjusting for baseline health with Score for Trauma Triage in the Geriatric and Middle-Aged and procedure type, only longer length of stay was found to be associated with the >24h (next calendar day) cohort (B = 0.407; P = 0.010). CONCLUSION/CONCLUSIONS:No notable differences were observed in key outcomes for patients undergoing <24 hours from ED arrival versus those who undergo surgery >24 hours after arrival but on the next calendar day. This study suggests that "next day hip fracture surgery" appears safe for patients with geriatric hip fracture.

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.

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.

BACKGROUND:Morbidity and mortality following geriatric hip fracture remains high. Increased time from hospital admission to hip fracture surgery is a factor that has been associated with adverse outcomes. The purpose of this study was to identify factors associated with delays to surgery greater than 1 day in geriatric hip fracture patients. The primary aim of this study was to identify and compare comorbidities between patients who underwent surgery within 1 day and those who did not using a large national data base. The null hypothesis was that patients with more acute medical comorbidities would not have a higher association with delays to surgery greater than 1 day. METHODS:Patients over the age of 65 who underwent a surgical repair for a hip fracture from 2005 to 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were grouped into those who had surgery less than 1 day after admission (n = 74,072) and those who had surgery greater than 1 day after admission (n = 21,481). Demographic data and comorbidities were collected and compared. Univariate regressions were performed to assess the effect of comorbidities on risk of surgery more than 1 day after admission. RESULTS:Hip fracture patients who did not undergo surgery within 1 day were older, more likely to be male, non-white, have lower functional status and greater ASA class. These patients had significantly greater preoperative comorbidities such as hypertension, bleeding disorder or anticoagulated status, obesity, chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). Patients who were ventilator dependent (OR: 10.09; 95% CI: [6.65, 15.79], p < 0.001), had preoperative transfusions (OR: 3.89; 95% CI: [3.64, 4.16], p < 0.001) or CHF (OR: 2.88, 95% CI: [2.68, 3.09], p < 0.001) had the greatest odds of not having surgery within 1 day. CONCLUSIONS:Hip fracture patients who did not get surgery within 1 day, had a greater preoperative comorbidity profile than those who did. Patients with certain comorbidities such as ventilator dependence, need for preoperative blood transfusion and congestive heart failure had greater odds of having surgery delayed beyond 1 day. Attention should be placed on patients who arrive with these risk factors and clinical pathways should be designed to expedite preoperative medical optimization and surgical treatment. LEVEL OF EVIDENCE/METHODS:III; Retrospective Comparative Study.

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: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 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.