Faculty Bibliography

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.

PURPOSE/OBJECTIVE:To characterise differences in baseline demographics, outcomes, and cost between 1st and 2nd (contralateral) hip fracture hospitalisations in the same patient that occur within 5 years of each other. METHODS:A retrospective review of operatively treated hip fractures was performed at an academic medical centre. INCLUSION CRITERIA/METHODS:age ⩾65 years, presence of a first and second, contralateral hip fracture with OTA 31A/B classification within 5 years of the hip fracture. Analysis was based on the chronological order of their fracture - 1st hip fracture versus 2nd hip fracture. Comparison of patients' demographics, postoperative complications, 90-day readmission rates, 1-year mortality, discharge location, and direct inpatient hospitalisation costs were compared. Major complications were defined as: sepsis, acute respiratory failure, myocardial infarction, stroke, pulmonary embolus, or death. RESULTS: = 0.08). There were no other differences in outcomes and hospitalisation cost. CONCLUSIONS:Patients who sustain a 2nd contralateral hip fracture within 5 years of their first hip fracture demonstrate a trend towards having more major and minor inpatient complications There are otherwise comparable hospital quality measures and cost profile during their 2nd hip fracture hospitalisation compared to their 1st hip fracture hospitalisation. Resources should be allocated to minimise the risk of complications in 2nd hip fracture patients.

OBJECTIVE:To examine factors associated with lag screw slide following fixation of intertrochanteric hip fractures with 1 type of cephalomedullary nail. METHODS:Retrospective review of patients operatively treated for intertrochanteric hip fractures (OTA/AO 31A1 and 31A2) with a single cephalomedullary nail (CMN) at a single academic medical centre between November 2014 and November 2023. CMN lag screw was placed in "dynamic" mode to allow for controlled collapse, or screw "slide." Screw slide was defined as the difference in lateral prominence of the lag screw at latest follow up compared to its initial position. Patients were grouped based on the amount of screw slide (<5 mm, 5-15 mm, >15 mm) and correlation analysis was performed. RESULTS: = 0.002) was associated with >15 mm screw slide. CONCLUSIONS:Excessive lag screw slide (>15 mm) was associated with higher patient BMI. Patients with higher BMIs should be monitored to identify excessive slide. Surgeons should attempt to keep the lag screw as close to the lateral cortex as possible. While the use of anti-osteoporotic therapy was associated with more slide, this was almost exclusively seen in patients only prescribed vitamin D and calcium.

PURPOSE/OBJECTIVE:The purpose of this study was to evaluate the effect that associated glenohumeral dislocations have on outcomes following surgical treatment of proximal humerus fractures. METHODS:This IRB-approved study reports on 301 patients, who underwent operative treatment for proximal humerus fractures at an academic medical center from January 2006 to January 2023. Fractures were classified according to the Neer system. Patients were separated into two cohorts based on whether a glenohumeral dislocation was present at the time of initial injury. Outcomes measured included the Disabilities of the Arm, Shoulder, and Hand (DASH) score, shoulder range of motion (forward elevation, external rotation, internal rotation), readmission rates, complications, hardware removal, and need for revision surgery. Independent samples t-tests and chi-squared analysis were used for continuous and categorical variables, respectively. A binary logistic regression was performed to analyze the influence of these factors on complication rate. RESULTS:230 patients sustained an isolated fracture (PHF) and 71 sustained a fracture-dislocation (FD). Significant differences were observed between the FD and PHF groups in all measured outcomes. The FD group had a poorer DASH score (24.38 ± 19.09 vs 10.54 ± 13.67; P < 0.001) and reduced range of shoulder motion in forward elevation (114° ± 40° vs 162° ± 19°; P < 0.001), external rotation (40° ± 19° vs 66° ± 19°; P < 0.001), and internal rotation (57° ± 26° vs 82° ± 21°; P < 0.001). Readmission rates were higher in the FD group (0.28 ± 0.85 vs 0.05 ± 0.28; P < 0.001). The FD cohort also had a higher rate of complications (25.35% vs 6.52%; P < 0.001), need for removal of hardware (14.08% vs 3.04%; P = 0.002), and overall revision surgery (11.27% vs 1.30%; P < 0.001). The FD cohort demonstrated a greater incidence of AVN (12.68% vs 4.35%; P = 0.012). No significant difference was observed regarding rates of fracture healing and recurrent dislocation. Multivariate analysis in the form of binary logistic regression indicated that fracture-dislocation significantly increased the complication risk (OR = 3.310, 95% CI = 1.42-7.70; P = 0.005). CONCLUSION/CONCLUSIONS:Proximal humerus fracture-dislocations are associated with worse functional outcomes and higher complication rates compared to those without dislocations. These findings highlight the potential need for specialized treatment strategies to mitigate the impact of dislocation on recovery.

BACKGROUND/UNASSIGNED:Basicervical (BC) hip fractures represent a unique proximal femur fracture pattern for which the optimal treatment approach remains uncertain. PURPOSE/UNASSIGNED:We sought to evaluate demographic, perioperative, and outcome differences among patients with BC (31B3), intertrochanteric (IT; 31A1.2), and valgus femoral neck (VFN; 31B1.1) fractures treated with internal fixation. METHODS/UNASSIGNED:We conducted a retrospective review using prospectively collected data from October 2014 to March 2025 from a hip fracture database comprising 2 urban trauma centers. Patients with AO/OTA-classified 31B3, 31A1.2, or 31B1.1 fractures treated with non-arthroplasty fixation were included. Demographics, comorbidities, fracture characteristics, surgical constructs, and short- and long-term outcomes were compared. Multivariate regressions adjusted for baseline health and procedure type. RESULTS/UNASSIGNED:Of the 875 patients who met inclusion criteria, 122 had BC fractures, 523 had IT fractures, and 230 had VFN fractures. Patients with BC fractures were significantly younger than those with IT fractures; they had higher American Society of Anaesthesiologist scores and a greater proportion of household ambulators compared to those with VFN fractures, but were otherwise similar in comorbidity status. The BC cohort had significantly more minor in-hospital complications compared to the VFN cohort, even after multivariate adjustment. No significant differences were observed in 30-day mortality or major complications. Long-term outcomes were comparable across all groups. No significant differences in short- or long-term outcomes were observed across surgical constructs within the BC cohort. CONCLUSION/UNASSIGNED:Despite differing in baseline health status and surgical fixation strategies, BC fractures demonstrated comparable long-term outcomes to IT and VFN fractures. However, higher rates of minor complications in the BC group, even after adjustment, highlight a potentially greater perioperative risk. These findings suggest that while fixation may be effective long-term, further research is warranted to optimize acute management strategies for this anatomically and clinically distinct fracture pattern. LEVEL OF EVIDENCE/UNASSIGNED:Level IV: Prognostic retrospective study.

PURPOSE/OBJECTIVE:This study aims to determine the impact of injury mechanism energy level on clinical outcomes following Galeazzi fracture. METHODS:A retrospective review was performed on 116 skeletally mature patients treated operatively for Galeazzi fractures between January 2000 and October 2023. Patients were categorized by mechanism of injury into high-energy (HE, n = 92) and low-energy (LE, n = 24) groups. Demographics, fracture characteristics, fixation details, and postoperative outcomes, including wrist and elbow range of motion, complications, radiographic healing time, and reoperations, were collected and compared between groups using standard parametric and nonparametric tests with significance set at P < .05. Normality was assessed using the Shapiro-Wilk test, and Fisher exact test was used for categorical variables with low expected counts. RESULTS:No differences were observed in body mass index or injury characteristics between groups. The HE group was younger and included a higher proportion of men. Wrist motion was more limited in the HE group across dorsiflexion, palmar flexion, pronation, and supination, and time to radiographic healing was longer compared with the LE group. Elbow motion and rates of nonunion, fracture-related infection, contracture, readmission, and distal radioulnar joint symptoms were similar between groups. CONCLUSIONS:HE Galeazzi fractures were associated with poorer wrist range of motion and toward delayed radiographic healing compared with LE injuries. Recognition of this association underscores the prognostic value of injury mechanism and may inform surgical planning, rehabilitation expectations, and patient counseling. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Prognostic III.

OBJECTIVES/OBJECTIVE:To evaluate the association between electronic health record (EHR)-based behavioral flag designation and postoperative outcomes in orthopedic trauma patients undergoing surgical fixation for acute fractures. DESIGN/METHODS:Retrospective cohort study with 1:1 propensity score matching. SETTING/METHODS:Level I trauma center. PATIENTS SELECTION CRITERIA/UNASSIGNED:Adult orthopedic trauma patients who underwent operative fixation for an acute fracture and received a long-term behavioral flag issued for documented disruptive, threatening, or violent behavior toward healthcare staff following institutional review either before surgery or within 1 year postoperatively were included. Those with pathologic fractures and those with inadequate follow-up were excluded. Each flagged patient was matched to an unflagged control based on age, sex, BMI, smoking status, comorbidity burden, and fracture type. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Primary outcomes included 1-year rates of major postoperative complications (e.g., fracture-related infection, nonunion, painful hardware) and reoperation. Subgroup analyses examined outcomes by timing of flag assignment. RESULTS:A total of 116 patients were included (58 flagged patients, 58 unflagged). Flagged patients had a mean age of 53.4 ± 18.1 years (range, 19-74) and were 55.2% male; unflagged controls had a mean age of 49.0 ± 13.6 years (range, 21-71) and were 55.2% male. Adequate covariate balance was achieved after 1:1 propensity score matching. Median follow-up was 12 months (range, 6 months to 9 years). Major postoperative complications occurred in 10 flagged patients (17.2%) and 2 controls (3.4%). Reoperations occurred in 9 flagged patients (15.5%) and 2 controls (3.4%). Compared with controls, patients with a behavioral flag assigned either before surgery or within 1 year postoperatively had higher odds of major complications (OR 5.57; 95% CI 1.99-18.30; p=0.002) and reoperation (OR 4.06; 95% CI 1.31-15.40; p=0.022). Among flagged patients, those with a preoperative behavioral flag had the highest odds of major complications (OR 14.74; 95% CI 2.52-282.0; p=0.014). CONCLUSIONS:EHR behavioral flag designation was associated with higher odds of major postoperative complications and reoperation after operative fixation of acute fractures. Preoperative behavioral flags demonstrated the strongest association with adverse outcomes. Behavioral flag status may serve as a useful marker of elevated perioperative risk in orthopedic trauma patients. LEVEL OF EVIDENCE/METHODS:Level III, Therapeutic.

INTRODUCTION/BACKGROUND:Hounsfield units (HU) are a validated marker of bone mineral density. This study aimed to determine whether low-energy Schatzker IV, V and VI tibial plateau fractures are associated with altered bone quality. METHODS:). Fractures were classified by injury mechanism (low- vs. high-energy) and HU thresholds were defined as poor (< 110) or normal (> 160). Clinical outcomes included major complications, reoperations, range of motion, Visual Analog Scale (VAS) pain scores, and Short Musculoskeletal Function Assessment (SMFA) scores. RESULTS:Low-energy fractures (n = 96) had significantly lower HU values (113.9 vs. 150.9, p < 0.0001) across all planes. No significant differences were found in clinical outcomes. CONCLUSION/CONCLUSIONS:Low-energy Schatzker IV-VI fractures indicate poor bone quality and may represent "fragility fractures" requiring further evaluation.

OBJECTIVE:To evaluate the effect of joint preparation and patient factors on outcomes and complications in patients treated acutely with hindfoot fusion nails for ankle and pilon fractures. DESIGN/METHODS:Retrospective chart review. SETTING/METHODS:Thirteen US trauma centers and 2 UK trauma centers. PATIENT SELECTION CRITERIA/UNASSIGNED:Ankle and pilon fractures (AO-OTA types A-C) from 2010 to 2020 acutely treated definitively with hindfoot fusion nail were reviewed. Patients at least 18 years old and with minimum 6 months follow-up or earlier diagnosis of complication were included. Exclusion criteria included nonambulatory at baseline, prior internal fixation that failed and underwent revision, and prior tibiotalar or subtalar arthrodesis. OUTCOME MEASUREMENTS AND COMPARISONS/UNASSIGNED:The primary outcome was final postoperative ambulatory status. Secondary outcomes were infectious and fracture-related complications. RESULTS:One hundred forty-nine patients (75 men; 74 women; age 20-99; median 63 years) were treated for ankle (104) or pilon (45; 8A, 13B, 24C) fractures. Eighty-five patients (44%) had open fractures and 55 (37%) had diabetes. Thirty-six patients (24%) had joint preparation at the time of surgery. Forty-five (30%) were made weight bearing as tolerated postoperatively; the median time to mobilize was 1.5 days (0-210) and to full weight bearing was 35 days (0-1462). Fifty-seven patients (85%) returned to their preinjury ambulatory status, which was not affected by joint preparation (50% vs. 59%, P = 0.327). Joint preparation led to higher articular fusion rates (94% vs. 24%; P = 0.001) and fewer hardware removals (19% vs. 42%, P = 0.013), but trended toward a higher fracture nonunion rate (19% vs. 8%, P = 0.053). Forty-five patients (30%) had infectious complications, 60 (40%) had a fracture-related complication, and 67 (45%) had additional procedures. Open fractures did not lead to any differences in superficial or deep infection. Insulin-dependent diabetes was associated with higher rates of infectious complications (31% vs. 15%, P = 0.028) and amputation (17% vs. 4%, P = 0.029). CONCLUSIONS:Hindfoot fusion nails for acute ankle and pilon injuries had high complication rates. More complications occurred in patients with insulin-dependent diabetes. While 95% regained ambulation, only 57% returned to preoperative status. Joint preparation led to higher rates of articular fusion (94% vs. 24%, P < 0.001) but not fracture union (81% vs. 66%, P = 0.106). LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.