Faculty Bibliography

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.

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.