Faculty Bibliography

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.

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:Understanding the current risk of inpatient mortality following hip fracture in the United States is of significant value to patient families and the health system. Currently, the literature lacks a national representation of the inpatient mortality following hip fracture. PURPOSE/OBJECTIVE:The purpose of this study was to investigate the incidence of inpatient mortality following hip fracture using Epic Cosmos-an aggregated, de-identified, multi-institutional data that includes over 280 million patients in the United States. METHODS:A "Cosmos hip fracture cohort" that included all adults (18 years or older) who sustained a femoral neck, intertrochanteric, or subtrochanteric hip fracture (ICD 72.0, S72.1, S72.2) between January 2019 and December 2024 was created. The dataset was queried for demographic data including age, sex, geographic location, incidence of inpatient mortality, and bone health medication use at the time of admission. RESULTS:The Cosmos database included 284,455,033 patients, of which 1,232,250 hip fracture hospital admissions between January 2019 and December 2024 were identified. Of these patients, 47,773 (3.9%) expired during their hip fracture hospital admission. The most common age bracket was 85 years or older (39.8%), followed by 75-85 (30.0%), and 65-75 (17.8%). Most patients were white (91%) females (55.5%). Most inpatient mortalities occurred in the South (38.4%), followed by the Midwest (31.8%), followed by the Northeast (23.6%), and last by the West (6.2%). CONCLUSION/CONCLUSIONS:The current inpatient mortality following hip fracture is 3.9%. Most inpatient mortalities occurred in white females above the age of 85 in the South of the country. LEVEL OF EVIDENCE/METHODS: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 determine if the occurrence of short-term post-operative altered mental status (AMS) was lower in geriatric patients undergoing operative repair of hip fractures with Monitored Anesthesia Care and Soft-Tissue Infiltration with Local Anesthesia (MAC-STILA) when compared with general anesthesia (GA). DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Two U.S. hospitals within a single academic medical center. PATIENT SELECTION CRITERIA/UNASSIGNED:Geriatric patients with hip fractures (AO/OTA 31A and 31B) undergoing operative repair were identified. Propensity matching was performed in a 1:2 ratio to minimize selection bias (age, sex, BMI, ASA class, fracture pattern, fixation construct, pre-injury ambulatory status, and assistive device use). OUTCOME MEASURES/METHODS:Patients who underwent surgical fixation with MAC-STILA were compared with GA. Primary outcome was post-operative AMS, defined as missing ≥1 items on the alert and oriented assessment (person, place, and time) at any point from post-operative days 0-3. RESULTS:After matching, 228 patients (76 MAC-STILA: 152 GA) were included in the analysis. The average age of patients in both groups was 83 years. In the MAC-STILA group, 62% were female and 33% had baseline dementia while in the GA group 66% were female and 29% had baseline dementia. Treating patients with MAC-STILA was associated with 72% lower odds of having AMS compared with GA, controlling for baseline comorbidity and dementia (OR: 0.28. 95% CI: 0.09-0.075, p=0.016). Among patients with baseline dementia, the rate of AMS was lower in patients treated with MAC-STILA compared with GA (64.0% vs 95.3%, p = 0.001). CONCLUSION/CONCLUSIONS:Monitored Anesthesia Care and Soft-Tissue Infiltration with Local Anesthesia (MAC-STILA) was associated with lower odds of short-term postoperative altered mental status (AMS) compared to general anesthesia (GA) in hip fracture patients undergoing operative repair. Given the high rate of post-operative AMS and complications associated with geriatric hip fracture patient, MAC-STILA should be considered for use in patients with increased risk of post-operative AMS, particularly in the setting of preoperative dementia. LEVEL OF EVIDENCE/METHODS:Therapeutic III.

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.

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.