Faculty Bibliography

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.

BACKGROUND:The purpose of this study was to compare hospital quality and patient outcomes of hip arthroplasty for femoral neck fractures (FNFs) based on the subspecialty training of the treating surgeon: orthopaedic trauma (OT) versus adult reconstruction (AR) fellowship training. METHODS:A retrospective review was conducted on 1,008 elderly patients treated for an FNF with hemiarthroplasty or total hip arthroplasty between 2014 and 2024. Patients were grouped by their surgeon's subspecialty training (OT versus AR). Outcomes analyzed included length of stay, complications, 30-day and 90-day readmissions, dislocations, infections, and 30-day mortality. Statistical significance was set at P < 0.05. RESULTS:Baseline patient demographics were similar between groups, except for a higher proportion of women in the AR cohort (P = 0.008) and Black patients in the OT cohort (P = 0.016). Although age-unadjusted Charlson Comorbidity Index (CCI) was significantly higher in the AR group (P = 0.046), Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) scores, which take CCI and other health factors into account, were not significantly different (P = 0.59). In-hospital outcomes, including length of stay (P = 0.89) and minor and major complication rates (P = 0.38, P = 0.38), demonstrated no significant differences between groups. Post-discharge outcomes, including readmissions (30-day: P = 0.52, 90-day: P = 0.16), infections (P = 0.25), dislocations (P = 0.89), and 30-day mortality (P = 0.14), were also similar. CONCLUSION/CONCLUSIONS:No differences were identified in any of the outcomes analyzed between OT-trained and AR-trained surgeons in our study. This suggests that when FNFs are treated at high-volume academic institutions, subspecialty training may not substantially influence the short-term results of FNFs treated with hip arthroplasty. These findings highlight the importance of timely surgical intervention rather than waiting for a particularly trained surgeon to be available.

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.

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.

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:Acute and chronic anemia is common in hip fracture patients, and blood transfusions may be necessary during pre-operative optimization. However, transfusions increase the risk of complications. This study evaluates the impact of red blood cell (RBC) transfusion timing on outcomes including mortality, major complications, and readmission rates for hip fracture patients who present with chronic anemia of at least 6 months. METHODS/UNASSIGNED:A retrospective chart review of chronically anemic hip fracture patients was conducted to assess demographics, lab values, transfusion timing, and outcomes. Charlson comorbidity index (CCI) and Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) were calculated for each patient. Patients were stratified into three transfusion cohorts: pre-operative transfusion, post-operative transfusion, and no-transfusion. Variables were compared using Chi-square and ANOVA as appropriate. Binary logistic regression analysis was performed to account for confounding variables. RESULTS/UNASSIGNED: < 0.001). Post-operative transfusion or no-transfusion was not linked to readmission rates, complications, or mortality. CONCLUSION/UNASSIGNED:Pre-operative RBC transfusion is an independent risk factor for 1-year mortality in chronically anemic hip fracture patients, suggesting careful consideration of transfusion timing.

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.