Faculty Bibliography

BACKGROUND/UNASSIGNED:Hip fracture patients may be hospice candidates if life expectancy is < 6 months. This study evaluates STTGMAHIP FX's ability to identify high-risk hip fracture patients for hospice discharge at emergency room presentation to guide end-of-life care planning. METHODS/UNASSIGNED:A retrospective analysis of a prospectively maintained registry of patients aged ≥55 with low-energy hip fractures (2014-2024) was conducted. Patients were stratified by STTGMAHIP FX percentiles: minimal (≤50th), low (50th-<80th), moderate (80th-<97.5th), and high (≥97.5th). Demographics, injury characteristics, treatment, and outcomes were recorded. The primary outcome was identification of Hospice Discharge Candidates (HDCs), defined as discharge to hospice during the index admission, inpatient mortality >48 h after surgery, or mortality <6 months post-operation. American Society of Anesthesiologists (ASA) score was compared to STTGMAHIP FX for the ability to cluster HDCs using area under receiver operating characteristic (AUROC) curve analysis and a two-proportion Z-test. RESULTS/UNASSIGNED:Among 2777 patients (mean age 81.18 ± 9.80 years), HDC incidence rose with STTGMAHIP FX risk level: 2.9% (minimal risk), 5.9% (low risk), 14.2% (moderate risk), and 29.6% (high risk) (p < 0.05). Only 17.0% of patients classified as ASA 4 were HDCs. Additionally, STTGMAHIP FX demonstrated a slightly better ability to discriminate HDCs compared to ASA, although not statistically significant (0.719 vs 0.683; p = 0.138). However, the STTGMAHIP FX high risk stratification was much more useful in identifying HDCs than ASA (29.6% vs 17.0%; p = 0.013). CONCLUSION/UNASSIGNED:STTGMAHIP FX identifies hospice-eligible hip fracture patients more effectively than ASA. High-risk patients per STTGMAHIP FX demonstrate elevated 6-month mortality and may benefit from early hospice planning at admission.

INTRODUCTION/BACKGROUND:The purpose of this study was to assess the effect of an acute traumatic meniscus tear that required repair in association with a tibial plateau fracture repair on outcomes. METHODS:Over a 17-year period, 843 patients presented with a tibial plateau fracture and were followed prospectively. 721 patients with Schatzker I-VI fractures were treated operatively via a standardized algorithm. 161 tibial plateau fractures (22.3 %) had an associated meniscus tear that underwent acute repair at the time of bony fixation. These patients were compared to operatively repaired tibial plateau fracture patients with no meniscus injury (NMR). Demographics were collected and outcomes including: radiographic healing, knee range of motion (ROM), and complication rates, were recorded. In addition, re-operation rates were compared and any reoperation for meniscus repair failure identified. All patients had a minimum of 1 year follow up. RESULTS:A total of 524 patients with a mean of 21.4 (range: 12-120) months follow up met inclusion criteria. Patients in the meniscus repair (MR) cohort had poorer knee extension (1.01 degrees, range: 0-30 degrees) compared to the NMR cohort (0.07 degrees, range: 0-10 degrees) (p < 0.001), in addition to poorer knee flexion (123 degrees, range: 0-145 degrees, p = 0.024). Additionally, MR patients reported higher pain scores (mean: 3 and range: 0-8, p = 0.005) at latest follow up. Finally, MR patients had higher rates of infection (8.1 % vs. 3.3 %, p = 0.025) and lateral collapse of the joint (p = 0.032). CONCLUSION/CONCLUSIONS:Patients who had a meniscus repair at the time of tibial plateau fracture repair were found to have poorer knee ROM, more patient reported pain at minimum 12 (mean 24) months post-operation. Additionally, these patients developed more post-operative complications than those patients who did not undergo a meniscus repair.

OBJECTIVES/OBJECTIVE:The purpose of this study is twofold: (1) to reliably define the concept of "extreme tibial nailing" and (2) assess the feasibility of tibial intramedullary nailing when the fracture extends into the nail's locking bolt zone. METHODS:Design: A retrospective review. SETTING/METHODS:A single academic center comprised of a specialty orthopedic hospital and a Level I Trauma Center. Patient Selection Criteria: 543 patients who sustained 555 tibia fractures between February 2014 and January 2024 were reviewed by two board-certified orthopedic surgeons. Cases were classified as "extreme nailing" based on the tibial fracture within the most proximal or distal 25% of the bone such that the fracture extended into the locking bolt section of the intramedullary nail used to treat the fracture. Patients with supplemental periarticular plating of the tibia were excluded. Outcome Measures and Comparisons: Data collected included patient demographics, hospital metrics, and outcomes. RESULTS:Twenty-five tibial fractures treated met radiographic criterion. The "extreme IMN" cohort was 45.8 years, 72% female with a mean BMI of 26.6. Over half of fractures resulted from high-energy injuries, and 40% were open. Patients were hospitalized for 92.8 h on average, and the 90-day readmission rate was 8.0%. The average time to weight-bearing allowance was 5.2 weeks post-op. Eight (32.0%) patients experienced complications: 12% developed fracture-related infection (FRI), 4% experienced hardware complications, and 20.0% developed nonunion requiring surgery. The rate of all-cause reoperation was 32.0%, and 28% of patients experienced knee or ankle pain at 6 months or later. The rate of malalignment was 8.0%, and the average time to radiographic healing was 5.7 months. CONCLUSION/CONCLUSIONS:Tibial nailing is an effective treatment for "extreme" tibial fractures that extend as far as the articular surface and interlocking cluster on either end. The majority of patients who underwent extreme tibial nailing recovered with acceptable alignment, minimal healing complications, and achieved radiographic union within 6 months. LEVEL OF EVIDENCE/METHODS:III.

PURPOSE/OBJECTIVE:Evaluate healing outcomes of patients who sustained a comminuted clavicle fracture and underwent operative fixation using a bridge plate technique or interfragmentary screw/neutralization plate. METHODS:Two hundred and seventy-one comminuted clavicle fractures that underwent operative fixation with minimum 6 months follow-up were retrospectively reviewed. Patients were grouped based on fixation methods. Data collected include patient demographics and injury information. Fracture healing, total complications, fracture related infection, removal of hardware, nonunion, and revision fracture surgery were reviewed. Clinical healing was defined as non-tenderness about the fracture site, and radiographic healing was defined as bridging callus and/ or lack of fracture line on X-ray. Chi square analysis, T test, and linear regression were used for analysis. RESULTS:There were 126 comminuted fractures fixed with a bridge plate and 145 comminuted fractures fixed with a plate and at least one interfragmentary screw both with a mean follow-up of 8.2 months. The bridge plated group was more female, the result of high-energy mechanisms, and had more anteroinferior plates (p < 0.05 for all). There were no differences in time to radiographic healing as well as incidence of nonunion between cohorts. Patients fixed with the bridge plate technique underwent a higher incidence of revision surgery, higher incidence of hardware removal, and had a longer time until clinically healed. On multivariate regression analysis, fixation method was not associated with any of these outcomes (p < 0.05 for all). CONCLUSION/CONCLUSIONS:Bridge plating and lag screw/neutralization plate fixation were both associated with similar rates of healing. Complication profiles were similar.

METHODS:This study assessed the safety of the lateral femoral cutaneous and over the hip (LOH) block, a regional anesthetic, in anticoagulated hip fracture patients while maintaining efficacy. A retrospective review of patients diagnosed with hip fractures (AO/OTA 31A/B) who presented to a single academic medical center and level 1 trauma center actively using oral anticoagulants. Patients were grouped based on anesthesia type: LOH block (LOH) versus general anesthesia (GA) and LOH versus spinal anesthesia (SA). LOH patients were matched based on anticoagulant type, OTA/AO classification, and risk (STTGMA) score with a 3:1 ratio to GA and a 1:1 ratio to SA. Outcome comparisons included: time to surgery, operative and anesthesia time, and bleeding complications, demographics (age, sex, race, BMI, CCI, and STTGMA), postoperative complications, 90-day readmission rates, mortality within 1 year, and discharge location. RESULTS:A total of 135 patients: 27 LOH, 27 SA, and 81 GA, were analyzed. Compared to GA, LOH block patients had a shorter time to surgery (1.31 ± 0.082 vs. 0.89 ± 0.69, p = 0.014), lower rates of 90-day readmission (3.7% vs. 19.8%, p = 0.047), and a greater discharge to home with health services rate (33.3% vs. 8.6%, p = 0.024). The GA population trended-toward more major complications (p = 0.077) and mortality within 1 year (p = 0.077). Compared to SA, LOH patients were slightly underweight (25.1 ± 4.19 vs. 22.7 ± 4.16, p = 0.035) and got to surgery faster (0.89 ± 0.69 vs 1.54 ± 1.48, p = 0.039). Across all groups, there were no differences in the need for blood transfusion or other quality markers. CONCLUSION/CONCLUSIONS:The LOH block was safe and effective for use in anticoagulated hip fracture patients. This technique provided an intraoperative safety profile similar to other anesthetic choices, allowed for less delay to surgery compared to spinal anesthesia and improved discharge parameters compared to GA. LEVEL OF EVIDENCE III/METHODS:Prognostic Level III.

INTRODUCTION/BACKGROUND:Several types of fifth metatarsal (MT) fractures exist and are treated with various methods of immobilization, weight bearing restrictions, and occasionally operative procedures. This study evaluated the differences in clinical and radiographic outcomes among pseudo-Jones fractures (Zones 1 and 2), true Jones fractures (Zone 3), and fifth metatarsal shaft and neck fractures. METHODS:A retrospective review of a consecutive series of patients presenting to a single academic medical center with a fifth metatarsal fracture between 2012 and 2022 was conducted. Radiographs obtained at the initial presentation were reviewed, and fracture patterns were categorized as either Zone 1, Zone 2, Zone 3, shaft, neck, or head fractures. RESULTS:In total, 1314 patients with isolated fifth metatarsal fractures were treated (mean age = 49.6 ± 18.0 years). In total, 1217 fractures (92.5%) were initially treated nonoperatively, and 97 fractures (7.5%) were treated operatively. The overall time to clinical and radiographic healing for all fifth metatarsal fractures treated nonoperatively was 9.9 ± 8.7 weeks and 17.9 ± 15.6 weeks, respectively (P = .245, P = .088). Immediate weightbearing led to a faster time to clinical healing by (P = .035). There was no statistically significant difference in time to clinical or radiographic union among the different fracture types (P = .496, P = .400). Likewise, there was no evidence of any difference in time to clinical or radiographic union for patients treated operatively versus nonoperatively (P > .05). CONCLUSION/CONCLUSIONS:.

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.

BACKGROUND/UNASSIGNED:The purpose of this study was to examine factors that were associated with a decline in functional ambulatory status following fractures of the tibial diaphysis. METHODS/UNASSIGNED:A retrospective review of an IRB-approved tibial diaphysis fracture database from 2012 to 2024 was conducted. Inclusion criteria were age ≥18, isolated OTA 42A-C tibia fracture treated with an intramedullary nail, and minimum 12 months follow-up. Demographics, injury, and surgical information were collected. Functional ambulatory status was measured at routine follow up intervals by the Functional Ambulatory Category (FAC) score, a six-point scale where zero represents non-ambulation and five represents normal ambulatory ability. Univariate analysis was performed using Student's T-tests and Chi-squared tests. A backwards stepwise multivariate logistic regression analysis was performed to determine factors that were independently associated with a decline in FAC score (SPSS version 29, Armonk, NY). RESULTS/UNASSIGNED:289 patients, with a mean follow up time of 15.04 ± 6.18 months, were included in the analysis with a mean age of 43.24 ± 16.22 years, body mass index of 27.19 ± 6.30, and age-unadjusted Charlson Comorbidity Index of 0.18 ± 0.54. 39.1 % of patients were female, 28.0 % patients sustained open fractures, and 52.6 % sustained high energy injuries. The logistic regression demonstrated that older age (OR = 1.04 p < .001), higher BMI (OR = 1.06 p = .024), high-energy mechanism (OR = 3.18 p = .003), nonunion (OR = 3.66, p = .005), and concomitant lower extremity fractures (OR = 4.47 p = 002), were risk factors for a decrease in final FAC score. The AUROC of the logistic regression equation was 0.787 indicating a moderate ability to discriminate between patients that will experience a loss in functional ambulatory ability and those who will not. CONCLUSION/UNASSIGNED:This study suggests that concomitant lower extremity injuries, increased age, increased BMI, high-energy mechanisms, and nonunion are risk factors that are associated with a decline in ambulatory capacity following diaphyseal tibia fractures.

PURPOSE/OBJECTIVE:To assess the healing outcomes of patients who sustained a comminuted clavicle fracture and underwent operative fixation with or without the addition of demineralized bone matrix (DBM). METHODS:A total of 271 comminuted midshaft clavicle fractures that presented to our hospital system and underwent operative fixation with a plate and screw construct were retrospectively reviewed. Data collected include patient demographics, initial injury information, and use of demineralized bone matrix during surgery to enhance bone healing. Patients were grouped based on whether or not their fixation was augmented with DBM. Fracture-related infection (FRI), lack of fracture healing, and the need for revision fracture surgery were reviewed. Adhesive capsulitis of the shoulder and screw back out were categorized as "minor complications." Clinical healing was defined as non-tenderness about the fracture site, and radiographic healing was defined as presence of bridging callus and lack of fracture line on X-ray. Chi-square, T-test, and linear regression analysis were used to determine any significant differences between cohorts. RESULTS:Sixty-nine patients had DBM used in their repair, and 202 patients did not. Cohorts had a similar follow-up (range: 6-18 months). There were no differences in patient demographics or fracture pattern between the two groups (P > 0.05 for all). There were no differences in major and minor complications; however, the cohort treated with DBM had shorter time to radiographic healing, confirmed with regression analysis (P < 0.05). CONCLUSION/CONCLUSIONS:Augmentation of midshaft clavicle fracture constructs with DBM was associated with quicker radiographic healing.

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.