Faculty Bibliography

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.

OBJECTIVE:To compare rates of nail breakage of three common cephalomedullary nails (CMNs) for the treatment of AO/OTA 31A1-3 femur fractures. METHODS:Design: multi-center retrospective study. SETTING/METHODS:13 Level I trauma centers. PATIENT SELECTION CRITERIA/UNASSIGNED:Adult patients with AO/OTA 31A1-3 femur fractures treated between 2014 and 2021with the Trochanteric Fixation Nail-Advanced (TFNA), Gamma3, or Trigen InterTAN were included. OUTCOME MEASUREMENTS AND COMPARISONS/UNASSIGNED:The primary outcome was implant (nail or head element) breakage. The secondary outcomes included nonunion, cut-out/cut-through and overall reoperation rate. Univariate and multivariable analyses were performed to compare breakage rates between implants while controlling for age, sex, AO/OTA 31A1-2 vs 31A3 fracture patterns, low vs high-energy mechanisms and post-operative neck shaft angle (NSA). RESULTS:2,130 patients were included: 770 (36.2%) TFNA, 1,073 (50.4%) Gamma3 and 287 (13.5%) InterTAN. The InterTAN group had younger patients (median age: InterTan: 74, TFNA: 77, Gamma3: 80, p<0.001), more high-energy mechanisms (InterTan: 23%, TFNA: 14%, Gamma3: 10%, p=0.001), and more varus malreductions (NSA<128.5: InterTan: 46%, Gamma3: 39%, TFNA: 34%, p=0.001). The TFNA group was more likely to have an AO/OTA 31A3 fracture pattern than the Gamma3 (TFNA: 17.3%, InterTAN: 14.3%, Gamma3: 12.1%, p=0.002). The overall rate of implant breakage was 1.4% in the InterTAN group, 1.2% in the TFNA group, and 0% in the Gamma3 group. All breakages occurred in the presence of a nonunion or delayed union. Only two of the 31A3 fracture patterns resulted in breakage, both in the TFNA group, while the remainder occurred in 31A1-2 fracture patterns (p = 1.0). After controlling for confounding factors listed above, the TFNA and InterTAN groups were associated with a marginally increased odds of implant breakage compared to the Gamma3 (TFNA vs Gamma3: OR 0.04, 95% CI <0.01-0.5, p=0.034; InterTAN vs Gamma3: OR 0.04, 95% CI <0.01-0.5, p=0.037), while there was no difference between the TFNA and InterTAN (p=0.991). Post-operative neck shaft angle was not independently predictive of breakage (p = 0.55). CONCLUSIONS:This study suggests that the TFNA may be slightly more prone to breakage than the Gamma3 when used for extracapsular proximal femur fractures. However, breakage is a rare event after cephalomedullary nailing with all implants evaluated, is always associated with nonunion or delayed union, and the magnitude of this difference may not be clinically relevant. LEVEL OF EVIDENCE/METHODS:III.

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.

INTRODUCTION/BACKGROUND:Tibial plateau fractures are some of the most commonly treated injuries around the knee and loss of range of motion has a significant effect on post-operative outcomes, very few studies have demonstrated the impact of flexion contractures. The purpose of this study was to determine the effect that development of a knee flexion contracture has on outcomes following operative repair of tibial plateau fractures. METHODS:Patients operatively treated for tibial plateau fractures (Schatzker II, IV, V, and VI) between 2005-2024 at a multi-center academic urban hospital system were included in this retrospective comparative study. Patients were grouped into 3 cohorts: 1. Full extension (FE), 2. 5-10 degrees of flexion contracture (Mild, ME) and 3. Greater than 10 degrees of flexion (Severe, SE) contracture at 6 months post-operatively. Patients with contracture were matched to patients who regained full extension based on age and Schatzker classification. Statistical analysis was used to evaluate outcomes including patient reported pain levels, Short Musculoskeletal Function Assessment (SMFA) scores, complication rates and reoperation rates. RESULTS:The cohort consisted of 3 groups of 30 patients (14 Schatzker II, 5 Schatzker IV, 3 Schatzker V, and 8 Schatzker VI). The average knee flexion contracture for the mild cohort was 5 degrees and the average knee flexion contracture for the severe cohort was 12.7 degrees. Patients who experienced flexion contracture had poorer SMFA scores at 6 months, and those in the severe cohort had the poorest SMFA scores (112.6) when compared to those with full extension at 6 months (77.7) (p<0.001). Flexion contractures were associated with higher rates of fracture related infection (FRI) (p =0.002). Patients with flexion contracture also had a higher rate of subsequent re-operation, with 36.7% of the ME undergoing re-operation and 40% of SE undergoing re-operation. CONCLUSIONS:Patients who developed a flexion contracture following repair of a tibial plateau fracture experienced worse outcomes, higher rates of complications, increased pain, and poorer function at long term follow up compared to those who achieved full knee extension.

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.

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.

In recent history, human life expectancy has increased significantly, resulting in a high burden of late-life morbidity and geriatric fractures. Changes to the body as a result of aging, such as degeneration of the bone marrow, osteoblast apoptosis, and a decline in hormone production, coupled with sarcopenia, are only a few factors that predispose the elderly to fractures. In addition, these factors further complicate surgical management, as they increase the risk of fixation failure, nonunion, malunion, and wound complications. As a result, the standards of geriatric fracture fixation must account for variables that are rarely included when planning for surgery in the younger population. Operative fixation should provide a stable limb to allow for early mobilization and weight bearing, lowering the risk of medical complications. Therefore, early mobility is of the utmost importance in the setting of most fragility fractures. However, early mobility in some, such as the pelvic fragility fracture, may lead to an increased risk for bleeding and death. Geriatric fractures carry significant morbidity, mortality, and financial risk, which indicates that there should be a continuing review and understanding of the multifactorial process leading toward and treatment strategies employed after geriatric fractures. The purpose of this review is to summarize the biology of aging, the causes, effects, and treatments of sarcopenia, the current fixation strategies of geriatric fractures, and the importance of mobility in the geriatric patient.

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:.

PURPOSE/OBJECTIVE:The purpose of this study is to examine the effect of age on outcomes following repair of acute displaced patella fractures Methods: 248 patients who sustained a displaced patella fracture and underwent open reduction and internal fixation were identified. Patients included underwent a similar operative protocol, were prescribed a standard post-operative protocol of therapy, and were seen at standard follow-up intervals. Patients were divided into groups of < 65 years old (young) and ≥ 65 years old (older). Statistical analysis was run to determine if there was a significant difference in range of knee motion and rate of major complications. RESULTS:Of the 248 patients, 149 were young and 99 were older. The mean age of the older group was 74.5 ± 6.7 and the mean age of the young group was 50 ± 12. Fracture pattern and BMI were similar the groups, however the older group had a higher average CCI (p<0.001). Additionally, the groups had similar length of follow up (p=0.693) and similar mean time to radiographic healing (p=0.533). Older patients had limited knee extension at 6 months (compared young patients (p=0.031). Finally, older patients had a higher rate of all complications compared to young patients. Two percent of older patients developed a fracture related infection (FRI), 4% developed a symptomatic nonunion and 11% were underwent re-operation including removal of hardware, total knee replacement, irrigation and debridement and manipulation under anesthesia. CONCLUSION/CONCLUSIONS:Complication rates following patella fracture fixation in older patients were higher than young patients, despite having similar injury patterns, surgical treatment and follow up. These findings can better inform treating physicians during surgical intervention of older patients with patella fractures.

OBJECTIVES/OBJECTIVE:To determine the most common reason for 30-day readmission following hospitalization for hip fractures. METHODS:Design: A retrospective review. SETTING/METHODS:Single academic medical center that includes a Level 1 Trauma Center. PATIENT SELECTION CRITERIA/UNASSIGNED:Included were all patients operatively treated for hip fractures (OTA 31) between October 2014 and November 2023. Patients that died during their initial admission were excluded. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Patient demographics, hospital quality measures, outcomes and readmission within 30-days following discharge for each patient were reviewed. 30-day readmission reason was recorded and correlation analysis was performed. RESULTS:A total of 3,032 patients were identified with a mean age of 82.1 years and 70.5% of patients being female. The 30-day readmission cohort was 2.6 years older (p<0.001) and 8.8% more male patients (p=0.027), had 0.5 higher CCI (p<0.001), 0.3 higher ASA class (p<0.001) and were 9.2% less independent at the time of admission (p= 0.003). Hemiarthroplasty procedure (32.7% vs. 24.1%) was associated with higher 30-day readmission compared to closed percutaneous screw fixation (4.5% vs. 8.8%) and cephalomedullary nail fixation (52.2% vs. 54.4%, p<0.001). Those readmitted by 30-days developed more major (16.7% vs. 8.0%) (p<0.001) and minor (50.5% vs. 36.4%) (p<0.001) complications during their initial hospitalization and had a 1.5 day longer LOS during their first admission (p<0.001). Those discharged home were less likely to be readmitted within 30-days (20.7% vs. 27.6%, (p=0.008). Multivariate regression revealed increasing ASA class (O.R. 1.47, p=0.002) and pre-injury ambulatory status (O.R. 1.42, p=0.007) were most associated with increased 30-day readmission. The most common reason for readmission was pulmonary complications (17.1% of complications) including acute respiratory failure, COPD exacerbation and pneumonia. CONCLUSION/CONCLUSIONS:Thirty-day readmission following hip fracture was associated with older, sicker patients with decreased pre-injury ambulation status. Hemiarthroplasty for femoral neck fracture was also associated with readmission. The most common reason for 30-day readmission following hip fracture was pulmonary complications. LEVEL OF EVIDENCE/METHODS:Prognostic Level III.