Faculty Bibliography

BACKGROUND/UNASSIGNED:The purpose of this study was to determine the efficacy of medial malleolar fixation with 1 vs 2 screws. METHODS/UNASSIGNED:Between April 2013 and February 2017, 196 patients who presented at 2 hospitals within one academic institution with an unstable rotational ankle fracture with a medial fracture and were treated operatively by a trained orthopedic surgeon were identified. These patients' charts were reviewed and their injury, radiographic, surgical, and follow-up data recorded. Medial malleolus fragment size was assessed on the anteroposterior (AP) and lateral views of the initial injury radiograph. Functional outcome was assessed using Maryland Foot Score (MFS). Patients were grouped based upon the number of screws utilized to fox the medial malleolar fragment. Data were assessed using Fisher exact tests and independent t tests with SPSS, version 23. RESULTS/UNASSIGNED:Out of the 196 patients who met inclusion criteria, 47 patients (24%) were fixed with 1 medial malleolar screw and 149 patients (76%) were fixed with 2 screws. There were no differences among patients who received 1 vs 2 screws with regard to age, gender, body mass index, American Society of Anesthesiologists grade, or smoking status. The average malleolar fragment size was smaller in those treated with 1 screw on both the AP and lateral radiographic views than those with 2 screws ( P = .009, P = .001, respectively). There was no difference between groups in ankle dorsiflexion or plantarflexion at 1 year postoperation ( P = .451, P = .581). Patients who received 1 screw did not differ from those who received 2 screws with respect to Maryland Foot Scores ( P = .924). There was no difference in rate of revision surgery or need for hardware removal between groups ( P = .093). Furthermore, time to healing and postoperative complication rate did not differ between groups. CONCLUSION/UNASSIGNED:The use of a single screw for medial malleolar fixation provided stable fixation to allow ankle fracture healing, without an increase in complications. This information is especially important in situations when the fragment is too small to accommodate multiple fixation points. LEVEL OF EVIDENCE/UNASSIGNED:Level III, retrospective case-control study.

BACKGROUND:Little evidence regarding the extent of recovery of radial nerve lesions with associated humerus trauma exists. The aim of this study is to examine the incidence and resolution of types of radial nerve palsy (RNP) in operative and nonoperative humeral shaft fracture populations. MATERIALS AND METHODS/METHODS:Radial nerve lesions were identified as complete (RNPc), which included motor and sensory loss, and incomplete (RNPi), which included sensory-only lesions. Charts were reviewed for treatment type, radial nerve status, RNP resolution time, and follow-up time. Descriptive statistics were used to document incidence of RNP and time to resolution. Independent-samples t-test was used to determine significant differences between RNP resolution time in operative and nonoperative cohorts. RESULTS:A total of 175 patients (77 operative, 98 nonoperative) with diaphyseal humeral shaft injury between 2007 and 2016 were identified and treated. Seventeen out of 77 (22.1%) patients treated operatively were diagnosed preoperatively with a radial nerve lesion. Two (2.6%) patients developed secondary RNPc postoperatively. Eight out of 98 (8.2%) patients presented with RNP postinjury for nonoperatively treated humeral shaft fracture. All patients who presented with either RNPc, RNPi, or iatrogenic RNP had complete resolution of their RNP. No statistically significant difference was found in recovery time when comparing the operative versus nonoperative RNPc, operative versus nonoperative RNPi, or RNPc versus RNPi patient groups. CONCLUSIONS:All 27 (100%) patients presenting with or developing radial nerve palsy in our study recovered. No patient required further surgery for radial nerve palsy. Radial nerve exploration in conjunction with open reduction and internal fixation (ORIF) appears to facilitate speedier resolution of RNP when directly compared with observation in nonoperative cases, although not statistically significantly so. These findings provide surgeons valuable information they can share with patients who sustain radial nerve injury with associated humerus shaft fracture or nonunion. LEVEL OF EVIDENCE/METHODS:Level III treatment study.

The purpose of this study was to evaluate whether patients with hip fractures receiving antiplatelet and direct oral anticoagulants treated within 48 hours of admission had worse surgical and clinical outcomes than those whose surgery was delayed more than 48 hours. Consecutive patients 55 years and older with an operatively treated hip fracture were analyzed. Patients receiving the following anticoagulants were included: antiplatelet drugs, factor Xa inhibitors, and direct thrombin inhibitors. Outcomes included surgical blood loss, procedure time, transfusion requirement, length of stay, complication rate, and need for intensive care unit or step-down unit level care. Patients who underwent surgery within 48 hours of presentation were compared with patients whose surgery was delayed more than 48 hours. Of 551 consecutive operative hip fracture patients, 78 (14.2%) were receiving the anticoagulant medications included in this study. Of these 78 patients, 58 had surgery within 48 hours and 20 had surgery after 48 hours. When comparing the early and delayed fixation cohorts, there was no difference in transfusion requirement, length of surgery, or blood loss. Type of anticoagulant made no difference in transfusion requirement, blood loss, or length of surgery. There was also no difference in the mean number of complications or in the need for intensive care unit or step-down unit level care. In this study, patients receiving antiplatelet therapy, factor Xa inhibitors, or direct thrombin inhibitors who underwent surgical fixation of their hip fracture within 48 hours of admission were at no higher risk for transfusion, increased surgical blood loss, longer operative time, or inpatient mortality. [Orthopedics. 201x; xx(x):xx-xx.].

OBJECTIVES/OBJECTIVE:Analyze the effectiveness of a BPCI (Bundle Payments for Care Improvement) initiative at a large urban medical center for hip fracture patients included in the bundle payment program with respect to improving patient outcomes and reducing cost DESIGN:: Retrospective cohort SETTING:: Single Academic Institution PATIENTS/PARTICIPANTS:: Patients discharged with the DRG codes 469-470 performed for hip fractures between July 2011 and September 2014 were evaluated. A BPCI initiative focused on optimizing care coordination, patient education, expectations, and minimizing post-acute facility and resource utilization was initiated in October 2013. Patient outcomes prior to the introduction of the BPCI initiative were compared to those who participated in the initiative. INTERVENTION/METHODS:Application of BPCI principles MAIN OUTCOME MEASURES:: length of stay, location of discharge, readmission within 90 days, and 90-day episode of care costs RESULTS:: Sixty-one patients received care prior to the initiative, and forty-four patients were treated with the initiative. The mean length of stay decreased from 6.8 to 5.3 days and the percentage of patients discharged home increased by nearly 10% with the introduction of the BPCI initiative (6.6% vs. 15.9%). There was a 13.1% reduction in total 90-day episode of care cost ($57,546 vs. $49,993, p=0.210) upon introduction of the initiative. There was no significant difference in readmission rate between the two cohorts. CONCLUSION/CONCLUSIONS:This study demonstrates the success of one such program for hip fracture arthroplasty patients aimed at care coordination and minimizing post-acute hospitalization facility care both with respect to improved patient outcomes and substantial cost reduction. LEVEL OF EVIDENCE/METHODS:Therapeutic Level IV.

PURPOSE/OBJECTIVE:The purpose of this study was to determine the effect of regional anaesthesia as compared to general anaesthesia on clinical, functional, and radiographic outcomes following long bone fracture nonunion repair. METHODS:262 patients who underwent operative repair of a long bone fracture nonunion and had at least 12 months of post-operative follow up were included in this study. Functional outcomes were assessed prospectively using the Short Musculoskeletal Function Assessment (SMFA) and Visual Analog Scale (VAS) pain scores prior to nonunion repair and at routine intervals post-operatively. Patients were divided into two matched groups based upon the type of anaesthetic method used in surgery. The regional anaesthesia cohort was composed of all patients who received regional anaesthesia (spinal anaesthesia or peripheral nerve block) alone or in addition to general anaesthesia, while patients who received general anaesthesia alone made up the general anaesthesia cohort. Univariate and multivariate analyses were performed to examine the effect of anaesthesia type on functional outcome scores, post-operative pain, bony healing, and complication rate. RESULTS:The regional anaesthesia and general anaesthesia cohorts each consisted of 131 patients. Multiple linear regression demonstrated there to be no significant association between anaesthetic method and total SMFA scores at all post-operative time points. Additionally, anaesthetic method was not associated with post-operative VAS pain scores, time to union, or the rate of post-operative complications. CONCLUSION/CONCLUSIONS:In this cohort, the use of regional anaesthesia during operative repair of long bone fracture nonunion was associated with no significant difference in functional outcome scores or pain levels at all post-operative time points. Furthermore, the use of regional anaesthesia had no effect on the rate of post-operative complications. Either type of anaesthetic appears to be safe and effective in performing these surgeries.

BACKGROUND:Socioeconomic disparities are an inherent and currently unavoidable aspect of medicine. Knowledge of these disparities is an essential component towards medical decision making, particularly among an increasingly diverse population. While healthcare disparities have been elucidated in a wide variety of orthopaedic conditions and management options, they have not been established among patients who present for treatment of an ununited fracture. The purpose of this study is to answer the following questions: 1) Following surgical management of (fracture) non-unions, are there differences in outcomes between differing ethnic groups? 2) Following surgical management of (fracture) non-unions, are there differences in outcomes between patients with differing education levels? 3) Following surgical management of (fracture) non-unions, are there differences in outcome between patients with differing incomes? METHODS:Between September 2004 and December 2017, operatively treated patients who presented with a long bone fracture non-union were prospectively followed. These patients presented with a variety of fracture non-unions that underwent surgical intervention. Sociodemographic factors were recorded at presentation. Long-term outcomes were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, post-operative complications and physical exam at latest follow up. The SMFA is a 46-item questionnaire, assessing patient functional and emotional response to musculoskeletal ailments. RESULTS:Three-hundred-twenty-nine patients met inclusion criteria. Patients with a lower education had worse long-term functional outcomes (P < 0.001) and increased pain scores (P = 0.002) at latest follow-up. Patients who made less than $50,000 annually had worse long-term functional outcomes (P = 0.002) and reported higher pain scores (P = 0.003) following surgical management of (fracture) non-unions. Multiple linear regression demonstrated education level to be an independent predictor of long-term functional outcomes following surgical management of (fracture) non-unions (B= -0.154, 95% Confidence Interval [CI]=-10.96 to -1.26, P = 0.014). No differences existed in outcomes or pain scores between those of different ethnic groups. No differences existed regarding post-operative complications and time to union between patients of different ethnic groups, educational levels and income status. CONCLUSION/CONCLUSIONS:Patients with lower education levels and individuals who make less than $50,000 annually have worse functional outcomes following surgical management of (fracture) non-unions. Orthopaedic trauma surgeons should therefore be aware of these disparities, and consider early interventions aimed at optimizing patient recovery in these subsets.

The purpose of this study was to analyze the perioperative complication rate and inpatient hospitalization costs associated with hip fractures in patients older than 90 years compared with patients younger than 90 years. Patients 60 years and older with hip fractures treated operatively at 1 academic medical center between October 2014 and September 2016 were analyzed. Patient demographics, comorbidities, length of stay, procedure performed, and inpatient complications were analyzed. Total cost of admission was obtained from the hospital finance department. Outcomes were compared between patients older than 90 years and patients younger than 90 years. A total of 500 patients with hip fractures were included in this study. There were 109 (21.8%) patients 90 years and older and 391 (78.2%) patients 60 to 89 years. There was no difference in fracture pattern, operation performed, Charlson Comorbidity Index, or length of stay between the 2 groups. The mean length of stay for patients 90 years and older with hip fractures was 7.8±4.3 days vs 7.6±4.2 days for the younger cohort (P=.552). There was no observed difference in perioperative complications. Finally, there was no difference in the total mean cost of admission. Patients 90 years and older are at no greater risk for perioperative complications based on age alone. They are also no more likely to require longer or more costly hospitalizations than patients younger than 90 years. [Orthopedics. 201x; xx(x):xx-xx.].

Introduction/UNASSIGNED:Lateral compression type 1 (LC1) pelvic ring fractures make up 63% of all pelvic ring injuries. This fracture pattern is typically seen in older patients. The purpose of this study is to assess the ambulatory status of individuals sustaining LC1 fractures at long-term follow-up and what specific characteristics, if any, effect this status or functional outcomes. Methods/UNASSIGNED:Over a 2-year period, all pelvic ring injury at 2 hospitals within one academic institution was queried. One hundred sixty-one low-energy LC1 pelvic fractures were identified. Results/UNASSIGNED:= .010). Forty-three (86%) patients didn't use an assistive ambulatory device prior to sustaining the LC1 fracture. Seven (14%) patients utilized assistive devices both before and after the LC1 injury. Thirteen (26%) patients, who did not utilize assistive ambulatory devices prior to their injury, necessitated them at long-term follow-up. Discussion/UNASSIGNED:Surgeons should be aware of these associations, as they can implement early interventions aimed at patients at risk, for assistive device use, following LC1 pelvic fractures. Conclusion/UNASSIGNED:More than a quarter of the patients sustaining an LC1 pelvic fracture continue to use an aid for ambulation at long-term follow-up. Older age, complications, and falls within 30 days of this injury are associated with the utilization of an assistive ambulatory device.

OBJECTIVE:To compare the incidence of venous thromboembolism (VTE) amongst patients with pelvic and/or lower extremity fractures directly admitted to our institution versus those transferred from an outside hospital for definitive management. DESIGN/METHODS:Retrospective cohort SETTING:: Tertiary care orthopedic hospital PATIENTS:: 690 patients who received definitive care for a lower extremity fracture at our institution between 2010 and 2017. INTERVENTION/METHODS:Inter-facility transfer for definitive management of pelvic or lower extremity fracture. MAIN OUTCOME MEASUREMENTS/METHODS:VTE incidence, time to surgery RESULTS:: The interfacility transfer (TR) group was comprised of 126 patients and the direct admission (DA) group was comprised of 564 patients. TR patients had a significantly higher incidence of VTE compared to the DA group: 9.5% vs 0.7%, respectively (p < 0.001). Time to surgery was also longer in the TR group compared to the DA group: 3.05 +/- 3.00 days vs. 2.16 +/- 2.42 days, respectively (p = 0.005). Demographics for TR and DA did not significantly differ with regards to age, gender, length of stay, or ASA score. In the TR group, no complete and explicit documentation regarding thromboprophylaxis administration while at the outside facility was found. CONCLUSIONS:Patients undergoing interfacility transfer for definitive management of pelvic and lower extremity fractures are at significantly increased risk for the development of VTE. LEVEL OF EVIDENCE/METHODS:Level III retrospective cohort.

BACKGROUND:The incidence and risk factors of wound-healing complications following rotational ankle fracture surgery are well documented in the literature. However, there is a paucity regarding management options following these complications. The goal of this study was to provide a descriptive analysis of one surgeon's experience managing wound complications in patients who have undergone ankle fracture surgery. METHODS:A total of 215 patients who were operatively treated for an unstable ankle were retrospectively identified. Patient demographics, medical histories, initial injury characteristics, surgical interventions, and clinical follow-up were collected. Twenty-five of these patients developed postoperative wound problems. RESULTS:Of the original cohort of 215 patients, 25 (11.6%) developed wound-healing complications. Their average age was 53.6 ± 18.0 years; there were 12 males (48.0%). Connective tissue/inflammatory disease (odds ratio [OR] 3.9), cardiovascular disease (OR 3.6), and active smoking (OR 3.3) were associated with an increased likelihood of developing postoperative wound complications. With regard to injuries, open fractures (OR 17.9) had the highest likelihood of developing postoperative complications, followed by type 44-C (OR 2.8) and trimalleolar fractures (OR 2.0). CONCLUSION/CONCLUSIONS:Wound complications following open treatment of ankle fractures occurred with an incidence of 11.6% in this series, of which only about half required operative intervention. A third of wounds were managed by orthopaedics in conjunction with plastic surgery. LEVELS OF EVIDENCE/METHODS:Level III: Retrospective comparative study.