Faculty Bibliography

Purpose/UNASSIGNED:The purpose of this study was 2-fold: 1) to investigate the age-related frequency, demographics and distribution of the middle-aged and geriatric orthopedic trauma population and 2) to describe the age-related frequency and distribution of hospital quality measure outcomes and inpatient cost. Methods/UNASSIGNED:All patients > 55 years of age who required orthopedic, trauma, or neurosurgery consults at 3 hospitals within an academic medical center from 2014 to 2017 were prospectively followed. On initial evaluation, each patient's demographics, injury severity, and functional status were collected. Patients were grouped into low and high-energy mechanism cohorts and divided into 5 groups based on age. Hospital quality measures including length of stay, complications, discharge location, and cost of care was compared between age groups. Data were analyzed using ANOVA and Chi-square tests. Results/UNASSIGNED:A total of 3965 patients were included in this study of which 3268 (82%) sustained low-energy trauma and 697 (18%) sustained high-energy trauma. With increasing age, more patients had more comorbidities, were less likely to be community ambulators, and more likely to use assistive devices (p < 0.05). Patients in older age groups had longer lengths of stay, more complications, were more likely to need ICU level care, and were less likely to be discharged home (p < 0.05). Rates of mortality were also greater in patients of more advanced age in both low and high-energy cohorts, and the calculated risk triage tool (STTGMA) score increased with each age bracket (p < 0.05). Total cost of care differed between age groups in the low-energy cohort (p = 0.003). Conclusion/UNASSIGNED:This epidemiological study provides a clear picture of the frequency and distribution of demographic, physiologic characteristics, outcomes, and cost of care in a middle-aged and geriatric orthopedic trauma population as evaluated by the STTGMA risk tool. Risk profiling of geriatric trauma patients allows for the establishment of baseline norms.

Purpose/UNASSIGNED:To characterize the volume and variation in orthopedic consults and surgeries that took place during a period of social distancing and pandemic. Methods/UNASSIGNED:All orthopedic consults and surgeries at an urban level 1 trauma center from 3/22/20-4/30/2020 were retrospectively reviewed (the social distancing period). Data from the same dates in 2019 were reviewed for comparison. Age, gender, Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) score and injury type were queried. Operating room data collected included: type of surgery performed, inpatient or outpatient status, and if the cases were categorized as elective, trauma or infectious cases. Results/UNASSIGNED:Compared to 2019, there was a 48.3% decrease in consult volume in 2020. The 2020 population was significantly older (44.0 vs 52.6 years-old, p = 0.001) and more male (65% vs 35%, p = 0.021). There were 23 COVID positive patients, 10 of which died within the collection period. Consult distribution dramatically changed, with decreases in ankle fractures, distal radius fractures and proximal humerus fractures of 76.5%, 77.4% and 55.0%, respectively. However, there was no significant difference in volume of hip, tibial shaft and femoral shaft fractures (p > 0.05). In 2020, there was a 41.4% decrease in operating room volume, no elective cases were performed, and cases were primarily trauma related. Conclusions/UNASSIGNED:During a period of pandemic and social distancing, the overall volume of orthopedic consults and surgeries significantly declined. However, hip fracture volume remained unchanged. Patients presenting with orthopedic injuries were older, and at higher risk for inpatient mortality.

OBJECTIVES/OBJECTIVE:Investigate the efficacy of a novel geriatric trauma risk assessment tool (STTGMA) designed to predict inpatient mortality to risk stratify measures of hospital quality and cost of care in middle-aged and geriatric orthopaedic trauma patients. DESIGN/METHODS:Prospective cohort study SETTING:: Academic medical center PATIENTS:: 1592 patients aged 55 and older who were evaluated by orthopaedic surgery in the emergency department between 10/1/2014-9/30/2016. INTERVENTION/METHODS:Calculation of inpatient mortality risk score (STTGMA) using each patient's demographics, injury severity, and functional status. Patients were stratified into minimal, low, moderate, and high-risk cohort groups based on risk of <0.9%, 0.9-1.9%, 1.9-5%, and >5%. MAIN OUTCOME MEASUREMENTS/METHODS:length of stay, complications, disposition, readmission, and cost RESULTS:: 1278 patients (80.3%) sustained low-energy injuries and 314 patients (19.7%) sustained high-energy injuries. The average age was 73.8 ± 11.8 years. The mean length of hospital stay was 5.2 days with a significant difference between the STTGMA risk groups. This risk stratification between groups was also seen in complication rate, need for ICU/SDU care, percentage of patients discharged home, and readmission within 30-days. The mean total cost of admission for the minimal risk group was less than one-third that of the high-risk cohort. CONCLUSIONS:the STTGMA tool is able to risk stratify hospital quality outcome measures and cost. Thus, it is a valuable clinical tool for health care providers in identifying high-risk patients in efforts to continue to provide high-quality resource conscious care to orthopaedic trauma patients. LEVEL OF EVIDENCE/METHODS:Prognostic Level II.

INTRODUCTION/BACKGROUND:Autogenous iliac crest bone graft (ICBG) is considered the benchmark graft for nonunion repair. However, ICBG harvest is invasive and may provide reduced benefit to elderly patients. The purpose of this study was to compare the clinical and functional outcomes of ICBG use in fixation of fracture nonunions between elderly and nonelderly patients. METHODS:Over a 13-year period, 242 patients who underwent operative repair of a long bone fracture nonunion and received autogenous ICBG were enrolled in a prospective research registry and followed. Data collected included patient demographics, injury information, and nonunion management. All patients had a minimum of 12 months of postoperative follow-up. Patients at least 65 years of age were classified as elderly, whereas younger patients were classified as nonelderly. Functional outcomes were evaluated at routine intervals postoperatively using the short musculoskeletal function assessment (SMFA) and visual analog scale pain scores. Bony union was determined radiographically. All postoperative complications were recorded. RESULTS:Of the 242 patients included, 44 were elderly and 198 were nonelderly. No differences were found between groups with respect to postoperative pain scores or SMFA scores. Furthermore, time to union, rate of union, and postoperative complication rate did not differ between groups. Multivariate linear regression demonstrated that older age was not associated with time to union, postoperative pain scores, or postoperative SMFA scores after controlling for possible confounding variables. DISCUSSION/CONCLUSIONS:The use of ICBG in nonunion repair among elderly patients is as effective as use in younger patients with a long bone nonunion. Concerns of increased postoperative complications and decreased rate of union in elderly patients receiving ICBG for treatment of fracture nonunion should be alleviated. ICBG remains the benchmark graft for nonunion repair among all age groups.

OBJECTIVES/OBJECTIVE:(1) To assess the correlation of psychosocial factors and long-term outcomes of proximal humerus fractures all in surgical repair; (2) to identify specific psychosocial factors with favorable and unfavorable outcomes; and (3) to assess the correlation between DSM-V mental health diagnoses and long-term Disabilities of Arm, Shoulder, and Hand (DASH) scores. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Academic medical center. PATIENTS/METHODS:Patients were screened and identified on presentation to the emergency department or in the clinical office for inclusion in an institutional review board-approved registry. One hundred eighty-five proximal humerus fractures of 247 met inclusion criteria. INTERVENTION/METHODS:Surgical repair of proximal humerus fractures. MAIN OUTCOME MEASURE/METHODS:All patients were prospectively followed up and assessed for clinical and functional outcomes at latest follow-up visit (mean = 24.8 months) using the DASH questionnaires along with ranges of motion and pain level. Psychosocial factors at 3 months were obtained from the DASH survey. RESULTS:Concomitant diagnosis of depressed mood (P = 0.001), anxiety (P < 0.0005), low energy level (P = 0.003), and fatigue (P = 0.001) correlated significantly with poorer outcome. All 6 psychosocial factors correlated directly and significantly with pain at latest follow-up (P < 0.0005). Multiple regression analysis revealed that the strongest predictor of the overall DASH score was the extent of interference with social life (P = 0.001). CONCLUSION/CONCLUSIONS:Analysis demonstrated that psychological and social factors at 3 months postoperatively have a strong correlation with negative long-term (>1 year) outcomes after proximal humerus fixation. Clinicians may offer psychological support and encourage social support to these patients postoperatively to improve pain and treatment outcomes. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:To propose a previous implant fractures (PIFs) classification system with good interobserver reliability. DESIGN/METHODS:Retrospective classification. SETTING/METHODS:Four academic medical centers. PATIENTS/PARTICIPANTS/METHODS:A retrospective review of PIFs treated at 4 academic medical centers over 10 years was performed. Data collected included initial implant and PIF radiographs. There were 103 PIFs in 96 patients during the study period. Seventy-three (70.9%) were about plate/screw (PS) constructs and 30 (29.1%) were about intramedullary (IM) devices. INTERVENTION/METHODS:Assignment of PIF classification. MAIN OUTCOME MEASUREMENTS/METHODS:PIFs were classified based on initial implant (PS or IM) and fracture location with respect to the initial implant (proximal or distal to the implant, at the tip of the construct, or within the construct). Reliability of this scheme was assessed among 5 observers using Fleiss' kappa tests. RESULTS:Of PIFs about plate/screw constructs, 26.0% were proximal/distal to the implant (classification: PS1), 57.5% involved bone between the most proximal/distal screw and the same end of the plate (classification: PS2), and 16.4% involved only bone between the most proximal and distal screws (classification: PS3). Of PIFs about IM, 43.3% were distal to the device (classification: IM1), 46.7% involved bone between the most proximal/distal locking bolt and the same end of the device (classification: IM2), and 10.0% involved only bone between locking bolts (classification: IM3). Interobserver reliability for the classification system was excellent between observers, κ = 0.839, P < 0.0005. CONCLUSIONS:The proposed system offers a simple method to classify and describe fractures that occur about a previously implanted fracture device. Development of a classification system will allow for comparison of treatment modalities between injury types.

INTRODUCTION/BACKGROUND:Periprosthetic fracture nonunions represent a rare problem in orthopaedic practice, although their incidence has increased with the increased frequency of joint replacement surgery. This video demonstrates the use of a linked nail-plate construct to repair a distal femoral periprosthetic fracture nonunion. METHODS:The patient is a 93-year-old woman who is 1-year status-post a left distal femoral periprosthetic fracture with known delayed healing. She presents with a low energy trauma and hardware failure. The patient was indicated for operative fixation using a linked nail-plate construct given the patient's previous hardware failure, advanced age, and poor bone quality. RESULTS:This video demonstrates the linked nail-plate technique for the repair of a distal femoral periprosthetic fracture nonunion. Anatomical reduction and stable fixation with bone graft was performed with excellent results. There were no intraoperative or postoperative complications and no issues related to metallurgy. CONCLUSIONS:In this video, we present the case of an atrophic distal femoral periprosthetic nonunion treated with a linked nail-plate construct with autologous bone graft. Although femoral periprosthetic fracture nonunions are a rare occurrence, they can be successfully treated with operative intervention aimed at compression plating with supplemental bone grafting.

INTRODUCTION/BACKGROUND:Approximately half of all hip fractures are intertrochanteric femur fractures. This video demonstrates the technique of repair of an unstable intertrochanteric hip fracture using a cephalomedullary device. METHODS:The patient is an 88-year-old woman presenting with an intertrochanteric hip fracture secondary to a low-energy injury. The patient was indicated for surgery due to the unstable nature of the fracture. RESULTS:This video demonstrates the cephalomedullary nailing technique for the repair of an unstable intertrochanteric hip fracture after a low-energy injury. Anatomical reduction and stable fixation were obtained with this technique. CONCLUSIONS:The case demonstrates a cephalomedullary technique of intertrochanteric fracture fixation using a cephalomedullary nail. The technique has significant advantages including minimal intraoperative blood loss, shorter operative times, potential for more biological healing with a load-sharing device, and low infection rate.

INTRODUCTION/BACKGROUND:Monteggia fractures are rare, although complex elbow injuries. Bado II Monteggia fractures are characterized by posterior dislocation of the radial head and concurrent fracture of the proximal or middle third of the ulna. This video demonstrates the open reduction and internal fixation of a complex Bado II Monteggia fracture dislocation. METHODS:The patient is a 65-year-old woman with a Bado II Monteggia fracture after a low-energy fall from standing height. Given the extent of comminution and the instability of the elbow, the patient was indicated for surgical fixation. RESULTS:This video demonstrates a locking plate technique for repair of a comminuted fracture of the proximal ulna. Anatomical reduction of ulnohumeral and radiocapitellar joints and stable fixation with bone grafting of the fracture are achieved with a medial 2.0/2.4-mm plate and a dorsal precontoured variable-angle locking plate. Demonstration of radial head arthroplasty is provided as an alternative for utilization in cases with a radial head fracture. CONCLUSIONS:Anatomical reduction and fixation of complex Monteggia fracture dislocations can be achieved with adherence to standard aspects of bony reconstruction. In this video we present the case of a Bado II Monteggia fracture surgically repaired with a locking plate construct.