Faculty Bibliography

OBJECTIVES/OBJECTIVE:To examine the efficacy of regional only anesthesia for arthroplasty surgery following displaced femoral neck fractures. METHODS:Design: Retrospective study. SETTING/METHODS:A single academic medical center and Level 1 Trauma Center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients with displaced femoral neck fracture (AO/OTA 31B1.3) treated with either hemi- or total hip arthroplasty were identified. Patients who had general (GA) and Spinal (SA) anesthesia were each matched 2:1 to those who underwent Lateral Femoral Cutaneous and Over the Hip (LOH),based on the Score for Trauma Triage in the Geriatric and Middle Aged (STTGMA) risk score and arthroplasty type. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Patient demographics, injury characteristics, and surgical history were compared. Outcomes included postoperative complications, 90-day readmission rates, 1-year mortality and discharge location. Significance was p>0.05. RESULTS:145 patients were analyzed: 58 GA, 58 SA, and 29 Regional. Cohorts were similar in demographics: mean age was 79.9 +9.9 for LOH, 79.8+11.00 for GA and 82.2+8.6 for SA (p=0.3), with 72% female patients in the LOH, 67% female in the GA and 76% female in SA (p=0.585). GA patients had the highest BMI (25.3±5.3 kg/m2, p=0.004). SA patients had the highest ASA score (2.9±0.7, p=0.036). GA patients had the longest anesthesia (2:55 hours, p=0.013) and operating room time (3:35, p=0.009). Regional anesthesia had the shortest anesthesia (2:26, p=0.013) and operating room time (2:54, p=0.009). GA had a higher complication rate (56.9%, p=0.039), including major complications (20.7%, p=0.025) and post-operative anemia (34.5%, p=0.049). GA had a longer length of stay (6.4±2.9 days, p=0.022). Patients operated on under regional only were discharged to home (62%, p=0.003) while more GA (79%) and SA (71%) patients were discharged to SNF (p<0.001). LOH patients ambulated sooner following surgery (1.03±0.2 days, p=0.001). No post-operative complications, blood transfusions (p=0.321), mortality (p=0.089), 30-day readmission (p=0.819), and post-operative delirium (p=0.514) were significantly different. CONCLUSION/CONCLUSIONS:Regional only anesthesia (LOH Block) was safe and effective for hemi and total hip arthroplasty for a displaced femoral neck fracture as compared to spinal and general anesthesia. This anesthetic approach allowed for successful procedures and yielded lower associated rates of post-operative complications and operative time in addition to improved quality measures. LEVEL OF EVIDENCE/METHODS:Prognostic Level III.

INTRODUCTION/BACKGROUND:The purpose of this study was to assess the demographic characteristics of hip fracture patients who followed up versus those who did not and secondarily to evaluate if follow-up duration correlated with long-term functional outcomes. METHODS:This was a retrospective review that queried a trauma database for all patients aged >55 years with hip fractures because of low-energy mechanisms between February 2019 and May 2020. Demographic characteristics, hospital quality measures, clinical outcomes, follow-up attendance, and 1-year functional outcomes were collected from the electronic medical record or through phone. Comparative analyses were conducted between patients who attended >50% of their follow-up appointments and those who attended <50% of their follow-up appointments. Patients were stratified based on the number of follow-up appointments attended and were compared. Multivariable regression analyses were conducted to identify factors influencing follow-up attendance and its association with functional outcomes. RESULTS:Four hundred fifty-two patients were included for analysis. Patients attending follow-up were younger, more likely to be community ambulators, White, and female. Multivariable regression revealed that younger age, White ethnicity, and female sex were independently associated with higher 1-year follow-up attendance. A positive linear relationship was observed between follow-up attendance and improved functional outcomes. Patients attending >50% of their appointments had better outcome scores. Overall, 218 patients were contacted through phone for 1-year follow-up and thus the 1-year follow-up rate increased to 69%. CONCLUSION/CONCLUSIONS:Consistent follow-up is associated with better 1-year outcomes in geriatric hip fracture patients. Recognizing the demographic factors associated with follow-up attendance can assist in patient education and engagement.

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.

PURPOSE/OBJECTIVE:The purpose of this study is to compare the quality and clinical outcomes of patients who underwent open reduction internal fixation for a proximal humerus fracture in a "timely manner" which was defined to be within 5 days of injury compared to those with "delayed intervention" (>5 Days) to determine the effect this had. METHODS:This IRB-approved study evaluated patients who sustained a proximal humerus fracture treated with plate and screw fixation (ORIF) between January 2004 and October 2022 and had time from injury to surgery documented. Patients were grouped based on the time to surgery (TTS) - Less than 5 Days (L5) vs. More than 5 Days (M5). TTS was also evaluated as a continuous variable. Univariable and multivariable analysis compared patient demographics, injury/surgical characteristics, postoperative complications, and clinical outcomes to determine effect of TTS. Clinical outcomes included shoulder range of motion (ROM) and Disabilities of the Arm, Shoulder, and Hand (DASH) score at least 1 year following the date of injury. Standard statistical tests were used (p<0.05 considered significant). RESULTS:, p=0.03, β= -0.27, 95% CI = -41.71- -2.89) surgery was associated with less passive forward elevation. CONCLUSION/CONCLUSIONS:Timing of surgery did not impact outcomes of patients who underwent open reduction internal fixation for proximal humerus fractures. Surgical intervention after 14 days was associated with diminished passive forward elevation only.

OBJECTIVES/OBJECTIVE:To determine if there is a correlation between time to surgery (TTS) and outcomes following repair of elbow fractures. METHODS:Design: Retrospective comparative study. SETTING/METHODS:A single, urban hospital system. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients from March 2011 to September 2022 who sustained an isolated fracture about the elbow joint (AO/OTA 13-A, B, and C and 21-A, B, and C), underwent surgical repair, and had at least 6 months of post-operative follow up identified from an Institutional Review Board-approved database. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Time to surgery, in days, was recorded. Radiographic and clinical follow up was obtained at all visits and a Mayo Elbow Performance Index (MEPI) was calculated based on the latest follow up. Complications recorded: elbow contracture, infection, early hardware failure, reoperation, and fracture nonunion. Multivariable regression and Spearman correlation analysis were used to determine any significant outcome differences based on time to surgery. RESULTS:351 patients included with a mean age of 54.8 (range: 18 - 86) years with 217 females (61.8%) and 134 males (38.2%). Eighty-two patients (23.4%) developed at least one complication while 269 patients (76.6%) did not. As a continuous variable, TTS was not correlated with arc of motion at any follow up visit nor with the latest recorded MEPI score (p > 0.05). Mean TTS for patients who did and did not experience a complication was 6 (range: 0-24) and 10 (range: 0-38) days, respectively, and this was not significantly different (p = 0.217). Complication rate and any of the individual complications were not associated with TTS following a multivariable analysis controlling for age, sex, injury mechanism, open fracture, Charlson Comorbidity Index, and AO/OTA classification (p > 0.05 for all). CONCLUSIONS:Timing of surgery following OTA 13 A-C and 21 A-C elbow fractures was not associated with differences in post-operative complications or range of elbow motion. LEVEL OF EVIDENCE/METHODS:Level III.

OBJECTIVES/OBJECTIVE:To identify which hip fracture patients benefit the most from operative repair within 24 hours of Emergency Department presentation based on patient risk stratification. DESIGN/METHODS:Retrospective Cohort. SETTING/METHODS:Academic Medical Center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients operatively treated for an AO/OTA 31 A, 31 B, or 32 A hip fracture. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Each patient was placed into an "individualized risk quartile" (Individual Risk Quartile) using a validated risk stratification tool (The Score for Trauma Triage in the Geriatric and Middle-Aged [Score for Trauma Triage and Geriatric Middle Aged], a tool proven to predict inpatient mortality in trauma patients). Patients were risk stratified into minimal-, low-, moderate-, and high-risk IRQs. In each cohort, patients were separated into 3 groups based on their time from Emergency Department arrival to surgery (<24 hours, >24 hours and <48 hours, and >48 hours). Each of these 12 groups was analyzed for complications (minor inpatient complications included acute kidney injury, urinary tract infection, decubitus ulcer, and acute blood loss anemia, while major inpatient complications included sepsis or septic shock, pneumonia, acute respiratory failure, stroke, myocardial infarction, cardiac arrest, and deep vein thrombosis or pulmonary embolism), mortality rates, and hospital quality measures (length of stay and readmission rates). The results were compared across cohorts. RESULTS:A total of 2472 patients were identified: the mean age of the cohort was 80.6 ± 10.3 and was predominantly female (69%) and white (71%). The data demonstrated improved outcomes (complications, mortality rates, hospital quality measures) across all patients (nonrisk stratified) for surgery within 24 hours compared with surgery between 24 hours and 48 hours and surgery greater than 48 hours (all outcomes P < 0.050). However, these effects were not evenly distributed among the IRQs. In the IRQ4 cohort, major complication rates progressed from 20% to 25% to 34% as a function of time to surgery ( P = 0.007). IRQ1 did not demonstrate similar results ( P = 0.756), with the rates essentially static across surgery time points (3%-2% to 4%). A similar trend was seen when analyzing mortality at 1 year for highest risk patients, with similar 1-year mortality rates across operating room windows of IRQs 1-3 (IRQ1: P = 0.061, IRQ2: P = 0.259, IRQ3: P = 0.524) but increased in IRQ4 with increasing time to surgery (21% vs. 33% vs. 33%, P = 0.006). CONCLUSIONS:This study demonstrates a differential impact of expedited time to surgery on patients when stratified by the risk profile. The lowest risk hip fracture patients do not fare worse if operated on within 48 hours as compared to 24 hours. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:To determine which in-hospital complications following the operative treatment of hip fractures are associated with increased inpatient, 30-day and 1 year mortality. METHODS:Design: Retrospective study. SETTING/METHODS:A single academic medical center and a Level 1 Trauma Center. PATIENT SELECTION CRITERIA/UNASSIGNED:All patients who were operatively treated for hip fractures (OTA/AO 31A, 31B and Vancouver A,B, and C periprosthetic fractures) at a single center between October, 2014 and June, 2023. OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:Occurrence of an in-hospital complication was recorded. Cohorts were based upon mortality time points (during admission, 30-days and 1-year) and compared to patients who were alive at those time points to determine which in- hospital complications were most associated with mortality. Correlation analysis was performed between patients who died and those who were alive at each time point. RESULTS:A total of 3,134 patients (average age of 79.6 years, range 18-104 years and 66.6% female) met inclusion for this study. The overall mortality rate during admission, 30 days and 1 year were found to be 1.6%, 3.9% and 11.1%, respectively. Sepsis was the complication most associated with increased in-hospital mortality (OR: 7.79, 95% CI 3.22 - 18.82, p<0.001) compared to other in-hospital complications. Compared to other in-hospital complications, stroke was the complication most associated with 30-day mortality (OR: 7.95, 95% CI 1.82 - 34.68, p<0.001). Myocardial infarction was the complication most associated with 1-year mortality (OR: 2.86, 95% CI 1.21 - 6.77, p=0.017) compared to other in-hospital complications. CONCLUSIONS:Post-operative sepsis, stroke and myocardial infraction were the three complications most associated with mortality during admission, 30-day mortality and 1-year mortality, respectively, during the operative treatment of hip fractures. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

INTRODUCTION/UNASSIGNED:This report describes the use of a combination of a retrograde femoral nail and distal femur locking plate for the treatment of an open intra-articular distal femur fracture in a 99-year-old female. The purpose of this report is to highlight that nail-plate fixation constructs can be performed percutaneously and expeditiously even in extremely old patients; therefore, patient age should not be a limiting factor in choosing this construct to allow for immediate weight-bearing. CASE REPORT/UNASSIGNED:The patient was a 99-year-old female who presented to the emergency room after a fall. Plain radiographs demonstrated a comminuted supracondylar distal femur fracture with a sagittal intercondylar split (OTA classification 33A3.3). She was indicated for operative repair and was fixed with a combination of a retrograde Stryker T2 alpha nail and Stryker distal femur locking plate. This method was chosen to allow the patient to be weight-bearing as tolerated after surgery so she could immediately start work with physical therapy to work towards getting back to her pre-injury ambulatory status. At 3 months post-operatively, she had minimal pain, no difficulties with activities of daily living, and was ambulating with the assistance of a cane. At 9 months post-operatively, she was ambulating with a cane (pre-injury status). She did not report any pain, and her radiographs illustrated fracture site consolidation. Furthermore, her short musculoskeletal functional assessment score was the same as it was pre-injury (81). CONCLUSION/UNASSIGNED:This case supports the idea of using a nail-plate combination for repair of intra-articular distal femur fractures, even in the very elderly as the patient's functional outcome data reached pre-injury levels. In addition, it allows even elderly patients to begin early weight-bearing and decreases complications related to lack of extremity use.

BACKGROUND:The purpose of this study is to stratify the age at which older adults are most likely to sustain injuries and major complications resulting from low-energy falls so that fall prevention strategies may be targeted to more susceptible age groups. METHODS:A consecutive series of 12 709 patients older than 55 years enrolled in an orthopedic trauma registry from October 2014 to April 2021 were reviewed for demographic factors, hospital quality measures, and outcomes. Patients were grouped by age brackets in 5-year intervals. Comparative analyses were conducted across age groups with an additional post hoc analysis comparing the 75- to 79-year-old cohort with others. All statistical analyses were conducted utilizing a Bonferroni-adjusted alpha. RESULTS:Of the 12 709 patients, 9924 patients (78%) sustained a low-energy fall. The mean age of the cohort was 75.3 (range: 55-106) years and the median number of complications per person was 1.0 (range: 0-7). The proportion of females increased across each age group. The mean Charlson Comorbidity Index increased across each age group, except in the cohort of 90+ years of age. There was a varied distribution of fractures among age groups with the incidence of hip fractures most prominently increasing with age. Complication rates varied significantly between all age groups. Between the ages of 70 to 74 years and 80 to 84 years, there was a 2-fold increase in complication rate, and between the ages of 70 to 74 years and 75 to 79 years, there was a near 2×/1.5×/1.4× increase in inpatient, 30-day, and 1-year mortality rate, respectively. When controlling for confounding demographic variables between age groups, the rates of complications and mortality still differed. CONCLUSIONS:Fall prevention interventions, while applicable to all older adult patients, could improve outcomes by offering additional resources particularly for individuals between 70 and 80 years of age. These additional resources can help minimize excessive hospitalizations, prolonged lengths of stay, and the detrimental complications that frequently coincide with falls. Although hip fractures are the most common fracture as patients get older, other fractures still occur with frequency, and fall prevention strategies should account for prevention of these injuries as well.