Faculty Bibliography

This study aims to identify if there are significant differences in hospital quality measures between hip fracture patients who were treated under the management of a dedicated Hip Fracture Care Coordinator (HFCC) and those who were not. An institutional review board-approved hip fracture registry was queried for patients who were admitted at an orthopedic hospital under the care of HFCC from October 2021 to April 2023 (2.5 years). A comparison cohort of patients was obtained from reviewing patients in the 2.5 years (April 2019-October 2021) before the hiring of the HFCC. Univariable comparisons and multivariable regression analyses were conducted to assess the impact of the HFCC on outcomes such as hospital quality measures, inpatient complications, discharge location, and readmission and mortality rates. One thousand fifty-six hip fracture patients were identified: 532 (50.4%) without-HFCC and 524 (49.6%) HFCC. When controlling for covariates using binary logistic regression, the presence of an HFCC was associated with a higher likelihood of home discharge (odds ratio = 2.481, p < .001). Regression analyses demonstrated similar benefits of the HFCC with outcome variables such as intensive care unit stay (p < .001) and time to surgery (p < .001). This study demonstrates an association between the HFCC and improved outcomes for both patients and the hospital system.

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.

INTRODUCTION/BACKGROUND:Patient-reported outcome measures (PROMs) are an important component of evaluating patient health and are increasingly utilized in orthopedics. However, their use remains inconsistent among orthopedic subspecialties, with only 21% of orthopedic trauma surgeons reporting regular use of PROMs in their practice. While tools for quantifying patient distress in response to pain have been developed, they are often difficult to apply due to extensive questioning and the need for prospective implementation. The purpose of this study was to propose a novel retrospective technique to measure the Pain Distress Index (PDI) using two common PROMs: the visual analog scale (VAS) and the short musculoskeletal functional assessment (SMFA). METHODS:A total of 797 patients who underwent operative repair of a tibial plateau fracture or revision of long bone nonunion were included. To quantify PDI, a linear trend line was calculated from a scatter plot of SMFA Bothersome Index (BI) vs. VAS pain scores at three months postoperatively. Reported SMFA BI was compared to predicted SMFA BI, and patients were stratified into three cohorts: "limited," "adequate," and "excellent" PDI. RESULTS:In both cohorts, SMFA Function Index scores at 6 and 12 months postoperatively differed significantly among the limited, adequate, and excellent PDI levels (p < 0.0005, p < 0.0005). Worse PDI (indicating greater distress from pain) was associated with poorer SMFA Function Index scores. CONCLUSIONS:The combination of SMFA BI and VAS scores may serve as a useful tool to quantify PDI without requiring an additional questionnaire. "Limited" PDI was associated with poorer functional outcomes at 6 and 12 months postoperatively. This method may help predict which patients are at risk for worse functional outcomes and could serve as a retrospective proxy for resilience in future research.

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.

INTRODUCTION/BACKGROUND:The purpose was to determine whether computed tomography (CT) Hounsfield units (HU) as a proxy for bone quality can predict postoperative complications following surgical treatment of proximal humerus fractures. METHODS:Sixty-six patients with 2-, 3-, or 4-part proximal humerus fractures who underwent surgical fixation at single institution and had complete radiographic data available were included. Radiographic measurements included the deltoid tuberosity index (DTI) on preoperative anterior-posterior shoulder radiographs, and the HU value from the surgical proximal humerus was determined by measuring the humeral head at the midaxial/coronal/sagittal CT image using a circle-type region of interest (≥35 mm2). Postoperative complications recorded were implant failure, development of osteonecrosis, nonunion, and acute periprosthetic fracture. Patients with and without complications were statistically compared, and binary logistic regression was performed to determine whether preoperative proximal humerus CT HU were predictive of complications. RESULTS:Eight patients (12.1%) developed 11 overall complications, with three patients experiencing multiple complications each. Complications included osteonecrosis (4), implant failure (5), nonunion (1), and acute periprosthetic fracture (1). No difference was observed in demographics or Neer or AO/OTA classification between those with and without complications. Patients with complications had markedly lower DTI and overall HU as well as HU in the coronal and sagittal planes. Regression analysis for average DTI demonstrated a higher DTI and had a 10 times decreased risk of complication (P = 0.040, odds ratio = -10.5, 95% confidence interval, 0.000 to 0.616). Regression analysis for average total HU also found a higher HU associated with a decreased risk of complications (P = 0.034, odds ratio = -0.020, 95% confidence interval, 0.980 to 0.962). Logistic regression analysis, including age, age-adjusted Charlson Comorbidity Index, mean DTI, and mean total HU, only found mean total HU to be notable within the model. DISCUSSION/CONCLUSIONS:CT HU may identify patients with poorer bone quality and thus help predict postoperative complications. LEVEL OF EVIDENCE/METHODS:Diagnostic Level III.

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.

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.

INTRODUCTION/UNASSIGNED:There is scarce data in literature on the demographics, treatment, and outcomes of subtrochanteric femur fracture patients. This study evaluated the effect of age on injury details, perioperative and hospital parameters, and outcomes following subtrochanteric fracture fixation. METHODS/UNASSIGNED:An IRB-approved review of a consecutive series of subtrochanteric femoral fractures was performed. Patient charts and radiographs were examined to confirm patients were operatively treated for an AO/OTA Type 32A, B or C subtrochanteric femur fracture, as well as for demographics, injury information, perioperative details, radiographic parameters, hospital quality measures, and outcomes. Patients were divided into younger (Y) (< 65 years old) and older (O) (≥ 65 years old) cohorts. Comparative analyses were conducted between cohorts. RESULTS/UNASSIGNED: < 0.001). There were no differences in post-op complications, readmission or mortality rates, nonunion, fixation failure, or radiographic time to healing between cohorts. CONCLUSION/UNASSIGNED:Younger patients present with different subtrochanteric fracture patterns and discharge profiles than older patients and are treated with different implants. However, despite these differences, younger and older patients have similar radiographic and clinical outcomes. LEVEL OF EVIDENCE/UNASSIGNED:III.

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.