Faculty Bibliography

PURPOSE/OBJECTIVE:To determine if the type of approach used for treatment of lateral split-depression tibial plateau fractures affects clinical outcome and complications rate. METHODS:This is a retrospective review of 169 patients who presented between 01/2005 and 12/2020 to a Level-I trauma center for operative management of an isolated lateral Schatzker II tibial plateau fractures (AO/OTA Type 41B3.1) treated through a single anterolateral approach: a 90-degree "L" (L), longitudinal vertical (V), or "lazy S" (S). Postoperative radiographic, clinical, and functional outcomes were assessed at 3, 6, 12 months, and beyond. RESULTS:Average time to radiographic healing was longer in the S incision cohort (p < 0.05). Furthermore, patients within the S incision cohort developed more postoperative wound complications at follow-up when compared to those within the L and V incision cohorts (p < 0.05). Additionally, reoperation rates were greater in the S incision cohort (p < 0.05). Lastly, on physical examination of the knee, patients within the S incision cohort had significantly poorer knee range of motion (p < 0.05). CONCLUSIONS:Our study demonstrates that skin incision type in the anterolateral approach to the proximal tibia has an association with outcomes following operative repair of tibial plateau fractures. The information from this study can be used to inform surgeons about the potential complications and long-term outcomes that patients may experience when undergoing operative repair of a tibial plateau fracture through a specific incision type. LEVEL OF EVIDENCE/METHODS:III.

PURPOSE/OBJECTIVE:To analyze clinical, radiographic and patient-reported outcomes of distal metaphyseal femoral nonunions treated with fixed-angle plates and screws. METHODS:All patients presenting with a distal metaphyseal femoral fracture nonunion repaired with fixed-angle plating from one urban level 1 trauma center and an orthopedic specialty hospital were identified. Baseline demographic, injury information, and outcomes (healing rates, Short Musculoskeletal Function Assessment, range of motion, and post-operative pain levels) at 12 months following nonunion repair were collected. Outcomes were evaluated between patients fixed with a blade plate and with a locking plate. RESULTS:Of these 31 patients, 27 (87.1%) healed after their index nonunion surgery, 2 (6.5%) healed after one reoperation, 1 (3.2%) healed after 2 reoperations, and 1 (3.2%) had a persistent nonunion but did not want further treatment. At one-year follow-up, the group demonstrated a significant improvement in functional recovery with a mean difference of 14.5 points (p = 0.007) when compared to status before fixed-angle fixation of the nonunion. There was also a significant change in patient-reported pain levels using the VAS scale with a mean difference of 2.0 points (p = 0.009). At one-year follow-up, 11 (39.3%) had full knee range of motion (0-130), 11 (39.3%) had flexion greater than 90 and less than 120°, and 6 (21.4%) had range of motion less than 90°. CONCLUSION/CONCLUSIONS:Patients who undergo fixed angle plating and autogenous bone grafting for distal femoral metapyseal nonunions demonstrate improved functional outcomes and VAS pain score at one year follow up.

BACKGROUND:The purpose of this study was to identify specific radiographic parameters that are predictive of associated PM fractures in TSFs. METHODS:All TSFs presenting over a 6-year period were identified. A review of plain radiographs and CT scans included: identification of an isolated PM fracture, AO/OTA classification, measurements of the fracture obliquity angle (FOA), absolute and relative distance from distal extent of fracture to plafond (DFP and DFP%), and presence and level of associated fibular fractures. Patients with and without PM fractures were compared. Multivariate logistic regression determined independent correlates of PM fractures and cutoff values for FOA and DFP%. RESULTS:A total of 405 TSFs in 397 patients were identified, and 94 TSFs (23.2%) had an associated PM fracture. The majority (85.1%) of TSFs with PM fractures were AO/OTA type 42-A1, 42-B1 or 42-C1 (p < 0.001). The mean FOA was 60.9 ± 12.1° in the PM group versus 40.8 ± 18.9° in the non-PM group (p < 0.001). The mean DFP was 5.9 ± 2.7 cm in the PM group versus 11.9 ± 7.9 cm in the non-PM group (p < 0.001). Multivariate regression demonstrated that AO/OTA classification type 42-A1, 42-B1 or 42-C1 (OR 4.7 [95% CI 2.4-9.8]; p < 0.001), FOA greater than 45° (OR 4.4 [95% CI 1.9-10.9]; p = 0.001) and fracture extension to the distal third of the tibia (DFP% < 33%; OR 18.3 [95% CI 3.8-330.4]; p = 0.005) were independent correlates of PMs fractures regardless of mechanism of injury or fibula fracture presence or location (AUROC 0.83 [95% CI 0.80-0.87]). Separate multivariate regression showed for every 1° increase in FOA, PM fracture odds increase 6% per degree and for every 1 cm increase in DFP odds of PM fracture decreased by 15%. CONCLUSIONS:Spiral fractures (simple, wedge or complex), fracture angles greater than 45° and extension into the distal 1/3 of the tibial shaft are independent predictors of PM fractures in TSFs regardless of mechanism of injury.

BACKGROUND:The purpose of this study is to determine the effects of energy mechanism on outcomes following repair of proximal humerus fractures (PHF) in the middle aged and geriatric population. METHODS:Two hundred sixty-nine patients who presented to our academic medical center between 2006 and 2020, and underwent operative treatment of a proximal humerus fracture were prospectively enrolled in an IRB-approved database. Patients above 55 were divided into high energy (motor vehicle accident, pedestrian struck, or fall > 2 stairs) or low energy mechanisms (fall from standing or < 2 stairs). Of 97 patients with complete documentation and follow-up, 72 were included in the low velocity (LV) group and 25 were included in the high velocity (HV) group. Demographic information, primary injury details, healing and time to union, range of motion (ROM), complications, and need for reoperation were assessed at initial presentation and subsequent follow-up appointments. RESULTS:Mean age, BMI, and gender were significantly different between the LV and HV cohorts (p = 0.01, 0.04, 0.01). OTA/AO fracture patterns were similar between the groups. (p = 0.14). Bony healing and complications occurred with similar frequency between groups (p = 1.00, 0.062). The most common complications in the LV and HV groups included avascular necrosis (9.7%, 16.0%), and screw penetration (4.2%, 12.0%), while the HV group also had rotator cuff issues including weakness and tendonitis (12.0%). There was no significant difference in need for reoperation between cohorts (p = 0.45). Time to healing, shoulder ROM, and DASH scores did not differ between each group. CONCLUSIONS:Energy and mechanism demonstrates similar outcomes in operatively treated proximal humerus fractures. These factors should not play a role in decisions for surgery in these patients and can help guide patient expectations.

BACKGROUND:The purpose of this study was to compare outcomes following surgical treatment of tibial plateau fractures in an elderly (≥ 65y) and non-elderly (< 65) population. METHODS:Patients with tibial plateau fractures were prospectively followed. Patients were included if they were operatively treated, had an Injury Severity Score of < 16, and had follow-up through 12 months. Clinical, radiographic, and functional outcomes were evaluated at the 3, 6, and 12-month follow-up points. RESULTS:Mean time to radiographic fracture union was by 4.68 and 5.26 months in young and elderly patients, respectively (p = 0.25). There was no difference in self-reported baseline SMFA (p = 0.617). SMFA scores were better in younger patients at 3 months (p = 0.031), however this did not hold when multivariate modeling controlled for other factors. There was no difference at 6 and 12 months (p = 0.475, 0.392). There was no difference in range of knee motion at 3 months. At 6 and 12 months, young patients had statistically but not clinically better range of knee motion (p = 0.045, 0.007). There were no differences in overall reoperation rates, conversion arthroplasty, post-traumatic osteoarthritis or wound complications. CONCLUSIONS:Age greater than 65 does not appear to portend poorer outcomes after surgical repair of a tibial plateau fracture. The complication profiles are similar. Elderly and younger patients had similar function at 12 months compared to their baseline. These data suggest that age should not be a disqualifying factor when considering whether a patient with a tibial plateau fracture should be treated operatively.

PURPOSE/OBJECTIVE:The purpose of this study is to compare medium to long term patient reported outcomes to one-year data for patients treated surgically for an aseptic fracture nonunion. METHODS:305 patients surgically treated for a fracture-nonunion were prospectively followed. Data collected included pain scores measured by the Visual Analog Scale (VAS), clinical outcomes assessed by the Short Musculoskeletal Functional Assessment (SMFA), and range of motion. 75% of patients in this study had lower extremity fracture nonunions and 25% had upper extremity fracture nonunions. Femur fracture nonunions were the most common. Data at latest follow-up was compared to one-year follow-up using the independent t-test. RESULTS:Sixty-two patients were available for follow-up data at an average of eight years. There were no differences in patient reported outcomes between one and eight years according to the standardized total SMFA (p = 0.982), functional index SMFA (p = 0.186), bothersome index SMFA (p = 0.396), activity index SMFA (p = 0.788), emotional index SMFA (p = 0.923), or mobility index SMFA (p = 0.649). There was also no difference in reported pain (p = 0.534). Range of motion data was collected for patients who followed up in clinic for an average of eight years after their surgical treatment. 58% of these patients reported a slight increase in range of motion at an average of eight years. CONCLUSION/CONCLUSIONS:Patient functional outcomes, range of motion, and reported pain all normalize after one year following surgical treatment for fracture nonunion and do not change significantly at an average of eight years. Surgeons can feel confident in counseling patients that their results will last and they do not need to follow up beyond one year, barring pain or other complications. LEVEL OF EVIDENCE/METHODS:Level IV.

INTRODUCTION/BACKGROUND:The purpose of this epidemiologic study was to analyze the care provided by our institution to middle-aged and geriatric hip fracture patients throughout the pandemic to examine for any differences compared to pre-pandemic care and across the pandemic stages. METHODS:Consecutive patients >55 years old treated for hip fractures at our institution between October 2014 and January 2022 were analyzed for demographics, coronavirus disease 2019 (COVID-19) and vaccination status at admission, injury characteristics, hospital quality measures, and outcomes. Patients were divided into three separate cohorts: Pre-COVID-19 (PRECOV), COVID-19 Pre-Vaccine (PREVAX), and COVID-19 Post-Vaccine (POSTVAX). A sub-analysis removed COVID-19-positive patients across the study period. Comparative analyses were conducted. RESULTS:A total of 2,633 hip fracture patients were included. For the overall cohort, there was no difference in the rate of inpatient deaths between the PRECOV, PREVAX, and POSTVAX cohorts (p=0.278). PRECOV had a significantly lower 30-day mortality rate compared to PREVAX or POSTVAX (p=0.012). Differences in complication rates for surgical site infection, urinary tract infection, and anemia (p<0.01 for all) were seen between cohorts. PRECOV had the longest length of hospital stay (p<0.01). PREVAX patients required more ICU level of care (p<0.01). When removing COVID-19-positive patients, all three cohorts had similar inpatient (p=0.872) and 30-day mortality rates (p=0.130). CONCLUSION/CONCLUSIONS:The care of patients treated for hip fractures did not change throughout the pandemic at our institution. The elevated mortality rate due to the effects of COVID-19 seen in the pre-vaccine cohort decreased over time as the understanding of COVID-19 improved and the vaccine was introduced. We recommend continuation of the same hip fracture care protocols as used pre-pandemic.

Objectives:To document discharge locations for geriatric patients treated for a hip fracture before and during the COVID pandemic and subsequent changes in outcomes seen between each cohort.
Design(s):Retrospective cohort study.
Setting(s):Academic medical center.Patients/Participants:Two matched cohorts of 100 patients with hip fracture treated pre-COVID (February-May 2019) and during COVID (February-May 2020).
Intervention(s):Discharge location and COVID status on admission. Discharge locations were home (home independently or home with health services) versus facility [subacute nursing facility (SNF) or acute rehabilitation facility].Main Outcome Measurements:Readmissions, inpatient and 1-year mortality, and 1-year functional outcomes (EQ5D-3L).
Result(s):In COVID+ patients, 93% (13/14) were discharged to a facility, 62% (8/13) of whom passed away within 1 year of discharge. Of COVID+ patients discharged to an SNF, 80% (8/10) died within 1 year. Patients discharged to an SNF in 2020 were 1.8x more likely to die within 1 year compared with 2019 (P = 0.029). COVID- patients discharged to an SNF in 2020 had a 3x increased 30-day mortality rate and 1.5x increased 1-year mortality rate compared with 2019. Patients discharged to an acute rehabilitation facility in 2020 had higher rates of 90-day readmission. There was no difference in functional outcomes.
Conclusion(s):All patients, including COVID- patients, discharged to all discharge locations during the onset of the pandemic experienced a higher mortality rate as compared with prepandemic. This was most pronounced in patients discharged to a skilled nursing facility in 2020 during the early stages of the pandemic. If this trend continues, it suggests that during COVID waves, discharge planning should be conducted with the understanding that no options eliminate the increased risks associated with the pandemic.
Level of Evidence:III.
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The aim of this study was to compare outcomes of tibial plateau fracture dislocations (FD) with tibial plateau fractures alone. This study was an analysis of a series of tibial plateau fractures, in which FD was defined as a fracture of the tibial plateau with an associated loss of congruent joint reduction and stability of the knee, and classified by the Moore system. Patient data collected included demographics, injury information, and functional outcomes (short musculoskeletal function assessment [SMFA] score and Pain by the visual analog scale). Clinical outcomes at follow-up were recorded including knee range of motion, knee stability and development of complications. There were a total of 325 tibial plateau fracture patients treated operatively, of which 22.2% were identified as FD (n = 72). At injury presentation there was no difference with regard to nerve injury or compartment syndrome (both p > 0.05). FD patients had a higher incidence of arterial injury and acute ligament repair (both p < 0.005). At a mean follow-up of 17.5 months, FD patients were similar with regard to pain, total SMFA scores, and return to sports than their non-FD counterparts (p = 0.884, p = 0.531, p = 0.802). FD patients were found to have decreased knee flexion compared with non-FD patients by 5 degrees (mean: 120 and 125 degrees) (p < 0.05). FD patients also had a higher incidence of late knee instability and subsequent surgery for ligament reconstruction (p < 0.005 & p < 0.05). However, there was no difference in neurological function between groups at follow-up (p = 0.102). Despite the higher incidence of ligamentous instability and decreased range of motion, FD patients appear to have similar long-term functional outcomes compared with non-FD of the tibial plateau. While FD patients initially presented with a higher incidence of arterial injury, neurovascular outcomes at final follow-up were similar to those without a dislocation.

OBJECTIVES/UNASSIGNED:To document discharge locations for geriatric patients treated for a hip fracture before and during the COVID pandemic and subsequent changes in outcomes seen between each cohort. DESIGN/UNASSIGNED:Retrospective cohort study. SETTING/UNASSIGNED:Academic medical center. PATIENTS/PARTICIPANTS/UNASSIGNED:Two matched cohorts of 100 patients with hip fracture treated pre-COVID (February-May 2019) and during COVID (February-May 2020). INTERVENTION/UNASSIGNED:Discharge location and COVID status on admission. Discharge locations were home (home independently or home with health services) versus facility [subacute nursing facility (SNF) or acute rehabilitation facility]. MAIN OUTCOME MEASUREMENTS/UNASSIGNED:Readmissions, inpatient and 1-year mortality, and 1-year functional outcomes (EQ5D-3L). RESULTS/UNASSIGNED:= 0.029). COVID- patients discharged to an SNF in 2020 had a 3x increased 30-day mortality rate and 1.5x increased 1-year mortality rate compared with 2019. Patients discharged to an acute rehabilitation facility in 2020 had higher rates of 90-day readmission. There was no difference in functional outcomes. CONCLUSIONS/UNASSIGNED:All patients, including COVID- patients, discharged to all discharge locations during the onset of the pandemic experienced a higher mortality rate as compared with prepandemic. This was most pronounced in patients discharged to a skilled nursing facility in 2020 during the early stages of the pandemic. If this trend continues, it suggests that during COVID waves, discharge planning should be conducted with the understanding that no options eliminate the increased risks associated with the pandemic. LEVEL OF EVIDENCE/UNASSIGNED:III.