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Evaluating the Severity Spectrum: A Hierarchical Analysis of Complications during Hip Fracture Admission Associated with Mortality

Pettit, Christopher J; Herbosa, Carolyn F; Ganta, Abhishek; Rivero, Steven; Tejwani, Nirmal; Leucht, Philipp; Konda, Sanjit R; Egol, Kenneth A
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.
PMID: 39207724
ISSN: 1531-2291
CID: 5729922

Hoffa fractures are slower to heal than entire condyle fractures of the distal femur: an analysis of type 33B fractures

Pettit, Christopher J; Konda, Sanjit R; Ganta, Abhishek; Tejwani, Nirmal C; Egol, Kenneth A
PURPOSE/OBJECTIVE:To examine patient demographic and clinical outcomes associated with partial articular distal femoral fractures. METHODS:An IRB-approved study was conducted on a consecutive series of patients being treated for isolated partial articular distal femoral fractures at a single academic medical center between August, 2011 and July, 2023. Patient demographics, hospital quality measures and outcomes for each patient were reviewed. All fractures were fixed using screws alone or plate and screw constructs. Fractures were grouped into isolated entire medial or lateral condyle (OTA/AO 33B1 or B2) and posterior unicondylar (Hoffa) fractures (OTA/AO 33B3.2). Cohorts were compared for clinical, radiographic and complication outcomes using Chi-Square Tests and ANOVA tests. RESULTS:A total of 30 patients were identified with a mean of 55.2 years. There were 16 (53.3%) isolated medial/lateral condylar fractures and 14 (46.7%) Hoffa fractures. There were no differences between the two fracture types in terms of baseline demographics. There was no difference in terms of length of stay or in-hospital complications between the fracture types. All fractures united. There was also no difference in range of knee motion at latest follow-up visit. Hoffa fractures required a longer time for radiographic healing (4.5 months vs. 3.05 months, p = 0.012). CONCLUSION/CONCLUSIONS:Hoffa fractures require longer time to radiographic healing compared to other partial articular distal femoral fractures; however no other differences were seen based on fracture patterns. LEVEL OF EVIDENCE/METHODS:III.
PMID: 39666105
ISSN: 1432-1068
CID: 5762922

Can We Predict 30-day Readmission Following Hip Fracture?

Pettit, Christopher J; Herbosa, Carolyn F; Ganta, Abhishek; Rivero, Steven; Tejwani, Nirmal; Leucht, Philipp; Konda, Sanjit R; Egol, Kenneth A
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.
PMID: 39655937
ISSN: 1531-2291
CID: 5762532

Open tibial shaft fracture fixation strategies: intramedullary nailing, external fixation, and plating

Shen, Michelle; Tejwani, Nirmal
Tibial shaft fractures are one of the most common orthopaedic injuries. Open tibial shaft fractures are relatively common because of the paucity of soft tissue surrounding the bone. Despite the prevalence of these injuries, the optimal fixation strategy is still a topic of debate. The purpose of this article was to review the current literature on open tibial shaft fracture fixation strategies including intramedullary nailing, external fixation, and plating.
PMCID:11149753
PMID: 38840705
ISSN: 2574-2167
CID: 5665462

Damage-control orthopedics or early total care: What you need to know

Stevens, Nicole M; Tejwani, Nirmal C
Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.
PMID: 38227676
ISSN: 2163-0763
CID: 5657042

The Effect of Underrepresented Minority Mentorship on Orthopaedic Spine Surgery Recruitment and Diversity: A 20-Year Analysis at a Single Institution

Owusu-Sarpong, Stephane; Williamson, Tyler K; Jegede, Kola; Tejwani, Nirmal C
INTRODUCTION/BACKGROUND:Despite national efforts to increase diversity and inclusion, underrepresented minority (URM) representation among orthopaedic spine surgery faculty remains low. Research has shown that URM trainees are more likely to pursue surgical careers when they have access to URM mentors. The purpose of this study was to explore the influence of URM representation among spine faculty on the rate of URM orthopaedic residents pursuing spine surgery fellowships. METHODS:From 2004 to 2023, data were collected from each residency class at our academic institution: residency year, number of residents per class (total and URM), and number of residents applying to spine surgery fellowships. These ethnicities were considered URM: Black or African American, Hispanic or Latino, and Native American. In 2018, two African American spine faculty were hired. Data were compared between Before and After their arrival. A subanalysis was done to include a period of increasing URM recruitment (2012 to 2018). Binary logistic regression analysis evaluated associations between appointment of URM faculty and fellowship choice of URM residents. RESULTS:Two hundred fifty-six residents were included. Thirty-one total URM residents were in the program during the study period (12.1%). Overall, URM representation in the program increased over time [OR: 1.1, 95% CI: 1.1 to 1.2], whereas residents applying to spine surgery fellowships did not change [OR: 1.0, 95% CI: 1.0 to 1.1]. Comparing Before-2012 and 2012 to 2018 groups with the After-2018 group demonstrated a significant difference in the proportion of URM residents applying to spine surgery fellowships after the hiring of URM spine faculty (0.0% versus 23.1% versus 74.1%; P = 0.001). CONCLUSION/CONCLUSIONS:This retrospective study provides empirical evidence of the importance of URM representation among orthopaedic spine surgery faculty and the potential effect on URMs pursuing orthopaedic fellowships. Institutions should consider prioritizing the representation of URM faculty in spine surgery to address the lack of current and future diversity in the field. LEVEL OF EVIDENCE/METHODS:III.
PMID: 38109731
ISSN: 1940-5480
CID: 5612502

Early Weight-bearing Following Surgical Treatment of Ankle Fractures Without Trans-syndesmotic Fixation Is Safe and Improves Short-term Outcomes

Herbosa, Christopher G; Saleh, Hesham; Kadiyala, Manasa L; Solasz, Sara; McLaurin, Toni M; Leucht, Philipp; Egol, Kenneth A; Tejwani, Nirmal C
OBJECTIVES/OBJECTIVE:The objective of this study was to ascertain outcome differences after fixation of unstable rotational ankle fractures allowed to weight-bear 2 weeks postoperatively compared with 6 weeks. DESIGN/METHODS:Prospective case-control study. SETTING/METHODS:Academic medical center; Level 1 trauma center. PATIENT SELECTION CRITERIA/UNASSIGNED:Patients with unstable ankle fractures (OTA/AO:44A-C) undergoing open reduction internal fixation (ORIF) were enrolled. Patients requiring trans-syndesmotic fixation were excluded. Two surgeons allowed weight-bearing at 2 weeks postoperatively (early weight-bearing [EWB] cohort). Two other surgeons instructed standard non-weight-bearing until 6 weeks postoperatively (non-weight-bearing cohort). OUTCOME MEASURES AND COMPARISONS/UNASSIGNED:The main outcome measures included the Olerud-Molander questionnaire, the SF-36 questionnaire, and visual analog scale at 6 weeks, 3 months, 6 months, and 12 months postoperatively and complications, return to work, range of ankle motion, and reoperations at 12 months were compared between the 2 cohorts. RESULTS:One hundred seven patients were included. The 2 cohorts did not differ in demographics or preinjury scores ( P > 0.05). Six weeks postoperatively, EWB patients had improved functional outcomes as measured by the Olerud-Molander and SF-36 questionnaires. Early weight-bearing patients also had better visual analog scale scores (standardized mean difference -0.98, 95% confidence interval [CI] -1.27 to -0.70, P < 0.05) and a greater proportion returning to full capacity work at 6 weeks (odds ratio = 3.42, 95% CI, 1.08-13.07, P < 0.05). One year postoperatively, EWB patients had improved pain measured by SF-36 (standardized mean difference 6.25, 95% CI, 5.59-6.92, P < 0.01) and visual analog scale scores (standardized mean difference -0.05, 95% CI, -0.32 to 0.23, P < 0.01). There were no differences in complications or reoperation at 12 months ( P > 0.05). CONCLUSIONS:EWB patients had improved early function, final pain scores, and earlier return to work, without an increased complication rate compared with those kept non-weight-bearing for 6 weeks. LEVEL OF EVIDENCE/METHODS:Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
PMID: 38117568
ISSN: 1531-2291
CID: 5633752

Bone Health Evaluations and Secondary Fragility Fractures in Hip Fracture Patients

Pflug, Emily M; Lott, Ariana; Konda, Sanjit R; Leucht, Philipp; Tejwani, Nirmal; Egol, Kenneth A
PURPOSE/UNASSIGNED:This study sought to examine the utilization of bone health evaluations in geriatric hip fracture patients and identify risk factors for the development of future fragility fractures. MATERIALS AND METHODS/UNASSIGNED:A consecutive series of patients ≥55 years who underwent surgical management of a hip fracture between September 2015 and July 2019 were identified. Chart review was performed to evaluate post-injury follow-up, performance of a bone health evaluation, and use of osteoporosis-related diagnostic and pharmacologic treatment. RESULTS/UNASSIGNED:A total of 832 patients were included. The mean age of the patients was 81.2±9.9 years. Approximately 21% of patients underwent a comprehensive bone health evaluation. Of this cohort, 64.7% were started on pharmacologic therapy, and 73 patients underwent bone mineral density testing. Following discharge from the hospital, 70.3% of the patients followed-up on an outpatient basis with 95.7% seeing orthopedic surgery for post-fracture care. Overall, 102 patients (12.3%) sustained additional fragility fractures within two years, and 31 of these patients (3.7%) sustained a second hip fracture. There was no difference in the rate of second hip fractures or other additional fragility fractures based on the use of osteoporosis medications. CONCLUSION/UNASSIGNED:Management of osteoporosis in geriatric hip fracture patients could be improved. Outpatient follow-up post-hip fracture is almost 70%, yet a minority of patients were started on osteoporosis medications and many sustained additional fragility fractures. The findings of this study indicate that orthopedic surgeons have an opportunity to lead the charge in treatment of osteoporosis in the post-fracture setting.
PMCID:10929537
PMID: 38420738
ISSN: 2287-3260
CID: 5681642

Atraumatic Idiopathic Compartment Syndrome Requiring Emergent Fasciotomy: A Case Report and Literature Review [Case Report]

Markus, Danielle; Bi, Andrew S; Neal, William; Fiedler, Benjamin; Tejwani, Nirmal
A 42-year-old male with no past medical history presented to an emergency room with increasing pain and swelling of his left lower extremity over 48 hours with no preceding trauma. A computed tomography scan demonstrated a hematoma (20 cm × 4 cm × 10 cm) present within the gastrocnemius-soleus complex. Acute compartment syndrome (ACS) was diagnosed clinically, confirmed intraoperatively with an arterial line transducer, and treated with emergent fasciotomy. Extensive workup found no evidence of coagulopathy or source of bleeding. This case presents a patient with ACS secondary to an atraumatic gastrocnemius hematoma discovered in the emergency room with no history of coagulopathies or anticoagulation.
PMCID:11056228
PMID: 38681317
ISSN: 2168-8184
CID: 5734122

Total Elbow Arthroplasty Historical and Current Concepts

Birnbaum, Amy; Campbell, Hilary; Tejwani, Nirmal; Ayalon, Omri; Kwon, Young
The evolution of total elbow arthroplasty (TEA) has laid the groundwork for modern day TEA and has contributed to our understanding of elbow biomechanics. Trends in the usage of TEA have also varied significantly over time. This article aims to review the history and evolution of the TEA implant with a focus on modern day implant biomechanics and the trends in TEA indications. Additionally, this review discusses various complications that can occur with modern day TEA and looks toward the future to identify innovation and future trends.
PMID: 38431971
ISSN: 2328-5273
CID: 5691742