Faculty Bibliography

BACKGROUND/UNASSIGNED:Liposomal bupivacaine (LB) was developed to provide longer lasting postoperative analgesia, but its clinical role is still being elucidated. We assessed the opioid-sparing effect of LB in patients undergoing total shoulder arthroplasty (TSA) with an interscalene block (ISB). METHODS/UNASSIGNED:Patients scheduled for TSA were randomized to receive either 20 mL of bupivacaine 5 mg/mL control or 10 ml of bupivacaine 5 mg/mL plus LB 133 mg experimental [EXP] for an ISB. The primary outcome was opioid consumption from 24 to 72 hours. The secondary outcomes were cumulative opioid consumption on postoperative days (PODs) 7, 14, and 30 and pain intensity scores measured by the Patient Reported Outcomes Measurement Information System scale. RESULTS/UNASSIGNED:< .05). CONCLUSION/UNASSIGNED:The addition of LB to plain bupivacaine for an ISB is associated with a statistically significant but not clinically meaningful reduction in opioid consumption over the first 72 hours following TSA. These findings should be considered when making an economical decision to use LB.

The efficacy of "Expanded Gram-Negative Antimicrobial Prophylaxis" (EGNAP) in preventing postoperative infections has been previously reported in total hip arthroplasty (THA). However, it remains unclear as to whether these benefits extend to total knee arthroplasty (TKA). This study investigated whether adding EGNAP to our institution's preoperative antibiotic prophylaxis protocol would affect periprosthetic joint infection (PJI) risk in TKA patients. We retrospectively reviewed 10,666 elective, unilateral, primary TKA cases performed at a single-specialty tertiary academic hospital from 2018 to 2022. Before June 2021, all patients received 2 g of cefazolin for 24 h as part of the prophylactic antibiotic protocol. After June 2021, gentamicin or aztreonam (EGNAP) was added to the protocol for all TKA patients. Patients were grouped based on whether they received EGNAP or not (control group) before surgery. The groups were propensity score-matched in a 2:1 ratio. PJI and nephrotoxicity (using RIFLE criteria) risk was compared. After matching, the final study population consisted of 3007 patients in the non-EGNAP group and 1503 patients in the EGNAP group. There was no significant difference between the EGNAP and no EGNAP groups in the overall incidence of PJI (1.9% vs. 2.0%; p = 0.111) or the incidence of Gram-positive PJIs (0.3% vs. 0.8%; p = 0.103). The incidence of Gram-negative PJIs was 0.5% in the EGNAP group and 0.4% in the no EGNAP group, which was also not different between the groups (p = 0.692). There were no differences in nephrotoxicity between groups (p = 0.521). The addition of EGNAP to the antibiotic prophylactic protocol prior to TKA had no effect on overall or Gram-negative PJI risk in TKA patients. The findings of this study suggest that while EGNAP is safe to use and has minimal nephrotoxic effects, its prophylactic benefits do not extend to the primary TKA population. This may be attributed to the generally low rate of Gram-negative infections in TKA patients, where adding EGNAP does not provide a clear advantage in reducing the risk of such infections, unlike its potential benefits in primary THA population. This study investigates the effects of using prophylactic Gram-negative antibiotics prior to TKA and shows that though it is safe to use, Gram-negative bacterial coverage may have no impact on postoperative infection incidence.

INTRODUCTION/BACKGROUND:Robotic-assisted technologies provide the ability to avoid soft tissue release by utilizing more accurate bony cuts during total knee arthroplasty (TKA). However, the ideal limb alignment is not yet established. The aim of this study was to predict postoperative Coronal Plane Alignment of the Knee (CPAK) using corresponding native bony measurements. METHODS:This study analyzed a retrospective cohort of 530 primary robotic-assisted TKAs. Machine learning was utilized to predict appropriate target lateral distal femoral angles (LDFA) and medial proximal tibial angles (MPTA). Normalization of LDFA and MPTA alignments was performed using the min-max scaler operation on the training set with feature range [-1, 1] and repeated separately for the input and target distributions. A neural network of hidden dimensions (16, 8, 4) was trained via supervised learning to predict planned LDFA and MPTA values from preoperative LDFA and MPTA measurements. RESULTS:The model converged after 104 epochs and batch size 4 with mean squared error ±1.82°. The model's regression agrees with the hypothesized change in preoperative to planned coronal alignment: valgus measurements are translated to neutral/aligned targets while varus alignments are translated to varus alignment of lesser severity. Evaluative statistics demonstrate this method for planning knee morphologies is significantly more accurate than making predictions about the mean (RMSE 1.440; R-squared 0.444; Nash Sutcliffe 0.579). CONCLUSION/CONCLUSIONS:This study's model provides accurate predictions for target knee alignment morphologies. Future work is warranted to evaluate this method's usefulness for planning robotic TKA.

BACKGROUND:The optimal nonoperative treatment for a Boutonniere deformity remains controversial. PURPOSE/OBJECTIVE:We aimed to evaluate the effect of nonsurgical treatment methods on finger motion for Boutonniere deformities. STUDY DESIGN/METHODS:Retrospective cohort study. METHODS:Conservative treatments included hand therapy, orthotic wear, and home finger exercises. Digit range of motion (ROM) and injury characteristics also were evaluated. Based upon active ROM at the proximal interphalangeal joint, digits were graded as Poor, Good, or Excellent, and then a change in ROM grade was calculated from pre- to post-treatment for each digit. Standard statistical analyses were performed to evaluate for significant influences on changes in ROM grade. RESULTS:One hundred and eleven digits (106 patients) were included. Traumatic injury was most common (87.4%). All digits but one received an orthotic. Average treatment and follow-up time was 14.6 weeks. Pre-treatment, there were 63 Poor, 29 Good, and 19 Excellent digits, with average total arc of motion of 47.3, 78.4, 84.2°, respectively (p < 0.01). Post-treatment, there were 28 Poor, 34 Good, and 49 Excellent digits, with average total arc of motion of 57.0, 81.4, 98.4°, respectively (p < 0.01). Forty nine digits had no change in ROM grade post-treatment, 37 had one grade of improvement, 18 had two grades of improvement, and seven had one grade worse. Across these four cohorts, digits that began treatment within 6 weeks of injury had the greatest amount of improvement (p = 0.02), whereas deformity from inflammatory arthritis were less likely to respond to treatment (p = 0.045). Otherwise, there were no differences in type or length of conservative treatment across cohorts (p > 0.1). CONCLUSIONS:Improvement in digit ROM was associated with initiation of treatment within 6 weeks, but not with any particular type or length of conservative treatment. One to two grades of ROM improvement can be achieved, although deformity can persist even after dedicated conservative management.

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.

BACKGROUND:Corticosteroid injections are a first-line treatment of trigger finger and de Quervain's tenosynovitis. Little research has evaluated preinjection patient-reported outcomes as a predictive factor for treatment success following corticosteroid injection. We hypothesized that patients with less pretreatment impairment would demonstrate greater post-treatment improvement than patients whose function was more severely impaired. METHODS:We retrospectively reviewed prospectively collected Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) scores in patients undergoing corticosteroid injection for trigger finger or de Quervain's tenosynovitis from 2017 to 2023. Independent variables were patient baseline characteristics, comorbidities, and baseline PROMIS UE. The primary outcome was treatment success between 30 days and 12 weeks, defined as achieving the minimal clinically important difference for PROMIS UE without undergoing surgery. RESULTS:= .44). CONCLUSION/CONCLUSIONS:Corticosteroid injection provides meaningful improvement for a subset of trigger finger and de Quervain's tenosynovitis patients. Corticosteroid injection remains a first-line treatment for trigger finger and de Quervain's tenosynovitis patients, especially for those with more severe functional impairment.

BACKGROUND:To compare clinical outcomes, return to activities, and rates of revision surgery following arthroscopic glenoid labral repair in patients who were prescribed NSAIDs as part of their postoperative pain management regimen versus those who were not. METHODS:Patients aged 18-55 who underwent primary arthroscopic labral repair at a single academic institution from the years 2016-2020 were retrospectively reviewed. Patients who underwent concomitant rotator cuff repair, remplissage, or did not have minimum 2-year postoperative follow-up were excluded. Patients who were prescribed postoperative NSAIDs were matched 1:1 to those who were not based on age, sex, BMI, and number of suture anchors. Outcomes were assessed using the Visual Analog Scale (VAS) for pain, American Shoulder and Elbow Surgeons Shoulder Score (ASES), Simple Shoulder Test (SST), Single Assessment Numeric Evaluation rating (SANE), and satisfaction. Pre-injury sport and work activity information were recorded. RESULTS:Of 269 eligible patients, 224 patients were included. Patients prescribed NSAIDs postoperatively had similar levels of pain (1.2 vs 1.0, p=0.527) and function (ASES: 90.8 vs 89.9, p=0.824; SST: 91.9 vs 90.6, p=0.646; SANE: 83.8 vs 85.3, p=0.550) compared to those who were not. Rates of revision surgery (2.7% vs 0.9%, p=0.622) and recurrent instability (5.4% vs 8.0%, p=0.594) were similar between NSAID and non-NSAID groups. Rates of return to sport (83.5% vs 77.8%, p=0.318) and return to pre-injury level (59.3% vs 61.6%, p=0.177) were similar between NSAID and non-NSAID groups. Prescription of postoperative NSAIDs was not associated with delayed return to sport (OR:1.47, 95%CI [0.68,3.18], p=0.327) or return to work (OR:0.56, 95%CI [0.14,2.28], p=0.416). CONCLUSIONS:Patients who were prescribed NSAIDs as a part of a postoperative pain management regimen following primary arthroscopic labral repair for glenohumeral instability had similar patient-reported outcomes, revision rates, and rates of return to pre-injury activities compared to those who were not prescribed NSAIDs.

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.

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.

BACKGROUND:Femoral neck fractures pose a notable health challenge globally, with a projected rise in cases due to aging populations. While treatment protocols are established, the effect of surgeon training on treatment decisions, particularly trauma versus arthroplasty fellowship training, remains less clear. METHODS:This study, using data from the Statewide Planning and Research Cooperative System in New York State, examined 26,761 patients meeting inclusion criteria. Among 951 treating surgeons, 20.6% had no subspecialty fellowship training while 4.6% had training in multiple subspecialties, with arthroplasty (232 surgeons, 24.4%), sports (230 surgeons, 24.2%), and trauma (93 surgeons, 9.8%) being the most common. RESULTS:Analysis revealed notable differences in surgical treatments based on subspecialty, with trauma surgeons favoring fixation and arthroplasty surgeons favoring total hip arthroplasty (THA). Even after adjusting for covariates, patients treated by arthroplasty-trained surgeons were more likely to receive THA. In addition, there was consistency between trauma and arthroplasty surgeons in treating lower functional demand patients with hemiarthroplasty. While trauma surgeons performed more fixations and arthroplasty surgeons more THAs, baseline characteristics and perioperative outcomes between fixation and THA patients were similar, indicating comparable baseline health despite treatment differences. Multivariable logistic regression confirmed that treatment by an arthroplasty surgeon markedly increased the odds of receiving THA. CONCLUSION/CONCLUSIONS:This study underscores the complexity added by surgeon subspecialty in femoral neck fracture management and emphasizes the importance of recognizing how surgeon-specific factors influence treatment decisions. Understanding these nuances can inform training optimization and promote collaborative approaches within the orthopaedic community, ultimately contributing to enhanced patient outcomes as femoral neck fracture management evolves.