Periprosthetic fracture following arthroplasty for femoral neck fracture: is a cemented stem protective?

BACKGROUND: Periprosthetic femoral fractures (PFF) carry significant morbidity following arthroplasty for femoral neck fracture (FNF). This study assessed fracture complications following arthroplasty for FNF and the effect of cement fixation of the femoral component on intraoperative and post-operative PFF. METHODS: Between February 2014 and September 2021, 740 patients with a FNF who underwent arthroplasty were analyzed for demographics, surgical management, use of cement for fixation of the femoral component, and subsequent PFF. Variables were compared with Mann-Whitney or Chi-square as appropriate. Multivariate logistic regression was used to assess independent risk factors associated with intraoperative or post-operative PFF. RESULTS: There were 163 THAs (41% cemented) and 577 HAs (95% cemented). There were 28 PFFs (3.8%): 18 post-operative and 10 intraoperative. Fewer post-operative PFFs occurred with cemented stems (1.63% vs. 6.30%, p = 0.002). Mean time from surgery to presentation with post-operative PFF was 14 months (0-45 months). Mean follow-up time was 10.3 months (range: 0-75.7 months). In multivariate regression, use of cement and THA was independently associated with decreased post-operative PFF (cement: OR 0.112, 95% CI 0.036-0.352, p < 0.001 and THA: OR 0.249, 95% CI 0.064-0.961, p = 0.044). More intraoperative fractures occurred during THA (3.68% vs. 0.69%, p = 0.004) and non-cemented procedures (5.51% vs. 0.49%, p < 0.001). In multivariate regression, use of cement was protective against intraoperative fracture (OR 0.100, CI 0.017-0.571, p = 0.010). CONCLUSIONS: In patients with a FNF treated with arthroplasty, cementing the femoral component is associated with a lower risk of intraoperative and post-operative PFF. Choice of procedure may be based on patient factors and surgeon preference.

No difference in clinical and hospital quality outcomes in treatment of reverse obliquity intertrochanteric Hip fractures (AO/OTA 31.A3) based on Cephalomedullary nail length.

INTRODUCTION: The purpose of this study was to evaluate outcomes following reverse obliquity (RO) intertrochanteric hip fractures based on the use of short cephalomedullary nails (CMNs) compared to long CMNs for fixation. METHODS: An IRB-approved prospectively collected hip fracture registry at an urban academic medical center was queried for all AO/OTA 31A3.1-3 reverse obliquity intertrochanteric (RO) fractures. One hundred and seventy patients with age > 55 years old and minimum 6-month follow-up were identified for analysis. Data was collected for patient demographics, injury details, intraoperative radiographic parameters, perioperative physiologic parameters, hospital quality measures, and outcomes including radiographic time to healing, need for reoperation, nonunion, and mortality. Comparative analyses were conducted between cohorts. Additional multivariable binary logistic and linear regression analyses were performed to evaluate for factors independently associated with short and long nail usage. RESULTS: The mean age of the entire cohort was 80.91±10.09 years: 103 patients had a long CMN implanted, and 67 patients had a short CMN implanted. There were no demographic differences or differences in radiographic time to healing, rates of mortality, readmission, nonunion, and need for reoperation. Univariable analysis revealed that short CMN had lower intraoperative blood loss (111.19±83.97 mL vs 176.72±161.45 mL, p = 0.002), decreased need for transfusion (37% vs. 55 %, p = 0.022), and shorter procedures (118.67±57.87 min vs. 148.95±77.83 min, p = 0.002. Multivariable analysis revealed that short nail usage was associated with decreased intraoperative blood loss, decreased need for transfusion, and shorter operative times. CONCLUSION: Nail length does not affect healing or hospital quality outcomes in the treatment of RO hip fractures. The use of short CMNs for these fractures did correlate with lower intraoperative blood loss, operative time, and need for blood transfusion, with non-inferior outcomes and similar hospital quality measures when compared to long CMNs.

The effect of traumatic head injuries on the outcome of middle-aged and geriatric orthopedic trauma patients.

BACKGROUND: The purpose of this study is to characterize the effects of head injuries amongst the middle-aged and geriatric populations on hospital quality measures, costs, and outcomes in an orthopedic trauma setting. METHODS: Patients with head and orthopedic injuries aged >55 treated at an academic medical center from October 2014-April 2021 were reviewed for their Abbreviated Injury Score for Head and Neck (AIS-H), baseline demographics, injury characteristics, hospital quality measures and outcomes. Univariate comparative analyses were conducted across AIS-H groups with additional regression analyses controlling for confounding variables. All statistical analyses were conducted with a Bonferroni adjusted alpha. RESULTS: A total of 1,051 patients were included. The mean age was 74 years, and median AIS-H score was 2 (range 1-6). While outcomes worsened and costs increased as AIS-H scores increased, the most drastic (and clinically relevant) rise occurs between scores 2-3. Patients who sustained a head injury warranting an AIS-H score of 3 experienced a significantly higher rate of major complications, need for ICU admission, inpatient and 1-year mortality with longer lengths of stay and higher total costs despite no differences in demographics or injury characteristics. Regression analysis found a higher AIS-H score was independently associated with greater mortality risk. CONCLUSION: AIS-H scores >2 correlate with significantly worse outcomes and higher hospital costs. Concomitant head injuries impact both outcomes and direct variable costs for middle-aged and geriatric orthopedic trauma patients. Clinicians, hospitals, and payers should consider the significant effect of head injuries on the hospitalization of these patients.

Diagnostic Accuracy of a Trauma Risk Assessment Tool Among Geriatric Patients With Crash Injuries.

ABSTRACT: The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a risk stratification tool. We evaluated the STTGMA's accuracy in predicting 30-day mortality and the odds of unfavorable clinical trajectories among crash-related trauma patients. This retrospective cohort study (n = 912) pooled adults aged 55 years and older from a single institutional trauma database. The data were split into training and test data sets (70:30 ratio) for the receiver operating curve analysis and internal validation, respectively. The outcome variables were 30-day mortality and measures of clinical trajectory. The predictor variable was the high-energy STTGMA score (STTGMAHE). We adjusted for the American Society of Anesthesiologists Physical Status. Using the training and test data sets, STTGMAHE exhibited 82% (95% CI: 65.5-98.3) and 96% (90.7-100.0) accuracies in predicting 30-day mortality, respectively. The STTGMA risk categories significantly stratified the proportions of orthopedic trauma patients who required intensive care unit (ICU) admissions, major and minor complications, and the length of stay (LOS). The odds of ICU admissions, major and minor complications, and the median difference in the LOS increased across the risk categories in a dose-response pattern. STTGMAHE exhibited an excellent level of accuracy in identifying middle-aged and geriatric trauma patients at risk of 30-day mortality and unfavorable clinical trajectories.

Cut-Through versus Cut-Out: No Easy Way to Predict How Single Lag Screw Design Cephalomedullary Nails Used for Intertrochanteric Hip Fractures Will Fail?

Purpose: This study aims to compare patients in whom fixation failure occurred via cut-out (CO) or cut-through (CT) in order to determine patient factors and radiographic parameters that may be predictive of each mechanism. Materials and Methods: This retrospective cohort study includes 18 patients with intertrochanteric (IT) hip fractures (AO/OTA classification 31A1.3) who underwent treatment using a single lag screw design intramedullary nail in whom fixation failure occurred within one year. All patients were reviewed for demographics and radiographic parameters including tip-to-apex distance (TAD), posteromedial calcar continuity, neck-shaft angle, lateral wall thickness, and others. Patients were grouped into cohorts based on the mechanism of failure, either lag screw CO or CT, and a comparison was performed. Results: No differences in demographics, injury details, fracture classifications, or radiographic parameters were observed between CO/CT cohorts. Of note, a similar rate of post-reduction TAD>25 mm (P=0.936) was observed between groups. A higher rate of DEXA (dual energy X-ray absorptiometry) confirmed osteoporosis (25.0% vs. 60.0%) was observed in the CT group, but without significance. Conclusion: The mechanism of CT failure during intramedullary nail fixation of an IT fracture did not show an association with clinical data including patient demographics, reduction accuracy, or radiographic parameters. As reported in previous biomechanical studies, the main predictive factor for patients in whom early failure might occur via the CT effect mechanism may be related to bone quality; however, conduct of larger studies will be required in order to determine whether there is a difference in bone quality.

Age Is Not Just a Number: The Intersection of Age, Orthopedic Injuries, and Worsening Outcomes Following Low-Energy Falls.

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.

Hip Fracture Care during COVID-19: Evolution through the Pandemic.

INTRODUCTION: 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: 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.

The Cost We Bear: Financial Implications for Hip Fracture Care Amidst the COVID-19 Pandemic.

INTRODUCTION: The purpose of this study was to assess the impact of COVID-19 on the cost of hip fracture care in the geriatric/middle-aged cohort, hypothesizing the cost of care increased during the pandemic, especially in COVID+ patients. METHODS: Between October 2014 and January 2022, 2,526 hip fracture patients older than 55 years were analyzed for demographics, injury details, COVID status on admission, hospital quality measures, and inpatient healthcare costs from the inpatient admission. Comparative analyses were conducted between: (1) All comers and high-risk patients in the prepandemic (October 2014 to January 2020) and pandemic (February 2020 to January 2022) cohorts and (2) COVID+ and COVID- patients during the pandemic. Subanalysis assessed the difference in cost breakdown for patients in the overall cohorts, the high-risk quartiles, and between the prevaccine and postvaccine pandemic cohorts. RESULTS: Although the total costs of admission for all patients, and specifically high-risk patients, were not notably higher during the pandemic, further breakdown showed higher costs for the emergency department, laboratory/pathology, radiology, and allied health services during the pandemic, which was offset by lower procedural costs. High-risk COVID+ patients had higher total costs than high-risk COVID- patients ( P < 0.001), most notably in room-and-board ( P = 0.032) and allied health ( P = 0.023) costs. Once the pandemic started, subgroup analysis demonstrated no change in the total cost in the prevaccine and postvaccine cohort. CONCLUSION: The overall inpatient cost of hip fracture care did not increase during the pandemic. Although individual subdivisions of cost signified increased resource utilization during the pandemic, this was offset by lower procedural costs. COVID+ patients, however, had notably higher total costs compared with COVID- patients driven primarily by increased room-and-board costs. The overall cost of care for high-risk patients did not decrease after the widespread administration of the COVID-19 vaccine. LEVEL OF EVIDENCE: III.

Poorly controlled diabetes: Glycosylated hemoglobin (HA1c) levels >8% are the tipping point for significantly worse outcomes following hip fracture in the geriatric population.

INTRODUCTION: The presence of diabetes has been associated with increased mortality risk after hip fracture, however, little has been published about the lab values of these diabetic patients and the role high labs play in morbidity and mortality. The purpose of this study is to quantify the severity of diabetes that is associated with worse outcomes in hip fracture patients. METHODS: A consecutive series of 2430 patients >55 years old who sustained a hip fracture between October 2014-November 2021 were reviewed for demographics, hospital quality measures, and outcomes. Each patient with a diagnosis of diabetes mellitus (DM) was reviewed for hemoglobin-A1c (HA1c) and glucose values at admission. Univariable comparisons and multivariable regression analyses were conducted to assess the impact of diabetes and elevated lab values (HA1c) on outcomes such as hospital quality measures, inpatient complications, readmission rates, and mortality rates. RESULTS: 565 patients (23%) carried a diagnosis of diabetes mellitus at the time of their injury. Considerable demographic and comorbidity differences between diabetic and non-diabetic cohorts indicated that the diabetic cohort was less healthy. The diabetic cohort had longer hospitalizations, higher rates of minor complications, readmissions within 90-days, and mortality within 30-days/1-year. Stratification by HA1c levels found patients with a HA1c>8% had a significantly higher rate of major complications, and mortality at all time points (inpatient/30-day/1-year). Multivariable regression found HA1c>8% to be independently associated with a higher rate of inpatient/30-day/1-year mortality in comparison to a diagnosis of diabetes alone which was not independently significant. CONCLUSION: While all patients with DM experienced worse outcomes than those without, those with poorly controlled diabetes (HA1c>8%) at the time of hip fracture injury experienced poorer outcomes compared to those with well-controlled diabetes. Treating physicians must recognize these patients with poorly controlled DM at the time of arrival to adjust care planning and patient expectations accordingly.

Does a hip fracture mean we should we operate on a concomitant proximal humerus fracture?

BACKGROUND: Concomitant upper extremity and hip fractures present a challenge in postoperative mobilization in the geriatric population. Operative fixation of proximal humerus fractures allows for upper extremity weight bearing. This retrospective study compared outcomes between operative and non-operative proximal humerus fracture patients with concomitant hip fractures. METHODS: A trauma database of 13,396 patients age > 55 years old was queried for concomitant hip and proximal humerus fracture patients between 2014-2021. Medical records were reviewed for demographics, hospital quality measures, Neer classification, morphine milligram equivalents (MME), and outcomes. All hip fractures were treated operatively. Patients were grouped based on operative vs. non-operative treatment of their proximal humerus fracture. Primary outcomes included comparing postoperative ambulatory status, pain, length of stay (LOS), intensive care unit (ICU) need, discharge disposition, and readmission rates. RESULTS: Forty-eight patients (0.4%) met inclusion criteria. Twelve patients (25%) underwent operative treatment for their proximal humerus fracture and 36 (75%) received non-operative treatment. Patients with operative fixations were younger (p < 0.01), had more complex Neer classifications (p = 0.031), more likely to be community ambulators (p < 0.01), and required more inpatient MMEs (p < 0.01). There were no differences in LOS (p = 0.415), need for ICU (p = 0.718), discharge location (p = 0.497), 30-day readmission (p = 0.228), or 90-day readmission (p = 0.135) between cohorts. At 6 months postoperatively, among community or household ambulators, a higher percentage of operative patients returned to their baseline ambulatory functional status, however, this was not significant (70% vs. 52%, p = 0.342). There were three deaths in the non-operative cohort and no deaths in the operative cohort. CONCLUSION: Patients with hip fractures and concomitant proximal humerus fractures treated operatively required more inpatient MMEs and trended toward maintaining baseline ambulatory function. There were no differences in inpatient LOS, ICU need, discharge location, or readmissions. Future larger, multicenter studies are needed to further delineate if operative repair of concomitant proximal humerus fractures provides a benefit in the geriatric population.

Implications of COVID-19 on hip fracture care discharge locations during the early stages of the 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: Retrospective cohort study. Setting: 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: 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). Results: 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. Conclusions: 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.

Impact of Poorly Controlled Diabetes and Glycosylated Hemoglobin Values in Geriatric Hip Fracture Mortality Risk Assessment.

Introduction The presence of poorly-controlled diabetes in the setting of geriatric hip fractures has been shown to increase all-cause mortality and worsen outcomes. This study aimed to assess whether the addition of a patient's glycated hemoglobin (A1c) value to a validated geriatric inpatient risk tool improves the predictive capacity of the risk tool. Methods A cohort of 2430 patients >55 years old treated for low-energy mechanism hip fractures between October 2014 to November 2021 were reviewed for demographics (including diabetes diagnoses and their respective hemoglobin A1c values at the time of admission), injury details, hospital quality measures, and mortality. As past work demonstrated a hemoglobin A1c value above 8% to be the tipping point for worse outcomes, the baseline Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) tool for inpatient mortality in hip fractures (STTGMAHIP_FX_SCORE - Score for Trauma Triage in the Geriatric and Middle-Aged Hip Fracture Score) was modified to include a patient's hemoglobin A1c using an 8% cutoff (STTGMAHIP_8%A1c - Score for Trauma Triage in the Geriatric and Middle-Aged Hip 8% Hemoglobin A1c Cutoff Score). The new model's predictive ability (as measured by the area under the receiver operating curves (AUROCs)) for inpatient mortality was compared to the baseline tool using DeLong's test. Risk quartiles were generated for the new tool, and comparative analyses were conducted on hospital quality measures and outcomes.  Results Five hundred and sixty-five patients (23%) were noted to have diabetes mellitus, and 76 patients had an A1c above 8%. Patients with a hemoglobin A1c above 8% had a higher rate of inpatient complications and mortality through one year. The STTGMAHIP_8%A1c score significantly improved the predictive capacity for inpatient mortality compared to STTGMAHIP_FX_SCORE (0.786 vs. 0.672, p=0.0456). Upon analysis of the risk quartiles, the highest risk cohort was found to have a longer length of stay (p<0.001), with higher rates of inpatient (p<0.001) and 30-day mortality (p<0.001) and need for admission to the intensive care unit (p<0.001) as compared to the minimal risk cohort. Patients in the lowest risk quartile were most likely to be discharged home (p<0.001). Conclusion Patients who present with a hemoglobin A1c above 8% experienced significantly worse outcomes than those below 8%. The inclusion of a patient's hemoglobin A1c as a cutoff score improves the STTGMAHIP_FX_SCORE tool to predict mortality and risk stratify patient outcomes. While diabetes presents another medical challenge to manage, providers may utilize this new variable to better highlight at-risk diabetic patients.

Defining Characteristics of Middle-Aged and Geriatric Orthopedic Trauma in New York City over a 7-Year Period.

OBJECTIVES: Examine the patterns and defining characteristics of middle-aged and geriatric patients who sustain orthopedic trauma in New York City. STUDY DESIGN: Retrospective cohort study. METHODS: 11,677 patients >55 years old treated for traumatic orthopedic injuries were grouped into cohorts based on their age group (cohorts of 55-64, 65-74, 75-84, 85-94, ≥95 years) and year of presentation (2014-2021). Each patient was reviewed for demographics/comorbidities, injury mechanism/type, mortality data. Comparative analyses were conducted. RESULTS: The average age of our cohort was 74 years old. The majority of patients were female (69%) and sustained their injuries via a ground level fall. The most common injuries sustained by patients occurred at the upper extremity (40%), hip (26%), and lower extremity (25%) with 820 (7%) patients sustaining polytrauma. The incidence of hip fractures and pelvic injuries increased with older age. Older patients had a higher rate of mortality through 1-year in addition to a longer length of stay. In contrast, the incidence of injury to the upper and lower extremity decreased with older age. CONCLUSIONS: The rate of mortality out through 1-year following orthopedic trauma increased as patients got older. Significantly more women experienced a traumatic injury during 2014-2021. As age increased, ground level falls were the most common mechanism of injury with injuries more likely to occur in the axial skeleton, notably the hip and pelvis. Younger patients experienced higher rates of upper and lower extremity trauma. Providers should keep these patterns in mind to optimize care for middle-aged and geriatric trauma patients.

One year later: How outcomes of hip fractures treated during the "first wave" of the COVID-19 pandemic were affected.

The purpose of this study was to assess the impact of COVID-19 on long-term outcomes in the geriatric hip fracture population. We hypothesize that COVID + geriatric hip fracture patients had worse outcomes at 1-year follow-up. Between February and June 2020, 224 patients > 55 years old treated for a hip fracture were analyzed for demographics, COVID status on admission, hospital quality measures, 30- and 90-day readmission rates, 1-year functional outcomes (as measured by the EuroQol- 5 Dimension [EQ5D-3L] questionnaire), and inpatient, 30-day, and 1-year mortality rates with time to death. Comparative analyses were conducted between COVID + and COVID- patients. Twenty-four patients (11%) were COVID + on admission. No demographic differences were seen between cohorts. COVID + patients experienced a longer length of stay (8.58 ± 6.51 vs. 5.33 ± 3.09, p < 0.01) and higher rates of inpatient (20.83% vs. 1.00%, p < 0.01), 30-day (25.00% vs. 5.00%, p < 0.01), and 1-year mortality (58.33% vs. 18.50%, p < 0.01). There were no differences seen in 30- or 90-day readmission rates, or 1-year functional outcomes. While not significant, COVID + patients had a shorter average time to death post-hospital discharge (56.14 ± 54.31 vs 100.68 ± 62.12, p = 0.171). Pre-vaccine, COVID + geriatric hip fracture patients experienced significantly higher rates of mortality within 1 year post-hospital discharge. However, COVID + patients who did not die experienced a similar return of function by 1-year as the COVID- cohort.

Crosswalk between Charlson Comorbidity Index and the American Society of Anesthesiologists Physical Status Score for Geriatric Trauma Assessment.

The American Society of Anesthesiologists Physical Status (ASA-PS) grade better risk stratifies geriatric trauma patients, but it is only reported in patients scheduled for surgery. The Charlson Comorbidity Index (CCI), however, is available for all patients. This study aims to create a crosswalk from the CCI to ASA-PS. Geriatric trauma cases, aged 55 years and older with both ASA-PS and CCI values (N = 4223), were used for the analysis. We assessed the relationship between CCI and ASA-PS, adjusting for age, sex, marital status, and body mass index. We reported the predicted probabilities and the receiver operating characteristics. A CCI of zero was highly predictive of ASA-PS grade 1 or 2, and a CCI of 1 or higher was highly predictive of ASA-PS grade 3 or 4. Additionally, while a CCI of 3 predicted ASA-PS grade 4, a CCI of 4 and higher exhibited greater accuracy in predicting ASA-PS grade 4. We created a formula that may accurately situate a geriatric trauma patient in the appropriate ASA-PS grade after adjusting for age, sex, marital status, and body mass index. In conclusion, ASA-PS grades can be predicted from CCI, and this may aid in generating more predictive trauma models.

Screws Alone for Acute Lisfranc Injuries Fixed Without Arthrodesis: A Better "Value" Than Plating in the Short Term.

This study compares outcomes of patients with Lisfranc injuries treated with screw only fixation constructs to those treated with dorsal plate and screw constructs. Seventy patients who underwent surgical treatment for acute Lisfranc injury without arthrodesis and minimum 6-month (mean >1-year) follow-up were identified. Demographics, surgical information, and radiographic imaging were reviewed. Cost data were compared. The primary outcome measure was the American Orthopedic Foot and Ankle Surgery (AOFAS) midfoot score. Univariate analysis through independent sample t tests, Mann-Whitney U, and chi-squared compared the populations. Twenty-three (33%) patients were treated with plate constructs and 47 (67%) with screw only fixation. The plate group was older (49 ± 18 vs 40 ± 16 years, p = .029). More screw constructs treated isolated medial column injuries compared to plate constructs (92% vs 65%, p = .006). At latest follow-up (mean 14 ± 13 months), all tarsometatarsal joints were aligned. There was no difference in AOFAS midfoot scores. Plate patients experienced longer operations (131 ± 70 vs 75 ± 31 minutes, p < .001) and tourniquet time (101 ± 41 vs 69 ± 25 minutes, p = .001). Plate constructs were more expensive than screw ($2.3X ± $2.3X vs $X ± $0.4X, p < .001) ($X is the mean cost of screws alone). Plate patients had a higher incidence of wound complications (13% vs 0%, p = .012). Treatment of Lisfranc fracture dislocation injuries with screws only demonstrated a higher value procedure as similar outcomes were found amidst lower implant costs. Screw only fixation required a shorter operative and tourniquet time with less frequent wound complications. Screw only fixations proved mechanically sound enough to achieve goals of repair without inferior outcomes.

A Biomechanical Comparison of Fixation Techniques in Metacarpal Shaft Fractures.

Background Typically, metacarpal shaft fractures are treated with closed reduction percutaneous pinning, intramedullary nails, or plate fixation. Recently some surgeons have begun using intramedullary headless compression screws. Questions/Purposes The purpose of this study was to compare intramedullary screw fixation to K-wire fixation, which is the standard of care in a transverse metacarpal midshaft fracture, using a cadaveric model. Our hypothesis was that intramedullary screw fixation would have a biomechanical advantage (higher stiffness and peak load to failure) when compared with dual Kirschner wire fixation of transverse metacarpal shaft fractures. Methods Four-point bend testing was performed to compare stiffness and failure load values of seven paired 2nd and 3rd metacarpals instrumented with headless intramedullary compression screw fixation or Kirschner wire fixation. Similar testing was performed on 14 unpaired 4th metacarpals. Results There was no significant difference in peak load ( p = 0.60) or stiffness ( p = 0.85) between fixation groups for the 2nd and 3rd instrumented metacarpals. For the instrumented 4th metacarpals, there was no significant difference in peak load ( p = 0.14), but the stiffness was significantly greater ( p = 0.01) for the compression screw group compared with the Kirschner wire fixation. Conclusions/Clinical Relevance In this study, the load to failure was not different between the two fixation methods and likely both techniques can sustain physiologic loads needed for rehabilitation. The greater stiffness in the 4th metacarpal compression screw group may be related to the smaller canal morphology than in the 2nd and 3rd metacarpals. Larger diameter screws may be needed to obtain a better fit particularly in the 2nd and 3rd metacarpals.

Comminuted Olecranon Fractures (Mayo IIB): Is Dynamic Tension Band Wiring Enough?

OBJECTIVES: To compare the efficacy and outcomes of dynamic tension band wiring (TBW) and plate and screw (PS) fixation of comminuted (Mayo Type IIB) olecranon fractures. DESIGN: Retrospective cohort. SETTING: Academic medical center. PATIENTS/PARTICIPANTS: Forty-one patients with Mayo type IIB (OTA/AO 2U1C) olecranon fractures were involved in the study. INTERVENTION: Patients with tensile Mayo type IIB olecranon fractures between August 2012 and November 2020 treated by a single surgeon with either TBW or PS fixation were reviewed for demographics, radiographic/surgical details, and clinical/functional outcomes. Descriptive fracture data included proximal olecranon fragment size and the presence of joint impaction at surgery. MAIN OUTCOME MEASUREMENTS: The main outcome measurements were Mayo Elbow Performance Score, elbow range of motion, patient-reported pain, and complications. RESULTS: The mean follow-up was 38 months. Fractures healed for all patients in both groups. No differences in clinical outcomes, functional outcomes, elbow range of motion, or complications were seen between fixation groups. There was no difference in proximal fragment size between the 2 groups. Fractures with articular impaction requiring elevation and grafting demonstrated no difference in clinical or functional outcomes when compared with those that did not have any impaction. However, patients with impacted articular fractures treated with TBW had a higher rate of implant removal (25% vs. 0%, P = 0.05) when compared with those treated with PS. CONCLUSIONS: Comminuted Mayo IIB olecranon fractures are amenable to TBW or plate construct, with similar clinical and functional outcomes. The presence of articular impaction is associated with a greater need for implant removal. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

COVID-19 vaccination improved outcomes in the treatment of geriatric hip fractures between December 2020 and January 2022.

INTRODUCTION: Geriatric hip fracture patients are at high risk for perioperative morbidity and mortality from COVID-19. This study analyses the impact of COVID-19 vaccination on geriatric hip fracture outcomes. We hypothesise that having the COVID-19 vaccine improves outcomes for geriatric patients treated for hip fracture. METHODS: Between December 2020 and January 2022, 506 patients treated for hip fracture were analysed for demographics, hospital quality measures, and outcomes. Patients were grouped according to vaccine series administration status. During the study period, there were 329 (65%) unvaccinated patients (NV), 14 (3%) partially vaccinated (PV) patients, 138 (27%) fully vaccinated (FV) patients, and 25 (5%) patients received a booster shot (BV). Variables were compared using chi square, independent sample t-tests or ANOVA as appropriate. Multivariable logistic regression was used to independently assess the impact of vaccination. RESULTS: The rate of minor complications decreased if any vaccination status was achieved (NV: 37.99%, PV: 21.34%, FV: 28.26%, BV: 20.00%; p = 0.054). Vaccinated patients had a decreased need for Intensive Care Unit (ICU) level care (NV: 14.89%, PV: 7.14%, FV: 5.80%, BV: 8.00%; p = 0.038). There were no differences in inpatient or 30-day mortality, major complications, length of stay, home discharge, or readmission within 30 or 90 days. Vaccination against COVID-19 was independently protective against the need for ICU level care. Additionally, female gender and vaccination against COVID-19 decreased the rate of minor complications. Older age and higher comorbidity burden increased the rate of minor complications. DISCUSSION: In the hip fracture population, vaccination against COVID-19 was protective against the need for ICU level care and decreased overall minor complications. Larger studies are needed to determine if vaccination decreases mortality in this population. These findings have resource allocation implications including ICU bed availability during pandemics and patient outreach to improve vaccination status.