Outcomes Following Open Reduction and Internal Fixation for Distal Humerus Fracture: Does Handedness Matter?

Introduction: No studies have assessed the relationship between extremity dominance and distal humerus fractures. This study sought to compare post-operative outcomes between patients with distal humerus fractures treated by open reduction and internal fixation (ORIF) of their non-dominant vs dominant arm. Methods: A retrospective review of patients who sustained a distal humerus fracture treated with ORIF at one hospital between 2011-2015 was performed. Data collection included demographics, hand dominance, injury information, and surgical management. Post-operative outcomes included complications, time to fracture union, painful hardware, removal of hardware, Mayo Elbow Performance Index (MEPI), and range of motion. Results: Of the 69 patients, 40 (58.0%) underwent ORIF of a distal humerus fracture on their non-dominant arm and 29 (42.0%) on their dominant arm. Groups did not differ with respect to demographics, injury information, or surgical management. Mean overall follow up was 14.1 ± 10.5 months with no difference in follow up or time to fracture union between groups. The non-dominant cohort experienced a higher proportion of post-operative complications (P = 0.048), painful hardware (P = 0.018), and removal of hardware (P = 0.002). At latest follow up, the non-dominant cohort had lower MEPI scores (86.4 vs 94.7, P = 0.037) but no difference in arc of motion (104.3° vs 112.5°, P = 0.314). Discussion: Patients who sustain a distal humerus fracture of their non-dominant arm treated surgically experience more post-operative complications and have worse functional recovery. Physicians should emphasize the importance of therapy and maintaining arm movement, especially with the non-dominant arm

The Coming Hip and Femur Fracture Bundle: A New Inpatient Risk Stratification Tool for Care Providers

Introduction: In response to increasing health-care costs, Centers for Medicare & Medicaid Services has initiated several programs to transition from a fee-for-service model to a value-based care model. One such voluntary program is Bundled Payments for Care Improvement Advanced (BPCI Advanced) which includes all hip and femur fractures that undergo operative fixation. The purpose of this study was to analyze the current cost and resource utilization of operatively fixed (nonarthroplasty) hip and femur fracture procedure bundle patients at a single level 1 trauma center within the framework of a risk stratification tool (Score for Trauma Triage in the Geriatric and Middle-Aged [STTGMA]) to identify areas of high utilization before our hospitals transition to bundle period. Materials and Methods: A cohort of Medicare-eligible patients discharged with the Diagnosis-Related Group (DRG) codes 480 to 482 (hip and femur fractures requiring surgical fixation) from a level 1 trauma center between October 2014 and September 2016 was evaluated and assigned a trauma triage risk score (STTGMA score). Patients were stratified into groups based on these scores to create a minimal-, low-, moderate-, and high-risk cohort. Length of stay (LOS), discharge location, need for Intensive Care Unit (ICU)/Step Down Unit (SDU) care, inpatient complications, readmission within 90 days, and inpatient admission costs were recorded. Results: One hundred seventy-three patients with a mean age of 81.5 (10.1) years met inclusion criteria. The mean LOS was 8.0 (4.2) days, with high-risk patients having 4 days greater LOS than lower risk patients. The mean number of total complications was 0.9 (0.8) with a significant difference between risk groups ( P = .029). The mean total cost of admission for the entire cohort of patients was US$25,446 (US$9725), with a nearly US$9000 greater cost for high-risk patients compared to the low-risk patients. High-cost areas of care included room/board, procedure, and radiology. Discussion: High-risk patients were more likely to have longer and more costly admissions with average index admission costs nearly US$9000 more than the lower risk patient cohorts. These high-risk patients were also more likely to develop inpatient complications and require higher levels of care. Conclusion: This analysis of a 2-year cohort of patients who would qualify for the BPCI Advanced hip and femur procedure bundle demonstrates that the STTGMA tool can be used to identify high-risk patients who fall outside the bundle

Admitting Service Affects Cost and Length of Stay of Hip Fracture Patients

Introduction: The purpose of this study was to analyze the effect of the admitting service on cost of care for hip fracture patients by comparing the cost difference between patients admitted to the medicine service versus those admitted to a surgical service. Methods: A 2-year cohort of patients 55 years or older who were admitted to a single level 1 trauma center with an operative hip fracture were included. Patient demographics, comorbidities, admitting service, complications, and hospital length of stay were recorded for each patient. Cost of hospitalization, discharge disposition, and 30-day readmissions were collected. Patients who were admitted to the medicine service (medicine cohort) were compared to those admitted to a surgery service (surgery cohort). Multivariate regression models controlling for age, Charlson comorbidity index (CCI), and American Society of Anesthesiology (ASA) scores were used to evaluate hospitalization costs with a P value of <.05 as significant. Results: Two hundred twenty-five hip fracture patients were included; 143 (63.6%) patients were admitted to a surgical service, while 82 (36.4%) were admitted to the medicine service. Patients admitted to medicine service had greater CCI and ASA scores, longer lengths of stay, and more complications than those patients admitted to surgery service. Linear regression model controlling for age, CCI, ASA score, and time to surgery demonstrates that patients admitted to a surgical service will have 2.0-day (95% confidence interval [CI]: 0.561-3.503; P = .007) shorter admissions with a US$4215 reduction in cost (95$314-US$8116; P = .034) compared to patients admitted to the medicine service. Discussions: In our urban safety net hospital, hip fracture patients admitted to medicine service had longer lengths of stay and higher total hospitalization costs than patients who were admitted to surgery service. Conclusions: This study highlights that the admitting service should be an area of focus for hospitals when developing programs to provide effective and cost-conscious care to hip fracture patients

Current Practices Regarding Perioperative Management of Patients With Fracture on Antiplatelet Therapy

Objective: There continues to be controversy over whether operative delay is necessary for patients on antiplatelet therapy, particularly for elderly patients with hip fractures. This study sought to assess current clinical practices of orthopedic surgeons regarding perioperative management of these patients. Methods: A 12-question, Web-based survey was distributed to orthopedic surgeons via e-mail. Questions regarding timing of surgery assumed patients were on antiplatelet therapy and assessed attitudes toward emergent and nonemergent orthopedic cases as well as operative delay for specific closed fracture types. Responses were compared using unpaired, 2-tailed Student t tests for continuous variables and Pearson chi-square tests with odds ratios (ORs) and 95% confidence intervals (CIs) for categorical variables. Statistical significance was defined as a P value <.05. Results: Overall 67 orthopedic surgeons responded. Fifty-two percent (n = 35) of the respondents described their practice as academic. Thirty-nine percent (n = 25) of the surgeons indicated that no delay was acceptable for urgent but nonemergent surgery, and 78% (n = 50) reported no delay for emergent surgery was acceptable. Sixty-eight percent (n = 46) of respondents felt patients on antiplatelet therapy with closed hip fractures did not require operative delay. Surgeons who opted for surgical delay in hip fractures were more likely to delay surgery in other lower extremity fracture types (OR = 16.4, 95% CI 4.48-60.61, P < .001). Sixty-four percent (n = 41) of the surgeons indicated there was no protocol in place at their institution. Conclusions: There continues to be wide variability among orthopedic surgeons with regard to management of patients with fracture on antiplatelet therapy. Over a quarter of surgeons continue to opt for surgical delay in patients with hip fracture. This survey highlights the need to formulate and better disseminate practice management guidelines for patients with fracture on antiplatelet therapy, particularly given the aging population in the United States

How Does Frailty Factor Into Mortality Risk Assessment of a Middle-Aged and Geriatric Trauma Population?

Introduction: Frailty in elderly trauma populations has been correlated with an increased risk of morbidity and mortality. The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a validated mortality risk score that evaluates 4 major physiologic criteria: age, comorbidities, vital signs, and anatomic injuries. The aim of this study was to investigate whether the addition of additional frailty variables to the STTGMA tool would improve risk stratification of a middle-aged and elderly trauma population. Methods: A total of 1486 patients aged 55 years and older who met the American College of Surgeons Tier 1 to 3 criteria and/or who had orthopedic or neurosurgical traumatic consultations in the emergency department between September 2014 and September 2016 were included. The STTGMA ORIGINAL and STTGMA FRAILTY scores were calculated. Additional “frailty variables” included preinjury assistive device use (disability), independent ambulatory status (functional independence), and albumin level (nutrition). The ability of the STTGMA ORIGINAL and the STTGMA FRAILTY models to predict inpatient mortality was compared using area under the receiver operating characteristic curves (AUROCs). Results: There were 23 high-energy inpatient mortalities (4.7%) and 20 low-energy inpatient mortalities (2.0%). When the STTGMA ORIGINAL model was used, the AUROC in the high-energy and low-energy cohorts was 0.926 and 0.896, respectively. The AUROC for STTGMA FRAILTY for the high-energy and low-energy cohorts was 0.905 and 0.937, respectively. There was no significant difference in predictive capacity for inpatient mortality between STTGMA ORIGINAL and STTGMA FRAILTY for both the high-energy and low-energy cohorts. Conclusion: The original STTGMA tool accounts for important frailty factors including cognition and general health status. These variables combined with other major physiologic variables such as age and anatomic injuries appear to be sufficient to adequately and accurately quantify inpatient mortality risk. The addition of other common frailty factors that account for does not enhance the STTGMA tool’s predictive capabilities

Does Use of Oral Anticoagulants at the Time of Admission Affect Outcomes Following Hip Fracture

Purpose: The purpose of this study was to compare hospital quality outcomes in patients over the age of 60 undergoing fixation of hip fracture based on their anticoagulation status. Materials and Methods: Patients aged 60 and older with isolated hip fracture injuries treated operatively at 1 academic medical center between October 2014 and September 2016 were analyzed. Patients on the following medications were included in the anticoagulation cohort: warfarin, clopidogrel, aspirin 325 mg, rivaroxaban, apixaban, dabigatran, and dipyridamole/aspirin. We compared outcome measures including time to surgery, length of stay (LOS), transfusion rate, blood loss, procedure time, complication rate, need for intensive care unit (ICU)/step-down unit (SDU) care, discharge disposition, and cost of admission. Outcomes were controlled for age, Charlson comorbidity index (CCI), and anesthesia type. Results: A total of 479 hip fracture patients met the inclusion criteria, with 367 (76.6%) patients in the nonanticoagulated cohort and 112 (23.4%) patients in the anticoagulated cohort. The mean LOS and time to surgery were longer in the anticoagulated cohort (8.3 vs 7.3 days, P = .033 and 1.9 vs 1.6 days, P = .010); however, after controlling for age, CCI, and anesthesia type, these differences were no longer significant. Surgical outcomes were equivalent with similar procedure times, blood loss, and need for transfusion. The mean number of complications developed and inpatient mortality rate in the 2 cohorts were similar; however, more patients in the anticoagulated cohort required ICU/SDU-level care (odds ratio = 2.364, P = .001, controlled for age, CCI, and anesthesia). There was increased utilization of post-acute care in the anticoagulated cohort, with only 10.7% of patients discharged home compared to 19.9% of the nonanticoagulated group ( P = .026). Lastly, there was no difference in cost of care. Conclusion: This study highlights that anticoagulation status alone does not independently put patients at increased risk with respect to LOS, surgical outcomes, and cost of hospitalization

Do Elderly Patients Fare Worse Following Operative Treatment of Distal Femur Fractures Using Modern Techniques?

Background: The purpose of this study was to compare the functional outcomes and quality of life of older and younger patients with similarly treated distal femur fractures. Methods: We conducted an assessment of 57 patients who sustained distal femur fractures (Orthopaedic Trauma Association Type 33B, C) and underwent surgical treatment at our academic medical center. Patients were divided into 2 groups for analysis: an elderly cohort of patients aged 65 or older and a comparison cohort of patients younger than age of 65. A retrospective review of demographics, preoperative ambulatory status, radiographic data, and physical examination data was collected from the medical records. Follow-up functional data were collected via telephone at a mean of 2.5 years (range 6 months-8 years) using a Short Musculoskeletal Functional Assessment (SMFA). All patients underwent standard operative treatment of either nail or plate fixation. Results: There was no statistical difference in gender, fracture type, surgical technique, surgeon, or institution where the surgery was performed. The percentage of patients with healed fractures at 6-months follow-up was not significantly different between the cohorts. The elderly cohort had slightly worse knee range of motion at 3, 6, and 12 months postoperatively but there was not a statistically significant difference between the groups. The SMFA Daily Activity, Functional, and Bother indices were significantly worse in the older cohort ( P < .01, P = .01, P = .02, respectively). However, there was no significant difference in the SMFA Emotional or Mobility indices. Conclusion: Despite lower quality of life and functional scores, this study suggests that relatively good clinical outcomes can be achieved with surgical fixation of distal femoral fractures in the elderly patients. Age should not be used as a determinate in deciding against operative treatment of distal femur fractures in the elderly patients

Zone 2 5th Metatarsal Fractures Treated Nonoperatively Have Similar Time to Healing to Those Treated Operatively

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: The purpose of this study was to quantify the time to clinical and radiographic healing in Zone 2 proximal 5th metatarsal (MT) fractures and to compare these outcomes to those of Zone 2 fractures treated operatively. Methods: A retrospective cohort study of all Zone 2 metatarsal fractures seen at a single large, urban, academic medical center between December 2012 and April 2022 was performed. Zone 2 injuries were defined as fractures entering the proximal 4-5 MT articulation on the oblique radiographic view. Clinical healing was characterized by the return to baseline ambulatory function without discomfort and a lack of tenderness on physical examination. Radiographic healing was defined as complete osseous consolidation. A total of 374 patients with Zone 2 proximal 5th MT fractures were included in the analysis. The mean age of patients was 53.8 +/- 16.6 years, and 74.3% were female. Results: 93.3% of patients with Zone 2 metatarsal fractures were treated nonoperatively. In the nonoperative group, 6.6% experienced delayed bony union with incomplete radiographic healing after 6 months, compared to 16.0% of the operative group (p = 0.095). However, by 1 year post-injury, 98.9% of patients who underwent nonoperative management and 96.0% of operative patients demonstrated radiographic union. Two patients failed nonoperative management and underwent operative fixation for symptomatic nonunions. There was no difference in time to radiographic healing between patients treated nonoperatively and those treated operatively (4.4 +/- 2.8 months vs 5.4 +/- 4.7 months, p = 0.413). Similarly, there was no difference in time to clinical healing between both groups (2.3 +/- 1.9 months vs 2.6 +/- 3.8 months, p = 0.723). Conclusion: Zone 2 5th metatarsal base fractures, which are often incorrectly referred to as Jones fractures despite being proximal to the fractures originally characterized by Jones, can be successfully treated with nonoperative management. There is no evidence that operative treatment leads to significantly faster clinical or radiographic healing for patients

Comparison of Short-Term Outcomes of Geriatric Distal Femur and Femoral Neck Fractures

Purpose: To compare and contrast postoperative complications in the geriatric population following open reduction and internal fixation (ORIF) for (DF) fractures relative to femoral neck (FN) fractures. Methods: Patients aged 65 years and older in the American College of Surgeons National Surgical Quality Improvement Program database who underwent ORIF for FN fractures or DF fractures from 2005 to 2012 were identified. Differences in rates of any adverse events (AAEs), serious adverse events (SAEs), infectious complications, and mortality between groups were explored using univariate and multivariate analyses. Results: The DF cohort had a higher proportion of females (81.95% vs 71.35%, P < .001), were younger (79.41 ± 7.93 vs 82.11 ± 7.26 years old, P < .001), and had a lower age adjusted modified Charlson comorbidity index score (4.22 ± 1.32 vs 4.49 ± 1.35, P = .02). Cases with DF and FN did not differ in AAE (20.05% vs 20.20%, P = .94), SAE (12.03% vs 13.19%, P = .51), infectious complication (4.26% vs 4.22%, P = .97), hospital length of stay (7.32 ± 6.73 days vs 7.02 ± 10.67 days, P = .59), or mortality rates (4.51% vs 5.99%, P = .23). Multivariate analyses revealed that fracture type did not impact AAE ( P = .28), SAE ( P = .58), infectious complications ( P = .83), or mortality ( P = .85) rates. Conclusion: Postoperative morbidity and mortality of geriatric patients who sustain DF and FN fractures treated operatively were comparable. This information can be used when risk stratifying and prognosticating for elderly patients undergoing these procedures

Older Age Does Not Affect Healing Time and Functional Outcomes After Fracture Nonunion Surgery

Introduction: Elderly patients are at risk of fracture nonunion, given the potential setting of osteopenia, poorer fracture biology, and comorbid medical conditions. Risk factors predicting fracture nonunion may compromise the success of fracture nonunion surgery. The purpose of this study was to investigate the effect of patient age on clinical and functional outcome following long bone fracture nonunion surgery. Materials and Methods: A retrospective analysis of prospectively collected data identified 288 patients (aged 18-91) who were indicated for long bone nonunion surgery. Two-hundred and seventy-two patients satisfied study inclusion criteria and analyses were performed comparing elderly patients aged ≥65 years (n = 48) with patients <65 years (n = 224) for postoperative wound complications, Short Musculoskeletal Functional Assessment (SMFA) functional status, healing, and surgical revision. Regression analyses were performed to look for associations between age, smoking status, and history of previous nonunion surgery with healing and functional outcome. Twelve-month follow-up was obtained on 91.5% (249 of 272) of patients. Results: Despite demographic differences in the aged population, including a predominance of medical comorbidities ( P < .01) and osteopenia ( P = .02), there was no statistical differences in the healing rate of elderly patients (95.8% vs 95.1%, P = .6) or time to union (6.2 ± 4.1 months vs. 7.2 ± 6.6, P = .3). Rates of postoperative wound complications and surgical revision did not statistically differ. Elderly patients reported similar levels of function up to 12 months after surgery. Regression analyses failed to show any significant association between age and final union or time to union. There was a strong positive association between smoking and history of previous nonunion surgery with time to union. Age was associated (positively) with 12-month SMFA activity score. Conclusions: Smoking and failure of previous surgical intervention were associated with nonunion surgery outcomes. Patient’s age at the time of surgery was not associated with achieving union. Advanced age was generally not associated with poorer nonunion surgery outcomes