Chapters Transcript Prognostic Uncertainty and Complex Medical Decision Making in Trauma Course: Interdisciplinary Palliative Care Conference 2024: Geriatric Trauma and Palliative Care All right, thank you, everyone. It's uh it's an honor to be here today and I'm gonna talk to you a little bit about um medical decision making and uh orthopedic trauma or in fractures in geriatric patients cause a lot of times they present with these injuries and uh it's not as straightforward as treating younger patients, you know, the goals of care are different and uh there are different challenges associated in this patient population. So what I'm gonna be talking about is uh just some general considerations for the geriatric uh patient population, and then I think the, the most important thing that a lot of people want to know about is which patients need surgery and which patients don't. And specifically, I'm gonna go into detail about hip fractures because they're extremely prevalent and uh the hospital administration is very interested in hip fractures because we spend a lot of healthcare dollars in there, and then there's a direct link between hip fracture surgery and risk for mortality. Uh, something that's a little bit less understood is the role of unstable ankle fractures and how that affects geriatric patients, and I'll explain, uh, which one of those may benefit from surgery and which ones don't need it. And then, uh, pathologic fractures, which are generally fractures through uh a bone lesion, usually in the setting of metastatic cancer. A lot of these patients do have malignancies and will come in, uh, because of a fracture through a lesion in a bone and so I'll address, uh, some of the most common malignancies and what the treatment options are for that. So in general, uh, these are patients that are at high risk. They're a vulnerable patient population. OK, they have decreased bone marrow density or osteoporosis, and that puts them at risk for what's called fragility fractures or fractures that uh wouldn't happen in younger patients. As patients also have limited mobility, so they're subject to other risks such as developing venous thrombosis or pneumonia. They have cognitive impairments, so they're not gonna be able to comply with some of the restrictions we give them, you know, if I tell them, you know, you can't walk on your leg for the next 6 weeks, a lot of those patients aren't gonna be able to do that, uh, either because they have a cognitive impairment or they're just not physically strong enough to be able to emulate without putting weight on their leg. They also have a lot of medical comorbidities and cancer like I mentioned, and pathologic fractures, and then sometimes poor nutrition can play a role in terms of uh wound healing and fracture healing. So, a little about osteopenia and osteoporosis, this could be an hour-long lecture by itself, uh, but just briefly, osteoporosis is a bone disease that occurs when the body, uh, either loses too much bone, makes too little bone, or both. And that's according to the Bone Health and Osteoporosis Foundation, and at a bio biologic level, uh, it's an alteration in the body's calcium and phosphate homeostasis, and it leads to decreased bone marrow mineralization and density. So how it's diagnosed is with a DEXA scan, and a lot of people I'm sure are familiar with this image. And basically, we check the density at the, usually in the lumbar spine and in the femoral neck because those are two of the most common places for fractures, secondary osteoporosis, and uh they're compared to something called the T score. And what a T score is, is it compares the bone marrow density of this patient to a healthy 30-year-old female, and then it gives it in terms of standard deviations. So, uh, if it's uh 1 to 2.5 standard deviations less than a healthy 30-year-old female, that's a diagnosis of osteopenia. And if it's more than 2.5 standard deviations below that, that's osteoporosis. There's also something called a Z score, but that's probably outside the scope of this talk. It's where it's compared to uh uh an age and sex matched control, and that's usually in younger patients. And this is extremely prevalent and underdiagnosed. Just looking at 50 year olds, over 20% of females already have osteoporosis by the time they're 50. So when we're looking at 80 and 90 year olds, it's much, much higher. OK. And as I alluded to, osteoporosis leads to fragility fractures. So these are low energy fractures, usually ground level falls, and they occur in metapocele bone, OK? And I know everybody knows the anatomy of a bone, so, you know, the diaphysis is the strong central portion where the cortices are the strongest and the epiphysis is the joint basically. In between there is the metaphysis, so that's kind of the reason where the bone is thinning out and it's going between the strong bone in the center and then the strong bone by the joints. And this can occur all over the body. So hip fractures, obviously, we see it in the knee. In the wrist, and the shoulder. And the other commonplaces in the spine, which is a little different. It's technically not the top seal bone there, but uh at the molecular level there's some of the same changes there that make the bone susceptible to fracture for the same reasons. So they're thinner cortices, the bone is spongy, and it's a transition zone. So the bone is very hard by the joint and the bone is very hard in the center, but then in between there, it's not as strong, and so there's a concentration of mechanical stress, and that's why people, when they're gonna break their bone, it's usually there. OK, so most of these fractures occur in people that have no idea they have osteoporosis. So as an orthopedic surgeon, sometimes I'm the first one that's telling them they have osteoporosis, which is a little weird, uh, but then it's my job to initiate that treatment, which a lot of orthopedists don't necessarily realize and they just think like, oh, OK, the PCP will take care of it. But if the patient doesn't tell them like, you know, I, I had this issue, it's never gonna get worked up. And treating it can be as simple as starting calcium and vitamin D. Usually, once you get into the diagnosis of osteoporosis when you're more than 2.2 standard deviations below, there'll also be some pharmacologic treatments started and the most common of these are are bisphosphonates like uh 1riate here. And a lot of times there's a lot of confusion about will this slow down the rate of fracture healing? And I get a lot of questions from people like do we need to hold the anti-osteoporosis medications and we don't. OK, the bone will still heal at the same rate there. And initiating these medications. It's not gonna help the fracture that they have heal any faster, but it will significantly uh decrease the risk of them having another fracture later. And just like everything else in medicine, the highest risk factor for having a fragility fracture is having a previous fragility fracture. So, starting these medications can really help these patients. So who needs surgery. All hip and femur fractures is a little bit of an asterisk. I'll go into that when I'm discussing hip fractures, but almost all the time, a patient with a hip fracture is gonna get surgery, even non-ambulatory patients, even patients that are near the end of life. Unstable ankle fractures. I'm gonna go into that in a little bit more depth. Open fractures, which is when the bone is actually poking through the skin, there's a direct communication from the outside world and the bone, extremely high infection risk, and so that's an indication for surgery and essentially anyone. And then some pathologic and impending pathologic fractures, which I'll address later as well. In contrast, who doesn't need surgery. So, in the geriatric population, almost all upper extremity fractures can be treated without surgery. There'll definitely be some impairment in function, OK? But in terms of medical comorbidity, survivability, mortality, almost all of these can be treated without surgery. It's a little counterintuitive is most pelvic fractures can actually be treated without surgery, and that's because pelvic fractures in the elderly have different patterns than in the younger patients, and they usually affect uh non-weight bearing portions of the pelvis, and because of that, people are still able to ambulate and bear weight despite not having surgery with pelvis fractures in the elderly. Uh, most vertebral fractures in the spine can also be treated without surgery in the elderly, and, uh, non-ambulatory patients will often not have surgery with the exception of hip fractures, and I'll explain that a little in a minute. The main questions that I always ask myself is, is me doing surgery gonna help this patient be able to get up and walk around? And is me doing surgery gonna provide any sort of pain relief? And if the answer is no to both of those questions, then why am I doing surgery? So going into hip fractures here. So briefly a review of the anatomy, so that the hip is a ball and socket joint, and so the ball is the femoral head, and then the socket is the acetabulum. There's a greater trocant and a lesser trochant, and these are muscular attachment sites, and In an intact bone, the muscles are in a perfect balance between flexion and extension, and it keeps everything stable. Once there's a fracture and it disrupts that balance, then we create large deforming forces, and that's what makes fractures unstable and what makes them unable to heal without intervention. This is a 3D model here looking at the same thing again, and I wanted to add this as well, because specifically in hip fractures, the hip capsule plays a significant role in us deciding what type of surgery we're gonna be able to offer this patient, whether it's a fracture we think is gonna heal, and we can fix it with some kind of plates, screws, or rod, or if it's something that's gonna need to be replaced, OK? The hip capsule is essentially ligamentous attachments between the pelvis and the proximal femur that encases the hip joint itself. And there's the intrajocanteric line is the is between the greater and lesser cancer, and that's an important landmark for decision making as an orthopedist. And then when you add in all the muscles here, you can see why these fractures are very unstable, and they get pulled in every which direction when there's a fracture separating the pieces. So, when we talk about hip fractures, it's a very common term, but it's also very vague. It can mean a lot of different things. However, we're almost always referring to the femur, not to the acetabulum or the pelvis. OK, and that could be in the femoral neck region, which is the area between the inner trochine and the femoral head. And those can be subcapital, which is almost all of them in uh geriatric and elderly patients, right below the head and has very poor healing potential. To be transcervical, this is usually younger high energy patients, you know, motorcycle accidents, things like that. It's not as common in the geriatric population. And then there's something called the Basy cervical fracture, which is rare, but it's a little bit weird. It's an outlier compared to the other two, and that affects treatment, and I'll I'll explain that. In contrast, introcantary fractures, which are the other form of very, very common hip fractures that we say exist between the greater and lesser uh trocants. Standard obliquity is uh kind of in this configuration. But they can also occur in this configuration, which is called reversible liquidy, which is just a little bit more unstable. It's gonna be a more invasive surgery, a little bit more challenging to treat. And then uh they can be 23 or 4 part. And then there's subtrochanteric fractures which are within 5 centimeters of the lesser trochanter up into the femoral shaft there, and uh these can be very challenging to treat because they have massive deforming forces. They're also a very common site for metastatic disease and pathologic fractures, and there's also something called atypical femur fractures that occur in this area as well, that's very common in the geriatric population. Regardless of if it's a femoral neck, inner trochanteric or subtrochanteric fracture, they're all gonna present the same. So they're all gonna have a short and externally rotated leg, they're gonna have a ton of uh pain with any kind of motion. A lot of people, especially ER doctors, they can see a patient from the door and they'll be like, OK, that's a hip fracture because they look very similar. But you need an X-ray in order to be able to know this is a femoral neck, this is inner troke subtroke, and that has big implications in terms of the treatment. OK, so the initial management. So actually admission to the orthopedic service is kind of a paradigm shift. This, uh, traditionally, uh, hip fracture patients were always admitted to the medicine service and then orthopedists would be on a console following to do the surgery and everything. And then, uh, around 2020 out of necessity during COVID, you know, medicine services were extremely overloaded with patients and overwhelmed. A lot of these patients started getting admitted to ortho instead. And we looked at this and we actually realized that uh is a decrease on to stay when people were admitted to orthopedic service. So, probably because the medicine seems to have many more patients on there, it's a lot harder to round on all those patients and to really be pushing the the discharge and then orthopedists are good at getting people out of the hospital, I guess. That's that. Regardless of the admission though, medical co-management is extremely, extremely important, and that's shared authority, responsibility and accountability for the care of the hospitalized patient. Because, to put it frank, if my mom was in the hospital with a hip fracture, I wouldn't want an orthopedist managing her medical conditions. So, On the same token, a medical doctor is not gonna know the specific surgical challenges that we need to, that we need to address. They don't know, are we doing a replacement, are we doing fixation? How invasive is the surgery? Can they bear weight? So it's not something that any one person can take on by themselves. So it requires coordination between services in order to treat these patients. And we know that there's a direct linear relationship between the time to OR and mortality, OK? So we really aggressively push to get these patients into the OR within 24 hours if we can, but definitely within 48 hours. After 48 hours is a significant increase in 1 and 2 year mortality if the surgery is delayed longer than that. And there's less overall complications if they're treated earlier. So in terms of optimization, there's often a point of contention between orthopedists and anesthesia services. A lot of people want echocardiograms. We've looked into this and actually a pre-op echocardiogram is not needed in the majority of patients. It's not actually gonna change their care because this is an urgent surgery and there's not many things that we can modify that quickly that's really gonna affect their surgery within the next 24 hours. And generally, if we delay to get the echocardiogram, it may seem like it's a couple hours, but that can be, you know, a significant difference in a patient with a hip fracture. The one exception is somebody with a systolic ejection murmur or aortic stenosis that can significantly affect the anesthesia plan. So that is one hard indication to get an echo, and unless the surgery is gonna be done under regional or local anesthesia, which actually is a thing, even though it seems crazy. And that can, by not getting all these echocardiograms, we can get people into the OR faster. Blood transfusions. So some people think that you shouldn't give blood pre-op increases the risk of infection, um, and, uh, potentially for mortality. We looked into this and found that it actually does not pre-op transfusion is associated with a 3 time decrease in the rate of pneumonia, and we shouldn't wait till they fall below 7. We gotta get ahead of the game because we know they have a fracture, we know they're bleeding into their thigh, they're gonna have surgery, they're gonna lose more blood. If it's 7.5 today, it's gonna be 6 tomorrow. So we need to start giving them blood ahead of time. So that they're not being as physiologically stressed after. And we do not need to hold anticoagulation. We used to be very worried about people that come in on Eliquis or Xarelto, and we would delay surgery for 48 hours to let it wash out, and the decrease in outcome from the delay is actually much more detrimental to their health than the increased blood loss in the surgery from operating through the anticoagulant. So, um, we operate straight through it. With that being said, we, we looked at this again and we actually found that there was no difference in the recorded blood loss and the recorded rates of transfusion, which again, you have to take us at our word because the blood loss is whatever we say it is during the surgery. So, according to our eyes, it didn't seem different. So, what are our treatment options for hip fractures? So, you can fix them, you can replace them, or you can do something palliative, which is, you know, the kind of the weird option. So, What are our fixation options? Percutaneous screws. We can do uh what's called a sliding hip screw. So this is uh this used to be the gold standard for hip fractures here, um, and it's basically, I don't know if you guys can see my mouse here. So, when you're bearing weight, all the force goes down this axis as it comes through your pelvis and goes into the hip, and this allows the fracture to slide here. There's no threads here, so it can compress, and that increases the chance that the fracture heals. And so this device was revolutionary when it came out cause it greatly increased the amount of healing of hip fractures. We went one step further, and now we do intramedullary nails, which is an even more stable construct, but it's got the same benefit of allowing that sliding and compression at the fracture site. Um, and this can actually be done less invasive than the plate option. This can be done prima mostly percutaneous at this point. My largest surgical incision for an intramedullary nail like this is about 3 centimeters. In terms of replacement options, this is what's called a hemiarthroplasty, and that's in contrast to a total hip arthroplasty. So, a total hip arthroplasty is replacing the femur and the acetabulum ball and socket, whereas a hemiarthroplasty, you're not addressing the socket at all, just the proximal femur. And again, I mentioned hip fractures are usually fractures of the proximal femur. The acetab is not involved and it's still OK, so we don't need to change it. And that saves surgical time, it saves blood loss, and there are also other benefits such as dislocation risk and fracture risk as well. And then palliative options, so there's something called a girdles stone, which is basically we just take the femoral neck out, and this is people that are non-ambulatory, and we're just doing this primarily for pain control. They're not gonna be able to walk, but at least the broken pieces of bone are not hitting each other whenever the patient's transferring in bed, and that can limit their pain control, or or that can limit the amount of pain they're feeling rather. Non-operative management in extreme cases, you know, patients that are, you know, we think are more likely to die by going into surgery, you know, that that's something we'd consider non-operative management. And then there's something called damage control pinning, and I'll address that in a couple slides here, but it's kind of a newer concept that we're uh pioneering out of NYU here. So, how do you know when to fix and when to replace? And that goes back to the hip capsule that I brought up before. It matters if it's an intra or an extra capsular fracture because of its implications and healing potential. OK, femoral neck fractures are intracapsular. They have poor healing potential. OK? In a young patient, you don't want to do a hip replacement in somebody that's 30 or 40 years old because that's probably not gonna last their life. So we have to fix these because it's really our only option. But in an older patient that does very well with a hip replacement, we don't try to fix these, we go straight to replacing it. In contrast, inner trochanteric, subtrochanteric, and then I mentioned Basy cervical is a little bit of the weird one because that actually acts more like an inner trochanteric fracture despite technically being a femoral neck, and that's because it's just outside of where that hip capsule is. And there's a lot of theories as to why, but, you know, people think that it's because the the the capsule causes a tamponade effect, and then therefore there's no blood getting to the fracture site, and that's why the fracture doesn't heal, whereas extracapsular fractures have a great blood supply and they heal pretty reliably. So these are better treated with internal fixation. The way I usually rephrase it to the to the family is, I can fix this hip as opposed to having to replace it. And usually patients are happy when they're able to keep all their original parts. And basically you can draw a line right here at the capsule. If it's to the left, you replace it, if it's to the right, you fix it. OK, that's kind of the the nutshell. All right, so arthroplasty versus internal fixation, arthroplasty is another word for hip replacement. Uh, and so displaced femoral neck fractures versus introcanteric or subtroerkenteric. So, Arthroplasty is considered a more invasive procedure, like I said, a a a nail for a choke and tear fracture, I can do percutaneously, whereas an arthroplasty you can't do percutaneously. You need to have a big open incision to do that. With that being said, our techniques are getting better and better over the years, our incisions are getting smaller and smaller, surgical time is is uh decreasing, and so is blood loss, but it's still never gonna be as low as uh as fixation. Uh, so somebody that's a sicker patient, not gonna be able to tolerate the blood loss, that's somebody that you might wanna hesitate doing an arthroplasty on. However, they do have equivalent outcomes long term. If they survived the surgery and they're able to, to get up and, you know, start ambulating, get to rehab, they do equivalent long term regard, you know, in terms of femoral neck versus inner trope. So, there's something called a valgus impacted femoral neck fracture. This is the exception to the rule, and that's because it's a stable fracture pattern. It basically hinges backwards and then impacts into place, and then it becomes very stable there, OK? And because it's stable, these are the small subset of femoral neck fractures that actually do heal. And because of that, these can be treated with internal fixation with smaller incisions, like the top, the percutaneous screws, I can do with a 2 centimeter incision and that's it, and it can be done under local anesthesia. So it's something that even in extremely sick patients, we can do something to give them more stability and able to transfer and ambulate. In contrast, the majority of femoral neck fractures are displaced in virus and retroversion, so you can see basically the head is falling down. And once it does that, the blood supply is generally torn, it's not gonna heal. You try and fix these and this is what happens. The screws rip out, they they cut right through the bone and they back out, and it causes more problems, uh, 40 to 50% failure rate with internal fixation. And so there's been a lot of work in the last 30, 40 years looking at this, and we've essentially abandoned trying to fix these, except in the sickest of patients. So the best treatment for these is a replacement. Whether that's a hemiarthroplasty or total hip arthroplasty is probably outside the scope of my talk, but some form of replacement is the best treatment for these patients. Debating between the two, total hip arthroplasty, you know, you, you may be able to notice the ball here is a little bit smaller than here, and so because of that, there's a higher dislocation risk with a total hip arthroplasty, so somebody with dementia that's not gonna be able to follow any kind of restrictions afterwards and range of motion, not a good candidate for a total hip. They're probably gonna dislocate easier. Uh, somebody with preexisting arthritis on the other hand, you know, they don't have a good socket. Their socket's already painful. So if I don't do anything to their socket and I just do a hemiarthroplasty, they're gonna continue to have pain and they're not gonna be happy. So that may be someone that you do consider a total hip arthroplasty on. And then cemented versus uncemented, uh, there's increased fracture risk when you don't cement, but you also save time and you save costs, which the hospital likes. Uh, but, quite frankly, I don't really care about the costs. I want the best outcome for the patients, so that this is what I always do, a cemented hemiarthroplasty for these patients unless they're in their 60s, um, and that that's considered still the gold standard, and it has been for many years. In contrast, intro enteric fractures, so they can be 23 or 4 part, as you can see in the 3 pictures here, with uh increasing energy, increasing challenge of surgery, but they're all treated the same way regardless of their 23 or 4 part, and it's really despite the fact that a 4 part fracture is a lot more complex and and more challenging from my standpoint to get it reduced, I can still do the same thing percutaneously with the same size incisions and the same amount of blood loss. They have very large deforming forces, so we usually use a fractured table to neutralize that, which if you've ever seen, almost kind of looks like a torture device where the leg pulled and twisted, but it neutralizes the forces and gets the fracture lined up pretty well, and that's how we can facilitate doing this procedure percutaneously. And again, that can be fixed with either a sliding hip screw or the gold standard now is an intramedullary nail. And this is probably the most common surgery I do because of how common these fractures are. In contrast, subtrochanteric fractures within 5 centimeters of the lesser trochant, these have massive deforming forces, that these are the people that are gonna have their leg twisted up like an accordion and then they're gonna look extremely uncomfortable while they're waiting for surgery. So, we usually put these patients in skeletal traction, which means that we drill a wire or or a a a bolt across their lower leg and we hang weights off of it, and that pulls the leg out to lens, so there's not a big spike of femur sticking up into their skin or into their artery or nerve or something like that. And that actually provides a significant amount of pain control until the patient can get to the OR, which is great for them, and then it also makes the surgery easier because it keeps the muscles from being overly contracted. And then the treatment for these is also an intramedullary nail, but it needs to be a long intramedullary nail that goes the whole length of the bone. Also still a percutaneous procedure. Uh, it just takes a little bit longer surgical time and a little bit increased blood loss, but again, still percutaneous. Atypical femur fractures is something that I briefly alluded to, and these are people that have been on bisphosphonates for, uh, usually over 5 years, and it's kind of a, it's kind of a paradoxical effect. If you take the bisphosphonates for too long, and for whatever reason, in the sub conic femur, they become extremely brittle, and they have repetitive micro trauma and stress fractures, and eventually they'll have an atraumatic, they'll just be walking at the grocery store and pop and they fall and they come into the office with their to the ER with this. And a lot of these people, if you see this on one side, get X-rays of the other side because it's probably there too, and you can intervene before that side breaks, and then that's much easier surgery, much easier recovery. And then again, uh, metastatic disease are pathologic fractures. This is a patient of mine I treated a few weeks ago, and if you look closely here, you can see that doesn't look like normal bone there. There's a, there's a big hole there, and that big hole in his case was actually colon cancer. And so the bone, you know, eventually the, the tumor had eaten away enough of the bone, the bone got very weak, and then he, he didn't even have any kind of fall, he was just walking at home and and twisted wrong and this happened. So, what are we hoping for with any surgery? We want them to be able to bear weight immediately and unrestricted. That is the goal for any of these surgeries. Elderly patients do not do well without being able to bear weight. They don't do well when they're laying around in bed, and they don't do well with trying to comply with, you know, non-weight bearing restrictions. So we wanna do some kind of surgery that's gonna let them be able to bear weight immediately without restrictions. 50% of these patients will decline by one functional level. So what does that mean? That means if they were uh a community amulator, you know, they may be a household amulator after this injury. If they were, you know, a household emulator with a walker, they may not be able to get back to that. OK? So you always have to counsel them that there's probably gonna be some decrease in your mobility after this. Not everybody gets back to the same level of function as they were before. Even in non-ambulatory patients, we still do surgery for hip fractures, and that's because you can't cast the hip, you can't splint the hip. There's nothing really you can do to immobilize that. And anytime you move, whether you're rolling around in bed or trying to sit up or do anything, you're moving through your hip and pelvis. So it's extremely painful to do pretty much anything when you have a broken hip. So, even in somebody that doesn't walk, there's a huge benefit to doing surgery for pain relief, ease of transfers just from bed to toilet, or bed to chair, uh, and providing hygiene for the patients. You can imagine trying just to to clean somebody after using the restroom, if they have a broken hip and you're trying to move their their leg is extremely painful, and that's a huge physiologic stress for geriatric patients, and it can cause a lot of other problems. So the mortality rates, these numbers are quoted all the time. So, mortality after hip fracture 1 year, 25 to 30% of patients will die after a hip fracture one year. Sometimes it's directly related to the surgery, sometimes it's related to their frailty that led them to have the fracture in the first place, uh, and just in general, these patients are old and have a lot of comorbidity, so in some cases it's completely unrelated, you know, but something else is going on. However, if you look at without surgery, It's very, very bad outcomes. 60 to 70% of patients will die in one year if they don't have surgery. So when I'm talking to patients, you know, a lot of times I get comments from family members like, you know, my mom's 97 years old, isn't she too old for surgery? And nobody is too old for hip fracture surgery. I, I, my oldest patient was 104 that I fixed the hip on. So you, you can, you know, basically the, the talk that I give them is that they're at high risk, OK? There is a chance that they won't make it through the surgery. However, if they make it through the surgery, they will have a much better chance at living and recovering and being functional afterwards than without. If we don't do the surgery, They are almost certainly gonna die within the next year or two, OK? Because they do not tolerate being immobilized, they do not tolerate the physiologic stress of a hip fracture. OK? So, I always argue that essentially, everyone is a candidate for hip fracture fixation. And these numbers have been unchanged for the last 30 years. We've been doing studies and NYU in particular, we have a database of about 2000 hip fractures that we do a lot of research on, and these numbers continue to be unchanged. However, this is all comers, this is everybody, you know, the, the healthy person that that fell versus, you know, the old patient that's in the hospital with cancer. This is when you pull everyone together. But not all hip fractures are created equal. So how do we assess risk and how do we try and, and parse out who's at high risk and and who's not. So we have a, a simple intrichoteric fracture here. We wanna do a short intramedullary nail, OK? Our patient may be this 70 year old female here, community ambulator, hypertension, she was playing pickle ball, you know, and, and fell, and she's gonna be a much healthier patient. Then the patient admitted to the hospital that has stents, she has diabetes, she's got metastatic cancer. She's got other injuries, she's got a brain injury, she's got rib fractures, and she was already a household walker, a household amulator with a walker before. They're both 70 year old females, but clearly not the same risk. OK, a patient on the left is gonna be minimal risk, our patient on the right is obviously gonna be very high risk. And if you calculate the numbers, now this patient has a very low chance of them being dead in 2 years, you know, because of this injury, whereas this unfortunate lady on the right, you know, there, there's a 35% chance at least that she's not gonna make it more than 1 year because of everything else going on with her. OK, so we have uh developed here my partner Sonny Konda has uh has really championed uh this for for hip fractures, trying to figure out a way that we can uh better detect who is and isn't at high risk, and uh he developed something called the stigma score or uh score for trauma triage in the geriatric and middle aged. And it takes a bunch of uh objective variables into account age, mechanism, uh Glasgow Coma scale, abbreviated injury score, also called a bidity index, ambulatory status. And then we put that into a website and we calculate a score. And then that score can be used to predict mortality, need for ICU, want to stay, complications, readmissions. It's actually been pretty impressive at the amount of things that we're able to figure out with this. And it seems pretty tedious. It seems like a lot of things that you need to put in there, but this is a a video of my partner Ken Eagle showing exactly how this is done. So you go to the web page up at the top there. There's a little Excel thing here. And just type in the variables. And as you can see on the left there, if you don't remember how to do an abbreviated injury score or Glasgow Coma Scale, there's links there that can help you, you know, figure out how to calculate that as well. So you put in your variables here. And then calculate the score for you. OK, so this patient with these made up numbers comes out with a 4.82. And then we input that into this table that we have here, and we can figure out exactly how high risk they are. And so these are divided up, it's important to note that these are not equal groups, OK? The majority of patients with hip fractures are not gonna be in the high risk category, but the ones that are, are extremely sick and they're extremely different. So the, the, the first category, the minimal risk category, is actually 50% of all patients are gonna be in the minimal risk, and then the next 30% are low risk, so 80% of all hip fractures are actually gonna be in that low risk category, believe it or not. But then the ones that are high risk, you know, the, especially the, the very high risk cohort on the right, that's only the top 5% of patients. But if you look at all of the variables here, mortality, inpatient 30, 30 day, 1 year, major and minor complications, ICU, even discharge disposition. Every single one of these is linearly increased by based on the stigma score and which cohort they're in. So we can based on on that score that we calculate, we can counsel the family on the likely need for discharge to rehab versus home, you know, need for ICU stay afterwards, we can give them a, you know, an idea of mortality, and, and you could see like that there are major differences between the two, you know, one year mortality in the minimal risk group is 4% versus in the high risk group, you know, it's, it's 40%. OK, so it's very good for prognostication and counseling for family members. And the patient So that led us to, to introduce this concept of damage control fixation for femoral neck fractures. And this was uh developed by Sonnyonda in 2021 as a feasibility series, and uh we've continued to do it ever since and we're continuing to, to publish papers seeing on how this actually affects patient care. And what the concept is, is people that have displaced femoral neck fractures that are best treated with an arthroplasty, but we think that they're way too sick to have an arthroplasty right now. And this is usually people that are acutely decompensated, so they're already in the hospital for a heart attack or for pneumonia or a COPD exacerbation, and then they fall while in the hospital and break their hip. So now they have a COPD exacerbation and a hip fracture, and they're getting tachycardia and dys dyspnea from their pain. On top of they already have a COPD exacerbation, so you can see how this is a very, very sick patient and very high risk. So, taking this patient for an arthroplasty may not be the best idea right now, but you also don't want to leave them in bed rolling around with a broken hip because that's extremely painful and a huge physiologic stress. So we decided like, is there anything we can do to try and help these people? So, we do what's called close reduction percutaneous pinning, which is usually with cannuated screws like you see in this image on the right here. And this can be done under local anesthesia, and just a little bit of sedation, infiltrate the area with anesthesia, and, and, you know, we can do it with minimal anesthetic risk in that sense, and It's minimally invasive, it allows them to mobilize, it provides some pain relief. And when we compare the outcomes between hemi arthroplasty and those patients that have this fixation, significantly less minor complications in the uh penning group versus hemi arthroplasty, and not surprising, the complications that we see less of our anemia because of smaller incisions and a smaller surgery, and then acute renal failure, which I guess could be due to a lot of reasons. The important thing also is that they're still able to emulate at the same ability, at least in the short term, the length of stay is about the same, and the major complications of mortality is about the same. OK. There is a 20% failure rate. However, historically that was 40 to 50%. So we've shown that uh with proper technique, proper reduction of um of the fracture, uh, it's actually decreases the failure rate, and most of them do occur early if they are gonna fail. However, if you get them through their acute period, you know, if they get through their acute MI or their COPD exacerbation, we can then return and convert them to a hemiarthroplasty more electively, and it's a much, much safer procedure at that point. So that's kind of the whole concept that we have here. OK. In terms of postoperative care. Ambulation, getting out of bed. That is the most important thing for all hip fracture patients. People that are able to ambulate on post-op day one compared to those that are not, have a 5 times lower uh risk of inpatient mortality, a 2 times lower risk of 1 year mortality, and also a significantly lower length of stay. OK, so I always tell the physical therapist that priority one of all the patients on their list should be all the post-op day one hip fractures. They absolutely need to be get uh taken out of bed and, and even if it's just bed to chair. That is a lot for a patient with a hip fracture. So just doing that is gonna significantly improve their outcome. Patients to stay around in bed, they get pneumonias, they get uh venous thromboembolism, they get pressure wounds, they get deconditioning, they don't do well. What about this position? So, We've also used the Sigma tool to help stratify who's gonna go to rehab and who's gonna be able to go home, and we've proven that that's reliable. Skilled nursing facilities we've shown have an increased risk of major and minor complications and overall greater costs, and then home discharges associated with lower rates of readmission and complications. However, you know, this data does need to be taken with a little bit of a caveat because, uh, with a grain of salt because. Uh, you know, if you're gonna be able to be discharged home, you're probably a healthier patient in the first place and so you're obviously gonna be at less risk of complications. So we are still gathering more data on this, but we do try and get people home as opposed to rehab when when possible. Uh, the other good thing about going home is that your family is there taking care of you and almost universally patients tell me that they feel like they receive better care with their family members than they do in, in a nursing facility or a rehab. So to summarize hip fractures, Almost all of them are treated surgically for pain relief and mobilization. As soon as possible, to decrease mortality. Arthroplasty for femoral necks, intrame nails for introgue and subtrope, 50% decline one functional level, 1 year mortality 25 to 30. Stigma tool to assist in uh risk stratification for high risk patients and damage control pending can be considered for high risk patients. And that ambulate as soon as possible post-op. OK. I want to throw one slide in here about distal femur fractures. I didn't wanna go too in depth cause this could be its own talk by itself, but these are almost all treated surgically as well for all of the same reasons as hip fractures, basically. You don't want people sitting around in bed, you want them to mobilize, you want pain controlled. A stable construct to allow them to walk right away. You can do nails, you can do plates, you can do both, or you can do uh replacements. And again, I won't get into the depth into the details, but it seems similar fixation principles. You know, something in the joint that's very common in there, a lot of pieces is gonna get it replaced. Something that's in the shaft of the bone or metaposis is gonna get fixed with a uh late or nailed. Similar 1 year mortality, 25%, and the stigma tool has also been shown that we can predict outcomes for these patients as well, similar to head fractures. And they also need to emulate as soon as possible post-op and be discharged home when able. So, uh, we've trained our residents now they calculate the stigma score on every single fracture that comes in, and so when I get, you know, uh uh an email in the morning with all the consults from overnight, it's already in there calculated by then. So moving on to ankle fractures. So, again, brief review of anatomy, it's a 3D image on the top, X-ray at the bottom. There's a lateral malleolus, which is the the fibula bone. The distal tibia, the lion is the actual weight bearing dome of the uh of the tibia, the medial malleolus on the medial side, and then on the lateral view, you could see what's called the posterior malleolus, which is the posterior lip of the ankle, and I'll explain why that's important. There's also ligamentous connections between the two that hold the ankle stable. So basically, the tailless bone or the square in here needs to be locked into the ankle and not be able to move. If that's able to move, there's instability and that uh people aren't gonna do well. So, they can be isolated about malleolus fractures. It's the most common type of fracture, could be isolated medial, they can be bimaleolar, which means that uh two or more are broken, and these are unstable, so medial and lateral, or lateral and posterior, you can see how compared to the images above, these look a lot more unstable. And then there could be trimal which all three are broken, and as you can see in the the image on the right at the bottom there, usually the talus gets dislocated out the back. So these are by far the most unstable, and it's very hard to treat these without surgery. It's also something called a Pon fracture. So that's different. All the other ones are rotational injuries. A Pilon fracture is an axial load injury. So it's basically a fall from height, uh, you know, a, a car accident where dashboard comes in, something like that, where there's an axial load, and these do very poorly. So these usually should be treated surgically as well. So, medial and lateral isolation are usually stable. In a young patient, we would do a stress test and you could see, oh, when we stress it, the ligaments must be injured, the talus can move in there. So that's somebody that would probably get surgery because if we leave it like that, they're probably gonna develop post-traumatic arthritis within a number of years. However, in the geriatric population, we're not really worried about them getting arthritis, you know, they're not gonna live long enough to develop symptomatic arthritis, so. These can be treated non-operatively in geriatric patients. So again, you want something they're gonna be able to walk on. So, I usually use boots like the lady on the left, but you can also do walking casts, and they work the same as well. Ballutrivale and peon fractures are very unstable. So this is a patient of mine from a couple of months ago, an 89 year old lady that, uh, came in, she fell off the toilet and had this injury. And so, uh, you know, I told them like, wow, that's pretty unstable. She probably needs surgery, and, uh, you know, my resident did a great job. He put it into a splint, it looks awesome. And, you know, he told me the sun is there, she doesn't really walk, she's in a wheelchair all day, they don't want surgery. So I was like, all right, let's try it, let's see what happens. In my office a week later and it displaces again. These are very unsealed, they're not gonna stay put, even in a cast, even in a split. So these are strongly considered surgery. But why? Like, what does it matter? Are we really worried about arthritis like I mentioned? No. But then you get patients that come in like this. This is a patient of my partners that literally walked into his office with these X-rays, bearing weight on this ankle. And it's a problem because, so that they have dementia, they don't even realize that they have a deformity in their ankle. They have neuropathy, they can't feel anything, so it's not even hurting. They're they're walking on this ankle and it's totally painless. But why is that a problem? Because you can see where that red arrow is, the bone is right up against the skin there, and old people don't have great quality skin. And that bone can rip right through there, OK? And then they come into your office and you're looking at the bone, and then that's a problem because they don't heal, OK? They have 4 vasculature. You call plastic surgery and ask them to do a free flap, and they're just like, come on, this lady's 90, she's not gonna tolerate a free flap either. So then it's like, what options do you have? The bones sticking out, they get septic arthritis, they get osteomyelitis of the bone. And at least amputations. OK, and old people do not do well with amputations. OK, so it may look like it's a benign ankle fracture, but we need to treat them very seriously so that they don't end up like this. Ankle fractures in elderly, also, we can't fix them the same way. They don't do as well. They have poor bone, they have 4 soft tissues, and they can't stay off of it. So we have to use other techniques. When we try standard stuff, it falls apart. OK, so increased wound complications, hardware failures, we need to do something different. So there's something that's called tibiolocalcaneal arthrodesis or TTC nailing for short, and it's something that can be done percutaneously and it lets them immediately bear weight. So you essentially send a rod through the bottom of the heel right up into the tibia. OK, it seems kind of crazy, but I will let this patient walk on this right after surgery with no splint or cast or anything. OK? Immediate weight-bearing, smaller incisions, so less risk of infection or wound breakdown. And this can also be done under regional or local anesthesia, so minimal anesthetic risk as well. How do they do? So this is kind of a newer technique. There's not a lot of research, not on it yet, but uh uh a prospective randomized study out of Greece looked at 43 versus 44, and they found about a uh a quarter of the complication rate with the TTC nailing as opposed to conventional techniques, shorter length of stay and no difference in functional scores, because they're a low functioning population at baseline, the fact that you're sacrificing motion in the joint usually doesn't affect their overall function. And a retrospective, or sorry, a systematic review also show that most of these actually do go on the heel, 95% union rate, and almost all of them can get back to their pre-injury mobilization status, in contrast to hip fractures, where a lot of them lose it. Most of these, if you treat them fast and get them rehab fast, you can get them back to what they were doing before. 19% overall complication rate, 11% required surgery. So it's not perfect. There's still gonna be complications, you know, they still have poor quality bone, but it's much, much lower risk than the conventional techniques. So it is a trade-off though. OK, the pros, they can bear weight right away, smaller incisions, decrease complications, but on the other hand, you have to tell them like, you're not gonna be able to flex and extend your ankle anymore, it's gonna be fused right there. You'll have a little bit of motion through the fore foot, but you're not gonna be able to move your ankle the way you were before. In younger patients that are gonna live longer, that does lead to increased stress on the other joints and probably will lead to progression of arthritis in the other joints. So these are usually patients with a limited life expectancy, elderly. This is an irreversible procedure. You can imagine if I send a huge rod through the ankle, even if I take it out, it's gonna be a big hole there, so it's not something I can undo later. So you need to know your patient, you need to clearly articulate your goals of care, and you need to have everybody on the same plan before you move forward. All right, so lastly, I just want to go a little bit into pathologic fractures and cancer. So, uh, 1.7 million new cancer diagnoses per year and 50% of these will develop bony metastases, the second most common place to metastasize to. And that's in contrast to there's only about 4000 new bone sarcomas in this country per year. That's only 0.2% of all cancers. But it's generally important to know the difference, because for a primary bone sarcoma, we're usually trying to do a curative procedure where we cut the entire tumor out, versus in a metastatic cancer, we're doing something palliative to provide pain control and ability to ambulate. So, any lytic lesion in in an adult requires further workup to determine if it's gonna be metastatic disease or if it's a primary bone sarcoma. And the other thing is infection can prevent present like this, you know, an abscess in the bone can look like a tumor, so that's always something that's gotta be in the differential as well. So, tumors that go to the bone, breast, lung, thyroid, kidney, prostate, and then much less common as GI uh ortho residents always memorize BLT with a kosher pickle, and so, Uh, you know, in, in most of these, it's gonna be a lytic bone lesion, but sometimes it can be blastic where it builds bone. It's usually prostate cancer. And, um, almost everybody, you know, we're we're all taught that when you see an elderly patient with a wooded bone region, that's myeloma lymphoma, and you rule all three of those out, you start looking for other stuff after. So, what's the workup? History and physical on everyone, labs on everyone. Specific things are gonna have different abnormalities in the labs, uh, you know, a lymphoma is gonna have a, you know, uh, abnormalities on the CBC, um, if you're worried about myeloma, uh, protein electrophoresis is gonna, is gonna be able to diagnose that, tumor specific markers if they have a history of something, uh, imaging of the whole bone, MRI with and without contrast. Basically, you're gonna, you're gonna work up everything. And it needs to be biopsy proven before ruling out definitive treatment because they could have a second primary. They could have a history of breast cancer but then develop an osteosarcoma in their leg and, you know, I, I think that I am just, uh, you know, putting a rod in their leg to, to stabilize their breast cancer, and turns out I put a rod through their osteosarcoma, and now they have osteosarcoma through their whole femur. And so at that point, it would have just been a resection of the tumor, now it's a resection of the whole femur or amputation. So that's why we need to rule out a primary sarcoma. And that's with a CT guided biopsy, or the gold standard is still an open surgical biopsy. But what it, you know, in, in the elderly patients, I get asked this all the time by family, like, does it matter? We don't really care if it's breast cancer, we don't care if it's our sarcoma. We know they're 95 years old, they don't have a lot of time to live. It can still make uh big differences in treatment of these these uh tumors because uh certain tumors have different characteristics that you're gonna have to address, uh, that other tumors don't necessarily have. So you need to consider what the primary malignancy is and the prognosis. Is there any role for non-operative management? So some tumors like multiple myeloma are extremely radio sensitive, and so you can radiate these and they will shrink, and they will ossify like this lesion here. Also, bisphosphonates can help with decreasing the amount of lysis of the bone from tumors. And what about impending pathologic fractures? So that's something that doesn't have a fracture yet, but they have a huge hole in their bone and it looks like it's gonna break any minute now. So there's something called the Moll score. So, uh it's calculated like this upper lower extremity periteranteric, and we calculate a score to determine exactly how high the risk is. The most important one to me is the pain score. So mild, moderate, or functional. It's a little weird, or, you know, people always ask me what does functional pain mean? And so mild and moderate pain, that's the tumor destroying the bone. OK, that's a painful process, that's gonna be there all the time. OK. Functional pain is only there when they're trying to get up, trying to move around. When they're at rest, it doesn't hurt at all. That might sound like a good thing. But that's actually bad because that lets you know the pain that they're feeling when they're getting up is the bone about to break. OK, so anybody with functional pain is somebody that I'm generally rushing to the OR to fix before it breaks. Anything with a score of 8 or higher warrants fixation. So a quick example of how that's done. Here's a patient with a lesion, periticenteric, with a bone lesion, moderate pain. And it's between 1/3 and 2/3 diameter. So this is 10 points, prophylactic fixation. So, in terms of who needs surgery, it's gonna be a goals of care discussion with the patient and family. These patients are obviously very sick, needed to consider their overall prognosis, their ability to ambulate even before the injury. Are they having a ton of pain? Is, is surgery gonna help relieve some pain? And what's their overall function? Similar principles to fragility fracture fixation in the in these patients, the bone quality is still, is still poor. Uh, most hip and lower extremity fractures are gonna need surgery and most upper extremity, spine and pelvis fractures can be managed without surgery. And the same questions. Will a surgery help this patient mobilize? Will the surgery provide pain relief? If the answer is yes to one of those questions, you should consider surgery, even if they seem like a very sick patient. The goals of care, these patients have limited life expectancy and they have poor potential for bony healing. It's pathologic bone, a lot of it's been radiated. They broke through a tumor. So even if I stabilize the bone and I line it up nice and straight, there's tumor there, OK? And the bone is not gonna heal through the tumor. So a lot of these, these uh fractures don't ever heal. And so we have to put in something that's gonna hold the bone stable despite the fact that it's not gonna heal. And essentially it's a race, you know, it's it's what's gonna fail first. Is the patient gonna die, or is this implant gonna fail? And so you wanna do something that you're hoping is gonna outlive the patient, as as morbid as that may sound. You know, it's the goals of surgery, you want to add extra fixation to at least last the rest of their life so that they don't need to have a second surgery. And again, immediate weight bearing and function, weight bearing is tolerated. Uh, some specific, uh, considerations you want to add additional fixation, so a lot of things will like curettage the lesion out and uh pack it with cement to try and increase the stability there, decrease the rate that the rod will break. Um, certain tumors like renal cell and thyroid are extremely vascular, so I may go in there trying to do a little percutaneous procedure to put a rod in and go right through an extremely vascular tumor, and then all of a sudden I'm going to get the catastrophic blood loss and this patient's like at risk of dying on the table, and that's because I didn't biopsy ahead of time, I didn't know what I was dealing with, and if I had known, I could have embolize this ahead of time. And then significantly decrease the morbidity, the procedure and the blood loss. So that's why it's still important to get a diagnosis, even if they're 95 years old and you don't really care about, you know, where it came from, we still need to know for the treatment. And then peri-articular fractures, we can replace pretty much anything now, hips, knees, shoulders, like, anything that's highly common like that. If it's somebody that does have more than a couple of months to live, we sometimes will consider replacing it to give them better long-term function. So in terms of outcomes, overall, it's very similar to the geriatricracor population as a whole, with the exception that there are increased complications because these patients are just sicker overall. And the best outcomes are are a multidisciplinary approach. This is not straightforward at all. So most hip fractures I talked about, it's usually medicine co-management and ortho, and then obviously nursing, physical therapy, social work plays a role in there as well. In oncology patients, it's even more complicated. Radiation oncology plays a role because a lot of these tumors can be radiated, palliative care. is kind of the theme of the day, so obviously we want them to be involved. Uh, pain management, so nerve blocks can go a long way in geriatric patients. And so I try and advocate to get nerve blocks on every single one of my hip fractures because it helps them get out of bed and helps them mobilize. So I think uh pain management should be, should be heavily involved and emphasis on early ambulation. Old people don't do well when they're sitting around in bed. They need to get out of bed, they need to walk. And then obviously DVT prophylaxis cancer patients are gonna be at higher risk of uh venous thromboembolism. Orthopedic patients in general are at very high risks, and now these patients are at even higher risk, so it's something you never want to forget about. So, to conclude, geriatric patients high risk for fragility and pathologic fractures. They do not tolerate immobilization, increased overall complications when they're laying around, and mortality. Unique surgical and postoperative challenges in these patients, upper extremity, spine and pelvis can usually be treated conservatively. Lower extremity usually requires surgery. Pain control, immediate unrestricted weight bearing are the goals of surgery because you want them to be able to walk. And best outcomes are with a multidisciplinary approach. Thank you. OK. The on button. Um, thank you so much. This is incredible. Um, I'm one of the geriatric co-management doctors at Morningside working with the ortho team on so many of these patients. Um, I'm wondering if you have any advice for the patient who clearly needs sub-acute rehab, the 95 year old, relatively functional and cognitively intact, uh, who's essentially just wants to go home. Do you have any advice should I be pushing harder for SAR or do those patients, can they do OK at home? So a lot of it depends on family. If they have family support, um, that's huge, and, and, you know, family support can be very variable that some of these patients will have children that are on top of every single aspect of their care. They will get them up out of bed, they will keep a close eye on them so that they're not getting pressure wounds and things like that. And in that situation, I think that is safe, especially because You have somebody that's reliable that if there is an issue, they're gonna call and be like, hey, we tried this, it didn't work out. I think we need to reconsider this thing for rehab. And I've had that happen a number of times, you know, the family wanted to take them home, but just realized they were overwhelmed when they got there. Uh, but it's definitely an option. And so if they do have that support, I think that the patients are certainly happier when they're at home. It can be very depressing being in rehab and then there's also, you know, sundowning and disorientation that can happen there, which can, uh, you know, affect their outcomes as well. Um, so I think, you know, it's definitely important to make them feel like they're actively participating in the process. I will usually tell them ahead of time, like a lot of people that are your age that have this injury do need to go to rehab, so don't be surprised if that's presented to you, but it'll depend on how you're doing with therapy, how you're feeling, and, you know, what the overall situation is. Do you have a lot of stairs at home, you know, does your, do your kids live with you, things like that. Um, and then you just have to get everybody on the same page, but I don't think it's unreasonable if they really, really want to go home and they have support, I think that's a good option for them. And I just had one other big difference between acute and SAR in rehab. Uh, I have a lot of patients that are kind of on the line, and I, I don't know if there's actually a huge difference if I should be pushing for acute rehab. Um. I don't know all the finer details of what the admission criteria are between uh uh acute and SAR. I know, I, I, I experienced that as well. A lot of them have very specific ideas or not even the patient as much as the children have very specific ideas of where they want their mom to go. A lot of it has to do with like how much exercise they're able to tolerate a day, you know, are they gonna be able to tolerate the amount of therapy they're gonna get at inpatient rehab, and if the answer is no, that's usually when some acute rehab is, is more appropriate. So I think when we're um having discussions with family about uh um. Goals of care and we're talking about invasive procedures, we typically have a gestalt for who's too sick to undergo quote procedures overall, but with orthopedic procedures, obviously that threshold is much higher because we are operating on very, very sick patients. And that that study that you showed where uh they had to score high risk before they got the pins, that high risk category was 95% to 100%. Yeah, that that's the top 5% of patients. So let's say. Their, uh, score was like 90%, um, it like, do you, uh, in your practice, are you using that as sort of a cutoff or if, if there's kind of an intermediate risk still a discussion. It's still a discussion with the family, and I tell them that like we can do this procedure, it's less risky. Like, you know, there's a higher failure rate, 20% failure rate, and if it fails, you know, we can go back to convert you later. And some of them will say, no, I don't want two surgeries. Like, give me the surgery that you think is gonna be best. Even if it's higher risk, and you know, if that's if they're informed about that and that's the way they want to proceed, then even if they're they're in that high risk category, we may still proceed with an arthroplasty. So, so it's a discussion. I is there, is there like a lower threshold before you will offer that kind of palliative? So I won't offer it in anybody in the first two categories. It'll, it's generally just that top one. Sometimes I'll offer it in, in the, uh, in the second category, you know, in special circumstances. Published May 3, 2024 Created by Related Presenters Steven Rivero, MD View full profile
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