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Ghoshal S, Stovall N, King AH, Miller AS, Harris MB, Succi MD. Orthopedic Surgery Volume Trends During the COVID-19 Pandemic and Postvaccination Era: Implications for Healthcare Planning. J Arthroplasty 2024:S0883-5403(24)00244-4. [PMID: 38513749 DOI: 10.1016/j.arth.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 03/10/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND The Coronavirus Disease 2019 (COVID-19) pandemic decreased surgical volumes, but prior studies have not investigated recovery through 2022, or analyzed specific procedures or cases of urgency within orthopedic surgery. The aims of this study were to (1) quantify the declines in orthopedic surgery volume during and after the pandemic peak, (2) characterize surgical volume recovery during the postvaccination period, and (3) characterize recovery in the 1-year postvaccine release period. METHODS We conducted a retrospective cohort study of 27,476 orthopedic surgeries from January 2019 to December 2022 at one urban academic quaternary referral center. We reported trends over the following periods: baseline pre-COVID-19 period (1/6/2019 to 1/4/2020), COVID-19 peak (3/15/2020 to 5/16/2020), post-COVID-19 peak (5/17/2020 to 1/2/2021), postvaccine release (1/3/2021 to 1/1/2022), and 1-year postvaccine release (1/2/2022 to 12/30/2022). Comparisons were performed with 2 sample t-tests. RESULTS Pre-COVID-19 surgical volume fell by 72% at the COVID-19 peak, especially impacting elective procedures (P < .001) and both hip and knee joint arthroplasty (P < .001) procedures. Nonurgent (P = .024) and urgent or emergency (P = .002) cases also significantly decreased. Postpeak recovery before the vaccine saw volumes rise to 92% of baseline, which further rose to 96% and 94% in 2021 and 2022, respectively. While elective procedures surpassed the baseline in 2022, nonurgent and urgent or emergency surgeries remained low. CONCLUSIONS The COVID-19 pandemic substantially reduced orthopedic surgical volumes, which have still not fully recovered through 2022, particularly nonelective procedures. The differential recovery within an orthopedic surgery program may result in increased morbidity and can serve to inform department-level operational recovery.
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Affiliation(s)
- Soham Ghoshal
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts
| | - Nasir Stovall
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts
| | - Alexander H King
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts
| | - Amitai S Miller
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts
| | - Mitchel B Harris
- Harvard Medical School, Boston, Massachusetts; Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Marc D Succi
- Harvard Medical School, Boston, Massachusetts; Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, Massachusetts
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Brameier DT, Tischler EH, Ottesen TD, McTague MF, Appleton PT, Harris MB, Weaver MJ, Suneja N. Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention. J Orthop Trauma 2024; 38:148-154. [PMID: 38385974 DOI: 10.1097/bot.0000000000002753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 02/23/2024]
Abstract
OBJECTIVES To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours. METHODS DESIGN Retrospective cohort study. SETTING Three academic Level 1 trauma centers. PATIENT SELECTION CRITERIA Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC. OUTCOME MEASURES AND COMPARISONS Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality. RESULTS Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons). CONCLUSIONS Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Devon T Brameier
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Eric H Tischler
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Taylor D Ottesen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael F McTague
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and
| | - Paul T Appleton
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nishant Suneja
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Striano BM, Patel SS, Parker E, Vaughn JJ, Smith JT, Harris MB, Chiodo CP. The Use of the Lateral Tibial Line to Assess Ankle Alignment: A Preliminary Investigation. J Am Acad Orthop Surg 2024; 32:41-46. [PMID: 37580051 DOI: 10.5435/jaaos-d-23-00271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/27/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Although the medial clear space (MCS) is commonly used to assess talar alignment and ankle stability, its measurement is variable with multiple reported normal values. We have observed that the lateral tibial shaft is a reliable landmark to assess talar alignment. The objective of the current investigation was to determine the normal relationship of the lateral tibia to the superolateral talus using a tangent drawn inferiorly from the lateral tibial shaft, which we refer to as the "lateral tibial line" (LTL). METHODS The relationship of the LTL to the superolateral talus was assessed by three reviewers on 99 standing ankle mortise radiographs in uninjured patients. This relationship was quantified by measuring the distance (in millimeters) between the LTL and the superolateral talus. In addition, the interobserver reliability of the LTL measurement was recorded and compared with that of the MCS. RESULTS The median value for the distance between the superolateral talus and LTL was -0.50 mm with an interquartile range of -1.4 to 0.0 mm. The LTL was within 1 mm of the lateral talus in 176 of 297 reviewer measurements (59.3%). Moreover, it was either lateral to or at most 1 mm medial to the lateral talus in 90.9% of cases. The LTL measurement also demonstrated good interobserver reliability (0.764, 95% confidence interval, 0.670 to 0.834), similar to the measurement of MCS (0.742, 95% confidence interval, 0.539 to 0.846). CONCLUSIONS The relationship between the LTL and superolateral talus is easily measured with good reliability for assessing the anatomic relationship of the tibia and talus. The LTL uncommonly fell more than 1 mm medial to the superolateral talus, as might be seen with displaced ankle fractures. These findings will hopefully serve as a basis for future studies evaluating its role in assessing lateral displacement and stability of isolated fibula fractures. LEVEL OF EVIDENCE Level III, retrospective review.
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Affiliation(s)
- Brendan M Striano
- From Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA (Striano), the Department of Orthopaedic Oncology, the University of Texas MD Anderson Cancer Center, Houston, TX (Patel), the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA (Parker, Smith, and Chiodo), Maine Medical Center, Portland, ME (Vaughn), and the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Harris)
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Nguyen AT, Aris IM, Snyder BD, Harris MB, Kang JD, Murray M, Rodriguez EK, Nazarian A. Musculoskeletal health: an ecological study assessing disease burden and research funding. Lancet Reg Health Am 2024; 29:100661. [PMID: 38225979 PMCID: PMC10788788 DOI: 10.1016/j.lana.2023.100661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 12/11/2023] [Accepted: 12/19/2023] [Indexed: 01/17/2024]
Abstract
Background Exacerbated by an aging population, musculoskeletal diseases are a chronic and growing problem in the United States that impose significant health and economic burdens. The objective of this study was to analyze the correlation between the burden of diseases and the federal funds assigned to health-related research through the National Institutes of Health (NIH). Methods An ecological study design was used to examine the relationship between NIH research funding and disease burden for 60 disease categories. We used the Global Burden of Disease (GBD) Study 2019 to measure disease burden and the NIH Research, Condition, and Disease Categories (RCDC) data to identify 60 disease categories aligned with available GBD data. NIH funding data was obtained from the RCDC system and the NIH Office of Budget. Using linear regression models, we observed that musculoskeletal diseases were among the most underfunded (i.e., negative residuals from the model) with respect to disease burden. Findings Musculoskeletal diseases were underfunded, with neck pain being the most underfunded at only 0.83% of expected funding. Low back pain, osteoarthritis, and rheumatoid arthritis were also underfunded at 13.88%, 35.08%, and 66.26%, respectively. Musculoskeletal diseases were the leading cause of years lived with disability and the third leading cause in terms of prevalence and disability-adjusted life years. Despite the increasing burden of these diseases, the allocation of NIH funding to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) has remained low compared to other institutes. Interpretation Despite the increasing health burden and economic cost of $980 billion annually, the allocation of NIH funding to the NIAMS has remained low compared to other institutes. These findings suggest that the NIH may need to reassess its allocation of research funding to align with the current health challenges of our country. Furthermore, these clinically relevant observations highlight the need to increase research funding for musculoskeletal diseases and improve their prevention, diagnosis, and treatment. Funding No funding.
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Affiliation(s)
- Andrew T. Nguyen
- Harvard Medical School, Boston, MA, USA
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Izzuddin M. Aris
- Division of Chronic Disease Across the Lifecourse, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Brian D. Snyder
- Harvard Medical School, Boston, MA, USA
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Mitchel B. Harris
- Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - James D. Kang
- Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Martha Murray
- Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Edward K. Rodriguez
- Harvard Medical School, Boston, MA, USA
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ara Nazarian
- Harvard Medical School, Boston, MA, USA
- Musculoskeletal Translational Innovation Initiative, Carl J. Shapiro Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Orthopaedic Surgery, Yerevan State University, Yerevan, Armenia
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Silvestre J, Ahn J, Mehta S, Harris MB. Impact of the SARS-CoV-2 outbreak on ACGME-accredited orthopaedic trauma fellowship training. Injury 2023; 54:111137. [PMID: 37919113 DOI: 10.1016/j.injury.2023.111137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/07/2023] [Accepted: 10/14/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION The SARS-CoV-2 viral outbreak created unprecedented challenges in surgical education. Yet, its impact on reported case volume during orthopaedic trauma fellowship training remains poorly understood. We hypothesized that cases performed during orthopaedic trauma fellowship training would decrease by 8 %-17 % during the 2019-2020 academic year corresponding to the 1-2 month moratorium of non-essential cases during the initial SARS-CoV-2 outbreak in the United States. METHODS We designed a retrospective cohort study of orthopaedic trauma fellows at Accreditation Council for Graduate Medical Education (ACGME)-accredited training programs (2018-2019 to 2021-2022). Mean case volumes were compared by case category across academic years. RESULTS There was a -13 % year-over-year decrease in reported case volume during the 2019-2020 academic year (505 ± 126 vs 441 ± 94, P = 0.079, Fig. 1). Case categories with the greatest percentage declines were Treatment of Nonunion / Malunion (-31 %), Fasciotomy (-25 %), External Fixation (-21 %), Forearm / Wrist (-21 %), and Intra-articular Distal Humerus Fracture (-17 %). There was a 7 % year-over-year increase in case volume during the subsequent 2020-2021 academic year with near universal increases in case volume across case categories. CONCLUSION There was a 13 % decrease in orthopaedic trauma case volume during the 2019-2020 academic year, corresponding to the SARS-CoV-2 outbreak. Certain trauma case categories experienced the greatest negative impact, which subsequently recovered during the next academic year. These results may help inform accrediting bodies and surgical educators on the impact of future viral outbreaks on orthopaedic trauma fellowship training.
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Affiliation(s)
- Jason Silvestre
- Medical University of South Carolina, Charleston, SC, United States.
| | - Jaimo Ahn
- University of Michigan Medical School, Ann Arbor, MI, United States
| | - Samir Mehta
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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Lightsey HM, Yeung CM, Rossi LP, Chen AF, Harris MB, Stenquist DS. OrthoPass: Long-term Outcomes following Implementation of an Orthopaedic Patient Handoff Template. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202312000-00002. [PMID: 38011052 PMCID: PMC10664846 DOI: 10.5435/jaaosglobal-d-23-00208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 10/01/2023] [Indexed: 11/29/2023]
Abstract
Standardized handoff tools improve communication and patient care; however, their widespread use in surgical fields is lacking. OrthoPass, an orthopaedic adaptation of I-PASS, was developed in 2019 to address handoff concerns and demonstrated sustained improvements across multiple handoff domains over an 18-month period. We sought to characterize the longitudinal effect and sustainability of OrthoPass within a single large residency program 3.5 years after its implementation. This mixed methods study involved electronic handoff review for quality domains in addition to survey distribution and evaluation. We conducted comparative analyses of handoff adherence and survey questions as well as a thematic analysis of provider-free responses. We evaluated 146 electronic handoffs orthopaedic residents, fellows, and advanced practice providers 3.5 years after OrthoPass implementation. Compared with 18-month levels, adherence was sustained across five of nine handoff domains and was markedly improved in two domains. Furthermore, provider valuations of OrthoPass improved regarding promoting communication and patient safety (83% versus 70%) and avoiding patient errors and near misses (72% versus 60%). These improvements were further substantiated by positive trends in Agency for Healthcare Research and Quality Surveys on Patient Safety Culture hospital survey data. Thematic analysis of free responses shared by 37 providers (42%) generated favorable, unfavorable, and balanced themes further contextualized by subthemes. At 3.5 years after its introduction, OrthoPass continues to improve patient handoff quality and to support provider notions of patient safety. Although providers acknowledged the benefits of this electronic handoff tool, they also shared unique insights into several drawbacks. This feedback will inform ongoing efforts to improve OrthoPass.
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Affiliation(s)
- Harry M. Lightsey
- From the Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA (Dr. Lightsey); the Rothman Orthopaedic Institute/Thomas Jefferson University Spine Fellowship Program, Philadelphia, PA (Dr. Yeung); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Rossi, Dr. Harris, and Dr. Stenquist); and the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Dr. Chen)
| | - Caleb M. Yeung
- From the Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA (Dr. Lightsey); the Rothman Orthopaedic Institute/Thomas Jefferson University Spine Fellowship Program, Philadelphia, PA (Dr. Yeung); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Rossi, Dr. Harris, and Dr. Stenquist); and the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Dr. Chen)
| | - Laura P. Rossi
- From the Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA (Dr. Lightsey); the Rothman Orthopaedic Institute/Thomas Jefferson University Spine Fellowship Program, Philadelphia, PA (Dr. Yeung); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Rossi, Dr. Harris, and Dr. Stenquist); and the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Dr. Chen)
| | - Antonia F. Chen
- From the Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA (Dr. Lightsey); the Rothman Orthopaedic Institute/Thomas Jefferson University Spine Fellowship Program, Philadelphia, PA (Dr. Yeung); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Rossi, Dr. Harris, and Dr. Stenquist); and the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Dr. Chen)
| | - Mitchel B. Harris
- From the Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA (Dr. Lightsey); the Rothman Orthopaedic Institute/Thomas Jefferson University Spine Fellowship Program, Philadelphia, PA (Dr. Yeung); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Rossi, Dr. Harris, and Dr. Stenquist); and the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Dr. Chen)
| | - Derek S. Stenquist
- From the Harvard Combined Orthopaedic Residency Program, Harvard Medical School, Boston, MA (Dr. Lightsey); the Rothman Orthopaedic Institute/Thomas Jefferson University Spine Fellowship Program, Philadelphia, PA (Dr. Yeung); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Rossi, Dr. Harris, and Dr. Stenquist); and the Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Dr. Chen)
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von Keudell A, Huebner KD, Mandell J, O'Brien M, Harris MB, Esposito JG, Caton T, Weaver MJ. Degree of articular injury as measured by CT cross sectional area is associated with physical function following the treatment of bicondylar tibial plateau fractures. J Orthop Surg (Hong Kong) 2023; 31:10225536231217148. [PMID: 38126258 DOI: 10.1177/10225536231217148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Bicondylar tibial plateau fractures are complex injuries that commonly require surgical repair. Long-term clinical outcome has been associated with discrepancies in leg alignment, instability and condylar width abnormalities. While intuitive, the degree of articular damage at time of injury has not been linked to outcomes in patients with bicondylar tibial plateau fractures. The aim of this study was to quantify percentage of articular surface cross sectional area disruption and assess for correlation between the degree of articular injury and patient reported physical function. METHODS Retrospective cohort study at two level 1 trauma centers. 57 consecutive patients undergoing surgical repair for bicondylar tibial plateau fractures between 2013 and 2016. MAIN OUTCOME MEASURE Preoperative CT scans were reviewed, and the percentage of articular surface disruption cross sectional area was calculated. PROMIS® scores were collected from patients at a minimum of 2 years. RESULTS 57 patients with an average age of 58 ± 14.3 years were included. The average PROMIS® score was 45.5. There was a correlation between percentage of articular surface disruption and total PROMIS® scores (0.4, CI: 0.2-0.5, p = .007) and the physical function of the PROMIS® score (0.4, CI: 0.2-0.6, p < .001). CONCLUSION Our method for calculating articular surface disruption on CT is a simple, reproducible and accurate method for assessing the degree of articular damage in patients with bicondylar tibial plateau fractures. We found that the percentage of cross-sectional articular surface disruption correlates with patient reported outcomes and physical function.
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Affiliation(s)
- Arvind von Keudell
- Harvard Orthopedic Trauma Service, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
- Rigshospitalet and Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kyla D Huebner
- Harvard Orthopedic Trauma Service, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Mitchel B Harris
- Harvard Orthopedic Trauma Service, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
| | - John G Esposito
- Harvard Orthopedic Trauma Service, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
| | - Tyler Caton
- Harvard Orthopedic Trauma Service, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
| | - Michael J Weaver
- Harvard Orthopedic Trauma Service, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
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M. Lightsey H, Maier SP, Bono CM, Kang JD, Harris MB. In-Hospital, 24-Hour Exercise Spaces for Resident and Staff Wellness. HSS J 2023; 19:140-145. [PMID: 37065098 PMCID: PMC10090845 DOI: 10.1177/15563316221131031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 08/22/2022] [Indexed: 04/18/2023]
Affiliation(s)
- Harry M. Lightsey
- Harvard Combined Orthopaedic Residency
Program, Harvard Medical School, Boston, MA, USA
| | - Stephen P. Maier
- Harvard Combined Orthopaedic Residency
Program, Harvard Medical School, Boston, MA, USA
| | - Christopher M. Bono
- Department of Orthopaedic Surgery,
Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James D. Kang
- Department of Orthopaedic Surgery, Brigham
and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchel B. Harris
- Department of Orthopaedic Surgery,
Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Tran NA, Pawar JP, Tobert D, Harris MB, Khurana B. Upper cervical spine fracture patterns and blunt cerebrovascular injuries. Emerg Radiol 2023; 30:315-323. [PMID: 37043145 DOI: 10.1007/s10140-023-02129-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/27/2023] [Indexed: 04/13/2023]
Abstract
PURPOSE To determine patterns of C1 and C2 vertebral fractures that are associated with blunt cerebrovascular injury (BCVI). METHODS Retrospective chart review of clinical and imaging reports at a level 1 trauma center over 10 consecutive years was conducted in patients with C1 and C2 fractures. Student t-test and chi-squared analyses were used to determine associations between fracture levels and fracture types with the presence of BCVI on CTA and/or MRI or stroke on CT and/or MRI. RESULTS Multilevel fractures were associated with higher incidence of BCVI compared to isolated C1 or C2 fractures (p < 0.01), but not with stroke (p = 0.16). There was no difference in incidence of BCVI or stroke between isolated C1 and isolated C2 fractures (p = 0.46, p = 0.25). Involvement of the transverse foramen (TF) alone was not associated with BCVI or stroke (p = 0.10-0.40, p = 0.34-0.43). However, TF fractures that were comminuted or contained fracture fragment(s) were associated with increased BCVI (p < 0.01, p = 0.02), though not with stroke (p = 0.11, p = 0.09). In addition, high-energy mechanism of injury was also associated with BCVI (p < 0.01) and stroke (p < 0.01). CONCLUSION C1 and C2 fractures are associated with BCVI in the presence of high-energy mechanism of injury, concomitant fractures of other cervical vertebral body levels, comminuted TF fractures, or TF fractures with internal fragments. Attention to these fracture parameters is important in evaluating C1 and C2 fractures for BCVI.
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Affiliation(s)
- Ngoc-Anh Tran
- Department of Radiology, Brigham & Women's Hospital, Boston, USA.
| | - Jayashri P Pawar
- Center for Clinical Data Science, Massachusetts General Hospital & Brigham & Women's Hospital, Boston, USA
| | - Daniel Tobert
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, USA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, USA
| | - Bharti Khurana
- Trauma Imaging Research and Innovation Center, Brigham & Women's Hospital, Boston, USA
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10
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Lightsey Iv HM, Giberson-Chen CC, Crawford AM, Striano BM, Harris MB, Bono CM, Simpson AK, Schoenfeld AJ. Thoracolumbar Injury Classification Systems: The Importance of Concepts and Language in the Move Toward Standardization. Spine (Phila Pa 1976) 2023; 48:436-443. [PMID: 36728030 DOI: 10.1097/brs.0000000000004578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Narrative review. OBJECTIVE To describe the evolution of acute traumatic thoracolumbar (TL) injury classification systems; to promote standardization of concepts and vocabulary with respect to TL injuries. SUMMARY OF BACKGROUND DATA Over the past century, numerous TL classification systems have been proposed and implemented, each influenced by the thought, imaging modalities, and surgical techniques available at the time. While much progress has been made in our understanding and management of these injuries, concepts, and terms are often intermixed, leading to potential confusion and miscommunication. METHODS We present a narrative review of the current state of the literature regarding classification systems for TL trauma. RESULTS The evolution of TL classification systems has broadly been characterized by a transition away from descriptive categorizations of fracture patterns to schema incorporating morphology, stability, and neurological function. In addition to these features, more recent systems have demonstrated the importance of predictive/prognostic capability, reliability, validity, and generalizability. The Arbeitsgemeinschaft fur Osteosynthesenfragen Spine Thoracolumbar Injury Classification System/Thoracolumbar Arbeitsgemeinschaft fur Osteosynthesenfragen Spine Injury Score represents the most modern and recently updated system, retiring past concepts and terminology in favor of clear, internationally agreed upon descriptors. CONCLUSIONS Advancements in our understanding of blunt TL trauma injuries have led to changes in management. Such advances are reflected in modern, dedicated classification systems. Over time, various key factors have been acknowledged and incorporated. In an effort to promote standardization of thought and language, past ideas and terminology should be retired.
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Affiliation(s)
- Harry M Lightsey Iv
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, MA
| | | | - Alexander M Crawford
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, MA
| | - Brendan M Striano
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, MA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrew K Simpson
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Yong TM, Rackard FA, Dutton LK, Sparks MB, Harris MB, Gitajn IL. Analyzing risk factors for treatment failure in fracture-related infection. Arch Orthop Trauma Surg 2023; 143:1387-1392. [PMID: 35043253 DOI: 10.1007/s00402-021-04277-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 11/24/2021] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Fracture-related infection (FRI) represents a challenging clinical scenario. Limited evidence exists regarding treatment failure after initial management of FRI. The objective of our investigation was to determine incidence and risk factors for treatment failure in FRI. MATERIALS AND METHODS We conducted a retrospective review of patients treated for FRI between 2011 and 2015 at three level 1 trauma centers. One hundred and thirty-four patients treated for FRI were identified. Demographic and clinical variables were extracted from the medical record. Treatment failure was defined as the need for repeat debridement or surgical revision seven or more days after the presumed final procedure for infection treatment. Univariate comparisons were conducted between patients who experienced treatment failure and those who did not. Multivariable logistic regression was conducted to identify independent associations with treatment failure. RESULTS Of the 134 FRI patients, 51 (38.1%) experienced treatment failure. Patients who failed were more likely to have had an open injury (31% versus 17%; p = 0.05), to have undergone implant removal (p = 0.03), and additional index I&D procedures (3.3 versus 1.6; p < 0.001). Most culture results identified a single organism (62%), while 15% were culture negative. Treatment failure was more common in culture-negative infections (p = 0.08). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common organism associated with treatment failure (29%; p = 0.08). Multivariate regression demonstrated a statistically significant association between treatment failure and two or more irrigation and debridement (I&D) procedures (OR 13.22, 95% CI 4.77-36.62, p < 0.001) and culture-negative infection (OR 4.74, 95% CI 1.26-17.83, p = 0.02). CONCLUSIONS The rate of treatment failure following FRI continues to be high. Important risk factors associated with treatment failure include open fracture, implant removal, and multiple I&D procedures. While MRSA remains common, culture-negative infection represents a novel risk factor for failure, suggesting aggressive treatment of clinically diagnosed cases remains critical even without positive culture data. LEVEL OF EVIDENCE Retrospective cohort study; Level III.
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Affiliation(s)
- Taylor M Yong
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | | | - Lauren K Dutton
- Department of Orthopedics, Naval Hospital, Jacksonville, Jacksonville, FL, USA
| | - Michael B Sparks
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ida L Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
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Alvarez-Nebreda ML, Weaver MJ, Uribe-Leitz T, Heng M, McTague MF, Harris MB. Epidemiology of pelvic and acetabular fractures in the USA from 2007 to 2014. Osteoporos Int 2023; 34:527-537. [PMID: 36577845 DOI: 10.1007/s00198-022-06636-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 12/05/2022] [Indexed: 12/29/2022]
Abstract
UNLABELLED Incidence of pelvic and acetabular fracture is increasing in Europe. From 2007 to 2014 in the USA, this study found an age-adjusted incidence of 198 and 40 fractures/100,000/year, respectively, much higher than what has been described before. Incidence remained steady over that period and only a small increase in incidence of pelvic fracture in men was identified. PURPOSE To determine the incidence of pelvic ring and acetabular fractures in the USA over the period 2007-2014 and to examine trends over time. METHODS Retrospective population-based observational study using data from the Nationwide Emergency Department Sample (NEDS), a 20% stratified all-payer sample of US hospital-based emergency departments (EDs). All patients seen in the ED and diagnosed with pelvic/acetabular fracture from 2007 to 2014 were included. The primary outcome was age-adjusted incidence of pelvic and acetabular fractures per 100,000 persons/years. Secondary outcomes included incidence stratified by age and sex, patient- and hospital-related characteristics, and ED procedures. Tests for linear trends were used to determine if there were statistically significant differences by sex and age groups over time. RESULTS The age-adjusted incidence of pelvic fracture was 198 fractures/100,000/year, 323 in women and 114 in men. The age-adjusted incidence of acetabular fracture was 40 fractures/100,000/year, 36 in women and 51 in men. A small increase in the age-adjusted incidence of pelvic fracture in men was the only significant trend observed during the study time (p = 0.03). Over that period, the mean age of patients at presentation increased, as well as their number of comorbidities and associated fragility fractures, and they were more often sent home or to nursing facilities. CONCLUSIONS When considering all patients coming to the ED, not only those admitted to the hospital, adjusted incidence of pelvic and acetabular fracture is much higher than what has been described before. Contrarily to the global increase seen in other countries, incidence of pelvic and acetabular fractures dropped in the USA from 2007 to 2014 and only a small increase in age-adjusted incidence of pelvic fracture in men was identified.
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Affiliation(s)
- Maria Loreto Alvarez-Nebreda
- Servicio de Geriatría, Hospital Universitario Ramón Y Cajal (IRICYS), M-607, Km. 9,100, 28034, Madrid, Spain.
- Harvard Medical School Orthopedic Trauma Initiative, Brigham & Women's Hospital, Boston, MA, USA.
| | - Michael J Weaver
- Harvard Medical School Orthopedic Trauma Initiative, Brigham & Women's Hospital, Boston, MA, USA
| | - Tarsicio Uribe-Leitz
- Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, MA, USA
| | - Marilyn Heng
- Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Boston, MA, USA
| | - Michael F McTague
- Harvard Medical School Orthopedic Trauma Initiative, Brigham & Women's Hospital, Boston, MA, USA
| | - Mitchel B Harris
- Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Boston, MA, USA
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13
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Shah AA, Karhade AV, Groot OQ, Olson TE, Schoenfeld AJ, Bono CM, Harris MB, Ferrone ML, Nelson SB, Park DY, Schwab JH. External validation of a predictive algorithm for in-hospital and ninety-day mortality after spinal epidural abscess. Spine J 2023; 23:760-765. [PMID: 36736740 DOI: 10.1016/j.spinee.2023.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/05/2023] [Accepted: 01/21/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND CONTEXT Mortality in patients with spinal epidural abscess (SEA) remains high. Accurate prediction of patient-specific prognosis in SEA can improve patient counseling as well as guide management decisions. There are no externally validated studies predicting short-term mortality in patients with SEA. PURPOSE The purpose of this study was to externally validate the Skeletal Oncology Research Group (SORG) stochastic gradient boosting algorithm for prediction of in-hospital and 90-day postdischarge mortality in SEA. STUDY DESIGN/SETTING Retrospective, case-control study at a tertiary care academic medical center from 2003 to 2021. PATIENT SAMPLE Adult patients admitted for radiologically confirmed diagnosis of SEA who did not initiate treatment at an outside institution. OUTCOME MEASURES In-hospital and 90-day postdischarge mortality. METHODS We tested the SORG stochastic gradient boosting algorithm on an independent validation cohort. We assessed its performance with discrimination, calibration, decision curve analysis, and overall performance. RESULTS A total of 212 patients met inclusion criteria, with a short-term mortality rate of 10.4%. The area under the receiver operating characteristic curve (AUROC) of the SORG algorithm when tested on the full validation cohort was 0.82, the calibration intercept was -0.08, the calibration slope was 0.96, and the Brier score was 0.09. CONCLUSIONS With a contemporaneous and geographically distinct independent cohort, we report successful external validation of a machine learning algorithm for prediction of in-hospital and 90-day postdischarge mortality in SEA.
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Affiliation(s)
- Akash A Shah
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA.
| | - Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Olivier Q Groot
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Thomas E Olson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Sandra B Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Don Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Karhade AV, Fenn B, Groot OQ, Shah AA, Yen HK, Bilsky MH, Hu MH, Laufer I, Park DY, Sciubba DM, Steyerberg EW, Tobert DG, Bono CM, Harris MB, Schwab JH. Development and external validation of predictive algorithms for six-week mortality in spinal metastasis using 4,304 patients from five institutions. Spine J 2022; 22:2033-2041. [PMID: 35843533 DOI: 10.1016/j.spinee.2022.07.089] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/06/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Historically, spine surgeons used expected postoperative survival of 3-months to help select candidates for operative intervention in spinal metastasis. However, this cutoff has been challenged by the development of minimally invasive techniques, novel biologics, and advanced radiotherapy. Recent studies have suggested that a life expectancy of 6 weeks may be enough to achieve significant improvements in postoperative health-related quality of life. PURPOSE The purpose of this study was to develop a model capable of predicting 6-week mortality in patients with spinal metastases treated with radiation or surgery. STUDY DESIGN/SETTING A retrospective review was conducted at five large tertiary centers in the United States and Taiwan. PATIENT SAMPLE The development cohort consisted of 3,001 patients undergoing radiotherapy and/or surgery for spinal metastases from one institution. The validation institutional cohort consisted of 1,303 patients from four independent, external institutions. OUTCOME MEASURES The primary outcome was 6-week mortality. METHODS Five models were considered to predict 6-week mortality, and the model with the best performance across discrimination, calibration, decision-curve analysis, and overall performance was integrated into an open access web-based application. RESULTS The most important variables for prediction of 6-week mortality were albumin, primary tumor histology, absolute lymphocyte, three or more spine metastasis, and ECOG score. The elastic-net penalized logistic model was chosen as the best performing model with AUC 0.84 on evaluation in the independent testing set. On external validation in the 1,303 patients from the four independent institutions, the model retained good discriminative ability with an area under the curve of 0.81. The model is available here: https://sorg-apps.shinyapps.io/spinemetssurvival/. CONCLUSIONS While this study does not advocate for the use of a 6-week life expectancy as criteria for considering operative management, the algorithm developed and externally validated in this study may be helpful for preoperative planning, multidisciplinary management, and shared decision-making in spinal metastasis patients with shorter life expectancy.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA.
| | - Brian Fenn
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | - Olivier Q Groot
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Akash A Shah
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Hung-Kuan Yen
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taiwan
| | - Mark H Bilsky
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Ming-Hsiao Hu
- Department of Orthopaedic Surgery, National Taiwan University Hospital, Taiwan
| | - Ilya Laufer
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Don Y Park
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA
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15
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Slobogean GP, Sprague S, Wells JL, Bhandari M, Harris AD, Mullins CD, Thabane L, Wood A, Della Rocca GJ, Hebden JN, Jeray KJ, Marchand LS, O'Hara LM, Zura RD, Lee C, Patterson JT, Gardner MJ, Blasman J, Davies J, Liang S, Taljaard M, Devereaux PJ, Guyatt G, Heels-Ansdell D, Marvel D, Palmer JE, Friedrich J, O'Hara NN, Grissom F, Gitajn IL, Morshed S, O'Toole RV, Petrisor B, Mossuto F, Joshi MG, D'Alleyrand JCG, Fowler J, Rivera JC, Talbot M, Pogorzelski D, Dodds S, Li S, Del Fabbro G, Szasz OP, Bzovsky S, McKay P, Minea A, Murphy K, Howe AL, Demyanovich HK, Hoskins W, Medeiros M, Polk G, Kettering E, Mahal N, Eglseder A, Johnson A, Langhammer C, Lebrun C, Nascone J, Pensy R, Pollak A, Sciadini M, Degani Y, Phipps H, Hempen E, Johal H, Ristevski B, Williams D, Denkers M, Rajaratnam K, Al-Asiri J, Gallant JL, Pusztai K, MacRae S, Renaud S, Adams JD, Beckish ML, Bray CC, Brown TR, Cross AW, Dew T, Faucher GK, Gurich Jr RW, Lazarus DE, Millon SJ, Moody MC, Palmer MJ, Porter SE, Schaller TM, Sridhar MS, Sanders JL, Rudisill Jr LE, Garitty MJ, Poole AS, Sims ML, Walker CM, Carlisle R, Hofer EA, Huggins B, Hunter M, Marshall W, Ray SB, Smith C, Altman KM, Pichiotino ER, Quirion JC, Loeffler MF, Cole AA, Maltz EJ, Parker W, Ramsey TB, Burnikel A, Colello M, Stewart R, Wise J, Anderson M, Eskew J, Judkins B, Miller JM, Tanner SL, Snider RG, Townsend CE, Pham KH, Martin A, Robertson E, Bray E, Sykes JW, Yoder K, Conner K, Abbott H, Natoli RM, McKinley TO, Virkus WW, Sorkin AT, Szatkowski JP, Mullis BH, Jang Y, Lopas LA, Hill LC, Fentz CL, Diaz MM, Brown K, Garst KM, Denari EW, Osborn P, Pierrie SN, Kessler B, Herrera M, Miclau T, Marmor MT, Matityahu A, McClellan RT, Shearer D, Toogood P, Ding A, Murali J, El Naga A, Tangtiphaiboontana J, Belaye T, Berhaneselase E, Pokhvashchev D, Obremskey WT, Jahangir AA, Sethi M, Boyce R, Stinner DJ, Mitchell PP, Trochez K, Rodriguez E, Pritchett C, Hogan N, Fidel Moreno A, Hagen JE, Patrick M, Vlasak R, Krupko T, Talerico M, Horodyski M, Pazik M, Lossada-Soto E, Gary JL, Warner SJ, Munz JW, Choo AM, Achor TS, Routt ML“C, Kutzler M, Boutte S, Warth RJ, Prayson MJ, Venkatarayappa I, Horne B, Jerele J, Clark L, Boulton C, Lowe J, Ruth JT, Askam B, Seach A, Cruz A, Featherston B, Carlson R, Romero I, Zarif I, Dehghan N, McKee M, Jones CB, Sietsema DL, Williams A, Dykes T, Guerra-Farfan E, Tomas-Hernandez J, Teixidor-Serra J, Molero-Garcia V, Selga-Marsa J, Porcel-Vazquez JA, Andres-Peiro JV, Esteban-Feliu I, Vidal-Tarrason N, Serracanta J, Nuñez-Camarena J, del Mar Villar-Casares M, Mestre-Torres J, Lalueza-Broto P, Moreira-Borim F, Garcia-Sanchez Y, Marcano-Fernández F, Martínez-Carreres L, Martí-Garín D, Serrano-Sanz J, Sánchez-Fernández J, Sanz-Molero M, Carballo A, Pelfort X, Acerboni-Flores F, Alavedra-Massana A, Anglada-Torres N, Berenguer A, Cámara-Cabrera J, Caparros-García A, Fillat-Gomà F, Fuentes-López R, Garcia-Rodriguez R, Gimeno-Calavia N, Martínez-Álvarez M, Martínez-Grau P, Pellejero-García R, Ràfols-Perramon O, Peñalver JM, Salomó Domènech M, Soler-Cano A, Velasco-Barrera A, Yela-Verdú C, Bueno-Ruiz M, Sánchez-Palomino E, Andriola V, Molina-Corbacho M, Maldonado-Sotoca Y, Gasset-Teixidor A, Blasco-Moreu J, Fernández-Poch N, Rodoreda-Puigdemasa J, Verdaguer-Figuerola A, Cueva-Sevieri HE, Garcia-Gimenez S, Viskontas DG, Apostle KL, Boyer DS, Moola FO, Perey BH, Stone TB, Lemke HM, Spicer E, Payne K, Hymes RA, Schwartzbach CC, Schulman JE, Malekzadeh AS, Holzman MA, Gaski GE, Wills J, Pilson H, Carroll EA, Halvorson JJ, Babcock S, Goodman JB, Holden MB, Williams W, Hill T, Brotherton A, Romeo NM, Vallier HA, Vergon A, Higgins TF, Haller JM, Rothberg DL, Olsen ZM, McGowan AV, Hill S, Dauk MK, Bergin PF, Russell GV, Graves ML, Morellato J, McGee SL, Bhanat EL, Yener U, Khanna R, Nehete P, Potter D, VanDemark III R, Seabold K, Staudenmier N, Coe M, Dwyer K, Mullin DS, Chockbengboun TA, DePalo Sr. PA, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Mayfield A, Sweeney J, Jaeblon T, Beer R, Bauer B, Meredith S, Talwar S, Domes CM, Gage MJ, Reilly RM, Paniagua A, Dupree J, Weaver MJ, von Keudell AG, Sagona AE, Mehta S, Donegan D, Horan A, Dooley M, Heng M, Harris MB, Lhowe DW, Esposito JG, Alnasser A, Shannon SF, Scott AN, Clinch B, Weber B, Beltran MJ, Archdeacon MT, Sagi HC, Wyrick JD, Le TT, Laughlin RT, Thomson CG, Hasselfeld K, Lin CA, Vrahas MS, Moon CN, Little MT, Marecek GS, Dubuclet DM, Scolaro JA, Learned JR, Lim PK, Demas S, Amirhekmat A, Dela Cruz YM. Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial. Lancet 2022; 400:1334-1344. [PMID: 36244384 DOI: 10.1016/s0140-6736(22)01652-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture. METHODS We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304. FINDINGS Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4). INTERPRETATION For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds. FUNDING US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.
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Guild TT, Stenquist DS, Yeung CM, Harris MB, Von Keudell AG, Smith RM. Single versus dual incision approaches for dual plating of bicondylar tibial plateau fractures have comparable rates of deep infection and revision surgery. Injury 2022; 53:3475-3480. [PMID: 35945091 DOI: 10.1016/j.injury.2022.07.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 07/20/2022] [Accepted: 07/22/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The use of one midline incision versus dual medial/lateral incisions for dual plating of bicondylar tibial plateau (BTP) fractures is controversial. This study aimed to compare rates of infection and secondary surgery in patients treated with dual plating for a BTP fracture using a single versus double incisions. DESIGN Retrospective cohort study. SETTING Two Level-1 trauma centers. PATIENTS/PARTICIPANTS Patients > 18 years with a closed AO/OTA 41-C BTP fracture without compartment syndrome treated with a single midline or dual incision (lateral with medial or posteromedial) approach for dual plating. INTERVENTION Dual plating through either a single anterior incision, or dual medial/lateral incisions. MAIN OUTCOME MEASUREMENTS Rates of deep infection and reoperation were compared using Chi-square analysis (p-value of < 0.05). RESULTS AND CONCLUSIONS In total 636 AO/OTA 41-C BTP fractures treated between 1/1/01 and 12/31/18 were identified and assessed. After exclusions for limited follow up, other techniques, open fracture and the need for fasciotomies, 346 patients were studied. Of these 254 had been treated with a single plate / single approach technique while 92 had been dual plated, 41 through a single anterior incision while 51 had dual plating through separate lateral and medial or posteromedial incisions. For these 92 fractures, there was no significant difference in the rate of deep infection (22.0% vs 23.5%, s=0.858) or reoperation (31.7% vs 31.4%, p=0.973) between the single and dual incision groups. Injuries that had been treated with single plating via a single incision had comparably lower rates of deep infection (10.2% vs. 22.8%, p=0.003) and reoperation (12.2% vs. 31.5%, p<0.001). There were no significant differences in any demographic parameters between patients undergoing single versus dual plating. Although retrospective, not randomized and subject to single surgeon bias these data suggest that these complications are more based on injury than the approach. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Caleb M Yeung
- Harvard Combined Orthopaedic Residency Program, Boston, MA USA
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Karhade AV, Bernstein DN, Desai V, Bedair HS, O’Donnell EA, Tanaka MJ, Bono CM, Harris MB, Schwab JH, Tobert DG. What Is the Clinical Benefit of Common Orthopaedic Procedures as Assessed by the PROMIS Versus Other Validated Outcomes Tools? Clin Orthop Relat Res 2022; 480:1672-1681. [PMID: 35543521 PMCID: PMC9384920 DOI: 10.1097/corr.0000000000002241] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 04/19/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs), including the Patient-reported Outcomes Measurement Information System (PROMIS), are increasingly used to measure healthcare value. The minimum clinically important difference (MCID) is a metric that helps clinicians determine whether a statistically detectable improvement in a PROM after surgical care is likely to be large enough to be important to a patient or to justify an intervention that carries risk and cost. There are two major categories of MCID calculation methods, anchor-based and distribution-based. This variability, coupled with heterogeneous surgical cohorts used for existing MCID values, limits their application to clinical care. QUESTIONS/PURPOSES In our study, we sought (1) to determine MCID thresholds and attainment percentages for PROMIS after common orthopaedic procedures using distribution-based methods, (2) to use anchor-based MCID values from published studies as a comparison, and (3) to compare MCID attainment percentages using PROMIS scores to other validated outcomes tools such as the Hip Disability and Osteoarthritis Outcome Score (HOOS) and Knee Disability and Osteoarthritis Outcome Score (KOOS). METHODS This was a retrospective study at two academic medical centers and three community hospitals. The inclusion criteria for this study were patients who were age 18 years or older and who underwent elective THA for osteoarthritis, TKA for osteoarthritis, one-level posterior lumbar fusion for lumbar spinal stenosis or spondylolisthesis, anatomic total shoulder arthroplasty or reverse total shoulder arthroplasty for glenohumeral arthritis or rotator cuff arthropathy, arthroscopic anterior cruciate ligament reconstruction, arthroscopic partial meniscectomy, or arthroscopic rotator cuff repair. This yielded 14,003 patients. Patients undergoing revision operations or surgery for nondegenerative pathologies and patients without preoperative PROMs assessments were excluded, leaving 9925 patients who completed preoperative PROMIS assessments and 9478 who completed other preoperative validated outcomes tools (HOOS, KOOS, numerical rating scale for leg pain, numerical rating scale for back pain, and QuickDASH). Approximately 66% (6529 of 9925) of patients had postoperative PROMIS scores (Physical Function, Mental Health, Pain Intensity, Pain Interference, and Upper Extremity) and were included for analysis. PROMIS scores are population normalized with a mean score of 50 ± 10, with most scores falling between 30 to 70. Approximately 74% (7007 of 9478) of patients had postoperative historical assessment scores and were included for analysis. The proportion who reached the MCID was calculated for each procedure cohort at 6 months of follow-up using distribution-based MCID methods, which included a fraction of the SD (1/2 or 1/3 SD) and minimum detectable change (MDC) using statistical significance (such as the MDC 90 from p < 0.1). Previously published anchor-based MCID thresholds from similar procedure cohorts and analogous PROMs were used to calculate the proportion reaching MCID. RESULTS Within a given distribution-based method, MCID thresholds for PROMIS assessments were similar across multiple procedures. The MCID threshold ranged between 3.4 and 4.5 points across all procedures using the 1/2 SD method. Except for meniscectomy (3.5 points), the anchor-based PROMIS MCID thresholds (range 4.5 to 8.1 points) were higher than the SD distribution-based MCID values (2.3 to 4.5 points). The difference in MCID thresholds based on the calculation method led to a similar trend in MCID attainment. Using THA as an example, MCID attainment using PROMIS was achieved by 76% of patients using an anchor-based threshold of 7.9 points. However, 82% of THA patients attained MCID using the MDC 95 method (6.1 points), and 88% reached MCID using the 1/2 SD method (3.9 points). Using the HOOS metric (scaled from 0 to 100), 86% of THA patients reached the anchor-based MCID threshold (17.5 points). However, 91% of THA patients attained the MCID using the MDC 90 method (12.5 points), and 93% reached MCID using the 1/2 SD method (8.4 points). In general, the proportion of patients reaching MCID was lower for PROMIS than for other validated outcomes tools; for example, with the 1/2 SD method, 72% of patients who underwent arthroscopic partial meniscectomy reached the MCID on PROMIS Physical Function compared with 86% on KOOS. CONCLUSION MCID calculations can provide clinical correlation for PROM scores interpretation. The PROMIS form is increasingly used because of its generalizability across diagnoses. However, we found lower proportions of MCID attainment using PROMIS scores compared with historical PROMs. By using historical proportions of attainment on common orthopaedic procedures and a spectrum of MCID calculation techniques, the PROMIS MCID benchmarks are realizable for common orthopaedic procedures. For clinical practices that routinely collect PROMIS scores in the clinical setting, these results can be used by individual surgeons to evaluate personal practice trends and by healthcare systems to quantify whether clinical care initiatives result in meaningful differences. Furthermore, these MCID thresholds can be used by researchers conducting retrospective outcomes research with PROMIS. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Aditya V. Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - David N. Bernstein
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Combined Orthopaedic Residency Program, Boston, MA, USA
| | - Vineet Desai
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hany S. Bedair
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Evan A. O’Donnell
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Miho J. Tanaka
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher M. Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchel B. Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel G. Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Pean C, Weaver MJ, Harris MB, Ly T, von Keudell AG. What Do Orthopedic Trauma Surgeons Want and Expect from Anesthesiologists? Anesthesiol Clin 2022; 40:547-556. [PMID: 36049881 DOI: 10.1016/j.anclin.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
From the orthopedic trauma surgeon's perspective, successful injury management hinges on fracture fixation and restoration of patient mobility in a safe and expeditious manner. Management of critically injured polytrauma patients and shared decisions regarding regional anesthetics presents a myriad of challenges for orthopedic trauma surgeons and anesthesiologists alike. As the populations age, the typical patient sustaining traumatic orthopedic injuries are increasingly frail and elderly. This trend in demographics has mandated that care for orthogeriatric patients is coordinated by multidisciplinary teams working in concert on medically complex cases to a common end. In this article, we highlight opportunities for improved communication and care integration between orthopedic trauma surgeons and anesthesiologists.
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Affiliation(s)
- Christian Pean
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Michael J Weaver
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Mitchel B Harris
- Massachusetts General Hospital, 55 Fruit Street #14, Boston, MA 02114, USA
| | - Thuan Ly
- Massachusetts General Hospital, 55 Fruit Street #14, Boston, MA 02114, USA
| | - Arvind G von Keudell
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Bispebjerg Hospital, Universtiy of Copenhagen, Bispebjerg Bakke 23, Copenhagen, KBH 2400, Denmark.
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Fleming ME, Harris MB. Shared Decision Making and Patient Preferences after Limb Threatening Injuries. Ann Surg 2022; Publish Ahead of Print:00000658-990000000-00224. [PMID: 35946820 DOI: 10.1097/sla.0000000000005578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Mark E Fleming
- Harvard Medical School Orthopedic Trauma Initiative, Boston, MA
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Mitchel B Harris
- Harvard Medical School Orthopedic Trauma Initiative, Boston, MA
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
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20
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Bernstein DN, Karhade AV, Bono CM, Schwab JH, Harris MB, Tobert DG. Sociodemographic Factors Are Associated with Patient-Reported Outcome Measure Completion in Orthopaedic Surgery: An Analysis of Completion Rates and Determinants Among New Patients. JB JS Open Access 2022; 7:e22.00026. [PMID: 35935603 PMCID: PMC9355105 DOI: 10.2106/jbjs.oa.22.00026] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Patient-reported outcome measures (PROMs) and, specifically, the Patient-Reported Outcomes Measurement Information System (PROMIS), are increasingly utilized for clinical research, clinical care, and health-care policy. However, completion of these outcome measures can be inconsistent and challenging. We hypothesized that sociodemographic variables are associated with the completion of PROM questionnaires. The purposes of the present study were to calculate the completion rate of assigned PROM forms and to identify sociodemographic and other variables associated with completion to help guide improved collection efforts. Methods All new orthopaedic patients at a single academic medical center were identified from 2016 to 2020. On the basis of subspecialty and presenting condition, patients were assigned certain PROMIS forms and legacy PROMs. Demographic and clinical information was abstracted from the electronic medical record. Bivariate analyses were performed to compare characteristics among those who completed assigned PROMs and those who did not. A multivariable logistic regression model was created to determine which variables were associated with successful completion of assigned PROMs. Results Of the 219,891 new patients, 88,052 (40%) completed all assigned PROMs. Patients who did not activate their internet-based patient portal had a 62% increased likelihood of not completing assigned PROMs (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.58 to 1.66; p < 0.001). Non-English-speaking patients had a 90% (OR, 1.90; 95% CI, 1.82 to 2.00; p < 0.001) increased likelihood of not completing assigned PROMs at presentation. Older patients (≥65 years of age) and patients of Black race had a 23% (OR, 1.23; 95% CI, 1.19 to 1.27; p < 0.001) and 24% (OR, 1.24; 95% CI, 1.19 to 1.30; p < 0.001) increased likelihood of not completing assigned PROMs, respectively. Conclusions The rate of completion of PROMs varies according to sociodemographic variables. This variability could bias clinical outcomes research in orthopaedic surgery. The present study highlights the need to uniformly increase completion rates so that outcomes research incorporates truly representative cohorts of patients treated. Furthermore, the use of these PROMs to guide health-care policy decisions necessitates a representative patient distribution to avoid bias in the health-care system. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- David N. Bernstein
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Aditya V. Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Harvard Combined Orthopaedic Residency Program, Boston, Massachusetts
| | - Christopher M. Bono
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mitchel B. Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel G. Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
Racial discrepancies among patients in the United States undergoing orthopedic trauma surgery have not been investigated. Issues relating to socioeconomic status and access to care have played a role in the health outcomes of racial groups. In orthopedic surgery, recent joint arthroplasty literature has shown significant racial differences in the use of elective joint arthroplasty. Furthermore, studies also suggest increased rates of early complication in racial minority groups. In general, little information exists on the postoperative outcomes of racial minority groups in orthopedic surgery. We retrospectively queried the National Surgical Quality Improvement Program database to identify patients undergoing orthopedic trauma surgery between 2008 and 2016. Patients of all ages who underwent orthopedic trauma surgery were identified using Current Procedural Terminology codes. Patients classified as either Black or White were included in the study. Demographic data, comorbidities, and basic surgical data were compared between the groups. Adverse outcomes in the initial 30 days postoperative were also examined. Higher frequencies of deep wound infection (0.5% vs 0.3%, P=.002) were noted among Black patients, with decreased mortality (0.3% vs 0.6%, P=.004) and postoperative transfusion (2.7% vs 3.8%, P<.001) rates, compared with White patients. Clear differences exist in the demographic, surgical, and outcome data between Black and White patients undergoing orthopedic trauma surgery. More epidemiological studies are required to further investigate racial differences in orthopedic trauma surgery. [Orthopedics. 2022;45(2):71-76.].
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22
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Zhang Z, Zhou J, Liu C, Zhang J, Shibata Y, Kong N, Corbo C, Harris MB, Tao W. Emerging biomimetic nanotechnology in orthopedic diseases: progress, challenges, and opportunities. Trends in Chemistry 2022. [DOI: 10.1016/j.trechm.2022.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Schoenfeld AJ, Ferrone ML, Blucher JA, Agaronnik N, Nguyen L, Tobert DG, Balboni TA, Schwab JH, Shin JH, Sciubba DM, Harris MB. Prospective comparison of the accuracy of the New England Spinal Metastasis Score (NESMS) to legacy scoring systems in prognosticating outcomes following treatment of spinal metastases. Spine J 2022; 22:39-48. [PMID: 33741509 PMCID: PMC8443703 DOI: 10.1016/j.spinee.2021.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/16/2021] [Accepted: 03/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT We developed the New England Spinal Metastasis Score (NESMS) as a simple, informative, scoring scheme that could be applied to both operative and non-operative patients. The performance of the NESMS to other legacy scoring systems has not previously been compared using appropriately powered, prospectively collected, longitudinal data. PURPOSE To compare the predictive capacity of the NESMS to the Tokuhashi, Tomita and Spinal Instability Neoplastic Score (SINS) in a prospective cohort, where all scores were assigned at the time of baseline enrollment. PATIENT SAMPLE We enrolled 202 patients with spinal metastases who met inclusion criteria between 2017-2019. OUTCOME MEASURES One-year survival (primary); 3-month mortality and ambulatory function at 3- and 6-months were considered secondarily. METHODS All prognostic scores were assigned based on enrollment data, which was also assigned as time-zero. Patients were followed until death or survival at 365 days after enrollment. Survival was assessed using Kaplan-Meier curves and score performance was determined via logistic regression testing and observed to expected plots. The discriminative capacity (c-statistic) of the scoring measures were compared via the z-score. RESULTS When comparing the discriminative capacity of the predictive scores, the NESMS had the highest c-statistic (0.79), followed by the Tomita (0.69), the Tokuhashi (0.67) and the SINS (0.54). The discriminative capacity of the NESMS was significantly greater (p-value range: 0.02 to <0.001) than any of the other predictive tools. The NESMS was also able to inform independent ambulatory function at 3- and 6-months, a function that was only uniformly replicated by the Tokuhashi score. CONCLUSIONS The results of this prospective validation study indicate that the NESMS was able to differentiate survival to a significantly higher degree than the Tokuhashi, Tomita and SINS. We believe that these findings endorse the utilization of the NESMS as a prognostic tool capable of informing care for patients with spinal metastases.
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Justin A Blucher
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Nicole Agaronnik
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Lananh Nguyen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Tracy A Balboni
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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24
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Khurana B, Keraliya A, Velmahos G, Maung AA, Bono CM, Harris MB. Clinical significance of "positive" cervical spine MRI findings following a negative CT. Emerg Radiol 2021; 29:307-316. [PMID: 34850316 DOI: 10.1007/s10140-021-01992-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 10/20/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To review and analyze the clinical significance of positive acute traumatic findings seen on MRI of the cervical spine (MRCS) following a negative CT of the cervical spine (CTCS) for trauma. METHODS We performed a sub-cohort analysis of 54 patients with negative CTCS and a positive MRCS after spine trauma from the previous multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Both CTCS and MRCS were independently reviewed by two emergency radiologists and two spine surgeons. The surgeons also commented on the clinical significance of the traumatic findings seen on MRCS and grouped them into unstable, potentially unstable, and stable injuries. RESULTS Among 35 unevaluable patients, MRCS showed one unstable (hyperextension) and two potentially unstable (hyperflexion) injuries. Subtle findings were seen on CTCS in 2 of 3 patients upon careful retrospective review that would have suggested these injuries. Of 19 patients presenting with cervicalgia, 2/5 (40%) patients with neurological deficit demonstrated clinically significant findings on MRCS with predisposing factors seen on CT. None of the 14 patients with isolated cervicalgia and no neurological deficit had clinically significant findings on their MRCS. CONCLUSION While CTCS is adequate for clearing the cervical spine in patients with isolated cervicalgia, MRCS can play a critical role in patients with neurological deficits and normal CTCS. Clinically significant traumatic findings were seen in 8.5% of unevaluable patients on MRCS, though these injuries in fact could be identified on the CT in 2 of 3 patients upon careful retrospective review.
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Affiliation(s)
- Bharti Khurana
- Trauma Imaging Research and Innovation Center, Department of Radiology, Brigham and Women's Hospital, 75 Francis St., MA, 02115, Boston, USA.
| | - Abhishek Keraliya
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - George Velmahos
- Trauma, Emergency Surgery, Surgery Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Adrian A Maung
- Yale New Haven Hospital, New Haven, USA.,Department of Surgery, Yale School of Medicine, New Haven, USA
| | - Christopher M Bono
- Department of Orthopedics, Massachusetts General Hospital, MA, 02114, Boston, USA
| | - Mitchel B Harris
- Department of Orthopedics, Massachusetts General Hospital, MA, 02114, Boston, USA
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25
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Shankar GM, Van Beaver LA, Choi BD, Hadzipasic M, Sivaganesan A, Karhade AV, Ferrone ML, Harris MB, Schoenfeld AJ, Sadow PM, Oh K, Schwab JH, Saylor PJ, Shin JH. Survival After Surgery for Renal Cell Carcinoma Metastatic to the Spine: Impact of Modern Systemic Therapies on Outcomes. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa224_s046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Gitajn IL, Werth PM, Sprague S, O’Hara N, Della Rocca G, Zura R, Marmor M, Domes CM, Hill LC, Churchill C, Townsend C, Van C, Hogan N, Girardi C, Slobogean GP, Slobogean GP, Sprague S, Wells J, Bhandari M, D'Alleyrand JC, Harris AD, Mullins DC, Thabane L, Wood A, Della Rocca GJ, Hebden J, Jeray KJ, Marchand L, O'Hara LM, Zura R, Gardner MJ, Blasman J, Davies J, Liang S, Taljaard M, Devereaux PJ, Guyatt GH, Heels-Ansdell D, Marvel D, Palmer J, Friedrich J, O'Hara NN, Grissom F, Gitajn IL, Morshed S, O'Toole RV, Petrisor BA, Camara M, Mossuto F, Joshi MG, Fowler J, Rivera J, Talbot M, Dodds S, Garibaldi A, Li S, Nguyen U, Pogorzelski D, Rojas A, Scott T, Del Fabbro G, Szasz OP, McKay P, Howe A, Rudnicki J, Demyanovich H, Little K, Boissonneault A, Medeiros M, Polk G, Kettering E, Hale D, Mahal N, Eglseder A, Johnson A, Langhammer C, Lebrun C, Manson T, Nascone J, Paryavi E, Pensy R, Pollak A, Sciadini M, Degano Y, Demyanovich HK, Joseph K, Phipps H, Hempen E, Johal H, Ristevski B, Williams D, Denkers M, Rajaratnam K, Al-Asiri J, Leonard J, Marcano-Fernández FA, Gallant J, Persico F, Gjorgjievski M, George A, McGaugh SM, Pusztai K, Piekarski S, Lyons M, Gennaccaro J, Natoli RN, Gaski GE, McKinley TO, Virkus WW, Sorkin AT, Szatkowski JP, Baele JR, Mullis BH, Jang Y, Hill LC, Hudgins A, Fentz CL, Diaz MM, Garst KM, Denari EW, Osborn P, Pierrie S, Martinez E, Kimmel J, Adams JD, Beckish ML, Bray CC, Brown TR, Cross AW, Dew T, Faucher GK, Gurich RW, Lazarus DE, Millon SJ, Palmer MJ, Porter SE, Schaller TM, Sridhar MS, Sanders JL, Rudisill LE, Garitty MJ, Poole AS, Sims ML, Carlisle RM, Adams-Hofer E, Huggins BS, Hunter MD, Marshall WA, Bielby Ray S, Smith CD, Altman KM, Bedard JC, Loeffler MF, Pichiotino ER, Cole AA, Maltz EJ, Parker W, Ramsey TB, Burnikel A, Colello M, Stewart R, Wise J, Moody MC, Anderson M, Eskew J, Judkins B, Miller JM, Tanner SL, Snider RG, Townsend CE, Pham KH, Martin A, Robertson E, Skyes JW, Kandemir U, Marmor M, Matityahu A, McClellan RT, Meinberg E, Miclau T, Shearer D, Toogood P, Ding A, Donohue E, Murali J, El Naga A, Tangtiphaiboontana J, Belaye T, Berhaneselase E, Paul A, Garg K, Pokhvashchev D, Gary JL, Warner SJ, Munz JW, Choo AM, Schor TS, Routt ML"C, Rao M, Pechero G, Miller A, Kutzler M, Hagen JE, Patrick M, Vlasak R, Krupko T, Sadasivan K, Talerico M, Horodyski M, Koenig C, Bailey D, Wentworth D, Van C, Schwartz J, Pazik M, Dehghan N, Jones CB, Watson JT, McKee M, Karim A, Sietsema DL, Williams A, Dykes T, Obremsky WT, Jahangir AA, Sethi M, Boyce R, Mitchell P, Stinner DJ, Trochez K, Rodriguez A, Gajari V, Rodriguez E, Pritchett C, Hogan N, Moreno AF, Boulton C, Lowe J, Wild J, Ruth JT, Taylor M, Askam B, Seach A, Saeed S, Culbert H, Cruz A, Knapp T, Hurkett C, Lowney M, Featherston B, Prayson M, Venkatarayappa I, Horne B, Jerele J, Clark L, Marcano-Fernández F, Jornet-Gibert M, Martinez-Carreres L, Marti-Garin D, Serrano-Sanz J, Sanchez-Fernandez J, Sanz-Molero M, Carballo A, Pelfort X, Acerboni-Flores F, Alavedra-Massana A, Anglada-Torres N, Berenguer A, Camara-Cabrera J, Caparros-Garcia A, Fillat-Goma F, Fuentes-Lopez R, Garcia-Rodriguez R, Gimeno-Calavia N, Graells-Alonso G, Martinez-Alvarez M, Martinez-Grau P, Pellejero-Garcia R, Rafols-Perramon O, Penalver JM, Domenech MS, Soler-Cano A, Velasco-Barrera A, Yela-Verdú C, Bueno-Ruiz M, Sánchez-Palomino E, Andriola V, Molina-Corbacho M, Maldonado-Sotoca Y, Gasset-Teixidor A, Blasco-Moreu J, Fernández-Poch N, Rodoreda-Puigdemasa J, Verdaguer-Figuerola A, Enrique Cueva-Sevieri H, Garcia-Gimenez S, Guerra-Farfan E, Tomas-Hernandez J, Teixidor-Serra J, Molero-Garcia V, Selga-Marsa J, Antonio Porcel-Vasquez J, Vicente Andres-Peiro J, Minguell-Monyart J, Nuñez-Camarena J, del Mar Villar-Casares M, Mestre-Torres J, Lalueza-Broto P, Moreira-Borim F, Garcia-Sanchez Y, Romeo NM, Vallier HA, Breslin MA, Fraifogl J, Wilson ES, Wadenpfuhl LK, Halliday PG, Heimke I, Viskontas DG, Apostle KL, Boyer DS, Moola FO, Perey BH, Stone TB, Lemke HM, Zomar M, Spicer E, Fan C"B, Payne K, Phelps K, Bosse M, Karunakar M, Kempton L, Sims S, Hsu J, Seymour R, Churchill C, Bartel C, Mayberry RM, Brownrigg M, Girardi C, Mayfield A, Sweeney J, Pollock H, Hymes RA, Schwartzbach CC, Schulman JE, Malekzadeh AS, Holzman MA, Wills J, Ramsey L, Ahn JS, Panjshiri F, Das S, English AD, Haaser SM, Cuff JAN, Pilson H, Carroll EA, Halvorson JJ, Babcock S, Goodman JB, Holden MB, Bullard D, Williams W, Hill T, Brotherton A, Higgins TF, Haller JM, Rothberg DL, Marchand LS, Neese A, Russell M, Olsen ZM, McGowan AV, Hill S, Coe M, Dwyer K, Mullin D, Reilly CA, DePalo P, Hall AE, Dabrowski RE, Chockbengboun TA, Heng M, Harris MB, Smith RM, Lhowe DW, Esposito JG, Bansal M, McTague M, Alnasser A, Bergin PF, Russell GV, Graves ML, Morellato J, Champion HK, Johnson LN, McGee SL, Bhanat EL, Thimothee J, Serrano J, Mehta S, Donehan D, Ahn J, Horan A, Dooley M, Kuczinski A, Iwu A, Potter D, VanDemark R, Pfaff B, Hollinsworth T, Atkins K, Weaver MJ, von Keudell AG, Allen EM, Sagona AE, Jaeblon T, Beer R, Bauer B, Meredith S, Stone A, Gage MJ, Reilly RM, Sparrow C, Paniagua A. Association of COVID-19 With Achieving Time-to-Surgery Benchmarks in Patients With Musculoskeletal Trauma. JAMA Health Forum 2021; 2:e213460. [PMID: 35977160 PMCID: PMC8727030 DOI: 10.1001/jamahealthforum.2021.3460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/31/2021] [Indexed: 11/14/2022] Open
Abstract
Question Were resource constraints due to the COVID-19 pandemic associated with a delay in urgent fracture surgery beyond national time-to-surgery benchmarks? Findings In this cohort pre-post study that included 3589 patients, there was no association between time to surgery and COVID-19 in either open fracture or closed femur/hip fracture cohorts. Meaning Despite concerns that the unprecedented challenges associated with the COVID-19 pandemic would delay acute management of urgent surgery, many hospital systems within the US were able to implement strategies in keeping with time-to-surgery standards for orthopedic trauma. Importance In response to the COVID-19 pandemic, many hospital systems were forced to reduce operating room capacity and reallocate resources. The outcomes of these policies on the care of injured patients and the maintenance of emergency services have not been adequately reported. Objective To evaluate whether the COVID-19 pandemic was associated with delays in urgent fracture surgery beyond national time-to-surgery benchmarks. Design, Setting, and Participants This retrospective cohort study used data collected in the Program of Randomized Trials to Evaluate Preoperative Antiseptic Skin Solutions in Orthopaedic Trauma among at 20 sites throughout the US and Canada and included patients who sustained open fractures or closed femur or hip fractures. Exposure COVID-19–era operating room restrictions were compared with pre–COVID-19 data. Main Outcomes and Measures Surgery within 24 hours after injury. Results A total of 3589 patients (mean [SD] age, 55 [25.4] years; 1913 [53.3%] male) were included in this study, 2175 pre–COVID-19 and 1414 during COVID-19. A total of 54 patients (3.1%) in the open fracture cohort and 407 patients (21.8%) in the closed hip/femur fracture cohort did not meet 24-hour time-to-surgery benchmarks. We were unable to detect any association between time to operating room and COVID-19 era in either open fracture (odds ratio [OR], 1.40; 95% CI, 0.77-2.55; P = .28) or closed femur/hip fracture (OR, 1.01; 95% CI, 0.74-1.37; P = .97) cohorts. In the closed femur/hip fracture cohort, there was no association between time to operating room and regional COVID-19 prevalence (OR, 1.07; 95% CI, 0.70-1.64; P = .76). Conclusions and Relevance In this cohort study, there was no association between meeting time-to-surgery benchmarks in either open fracture or closed femur/hip fracture during the COVID-19 pandemic compared with before the pandemic. This is counter to concerns that the unprecedented challenges associated with managing the COVID-19 pandemic would be associated with clinically significant delays in acute management of urgent surgical cases and suggests that many hospital systems within the US were able to effectively implement policies consistent with time-to-surgery standards for orthopedic trauma in the context of COVID-19–related resource constraints.
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Affiliation(s)
| | - Paul M. Werth
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Nathan O’Hara
- University of Maryland School of Medicine, Baltimore
| | | | - Robert Zura
- Louisiana State University Medical Center, New Orleans
| | | | | | | | - Christine Churchill
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | | | - Chi Van
- University of Florida, Gainesville
| | | | - Cara Girardi
- Carolinas Medical Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
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- for the PREP-IT Investigators
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Ziino C, Karhade AV, Schoenfeld AJ, Harris MB, Schwab JH. Characteristics of postoperative opioid prescription use following lumbar discectomy. J Neurosurg Spine 2021; 35:710-714. [PMID: 34450580 DOI: 10.3171/2021.2.spine202041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The role of spine surgeons in precipitating and mediating sustained prescription opioid use remains controversial at this time. The purpose of this study was to identify prescription opioid use following lumbar discectomy and characterize the source of opioid prescriptions by clinician specialty (surgeon vs nonsurgeon). METHODS Using a retrospective review, the authors identified adult patients undergoing lumbar discectomy for a primary diagnosis of disc herniation between 2010 and 2017. The primary outcome was sustained prescription opioid use, defined as issue of an opioid prescription at a time point 90 days or longer after the surgical procedure. The primary predictor variable was prescriber specialty (surgeon vs nonsurgeon). The independent effect of provider specialty on the number of opioid prescriptions issued to patients was assessed using multivariable Poisson regression that accounted for confounding from all other clinical and sociodemographic variables. RESULTS This study included 622 patients who underwent a lumbar discectomy. A total of 610 opioid prescriptions were dispensed for this population after surgery. In total, 126 patients (20.3%) had at least one opioid prescription in the period beyond 90 days following their surgery. The majority of opioid prescriptions, 494 of 610 (81%), were non-inpatient prescriptions. Among these, only a minority (26%) of outpatient opioid prescriptions were written by surgical providers. Following multivariable Poisson regression analysis, surgical providers were found to have a lower likelihood of issuing an opioid prescription compared to nonsurgical clinicians (incidence rate ratio [IRR] 0.78; 95% CI 0.68-0.89; p = 0.001). CONCLUSIONS A minority of lumbar discectomy patients continue to receive opioid prescriptions up to 15 months after surgery. Many of these prescriptions are written by nonsurgical providers unaffiliated with the operative team.
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Affiliation(s)
- Chason Ziino
- 1Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School; and.,2Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aditya V Karhade
- 1Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School; and.,2Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- 2Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mitchel B Harris
- 1Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School; and
| | - Joseph H Schwab
- 1Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School; and
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Thomas R, Dyer GSM, Tornetta Iii P, Park H, Gujrathi R, Gosangi B, Lebovic J, Hassan N, Seltzer SE, Rexrode KM, Boland GW, Harris MB, Khurana B. Upper extremity injuries in the victims of intimate partner violence. Eur Radiol 2021; 31:5713-5720. [PMID: 33459857 PMCID: PMC7812562 DOI: 10.1007/s00330-020-07672-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/01/2020] [Accepted: 12/23/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To recognize most common patterns of upper extremity (UE) injuries in victims of Intimate Partner Violence (IPV). METHODS Radiological review of 308 patients who reported physical IPV at our institution from January 2013 to June 2018, identified 55 patients with 88 unique UE injuries. Demographic data and injury patterns and associations were collected from the electronic medical records. RESULTS The cohort included 49 females and 6 males (age 19-63, mean 38). At the time of injury, IPV was reported in 15/88 (17%) and IPV screening was documented for 22/88 (25%) injuries. There were 46 fractures, 8 dislocations or subluxations, and 34 isolated soft tissue injuries, most commonly involving the hand (56/88). Fractures most commonly involved the fingers (21/46, 46%) and the 5th digit (8/27, 30%). Medial UE fractures (5th digit, 4th digit) constituted 44% of hand and finger fractures (12/27) and 26% of all fractures (12/46). Comminuted and displaced fractures were rare (8/46, 17%). Head and face injuries were the most common concomitant injuries (9/22, 41%) and subsequent injuries (21/61, 35%). Of 12 patients with recurrent UE injuries, 6 had recurrent injuries of the same hand. Five of 6 non-acute fractures (83%) were of the hand. CONCLUSIONS Hand and finger injuries are the most common UE injuries in patients with IPV, with finger being the most common site and medial hand the most common region of fracture. Repeated injuries involving the same site and a combination of medial hand and head or face injuries could indicate IPV. KEY POINTS • Upper extremity injuries in victims of intimate partner violence are most commonly seen in the hand and fingers. • Fingers are the most common site of fracture and the medial hand is the most common region of fracture in the upper extremity in victims of intimate partner violence. • In intimate partner violence victims with upper extremity injuries, concomitant injuries and subsequent injuries are most commonly seen in the head and neck region.
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Affiliation(s)
- Richard Thomas
- Department of Radiology, Division of Emergency Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - George S M Dyer
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Paul Tornetta Iii
- Department of Orthopedic Surgery, Boston Medical Center, 725 Albany St 4th Floor, Suite 4B, Boston, MA, 02118, USA
| | - Hyesun Park
- Department of Radiology, Division of Emergency Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Rahul Gujrathi
- Department of Radiology, Division of Emergency Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Babina Gosangi
- Department of Radiology, Division of Emergency Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Jordan Lebovic
- Department of Orthopedic Surgery, Hospital for Joint Diseases, 301 E 17th St, New York, NY, 10003, USA
| | - Najmo Hassan
- Department of Radiology, Division of Emergency Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Steven E Seltzer
- Department of Radiology, Division of Emergency Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Kathryn M Rexrode
- Division of Women's Health, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Giles W Boland
- Department of Radiology, Division of Emergency Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Bharti Khurana
- Department of Radiology, Division of Emergency Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Schoenfeld AJ, Bensen GP, Blucher JA, Ferrone ML, Balboni TA, Schwab JH, Harris MB, Katz JN, Losina E. The Cost-Effectiveness of Surgical Intervention for Spinal Metastases: A Model-Based Evaluation. J Bone Joint Surg Am 2021; 103:00004623-990000000-00293. [PMID: 34288901 PMCID: PMC8776911 DOI: 10.2106/jbjs.21.00023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Operative and nonoperative treatments for spinal metastases are expensive interventions with a high rate of complications. We sought to determine the cost-effectiveness of a surgical procedure compared with nonoperative management as treatment for spinal metastases. METHODS We constructed a Markov state-transition model with health states defined by ambulatory status and estimated the quality-adjusted life-years (QALYs) and costs for operative and nonoperative management of spine metastases. We considered 2 populations: 1 in which patients presented with independent ambulatory status and 1 in which patients presented with nonambulatory status due to acute (e.g., <48 hours) metastatic epidural compression. We defined the efficacy of each treatment as a likelihood of maintaining, or returning to, independent ambulation. Transition probabilities for the model, including the risks of mortality and becoming dependent or nonambulatory, were obtained from secondary data analysis and published literature. Costs were determined from Medicare reimbursement schedules. We conducted analyses over patients' remaining life expectancy from a health system perspective and discounted outcomes at 3% per year. We conducted sensitivity analyses to account for uncertainty in data inputs. RESULTS Among patients presenting as independently ambulatory, QALYs were 0.823 for operative treatment and 0.800 for nonoperative treatment. The incremental cost-effectiveness ratio (ICER) for a surgical procedure was $899,700 per QALY. Among patients presenting with nonambulatory status, those undergoing surgical intervention accumulated 0.813 lifetime QALY, and those treated nonoperatively accumulated 0.089 lifetime QALY. The incremental cost-effectiveness ratio for a surgical procedure was $48,600 per QALY. The cost-effectiveness of a surgical procedure was most sensitive to the variability of its efficacy. CONCLUSIONS Our data suggest that the value to society of a surgical procedure for spinal metastases varies according to the features of the patient population. In patients presenting as nonambulatory due to acute neurologic compromise, surgical intervention provides good value (ICER, $48,600 per QALY). There is a low value for a surgical procedure performed for patients who are ambulatory at presentation (ICER, $899,700 per QALY). LEVEL OF EVIDENCE Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gordon P Bensen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justin A Blucher
- Rutgers Institute for Translational Medicine and Science, Rutgers Biomedical and Health Sciences, New Brunswick, New Jersey
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tracy A Balboni
- Department of Radiation Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey N Katz
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Elena Losina
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Jarman MP, Weaver MJ, Haider AH, Salim A, Harris MB. Geographic Distribution of Orthopaedic Trauma Resources and Service Use in the United States: A Cross Sectional Analysis. J Surg Res 2021; 267:328-335. [PMID: 34186309 DOI: 10.1016/j.jss.2021.05.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 04/15/2021] [Accepted: 05/26/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Management of orthopaedic injury is an essential component of comprehensive trauma care, and availability of orthopaedic surgeons impacts trauma system capacity and accessibility of care. We sought to estimate the geographic distribution of orthopaedic injury in the United States and identify regions needing additional orthopaedic trauma resources. METHODS In this retrospective cross-sectional study using 2014 Agency for Healthcare Research and Quality State Inpatient Datasets from 26 states and the District of Columbia, administrative data were used to determine hospital referral region (HRR)-level incidence of orthopaedic trauma and surgical care. Factors associated with HRR-level orthopaedic trauma volume were identified using negative binomial regression, and model parameters were used to estimate injury incidence and operative volume in unobserved HRRs. The primary outcomes of interest were HRR-level incidence of orthopaedic injury, polytrauma, and emergency orthopaedic surgery, as well and the number of emergency orthopaedic surgery patients per orthopaedic surgeon. RESULTS Orthopaedic injury incidence and operative patients per orthopaedic surgeon were associated with HRR-level volume of medical service use, population characteristics, geographic characteristics, and existing trauma care resources. Orthopaedic injury incidence ranged from 20 patients/HRR to 33,260 patients/HRR. Polytrauma incidence ranged from < 10 patients/HRR to 12,140 patients/HRR. Emergency orthopaedic surgery incidence ranged from < 10 patients/HRR to 18,759 patients/HRR. The volume of operative orthopaedic trauma patients per orthopaedic surgeon ranged from < 10 patients/surgeon to 224 patients and/or surgeon. DISCUSSION The incidence of orthopaedic injury and volume of injury patients per orthopaedic surgeon varies substantially across HRRs in the United States. Regions with high patient volume and moderate patient-to-provider ratios may be ideal settings for orthopaedic trauma training programs or post-fellowship professional opportunities. Future research should examine the impact of high volume orthopaedic trauma volume and high patient-to-provider ratios on health outcomes.
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Affiliation(s)
- Molly P Jarman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
| | - Michael J Weaver
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; College of Medicine, Aga Khan University, Karachi, Pakistan
| | - Ali Salim
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Ross BJ, Lee OC, Harris MB, Dowd TC, Savoie FH, Sherman WF. Rates of Osteoporosis Management and Secondary Preventative Treatment After Primary Fragility Fractures. JB JS Open Access 2021; 6:JBJSOA-D-20-00142. [PMID: 34136740 PMCID: PMC8202643 DOI: 10.2106/jbjs.oa.20.00142] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Fragility fractures are often sentinel events in documenting new cases of osteoporosis. Numerous analyses have demonstrated low rates of adequate osteoporosis evaluation and treatment following primary fragility fractures. The purpose of this study was to quantify the incidence of primary fragility fractures in America and the rates of osteoporosis screening and management before and after fracture.
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Affiliation(s)
- Bailey J Ross
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Olivia C Lee
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, Louisiana
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas C Dowd
- Department of Orthopaedic Surgery, San Antonio Uniformed Services Health Education Consortium Orthopaedic Residency Program, Fort Sam Houston, Texas
| | - Felix H Savoie
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - William F Sherman
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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Shah NG, Keraliya A, Harris MB, Bono CM, Khurana B. Spinal trauma in DISH and AS: is MRI essential following the detection of vertebral fractures on CT? Spine J 2021; 21:618-626. [PMID: 33130303 DOI: 10.1016/j.spinee.2020.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/01/2020] [Accepted: 10/26/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Both ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) cause a rigid spine, but through different pathophysiology. Recent data has shown that characteristic fracture patterns may also differ following trauma since the posterior osseous and soft tissue elements are often spared in DISH. CT and MRI are important in diagnosing spine injury, but given the differences between AS and DISH, the utility of obtaining both studies in all patients warrants scrutiny. PURPOSE To assess the prevalence of posterior element injury on CT and MRI in DISH and AS patients with known vertebral body injury detected on CT; to determine whether MRI demonstrates additional injuries in neurologically intact patients presumed to have isolated vertebral body injuries on CT. STUDY DESIGN Multicenter, retrospective, case-control study. PATIENT SAMPLE DISH and AS patients presenting after spine trauma between 2007 and 2017. OUTCOME MEASURES Review of CT and MRI findings at the time of presentation. METHODS One hundred sixty DISH and 85 AS patients presenting after spine trauma were identified from 2 affiliated academic hospitals serving as level 1 trauma and tertiary referral centers. A diagnosis of DISH or AS was verified by a board-certified emergency radiologist with 3 years of experience. Age, gender, mechanism of injury, fracture type, spine CT and MRI imaging findings, surgical intervention, and neurologic deficit were recorded. The CT and MRI studies were reviewed by the same radiologist for fracture location and type using the AO spine classification. No funding source or conflict of interest was present. RESULTS Median age was 72 and 79 years old for the AS and DISH groups, respectively. Both were predominantly male (81%) and most presented after a low energy mechanism of injury (74% and 73%). Type C AO spine injuries were seen in 52% of AS patients but only 4% of DISH patients. In patients with known vertebral body injury on CT, additional injury to the posterior elements on CT or MRI in DISH patients was 51% versus 92% in AS patients. However, in patients with an isolated vertebral body fracture on CT and no neurological deficit, MRI identified posterior element injury in only 4/22 (18%) DISH patients compared to 5 of 7 (71%) AS patients. None of the MRI findings in the DISH patients were considered clinically important while all 5 AS patients eventually underwent operative treatment despite having no neurological deficit. Epidural hematoma on MRI was seen in 43% of AS patients as opposed to 5% of DISH patients. CONCLUSION Based on our small sample size, CT alone may be adequate in DISH patients with isolated vertebral body fractures and no neurologic deficit, but an additional MRI should be considered in the presence of an unclear neurological exam or deficit. MRI should be strongly considered for any AS patient regardless of neurologic status.
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Affiliation(s)
- Nandish G Shah
- Brigham and Women's Hospital, Department of Radiology, Boston, MA, USA
| | - Abhishek Keraliya
- Brigham and Women's Hospital, Department of Radiology, Boston, MA, USA
| | - Mitchel B Harris
- Massachusetts General Hospital, Department of Orthopedic Surgery, Boston, MA, USA
| | - Christopher M Bono
- Massachusetts General Hospital, Department of Orthopedic Surgery, Boston, MA, USA
| | - Bharti Khurana
- Brigham and Women's Hospital, Department of Radiology, Boston, MA, USA.
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Donnelley CA, Devlin VJ, Harris MB, Poggie RA, Sanders RW, Morshed S. Regulation of orthopaedic devices: Future implications for research and innovation. OTA Int 2021; 4:e101(1-7). [PMID: 37608857 PMCID: PMC10441672 DOI: 10.1097/oi9.0000000000000101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/09/2020] [Accepted: 12/13/2020] [Indexed: 08/24/2023]
Abstract
The conception-to-market development of orthopaedic devices occurs across the total product life cycle including device design and preclinical testing, clinical investigations to support marketing applications, and monitoring of device performance after market introduction. This process involves industry, regulatory agencies, health care providers, engineers, scientists, and patients. The Food and Drug Administration (FDA) is responsible for regulating medical devices in the United States, and uses a 3-tier classification system based on the level of control necessary to provide reasonable assurance of safety and effectiveness. Classification directs the required regulatory pathway and premarket submission type. Variations in global regulations, particularly between the United States, European Economic Area (EEA), and the United Kingdom (UK), may impact industry response to orthopaedic device development. Changing device innovation and reimbursement models have led to the consolidation of market share among larger companies. Although larger companies are better able to cope with more rigorous regulatory requirements, this leads to decreased competition and increased upward price pressure. To assist with the complex regulatory processes, the FDA offers pre-submission assistance as an opportunity for early collaboration and discussion about the medical device or device-led combination product submissions. Orthopaedic organizations, such as the Orthopaedic Trauma Association (OTA), may assist in postmarket device surveillance through the coordinated development and maintenance of clinical data registries. Such registries can longitudinally follow patients with a specific orthopaedic pathology or device usage, and monitor outcomes towards improvements in next-generation device development. As technology evolves, the nexus of regulation, industry, and patient outcome monitoring will continue to support safe and effective device innovation.
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Affiliation(s)
- Claire A Donnelley
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA
| | - Vincent J Devlin
- Office of Health Technology 6, Office of Orthopedic Device, Office of Product Evaluation and Quality, Center for Devices and Radiological Health, United States Food and Drug Administration, Silver Spring, MD
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Roy W Sanders
- Department of Orthopaedic Surgery, University of South Florida/Florida Orthopaedic Institute, Tampa, FL
| | - Saam Morshed
- Institute for Global Orthopaedics and Traumatology, Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA
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Shokouhimehr M, Theus AS, Kamalakar A, Ning L, Cao C, Tomov ML, Kaiser JM, Goudy S, Willett NJ, Jang HW, LaRock CN, Hanna P, Lechtig A, Yousef M, Martins JDS, Nazarian A, Harris MB, Mahmoudi M, Serpooshan V. 3D Bioprinted Bacteriostatic Hyperelastic Bone Scaffold for Damage-Specific Bone Regeneration. Polymers (Basel) 2021; 13:polym13071099. [PMID: 33808295 PMCID: PMC8036866 DOI: 10.3390/polym13071099] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022] Open
Abstract
Current strategies for regeneration of large bone fractures yield limited clinical success mainly due to poor integration and healing. Multidisciplinary approaches in design and development of functional tissue engineered scaffolds are required to overcome these translational challenges. Here, a new generation of hyperelastic bone (HB) implants, loaded with superparamagnetic iron oxide nanoparticles (SPIONs), are 3D bioprinted and their regenerative effect on large non-healing bone fractures is studied. Scaffolds are bioprinted with the geometry that closely correspond to that of the bone defect, using an osteoconductive, highly elastic, surgically friendly bioink mainly composed of hydroxyapatite. Incorporation of SPIONs into HB bioink results in enhanced bacteriostatic properties of bone grafts while exhibiting no cytotoxicity. In vitro culture of mouse embryonic cells and human osteoblast-like cells remain viable and functional up to 14 days on printed HB scaffolds. Implantation of damage-specific bioprinted constructs into a rat model of femoral bone defect demonstrates significant regenerative effect over the 2-week time course. While no infection, immune rejection, or fibrotic encapsulation is observed, HB grafts show rapid integration with host tissue, ossification, and growth of new bone. These results suggest a great translational potential for 3D bioprinted HB scaffolds, laden with functional nanoparticles, for hard tissue engineering applications.
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Affiliation(s)
- Mohammadreza Shokouhimehr
- Department of Materials Science and Engineering, Research Institute of Advanced Materials, Seoul National University, Seoul 08826, Korea; (M.S.); (H.W.J.)
| | - Andrea S. Theus
- Department of Biomedical Engineering, Georgia Institute of Technology, School of Medicine, Emory University, Atlanta, GA 30322, USA; (A.S.T.); (L.N.); (M.L.T.); (N.J.W.)
| | - Archana Kamalakar
- Department of Otolaryngology, School of Medicine, Emory University, Atlanta, GA 30322, USA; (A.K.); (S.G.)
| | - Liqun Ning
- Department of Biomedical Engineering, Georgia Institute of Technology, School of Medicine, Emory University, Atlanta, GA 30322, USA; (A.S.T.); (L.N.); (M.L.T.); (N.J.W.)
| | - Cong Cao
- Department of Physics, Emory University, Atlanta, GA 30322, USA;
| | - Martin L. Tomov
- Department of Biomedical Engineering, Georgia Institute of Technology, School of Medicine, Emory University, Atlanta, GA 30322, USA; (A.S.T.); (L.N.); (M.L.T.); (N.J.W.)
| | - Jarred M. Kaiser
- Department of Orthopedics, Emory University, Atlanta, GA 30322, USA;
- Atlanta Veteran’s Affairs Medical Center, Decatur, GA 30033, USA
| | - Steven Goudy
- Department of Otolaryngology, School of Medicine, Emory University, Atlanta, GA 30322, USA; (A.K.); (S.G.)
| | - Nick J. Willett
- Department of Biomedical Engineering, Georgia Institute of Technology, School of Medicine, Emory University, Atlanta, GA 30322, USA; (A.S.T.); (L.N.); (M.L.T.); (N.J.W.)
- Department of Orthopedics, Emory University, Atlanta, GA 30322, USA;
- Atlanta Veteran’s Affairs Medical Center, Decatur, GA 30033, USA
| | - Ho Won Jang
- Department of Materials Science and Engineering, Research Institute of Advanced Materials, Seoul National University, Seoul 08826, Korea; (M.S.); (H.W.J.)
| | - Christopher N. LaRock
- Department of Microbiology and Immunology, School of Medicine, Emory University, Atlanta, GA 30322, USA;
| | - Philip Hanna
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (P.H.); (A.L.); (A.N.)
| | - Aron Lechtig
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (P.H.); (A.L.); (A.N.)
| | - Mohamed Yousef
- Department of Orthopedic Surgery, Sohag University, Sohag 82524, Egypt;
| | - Janaina Da Silva Martins
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, 50 Blossom St, Thier 11, Boston, MA 02114, USA;
| | - Ara Nazarian
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (P.H.); (A.L.); (A.N.)
- Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan 0025, Armenia
| | - Mitchel B. Harris
- Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Morteza Mahmoudi
- Precision Health Program & Department of Radiology, Michigan State University, East Lansing, MI 48824, USA;
| | - Vahid Serpooshan
- Department of Biomedical Engineering, Georgia Institute of Technology, School of Medicine, Emory University, Atlanta, GA 30322, USA; (A.S.T.); (L.N.); (M.L.T.); (N.J.W.)
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA 30322, USA
- Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
- Correspondence:
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Karhade AV, Fogel HA, Cha TD, Hershman SH, Doorly TP, Kang JD, Bono CM, Harris MB, Schwab JH, Tobert DG. Development of prediction models for clinically meaningful improvement in PROMIS scores after lumbar decompression. Spine J 2021; 21:397-404. [PMID: 33130302 DOI: 10.1016/j.spinee.2020.10.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/11/2020] [Accepted: 10/26/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The ability to preoperatively predict which patients will achieve a minimal clinically important difference (MCID) after lumbar spine decompression surgery can help determine the appropriateness and timing of surgery. Patient-Reported Outcome Measurement Information System (PROMIS) scores are an increasingly popular outcome instrument. PURPOSE The purpose of this study was to develop algorithms predictive of achieving MCID after primary lumbar decompression surgery. PATIENT SAMPLE This was a retrospective study at two academic medical centers and three community medical centers including adult patients 18 years or older undergoing one or two level posterior decompression for lumbar disc herniation or lumbar spinal stenosis between January 1, 2016 and April 1, 2019. OUTCOME MEASURES The primary outcome, MCID, was defined using distribution-based methods as one half the standard deviation of postoperative patient-reported outcomes (PROMIS physical function, pain interference, pain intensity). METHODS Five machine learning algorithms were developed to predict MCID on these surveys and assessed by discrimination, calibration, Brier score, and decision curve analysis. The final model was incorporated into an open access digital application. RESULTS Overall, 906 patients completed at least one PROMs survey in the 90 days before surgery and at least one PROMs survey in the year after surgery. Attainment of MCID during the study period by PROMIS instrument was 74.3% for physical function, 75.8% for pain interference, and 79.2% for pain intensity. Factors identified for preoperative prediction of MCID attainment on these outcomes included preoperative PROs, percent unemployment in neighborhood of residence, comorbidities, body mass index, private insurance, preoperative opioid use, surgery for disc herniation, and federal poverty level in neighborhood of residence. The discrimination (c-statistic) of the final algorithms for these outcomes was 0.79 for physical function, 0.74 for pain interference, and 0.69 for pain intensity with good calibration. The open access digital application for these algorithms can be found here: https://sorg-apps.shinyapps.io/promis_pld_mcid/ CONCLUSION: Lower preoperative PROMIS scores, fewer comorbidities, and certain sociodemographic factors increase the likelihood of achieving MCID for PROMIS after lumbar spine decompression.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Harold A Fogel
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Thomas D Cha
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Stuart H Hershman
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Terence P Doorly
- Department of Neurosurgery, North Shore Medical Center, Boston, MA, USA
| | - James D Kang
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Daniel G Tobert
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA.
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Sun EX, Mandell JC, Weaver MJ, Kimbrell V, Harris MB, Khurana B. Clinical utility of a focused hip MRI for assessing suspected hip fracture in the emergency department. Emerg Radiol 2020; 28:317-325. [PMID: 33175269 DOI: 10.1007/s10140-020-01870-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 11/01/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE A focused hip MRI (FHMR) for the detection of radiographically occult hip fractures was implemented in our emergency department (ED) in 2013. The goal of this study was to assess the clinical utility of this protocol. METHODS We retrospectively reviewed radiology reports of 262 unique patients who underwent 263 FHMR (coronal T1, coronal STIR, axial T2 fat saturated) for suspected hip fracture in the ED from October 2013 to March 2020. Electronic medical records were reviewed for the ED course, follow-up imaging, and clinical management within 90 days. RESULTS Seventy-one patients had one or more fractures identified by FHMR: one-third had proximal femoral fractures; two-third had pelvic fractures. Of these 71 patients, 53 (74%) had radiographically occult fractures, including 14 (20%) with occult proximal femoral fractures; 4 patients had fractures occult on CT. Nineteen patients with a suspected fracture on radiography were found to have no fracture on FHMR. Four fractures not reported on FHMR were later seen on follow-up imaging: these included 1 isolated greater trochanter, 1 additional ischial tuberosity, 1 additional superior pubic ramus, and 1 additional sacrum. All four fractures were treated non-operatively. Muscle/tendon injury was the most common type of injury, seen in 50% (130/262) patients with the most commonly torn tendons being the hamstring (44%; 15/34) followed by gluteus medius tendon (18%; 6/34). A full-hip or pelvis MRI was done after FHMR in only 5 patients, primarily for the purpose of better characterizing findings already identified on FHMR (2 for fracture, 2 for tendon injury, 1 for soft tissue metastasis). Only one of these five studies provided new information: ruling out a previously questioned fracture. Clinical management of the vast majority of patients was based solely on findings from the FHMR. CONCLUSIONS FHMR offers reliable identification of radiographically occult hip fractures and muscle/tendon injuries. The protocol is well trusted in guiding patient management in our ED.
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Affiliation(s)
- Ellen X Sun
- Department of Radiology, Division of Emergency Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02215, USA.
| | - Jacob C Mandell
- Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02215, USA
| | - Michael J Weaver
- Department of Orthopedic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02215, USA
| | - Vera Kimbrell
- Department of Radiology, Duke University Hospital, 2301 Erwin Rd, Durham, NC, 27710, USA.,Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02215, USA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Bharti Khurana
- Trauma Imaging Research and Innovation Center, Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02215, USA
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Karhade AV, Schwab JH, Harris MB, Schoenfeld AJ. Comparison of the Stopping Opioids after Surgery (SOS) score to preoperative morphine milligram equivalents (MME) for prediction of opioid prescribing after lumbar spine surgery. Spine J 2020; 20:1798-1804. [PMID: 32534136 DOI: 10.1016/j.spinee.2020.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/09/2020] [Accepted: 06/03/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Reliable estimation of the likelihood for prolonged postoperative opioid use may aid targeted interventions for high-risk patients. Previous studies have recommended differing methodologies for prediction of sustained postoperative opioid use. PURPOSE To compare the performance of the Stopping Opioids after Surgery (SOS) score and preoperative morphine milligram equivalents (MME) for postoperative opioid prescription exposure in a contemporary cohort of lumbar surgery patients. PATIENT SAMPLE Adult patients undergoing posterior decompression with or without fusion for degenerative lumbar conditions between January 31, 2016 and May 31, 2019. STUDY DESIGN/SETTING Retrospective review at two academic medical centers and three community hospitals. OUTCOME MEASURES The primary outcome was sustained postoperative prescription opioid exposure at 3 months and 6 months. Reoperations and readmissions were considered secondarily. METHODS The Stopping Opioids after Surgery score and MME were assigned to patients based on data from their preoperative surgical evaluation. Performance for both measures was assessed for all outcomes by discrimination, including c-statistic and receiver-operating curve analysis. Calibration of the low, medium and high-risk strata with the observed rates of postoperative adverse events were examined. RESULTS Overall, 4,165 patients were included in this study. Preoperative prevalence of prescription opioid use was 31%. Rates of postoperative opioid prescriptions at 3 months and 6 months, were 3.3% (n=136) and 1.5% (n=61). The c-statistics of preoperative oral MME and SOS score for 3-month sustained opioid prescriptions were 0.64 and 0.78, respectively. The c-statistics of preoperative oral MME and SOS score for 6-month sustained opioid prescriptions were 0.64 and 0.82, respectively. C-statistics of preoperative oral MME and SOS score were much lower for reoperation and readmission, although SOS score outperformed MME for both outcomes. CONCLUSIONS The SOS score clinically outperformed oral MME as a predictive measure for outcomes following lumbar spine surgery. The SOS score may be valuable for identifying individuals at high-risk for sustained prescription opioid use and associated adverse events following spine surgery.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Alessandrino F, Keraliya A, Lebovic J, Mitchell Dyer GS, Harris MB, Tornetta P, Boland GWL, Seltzer SE, Khurana B. Intimate Partner Violence: A Primer for Radiologists to Make the "Invisible" Visible. Radiographics 2020; 40:2080-2097. [PMID: 33006922 DOI: 10.1148/rg.2020200010] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Intimate partner violence (IPV) is the physical, sexual, or emotional violence between current or former partners. It is a major public health issue that affects nearly one out of four women. Nonetheless, IPV is greatly underdiagnosed. Imaging has played a significant role in identifying cases of nonaccidental trauma in children, and similarly, it has the potential to enable the identification of injuries resulting from IPV. Radiologists have early access to the radiologic history of such victims and may be the first to diagnose IPV on the basis of the distribution and imaging appearance of the patient's currrent and past injuries. Radiologists must be familiar with the imaging findings that are suggestive of injuries resulting from IPV. Special attention should be given to cases in which there are multiple visits for injury care; coexistent fractures at different stages of healing, which may help differentiate injuries related to IPV from those caused by a stranger; and injuries in defensive locations and target areas such as the face and upper extremities. The authors provide an overview of current methods for diagnosing IPV and define the role of the radiologist in cases of IPV. They also describe a successful diagnostic imaging-based approach for helping to identify IPV, with a specific focus on the associated imaging findings and mechanisms of injuries. In addition, current needs and future perspectives for improving the diagnosis of this hidden epidemic are identified. This information is intended to raise awareness among radiologists, with the ultimate goal of improving the diagnosis of IPV and thus reducing the devastating effects on victims' lives. ©RSNA, 2020.
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Affiliation(s)
- Francesco Alessandrino
- From the Departments of Radiology (F.A., A.K., G.W.L.B., S.E.S., B.K.) and Orthopaedic Surgery (G.S.M.D.) and the Trauma Imaging Research and Innovation Center (B.K.), Brigham and Women's Hospital; and Department of Orthopaedic Surgery, Massachusetts General Hospital (M.B.H.), Harvard Medical School (J.L.), 75 Francis St, Boston, MA 02115; and Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Mass (P.T.)
| | - Abhishek Keraliya
- From the Departments of Radiology (F.A., A.K., G.W.L.B., S.E.S., B.K.) and Orthopaedic Surgery (G.S.M.D.) and the Trauma Imaging Research and Innovation Center (B.K.), Brigham and Women's Hospital; and Department of Orthopaedic Surgery, Massachusetts General Hospital (M.B.H.), Harvard Medical School (J.L.), 75 Francis St, Boston, MA 02115; and Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Mass (P.T.)
| | - Jordan Lebovic
- From the Departments of Radiology (F.A., A.K., G.W.L.B., S.E.S., B.K.) and Orthopaedic Surgery (G.S.M.D.) and the Trauma Imaging Research and Innovation Center (B.K.), Brigham and Women's Hospital; and Department of Orthopaedic Surgery, Massachusetts General Hospital (M.B.H.), Harvard Medical School (J.L.), 75 Francis St, Boston, MA 02115; and Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Mass (P.T.)
| | - George Sinclair Mitchell Dyer
- From the Departments of Radiology (F.A., A.K., G.W.L.B., S.E.S., B.K.) and Orthopaedic Surgery (G.S.M.D.) and the Trauma Imaging Research and Innovation Center (B.K.), Brigham and Women's Hospital; and Department of Orthopaedic Surgery, Massachusetts General Hospital (M.B.H.), Harvard Medical School (J.L.), 75 Francis St, Boston, MA 02115; and Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Mass (P.T.)
| | - Mitchel B Harris
- From the Departments of Radiology (F.A., A.K., G.W.L.B., S.E.S., B.K.) and Orthopaedic Surgery (G.S.M.D.) and the Trauma Imaging Research and Innovation Center (B.K.), Brigham and Women's Hospital; and Department of Orthopaedic Surgery, Massachusetts General Hospital (M.B.H.), Harvard Medical School (J.L.), 75 Francis St, Boston, MA 02115; and Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Mass (P.T.)
| | - Paul Tornetta
- From the Departments of Radiology (F.A., A.K., G.W.L.B., S.E.S., B.K.) and Orthopaedic Surgery (G.S.M.D.) and the Trauma Imaging Research and Innovation Center (B.K.), Brigham and Women's Hospital; and Department of Orthopaedic Surgery, Massachusetts General Hospital (M.B.H.), Harvard Medical School (J.L.), 75 Francis St, Boston, MA 02115; and Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Mass (P.T.)
| | - Giles W L Boland
- From the Departments of Radiology (F.A., A.K., G.W.L.B., S.E.S., B.K.) and Orthopaedic Surgery (G.S.M.D.) and the Trauma Imaging Research and Innovation Center (B.K.), Brigham and Women's Hospital; and Department of Orthopaedic Surgery, Massachusetts General Hospital (M.B.H.), Harvard Medical School (J.L.), 75 Francis St, Boston, MA 02115; and Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Mass (P.T.)
| | - Steven E Seltzer
- From the Departments of Radiology (F.A., A.K., G.W.L.B., S.E.S., B.K.) and Orthopaedic Surgery (G.S.M.D.) and the Trauma Imaging Research and Innovation Center (B.K.), Brigham and Women's Hospital; and Department of Orthopaedic Surgery, Massachusetts General Hospital (M.B.H.), Harvard Medical School (J.L.), 75 Francis St, Boston, MA 02115; and Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Mass (P.T.)
| | - Bharti Khurana
- From the Departments of Radiology (F.A., A.K., G.W.L.B., S.E.S., B.K.) and Orthopaedic Surgery (G.S.M.D.) and the Trauma Imaging Research and Innovation Center (B.K.), Brigham and Women's Hospital; and Department of Orthopaedic Surgery, Massachusetts General Hospital (M.B.H.), Harvard Medical School (J.L.), 75 Francis St, Boston, MA 02115; and Department of Orthopaedic Surgery, Boston Medical Center, Boston University Medical School, Boston, Mass (P.T.)
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Watane GV, Gosangi B, Thomas R, Gujrathi R, Park H, Harris MB, Khurana B. Incidence and characteristics of spinal injuries in the victims of intimate partner violence (IPV). Emerg Radiol 2020; 28:283-289. [PMID: 33000362 PMCID: PMC7527263 DOI: 10.1007/s10140-020-01853-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/17/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To describe the incidence and patterns of the spinal injuries in the victims of physical IPV. MATERIALS AND METHODS With institutional review board (IRB) approval, we retrospectively reviewed patients referred to our institution's domestic violence intervention and prevention program with a diagnosis directly related to physical abuse between January 2013 and June 2018. Electronic health records and radiology reports were reviewed for all patients. RESULTS A total of 21/688 (3%) IPV patients with 41 vertebral injuries were identified. The study population comprised of 19/21 (90%) females. Median age of the included patients was 43 years with a range of 21-72 years. All vertebral injuries were AO type A spinal injuries. Upper lumbar spine (L1 and L2) was the most common level of injury followed by upper to mid-thoracic spine. The reported mechanism of the injury was IPV in 8/21 (38.0%), fall in 8/21(38.0%), and incidental in 5/21 (24.0%). Ten out of 21 (48%) patients had concomitant injuries, most commonly to the craniofacial region 5/21 (23%). Psychiatry history was positive in 17/21 (81%), and substance abuse was positive in 15/21 (71%) of the patients. CONCLUSION Incidence of spinal injuries is relatively low in IPV with morphologic AO type A injury being the most common type of injury and the upper lumbar spine being the most common level of injury.
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Affiliation(s)
- Gaurav V Watane
- Division of Emergency Radiology, Department of Radiology, Brigham & Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Babina Gosangi
- Department of Radiology, Yale New Haven Health, New Haven, CT, 06510, USA
| | - Richard Thomas
- Lahey Hospital and Medical Center, 41 Mall road, Burlington, MA, 01805, USA
| | - Rahul Gujrathi
- Division of Emergency Radiology, Department of Radiology, Brigham & Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Hyesun Park
- Division of Emergency Radiology, Department of Radiology, Brigham & Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Bharti Khurana
- Division of Emergency Radiology, Department of Radiology, Brigham & Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
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Karhade AV, Bongers MER, Groot OQ, Cha TD, Doorly TP, Fogel HA, Hershman SH, Tobert DG, Schoenfeld AJ, Kang JD, Harris MB, Bono CM, Schwab JH. Can natural language processing provide accurate, automated reporting of wound infection requiring reoperation after lumbar discectomy? Spine J 2020; 20:1602-1609. [PMID: 32145358 DOI: 10.1016/j.spinee.2020.02.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/05/2020] [Accepted: 02/28/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgical site infections are a major driver of morbidity and increased costs in the postoperative period after spine surgery. Current tools for surveillance of these adverse events rely on prospective clinical tracking, manual retrospective chart review, or administrative procedural and diagnosis codes. PURPOSE The purpose of this study was to develop natural language processing (NLP) algorithms for automated reporting of postoperative wound infection requiring reoperation after lumbar discectomy. PATIENT SAMPLE Adult patients undergoing discectomy at two academic and three community medical centers between January 1, 2000 and July 31, 2019 for lumbar disc herniation. OUTCOME MEASURES Reoperation for wound infection within 90 days after surgery METHODS: Free-text notes of patients who underwent surgery from January 1, 2000 to December 31, 2015 were used for algorithm training. Free-text notes of patients who underwent surgery after January 1, 2016 were used for algorithm testing. Manual chart review was used to label which patients had reoperation for wound infection. An extreme gradient-boosting NLP algorithm was developed to detect reoperation for postoperative wound infection. RESULTS Overall, 5,860 patients were included in this study and 62 (1.1%) had a reoperation for wound infection. In patients who underwent surgery after January 1, 2016 (n=1,377), the NLP algorithm detected 15 of the 16 patients (sensitivity=0.94) who had reoperation for infection. In comparison, current procedural terminology and international classification of disease codes detected 12 of these 16 patients (sensitivity=0.75). At a threshold of 0.05, the NLP algorithm had positive predictive value of 0.83 and F1-score of 0.88. CONCLUSION Temporal validation of the algorithm developed in this study demonstrates a proof-of-concept application of NLP for automated reporting of adverse events after spine surgery. Adapting this methodology for other procedures and outcomes in spine and orthopedics has the potential to dramatically improve and automatize quality and safety reporting.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michiel E R Bongers
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Q Groot
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas D Cha
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Terence P Doorly
- Department of Neurosurgery, North Shore Medical Center, Boston, MA, USA
| | - Harold A Fogel
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Stuart H Hershman
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel G Tobert
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - James D Kang
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Brigham and Women's Faulkner Hospital, Boston, MA, USA
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher M Bono
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Newton Wellesley Hospital, Newton, MA, USA.
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Gosangi B, Park H, Thomas R, Gujrathi R, Bay CP, Raja AS, Seltzer SE, Balcom MC, McDonald ML, Orgill DP, Harris MB, Boland GW, Rexrode K, Khurana B. Exacerbation of Physical Intimate Partner Violence during COVID-19 Pandemic. Radiology 2020; 298:E38-E45. [PMID: 32787700 PMCID: PMC7427119 DOI: 10.1148/radiol.2020202866] [Citation(s) in RCA: 132] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Intimate partner violence (IPV) is a global social and public health problem, but published literature regarding the exacerbation of physical IPV during the coronavirus disease 2019 (COVID-19) pandemic is lacking. Purpose To assess the incidence, patterns, and severity of injuries in IPV victims during the COVID-19 pandemic in 2020 compared with the prior 3 years. Materials and Methods The demographics, clinical presentation, injuries, and radiologic findings of patients reporting physical abuse arising from IPV during the statewide COVID-19 pandemic between March 11 and May 3, 2020, were compared with data from the same period for the past 3 years. Pearson χ2 and Fisher exact tests were used for analysis. Results A total of 26 victims of physical IPV from 2020 (mean age, 37 years ± 13 [standard deviation]; 25 women) were evaluated and compared with 42 victims of physical IPV (mean age, 41 years ± 15; 40 women) from 2017 to 2019. Although the overall number of patients who reported IPV decreased during the pandemic, the incidence of physical IPV was 1.8 times greater (95% CI: 1.1, 3.0; P = .01). The total number of deep injuries was 28 during 2020 versus 16 from 2017 to 2019; the number of deep injuries per victim was 1.1 during 2020 compared with 0.4 from 2017 to 2019 (P < .001). The incidence of high-risk abuse defined by mechanism was two times greater in 2020 (95% CI: 1.2, 4.7; P = .01). Patients who experienced IPV during the COVID-19 pandemic were more likely to be White; 17 (65%) victims in 2020 were White compared with 11 (26%) in the prior years (P = .007). Conclusion There was a higher incidence and severity of physical intimate partner violence (IPV) during the coronavirus disease 2019 (COVID-19) pandemic compared with the prior 3 years. These results suggest that victims of IPV delayed reaching out to health care services until the late stages of the abuse cycle during the COVID-19 pandemic. © RSNA, 2020.
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Affiliation(s)
- Babina Gosangi
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Hyesun Park
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Richard Thomas
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Rahul Gujrathi
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Camden P Bay
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Ali S Raja
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Steven E Seltzer
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Marta Chadwick Balcom
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Meghan L McDonald
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Dennis P Orgill
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Mitchel B Harris
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Giles W Boland
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Kathryn Rexrode
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
| | - Bharti Khurana
- From the Department of Radiology (B.G., H.P., R.T., R.G., C.P.B., S.E.S., G.W.B., B.K.), Violence Intervention and Prevention Programs, Center for Community Health and Health Equity (M.C.B.), Department of Surgery (M.L.M., D.P.O.), and Division of Women's Health (K.R.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115; and Departments of Emergency Medicine (A.S.R.) and Orthopedic Surgery (M.B.H.), Massachusetts General Hospital, Boston, Mass
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Gitajn IL, Slobogean GP, Henderson ER, von Keudell AG, Harris MB, Scolaro JA, O’Hara NN, Elliott JT, Pogue BW, Jiang S. Perspective on optical imaging for functional assessment in musculoskeletal extremity trauma surgery. J Biomed Opt 2020; 25:JBO-200070-PER. [PMID: 32869567 PMCID: PMC7457961 DOI: 10.1117/1.jbo.25.8.080601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/12/2020] [Indexed: 06/11/2023]
Abstract
SIGNIFICANCE Extremity injury represents the leading cause of trauma hospitalizations among adults under the age of 65 years, and long-term impairments are often substantial. Restoring function depends, in large part, on bone and soft tissue healing. Thus, decisions around treatment strategy are based on assessment of the healing potential of injured bone and/or soft tissue. However, at the present, this assessment is based on subjective clinical clues and/or cadaveric studies without any objective measure. Optical imaging is an ideal method to solve several of these issues. AIM The aim is to highlight the current challenges in assessing bone and tissue perfusion/viability and the potentially high impact applications for optical imaging in orthopaedic surgery. APPROACH The prospective will review the current challenges faced by the orthopaedic surgeon and briefly discuss optical imaging tools that have been published. With this in mind, it will suggest key research areas that could be evolved to help make surgical assessments more objective and quantitative. RESULTS Orthopaedic surgical procedures should benefit from incorporation of methods to measure functional blood perfusion or tissue metabolism. The types of measurements though can vary in the depth of tissue sampled, with some being quite superficial and others sensing several millimeters into the tissue. Most of these intrasurgical imaging tools represent an ideal way to improve surgical treatment of orthopaedic injuries due to their inherent point-of-care use and their compatibility with real-time management. CONCLUSION While there are several optical measurements to directly measure bone function, the choice of tools can determine also the signal strength and depth of sampling. For orthopaedic surgery, real-time data regarding bone and tissue perfusion should lead to more effective patient-specific management of common orthopaedic conditions, requiring deeper penetrance commonly seen with indocyanine green imaging. This will lower morbidity and result in decreased variability associated with how these conditions are managed.
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Affiliation(s)
- Ida L. Gitajn
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire, United States
| | - Gerard P. Slobogean
- University of Maryland, Orthopaedic Associates, Baltimore, Maryland, United States
| | - Eric R. Henderson
- Dartmouth-Hitchcock Medical Center, Department of Orthopaedics, Lebanon, New Hampshire, United States
| | - Arvind G. von Keudell
- Brigham and Women’s Hospital, Department of Orthopaedic Surgery, Boston, Massachusetts, United States
| | - Mitchel B. Harris
- Massachusetts General Hospital, Department of Orthopaedic Surgery, Boston, Massachusetts, United States
| | - John A. Scolaro
- University of California, Irvine, Department of Orthopaedic Surgery, Orange, California, United States
| | - Nathan N. O’Hara
- University of Maryland, Orthopaedic Associates, Baltimore, Maryland, United States
| | - Jonathan T. Elliott
- Dartmouth-Hitchcock Medical Center, Department of Surgery, Lebanon, New Hampshire, United States
| | - Brian W. Pogue
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - Shudong Jiang
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
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Shankar GM, Van Beaver LA, Choi BD, Hadzipasic M, Sivaganesan A, Karhade AV, Ferrone ML, Harris MB, Schoenfeld AJ, Sadow PM, Oh K, Schwab JH, Saylor PJ, Shin JH. Survival After Surgery for Renal Cell Carcinoma Metastatic to the Spine: Impact of Modern Systemic Therapies on Outcomes. Neurosurgery 2020; 87:1174-1180. [PMID: 32521012 DOI: 10.1093/neuros/nyaa224] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 03/26/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Modern medical management of metastatic renal cell carcinoma (RCC) includes therapies targeting tyrosine kinases, growth pathways (mammalian target of rapamycin (mTOR)), and immune checkpoints. OBJECTIVE To test our hypothesis that patients with spinal metastases would benefit from postoperative systemic therapy despite presenting with disease that, in many cases, was resistant to prior systemic therapy. METHODS This is an Institutional Review Board-approved clinical retrospective cohort analysis. A sample of adult patients with RCC metastatic to the spine who underwent operative intervention between January 2010 and December 2017 at 2 large academic medical centers was used in this study. RESULTS We identified 78 patients with metastatic RCC in whom instrumented stabilization was performed in 79% and postoperative stereotactic radiosurgery was performed in 41% of patients. Of patients presenting with weakness or myelopathy, 93% noted postoperative improvement and 78% reported improvement in radicular and axial paraspinal pain severity. Increased overall survival (OS) (913 d (95% CI: 633-1975 d, n = 49) vs 222 d (95% CI: 143-1005 d, n = 29), P = .003) following surgery was noted in patients who received postoperative systemic therapy a median of 80 d (interquartile range 48-227 d) following the surgical intervention. CONCLUSION Postoperative outcomes and palliation of symptoms for metastatic RCC without targeted therapies in this cohort are similar to those reported in earlier series prior to the adoption of these systemic therapies. We observed a significantly longer OS among patients who received modern systemic therapies postoperatively. These findings have implications for the preoperative evaluation of patients with systemic disease who may have been deemed poor surgical candidates prior to the availability of these systemic therapies.
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Affiliation(s)
- Ganesh M Shankar
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Laura A Van Beaver
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Bryan D Choi
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Muhamed Hadzipasic
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ahilan Sivaganesan
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aditya V Karhade
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Marco L Ferrone
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kevin Oh
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Philip J Saylor
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
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Lipa SA, Greene N, Reyes AM, Blucher JA, Makhni MC, Simpson AK, Harris MB, Schoenfeld AJ. Prognostic value of laboratory values in older patients with cervical spine fractures. Clin Neurol Neurosurg 2020; 194:105781. [PMID: 32278269 DOI: 10.1016/j.clineuro.2020.105781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/18/2020] [Accepted: 03/11/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To understand the prognostic value of laboratory markers at presentation on post-treatment survival of patients 50 and older following cervical spine fracture. PATIENTS AND METHODS We obtained clinical data on patients 50 and older treated for cervical spine fracture in a single healthcare system (2006-2016). Our primary outcome consisted of 1-year mortality, with mortality within 3-months of presentation considered secondarily. Our primary predictors included serum glucose, serum creatinine, platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) at presentation. We used multivariable logistic regression to adjust for confounding from sociodemographic and clinical characteristics. Point estimates and 95 % confidence intervals (CI) from the final model were refined using Bayesian regression techniques. RESULTS We included 1781 patients in this analysis, with an average age of 75.3 (SD 12.0). The mortality rate at 3-months was 12 % and 17 % at 1-year. In multivariable testing, neither elevated PLR or NLR were significant predictors of 1-year mortality. Elevated serum creatinine was associated with increased mortality at 1-year (OR 1.89; 95 % CI 1.30, 2.74), as was hyperglycemia (OR 1.50; 95 % CI 1.06, 2.13). Elevated serum creatinine remained influential (OR 1.64; 95 % CI 1.06, 2.54) on mortality at 3-months. CONCLUSIONS This is the first study to evaluate laboratory values at presentation in conjunction with survival following cervical fractures. The results can be used to help forecast natural history and in expectation management. They may also help formulate treatment plans, especially when the need for surgical intervention is not clearly defined.
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Affiliation(s)
- Shaina A Lipa
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States
| | - Nattaly Greene
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States
| | - Angel M Reyes
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States
| | - Justin A Blucher
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States
| | - Melvin C Makhni
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States
| | - Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, United States
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States.
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Affiliation(s)
- George S.M. Dyer
- Massachusetts General Hospital, Boston, Massachusetts,Brigham and Women’s Hospital, Boston, Massachusetts,Email address for G.S.M. Dyer:
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Fandino LB, Bhashyam A, Harris MB, Zhang D. Factors associated with discharge opioid prescription after hip fracture fixation. Musculoskeletal Care 2020; 18:352-358. [PMID: 32202702 DOI: 10.1002/msc.1466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/14/2020] [Accepted: 03/15/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Opioid prescribing after hip fracture fixation is variable, but the factors that drive this prescribing variation are not well-described. The purpose of this study was to determine independent factors associated with increased opioid prescription upon discharge after hip fracture fixation. METHODS A retrospective cohort study of 296 adult patients who underwent hip fracture fixation between January 2016 and December 2017 at two Level I trauma centers were included in our study. The primary outcome measurement was opioid prescription at discharge in morphine milligram equivalents (MME). Bivariate analysis was used to screen for factors, and multivariable regression analysis was used to identify independent factors associated with opioid prescription upon discharge from the hospital. RESULTS Discharge opioid prescription amounts were available for 280 out of 296 patients (95%). The mean (±standard deviation) discharge opioid prescription was 212 (±319) MME. Multivariable regression analysis showed that younger age (p = 0.004), diabetes mellitus (p = 0.02), smoking (p < 0.001), treatment at hospital #2 (p < 0.001), and weekend discharge (p = 0.03) were associated with increased opioid prescription at discharge. CONCLUSIONS Increased opioid prescribing after hip fracture fixation is associated with patient- and system-related factors. Prescriber education programs, prescription guidelines, and safe handoff practices that focus on these factors may help to decrease prescription variability and opioid overprescription across institutions.
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Affiliation(s)
| | - Abhiram Bhashyam
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mitchel B Harris
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dafang Zhang
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Karhade AV, Thio QCBS, Ogink PT, Shah AA, Bono CM, Oh KS, Saylor PJ, Schoenfeld AJ, Shin JH, Harris MB, Schwab JH. Development of Machine Learning Algorithms for Prediction of 30-Day Mortality After Surgery for Spinal Metastasis. Neurosurgery 2020; 85:E83-E91. [PMID: 30476188 DOI: 10.1093/neuros/nyy469] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/31/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Preoperative prognostication of short-term postoperative mortality in patients with spinal metastatic disease can improve shared decision making around end-of-life care. OBJECTIVE To (1) develop machine learning algorithms for prediction of short-term mortality and (2) deploy these models in an open access web application. METHODS The American College of Surgeons, National Surgical Quality Improvement Program was used to identify patients that underwent operative intervention for metastatic disease. Four machine learning algorithms were developed, and the algorithm with the best performance across discrimination, calibration, and overall performance was integrated into an open access web application. RESULTS The 30-d mortality for the 1790 patients undergoing surgery for spinal metastatic disease was 8.49%. Preoperative factors used for prognostication were albumin, functional status, white blood cell count, hematocrit, alkaline phosphatase, spinal location (cervical, thoracic, lumbosacral), and severity of comorbid systemic disease (American Society of Anesthesiologist Class). In this population, machine learning algorithms developed to predict 30-d mortality performed well on discrimination (c-statistic), calibration (assessed by calibration slope and intercept), Brier score, and decision analysis. An open access web application was developed for the best performing model and this web application can be found here: https://sorg-apps.shinyapps.io/spinemets/. CONCLUSION Machine learning algorithms are promising for prediction of postoperative outcomes in spinal oncology and these algorithms can be integrated into clinically useful decision tools. As the volume of data in oncology continues to grow, creation of learning systems and deployment of these systems as accessible tools may significantly enhance prognostication and management.
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Affiliation(s)
- Aditya V Karhade
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Quirina C B S Thio
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Paul T Ogink
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Akash A Shah
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher M Bono
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kevin S Oh
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Phil J Saylor
- Department of Hematology/Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph H Schwab
- Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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48
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Jarman MP, Weaver MJ, Haider AH, Salim A, Harris MB. The National Burden of Orthopedic Injury: Cross-Sectional Estimates for Trauma System Planning and Optimization. J Surg Res 2020; 249:197-204. [PMID: 31991329 DOI: 10.1016/j.jss.2019.12.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 11/26/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Management of orthopedic injuries is a critical component of comprehensive trauma care. As patterns of injury incidence and recovery change in the face of emerging injury prevention efforts and technologies and an aging US population, assessment of the burden of orthopedic injury is essential to optimize trauma system planning. We sought to estimate the incidence of orthopedic injury requiring emergency orthopedic surgery in the United States. METHODS Using nationally representative samples from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, we estimated the incidence of orthopedic injury, polytrauma with orthopedic injury, and emergency operative orthopedic procedures performed for the management of traumatic injury. We used multivariable logistic regression to identify patient, injury, and hospital characteristics associated with odds of emergency orthopedic surgery. RESULTS A total of 7,214,915 patients were diagnosed with orthopedic injury in 2013-2014, resulting in 1,167,656 emergency orthopedic surgical procedures. Fall-related injuries accounted for 51% of health care encounters and 61% of emergency orthopedic surgical procedures. Odds of emergency orthopedic surgery were 2.04 times greater for patients with polytrauma, compared with isolated orthopedic injury (P < 0.001). CONCLUSIONS The total burden or orthopedic injury in the United States is substantial, and there is considerable heterogeneity in demand for care and practice patterns in the orthopedic trauma community. Population-based trauma system planning and tailored care delivery models would likely optimize initial treatment, recovery, and health outcomes for orthopedic trauma patients.
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Affiliation(s)
- Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts.
| | - Michael J Weaver
- Division of Orthopaedic Trauma, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; College of Medicine, Aga Khan University, Karachi, Pakistan
| | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts; Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchel B Harris
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Schoenfeld AJ, Ferrone ML, Passias PG, Blucher JA, Barton LB, Shin JH, Harris MB, Schwab JH. Laboratory markers as useful prognostic measures for survival in patients with spinal metastases. Spine J 2020; 20:5-13. [PMID: 31125700 PMCID: PMC6872928 DOI: 10.1016/j.spinee.2019.01.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/19/2018] [Accepted: 01/03/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Laboratory values have been found to be useful predictive measures of survival following surgery. The utility of laboratory values for prognosticating outcomes among patients with spinal metastases has not been studied. PURPOSE To determine the prognostic capacity of laboratory values at presentation including white blood cell count, serum albumin and platelet-lymphocyte ratio (PLR) in patients with spinal metastases. STUDY DESIGN Retrospective review of records from two tertiary care centers (2005-2017). PATIENT SAMPLE Patients, aged 40 to 80, who received operative or nonoperative management for spinal metastases. OUTCOME MEASURES Survival, complications, or hospital readmissions within 90 days of treatment and a composite measure for treatment failure accounting for changes in ambulatory function and mortality at 6 months following presentation. METHODS Multivariable Cox proportional hazard regression analysis was used to analyze the relationship between laboratory values and length of survival, adjusting for confounders. Multivariable logistic regression was used in analyses related to 6-month and 1-year mortality, complications, readmissions, and treatment failure. A scoring rubric was developed based on the performance of laboratory values in the multivariable tests. Internal validation was performed using a bootstrap simulation that consisted of sampling with replacement and 1,000 replications. RESULTS We included 1,216 patients. Thirty-seven percent of patients received a surgical intervention and 63% were treated nonoperatively. Median survival for the cohort as a whole was 255 days (interquartile range 93-642 days). The PLR (hazard ratio [HR] 1.53; 95% confidence interval [CI] 1.29, 1.80; p<.001) and albumin (HR 0.54; 95% CI 0.45, 0.64; p<.001) were significantly associated with survival, whereas WBC count (HR 1.08; 95% CI 0.86, 1.36; p=.50) was not associated with this outcome. Similar findings were encountered for 6-month and 1-year mortality as well as the composite measure for treatment failure. The PLR and albumin performed well in our scoring rubric and findings were preserved in the bootstrapping validation. CONCLUSIONS Individuals with low serum albumin and elevated PLR should be advised regarding the impact of these laboratory markers on outcomes including survival, irrespective of treatments received. An effort should also be made to optimize nutrition and PLR, if practicable, before treatment to minimize the potential for development of adverse events.
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Affiliation(s)
- Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115
| | - Marco L. Ferrone
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115
| | - Peter G. Passias
- New York Spine Institute, New York University Langone Medical Center, 761 Merrick Avenue, Westbury, NY 11590
| | - Justin A. Blucher
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115
| | - Lauren B. Barton
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115
| | - John H. Shin
- Department of Neurosurgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02214
| | - Mitchel B. Harris
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02214
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02214
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50
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Gupta S, Hauser BM, Zaki MM, Xu E, Cote DJ, Lu Y, Chi JH, Groff M, Khawaja AM, Harris MB, Smith TR, Zaidi HA. Morbidity after traumatic spinal injury in pediatric and adolescent sports-related trauma. J Neurosurg Spine 2019; 32:642-648. [PMID: 31881536 PMCID: PMC7383358 DOI: 10.3171/2019.10.spine19712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 10/14/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sports injuries present a considerable risk of debilitating spinal injury. Here, the authors sought to profile the epidemiology and clinical risk of traumatic spinal injuries (TSIs) in pediatric sports injuries. METHODS The authors conducted a retrospective cohort analysis of pediatric patients who had experienced a sports-related TSI, including spinal fractures and spinal cord injuries, encoded in the National Trauma Data Bank in the period from 2011 to 2014. RESULTS Included in the analysis were 1723 cases of pediatric sports-related TSI, which represented 3.7% of all pediatric sports-related trauma. The majority of patients with TSI were male (81%), and the median age was 15 years (IQR 13-16 years). TSIs arose most often from cycling accidents (47%) and contact sports (28%). The most frequently fractured regions were the thoracic (30%) and cervical (27%) spine. Among patients with spinal cord involvement (SCI), the cervical spine was involved in 60% of cases.The average length of stay for TSIs was 2 days (IQR 1-5 days), and 32% of the patients required ICU-level care. Relative to other sports-related trauma, TSIs without SCI were associated with an increased adjusted mean length of stay by 1.8 days (95% CI 1.6-2.0 days), as well as the need for ICU-level care (adjusted odds ratio [aOR] 1.6, 95% CI 1.3-1.9). Also relative to other sports-related trauma, TSIs with SCI had an increased length of stay by 2.1 days (95% CI 1.8-2.6 days) and the need for ICU-level care (aOR 3.6, 95% CI 2.6-4.8).TSIs without SCI were associated with discharge to or with rehabilitative services (aOR 1.7, 95% CI 1.5-2.0), as were TSIs with SCI (aOR 4.0, 95% CI 3.2-4.9), both relative to other sports-related trauma. Among the patients with TSIs, predictors of the need for rehabilitation at discharge were having a laminectomy or fusion, concomitant lower-extremity injury, head injury, and thoracic injury. Although TSIs affected 4% of the study cohort, these injuries were present in 8% of patients discharged to or with rehabilitation services and in 17% of those who died in the hospital. CONCLUSIONS Traumatic sports-related spinal injuries cause significant morbidity in the pediatric population, especially if the spinal cord is involved. The majority of TSI cases arose from cycling and contact sports accidents, underscoring the need for improving education and safety in these activities.
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Affiliation(s)
- Saksham Gupta
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Blake M. Hauser
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Mark M Zaki
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Edward Xu
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - David J. Cote
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
- Channing Division of Network Medicine, Department of Medicine/Brigham and Women’s Hospital, Harvard Medical School/Boston/MA/USA
| | - Yi Lu
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - John H. Chi
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Michael Groff
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Ayaz M. Khawaja
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
- Channing Division of Network Medicine, Department of Medicine/Brigham and Women’s Hospital, Harvard Medical School/Boston/MA/USA
| | - Mitchel B. Harris
- Department of Orthopedics/Massachusetts General Hospital, Harvard Medical School/Boston/MA/USA
| | - Timothy R. Smith
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
| | - Hasan A. Zaidi
- Computational Neurosciences Outcomes Center, Department of Neurosurgery/Harvard Medical School, Brigham and Women’s Hospital/Boston/MA/USA
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