Sean Childs

Hourly neurologic assessments for traumatic brain injury in the ICU.

Abstract Objectives: Hourly neurologic assessments for traumatic brain injury (TBI) in the critical care setting are common practice but prolonged use may actually be harming patients through sleep deprivation. We reviewed practice patterns at our institution in order to gain insight into the role of frequent neurological assessments. Methods: A 6-month retrospective review was performed for patients who were admitted to an intensive care unit (ICU) with the diagnosis of TBI. Electronic medical records were reviewed based on billing codes. Variables collected included but were not limited to patient demographics, frequency of nursing neurologic evaluations, Glasgow coma scale (GCS), length of stay (LOS), and disposition. Results: A total of 124 patients were identified, 71% male with the average age of 52 years (range 19–96). Traumatic brain injury was classified as severe in 44, moderate in 18, and mild in 62 patients. A total of 89 (71·8%) patients underwent hourly nursing assessments for an average of 2·82 days. The median LOS for all patients was 7 days (range 0–109). There were 18 patients who remained on hourly neurological assessments for greater than 4 days and had a greater LOS (23 days vs 9 days, P  =  0·001). Only two patients required surgery after 48 hours, both for chronic subdural hematomas. Discussion: Hourly neurologic checks are necessary in the acute period for patients with potentially expansible intracranial hemorrhages or malignant cerebral edema, but prolonged use may be harmful. Patients with a low probability of requiring neurosurgical intervention may benefit from reducing the total duration of hourly assessments.

The impact of residual angulation on patient reported functional outcome scores after non-operative treatment for humeral shaft fractures.

PURPOSE To determine if residual angular deformity following non-operative treatment of humeral diaphyseal fractures correlates with patient reported outcomes. METHODS Skeletally mature patients treated by one of three orthopaedic trauma surgeons at a level 1 trauma centre with humeral shaft fractures treated without surgery were retrospectively identified over a 7 year period. After inclusion and exclusion criteria, 42 patients were eligible for the study. Disabilities of the Arm, Shoulder, and Hand (DASH); Simple Shoulder Test (SST); General health questionnaire SF-12 physical component summary (SF-12 PCS) and mental component summary (SF-12 MCS) were obtained from study participants. Healed angular deformity was obtained from patient charts. RESULTS Thirty two subjects were successfully recruited (32/42 or 76%). Average age was 45 ± 22 with average study follow up being 47 ± 29 months. Average outcome scores were DASH 12 ± 16, SST 10 ± 2.7, SF-12 PCS 50 ± 7.9, and SF-12 MCS 54 ± 8.8. Healed sagittal plane deformity averaged 8 ± 5.7° [range 0-18], and 15 ± 7.9° [range 2-27] in the coronal plane. There was no correlation between residual sagittal or coronal plane deformity and outcome scores (DASH and SST for both p>0.05). Patients with at least 20° (n=7; 22%) of healed coronal deformity had similar outcomes to those with <20° ([DASH (13.2 ± 18.7 vs 11.7 ± 16.1; p=0.83]; [SST (10.3 ± 2 vs 10.0 ± 2.9; p=0.81]). Higher SF-12 PCS and MCS scores correlated with better DASH and SST scores (p<0.05 for all). CONCLUSION Residual angular deformity ranging from 0 to 18° in the sagittal plane and from 2 to 27° in the coronal plane after non-operative treatment for humeral shaft fractures had no correlation with patient reported DASH scores, SST scores, or patient satisfaction. Instead, overall physical and mental health status as measured by the SF-12 significantly correlated with patient reported outcomes.

Patient-Specific 3-Dimensional Modeling and Its Use for Preoperative Counseling of Patients Undergoing Hip Arthroscopy

Background: Femoroacetabular impingement (FAI) represents complex alterations in the bony morphology of the proximal femur and acetabulum. Imaging studies have become crucial in diagnosis and treatment planning for symptomatic FAI but also have limited patient understanding and satisfaction. Exploration of alternative patient counseling modalities holds promise for improved patient understanding, satisfaction, and ultimately for outcomes. Purpose: To compare perceived understanding of functional anatomy and FAI pathomorphology among patients counseled with routine computed tomography (CT), generic hip models, and a 3-dimensional (3D) model printed in accordance with a patient’s specific anatomy. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective randomized analysis of patients presenting with radiographically confirmed FAI was conducted between November 2015 and April 2017. Patients were randomized into groups that received preoperative counseling with CT imaging alone, a generic human hip model, or a haptic 3D model of their hip. All groups were subjected to a novel questionnaire examining patient satisfaction and understanding on a variety of topics related to FAI. Data were compared with bivariate and multivariate analyses. Statistical significance was determined as P < .05. Results: Thirty-one patients were included in this study (25 men, 6 women). Ten patients were randomized to the CT-only group, 11 to the generic hip model group, and 10 to receive custom 3D-printed models of their hips. Patients preoperatively counseled with isolated CT imaging or a generic hip model reported greater understanding of their pathophysiology and the role of surgical intervention when compared with those counseled with haptic 3D models (P = .03). At final follow-up, patients counseled with the use of isolated CT imaging or haptic 3D models reported greater increases and retention of understanding as compared with those counseled with generic hip models alone (P = .03). Conclusion: Preoperative counseling with haptic 3D hip models does not appear to favorably affect patient-reported understanding or satisfaction with regard to FAI when compared with the use of CT imaging alone. Continued research into alternative counseling means may serve to further improve patient understanding and satisfaction on this complex anatomic phenomenon.

Validity of QuickDASH at day of surgery versus day of initial consultation: Does informed consent make a difference?

Introduction: The trend toward requiring explicit consent from patients participating in observational research increases time and resources required to perform such research. Informed consent introduces the potential for “consent bias”—either through selection bias or through the “Hawthorne effect,” where patients may alter responses based upon the awareness of participation in a study, thus potentially limiting its applicability to a generalized orthopedic practice. We hypothesized that administering Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) to patients on the day of surgery with informed consent would alter responses in a statistically and clinically meaningful way compared to patients who complete QuickDASH as a quality control measure. Methods: We previously instituted the QuickDASH questionnaire as the standard new patient intake and postoperative questionnaire for quality assurance purposes. We retrospectively reviewed data on a cohort of patients who underwent isolated carpal tunnel release (CTR) who had completed preoperative and postoperative QuickDASH forms without providing consent for study participation. Next, a cohort of patients scheduled to undergo isolated CTR who completed the intake questionnaire was approached on the day of surgery for consent to participate in the study. After obtaining consent but prior to surgery, these patients completed a second questionnaire and then completed a postoperative questionnaire on follow-up at a mean of 8 weeks postoperatively. Results: Thirty-nine patients and 35 patients were included in the retrospective and prospective cohorts, respectively. No significant differences were observed in age, gender, symptom duration, nerve conduction study/electromyography results, or disease severity between the two groups. We identified no statistically significant difference in preoperative or postoperative QuickDASH score between the retrospective and prospective cohorts (39.8 ± 22.7 vs. 39.7 ± 19.1 preoperatively; 27.3 ± 24.7 vs. 18.7 ± 13.3 postoperatively) or within the prospective cohort before and after obtaining informed consent. Conclusion: Informed consent did not significantly alter patient responses to the QuickDASH questionnaire. These results suggest that both “opt-in” and “opt-out” approaches to observational research in hand surgery provide results that may be applicable to a generalized orthopedic practice. Clinical Relevance: This study provides evidence that will inform the interpretation of observational research findings in hand surgery.

Lumbar Spine Infection by Granulicatella and Abiotrophia Species

BACKGROUND The Granulicatella and Abiotrophia species are streptococci and natural inhabitants of the oral and urogenital flora. They are uncommonly associated with human pathology, although they can cause septicemia, endocarditis, or bacteremia. These microorganisms are difficult to culture and identify due to particular microenvironment requirements. Rarely, presentation is osteomyelitis or infections of the spine. CASE DESCRIPTION The case report referenced patient notes, laboratory values, and imaging from the electronic health record. In this 48-year-old male with a history of hepatitis C and intravenous drug use, back pain was a relatively common presentation of an uncommon infection. His hospital course was significant for low back pain that did not resolve with conservative measures. Imaging was concerning for infection of the lumbar spine. Biopsies, negative early on, were ultimately positive for Granulicatella and Abiotrophia species, a rare infectious etiology. This infection uncommonly affects the lumbar spine and has not been previously documented in IV drug users. Intravenous antibiotics were prescribed for 6 weeks, after which the patient demonstrated significant clinical improvement. CONCLUSION With such an uncommon pathogen, there are no universal protocol changes indicated. However, awareness of such unusual microbes and their potential role as the etiology of more common infections, such as lumbar osteomyelitis, is crucial in developing a thorough infectious workup in cases resistant to treatment targeting typical microorganisms.

Multi-centered Comparison of Patient Reported Outcomes After Hip Arthroscopy versus Combined Hip Arthroscopy Alone and Peri-acetabular Osteotomy in Patients with Acetabular Dysplasia:

Objectives: The purpose of this study was to compare prospectively collected patient reported outcomes (PRO) data in patients undergoing Hip Arthroscopy alone versus combined Hip Arthroscopy and Peri-acetubular Osteotomy (HA/PAO). Methods: Prospectively collected PRO data was reviewed in patients enrolled in IRB approved studies at two high volume hip preservation centers who underwent either Hip Arthroscopy alone or combined HA/PAO. Patients were included who had a lateral center edge angle <25 degrees, completed pre-operative and a minimum of 1 year post-operative PRO data. Questionnaires were administered to patients at intervals including pre-operative, 3 months, 1 year and 2 years post-operative. Questionnaires were composed of validated PRO scores: modified Harris Hip Score (mHHS), Hip Outcome Score (HOS) Activities of Daily Living (ADL) and Sports subscales, Non-arthritic Hip Score (NAHS) and Pain Visual Analog Scale (VAS). Results: Prospectively collected data was reviewed for 91 patients who underwent Hip Arthroscopy and 34 patients who underwent HA/PAO. Average age at the time of surgery was 32 years old (range 14-62) for arthroscopy and 31 years old (range 15-51) for combined surgery. Hip Arthroscopy patients were 35% male and 65% female. HA/PAO patients were 15% male and 85% female. PRO data for Hip Arthroscopy, reported as averages with 95% confidence intervals in parentheses at pre-operative, 3 months, 1 year and 2 years post-operatively. mHHS: 66.3 (3.1), 83.8 (3.5), 84.3 (4.1), 84.4 (3.4). HOS ADL: 70.1 (4.0), 85.3 (3.2), 87.1 (4.2), 87.4 (4.0). HOS Sports: 47.3 (4.6), 64.7 (6.6), 73.7 (8.1), 75.2 (5.9). NAHS: 65.5 (3.7), 80.1 (3.3), 83.8 (4.5), 83.8 (3.9). Pain VAS: 5.4 (0.5), 2.6 (0.5), 2.5 (0.6), 2.6 (0.6). PRO data for HA/PAO, reported as averages with 95% confidence intervals in parentheses at pre-operative, 3 months, 1 year and 2 years post-operatively. mHHS: 51.1 (4.6), 58.7 (7.9), 71.7 (7.3), 74.7 (13.1). HOS ADL: 58.3 (6.5), 65.7 (9.0), 83.6 (9.8), 85.1 (18.7). HOS Sports: 41.7 (7.2), 38.0 (11.7), 72.5 (11.5), 79.3 (11.9). NAHS: 56.7 (5.2), 71.6 (5.3), 80.2 (7.7), 83.4 (11.8). Pain VAS: 5.3 (0.9), 1.9 (0.8), 2.2 (1.0), 1.0 (0.9). Conclusion: Both cohorts had significant improvement in all PRO measures at 1 and 2 years when compared to pre-operative PRO measures. HA/PAO patients had significantly lower mHHS and HOS ADL pre-operatively; NAHS approached significance. HOS Sports and Pain VAS had no significant pre-operative differences between groups. At 3 months, the HA/PAO patients had significantly lower mHHS, HOS ADL and HOS Sports, while again NAHS approached significance. There was no significant difference in Pain VAS at 3 months. Only the mHHS remained significantly lower for the HA/PAO patients at 1 year. At 2 years, only Pain VAS showed significantly better pain scores for HA/PAO patients, although lacking clinical significance. All other PRO measures showed no significant difference at 2 years. Patients who underwent HA/PAO had significantly lower pre-operative and early post-operative PRO measures. HA/PAO patients, however, reached similar values for PRO measures by 1 year; only the mHHS remained lower. At 2 years, neither group showed statistical or clinical difference in PRO measures.

Intra-articular “Cocktail” Offers Clinical Advantages over Femoral Nerve Block for Postoperative Analgesia in Patients Undergoing Arthroscopic Hip Surgery

Objectives: Arthroscopic hip surgery has gained considerable popularity over the past several years. Attempts to optimize peri and postoperative pain control continues to represent a challenge and opportunity for clinical improvement. Multiple regional anesthesia strategies have been utilized by arthroscopic hip surgeons, including lumbar plexus and femoral nerve blockade, however these options can be associated with setbacks including technical difficulty, intravascular injection, increased post-operative fall risk and the development of peripheral neuritis. Therefore, exploration of alternative regional anesthesia strategies holds promise for improved clinical outcomes. This study aims to explore the efficacy and complication rate of intra-articular anesthetic administration in patients undergoing arthroscopic hip surgery. Methods: A retrospective analysis of prospectively collected data was conducted to identify all patients undergoing elective arthroscopic hip surgery between November 2013 and April 2015. Subjects were stratified into either a group that had received a preoperative femoral nerve block for perioperative pain control or a group that had an intra-articular injection of local anesthetic administered by the surgical team intraoperatively. Objective data, including pre and post-op pain scores in the PACU, total dose of narcotics required perioperatively, occurrence of falls and development of peripheral neuropathy were collected for analysis. Data was compared between the two groups using linear and logistic regression modeling. Statistical significance was determined as p<0.05. Results: After excluding patients who did not meet the criteria for study participation, a total of 193 patients were included in this study. At the time of surgery, one hundred eighty three patients (95%) demonstrated evidence of labralchondral pathology and bony morphology characteristic of femoroacetabular impingement (FAI). One hundred five patients (54%) received a pre-operative femoral nerve block and 88 patients (46%) received an intra-operative intra-articular injection of anesthetic agents. Linear models for post-operative pain, controlled for patient age and pre-operative pain levels, revealed that patients receiving pre-operative femoral nerve blocks had significantly less pain at discharge (p<0.05). There was no statistically significant difference in pain scores between patients receiving pre-operative femoral nerve blocks and those receiving intra-articular injections at post-operative weeks 1, 3 and 6. Patients receiving pre-operative femoral nerve blocks were found to be 3.6 times more likely to experience a post-operative fall (OR 3.58, p < 0.05) and were 14 times more likely to experience post-operative neuropathy (OR 13.99, p < 0.01) than patients receiving an intra-articular injection. Conclusion: Intra-articular anesthetic administration was found to be similar in efficacy to pre-operative femoral nerve blocks at reducing post-operative pain in patients undergoing hip arthroscopy. Additionally, patients receiving intra-articular injections had a significantly decreased risk of falling post-operatively or developing peripheral neuritis, known complications of femoral nerve blocks. With this information, intra-articular anesthetic administration appears to be a safe alternative to femoral nerve blocks in patients undergoing hip arthroscopy. Table 1 Demographic Data Group 1: FemBlock (n=105) Group 2: IABlock (n=88) P value Sex, n  Male 38 27 0.42  Female 67 61 Age, mean ± SD, y 33.4 ± 13.02 31.3 ± 14.05 0.29 Smoking history, n 0.66  Yes 28 26  No 77 62 Workers Compensation, n 0.24  Yes 4 1  No 101 67 History of Chronic Pain, n 0.35  Yes 4 6  No 101 82 Table 2 Outcomes Group 1: FemBlock (n=105) Group 2: IA Block(n=88) P Value Preoperative Preoperative pain, mean ± SD 3.54 ± 2.69 3.69 ± 2.43 0.69 Intraoperative Total Dose of Dilaudid, mean ± SD, mg 0.18 ± 0.33 0.22 ± 0.37 0.40 Postoperative Pain on PACU Arrival 4.59 ± 2.85 6.16 ± 2.56 <0.01* Pain at Discharge 3.55 ± 2.26 4.28 ± 3.13 0.03* Pain at 1 week 3.05 ± 2.18 2.75 ± 2.16 0.34 Pain at 3 weeks 1.96 ± 2.13 1.82 ± 2.07 0.64 Pain at 6 weeks 1.70 ± 2.09 1.59 ± 1.95 0.7 Reported a fall, n 19 5 <0.01* Developed Peripheral Neuritis, n 26 2 <0.01*

Differences in the Treatment of Distal Radius Fractures by Hand Fellowship Trained Surgeons: A Study of ABOS Candidate Data

PURPOSE The management of distal radius fractures differs based on the nature of the fracture and the experience of the surgeon. We hypothesized that patients requiring surgical intervention would undergo different procedures when in the care of a surgeon with subspecialty training in hand surgery as compared with surgeons with no subspecialty training in hand surgery. METHODS We queried the ABOS database for case log information submitted for part II of the ABOS examination. Queries for all codes involved with distal radius fracture management were combined with associated codes for the management of median nerve neuropathy, triangular fibrocartilage complex tears, ulnar shaft, and styloid fractures. Hand fellowship trained orthopedic surgeons were compared with those completing other fellowships and non-fellowship trained orthopedic surgeons during their board collection period. RESULTS During the study period, 2,317 orthopedic surgeons reported treatment of 15,433 distal radius fractures. Of these surgeons, 411 had hand fellowship training. On a per surgeon basis, fellowship trained hand surgeons operatively treated more multifragment intra-articular distal radius fractures than their non-hand fellowship trained counterparts (5.3 vs 1.2). Additional procedures associated with the management of distal radius fractures were also associated with the fellowship training of the treating surgeon. CONCLUSIONS Among orthopedic surgeons taking part II of the ABOS certifying examination, differences exist in the type, management, and reporting of distal radius fractures among surgeons with different areas of fellowship training. CLINICAL RELEVANCE This study describes the association of hand surgery fellowship training on the choice of intervention for distal radius fractures and associated conditions.

Combined Cubital and Carpal Tunnel Release Results in Symptom Resolution Outside of the Median or Ulnar Nerve Distributions

BACKGROUND Resolution of symptoms including pain, numbness, and tingling outside of the median nerve distribution has been shown to occur following carpal tunnel release. We hypothesized that a similar effect would be found after combined release of the ulnar nerve at the elbow with simultaneous release of the median nerve at the carpal tunnel. METHODS 20 patients with combined cubital and carpal tunnel syndrome were prospectively enrolled. The upper extremity was divided into six zones and the location of pain, numbness, tingling, or strange sensations was recorded pre-operatively. Two-point discrimination, Semmes-Weinstein monofilament testing, and validated questionnaires were collected pre-operatively and at six-week follow-up. RESULTS Probability of resolution was greater in the median nerve distribution than the ulnar nerve for numbness (71% vs. 43%), tingling (86% vs. 75%). Seventy percent of the cohort reported at least one extra-anatomic symptom pre-operatively, and greater than 80% of these resolved at early follow-up. There was a decrease in pain as measured by validated questionnaires. CONCLUSION This study documents resolution of symptoms in both extra-ulnar and extra-median distributions after combined cubital and carpal tunnel release. Pre-operative patient counseling may therefore include the likelihood of symptomatic improvement in a non-expected nerve distribution after this procedure, assuming no other concomitant pathology which may cause persistent symptoms. Future studies could be directed at correlating pre-operative disease severity with probability of symptom resolution using a larger population.