Baseline neurocognitive testing in sports-related concussions: the importance of a prior night's sleep.

BACKGROUND: The management of sports-related concussions (SRCs) utilizes serial neurocognitive assessments and self-reported symptom inventories to assess recovery and safety for return to play (RTP). Because postconcussive RTP goals include symptom resolution and a return to neurocognitive baseline levels, clinical decisions rest in part on understanding modifiers of this baseline. Several studies have reported age and sex to influence baseline neurocognitive performance, but few have assessed the potential effect of sleep. We chose to investigate the effect of reported sleep duration on baseline Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) performance and the number of patient-reported symptoms. HYPOTHESIS: We hypothesized that athletes receiving less sleep before baseline testing would perform worse on neurocognitive metrics and report more symptoms. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: We retrospectively reviewed 3686 nonconcussed athletes (2371 male, 1315 female; 3305 high school, 381 college) with baseline symptom and ImPACT neurocognitive scores. Patients were stratified into 3 groups based on self-reported sleep duration the night before testing: (1) short, <7 hours; (2) intermediate, 7-9 hours; and (3) long, ≥9 hours. A multivariate analysis of covariance (MANCOVA) with an α level of .05 was used to assess the influence of sleep duration on baseline ImPACT performance. A univariate ANCOVA was performed to investigate the influence of sleep on total self-reported symptoms. RESULTS: When controlling for age and sex as covariates, the MANCOVA revealed significant group differences on ImPACT reaction time, verbal memory, and visual memory scores but not visual-motor (processing) speed scores. An ANCOVA also revealed significant group differences in total reported symptoms. For baseline symptoms and ImPACT scores, subsequent pairwise comparisons revealed these associations to be most significant when comparing the short and intermediate sleep groups. CONCLUSION: Our results indicate that athletes sleeping fewer than 7 hours before baseline testing perform worse on 3 of 4 ImPACT scores and report more symptoms. Because SRC management and RTP decisions hinge on the comparison with a reliable baseline evaluation, clinicians should consider sleep duration before baseline neurocognitive testing as a potential factor in the assessment of athletes' recovery.

One-year mortality after acetabular fractures in elderly patients presenting to a level-1 trauma center.

OBJECTIVES: To evaluate the 1-year mortality of elderly patients after isolated acetabular fractures treated both operatively and nonoperatively, and compared with nonisolated fractures. DESIGN: Retrospective review. SETTING: Single level 1 trauma center. PATIENTS/PARTICIPANTS: All consecutive patients who were 60 years of age and older were treated for acetabular fractures over a 12-year period (n = 176). INTERVENTION: Operative and nonoperative management. MAIN OUTCOME MEASUREMENTS: 1-year mortality. METHODS: Exclusion criteria for the isolated group included associated injuries to other body systems (Abbreviated Injury Score >2), long bone fractures, and concurrent sacral fractures. Mortality data were obtained from the Social Security Death Index. RESULTS: The isolated group (n = 86) had an average age of 71.1 ± 7.1 years with 64.0% fractures treated operatively. Mortality rates for the isolated group at 30 days, 3 months, 6 months, and 1 year were 2.3%, 5.8%, 8.1%, and 8.1%, respectively. No significant differences in mortality rates were seen between operative and nonoperative patients across all time points for the isolated group (P = 0.093-0.346). Mortality rates were lower at all time points for the isolated group than for the nonisolated group (n = 90; P = 0.0002-0.02). However, the 1-year postdischarge mortality rates for patients who were discharged from the hospital were similar for the nonisolated and isolated groups (6.8% vs. 7.1%; P = 0.76). CONCLUSIONS: The mortality rates for elderly patients with isolated acetabular fractures were found to be significantly lower than those for acetabular fractures with concurrent injuries. Age was identified as the only significant variable differing between patients treated operatively versus nonoperatively, as opposed to medical comorbidities in the isolated acetabular fracture group. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Analysis of single-incision versus dual-incision fasciotomy for tibial fractures with acute compartment syndrome.

OBJECTIVES: To analyze the rate of postoperative infection and nonunion after tibial fractures in patients treated for acute compartment syndrome (ACS) using (1) single-incision versus (2) dual-incision fasciotomy technique. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Review of all adult tibial fractures operatively treated (n = 2756) over a 12-year period identified 175 patients with concurrent ACS requiring fasciotomy. Of 60 patients treated with intramedullary nails, 36 patients had single-incision fasciotomy and 24 had dual-incision fasciotomy. Of 81 patients treated with plate fixation, 59 patients had single-incision fasciotomy and 22 had dual-incision fasciotomy. INTERVENTION: Tibial fixation with fasciotomy for ACS. MAIN OUTCOME MEASUREMENTS: Occurrence of postoperative infection and nonunion. RESULTS: Both fasciotomy groups were similar across recorded patient and treatment characteristics. Need for skin graft was similar between fasciotomy groups. For patients treated with intramedullary nail (n = 60), 1 infection (2.8%) occurred in single-incision group versus 2 (8.3%) in dual-incision group (P = 0.558). Seven nonunions (19.4%) occurred in single-incision group versus 3 (12.5%) in dual-incision group (P = 0.726). For plate fixation patients (n = 81), 15 infections (25.4%) occurred with single-incision fasciotomy versus 5 infections (22.7%) with dual-incision fasciotomy (P = 1.000). Seven nonunions (11.9%) occurred with single-incision group versus 4 nonunions (18.2%) with dual-incision group (P = 0.479). CONCLUSIONS: This is the first study to compare a single-incision fasciotomy technique to a dual-incision technique in the setting of tibial fractures with ACS, with similar infection and nonunion rates with either technique. The choice of fasciotomy technique can be based on surgeon experience or patient condition as opposed to a suspected elevated infection or nonunion risk with either technique. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.