Canal narrowing in adult patients with cervical spinal cord injury without computed tomography evidence of trauma.

PURPOSE: Cervical spinal cord injury can be a particularly devastating sequela of trauma. The purpose of this study was to describe the imaging findings of adult patients with cervical spinal cord injury without computed tomography evidence of trauma (SCIWOCTET). METHODS: All adult patients (≥18 years) treated for acute cervical SCIWOCTET at a single Level I adult trauma center over an eight-year period were retrospectively identified. CT imaging was evaluated for degenerative changes narrowing the midsagittal canal diameter (SCD) of the cervical spine and relative congenital cervical stenosis (CCS; congenital narrowing of the SCD <13 mm). Magnetic resonance imaging (MRI) scans were evaluated for signal intensity change (SIC) suspicious for cord edema/contusion as well as ligamentous injury, hemorrhage, and epidural hematoma. RESULTS: Ninety-six patients with cervical SCIWOCTET met inclusion criteria. The most common mechanism of injury was fall from standing (47.9%). On CT, 86 patients (89.6%) had CCS. Degenerative changes were present in 95 patients (99.0%). In 98/99 patients (99.0%), the point of narrowest cervical SCD was ≤8 mm. On MRI, 79 patients (82.3%) demonstrated signal intensity change (SIC) indicative of cord edema/contusion, while 16 (16.7%) had ligamentous injury. Intramedullary cord hemorrhage was seen in two patients (2.1%) and epidural hematoma in three (3.1%). CONCLUSION: Degenerative changes or CCS may narrow the minimum cervical SCD beyond the threshold at which low-energy trauma results in C-SCI. Adult patients with cervical spinal stenosis, whether congenital and/or degenerative, and neurologic findings referable to the cervical spine should be assessed for C-SCI.

Unicompartmental Knee Arthroplasty in Octogenarians versus Younger Patients: A Comparison of 30-Day Outcomes.

As the United States' octogenarian population (persons 80-89 years of age) continues to grow, understanding the risk profile of surgical procedures in elderly patients becomes increasingly important. The purpose of this study was to compare 30-day outcomes following unicompartmental knee arthroplasty (UKA) in octogenarians with those in younger patients. The American College of Surgeons National Surgical Quality Improvement Program database was queried. All patients, aged 60 to 89 years, who underwent UKA from 2005 to 2016 were included. Patients were stratified by age: 60 to 69 (Group 1), 70 to 79 (Group 2), and 80 to 89 years (Group 3). Multivariate regression models were estimated for the outcomes of hospital length of stay (LOS), nonhome discharge, morbidity, reoperation, and readmission within 30 days following UKA. A total of 5,352 patients met inclusion criteria. Group 1 status was associated with a 0.41-day shorter average adjusted LOS (99.5% confidence interval [CI]: 0.67-0.16 days shorter, p < 0.001) relative to Group 3. Group 2 status was not associated with a significantly shorter LOS compared with Group 3. Both Group 1 (odds ratio [OR] = 0.15, 99.5% CI: 0.10-0.23) and Group 2 (OR = 0.33, 99.5% CI: 0.22-0.49) demonstrated significantly lower adjusted odds of nonhome discharge following UKA compared with Group 3. There was no significant difference in adjusted odds of 30-day morbidity, readmission, or reoperation when comparing Group 3 patients with Group 1 or Group 2. While differences in LOS and nonhome discharge were seen, octogenarian status was not associated with increased adjusted odds of 30-day morbidity, readmission, or reoperation. Factors other than age may better predict postoperative complications following UKA.

Using the STTGMA Risk Stratification Tool to Predict Complications, Additional Operations, and Functional Outcomes After Ankle Fracture.

OBJECTIVES: To determine the usefulness of a validated trauma triage score to stratify postdischarge complications, secondary procedures, and functional outcomes after ankle fracture. DESIGN: Retrospective cohort. SETTING: Level 1 trauma center. PATIENTS: Four hundred fifteen patients 55 years of age and older with 431 ankle fractures. INTERVENTION: Closed or open reduction. MAIN OUTCOME MEASUREMENTS: Score for Trauma Triage in Geriatric and Middle-Aged Patients (STTGMA), postdischarge complications, secondary operations, Foot Function Index (FFI, n = 167), and Short Musculoskeletal Function Assessment (SMFA, n = 165). RESULTS: Mean age was 66 years, 38% were men, and 68% of fractures were secondary to ground-level falls. Forty patients (9.6%) required an additional procedure, with implant removal most common (n = 21, 5.1%), and 102 (25%) experienced a postdischarge complication. On multiple linear regression, STTGMA was not a significant independent predictor of complications or secondary procedures. Patients completed FFI and SMFA surveys a median of 62 months (5.2 years) after injury. On the FFI, low-risk STTGMA stratification was an independent predictor of worse functional outcomes. Similarly, low-risk stratification was a predictor of worse scores on the SMFA dysfunction and daily activity subcategories (both B > 10, P < 0.05). CONCLUSIONS: Low-risk STTGMA stratification predicted worse long-term function. The STTGMA tool was not able to meaningfully stratify risk of postdischarge complications and secondary procedures after ankle fracture. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The change in postoperative opioid prescribing after lumbar decompression surgery following state-level opioid prescribing reform.

OBJECTIVE: On August 31, 2017, the state of Ohio implemented legislation limiting the dosage and duration of opioid prescriptions. Despite the widespread adoption of such restrictions, few studies have investigated the effects of these reforms on opioid prescribing and patient outcomes. In the present study, the authors aimed to evaluate the effect of recent state-level reform on opioid prescribing, patient-reported outcomes (PROs), and postoperative emergency department (ED) visits and hospital readmissions after elective lumbar decompression surgery. METHODS: This study was a retrospective cohort study of patients who underwent elective lumbar laminectomy for degenerative disease at one of 5 hospitals within a single health system in the years prior to and after the implementation of the statewide reform (September 1, 2016-August 31, 2018). Patients were classified according to the timing of their surgery relative to implementation of the prescribing reform: before reform (September 1, 2016-August 31, 2017) or after reform (September 1, 2017- August 31, 2018). The outcomes of interest included total outpatient opioids prescribed in the 90 days following discharge from surgery as measured in morphine-equivalent doses (MEDs), total number of opioid refill prescriptions written, patient-reported pain at the first postoperative outpatient visit as measured by the Numeric Pain Rating Scale, improvement in patient-reported health-related quality of life as measured by the Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) questionnaire, and ED visits or hospital readmissions within 90 days of surgery. RESULTS: A total of 1031 patients met the inclusion criteria for the study, with 469 and 562 in the before- and after-reform groups, respectively. After-reform patients received 26% (95% CI 19%-32%) fewer MEDs in the 90 days following discharge compared with the before-reform patients. No significant differences were observed in the overall number of opioid prescriptions written, PROs, or postoperative ED or hospital readmissions within 90 days in the year after the implementation of the prescribing reform. CONCLUSIONS: Patients undergoing surgery in the year after the implementation of a state-level opioid prescribing reform received significantly fewer MEDs while reporting no change in the total number of opioid prescriptions, PROs, or postoperative ED visits or hospital readmissions. These results demonstrate that state-level reforms placing reasonable limits on opioid prescriptions written for acute pain may decrease patient opioid exposure without negatively impacting patient outcomes after lumbar decompression surgery.

Transcutaneous Hemoglobin Screening in an Adult Orthopaedic Trauma Population.

OBJECTIVES: To evaluate a noninvasive hemoglobin measurement device in an orthopaedic trauma population. DESIGN: Prospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred five patients consecutively admitted to the orthopaedic trauma service after surgical treatment of fracture. INTERVENTION: Transcutaneous hemoglobin (TcHgb) monitoring using the Masimo Pronto Pulse CO-Oximeter model with Rainbow SET Technology for spot TcHgb measurement. MAIN OUTCOME MEASUREMENTS: TcHgb measurements and standard venipuncture hemoglobin (vHgb) were obtained. Patient preferences for each were recorded. RESULTS: TcHgb measurements were obtained in 100 patients and compared with their corresponding vHgb measurements. The mean vHgb and TcHgb were 10.2 ± 1.9 g/dL and 11.2 ± 2.1 g/dL, respectively, and the mean difference was 1.1 ± 1.6 g/dL, which was statistically different from 0 (P < 0.001). In 76% of cases, the TcHgb device overestimated vHgb. In a subgroup of patients undergoing procedures with minimal expected blood loss (external fixators of knee or ankle, irrigation and debridement, or open reduction and internal fixation of ankle or calcaneal fractures), the mean difference between vHgb and TcHgb was 0.68 ± 1.6 g/dL (P = 0.06). CONCLUSIONS: A preliminary study of TcHgb monitoring with the tested device as a potential screening mechanism to limit unnecessary blood draws showed statistical difference from vHgb; however, the mean bias 1.1 g/dL of hemoglobin was notably small. In a subgroup of patients undergoing procedures with minimal expected blood loss, the device may have merit. Larger studies are required to determine the clinical relevance of differences in measurements between the 2 methods. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Factors associating with surgical site infection following operative management of malleolar fractures at an urban level 1 trauma center.

OBJECTIVES: To identify comorbidities and injury characteristics associated with surgical site infection (SSI) following internal fixation of malleolar fractures in an urban level 1 trauma setting. DESIGN: Retrospective. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seven-hundred seventy-six consecutive patients with operatively managed malleolar fractures from 2006 to 2016. INTERVENTION: Open reduction internal fixation. MAIN OUTCOME MEASUREMENTS: Superficial SSI (erythema and drainage treated with oral antibiotics and wound care) or deep SSI (treated with surgical debridement and antibiotics). RESULTS: Fifty-six (7.2%) patients developed SSI, with 17 (30%) of these being deep infections. An a-priori power analysis of n = 325 (α=0.05, ß=0.2) was tabulated for differences in univariate analysis. Univariate analysis identified categorical associations (P < .05) between SSI and diabetes mellitus, drug abuse, open fracture, and renal disease but not tobacco abuse, body mass index, or neuropathy. Multivariate logistic regression identified categorical associations between diabetes (OR = 2.2, 95% CI: 1.1-4.3), drug abuse (OR = 3.9, 95% CI: 1.2-12.7), open fracture (OR = 4.1, 95% CI: 1.3-12.8), and renal disease (OR = 2.7, 95% CI: 1.4-5.0) and any (superficial or deep) SSI. A separate multivariate logistic regression analysis found categorical associations between deep SSI requiring reoperation and diabetes (OR = 4.4, 95% CI: 1.6-12.2) and open fracture (OR = 4.1, 95% CI: 1.3-12.8). Furthermore, American society of anesthesiologists classification (ASA) Class 4 patients were (OR = 9.2, 95% CI: 2.0-41.79) more likely to experience an SSI than ASA Class 1 patients. CONCLUSIONS: Factors associated with SSI following malleolar fracture surgery in a single urban level 1 trauma center included diabetes, drug abuse, renal disease, and open fracture. The presence of diabetes or open type fractures were associated with deep SSI requiring reoperation. LEVEL OF EVIDENCE: Level 3 prognostic: retrospective cohort study.

Predicting Length of Stay and Readmissions After an Ankle Fracture Using a Risk Stratification Tool (STTGMA).

OBJECTIVES: To determine the usefulness of a validated trauma triage score to stratify short-term outcomes including hospital length of stay (LOS), in-hospital complications, discharge location, and rate of readmission after an ankle fracture. DESIGN: Retrospective cohort. SETTING: Level 1 trauma center. PATIENTS: Four hundred fifteen patients, age ≥55 with 431 ankle fractures. INTERVENTION: Closed or open reduction. MAIN OUTCOME MEASUREMENTS: Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA). RESULTS: Of the 415 patients, 38% were male, 72% were white, and the mean age was 66 years. The mean LOS was 4.4 days, and this increased from 2.6 days in the minimal-risk group to 11.8 days in the high-risk group (P < 0.001). Similarly, 74% of minimal-risk patients were discharged home versus 13% of high-risk patients (P < 0.001). There were 19 readmissions (4.6%) within 30 days, ranging from 1.5% to 10% depending on the risk cohort (P = 0.006). Seventy-three patients (18%) experienced an in-hospital complication. On multiple linear regression, moderate- and high-risk STTGMA stratification was predictive of a longer hospital LOS, and moderate-risk STTGMA stratification was predictive of subsequent readmission after injury. CONCLUSIONS: Calculation of the STTGMA score is helpful for stratifying patients according to hospital LOS and readmission rates, which have substantial bearing on resource utilization and cost of care. The STTGMA tool may allow for effective identification of patients to potentially ameliorate these common issues and to inform payers and policymakers regarding patients at risk for greater costs of care. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.