Heather A Vallier

Case Western Reserve University School of Medicine , Cleveland, OH, United States

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Publications (31)50.69 Total impact

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    ABSTRACT: The purpose of the study was to review diagnostic imaging in trauma patients. We hypothesized that diagnostic musculoskeletal imaging has increased over time, but at a lesser rate than radiography performed for other purposes. Two trauma centers were compared. retrospective, multi-center SETTING:: Two level 1 trauma centers PATIENTS/PARTICIPANTS:: 500 patients per year from each trauma centers were reviewed for 2002, 2005, and 2008. Effective doses (mSv) and total charges for radiography were calculated. Most imaging was done within 24 hours of injury. In 2002, 15% of all radiographic studies were CT scans versus 33% in 2008 (p<0.0001). Center 1 used more CT, and Center 2 used more projection (plain) radiography. The percentage of musculoskeletal CTs increased from 26% in 2002 to 49% in 2008 (p<0.0001), without change in patient acuity. Mean effective dose per patient was 17.3 mSv in 2002, 30.0 mSv in 2005, and 34.1 mSv in 2008 (p<0.001). The percentage of total dose attributable to musculoskeletal studies increased from 25% in 2002, to 29% in 2005, and 31% in 2008 (p<0.001). Mean total charges per patient were $4,529 in 2002; $6,922 in 2005; and $7,750 in 2008 (p<0.001), with higher 2008 mean charges at Center 1 versus 2 ($8,694 versus $6,806, p=0.001), primarily because of more CT scans. The number of diagnostic imaging tests, radiation dose, and related charges in trauma patients increased over time at both trauma centers, with CT scans accounting for the majority of the radiation dose and costs. A shift toward more advanced imaging from conventional projection radiography was noted at both trauma centers. Effective dose per patient more than doubled over the course of study at Center 1. By 2008 half of all radiographic studies were for musculoskeletal purposes. Previous studies have suggested an increased risk of cancer with exposures of 20 to 40 mSv, making the mean total radiation doses in excess of 30.0 mSv since 2005 of great concern. Variability in ordering patterns between the two centers with similar patient acuity suggests opportunity for discussion about indications for utilization, which could result in lower radiation doses and fewer expenses.
    Journal of orthopaedic trauma 02/2014; · 1.78 Impact Factor
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    ABSTRACT: Osteonecrosis and posttraumatic arthritis are common after talar neck fracture. We hypothesized that delay of definitive fixation would not increase the rate of osteonecrosis, but that the amount of initial fracture displacement, including subtalar and/or tibiotalar dislocations, would be predictive. We investigated the possibility of dividing the Hawkins type-II classification into subluxated (type-IIA) and dislocated (type-IIB) subtalar joint subtypes. The cases of eighty patients with eighty-one talar neck and/or body fractures who had a mean age of 36.7 years were reviewed. The fractures included two Hawkins type-I, forty-four type-II (twenty-one type-IIA and twenty-three type-IIB), thirty-two type-III, and three type-IV fractures. Open fractures occurred in twenty-four patients (30%). One deep infection, two nonunions, and two malunions occurred. After a mean of thirty months of follow-up, sixteen of sixty-five fractures developed osteonecrosis, but 44% of them revascularized without collapse. Osteonecrosis never occurred in fractures without subtalar dislocation (Hawkins type I and IIA), but 25% of Hawkins type-IIB patterns developed osteonecrosis (p = 0.03), and 41% of Hawkins type-III fractures developed osteonecrosis (p = 0.004). Osteonecrosis occurred after 30% of open fractures versus 21% of closed fractures (p = 0.55). Forty-six fractures were treated with urgent open reduction and internal fixation (ORIF) at a mean of 10.1 hours, primarily for open fractures or irreducible dislocations. With the numbers studied, the timing of reduction was not related to the development of osteonecrosis. Thirty-five patients had delayed ORIF (mean, 10.6 days), including ten with Hawkins type-IIB and ten with Hawkins type-III fractures initially reduced by closed methods, and one (5%) of the twenty developed osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01). Following talar neck fracture, osteonecrosis of the talar body is associated with the amount of the initial fracture displacement, and separating Hawkins type-II fractures into those without (type IIA) and those with (type-IIB) subtalar dislocation helps to predict the development of osteonecrosis as in this series. It never occurred when the subtalar joint was not dislocated. When it does develop, osteonecrosis often revascularizes without talar dome collapse. Delaying reduction and definitive internal fixation does not increase the risk of developing osteonecrosis. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. PEER REVIEW This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
    The Journal of Bone and Joint Surgery 02/2014; 96(3):192-7. · 3.23 Impact Factor
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    ABSTRACT: The purpose of this study is to characterize the presentation, size, treatment, and complications of pulmonary embolism (PE) in a large series of orthopaedic trauma patients who developed PE after injury. We reviewed the records of orthopaedic trauma patients who developed a PE within 6 months of injury at 9 trauma centers and 2 tertiary care facilities. There were 312 patients, 186 men and 126 women, avg age 58. Average BMI was 29.6, avg ISS was 18. 17% received anticoagulation prior to injury, and 5% had a prior history of PE. After injury, 87% were placed on prophylactic anticoagulation; 68% with low molecular weight heparin. 53% of patients exhibited shortness of breath or chest pain. Average heart rate and O2 saturation prior to PE diagnosis were 110 and 94, respectively. 39% had abnormal ABG and 30% had abnormal EKG findings. 89% had CTPA for diagnosis. Most clots were segmental (63%), followed by subsegmental (21%), lobar (9%), and central (7%). The most common treatment was unfractionated heparin and Coumadin (25%). Complications of anticoagulation were common: 10% had bleeding at the surgical site. Other complications of anticoagulation included GI bleed, anemia, wound complications, death, and compartment syndrome. PE recurred in 1%. 4% died of PE within 6 months. This is the first large data set to evaluate the course of PE in an orthopaedic trauma population. The complications of anticoagulation are significant and were as common in the patients with lower risk clots as those with higher risk clots. III (retrospective).
    Journal of orthopaedic trauma 12/2013; · 1.78 Impact Factor
  • Heather A Vallier
    Journal of orthopaedic trauma 10/2013; · 1.78 Impact Factor
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    ABSTRACT: OBJECTIVES:: The purpose was to define which clinical conditions warrant delay of definitive fixation for pelvis, femur, acetabulum, and spine fractures. A model was developed to predict complications. DESIGN:: Statistical modeling based on retrospective database SETTING:: Level 1 trauma center Patients/participants: 1443 adults with pelvis (n=291), acetabulum (n=399), spine (n=102), and/or proximal or diaphyseal femur (n=851) fractures INTERVENTION:: All fractures were treated surgically. MAIN OUTCOME MEASUREMENTS:: Univariate and multivariate analysis of variance assessed associations of parameters with complications. Logistic predictive models were developed with the incorporation of multiple fixed and random-effect covariates. Odds ratios, F-tests, and receiver operating characteristic (ROC) curves were calculated. RESULTS:: 12% had pulmonary complications, with 8.2% overall developing pneumonia. pH and base excess values were lower (p<0.0001), and the rate of improvement was also slower (all p<0.007), with pneumonia or any pulmonary complication. Similarly, lactate values were greater with pulmonary complications (all p<0.02), and lactate was the most specific predictor of complications. Chest injury was the strongest independent predictor of pulmonary complication. Initial lactate was a stronger predictor of pneumonia (p=0.0006) than initial pH (p=0.047) or the rate of improvement of pH over the first 8 hours (p=0.0007). An uncomplicated course was associated with absence of chest injury (p<0.0001) and definitive fixation within 24 (p=0.007) or 48 hours (p=0.005). Models were developed to predict probability of complications with various injury combinations using specific laboratory parameters measuring residual acidosis. CONCLUSIONS:: Acidosis on presentation is associated with complications. Correction of pH within 8 hours to >7.25 was associated with fewer pulmonary complications. Presence and severity of chest injury, number of fractures, and timing of fixation are other significant variables to include in a predictive model and algorithm development for Early Appropriate Care. The goal is to minimize complications by definitive management of major skeletal injury once the patient has been adequately resuscitated. LEVEL OF EVIDENCE:: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 06/2013; · 1.78 Impact Factor
  • Nickolas J Nahm, John J Como, Heather A Vallier
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    ABSTRACT: Abdominal injury has been shown to be an independent risk factor for pulmonary complications in patients with extremity injuries. We propose to characterize orthopedic patients with severe abdominal trauma. We hypothesize that operative fractures of the thoracolumbar spine, pelvis, acetabulum, or femur increase systemic complications in patients with blunt abdominal injury. A retrospective review of patients presenting to a Level I trauma center with abdominal injury between 2000 and 2006 was performed. Adult patients between the ages of 18 years and 65 years with high-energy, blunt trauma resulting in severe abdominal injury (abdomen Abbreviated Injury Scale [AIS] score ≥ 3) and Injury Severity Score (ISS) of 18 or greater were included. Patients were divided into two comparison groups as follows: the fracture group had operative fractures of the pelvis, acetabulum, thoracolumbar spine, and/or femur, and the control group did not sustain these fractures of interest. Systemic complications were documented. Unadjusted and multivariable logistic regression analyses were performed. The control group included 91 patients, and the fracture group included 106 patients with 136 fractures of interest. With unadjusted analysis, the fracture group had more complications (34% [36 of 106] vs. 18% [16 of 91], p = 0.010), including adult respiratory distress syndrome (8% [8 of 106] vs. 1% [1 of 91], p = 0.040), and sepsis (11% [12 of 106] vs. 3% [3 of 91], p = 0.056). Logistic regression modeling demonstrates that the presence of an operative fracture increased the odds of developing at least one complication approximately three times (odds ratio, 2.88, p = 0.006), after controlling for presence of chest injury and type of injured abdominal organ. Operative fractures of the thoracolumbar spine, pelvis, acetabulum and femur increase the risk of developing systemic complications in patients with blunt abdominal injury. Further study is necessary to optimize treatment protocols for these high-risk patients. Prognostic study, level III.
    The journal of trauma and acute care surgery. 05/2013; 74(5):1307-14.
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    ABSTRACT: OBJECTIVES:: We hypothesized that early definitive management (within 24 hours of injury) of mechanically unstable fractures of the pelvis, acetabulum, femur and spine would reduce complications and shorten length of stay. DESIGN:: Retrospective review SETTING:: Level 1 trauma center PATIENTS/PARTICIPANTS:: 1005 skeletally-mature patients with ISS≥18 with pelvis (n= 259), acetabulum (n= 266), proximal or diaphyseal femur (n= 569), and/or thoracolumbar spine (n= 98) fractures. Chest (n=447), abdomen (n=328) and head (n=155) injuries were present. INTERVENTION:: Definitive surgery was within 24 hours in 572 patients and after 24 hours in 433. MAIN OUTCOME MEASUREMENTS:: Complications related to the initial trauma episode included infections, sepsis, pneumonia, deep venous thrombosis, pulmonary embolism, acute respiratory distress syndrome (ARDS), organ failure, and death. RESULTS:: Days in ICU and total hospital stay were lower with early fixation (5.1±8.8 vs 8.4±11.1 ICU days (p=0.006); 10.5±9.8 vs 14.3±11.4 total days (p=0.001), after adjusting for ISS and age. Fewer complications (24.0% vs 35.8%, p=0.040), ARDS (1.7% vs 5.3%, p=0.048), pneumonia (8.6% vs 15.2%, p=0.070), and sepsis (1.7% vs 5.3%, p=0.054) occurred with early vs delayed fixation. Logistic regression was used to account for differences in age and ISS between the early and delayed groups. Adjustment for severity of chest injury was included when analyzing pulmonary complications including pneumonia and ARDS. CONCLUSIONS:: Definitive fracture management within 24 hours resulted in shorter ICU and hospital stays and fewer complications and ARDS, after adjusting for age and associated injury types and severity. Surgical timing must be determined with consideration of the physiology of the patient and complexity of surgery. Parameters should be established within which it is safe to proceed with fixation. These data will serve as a baseline for comparison with prospective evaluation of such parameters in the future. LEVEL OF EVIDENCE:: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 01/2013; · 1.78 Impact Factor
  • Nickolas J Nahm, Heather A Vallier
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    ABSTRACT: Optimal timing of definitive treatment of femoral shaft fractures in patients with multiple injuries remains controversial. This study aimed to determine the impact of timing of definitive treatment (early, delayed, or damage-control orthopedics [DCO]) of femoral shaft fractures on the incidence of adult respiratory distress syndrome (ARDS), mortality rate, and hospital length of stay (LOS) in patients with multiple injuries. A systematic review of published English-language reports using MEDLINE (1946-2011), Embase (1947-2011), and Cochrane Library. Search terms included femoral fractures, multiple trauma, fracture fixation, and time factors. This study reviewed randomized and nonrandomized studies that (1) compared early and delayed treatment or early treatment and DCO and (2) reported the incidence of ARDS, mortality rate, or LOS. Extraction of articles was performed by one of the authors using predefined data fields. Thirty-eight studies met our inclusion criteria. Studies were grouped into heterogeneous injuries with early versus delayed treatment (17 studies), heterogeneous injuries with early versus DCO (8 studies), head injury (13 studies), and chest injury (7 studies). Most of the studies (≥50%) reporting ARDS and mortality rate showed no difference in each of these groups. However, 6 of 7 and 2 of 3 studies reporting LOS in the heterogeneous injuries with early versus delayed and heterogeneous injuries with early versus DCO, respectively, showed shorter stay for early treatment. Pooled analyses were not conducted owing to changes in critical care delivery during the study period and variations in definitions of early treatment, ARDS, and multiple injuries. Thirty-five reports were based on nonrandomized trials and were subject to biases inherent in retrospective studies. The review process was limited by language and publication status. The literature suggests that early definitive treatment may be used safely for most patients with multiple injuries. However, a subgroup of patients with multiple injuries may benefit from . Systematic review, level III.
    The journal of trauma and acute care surgery. 11/2012; 73(5):1046-63.
  • Nickolas J Nahm, Brendan M Patterson, Heather A Vallier
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    ABSTRACT: This study investigates the impact of injury severity, patient origin, and payer on charges and payments associated with treatment of femoral fractures at a Level I trauma center. We hypothesized that transfer patients and patients with minor injury would be underinsured, whereas reimbursement rate would be higher for patients with severe injury. Medical and financial records of 420 adult patients treated for femoral fractures at a public, urban Level I trauma center were reviewed. Facility and professional charges and payments were determined. Reimbursement rate was defined as the ratio of payment to charge. Payer groups included Medicare, Medicaid, commercial, managed care, workers' compensation, and self-pay. Severe injury was defined by Injury Severity Score of 18 or higher. Patients with Injury Severity Score of less than 18 were more often uninsured compared with the severe injury group (25% vs. 14%, p = 0.005). Patients with severe injury had higher facility (0.47 vs. 0.39, p = 0.005) and total reimbursement rates (0.41 vs. 0.34, p = 0.002) compared with patients with minor injury. Likewise, transfer patients trended toward higher overall reimbursement rate compared with nontransfer patients (0.42 vs. 0.37, p = 0.056). Patients with severe injury were more likely to have commercial insurance (28 vs. 20%, p = 0.06), and transferred patients were more likely to have insurance (88% vs. 79%, p = 0.034). The higher proportion of self-pay in the nontransfer group may be caused by the large population of uninsured patients in the area surrounding our trauma center. Favorable payer mix and higher facility reimbursement rate for patients with severe injury may be an incentive for trauma centers to continue providing care for patients with multiple injuries. Prognostic/epidemiologic study, level III. Economic analysis, level IV.
    The journal of trauma and acute care surgery. 07/2012; 73(4):957-65.
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    ABSTRACT: OBJECTIVES:: The purpose was to define charges and reimbursement in the management of pelvis and acetabulum fractures and to identify opportunities for revenue enhancement. DESIGN:: Retrospective review SETTING:: Level 1 trauma center PATIENTS/PARTICIPANTS:: 465 patients with 210 pelvic ring injuries and 285 acetabulum fractures INTERVENTION:: All fractures were treated surgically. MAIN OUTCOME MEASUREMENTS:: Professional and facility charges and collections were determined for each patient. Costs of care and profitability were calculated for patients with isolated pelvis or acetabulum fractures. RESULTS:: Definitive fixation was ≤24 hours of injury in 35% and >72 hours in 24%. Mean length of hospital stay (LOS) was 9.2 days, with mean 3.1 ICU days. Mean facility charges were $51,069 with collections of $22,702 (44%). Mean orthopaedic professional charges were $20,184 with collections of $4,629 (23%). Combined pelvis and acetabulum fractures had the highest facility collection rates (49%) with lower professional collections (21%) versus isolated fractures (25%, p=0.03). The payer mix had significantly more commercial (27%), managed care (27%), and Bureau of Worker's Compensation (BWC) (10%) versus the entire hospital, despite progressively more patients with Medicaid or no insurance during the study. Uninsured patients were significantly younger with lower ISS. Fractures managed definitively ≤24 hours had shorter LOS, shorter ICU stay, and fewer complications, with mean net facility revenue over costs of $2,376. Longer LOS due to complications increased initial hospital costs by a mean of $14,829. CONCLUSIONS:: Patients with multiple injuries generated higher facility charges and collection rates. Professional collection rates were lower in patients with more than one surgical procedure in the same setting. Trauma patients were more likely to have commercial, managed care, and BWC insurance versus the entire hospital. Fractures managed definitively within 24 hours were associated with shorter LOS, shorter ICU stay, and fewer complications, resulting in lower treatment expenses. Fracture care was profitable to the hospital when definitively completed within 72 hours. Prolonged LOS and complications were associated with larger costs of care.
    Journal of orthopaedic trauma 07/2012; · 1.78 Impact Factor
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    ABSTRACT: A conventional transtibial amputation may not be possible when the zone of injury involves the proximal part of the tibia, or in cases of massive tibial bone and/or soft-tissue loss. The purpose of this study was to examine the outcomes of salvage of a transtibial amputation level with a rotational osteocutaneous pedicle flap from the ipsilateral hindfoot. Fourteen patients who had an osteocutaneous pedicle flap from the ipsilateral foot were included in the study. Twelve patients were followed for more than twenty-four months (mean, 60.2 months) and were evaluated with use of the Sickness Impact Profile (SIP), Musculoskeletal Function Assessment (MFA), and a 100-ft (30.48-m) timed walking test. There were ten men and four women with mean age of 43.2 years. Thirteen patients had a type-IIIB open tibial fracture, and one had extensive soft-tissue loss secondary to a burn. Four patients were treated for infection after the index procedure. There were no nonunions of the tibia to the calcaneus. Three patients underwent late reconstructive procedures to improve prosthetic fit. No patient required subsequent revision to a more proximal amputation level. Mean knee flexion was 139°. A novel technique has been developed to salvage a transtibial amputation level with use of a rotational osteocutaneous flap from the hindfoot. In the absence of adequate tibial length and/or soft-tissue coverage to salvage the entire limb or to perform a conventional-length transtibial amputation, this technique is a highly functional alternative that does not require microvascular free tissue transfer.
    The Journal of Bone and Joint Surgery 03/2012; 94(5):447-54. · 3.23 Impact Factor
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    ABSTRACT: Residual dysfunction after pelvic trauma has been previously described, but limited functional outcome data are available in the female population after high-energy pelvic ring injury. The purposes of this study were to determine functional outcomes and to characterize factors predictive of outcome. Prospective collection of functional outcomes data. Level I trauma center. Eighty-seven women with mean age of 33.5 years and mean Injury Severity Score of 23.1 were included. The Orthopaedic Trauma Association classification included 32 B-type and 55 C-type fractures. Four were open fractures and six had bladder ruptures. Forty-nine patients were treated operatively and 38 nonoperatively. Musculoskeletal Functional Assessment (MFA) questionnaires were completed after a minimum of 16 months and a mean of 41 months of follow-up. The mean MFA score was 33. Only 15 women (17.2%) had MFA scores comparable with an uninjured reference value (9.3), and 34 (39.1%) had better than the reference value for prior hip injury (25.5). Anteroposterior compression injuries had worse scores versus other patterns (48.3 vs 31.0, P = 0.01), and trends toward worse outcomes were noted after symphyseal disruption (P = 0.11) and transsymphyseal plating (P = 0.09). Sacral fracture or sacroiliac injury, amount of initial or final displacement, and type of posterior ring treatment were not associated with MFA scores. Mean scores were 32.3 after surgery and 34.0 after nonoperative management (P = 0.67). Functional outcomes were not related to age or Injury Severity Score, but isolated pelvis fractures had better MFA scores (21.1 vs 35.5, P = 0.008) and worse MFA scores (41.7 vs 29.1, P = 0.004) were seen with other lower extremity fractures. Those with bladder ruptures (n = 6) also had poor outcomes, mean MFA 50.0 (P = 0.078). Wide variation is seen in functional outcome of women after high-energy pelvic ring fracture as measured by the MFA with mean scores demonstrating substantial residual dysfunction. Better outcomes were noted after isolated fractures and in women who had not sustained other fractures in their lower extremities. History of bladder rupture or anteroposterior compression injury was associated with poor MFA scores. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 02/2012; 26(5):296-301. · 1.78 Impact Factor
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    ABSTRACT: Computed tomography (CT) scans have become imaging modalities of choice in trauma centers. The purposes of this study were to evaluate the trend of radiation exposure in acute trauma patients. Our hypothesis was that radiation dosage and charges would increase over time without change in patient acuity or outcome. Five hundred consecutive trauma patients were retrospectively reviewed for the years 2002, 2005, and 2008. Total number of CT scans, plain radiographs, and total radiation dosage (milliSieverts [mSV]) were determined. Charges were calculated. Injury severity scores and mortality were determined. The mean number of CT scans for category 1 patients in 2002, 2005, and 2008 was 1.5, 3.1, and 4.6, respectively (p = 0.01). This trend was similar in category 2 patients: 2.0, 3.5, 5.1, respectively (p < 0.01). Significant decreases in plain radiography were noted concurrently. This contributed to increased total radiation exposure to categories 1 and 2 patients over 2002, 2005, and 2008: 12.0 mSV, 23.6 mSV, and 33.6 mSV (p = 0.02); and 17.5 mSV, 24.1 mSV, and 37.5 mSV (p < 0.001), respectively. Charges for diagnostic imaging per patient also increased for categories 1 and 2 patients over 2002, 2005, and 2008: $2,933, $4,656, and $6,677; and $4,105, $5,344, and $7,365, respectively (all p < 0.01). Over the course of a year for 4,800 trauma patients treated at our hospital, this is expected to accrue additional charges of $13 million. The number of CT scans per trauma patient has more than doubled over 6 years, generating more radiation exposure and charges per patient, despite no change in mortality or injury severity. Judicious use of advanced imaging may control risks and costs without compromising care. III, retrospective.
    The journal of trauma and acute care surgery. 02/2012; 72(2):410-5.
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    ABSTRACT: Surgical treatment of displaced distal tibia fractures yields reliable results with either plate or nail fixation. Comparative studies suggest more malalignment and nonunions with nails. Some studies have reported knee pain after tibial nailing. However, plates may be associated with soft tissue complications, such as infections or wound-healing problems. The purpose of this study was to assess functional outcomes after distal tibia shaft fractures treated with a plate or a nail. We hypothesized that tibial nails would be associated with more knee pain and that plates would be associated with pain from implant prominence, each of which would adversely affect functional outcome scores. Randomized prospective study. Level 1 trauma center. One hundred four patients with extra-articular distal tibia shaft fractures (OTA 42), mean age of 38 years (range, 18-95), and mean Injury Severity Score of 14.3 (range, 9-50). Patients were randomized to treatment with a reamed intramedullary nail (n = 56) or standard large fragment medial plate (n = 48). Ability to work was evaluated after a minimum of 12 months, with mean of 22 months. Foot Function Index (FFI) and Musculoskeletal Function Assessment (MFA) questionnaires were completed. Mean MFA was 27.5, and mean total FFI was 0.26; P < 0.0001 versus an uninjured reference population. Sixty-one of 64 patients (95%) employed at the time of injury had returned to work, although 31% had modified their work duties because of injury. Three patients were unable to find work. None reported unemployment secondary to their tibial fracture. Forty percent of all patients described some persistent ankle pain, and 31% had knee pain after nailing, versus 32% and 22%, respectively after plating. Both knee and ankle pain were present in 27% with nails and 15% with plates (P = 0.08), and rates of implant removal were similar after nails versus plates. Patients with malunion ≥5 degrees were more likely to report knee or ankle pain (36% vs 20%, P < 0.05). Except 1 patient with knee pain when kneeling, none reported modifying activity because of persistent knee or ankle pain, although knee and ankle pain were more frequent in the unemployed (P = 0.03). Unemployed patients requested implant removal more frequently (24% vs 9.2%, P = 0.07) and continued to report pain afterward. Although FFI and MFA scores were not related to plate or nail fixation, open fracture, fracture pattern, multiple injuries, Injury Severity Score, or age, both MFA and FFI scores were worse when knee pain or ankle pain was present (all Ps < 0.004) and in patients who remained unemployed (P < 0.0001). All 4 patients with work-related injuries had returned to employment but had worse FFI scores (P = 0.01). Mean MFA and FFI scores suggest substantial residual dysfunction after distal tibia fractures when compared with an uninjured population. Mild ankle or knee pain was reported frequently after plate or nail fixation but was not limiting to activity in most. Angular malunion was associated with both knee and ankle pain, and there was a trend toward more patients with knee and ankle pain after tibial nailing. No patients reported unemployment because of their tibia fracture, but unemployed people described knee and ankle pain more frequently and had the worst functional outcome scores.
    Journal of orthopaedic trauma 12/2011; 26(3):178-83. · 1.78 Impact Factor
  • Heather A Vallier, Wes Immler
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    ABSTRACT: In the distal femur, locked plating is efficacious when coronal fractures preclude the use of a conventional fixed-angle device. However, minimal comparative data exist for supracondylar fracture patterns, which could be treated with other devices. The purpose of this study was to compare the 95-degree angled blade plate (ABP) versus the Locking Condylar Plate (LCP) by assessing complications and secondary procedures in fractures amenable to treatment with either implant. Retrospective review. Level 1 trauma center. Seventy patients with 71 distal femoral fractures (OTA 33-A, 33-C1, 33-C2) amenable to either ABP or LCP with a mean age of 59.5 years (range, 20-92 years) were included. Seventeen fractures (24%) occurred adjacent to a previous knee arthroplasty (10 ABP and 7 LCP). The 2 groups were similar with respect to age, fracture pattern, and the presence of open fracture. Most injuries were the result of high-energy trauma, and 21% were open fractures. Thirty-two fractures (45%) were treated with an ABP, and 39 (55%) were treated with the LCP. Complications, including infection, nonunion, and malunion, and secondary operations were determined. After a mean of 26-month follow-up, 4 patients (6.0%) were treated for infections. Malunions occurred in 11% of LCP patients and in 1 ABP patient (3.4%, P = 0.14). All patients with malunions were older than 55 years. Seven patients (11%) were treated for nonunions. Six of the nonunions occurred after LCP (16% vs. 3.4%, P = 0.11) Complications were more frequent in LCP patients (35%) versus ABP patients (10%, P = 0.001). Complications were not related to fracture pattern, periprosthetic fracture, or open fracture. Mean age of patients with complications was 64 years (vs. 53 years, P = 0.01), and they were more likely to have lower energy mechanisms (P = 0.017). Overall, 18 patients (27%) underwent secondary procedures, including treatment of infection, nonunion, malunion, or prominent implant removal. Secondary procedures were more common after LCP (43%) versus ABP (6.9%, P = 0.0008) patients. Painful prominent implants were removed from 7 LCP patients (18%) and no ABP patients (P = 0.01). Distal femur fractures are often associated with prolonged healing and rehabilitation times, which increase substantially when complications occur. Internal fixation of these fractures may be performed successfully with ABP or LCP. In our review of fractures that could be treated with either implant, patients treated with locking plates had more complications and nonunions, requiring more secondary procedures to treat complications and to remove prominent implants. Furthermore, locking plates are substantially more expensive than conventional fixed-angle devices. Future investigation is needed in the form of a large randomized prospective study to clearly define clinical differences, functional outcomes, and costs of care. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 12/2011; 26(6):327-32. · 1.78 Impact Factor
  • Heather A Vallier, Beth Ann Cureton, Dianne Schubeck
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    ABSTRACT: Previous studies reported negative effects of pelvic trauma on genitourinary and reproductive function with frequent cesarean delivery. Risk factors for cesarean delivery have not been well defined. The purpose of this project was to evaluate outcomes of pregnancy after pelvic ring injury. We hypothesized that cesarean delivery would be more frequent after pelvic fracture with potential causes including patient and physician preference, malunion, and retained hardware. Retrospective review with prospective collection of obstetric information. Level I trauma center. Thirty-one women, 16 to 40 years old, with pregnancy after healed pelvic fracture. Orthopaedic Trauma Association (OTA) classification included 10 B-type and 21 C-type fractures, 17 (55%) of which were treated surgically. Obstetric questionnaires were obtained for 54 pregnancies after a mean 72 months follow-up. Sixteen women had 25 vaginal deliveries; 28% after surgical treatment for their pelvic fracture with retained anterior (16%) and/or posterior (16%) hardware, including transsymphyseal plating in three patients (12%). Thirteen women had 26 cesarean deliveries, 46% after surgical treatment for their pelvis. The new cesarean delivery rate was 44% versus 17% preinjury (P = 0.02). Two had cesarean deliveries as repeat procedures after preinjury cesarean delivery. Four had cesarean deliveries as a result of medical complications (pre-eclampsia, n = 2; breech, n = 1; labor arrest, n = 2). Seven women (54%) reported 12 cesarean deliveries (46%) resulting from pelvic fracture; three elected cesarean delivery despite their physician offering a trial of labor, whereas four were advised by their obstetrician. Cesarean delivery was not related to age, fracture pattern, treatment type, or residual pelvic displacement. A trend for cesarean delivery related to retained hardware was observed (P = 0.06). Uncomplicated pregnancies and deliveries are possible after pelvic fracture. The new cesarean delivery rate among these women is significantly increased with over half related to patient and obstetrical preferences. Fracture pattern, minor malalignment, and retained hardware are not absolute indications for cesarean delivery. Neither surgical care of the pelvis or retained fixation precludes successful vaginal delivery. Development of guidelines and objective indications for trial of normal labor after pelvic fracture is needed. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 10/2011; 26(5):302-7. · 1.78 Impact Factor
  • Heather A Vallier, Beth Ann Cureton, Dianne Schubeck
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    ABSTRACT: Previous studies have reported a negative effect of pelvic trauma on genitourinary and reproductive function of women. However, fracture pattern, injury severity, and final fracture alignment have not been well studied. The purpose of this project was to describe sexual function in women after pelvic ring injury. Cohort study: a prospective collection of sexual function data for women with prior pelvic ring injury versus control groups of uninjured women and other women from the orthopaedic trauma clinic. Level I trauma center. One hundred eighty-seven women younger than age 55 years with pelvic ring injury, including 101 B-type (61-B1: n = 25, B2: n = 69, B3: n = 7) and 86 C-type (61-C1: n = 56, C2: n = 18, C3: n = 12) fractures. Four had open fractures, and 23 had associated genitourinary injury. Seventy-four were treated operatively. Surgical treatment was percutaneous in 62: iliosacral screws (n = 58), external fixation (n = 4), or both (n = 19). Open reduction and internal fixation was performed for the pubis symphysis (n = 27), sacroiliac joint (n = 2), and posterior ileum (n = 3). Sexual function questionnaires were completed for 92 patients (49%) with minimum 12 months and mean 46 months follow-up. Forty-eight patients (56%) reported pain with intercourse. Their mean Musculoskeletal Function Assessment was 44.3 versus 20.9 without dyspareunia (P < 0.0001). Seventy-eight percent of patients with B-type fractures and 43% of patients with C-type fractures had dyspareunia (P = 0.002). Dyspareunia occurred after 91% of anteroposterior compression injuries (P = 0.02) and in 79% with a symphyseal disruption treated with plate fixation (P = 0.005). All patients with bladder ruptures (n = 5) reported dyspareunia. Sacral fracture or sacroiliac injury, type of posterior treatment, and residual malalignment of the posterior ring were not associated with dyspareunia. Fourteen patients each had associated femur fractures and/or tibia fractures. Seventeen of them had pain during intercourse (P = 0.19 for association of femoral or tibial fractures with dyspareunia). Dyspareunia is common in women after pelvic ring fracture. Women with pelvic ring injury are more likely to report dyspareunia than other female patients with musculoskeletal trauma. Dyspareunia was related to anteroposterior compression and B-type injuries. Symphyseal plate fixation is also associated with dyspareunia. Pain with intercourse was also noted in all patients with a history of bladder rupture. Poor functional outcomes as measured by Musculoskeletal Function Assessment scores were reported in women with dyspareunia. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 10/2011; 26(5):308-13. · 1.78 Impact Factor
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    ABSTRACT: Malalignment has been frequently reported after intramedullary stabilization of distal tibia fractures. Nails have also been associated with knee pain in several studies. Historically, plate fixation has resulted in increased risks of infection and nonunion. Our purposes were to compare plate and nail stabilization for distal tibia shaft fractures by assessing complications and secondary procedures. We hypothesized that nails would be associated with more malalignment and nonunion. Randomized, prospective study. Level I trauma center. One hundred four skeletally mature patients with extra-articular distal tibia shaft fractures with a mean age of 38 years (range, 18-95 years) and mean Injury Severity Score of 13.5 (range, 9-50). The majority had high-energy injuries. Patients were randomized to a reamed intramedullary nail (n = 56) or a large fragment medial plate (n = 48). Forty fractures (39%) were open. Twenty-eight (27%) had concomitant fibula fractures that were stabilized. Malunion, nonunion, infection, and secondary operations. The two treatment groups were evenly matched with respect to age, gender, Injury Severity Score, fracture pattern, and presence of open fracture. Six patients (5.8%) developed deep infection with equal numbers in the two groups. Eighty-three percent of infections occurred after open fracture (P < 0.001). Four patients (7.1%) developed nonunion after nailing versus two (4.2%) after plating (P = 0.25) with a trend for nonunion in patients who had distal fibula fixation (12% versus 4.1%, P = 0.09). All nonunions occurred after open fracture (P = 0.0007); the primary union rate for closed fractures was 100%. Primary angular malalignment of 5° or greater occurred in 13 patients with nails (23% of all nails) and four with plates (8.3% of all plates; P = 0.02 for plates versus nails). Six additional patients experienced malalignment after immediate weightbearing against medical advice. Valgus was the most common deformity (n = 16). Malunion was more common after open fracture (55%, P = 0.04). Eighty-five percent of patients with malalignment after nailing did not have fibula fixation. Eleven patients underwent 15 secondary procedures after plating, five of which were for prominent implant removal. This was not significantly different from patients treated with nailing: 10 patients had 14 procedures and five for prominent implant removal. High primary union rates were noted after surgical treatment of distal tibia shaft fractures with both nonlocked plates and reamed intramedullary nails. Rates of infection, nonunion, and secondary procedures were similar. Open fractures had higher rates of infection, nonunion, and malunion. Intramedullary nailing was associated with more malalignment versus plating. Fibula fixation may facilitate reduction of the tibia at the time of surgery. The effect of fibula fixation on tibia healing deserves further study. Economic assessment and functional outcomes data for this population will help to enhance our treatment decision-making.
    Journal of orthopaedic trauma 09/2011; 25(12):736-41. · 1.78 Impact Factor
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    ABSTRACT: We conducted a study to evaluate the functional outcomes of elderly patients after open reduction internal fixation of intra-articular distal humerus fractures. Retrospective clinical and radiographic evaluation. A Level I trauma and tertiary referral center. We identified 23 eligible patients aged older than 65 years from the center's orthopaedic trauma registry between 1997 and 2005. Fourteen patients were available for follow-up. We had a mean follow-up of 51 months with a range of 20 to 99 months. All enrolled patients were acutely treated with open reduction internal fixation of their distal humerus. All enrolled patients were contacted and evaluated radiographically and with physical examination. Functional outcome was assessed with the Mayo Elbow Performance, Disabilities of Arm and Shoulder and Hand, and Musculoskeletal Functional Assessment functional questionnaires. All 14 fractures united. The mean Mayo Elbow Performance score was 83. The mean elbow flexion-extension arc was 20° to 120°. There was no significant loss of forearm pronation-supination (P > 0.05) or grip strength (32.6 versus 34.0 lbs, P > 0.05) compared with the contralateral arm. The mean Disabilities of Arm and Shoulder and Hand score was 37.6. Musculoskeletal Functional Assessment scores demonstrated disability with a mean total score of 33.4 (normative 9.3), hand score of 34.7 (normative 3.7), and self-care score of 31.8 (normative 1.7). One patient required reoperation for a disabling flexion contracture. Intra-articular distal humerus fractures are severely disabling injuries, particularly in the elderly population. Good results can be achieved with stable fixation and fracture union. Despite reasonable range of motion, patient-directed questionnaires revealed persistent pain and functional limitations.
    Journal of orthopaedic trauma 04/2011; 25(5):259-65. · 1.78 Impact Factor
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    ABSTRACT: Type and timing of treatment of femur fractures is controversial. Although reported as safe and effective in many reports, others have suggested that early definitive stabilization may cause complications, particularly in patients with chest and head injuries. Damage control orthopedics was proposed as an alternative in unstable patients. This study examines the effects of timing of fixation and investigates risk factors for complications. Seven hundred fifty patients with femur fractures treated between 1999 and 2006 were reviewed. Skeletally mature patients with mean age 35.8 years and mean Injury Severity Score (ISS) 23.7 were included. Four hundred ninety-two patients had ISS ≥18. Early stabilization (n = 656) was defined as definitive treatment of the femur fracture within 24 hours of injury. Early definitive stabilization in patients with multiple injuries was associated with fewer complications than delayed stabilization (18.9% vs. 42.9%, p < 0.037) after adjusting for patient age and ISS. Early treatment was also associated with shorter hospital stay, intensive care unit stay, and ventilator days (p < 0.001). Severe (Abbreviated Injury Scale score ≥3) abdominal injury was associated with more complications than severe head (Glasgow Coma Scale score ≤8) and chest (Abbreviated Injury Scale score ≥3) injuries (44.2% vs. 40.9%, p = 0.68, and 34.4%, p = 0.024, respectively) and was an independent risk factor for complications (p < 0.0001). Chest injury was an independent risk factor for pulmonary complications (p < 0.001), but surgical delay in patients with chest injury was also associated with pulmonary complications (p = 0.04). More sepsis was noted patients with severe head injury (22.7% vs. 4.5%, p = 0.037) or severe chest injury (10.2% vs. 2.5%, p = 0.044) when treated on a delayed basis. More patients transferred from other hospitals were treated on a delayed basis (48.9% vs. 37.5%, p = 0.04). Early definitive stabilization is associated with acceptably low rates of complications and is safe in most patients with multiple injuries, including some with severe abdominal, chest, or head injuries with attention to resuscitation before surgery. More complications and longer hospital stay were noted with delayed fixation after adjusting for age and ISS. Chest injury was associated with pulmonary complications; however, the presence of severe abdominal injury was the greatest risk factor for complications. Expediting access to definitive care may reduce complications and expenses.
    The Journal of trauma 02/2011; 71(1):175-85. · 2.35 Impact Factor

Publication Stats

204 Citations
50.69 Total Impact Points


  • 2012–2013
    • Case Western Reserve University School of Medicine
      • Department of Surgery
      Cleveland, OH, United States
  • 2011–2013
    • Case Western Reserve University
      • • Division of Hospital Medicine (MetroHealth Medical Center)
      • • MetroHealth Medical Center
      Cleveland, OH, United States
    • University of Washington Seattle
      • Department of Orthopaedics and Sports Medicine
      Seattle, WA, United States
  • 2008–2012
    • The MetroHealth System
      Cleveland, Ohio, United States
    • Metro Health Hospital
      Wyoming, Michigan, United States
  • 2006–2012
    • MetroHealth Medical Center
      Cleveland, Ohio, United States
  • 2005
    • Swedish Medical Center Seattle
      Seattle, Washington, United States
  • 2004
    • Swedish Medical Center Seattle
      Seattle, Washington, United States