Heather A Vallier

Case Western Reserve University, Cleveland, Ohio, United States

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Publications (39)67.63 Total impact

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    ABSTRACT: The objective of this study is to characterize relationships between obesity and initial hospital stay, including complications, in patients with multiple system trauma and surgically treated fractures. Prospective, observational. Level 1 trauma center. 376 patients with an Injury Severity Score (ISS) greater than 16 and mechanically unstable, high energy fractures of the femur, pelvic ring, acetabulum, or spine requiring stabilization. Data for obese [body mass index (BMI)≥ 30)] versus non-obese patients included presence of pneumonia, deep vein thrombosis (DVT), pulmonary embolism, infection, organ failure, and mortality. Days in ICU and hospital, days on ventilator, transfusions, and surgical details were documented. Complications occurred more often in obese patients (38.0% v 28.4%, p=0.03), with more acute renal failure (ARF) (5.70% v 1.38%, p=0.02), and infection (11.4% v 5.50%, p=0.04). Days in ICU and mechanical ventilation times were longer for obese patients (7.06 v 5.25 days, p=0.05; and 4.92 v 2.90 days, p=0.007, respectively). Mean total hospital stay was also longer for obese patients (12.3 v 9.79 days, p=0.009). No significant differences in rates of mortality, multiple organ failure, or pulmonary complications were noted. Medically stable obese patients were almost twice as likely to experience delayed fracture fixation due to preference of the surgeon and were more likely to experience delay overall (26.0% v 16.1% p=0.02). Mean time from injury to fixation was 34.9 hours in obese patients versus 23.7 hours in non-obese patients (p=0.03). Obesity was noted among 42% of our trauma patients. In obese patients complications occurred more often, and hospital and ICU stays were significantly longer. These increases are likely to be associated with greater hospital costs. Surgeon decision to delay procedures in medically stable obese patients may have contributed to these findings; definitive fixation was more likely to be delayed in obese patients. Further study to optimize the care of patients with increased BMI may help to improve outcomes and minimize additional treatment expenses. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
    Journal of Orthopaedic Trauma 03/2015; DOI:10.1097/BOT.0000000000000324 · 1.54 Impact Factor
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    ABSTRACT: Objective: To characterize the timing, indications, and success rates of secondary interventions, dynamization and exchange nailing, in a large series of tibial nonunions. Setting: Retrospective multicenter analysis from level 1 trauma hospitals Patients: 194 tibia fractures that underwent dynamization or exchange nailing for delayed/nonunion. Intervention: Records and radiographs to characterize demographic data, fracture type, and cortical contact following tibial nailing were gathered. The radiographic union score for tibias (RUST) and the timing of intervention and time to union were calculated. Main Outcome Measures: The primary outcome was success of either intervention, defined as achieving union, with the need for further intervention defining failure. Other outcomes included RUST scores at intervention and union, and timing to intervention and union for both techniques. Two tailed t-tests and Fisher's exact with p set at <0.05 for significance were used as indicated. Results: A total of 194 tibia fractures underwent dynamization (97) or exchange nailing (97). No statistical differences were found between groups with demographic characteristics. The presence of a fracture gap (p=0.01), and comminuted fractures (p = 0.002) were more common in the exchange group. The success rates of the interventions and RUST scores were not different when performed before vs. after 6 months; therefore data was pooled. The RUST scores at the time of intervention were not different for successful or failed dynamizations (7.13 vs 7.07, P=0.83) or exchanges (6.8 vs 7.3, P=0.37). Likewise, the time to successful vs. failed dynamization (165 vs 158 days, P=0.91) or exchange nailing (224 vs 201 days, P=0.48) was not different. No cortical contact or a gap was a statistically negative factor for both exchange nails (P=0.09) and dynamizations (P=0.06). When combined, the success in the face of a gap was 78% vs 92% when no gap was present (P=0.02). Conclusion: Prior literature has few reports of the success rates of secondary interventions for tibial nonunions. The indications for dynamization and exchange were similar. Comminuted fracture and those having no cortical contact or gap favored having and exchange nail performed, and was a negative prognostic factor for both procedures. The current study demonstrates high rates of union for both interventions, making them both viable options. Copyright
    Journal of Orthopaedic Trauma 02/2015; DOI:10.1097/BOT.0000000000000311 · 1.54 Impact Factor
  • Nickolas J Nahm, Timothy A Moore, Heather A Vallier
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    ABSTRACT: BACKGROUND: The early appropriate care (EAC) protocol and clinical grading system (CGS(1)) propose criteria that suggest timing of definitive fracture fixation by assessing risk for complications. This study applies these criteria to a cohort of patients with orthopedic injuries and determines clinical outcomes for groups stratified by risk and timing of fracture fixation. METHODS: This retrospective work was performed at a Level I trauma center. Patients with operative femur, pelvis, acetabulum, and/or thoracolumbar spine injuries were included. Fractures were treated surgically, either early or delayed. Patients were retrospectively categorized into low-or high-risk groups using the EAC protocol and described as stable, borderline, unstable, or in extremis using a modified CGS (mCGS). RESULTS: In the EAC analysis, low-risk patients treated early had fewer complications compared with delayed treatment. Among high-risk patients, no significant difference was noted. With the use of the mCGS, stable patients treated early had fewer complications compared with delayed patients. No difference in complications was detected for unstable and in extremis patients. Borderline patients treated early had fewer complications compared with delayed treatment, although results were not supported by sensitivity analysis. CONCLUSION: The EAC protocol can effectively distinguish patients who are at high risk for complications if treated early. Early treatment in the low-risk group was associated with fewer complications. The mCGS differentiates stable patients who benefit from early definitive treatment of fractures as well as severely injured patients (unstable or in extremis) who may benefit from damage-control orthopedics. Borderline patients may also benefit from early definitive treatment, but criteria defining borderline patients require further study. Copyright (C) 2014 by Lippincott Williams & Wilkins
    Journal of Trauma and Acute Care Surgery 08/2014; 77(2):268-279. DOI:10.1097/TA.0000000000000283 · 1.97 Impact Factor
  • Benjamin R Childs, Heather A Vallier
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    ABSTRACT: Changes in health care reimbursement will reward systems that can improve patient outcomes and reduce costs. We implemented an integrated-care pathway protocol that coordinates the efforts of all the teams involved in the care of multiple-trauma patients by providing standard resuscitation parameters to recommend timing of definitive fracture fixation. The Early Appropriate Care (EAC) protocol was projected to reduce complications and length of stay (LOS) in the hospital. We propose to calculate the projected cost savings associated with reductions in complications and shorter LOS from implementing the protocol. To determine complication rates, LOS, and costs of care, we reviewed the cases of 1114 patients treated surgically for femur, pelvis, or acetabulum fractures between 2000 and 2006. Complications increased LOS by 12.2 days in femur patients and 13.8 days in pelvis and acetabulum patients. Mean additional cost per day was $4368 for femur patients and $4304 for pelvis/acetabulum patients. Mean cost per complication was $58,968 for femur patients and $98,465 for acetabulum patients. Projecting a 10% reduction in complications with EAC forecasts a $2,746,638 or $2,145,847 reduction in costs based on reduced per-complication costs or reduced LOS, respectively. Initial EAC implementation has resulted in fewer complications with an estimated annual cost reduction of $2,227,151, consistent with the projections. Literature review yielded cost estimates of $2480 per hospital day and $37,772 per complication. These literature estimates forecast total cost savings of $888,940 per reduction in LOS and $1,531,646 per reduction in complications. In spite of the wide range of estimates for the total cost reduction, it is clear that the reduction in costs associated with a 10% reduction in complications from implementing the EAC protocol will be substantial. Initial clinical data have shown up to 17% fewer complications with EAC adherence, which is projected to reduce our hospital costs by $2 million per year. These cost reductions justify further investment in refining the EAC protocol and securing hospital resources needed to support further implementation.
    American journal of orthopedics (Belle Mead, N.J.) 07/2014; 43(7):309-315.
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    Erik Schnaser, Nicholas R Scarcella, Heather A Vallier
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    ABSTRACT: Little data exist regarding the outcomes of total hip arthroplasty (THA) after acetabular fracture treatment failure. We hypothesize that these patients achieve a lower level of function than those who undergo primary total hip arthroplasty for osteoarthritis (atraumatic). Retrospective review. Control group consisted of sequential patients who underwent a primary total hip arthroplasty for osteoarthritis and were 60 years old or greater at the time of surgery. Level I Academic Trauma Center PATIENTS:: 171 patients over 60 years old when they sustained an acetabular fracture were included in this study. 17 (10%) patients were converted to THA. Control patients were treated with primary THA for osteoarthritis. Musculoskeletal function assessment (MFA) scores and Harris Hip (HHS) Scores were obtained after a minimum follow up of 2 years. Thirteen patients underwent ORIF, 3 underwent non-operative treatment, and 1 received an acute THA. The most common fracture patterns converted to THA were associated both column (n=5) and posterior column with posterior wall (n=5). The average time to conversion to THA was 35 months. When compared to controls, patients who had THA after an acetabular fracture had significantly higher MFA scores and significantly lower HHS, indicating worse level of function. Patients who undergo THA after acetabular fracture have significantly worse functional outcome scores when compared to patients who undergo a primary THA for osteoarthritis. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 04/2014; DOI:10.1097/BOT.0000000000000145 · 1.54 Impact Factor
  • Heather A Vallier, Nathaniel A Parker, Meghan E Beddow
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    ABSTRACT: Our purpose was to compare patients transferred from another hospital to our trauma center with those arriving directly, in order to identify barriers to care of similar fractures. We hypothesized the most frequent reason for delayed definitive fixation would be inter-hospital transfer and that patients would be transferred primarily for two reasons: complex patients with more severe injuries, and less complex patients without insurance. Retrospective review SETTING:: Level 1 trauma center PATIENTS/PARTICIPANTS:: 1549 skeletally mature patients with 1655 fractures: 379 acetabulum, 301 pelvic ring, 876 femur, and 99 spine. All patients were treated surgically, with early fixation < 24 hours after injury. Demographic and injury characteristics were recorded. Reasons for and timing of transfer were determined. 814 (53%) were transferred from another hospital, including 66% of acetabular and 62% of pelvic ring fractures. Transferred patients were older (39.1 versus 36.6, p=0.002), had more commercial insurance (21% versus 17%, p=0.10) and were less often uninsured (27% versus 31%, p=0.11). However, the mean ISS of uninsured transferred patients was lower than other transferred patients (22.9 versus 25.8, p<0.0001). Transfer was not related to weekday or time of injury. 973 patients (63%) had early definitive fixation. Delayed fixation was often for surgeon preference (57%). Transferred patients were more likely to have delayed fixation (43% versus 31% of non-transferred, p<0.0001). Internal barriers to definitive fracture care were noted, the most frequent of which is surgeon preference. Treatment delays due to transfer accounted for 12% of all delays. Many transferred patients appeared appropriate based on injury complexity. However, over one-fourth of those transferred had low ISS and a significantly higher incidence of no insurance. Communication and transparency about these issues may serve to expedite care and to enhance financial stability of larger trauma centers. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
    Journal of orthopaedic trauma 04/2014; DOI:10.1097/BOT.0000000000000134 · 1.54 Impact Factor
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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; DOI:10.1097/BOT.0000000000000076 · 1.54 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. DOI:10.2106/JBJS.L.01680 · 4.31 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; DOI:10.1097/BOT.0000000000000061 · 1.54 Impact Factor
  • Heather A Vallier
    Journal of orthopaedic trauma 10/2013; DOI:10.1097/BOT.0000000000000028 · 1.54 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; 27(10). DOI:10.1097/BOT.0b013e31829efda1 · 1.54 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.
    05/2013; 74(5):1307-14. DOI:10.1097/TA.0b013e31828c3f59
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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; DOI:10.1097/BOT.0b013e3182820eba · 1.54 Impact Factor
  • Erik Schnaser, Heather Vallier
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    ABSTRACT: This CORR Insights™ is a commentary on the article "Locking Buttons Increase Fatigue Life of Locking Plates in a Segmental Bone Defect Model" by Tompkins et al. available at DOI 10.1007/s11999-012-2664-1 .
    Clinical Orthopaedics and Related Research 12/2012; 471(3). DOI:10.1007/s11999-012-2743-3 · 2.88 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.
    11/2012; 73(5):1046-63. DOI:10.1097/TA.0b013e3182701ded
  • 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.
    07/2012; 73(4):957-65. DOI:10.1097/TA.0b013e31825a7723
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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; 27(5). DOI:10.1097/BOT.0b013e318269b2c3 · 1.54 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. DOI:10.2106/JBJS.J.01929 · 4.31 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. DOI:10.1097/BOT.0b013e318221e94e · 1.54 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.
    02/2012; 72(2):410-5. DOI:10.1097/TA.0b013e31823c59ee

Publication Stats

513 Citations
67.63 Total Impact Points


  • 2011–2014
    • Case Western Reserve University
      Cleveland, Ohio, United States
    • University of Washington Seattle
      • Department of Orthopaedics and Sports Medicine
      Seattle, WA, United States
  • 2006–2014
    • MetroHealth Medical Center
      Cleveland, Ohio, United States
  • 2008
    • The MetroHealth System
      Cleveland, Ohio, United States
  • 2004–2005
    • Swedish Medical Center Seattle
      Seattle, Washington, United States