Heather A Vallier

Case Western Reserve University, Cleveland, Ohio, United States

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Publications (44)85.99 Total impact

  • Journal of Orthopaedic Surgery and Research 12/2015; 10(1). DOI:10.1186/s13018-015-0298-1 · 1.39 Impact Factor
  • Benjamin R Childs · Timothy A Moore · John J Como · Heather A Vallier
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    ABSTRACT: Study design: Retrospective review. Objective: The objective of this study was to evaluate the ability of the American Spinal Injury Association (ASIA) Impairment Scale and neurological level of injury to predict the need for mechanical ventilation as well as tracheostomy. Summary of background data: High-level cervical spinal cord injuries, high Injury Severity Score, and low Glasgow Coma Scale have been shown to predict tracheostomy. Methods: A total of 383 patients with fractures, dislocations, or ligamentous injury of the cervical spine were included in the study. Charts were reviewed to determine demographics, Injury Severity Score, Glasgow Coma Scale, presence and severity of chest injuries, length of hospital stay, intensive care unit stay, mechanical ventilation time, and mortality. Results: Fifty-nine patients (15.4%) underwent tracheostomy. An ASIA Impairment Scale of A had a specificity of 98.8% and sensitivity of 32.2% for predicting the need for tracheostomy. This yielded a 1.2% false-positive rate. The ASIA Impairment Scale remained the most significant predictor after regression for Injury Severity Score, Glasgow Coma Scale, and Chest Abbreviated Injury Scale. Neurological level of injury was not a significant predictor of tracheostomy. Conclusion: An ASIA Impairment Scale of A at any level of injury is a specific predictor of the need for tracheostomy with a low false-positive rate. Given the relatively low risk of early tracheostomy and the potential benefits, an ASIA Impairment Scale of A would be a sensible early criterion to determine the need for tracheostomy. Level of evidence: 3.
    Spine 10/2015; 40(18):1407-1413. DOI:10.1097/BRS.0000000000001008 · 2.30 Impact Factor
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    ABSTRACT: Background: Optimal patterns for fluid management are controversial in the resuscitation of major trauma. Similarly, appropriate surgical timing is often unclear in orthopedic polytrauma. Early appropriate care (EAC) has recently been introduced as an objective model to determine readiness for surgery based on the resuscitation of metabolic acidosis. EAC is an objective treatment algorithm that recommends fracture fixation within 36 h when either lactate <4.0 mmol/L, pH ≥ 7.25, or base excess (BE) ≥-5.5 mmol/L. The aim of this study is to better characterize the relationship between post-operative complications and the time required for resuscitation of metabolic acidosis using EAC. Methods: At an adult level 1 trauma center, 332 patients with major trauma (Injury Severity Score (ISS) ≥16) were prospectively treated with EAC. The time from injury to EAC resuscitation was determined in all patients. Age, race, gender, ISS, American Society of Anesthesiologists score (ASA), body mass index (BMI), outside hospital transfer status, number of fractures, and the specific fractures were also reviewed. Complications in the 6-month post-operative period were adjudicated by an independent multidisciplinary committee of trauma physicians and included infection, sepsis, pulmonary embolism, deep venous thrombosis, renal failure, multiorgan failure, pneumonia, and acute respiratory distress syndrome. Univariate analysis and binomial logistic regression analysis were used to compare complications between groups. Results: Sixty-six patients developed complications, which was less than a historical cohort of 1,441 patients (19.9 % vs. 22.1 %). ISS (p < 0.0005) and time to EAC resuscitation (p = 0.041) were independent predictors of complication rate. A 2.7-h increase in time to resuscitation had odds for sustaining a complication equivalent to a 1-unit increase on the ISS. Conclusions: EAC guidelines were safe, effective, and practically implemented in a level 1 trauma center. During the resuscitation course, increased exposure to acidosis was associated with a higher complication rate. Identifying the innate differences in the response, regulation, and resolution of acidosis in these critically injured patients is an important area for trauma research. Level of evidence: Level 1: prognostic study.
    Journal of Orthopaedic Surgery and Research 09/2015; 10(1):153. DOI:10.1186/s13018-015-0288-3 · 1.39 Impact Factor
  • Mark K Lane · Nickolas J Nahm · Heather A Vallier
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    ABSTRACT: Bilateral femur fractures have been associated with frequent morbidity and mortality. Associated injuries and massive hemorrhage contributed to mortality rates that were as high as 27% in previous reports. The goals of this study were to determine the frequency of associated complications, including mortality, and to identify which patient and injury features are associated with increased morbidity and mortality. The authors proposed that some patients with bilateral femur fractures may undergo early definitive fixation with an acceptable rate of complications. Patients who had bilateral femur fractures during the same injury event were retrospectively reviewed. Demographic characteristics, associated injuries, and the type and timing of treatment were determined. Complications were identified. The authors identified 50 men and 22 women, with a mean age of 41.5 years, who had high-energy bilateral femur fractures. These patients accounted for 5.5% of all femur fractures treated at the authors' institution over a period of 11 years. Two patients died before fixation. In addition, 13 other patients (19%) had 21 complications, including pneumonia in 6 (8.6%) and deep venous thrombosis in 7 (10%). No patient had adult respiratory distress syndrome, but 2 died of multiple organ failure. All patients with pulmonary complications had an underlying chest injury (P=.004). The overall mortality rate was 6.9%, and mortality was associated with higher mean age and higher Injury Severity Score (ISS). Of the 60 patients who had definitive fixation within 24 hours of injury, 53 (88%) had no complications. Complication rates were similar to those reported in the literature, with a mortality rate of 6.9%, including 3 patients who died after femoral fixation. Mortality was associated with advanced age and higher ISS. Chest injuries were associated with pulmonary complications. Most patients had early definitive fixation without complications, but it is not possible to predict which patients may be safely treated on an early basis. [Orthopedics. 2015; 38(7):e588-e592.]. Copyright 2015, SLACK Incorporated.
    Orthopedics 07/2015; 38(7):e588-e592. DOI:10.3928/01477447-20150701-56 · 0.96 Impact Factor
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    ABSTRACT: We developed a protocol to determine timing of definitive fracture care based on the adequacy of resuscitation. Inception of this project required a multidisciplinary group, including physicians from anesthesiology, general trauma and critical care, neurosurgery, orthopaedic spine and orthopaedic trauma. The purposes of this study were to review our initial experience with adherence to protocol recommendations and to assess barriers to implementation. Prospective SETTING:: Level 1 trauma center INTERVENTION:: Definitive fixation of pelvis, acetabulum, spine and femur fractures within 36 hours of injury, based on laboratory parameters for acidosis. 305 consecutive skeletally mature patients with ISS≥16 (mean 26.4) and 346 fractures of the proximal or diaphyseal femur (n=152), pelvic ring (n=56), acetabulum (n=44), and/or spine (n=94) were treated surgically. Adherence to the protocol was defined as definitive fixation within 36 hours of injury in resuscitated patients. All patients were adequately resuscitated within that time. Patient demographic and injury characteristics, date and time of presentation, and reasons for delay were recorded. 251 patients (82%) with 287 fractures were treated according to the protocol, while 54 patients (18%) with 59 fractures were definitively stabilized on a delayed basis (mean 90 hours). Delay was not related to patient age, ISS, day of week, or time of presentation. Before implementation of this protocol 76% were treated on a delayed basis, demonstrating improvement for each fracture type: spine (79% of previous patients with delay), pelvis (57%), acetabulum (72%), and femur (22%); all p<0.0001 for more frequently delayed surgery before the protocol. Surgeon choice to delay the procedure accounted for 67% of reasons for delay. Other reasons included intensivist choice (13%), OR availability (7.4%), patient choice (3.7%), severe head injury (5.6%) or cardiac issues (3.7%). Our trauma center and surgeons became more accustomed to the protocol and had fewer delays over time; 10% were delayed two years after implementation. Management of trauma patients with injury to multiple systems requires teamwork among providers from related specialties and hospital support, in terms of operating room access, with appropriate ancillary personnel and equipment. Our system adjusted quickly to the protocol. Surgeon preference was the most common reason for delayed fixation, but within 24 months only 10% of fractures were treated on a delayed basis, as long as patients were resuscitated.
    Journal of orthopaedic trauma 06/2015; DOI:10.1097/BOT.0000000000000383 · 1.80 Impact Factor
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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; Publish Ahead of Print. DOI:10.1097/BOT.0000000000000324 · 1.80 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; Publish Ahead of Print. DOI:10.1097/BOT.0000000000000311 · 1.80 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 · 2.74 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; 28(12). DOI:10.1097/BOT.0000000000000145 · 1.80 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; 28(12). DOI:10.1097/BOT.0000000000000134 · 1.80 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; 28(10). DOI:10.1097/BOT.0000000000000076 · 1.80 Impact Factor
  • Heather A Vallier · Stephen G Reichard · Alysse J Boyd · Timothy A Moore
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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 · 5.28 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; 28. DOI:10.1097/BOT.0000000000000061 · 1.80 Impact Factor
  • Heather A Vallier
    Journal of orthopaedic trauma 10/2013; DOI:10.1097/BOT.0000000000000028 · 1.80 Impact Factor
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    Heather A Vallier · Xiaofeng Wang · Timothy A Moore · John H Wilber · John J Como
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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 · 1.80 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
  • Heather A Vallier · Dennis M Super · Timothy A Moore · John H Wilber
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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; 27(7). DOI:10.1097/BOT.0b013e3182820eba · 1.80 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 · 2.77 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

Publication Stats

547 Citations
85.99 Total Impact Points


  • 2011–2015
    • Case Western Reserve University
      • • Center for Sleep Medicine (MetroHealth Medicine Center)
      • • MetroHealth Medical Center
      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
  • 2004–2005
    • Swedish Medical Center Seattle
      Seattle, Washington, United States