W Timothy Ward

University of Pittsburgh, Pittsburgh, Pennsylvania, United States

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Publications (12)17.77 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Study Design Retrospective. Objectives To identify the clinical factors suggestive of infected and non-infected drainage to help clinical decision making. Summary of Background Data Differentiating between drainage caused by a benign seroma and deep spinal infection may be difficult in the early postoperative period. Methods Institutional spine surgery database was searched to identify the cases that were taken back to the operating room for drainage from the surgical wound in the early postoperative period between 2000 and 2012. Results A total of 38 cases of early wound drainage (within 6 weeks postoperatively) were identified that were treated with opening all layers, irrigation, and debridement. Intraoperative cultures were sent in all cases. Twenty-five patients proved to have non-infected drainage and did not require further treatment. In 13 patients, infection was confirmed with intra-operative findings and cultures; these patients were treated with serial debridements. In 4 cases, implants had to be removed after multiple debridements (after a quiescent period). The group with non-infected drainage differed from the infection group in that most patients (21 of 25) had non-neuromuscular deformities, whereas 77% of the infected group had neuromuscular etiology (10 of 13) (p = .0004). Average number of days to revision was 8.5 (range, 5–14 days) for the non-infected group. Of the 25 patients, 23 presented in the first 10 days. In the infected group, average number of days to revision was 19. Ten of the 13 patients presented on postoperative day 14 or later. Logistic regression analysis showed a significant association between increased likelihood of infection and increased time from the index procedure (p = .0085). Conclusions The findings suggest that early presenting drainage in pediatric idiopathic spine deformity is often not infected. Drainage, especially presenting after the second postoperative week in neuromuscular patients, proved to be mostly deep spinal wound infections.
    Spine Deformity. 03/2014; 2(2):104–109.
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    ABSTRACT: Study Design. Retrospective Case SeriesObjective. This study evaluated the incidence of postoperative neurological symptoms following a free hand pedicle screw insertion technique in idiopathic posterior scoliosis surgery.Summary of Background Data. It is generally accepted that pedicle screws can be inserted by a free hand technique in the thoracic and lumbar spine in patients with adolescent idiopathic scoliosis with a very low frequency of major complications. The prevalence of clinically significant screw misplacement, with or without the need for revision surgery is less well defined.Methods. Between 1/1/2000 and 10/2/2012, 559 patients with adolescent idiopathic scoliosis (AIS) had thoracolumbar posterior instrumented spine surgery at our institution. Each patient's chart and radiographs were reviewed and only those with AIS were included. Patients with neuromuscular and syndromic diagnoses were excluded as well as those with congenital or traumatic etiologies, incomplete charts, less than 3 months of follow-up and those without pedicle screws. The records were studied for complaints of radicular pain, neurological deficit, or severe headache which could be indicative of potential screw misplacement.Results. 481 patients with a 5923 pedicle screws met the inclusion criteria. 9 patients (1.9%) developed symptoms and underwent CT scanning. 6 patients were found to have pedicle screw malposition (8 screws) and 3 of these patients underwent revision surgery. Of the three revision patients, two presented with radicular symptoms (leg pain) and one with an orthostatic headache due to CSF leakage. At final follow up all revision patients had complete symptom resolution. In total, there were 8 symptomatic, misplaced pedicle screws (0.14%) in 6 patients (1.25%).Conclusions. Over a 12 year period in a dedicated pediatric orthopaedic hospital using the free hand placement technique the incidence of symptomatic misplaced pedicle screws was exceedingly low.
    Spine 11/2013; · 2.16 Impact Factor
  • Ozgur Dede, W. Timothy Ward
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    ABSTRACT: Residual hip dysplasia often progresses to early osteoarthritis with many patients requiring arthroplasty at a relatively young age to relieve symptoms. Alternatively, reconstructive pelvic surgery is directed at correcting hip mechanics with the expectation that the need for arthroplasty will be delayed or even eliminated. Bernese periacetabular osteotomy has proven effective in delaying the development of arthritic changes and good mid- to long-term outcomes have been reported. This article describes the technical details of the Bernese periacetabular osteotomy.
    Operative Techniques in Orthopaedics 09/2013; 23(3):127–133.
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    ABSTRACT: STUDY DESIGN:: Case control study. OBJECTIVE:: The purposes of this study were to establish the prevalence of venous thromboembolic disease in patients undergoing elective major thoracolumbar degenerative spine surgery and identify risk factors. SUMMARY OF BACKGROUND DATA:: Venous thromboembolic events (VTE) are a serious complication of orthopaedic surgery, but the prevalence of VTE following elective thoracolumbar degenerative spine surgery is not well known. METHODS:: This was a case control study of 5766 consecutive elective thoracolumbar degenerative spine surgeries. Symptomatic pulmonary emboli (PE) were diagnosed by spiral chest CT scans, nuclear scintigraphic ventilation-perfusion, and angiography. Deep vein thromboses (DVT) were diagnosed by venous duplex scans. The prevalence of venous thromboembolic events was analyzed according to patient demographic variables and type of surgery performed. RESULTS:: The prevalence of developing a VTE was 1.5% (89/5766), with a prevalence of symptomatic PE of 0.88% (51/5766) and DVT of 0.66% (38/5766). There were 47% males and 53% females with a mean age of 60.3. In patients undergoing 5 segment fusions the prevalence of PE was 3.1% (P-value=0.022). Patients who had 4 or more segments fused had a prevalence of PE of 1.7% (P-value=0.014). The odds of having a PE in those >65 at the time of surgery was 2.196 times as large as for those <65. Noncontributory factors included gender, instrumentation, and revision surgery. CONCLUSIONS:: This case control study of 5766 patients who underwent elective thoracolumbar degenerative spine surgery revealed a prevalence of venous thromboembolic events of 1.5%, with a prevalence of PE of 0.88% and DVT of 0.66%. Patients with increasingly extensive surgery had a higher risk of PE, specifically those undergoing fusion of 5 or more segments.
    Journal of spinal disorders & techniques 03/2013; · 1.21 Impact Factor
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    ABSTRACT: Study DesignProspective questionnaire administration study.Objectives To assess the ability to translate total and domain scores from Scoliosis Research Society (SRS)-24 to SRS-22r in a surgical-range, medical/interventional adolescent idiopathic scoliosis (AIS) patient population.Summary of Background DataConversion of SRS-24 to SRS-22r is demonstrated in an operative cohort of patients with AIS, but not in a medical/interventional patient population.Methods We simultaneously administered SRS-24 and SRS-22r questionnaires to 75 surgical-range, medical/interventional AIS patients and compared them. We performed analysis by regression modeling to produce conversion equations from SRS-24 to SRS-22r.ResultsThe total SRS-24 score for these medical/interventional AIS patients was 92.5 ± 9.45 (mean, 3.9 ± 0.39), and the total SRS-22r score was 93.5 ± 9.63 (mean, 4.3 ± 0.44). The correlation between these 2 groups was fair (R2 = 0.77) and improved to good when mental health or recall questions were removed. The correlation was also fair for total pain domains (R2 = 0.73). However, there was poor correlation for general self-image (R2 = 0.6) and unacceptable for post-treatment self-image (R2 = 0.01), general function (R2 = 0.52), activity function (R2 = 0.56), and satisfaction (R2 = 0.53). Compared with a published population of operative AIS patients, R2 values for total SRS-24 scores, pain, general self-image, activity function, and satisfaction were similar (p > .05). The R2 values for general function and combined general and activity function were significantly different between the operative and medical/interventional cohorts.Conclusions Scoliosis Research Society-24 can be converted to SRS-22r scores with fair accuracy in the surgical-range, medical/interventional AIS patient population for total score, and total pain domains. The SRS-24 translates unacceptably to the SRS-22r in self-image, function, and satisfaction domains. The SRS-24 to SRS-22r conversion equations are similar to operative AIS patients, except for the function domain. Caution should be used when interpreting results based on translation of SRS-24 to SRS-22r values.
    Spine Deformity. 03/2013; 1(2):108–114.
  • The Journal of Bone and Joint Surgery 12/2009; 91(12):2992-8. · 3.23 Impact Factor
  • Journal of pediatric orthopedics 01/2009; 28(8):795-8. · 1.23 Impact Factor
  • Jeffrey A Rihn, Joon Y Lee, W Timothy Ward
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    ABSTRACT: Retrospective case-control. The purpose of this study was to evaluate a single surgeon's experience with infection after surgical treatment of adolescent idiopathic scoliosis, with a focus on the diagnosis, treatment, and impact on radiographic and patient-reported outcomes. Although previous studies have evaluated this postoperative complication, no studies to date have looked at the impact of this complication on both radiographic and patient-reported outcomes. From 1986 to 2004, 236 patients were identified who underwent surgical treatment of adolescent idiopathic scoliosis and had at least 2-year follow-up. The medical records of patients who developed infection were retrospectively reviewed in detail. Preoperative and most recent postoperative radiographic parameters and Scoliosis Research Society 24 outcomes of both infected and noninfected patients were compared. Of 236 patients 7 (3%) developed an infection. One was acute (17 days postoperative), and 6 were delayed (average 34.2 months postoperative). The most common presenting complaints included back pain (5 of 7) and localized swelling (4 of 7). All patients with delayed infection were treated with 1 surgery (irrigation and debridement, instrumentation removal) and 6 weeks of intravenous antibiotics. Of 6 patients 3 had pseudarthrosis. Culture results were: Staphylococcus epidermidis (n = 2), Propionibacterium acnes (n = 1), Enterococcus faecalis (n = 1), Group A Streptococcus (n = 1), no growth (n = 1). The patient with acute infection required 6 surgical procedures and 16 weeks of antibiotics. Cultures were positive for methicillin resistant Staphylococcus aureus and Serratia marscesens. Revision fusion surgery was performed 5 months after the infection was treated. Compared with the noninfected patients, those with infection had lower percent thoracic (P = 0.01) and lumbar (P = 0.06) curve correction. There was no difference in the pain, function, self-image, satisfaction, or total Scoliosis Research Society 24 scores. Postoperative infection after the surgical treatment of idiopathic scoliosis can successfully be treated with irrigation and debridement, instrumentation removal, and a course of antibiotics. Although less curve correction was achieved in the infected group, there were no differences in patient-reported outcomes when compared with the noninfected group.
    Spine 03/2008; 33(3):289-94. · 2.16 Impact Factor
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    ABSTRACT: Retrospective case control study. To evaluate the use of the Lenke and King classification systems in the surgical treatment of main thoracic adolescent idiopathic scoliosis (AIS), with a specific focus on radiographic and patient reported outcomes. There is considerable debate as to whether King or Lenke classification best fulfills the criteria for a useful classification to determine distal fusion level, i.e., is mentally descriptive of the curve being treated, uses reproducible information to provide guidance in determining distal fusion level, is prognostic of patient reported and radiographic outcomes, and has good user reproducibility. Patients operated for AIS between 1986 and 2002 with posterior spinal fusion and dual rod posterior instrumentation were retrospectively classified according to the Lenke and King classification systems. Only patients with Lenke type I curves and minimum 2-year follow-up were included. Preoperative and most recent postoperative radiographs were reviewed. The Lenke and King recommended distal fusion levels were calculated for each patient according to criteria obtained from the literature, and were compared to our actual fusion level. Patients were divided into groups based on our actual distal fusion level (i.e., longer, shorter, or in agreement with Lenke and King). The radiographic parameters and SRS 24 outcomes of patients within each group were compared. Seventy-five patients with Lenke type 1 AIS were included in the study. The distribution of King curve types were: 31 King II curves, 34 King III curves, 9 King IV curves, and 1 double major curve. Our actual distal fusion level was in agreement with the calculated Lenke recommendation in 49% and the King recommendation in 51% of the cases. Difficulties in using the Lenke classification system were identified in up to 59% of the study patients. There were no statistically significant objectives or patient reported (SRS) differences between the groups fused in agreement, longer, or shorter than the calculated Lenke or King recommendations. At intermediate follow-up, there does not seem to be significant radiographic or patient reported differences whether fusion levels are in agreement, longer, or shorter than those recommended by the Lenke or King classification systems.
    Spine 02/2008; 33(1):52-60. · 2.16 Impact Factor
  • W Timothy Ward, Jeffrey A Rihn
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    ABSTRACT: The demographic features, work relative value units (WRVUs), and financial implications of pediatric emergency department (ED) manipulative fracture treatment are presented. The aims of this study are to quantify these parameters and gauge their impact on lifestyle and reimbursement. All ED fracture reductions performed by orthopaedic residents in a children's hospital for fiscal year 2004 were grouped by month, day, time, anatomical location, and payer mix. Work relative value units and reimbursement were assigned for each fracture, contrasting the use of global current procedural terminology manipulation facture codes to the actual use of global current procedural terminology nonmanipulation codes first generated when the child presented to the senior staff office. Three hundred seventy-five fractures were manipulated in the ED. Eighty-one manipulations were done on Saturday and 61 on Sunday compared with an average of 47 for the other 5 days. Nineteen percent of manipulations were performed between 7 AM and 6 PM, 37% between 6 and 11 PM, and 44% between 11 PM and 7 AM. Sixty-nine percent of the children had private insurance, 29% had Medicaid, and 2% had no medical coverage. Potentially 2358 WRVUs could have been recorded had senior staff been present for the reduction in the ED compared with the actual total of 1168 WRVUs recorded in the office a few days later. Using a proxy model of 100% Western Pennsylvania Medicare coverage for these fractures, $179,754 of reimbursement was available with manipulation included compared with $106,010 without manipulation. For our actual payer mix, manipulation would have contributed a 37% increase to fracture care margin for these 375 fractures but would have only provided a 2.5% increase to overall pediatric orthopaedic revenue production for fiscal year 2004. The component of reimbursement resulting from manipulation contributed significantly to fracture care margin for those fractures requiring manipulation but did not have a significant impact on overall pediatric orthopaedic revenue production. The added senior staff work effort required to gain the manipulation reimbursement component of fracture care in the ED is substantial considering the small contribution to overall revenue. Alternative mechanisms of compensation should be devised if the goal is to offer financial incentive to senior staff for their availability for all fracture manipulations in the ED.
    Journal of Pediatric Orthopaedics 01/2008; 27(8):877-81. · 1.16 Impact Factor
  • W Timothy Ward, Jeffrey A Rihn
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    ABSTRACT: National data documenting the impact of pediatric trauma in general and of pediatric orthopaedic trauma in particular on the rates of hospital admissions and emergency-room visits have been reported. This study documents the frequency of and work involved in the care of pediatric orthopaedic trauma by a single urban pediatric orthopaedic group practice. The computerized billing records of a single practice group of 3.4 full-time-equivalent, fellowship-trained pediatric orthopaedic surgeons practicing in a freestanding pediatric hospital with a level-I trauma center were analyzed for one year (from July 2004 through June 2005). Every office visit and operative procedure was specifically sorted to determine the component of trauma care in the group's pediatric orthopaedic practice. Descriptive statistics, including the actual numbers and percentages of office fracture visits and operations for fracture care as well as the actual numbers and percentages of work relative value units generated by the physicians, are presented. The practice generated 36,771 work relative value units, with 18,693 units (51%) from treatment provided in the operating room and 18,078 units (49%) from treatment provided in the office. A total of 1903 new fractures was seen and accounted for 5698 work relative value units (32% of all work relative value units for treatment provided in the office). The four fractures that were most frequently seen in the office were in the distal aspect of the radius (23%), forearm (14%), tibia (13%), and elbow (10%). Of the 18,693 work relative value units generated in the operating room, 5975 (32%) were from fracture care, representing the largest single category of work done in the operating room. Trauma-related operations were most commonly done for fractures of the elbow (25.3%), tibia (12%), femur (9.8%), forearm (5.5%), and the distal aspect of the radius (5%). Technically demanding fixation techniques, which are commonly used to treat fractures in adults, were frequently used, particularly for femoral and tibial fractures. This study documents the frequency and work relative value of the care of musculoskeletal injuries in an urban pediatric orthopaedic practice in the outpatient and inpatient settings. It is a snapshot in time of current trends in pediatric orthopaedic practice, but these data may have implications for future resource allocation of the pediatric orthopaedic manpower in North America.
    The Journal of Bone and Joint Surgery 01/2007; 88(12):2759-64. · 3.23 Impact Factor
  • Edward R Westrick, W Timothy Ward
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    ABSTRACT: Surgical intervention for adolescent idiopathic scoliosis (AIS) should be proven to alter the natural history without introducing iatrogenic complications. The risks of surgery should be substantiated by a body of scientific research, which should show a clear superiority of surgery over observation, both in the short term and the long term. The purpose of this review was to conduct a systematic search of the literature to critically evaluate the scientific evidence on the long-term outcomes and complications of surgical intervention for AIS. Our search identified 39 distinct patient populations with a minimum average follow-up of 5 years. No long-term, prospective controlled studies exist to support the hypothesis that surgical intervention for AIS is superior to natural history. Although surgery reliably arrests the progression of deformity, achieves permanent correction, and improves appearance, there is no medical necessity for surgery based on the current body of literature. However, the surgeon must not underestimate the psychological indication that occurs when a patient is no longer able to cope with the deformity.
    Journal of pediatric orthopedics 31(1 Suppl):S61-8. · 1.23 Impact Factor

Publication Stats

66 Citations
17.77 Total Impact Points

Institutions

  • 2007–2013
    • University of Pittsburgh
      • Department of Orthopaedic Surgery
      Pittsburgh, Pennsylvania, United States
  • 2009
    • Childrens Hospital of Pittsburgh
      Pittsburgh, Pennsylvania, United States