Jonathan N Grauer

Yale-New Haven Hospital, New Haven, Connecticut, United States

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Publications (170)293.57 Total impact

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    ABSTRACT: Background There is currently no standard of care for imaging after hand and upper-extremity procedures, and current imaging practices have not been characterized. Questions/Purposes To characterize current imaging practices and to compare those practices to the best available evidence. Patients and Methods A survey was distributed to attending-level surgeons at a regional hand and upper-extremity surgery conference in the United States in 2013. 40 out of 75 surgeons completed the survey (53%). Results All results are presented for distal radius and scaphoid fractures, respectively. There was a high degree of variability between respondents in the number of radiographic series routinely ordered during follow-up of asymptomatic patients, with the number of series ranging from 1-6 and 1-6. On average, respondents did not order an excessive number of follow-up radiographs for asymptomatic patients, with means (± standard deviations) of 2.6 ± 1.0 and 3.3 ± 1.2 radiographic series. Radiographic series were taken at only 74% and 81% of postoperative visits with asymptomatic patients. Only 10% and 8% of respondents felt it was acceptable medical practice to save costs by ordering postoperative radiographs only when patients are symptomatic. Conclusions Among a sample of 40 fellowship-trained hand surgeons, these findings demonstrate a high degree of variability in number of radiographs obtained after operative repair of distal radius and scaphoid fractures. On average, respondents were relatively efficient with respect to total number of postoperative radiographs ordered. Level of Evidence Diagnostic study, level IV.
    Journal of wrist surgery. 11/2014; 3(4):239-44.
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    ABSTRACT: After lower-extremity orthopedic trauma and surgery, patients are often advised to restrict weight bearing on the affected limb. Conventional training methods are not effective at enabling patients to comply with recommendations for partial weight bearing. The current study assessed a novel method of using real-time haptic (vibratory/vibrotactile) biofeedback to improve compliance with instructions for partial weight bearing. Thirty healthy, asymptomatic participants were randomized into 1 of 3 groups: verbal instruction, bathroom scale training, and haptic biofeedback. Participants were instructed to restrict lower-extremity weight bearing in a walking boot with crutches to 25 lb, with an acceptable range of 15 to 35 lb. A custom weight bearing sensor and biofeedback system was attached to all participants, but only those in the haptic biofeedback group were given a vibrotactile signal if they exceeded the acceptable range. Weight bearing in all groups was measured with a separate validated commercial system. The verbal instruction group bore an average of 60.3±30.5 lb (mean±standard deviation). The bathroom scale group averaged 43.8±17.2 lb, whereas the haptic biofeedback group averaged 22.4±9.1 lb (P<.05). As a percentage of body weight, the verbal instruction group averaged 40.2±19.3%, the bathroom scale group averaged 32.5±16.9%, and the haptic biofeedback group averaged 14.5±6.3% (P<.05). In this initial evaluation of the use of haptic biofeedback to improve compliance with lower-extremity partial weight bearing, haptic biofeedback was superior to conventional physical therapy methods. Further studies in patients with clinical orthopedic trauma are warranted.
    Orthopedics 11/2014; 37(11):e993-8. · 1.05 Impact Factor
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    ABSTRACT: Cervical spine range of motion (ROM) is a common measure of cervical conditions, surgical outcomes, and functional impairment. Although ROM is routinely assessed by visual estimation in clinical practice, visual estimates have been shown to be unreliable and inaccurate. Reliable goniometers can be used for assessments, but the associated costs and logistics generally limit their clinical acceptance. To investigate whether training can improve visual estimates of cervical spine ROM, we asked attending surgeons, residents, and medical students at our institution to visually estimate the cervical spine ROM of healthy subjects before and after a training session. This training session included review of normal cervical spine ROM in 3 planes and demonstration of partial and full motion in 3 planes by multiple subjects. Estimates before, immediately after, and 1 month after this training session were compared to assess reliability and accuracy. Immediately after training, errors decreased by 11.9° (flexion-extension), 3.8° (lateral bending), and 2.9° (axial rotation). These improvements were statistically significant. One month after training, visual estimates remained improved, by 9.5°, 1.6°, and 3.1°, respectively, but were statistically significant only in flexion-extension. Although the accuracy of visual estimates can be improved, clinicians should be aware of the limitations of visual estimates of cervical spine ROM. Our study results support scrutiny of visual assessment of ROM as a criterion for diagnosing permanent impairment or disability.
    American journal of orthopedics (Belle Mead, N.J.) 11/2014; 43(11):E261-E265.
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    ABSTRACT: Ankle fractures are common and can be associated with severe morbidity. Risk factors for short-term adverse events and readmission after open reduction and internal fixation (ORIF) of ankle fractures have not been fully characterized.
    Clinical Orthopaedics and Related Research 10/2014; · 2.79 Impact Factor
  • Jonathan N Grauer, Andre M Samuel
    Clinical Orthopaedics and Related Research 10/2014; · 2.79 Impact Factor
  • Michael C Fu, Rafael A Buerba, Jonathan N Grauer
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    ABSTRACT: Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP), a prospectively-collected multicenter surgical outcomes database.
    Journal of spinal disorders & techniques. 10/2014;
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    ABSTRACT: Retrospective cohort study.
    Journal of spinal disorders & techniques. 10/2014;
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    ABSTRACT: Recent studies have questioned the efficacy of meniscectomy in older patients with and without evidence of osteoarthritis; however, it continues to be frequently performed. There is limited information about age and other risk factors for adverse events and readmission after the procedure. This knowledge is vital to understand the true risk profile of this common surgery.
    The American journal of sports medicine. 10/2014;
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    ABSTRACT: Background context Magnetic resonance imaging (MRI) is frequently used in the evaluation of degenerative conditions in the lumbar spine. The relative inter-rater and intra-rater agreements of MRI findings across different pathological conditions are underexplored, as most studies are focused on specific findings. Purpose To characterize the inter-rater and intra-rater agreement of MRI findings used to assess the degenerative lumbar spine. Study Design A retrospective diagnostic study at a large academic medical center was undertaken with a panel of orthopaedic surgeons and musculoskeletal radiologists to assess lumbar MRIs using standardized criteria. Patient Sample Seventy-five subjects who underwent routine lumbar spine MRI at our institution. Outcome Measures Each MRI study was assessed for ten lumbar degenerative findings using standardized criteria. Lumbar vertebral levels were assessed independently, where applicable, for a total of 52 data points collected per study. Methods T2-weighted axial and sagittal MRI sequences were presented in random order to the four reviewers (two orthopaedic spine surgeons and two musculoskeletal radiologists) independently to determine inter-rater agreement. The first ten studies were re-evaluated at the end to determine intra-rater agreement. Images were assessed using standardized and pilot-tested criteria to assess disc degeneration, stenosis, and other degenerative changes. Inter-rater and intra-rater absolute percent agreements were calculated. To highlight the most clinically important MRI disagreements, a modified agreement analysis was also performed (in which disagreements between the lowest two severity grades for applicable conditions were ignored). Fleiss' kappa coefficients for inter-rater agreement were determined. There were no sources of funding or conflicts of interest related to this study. Results The overall absolute and modified inter-rater agreements were 76.9% and 93.5%, respectively. The absolute and modified intra-rater agreements were 81.3% and 92.7%. Average Fleiss' kappa coefficient was 0.431, suggesting moderate overall agreement. However, when stratified by condition, absolute inter-rater agreement ranged from 65.1% to 92.0%. Disc hydration, disc space height, and bone marrow changes exhibited the lowest absolute inter-rater agreements. The absolute intra-rater agreement had a narrower range, from 74.5% to 91.5%. Fleiss' kappa coefficients ranged from fair to substantial agreement (0.282-0.618). Conclusions Even in a study using standardized evaluation criteria, there was significant variability in the inter-rater and intra-rater agreement of MRI in assessing different degenerative conditions of the lumbar spine. Clinicians should be aware of the condition-specific diagnostic limitations of MRI interpretation.
    The spine journal: official journal of the North American Spine Society 10/2014; · 2.90 Impact Factor
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    ABSTRACT: Study Design. Retrospective cohort analysis of anterior cervical discectomy and fusion (ACDF) surgeries using a prospectively collected database.Objective. To characterize the 30-day postoperative outcomes in elderly patients undergoing ACDF after adjustment for comorbidities using a multi-institutional database.Summary of Background Data. Prior studies on the effect of age after ACDF have mostly focused on in-hospital complications, have come from single institutions, or have included ACDF in pooled analyses and have not distinctly analyzed the specific complications associated with age after ACDF.Methods. Patients undergoing ACDF were selected in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005-2012. Patients were stratified into four age groups: 18-39, 40-64, 65-74, and ≥75 years old (based on standard deviation cohorts). Patients in the different age categories were compared using χ, Fisher's exact test, and ANOVA. Multivariate linear/logistic regression models were used to adjust for preoperative comorbidities. Significance was defined as P <0.05.Results. Data were available for 6,253 patients who underwent ACDF. On multivariate logistic regression both groups of elderly patients (65-74 years and ≥75 years old) were more likely to have blood transfusions, re-operations, urinary complications, extended length of stays, and ≥1 complication overall. Only patients of 65-74 years were more likely to have a PE/DVT, while only patients aged ≥75 were more likely to experience respiratory complications, CNS complications, or death. There were no differences in complication rates between the 18-39 and 40-64 age groups. The 18-39 and ≥ 75 year-old age groups had shorter operating room times.Conclusions. Older age is an independent risk factor for greater morbidity and longer hospitalizations after ACDF, even after adjustment for comorbidities when compared to younger patients. Surgeons should be aware of the increased risk of multiple complications for patients of advanced age in their surgical-decision making.
    Spine 09/2014; · 2.16 Impact Factor
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    ABSTRACT: Diabetes and hip fractures in geriatric patients are common, and many elderly patients have a history of diabetes. However, the influence of diabetes on surgical complications may vary based on which particular type of diabetes a patient has. To our knowledge, no prior study has stratified patients with diabetes to compare patients with noninsulin-dependent and insulin-dependent diabetes regarding rates of postoperative adverse events, length of hospitalization, and readmission rate after surgical stabilization of hip fractures in geriatric patients.
    Clinical Orthopaedics and Related Research 09/2014; · 2.79 Impact Factor
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    ABSTRACT: To identify factors associated with increased postoperative length of stay (LOS) and readmission after surgical repair of geriatric hip fractures.
    Journal of Orthopaedic Trauma 09/2014; · 1.75 Impact Factor
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    ABSTRACT: Posterior spinal fusion (PSF) is commonly performed for patients with adolescent idiopathic scoliosis (AIS). Identifying factors associated with perioperative morbidity and PSF may lead to strategies for reducing the frequency of adverse events (AEs) in patients and total hospital costs.
    Clinical Orthopaedics and Related Research 09/2014; · 2.79 Impact Factor
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    ABSTRACT: : Study Design. Cross-sectionalObjective. To objectively evaluate the ability of International Classification of Diseases, Ninth Revision (ICD-9) codes, which are used as the foundation for administratively coded national databases, to identify preoperative anemia in spinal fusion patients.Summary of Background Data. National database research in spine surgery continues to rise. However, the validity of studies based on administratively coded data, such as the Nationwide Inpatient Sample (NIS), are dependent on the accuracy of ICD-9 coding. Such coding has previously been found to have poor sensitivity for conditions such as obesity and infection.Methods. A cross-sectional study was performed at an academic medical center. Hospital-reported anemia ICD-9 codes (those used for administratively coded databases) were directly compared to the chart-documented preoperative hematocrits (true laboratory values). A patient was deemed to have preoperative anemia if the preoperative hematocrit was less than the lower end of the normal range (36.0% for females and 41.0% for males).Results. The study included 260 patients. Of these, 37 patients (14.2%) were anemic; however, only 10 patients (3.8%) received an "anemia" ICD-9 code. Of those coded as anemic, 7 of these 10 patients were anemic by definition, while 3 were not, and thus were miscoded. This equates to an ICD-9 code sensitivity of 0.19, with a specificity of 0.99, and positive and negative predictive values of 0.70 and 0.88, respectively.Conclusions. The current study uses preoperative anemia to demonstrate the potential inaccuracies of ICD-9 coding. These results have implications for publications using databases that are compiled from ICD-9 coding data. Furthermore, the findings of the current investigation raise concerns regarding the accuracy of additional comorbidities. Although administrative databases are powerful resources that provide large sample sizes, it is crucial that we further consider the quality of the data source relative to its intended purpose.
    Spine 09/2014; · 2.16 Impact Factor
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    ABSTRACT: To identify factors that are associated with short-term outcomes following open reduction and internal fixation (ORIF) for tibial plateau fracture.
    Journal of Orthopaedic Trauma 08/2014; · 1.75 Impact Factor
  • Jason O Toy, Bryce A Basques, Jonathan N Grauer
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    ABSTRACT: : Study Design. Retrospective cohort.Objective. To identify risk factors for poor short-term outcomes after vertebral augmentation procedures.Summary of Background Data. Vertebral compression fractures are the most common fractures of osteoporosis and are frequently treated with vertebroplasty or kyphoplasty. There is a shortage of information about risk factors for short-term, general health outcomes after vertebral augmentation in the literature.Methods. Patients aged 65 and over who underwent vertebroplasty or kyphoplasty in 2011 and 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patient characteristics were tested for association with 30-day adverse events, mortality, and readmission using bivariate and multivariate analyses.Results. A total of 850 patients met inclusion criteria. The average age was 78.9 ± 11.7 years (mean ± standard deviation) and the cohort was 70.8% female. Of these patients, 9.5% had any adverse event (AAE), and 6.6% had a severe adverse event (SAE). Death occurred in 1.5% of patients, and 10.8% were readmitted within the first 30 postoperative days.On multivariate analysis, AAE and SAE were both significantly associated with American Society of Anesthesiologists (ASA) class 4 (AAE: odds ratio [OR] = 2.7, p = 0.013; SAE: OR = 2.5, p = 0.040) and inpatient status before procedure (AAE: OR = 2.7, p <0.001, SAE: OR = 2.4, p = 0.003). Increased postoperative mortality was associated with ASA class 4 (OR = 6.4, p = 0.024) and the use of non-general anesthesia (OR = 4.0, p = 0.022). Readmission was associated with history of pulmonary disease (OR = 2.0, p = 0.005) and inpatient status before procedure (OR = 1.9, p = 0.005).Conclusions. Adverse general health outcomes were relatively common, and the above-identified factors associated with patient outcomes after vertebral augmentation may be useful for preoperative discussions and counseling.
    Spine 08/2014; · 2.16 Impact Factor
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    ABSTRACT: : Study Design. Retrospective database review.Objective. To evaluate whether microscope use during spine procedures is associated with increased operating room times or increased risk of infection.Summary of Background Data. Operating microscopes are commonly used in spine procedures. It is debated whether the use of an operating microscope increases operating room time or confers increased risk of infection.Methods. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, which includes data from over 370 participating hospitals, was used to identify patients undergoing elective spinal procedures with and without an operating microscope for the years 2011 and 2012. Bivariate and multivariate linear regressions were used to test the association between microscope use and operating room times. Bivariate and multivariate logistic regressions were similarly conducted to test the association between microscope use and infection occurrence within 30 days of surgery.Results. A total of 23,670 elective spine procedures were identified, of which 2,226 (9.4%) used an operating microscope. The average patient age was 55.1 ± 14.4 years. The average operative time (incision to closure) was 125.7 ± 82.0 minutes.Microscope use was associated with minor increases in preoperative room time (+2.9 minutes, p = 0.013), operative time (+13.2 minutes, p<0.001), and total room time (+18.6 minutes, p<0.001) on multivariate analysis.A total of 328 (1.4%) patients had an infection within 30 days of surgery. Multivariate analysis revealed no significant difference between the microscope and non-microscope groups for occurrence of any infection, superficial surgical site infection (SSI), deep SSI, organ space infection, or sepsis/septic shock, regardless of surgery type.Conclusions. We did not find operating room times or infection risk to be significant deterrents for use of an operating microscope during spine surgery.
    Spine 08/2014; · 2.16 Impact Factor
  • Jonathan N Grauer, Andrea Halim, Kristaps J Keggi
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    ABSTRACT: Total hip arthroplasty (THA) and revision total hip arthroplasty are among the most commonly performed orthopedic procedures. There are many reported complications of THA, but intrapelvic complications are a rare subset. Bladder injuries have infrequently been described in association with this common procedure. We present an unusual case of a bladder tear occurring intraoperatively during a revision THA. It is suspected that the patient's history of multiple prior hip procedures caused adhesions of the bladder to the pelvic floor and predisposed the bladder to injury during acetabular revision. Previous reports of bladder injury relating to THA have described thermal necrosis, component migration, and occasional direct perforation. There are no prior case reports describing bladder tears related to adhesions occurring intraoperatively during revision THA. This case report highlights the importance of surgeon awareness of an unusual complication. In this case, intraoperative and postoperative recognition of a hematuria diagnosis led to the appropriate treatment, and this patient had an acceptable outcome.
    American journal of orthopedics (Belle Mead, N.J.) 08/2014; 43(8):E185-E188.
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    ABSTRACT: Study Design. Retrospective cohort.Objective. To determine the effect of non-insulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM) on postoperative complications following elective lumbar fusion surgery.Summary of Background Data. Diabetes mellitus (DM) is a common chronic disease. The effects of NIDDM and IDDM on rates of postoperative complications, extended length of stay, and readmission after lumbar fusion surgery are not well established.Methods. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients undergoing lumbar fusion between 2005 and 2012 were identified and characterized as having NIDDM, IDDM, or neither. Bivariate and multivariate analyses were used to test NIDDM and IDDM patients for increased risk of adverse postoperative outcomes over the initial 30 postoperative days.Results. 15,480 patients who underwent lumbar fusion were identified (13,043 were non-DM patients, 1,650 patients had NIDDM, and 787 patients had IDDM).NIDDM was independently associated with an increased risk of wound dehiscence (Relative Risk = 2.3; p = 0.033) and extended length of stay (1.2; p < 0.003).IDDM was independently associated with an increased risk of death (2.7; p = 0.020), sepsis (2.2; p = 0.002), septic shock (3.3; p = 0.032), unplanned intubation (2.8; p = 0.003), ventilator-assisted respiration > 48 hours postoperatively (2.8; p = 0.005), wound-related infection (1.9; p = 0.001), urinary tract infection (1.6, p = 0.011), pneumonia (3.1; p < 0.001), extended length of stay (1.5; p < 0.001), and readmission within 30 days (1.5, p = 0.036).Conclusions. Compared to non-DM patients, IDDM was associated with an increased risk of a considerably higher number of postoperative complications than NIDDM. These complications were also of greater severity. This important designation may improve preoperative risk stratification and counseling of diabetic patients prior to lumbar fusion surgery.
    Spine 07/2014; · 2.16 Impact Factor
  • Andrea Halim, Jonathan Grauer
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    ABSTRACT: We report a case of a C7 pars fracture subadjacent to C7 pedicle screw instrumentation at the caudal end of posterior cervical instrumentation construct. To date, posterior cervical instrumentation has been "off label"; however, the US Food and Drug Administration is considering approving label indication of such instrumentation for this common surgical practice. Complications related to the techniques are reported to be relatively low. We know of no previous reports of pars fractures occurring subadjacent to such instrumentation. A 43-year-old man underwent posterior C5-C7 instrumented fusion. Postoperatively, the patient experienced cervical spine injury after a mechanical fall down stairs. Work-up detected bilateral C7 pars fractures subadjacent to the posterior instrumentation construct. After we treated the pars fracture with distal extension of the posterior fusion to the level of T2, the patient progressed to union and marked improvement of initial clinical symptoms that was maintained 2.5 years after posterior instrumentation. To our knowledge, a C7 pars fracture subadjacent to posterior cervical instrumentation construct has not been reported. We hypothesize that the pars may have been vulnerable to fracture because of excessive bone resection during foraminotomy or decortication. This complication was successfully treated by extending the fusion caudally.
    American journal of orthopedics (Belle Mead, N.J.) 07/2014; 43(7):E137-E139.

Publication Stats

2k Citations
293.57 Total Impact Points

Institutions

  • 1997–2014
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
  • 1997–2013
    • Yale University
      • Department of Orthopaedics and Rehabilitation
      New Haven, CT, United States
  • 2011
    • University Center Rochester
      Rochester, Minnesota, United States
    • Brigham and Women's Hospital
      • Department of Medicine
      Boston, MA, United States
  • 2009
    • Kansas City VA Medical Center
      Kansas City, Missouri, United States
    • University of Rochester
      • Department of Orthopaedics and Rehabilitation
      Rochester, NY, United States
  • 2008
    • University of New Haven
      New Haven, Connecticut, United States
  • 2003–2007
    • Thomas Jefferson University
      • • Rothman Institute
      • • Department of Orthopaedic Surgery
      Philadelphia, Pennsylvania, United States
  • 2003–2005
    • Rothman Institute
      Philadelphia, Pennsylvania, United States