Jonathan N Grauer

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

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Publications (190)400.14 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Survey of spine surgeons and biomechanical comparison of screw pullout forces. To investigate what may be a suboptimal practice regularly occurring in spine surgery. In order for a tap to function in its intended manner, the pitch of the tap should be the same as the pitch of the screw. Under-tapping has been shown to increase the pullout force of pedicle screws compared to line-to-line tapping. However, given the way current commercial lumbar pedicle screw systems are designed, under-tapping may result in a tap being used that has a different pitch from that of the screw (incongruent pitch). A survey asked participants questions to estimate the proportion of cases each participant performed in the prior year using various hole preparation techniques. Participant responses were interpreted in the context of manufacturing specifications of specific instrumentation systems. Screw pullout forces were compared between under-tapping with incongruent pitch and under-tapping with congruent pitch using 0.16g/cm polyurethane foam block and 6.5mm screws. Of the 3,679 cases in which participants reported tapping, participants reported line-to-line tapping in 209 cases (5%), under-tapping with incongruent pitch in 1,156 cases (32%), and under-tapping with congruent pitch in 2,314 cases (63%). The mean pullout force for under-tapping with incongruent pitch was 56N (8%) less than the mean pullout force for under-tapping with congruent pitch. This is equivalent to 13 pounds. This study estimates that for about 1 out of every 3 surgical cases with tapping of lumbar pedicle screws in the United States, hole preparation is being performed by under-tapping with incongruent pitch. This study also shows that under-tapping with incongruent pitch results in a decrease in pullout force by 8% compared to under-tapping with congruent pitch. Steps should be taken to correct this suboptimal practice.
    Spine 04/2015; DOI:10.1097/BRS.0000000000000922 · 2.45 Impact Factor
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    ABSTRACT: Total hip arthroplasty may be performed under general or spinal anesthesia. The purpose of the current study was to compare perioperative outcomes between anesthetic types for patients undergoing primary elective total hip arthroplasty. Patients who had undergone primary elective total hip arthroplasty from 2010 to 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Operating room times, length of stay, thirty-day adverse events, and readmission were compared between patients who had received general anesthesia and those who had received spinal anesthesia. Propensity-adjusted multivariate analysis was used to control for selection bias and baseline patient characteristics. A total of 20,936 patients who had undergone total hip arthroplasty met inclusion criteria for this study. Of these, 12,752 patients (60.9%) had received general anesthesia and 8184 patients (39.1%) had received spinal anesthesia. On propensity-adjusted multivariate analyses, general anesthesia for total hip arthroplasty was associated with increased operative time (+12 minutes [95% confidence interval, +11 to +13 minutes]; p < 0.001) and postoperative room time (+5 minutes [95% confidence interval, +4 to +6 minutes]; p < 0.001). General anesthesia was also associated with the occurrence of any adverse event (odds ratio, 1.31 [95% confidence interval, 1.23 to 1.41]; p < 0.001), prolonged postoperative ventilator use (odds ratio, 5.81 [95% confidence interval, 1.35 to 25.06]; p = 0.018), unplanned intubation (odds ratio, 2.17 [95% confidence interval, 1.11 to 4.29]; p = 0.024), stroke (odds ratio, 2.51 [95% confidence interval, 1.02 to 6.20]; p = 0.046), cardiac arrest (odds ratio, 5.04 [95% confidence interval, 1.15 to 22.07]; p = 0.032), any minor adverse event (odds ratio, 1.35 [95% confidence interval, 1.25 to 1.45]; p = 0.001), and blood transfusion (odds ratio, 1.34 [95% confidence interval, 1.25 to 1.45]; p < 0.001). General anesthesia was not associated with any difference in preoperative room time, postoperative length of stay, or readmission. General anesthesia was associated with an increased rate of adverse events and mildly increased operating room times. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.
    The Journal of Bone and Joint Surgery 03/2015; 97(6):455-61. DOI:10.2106/JBJS.N.00662 · 4.31 Impact Factor
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    ABSTRACT: Study Design. A retrospective study of surgically treated cervical spinal cord injury (SCI) patients from the National Trauma Data Bank Research Data Set (NTDB RDS). To determine how time to surgery differs between SCI subtypes, where delays before surgery occur, and what factors are associated with delays. Studies have shown that cervical SCI patients receiving surgery within 24 hours after injury have superior neurological outcomes to patients receiving later surgery, with most evidence coming from the incomplete SCI subpopulation. Surgically treated cervical SCI patients from 2011 and 2012 were identified in NTDB RDS and divided into subpopulations of complete, central, and other incomplete SCIs. Relationships between surgical timing and patient and injury characteristics were analyzed using multivariate regression. A total of 2,636 cervical SCI patients were identified: 803 with complete SCI, 950 with incomplete SCI, and 883 with central SCI. The average time to surgery was 51.1 hours for complete SCI patients, 55.3 hours for incomplete SCI patients, and 83.1 hours for central SCI patients. Only 44% of SCI patients underwent surgery within the first 24 hours after injury, including only 49% of patients with incomplete SCI.The vast majority of time between injury and surgery was after admission, rather than in the emergency department or in the field. Upper cervical injuries and greater Charlson comorbidity index were associated with later surgery in all three SCI subpopulations. The majority of SCI patients do not receive surgery within the first 24 hours after injury, and the majority of delays occur after inpatient admission. Factors associated with these delays highlight areas of focus for expediting care in these patient populations.
    Spine 03/2015; DOI:10.1097/BRS.0000000000000883 · 2.45 Impact Factor
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    ABSTRACT: A retrospective study of surgically treated patients with acute traumatic central cord syndrome (ATCCS) from the National Trauma Data Bank Research Data Set. To determine the association of time to surgery, pre-existing comorbidities, and injury severity on mortality and adverse events in surgically treated patients with ATCCS. Although earlier surgery has been shown to be beneficial for other spinal cord injuries, the literature is mixed regarding the appropriate timing of surgery after ATCCS. Traditionally, this older population has been treated with delayed surgery because medical optimization is often indicated preoperatively. Surgically treated patients with ATCCS in the National Trauma Data Bank Research Data Set from 2011 and 2012 were identified. Time to surgery, Charlson Comorbidity Index, and injury severity scores were tested for association with mortality, serious adverse events, and minor adverse events using multivariate logistic regression. A total of 1060 patients with ATCCS met inclusion criteria. After controlling for pre-existing comorbidity and injury severity, delayed surgery was associated with a decreased odds of inpatient mortality (odds ratio = 0.81, P = 0.04), or a 19% decrease in odds of mortality with each 24-hour increase in time until surgery. The association of time to surgery with serious adverse events was not statistically significant (P = 0.09), whereas time to surgery was associated with increased odds of minor adverse events (odds ratio = 1.06, P < 0.001). Although the potential neurological effect of surgical timing for patients with ATCCS remains controversial, the decreased mortality with delayed surgery suggests that waiting to optimize general health and potentially allow for some spinal cord recovery in these patients may be advantageous. 3.
    Spine 03/2015; 40(5):349-356. DOI:10.1097/BRS.0000000000000756 · 2.45 Impact Factor
  • Jonathan N Grauer, Seth S Leopold
    Clinical Orthopaedics and Related Research 02/2015; DOI:10.1007/s11999-015-4223-z · 2.88 Impact Factor
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    ABSTRACT: To test the hypothesis that clinical assessment reliably identifies patients with radiographic changes (including loss of reduction, hardware failure, and hardware migration) at the initial visit following operative repair of distal radius fractures. We identified 102 patients undergoing operative repair of distal radius fractures. Radiographs and clinical notes were reviewed. At the initial postoperative visit, 11 patients had more than normal postoperative pain, 0 had deformity, 0 had crepitus with gentle motion, and 0 had instability at the fracture site on examination. These 11 patients were considered to have positive clinical assessments, but none had radiographic changes on x-rays taken that day. Three patients had negative clinical assessments but had radiographic changes noted at the initial postoperative visit. There were no additional radiographic changes between the series taken at the initial postoperative visit and series taken at later postoperative visits. These data suggest that for purposes of detecting radiographic changes, radiography at the initial visit is helpful, whereas radiography at subsequent visits may not be. Radiography at subsequent visits may be useful to monitor bony healing, which we did not investigate. Diagnostic IV. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
    The Journal Of Hand Surgery 01/2015; 40(1):49-56. DOI:10.1016/j.jhsa.2014.08.038 · 1.66 Impact Factor
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    ABSTRACT: Study Design. Retrospective cohort.Objective. To evaluate whether myelopathy is associated with increased morbidity and mortality after anterior cervical discectomy and fusion (ACDF) compared to other indications for this procedure.Summary of Background Data. ACDF is the most common surgical procedure for the management of a spectrum of cervical spine pathologies. As a more advanced condition, myelopathy is generally believed to be associated with higher morbidity and mortality after this procedure, but there is limited evidence to support this supposition. The current study compares outcomes of ACDF procedures performed for myelopathy to those performed for other indications, controlling for other patient factors.Methods. Patients who underwent ACDF between 2010 and 2012 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Myelopathic patients were identified by diagnosis codes for cervical myelopathy. Bivariate and multivariate logistic regressions were performed to compare 30-day adverse events and readmission between groups. Multivariate analyses controlled for patient and surgical characteristics.Results. A total of 5,256 ACDF procedures met inclusion criteria, of which 1,425 (27.3%) were performed for cervical myelopathy. Myelopathic patients were older and were less healthy compared to non-myelopathic patients. Multivariate analysis controlling for baseline patient characteristics found that myelopathic patients were at significantly increased risk of any adverse event (odds ratio [OR] = 1.5), any severe adverse event (OR = 1.8), and death (OR = 8.9) compared to non-myelopathic patients.Conclusion. After adjusting for baseline patient characteristics, not only were any adverse events and serious adverse events more common following ACDF for myelopathic patients compared to non-myelopathic patients, but mortality was approximately nine times more likely. It is important for surgical planning and patient counselling to keep this significant difference in mind for this common procedure that has different morbidities based on the pathology for which it is performed.
    Spine 01/2015; DOI:10.1097/BRS.0000000000000785 · 2.45 Impact Factor
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    ABSTRACT: The Spine Patient Outcomes Research Trial (SPORT) is a highly referenced clinical trial that randomized patients with lumbar pathology to receive surgery or continued conservative treatment. Compare the SPORT lumbar disc herniation cohort and an analogous cohort from the National Surgical Quality Improvement Program (NSQIP) database. Study Design/Setting: Retrospective cohort study comparing a national database population to a randomized clinical trial. Elective lumbar discectomies from NSQIP between 2010 and 2012. Demographics were compared between the randomized SPORT cohorts (surgical and nonoperative) and NSQIP. Perioperative factors and complications were then compared between SPORT discectomy patients and NSQIP. No funding sources or potential conflicts of interest exist. Using current procedural terminology (CPT) and International Classification of Diseases, 9(th) revision (ICD-9) codes, all elective lumbar discectomies from NSQIP between 2010 and 2012 were identified. Where possible based on published data and variables available in each cohort, the two populations were compared. 6,846 NSQIP discectomy patients were compared to the randomized SPORT surgical and nonoperative cohorts. Demographic comparisons showed NSQIP patients were older (average age 48.2 ± 14.5 years [mean ± standard deviation], versus 41.7 ± 11.8 and 43.0 ± 11.3 years, respectively [p<0.001]) and had higher BMI (29.6 ± 6.2 kg/m(2), versus 27.8 ± 5.6 and 28.2 ± 5.4 kg/m(2), respectively [p<0.001]). No statistical differences existed for gender or race. Smoking status was not different between the SPORT nonoperative group and NSQIP, but was higher in NSQIP compared to SPORT surgical patients (p=0.020 by 7%). Perioperative factors and complications comparisons between the SPORT surgical cohort and NSQIP showed no statistical difference in average operative time, length of stay, deep wound infections, wound dehiscence, total wound complications, or blood transfusions. SPORT superficial wound infection rates were higher than NSQIP (p=0.029 by 1.4%). As expected, SPORT one-year reoperation rates were higher than NSQIP 30-day rates (7% versus 2%, p<0.001). SPORT lumbar disc herniation results are similar to those from a large national patient sample. Even statistically significant differences would be considered clinically similar. These findings support the generalizability of the SPORT lumbar disc herniation results. Copyright © 2014 Elsevier Inc. All rights reserved.
    The spine journal: official journal of the North American Spine Society 12/2014; DOI:10.1016/j.spinee.2014.12.008 · 2.80 Impact Factor
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    ABSTRACT: Interest has increased in adolescent idiopathic scoliosis braces that are worn only part time. One such brace, the Providence brace, is being used with increasing frequency despite limited literature evaluating its ability to alter the natural course of disease. The authors retrospectively identified 34 patients meeting modified Scoliosis Research Society (SRS) inclusion criteria who were treated with the Providence brace. In accordance with SRS criteria, patients were followed for progression more than 5°, progression to more than 45°, and recommendation for or performance of surgical fusion. Seventeen (50%) patients progressed more than 5°, and 9 (26%) progressed to more than 45° and had fusion surgery recommended or performed. Noncompliance was associated with progression to more than 45° (P=.045) and having fusion surgery recommended or performed (P=.045). Males had a higher rate of progression more than 5° than did females (100% vs 41%; P=.015). This is only the second study of the Providence brace to be guided by SRS criteria. The somewhat higher rates of progression more than 5° reported in these 2 studies compared with those reported in earlier studies likely result from this distinction. This study suggests a rate of progression that is similar to or lower than rates reported in natural history studies, possibly supporting the efficacy of the Providence brace. Additional studies using SRS criteria, including high-quality randomized, controlled trials, will be important to further understanding the relative effectiveness of this and other bracing protocols. [Orthopedics. 2014; 37(12):e1085-e1090.]. Copyright 2014, SLACK Incorporated.
    Orthopedics 12/2014; 37(12):e1085-90. DOI:10.3928/01477447-20141124-56 · 0.98 Impact Factor
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    ABSTRACT: For more than thirty-five years, the sliding hip screw, an extramedullary implant, has been the standard treatment for the stabilization of intertrochanteric fractures. Over the last decade, intramedullary implants have replaced extramedullary implants as the most commonly used type of implant in the United States for the treatment of this condition, without strong evidence of superior outcomes. We conducted a retrospective cohort study with use of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Patients seventy years of age or older who had sustained an intertrochanteric fracture treated with extramedullary or intramedullary implant during 2009 to 2012 were identified. General surgical outcomes were compared between implant types, with adjustment for demographic data and comorbidities. A total of 4432 patients were identified; 1612 (36.4%) were treated with an extramedullary implant, and 2820 (63.6%) with an intramedullary implant. The rates of the composite outcomes "serious adverse events" and "any adverse events" did not differ by implant type. The mean postoperative length of stay was shorter for patients treated with an intramedullary implant compared with those treated with an extramedullary implant (5.4 compared with 6.5 days; p < 0.001). Operation time, operating room time, and the rate of hospital readmission did not differ by implant type. These results reinforce the results of previous randomized trials, demonstrating little difference in rates of general surgical adverse events between implant types. The present study presents an important departure from previous trials in its finding that patients treated with intramedullary implants have, on average, a shorter postoperative length of stay (by 1.1 days). The finding may negate the perceived excess cost associated with intramedullary treatment. Limitations regarding the ACS NSQIP database include a lack of detail regarding fracture subtype, outcomes beyond thirty days, and orthopaedic-specific outcomes. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.
    The Journal of Bone and Joint Surgery 11/2014; 96(22):1871-7. DOI:10.2106/JBJS.N.00041 · 4.31 Impact Factor
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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.
    11/2014; 3(4):239-44. DOI:10.1055/s-0034-1394131
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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: 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. DOI:10.3928/01477447-20141023-56 · 0.98 Impact Factor
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    ABSTRACT: Background Context The use of national inpatient databases for spine surgery research has been increasing. Unfortunately, without firsthand knowledge of each specific database, it can be difficult to judge the validity of such studies. Large databases that rely on administrative data, such as International Classification of Diseases, Ninth Revision (ICD-9) codes, may misrepresent patient information and could thus affect the results of studies that use this data. Purpose The present study uses obesity, an easily quantified and objective variable, as an example comorbidity to assess the accuracy of ICD-9 codes in the setting of their continued use in spine database studies. Study Design/Setting A cross-sectional study at a large academic medical center. Patient Sample All patients spending at least one night in the hospital as an inpatient between April 1, 2013 and April 16, 2013. Obstetrics and gynecology, psychiatry, and pediatric patients were excluded. Outcome Measures Proportion of patients for whom ICD-9 obesity diagnosis codes assigned at hospital discharge match chart-documented BMI. Methods The medical record was reviewed for each patient, and obesity ICD-9 codes were directly compared to documented body mass index (BMI). No known conflicts of interest exist for this study. Results The study included 2,075 patients. Of 573 “obese” patients (calculated BMI 30-39.9), only 109 received the correct code (278.00), giving this ICD-9 code a sensitivity of 0.19. Of 174 “morbidly obese” patients (calculated BMI > 40), only 84 received the correct code (278.01), giving this ICD-9 code a sensitivity of 0.48. Conclusions Using obesity as an example, this study highlights the potential errors inherent to using ICD-9-coded databases for spine surgery research. Should a study based on such data use “obesity” as a variable in any analyses, the reader should interpret these results with caution. We further suggest that obesity is likely not the only comorbidity to which these results apply. As database research continues to represent an increasing proportion of publications in the field of spine surgery, it is important to realize that study outcomes can be skewed by data accuracy, and thus should not be blindly accepted simply by virtue of large sample sizes.
    The Spine Journal 11/2014; DOI:10.1016/j.spinee.2014.08.134 · 2.80 Impact Factor
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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; 473(3). DOI:10.1007/s11999-014-4005-z · 2.88 Impact Factor
  • Jonathan N Grauer, Andre M Samuel
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    ABSTRACT: Where Are We Now?The interesting and timely paper by Nota and colleagues describes how different definitions of surgical site infection in spine surgery patients from a large institutional database might affect study results. The study highlights some of the limitations of database studies that must be considered as we are turning to large databases more and more frequently to address surgical outcome questions.Three different definitions of surgical site infection are used: ICD-9 coding of infection (led to 6% infection rate in this study cohort), CDC definition of deep infection (led to 3.8% infection rate), and documented incision and débridement for infection (led to 3.2% infection rate). Based on these definitions, the authors reported both similarities and differences in determining what ICD-9-defined variables were associated with higher risk for surgical site infection. This was true for identifying surgical site infections, as well as the independent variables in the study, su ...
    Clinical Orthopaedics and Related Research 10/2014; 473(5). DOI:10.1007/s11999-014-4002-2 · 2.88 Impact Factor
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    ABSTRACT: Study Design: Retrospective cohort study. Objective: To compare the short-term outcomes for patients undergoing cervical laminoplasty versus posterior decompression and fusion for multilevel cervical pathology. Summary of Background Data: There is conflicting data regarding the merits of cervical laminoplasty and posterior decompression and fusion for the treatment of multilevel cervical pathology. Methods: Patients who underwent cervical laminoplasty or posterior decompression and fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2010 to 2012. Baseline patient characteristics were compared using bivariate logistic regression. Propensity-adjusted multivariate regressions were performed to assess differences in postoperative length of stay, adverse events, and 30-day readmission. Results: A total of 779 patients were included in this study: 437 (56.1%) underwent cervical decompression and fusion and 342 (43.9%) underwent cervical laminoplasty. Decompression and fusion patients were found to be more comorbid at baseline than laminoplasty patients based on increased American Society of Anesthesiologists (ASA) scores and Charlson Comorbidity Index (CCI). Propensity-adjusted multivariate analysis was used to control for differences in baseline patient characteristics, and found that compared to laminoplasty patients, decompression and fusion patients had increased length of stay (+1.2 d, P<0.001), greater rates of any adverse event (OR=1.7, P=0.018), and were more likely to be readmitted (OR=2.3, P=0.028). Conclusion: Posterior cervical decompression and fusion patients were found to have moderately worse short-term outcomes than laminoplasty patients. The information provided here can be used to inform patients and surgeons about the likely perioperative experience after they have made the decision to pursue one of these two procedures.
    The Spine Journal 10/2014; DOI:10.1097/BSD.0000000000000183 · 2.80 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; DOI:10.1097/BSD.0000000000000181 · 1.89 Impact Factor
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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; DOI:10.1177/0363546514551923 · 4.70 Impact Factor
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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; 14(10). DOI:10.1016/j.spinee.2014.03.010 · 2.80 Impact Factor

Publication Stats

2k Citations
400.14 Total Impact Points


  • 1997–2015
    • Yale-New Haven Hospital
      New Haven, Connecticut, United States
  • 2012–2014
    • Yale University
      • Department of Orthopaedics and Rehabilitation
      New Haven, Connecticut, United States
    • Duke University
      Durham, North Carolina, United States
  • 2011
    • University Center Rochester
      Rochester, Minnesota, United States
    • Columbia University
      New York, New York, United States
  • 2009
    • Kansas City VA Medical Center
      Kansas City, Missouri, 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
  • 2006
    • University of Pittsburgh
      • Department of Orthopaedic Surgery
      Pittsburgh, Pennsylvania, United States
  • 2003–2005
    • Rothman Institute
      Philadelphia, Pennsylvania, United States
  • 2004
    • Keio University
      • Department of Orthopedic Surgery
      Edo, Tōkyō, Japan