Publications by authors named "Nickolas J Nahm"

17 Publications

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Single-event multilevel surgery in cerebral palsy: Value added by a co-surgeon.

Medicine (Baltimore) 2021 Jun;100(24):e26294

National Academy of Medicine Fellowship, American Osteopathic Association, Chicago, IL, USA.

Abstract: The aim of this study was to compare outcomes for single-event multilevel surgery (SEMLS) in cerebral palsy (CP) performed by 1 or 2 attending surgeons.A retrospective review of patients with CP undergoing SEMLS was performed. Patients undergoing SEMLS performed by a single senior surgeon were compared with patients undergoing SEMLS by the same senior surgeon and a consistent second attending surgeon. Due to heterogeneity of the type and quantity of SEMLS procedures included in this study, a scoring system was utilized to stratify patients to low and high surgical burden. The SEMLS events scoring less than 18 points were categorized as low burden surgery and SEMLS scoring 18 or more points were categorized as high burden surgery. Operative time, estimated blood loss, hospital length of stay, and operating room (OR) utilization costs were compared.In low burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 8 patients had SEMLS performed by 2 surgeons. In high burden SEMLS, 10 patients had SEMLS performed by a single surgeon and 12 patients had SEMLS performed by 2 surgeons. For high burden SEMLS, operative time was decreased by a mean of 69 minutes in cases performed by 2 co-surgeons (P = 0.03). Decreased operative time was associated with an estimated savings of $2484 per SEMLS case. In low burden SEMLS, a trend toward decreased operative time was associated for cases performed by 2 co-surgeons (182 vs 221 minutes, P = 0.11). Decreased operative time was associated with an estimated savings of $1404 per low burden SEMLS case. No difference was found for estimated blood loss or hospital length of stay between groups in high and low burden SEMLS.Employing 2 attending surgeons in SEMLS decreased operative time and OR utilization cost, particularly in patients with a high surgical burden. These findings support the practice of utilizing 2 attending surgeons for SEMLS in patients with CP.Level of Evidence: Level III.
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http://dx.doi.org/10.1097/MD.0000000000026294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213317PMC
June 2021

Intraoperative Neurological Monitoring in Lower Limb Surgery for Patients With Mucopolysaccharidoses.

J Pediatr Orthop 2021 Mar;41(3):182-189

Gillette Children's Specialty Healthcare, Saint Paul.

Background: There are reports of spinal cord injury (SCI) occurring after lower extremity (LE) surgery in children with mucopolysaccharidoses (MPS). Intraoperative neurological monitoring (IONM) has been adopted in some centers to assess real-time spinal cord function during these procedures. The aim of this investigation was to review 3 specialty centers' experiences with MPS patients undergoing LE surgery. We report how IONM affected care and the details of spinal cord injuries in these patients.

Methods: All pediatric MPS patients who underwent LE surgery between 2001 and 2018 were reviewed at 3 children's orthopaedic specialty centers. Demographic and surgical details were reviewed. Estimated blood loss (EBL), surgical time, positioning, use of IONM, and changes in management as a result of IONM were recorded. Details of any spinal cord injuries were examined in detail.

Results: During the study period, 92 patients with MPS underwent 252 LE surgeries. IONM was used in 83 of 252 (32.9%) surgeries, and intraoperative care was altered in 17 of 83 (20.5%) cases, including serial repositioning (n=7), aggressive blood pressure management (n=6), and abortion of procedures (n=8). IONM was utilized in cases with larger EBL (279 vs. 130 mL) and longer operative time (274 vs. 175 min) compared with procedures without IONM. Three patients without IONM sustained complete thoracic SCI postoperatively, all from cord infarction in the upper thoracic region. These 3 cases were characterized by long surgical time (328±41 min) and substantial EBL (533±416 mL or 30.5% of total blood volume; range, 11% to 50%). No LE surgeries accompanied by IONM experienced SCI.

Conclusions: Patients with MPS undergoing LE orthopaedic surgery may be at risk for SCI, particularly if the procedures are long or are expected to have large EBL. One hypothesis for the etiology of SCI in this setting is hypoperfusion of the upper thoracic spinal cord due to prolonged intraoperative or postoperative hypotension. IONM during these procedures may mitigate the risk of SCI by identifying real-time changes in spinal cord function during surgery, inciting a change in the surgical plan.

Level Of Evidence: Level III-retrospective comparative series.
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http://dx.doi.org/10.1097/BPO.0000000000001720DOI Listing
March 2021

Surgical treatment of pes planovalgus in ambulatory children with cerebral palsy: Static and dynamic changes as characterized by multi-segment foot modeling, physical examination and radiographs.

Gait Posture 2020 02 12;76:168-174. Epub 2019 Dec 12.

Gillete Children's Specialty Healthcare, 200 University Ave East St. Paul, MN, 55101, USA. Electronic address:

Background: This study employs multi-segment foot modeling (MSFM) to examine flatfoot reconstruction among ambulatory children with cerebral palsy (CP).

Research Question: Does flatfoot reconstruction improve MSFM measures, physical examination and radiographic variables for forefoot varus and midfoot collapse and associated multi-planar compensatory features?

Methods: MSFM was performed preoperatively and postoperatively in a cohort of ambulatory CP patients undergoing flatfoot reconstruction (surgical group, n = 24). A comparison group of non-surgical group of ambulatory CP patients with pes planovalgus (flatfoot) who did not undergo flatfoot reconstruction was also identified (n = 17). All patients in this comparison group underwent MSFM at two separate time points. Physical examination was performed and standing AP and lateral foot radiographs were obtained during each gait analysis session.

Results: Patients in the surgical group had improvement in their forefoot varus deformity, as documented on physical examination and kinematics in the STJN position of the foot and ankle, as well as in the compensatory hindfoot eversion and midfoot abduction during stance phase of gait. Furthermore, patients in the surgical group had improvement in midfoot collapse as identified kinematically by midfoot dorsiflexion, physical examination descriptors of midfoot position, and radiographic measures of calcaneal pitch and AP and lateral talar-first metatarsal angle. Patients in the non-surgical comparison group did not demonstrate these changes.

Significance: Improvements in foot motion after flatfoot reconstruction in ambulatory CP patients were identified by MSFM, physical examination measures, and radiographs. Patients in the surgical and non-surgical groups had similar pre-operative radiographic findings, suggesting that physical examination and MSFM data were important in the surgical decision making process. Finally, surgical intervention did not fully restore normal foot kinematic, physical examination, and radiographic parameters, which suggests that a different, perhaps more aggressive, surgical approach for flatfoot reconstruction is needed.
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http://dx.doi.org/10.1016/j.gaitpost.2019.12.004DOI Listing
February 2020

Radiographic Predictors of Screw Cutout for Intertrochanteric Fractures Treated With Cephalomedullary Nails.

J Surg Orthop Adv 2019 ;28(2):115-120

Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan.

The objective of this study was to determine the predictive value of tip-apex distance (TAD) and Parker's ratio for screw cutout after treatment of intertrochanteric hip fractures with a long cephalomedullary nail. A total of 97 patients with AO/OTA 31-A1-A3 intertrochanteric fractures and a minimum follow-up of 8 weeks were included. Increased Parker's ratio on the anteroposterior radiograph (OR = 1.386, p < .003) and lateral radiograph (OR = 1.138, p < .028) was significantly associated with screw cutout. In a multivariable regression analysis, only the Parker's anteroposterior ratio was significantly associated with risk of screw cutout (OR = 1.393, p = .004), but TAD (OR = 0.977, p = .764) and Parker's lateral ratio (OR 1.032, p = .710) were not independent predictors of cutout. The study concluded that Parker's anteroposterior ratio is the most helpful measurement in predicting screw cutout. (Journal of Surgical Orthopaedic Advances 28(2):115-120, 2019).
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October 2019

Management of hypertonia in cerebral palsy.

Curr Opin Pediatr 2018 02;30(1):57-64

Department of Orthopaedic Surgery, Gillette Children's Specialty Healthcare, St. Paul, Minnesota, USA.

Purpose Of Review: The review provides an update on the treatment of hypertonia in cerebral palsy, including physical management, pharmacotherapy, neurosurgical, and orthopedic procedures.

Recent Findings: Serial casting potentiates the effect of Botulinum neurotoxin A injections for spasticity. Deep brain stimulation, intraventricular baclofen, and ventral and dorsal rhizotomy are emerging tools for the treatment of dystonia and/or mixed tone. The long-term results of selective dorsal rhizotomy and the timing of orthopedic surgery represent recent advances in the surgical management of hypertonia.

Summary: Management of hypertonia in cerebral palsy targets the functional goals of the patient and caregiver. Treatment options are conceptualized as surgical or nonsurgical, focal or generalized, and reversible or irreversible. The role of pharmacologic therapies is to improve function and mitigate adverse effects. Further investigation, including clinical trials, is required to determine the role of deep brain stimulation, intraventricular baclofen, orthopedic procedures for dystonia, and rhizotomy.
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http://dx.doi.org/10.1097/MOP.0000000000000567DOI Listing
February 2018

Short Versus Long Cephalomedullary Nails for Pertrochanteric Hip Fracture.

Orthopedics 2017 Mar 23;40(2):83-88. Epub 2016 Nov 23.

This study compared patients who underwent treatment with short or long cephalomedullary nails with integrated cephalocervical screws and linear compression. Patients with AO/OTA 31-A2 or A3 pertrochanteric fractures treated with either short (n=72) or long (n=97) InterTAN (Smith & Nephew, Memphis, Tennessee) cephalomedullary nails were reviewed. Information on perioperative measures (estimated blood loss, surgical time, and fluoroscopy time) and postoperative orthopedic complications (infection, implant failure, screw cutout, and periprosthetic femur fracture) was included. Estimated blood loss (short nail, 161 mL; long nail, 208 mL; P=.002) and surgical time (short nail, 64 minutes; long nail, 83 minutes; P=.001) were lower in the short nail group. There were no differences in fluoroscopy time (short nail, 90 seconds; long nail, 142 seconds; P=.071) or rates of infection (short nail, 1.4%; long nail, 3.1%; P=.637) or overall orthopedic complications (short nail, 11.1%; long nail, 9.3%; P=.798) between the 2 groups. The long nail group had a trend toward more screw cutouts (long nail, 5.2%; short nail, 0.0%; P=.134) but fewer periprosthetic femur fractures (short nail, 8.3%; long nail, 0.0%; P=.013). This study found a similar overall rate of orthopedic complications between short and long nails with integrated cephalocervical screws and linear compression. These results confirm the suspected advantages of short nails, including faster surgery and less blood loss; however, the rate of periprosthetic femur fracture remains high, despite changes to implant design. [Orthopedics. 2017; 40(2):83-88.].
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http://dx.doi.org/10.3928/01477447-20161116-01DOI Listing
March 2017

Multiple Procedures in the Initial Surgical Setting: When Do the Benefits Outweigh the Risks in Patients With Multiple System Trauma?

J Orthop Trauma 2016 Aug;30(8):420-5

MetroHealth Medical Center, Department of Orthopaedic Surgery, Cleveland, OH.

Objectives: To compare single versus multiple procedures in the same surgical setting. We hypothesized that complication rates would not be different and length of stay would be shorter in patients undergoing multiple procedures.

Design: Prospective, cohort.

Setting: Level 1 trauma center.

Patients/participants: A total of 370 patients with high-energy fractures were treated after a standard protocol for resuscitation to lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥-5.5 mmol/L. Fractures included femur (n = 167), pelvis (n = 74), acetabulum (n = 54), and spine (n = 107).

Main Outcome Measurements: Complications, including pneumonia, acute respiratory distress syndrome, infections, deep venous thrombosis, pulmonary embolism, sepsis, multiple organ failure, and death, and length of stay.

Results: Definitive fixation was performed concurrently with another procedure in 147 patients. They had greater ISS (29.4 vs. 24.6, P < 0.01), more transfusions (8.9 U vs. 3.6 U, P < 0.01), and longer surgery (4:22 vs. 2:41, P < 0.01) than patients with fracture fixation only, but no differences in complications. When patients who had definitive fixation in the same setting as another procedure were compared only with other patients who required more than 1 procedure performed in a staged manner on different days (n = 71), complications were fewer (33% vs. 54%, P = 0.004), and ventilation time (4.00 vs. 6.83 days), intensive care unit (ICU) stay (6.38 vs. 10.6 days), and length of stay (12.4 vs. 16.0 days) were shorter (all P ≤ 0.03) for the nonstaged patients.

Conclusions: In resuscitated patients, definitive fixation in the same setting as another procedure did not increase the frequency of complications despite greater ISS, transfusions, and surgical duration in the multiple procedure group. Multiple procedures in the same setting may reduce complications and hospital stay versus additional surgeries on other days.

Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000000556DOI Listing
August 2016

Re: Issues regarding patient assessment scores that focus on acid base changes in fracture patients.

J Trauma Acute Care Surg 2016 May;80(5):838-9

Clyde L. Nash MD Professor of Orthopaedic Education Professor of Orthopaedic Surgery Case Western Reserve University The MetroHealth System Cleveland, OH Director of Spine Trauma Associate Professor of Orthopaedic Surgery Case Western Reserve University The MetroHealth System Cleveland, OH Resident in Orthopaedic Surgery Henry Ford Hospital Detroit, MI.

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http://dx.doi.org/10.1097/TA.0000000000000991DOI Listing
May 2016

Morbidity and Mortality of Bilateral Femur Fractures.

Orthopedics 2015 Jul;38(7):e588-92

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.
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http://dx.doi.org/10.3928/01477447-20150701-56DOI Listing
July 2015

Obesity Is Associated With More Complications and Longer Hospital Stays After Orthopaedic Trauma.

J Orthop Trauma 2015 Nov;29(11):504-9

*Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH.

Objective: The objective of this study was to characterize relationships between obesity and initial hospital stay, including complications, in patients with multiple system trauma and surgically treated fractures.

Design: Prospective, observational.

Setting: Level 1 trauma center.

Patients: Three hundred seventy-six patients with an Injury Severity Score greater than 16 and mechanically unstable high-energy fractures of the femur, pelvic ring, acetabulum, or spine requiring stabilization.

Main Outcome Measurements: Data for obese (body mass index ≥ 30) versus nonobese patients included presence of pneumonia, deep vein thrombosis, pulmonary embolism, infection, organ failure, and mortality. Days in ICU and hospital, days on ventilator, transfusions, and surgical details were documented.

Results: Complications occurred more often in obese patients (38.0% vs. 28.4%, P = 0.03), with more acute renal failure (5.70% vs. 1.38%, P = 0.02) and infection (11.4% vs. 5.50%, P = 0.04). Days in ICU and mechanical ventilation times were longer for obese patients (7.06 vs. 5.25 days, P = 0.05 and 4.92 vs. 2.90 days, P = 0.007, respectively). Mean total hospital stay was also longer for obese patients (12.3 vs. 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% vs. 16.1%; P = 0.02). Mean time from injury to fixation was 34.9 hours in obese patients versus 23.7 hours in nonobese patients (P = 0.03).

Conclusions: 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 body mass index may help to improve outcomes and minimize additional treatment expenses.
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http://dx.doi.org/10.1097/BOT.0000000000000324DOI Listing
November 2015

Use of two grading systems in determining risks associated with timing of fracture fixation.

J Trauma Acute Care Surg 2014 Aug;77(2):268-79

From the Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio.

Background: The early appropriate care (EAC) protocol and clinical grading system (CGS) 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.

Level Of Evidence: Prognostic study, level III.
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http://dx.doi.org/10.1097/TA.0000000000000283DOI Listing
August 2014

The impact of major operative fractures in blunt abdominal injury.

J Trauma Acute Care Surg 2013 May;74(5):1307-14

Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio 44109, USA.

Background: 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.

Methods: 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.

Results: 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.

Conclusion: 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.
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http://dx.doi.org/10.1097/TA.0b013e31828c3f59DOI Listing
May 2013

Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries: a systematic review of randomized and nonrandomized trials.

J Trauma Acute Care Surg 2012 Nov;73(5):1046-63

Department of Orthopaedic Surgery, MetroHealth Medical Center, affiliated with Case Western Reserve University, Cleveland, OH 44109, USA.

Background: 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.

Methods: 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.

Results: 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.

Conclusion: 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 DCO [corrected].

Level Of Evidence: Systematic review, level III.
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November 2012

The impact of injury severity and transfer status on reimbursement for care of femur fractures.

J Trauma Acute Care Surg 2012 Oct;73(4):957-65

Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA.

Background: This study investigates the impact of injury severity, patient origin, and payer on charges and payments associated with treatment of femoral fractures at a Level I trauma center. We hypothesized that transfer patients and patients with minor injury would be underinsured, whereas reimbursement rate would be higher for patients with severe injury.

Methods: Medical and financial records of 420 adult patients treated for femoral fractures at a public, urban Level I trauma center were reviewed. Facility and professional charges and payments were determined. Reimbursement rate was defined as the ratio of payment to charge. Payer groups included Medicare, Medicaid, commercial, managed care, workers' compensation, and self-pay. Severe injury was defined by Injury Severity Score of 18 or higher.

Results: Patients with Injury Severity Score of less than 18 were more often uninsured compared with the severe injury group (25% vs. 14%, p = 0.005). Patients with severe injury had higher facility (0.47 vs. 0.39, p = 0.005) and total reimbursement rates (0.41 vs. 0.34, p = 0.002) compared with patients with minor injury. Likewise, transfer patients trended toward higher overall reimbursement rate compared with nontransfer patients (0.42 vs. 0.37, p = 0.056). Patients with severe injury were more likely to have commercial insurance (28 vs. 20%, p = 0.06), and transferred patients were more likely to have insurance (88% vs. 79%, p = 0.034).

Conclusion: The higher proportion of self-pay in the nontransfer group may be caused by the large population of uninsured patients in the area surrounding our trauma center. Favorable payer mix and higher facility reimbursement rate for patients with severe injury may be an incentive for trauma centers to continue providing care for patients with multiple injuries.

Level Of Evidence: Prognostic/epidemiologic study, level III. Economic analysis, level IV.
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http://dx.doi.org/10.1097/TA.0b013e31825a7723DOI Listing
October 2012

Early appropriate care: definitive stabilization of femoral fractures within 24 hours of injury is safe in most patients with multiple injuries.

J Trauma 2011 Jul;71(1):175-85

Department of Orthopaedic Surgery, MetroHealth Medical Center, Cleveland, OH, USA.

Background: Type and timing of treatment of femur fractures is controversial. Although reported as safe and effective in many reports, others have suggested that early definitive stabilization may cause complications, particularly in patients with chest and head injuries. Damage control orthopedics was proposed as an alternative in unstable patients. This study examines the effects of timing of fixation and investigates risk factors for complications.

Methods: Seven hundred fifty patients with femur fractures treated between 1999 and 2006 were reviewed. Skeletally mature patients with mean age 35.8 years and mean Injury Severity Score (ISS) 23.7 were included. Four hundred ninety-two patients had ISS ≥18. Early stabilization (n = 656) was defined as definitive treatment of the femur fracture within 24 hours of injury.

Results: Early definitive stabilization in patients with multiple injuries was associated with fewer complications than delayed stabilization (18.9% vs. 42.9%, p < 0.037) after adjusting for patient age and ISS. Early treatment was also associated with shorter hospital stay, intensive care unit stay, and ventilator days (p < 0.001). Severe (Abbreviated Injury Scale score ≥3) abdominal injury was associated with more complications than severe head (Glasgow Coma Scale score ≤8) and chest (Abbreviated Injury Scale score ≥3) injuries (44.2% vs. 40.9%, p = 0.68, and 34.4%, p = 0.024, respectively) and was an independent risk factor for complications (p < 0.0001). Chest injury was an independent risk factor for pulmonary complications (p < 0.001), but surgical delay in patients with chest injury was also associated with pulmonary complications (p = 0.04). More sepsis was noted patients with severe head injury (22.7% vs. 4.5%, p = 0.037) or severe chest injury (10.2% vs. 2.5%, p = 0.044) when treated on a delayed basis. More patients transferred from other hospitals were treated on a delayed basis (48.9% vs. 37.5%, p = 0.04).

Conclusions: Early definitive stabilization is associated with acceptably low rates of complications and is safe in most patients with multiple injuries, including some with severe abdominal, chest, or head injuries with attention to resuscitation before surgery. More complications and longer hospital stay were noted with delayed fixation after adjusting for age and ISS. Chest injury was associated with pulmonary complications; however, the presence of severe abdominal injury was the greatest risk factor for complications. Expediting access to definitive care may reduce complications and expenses.
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http://dx.doi.org/10.1097/TA.0b013e3181fc93a2DOI Listing
July 2011

Intraprotein electron transfer in inducible nitric oxide synthase holoenzyme.

J Biol Inorg Chem 2009 Jan 2;14(1):133-42. Epub 2008 Oct 2.

College of Pharmacy, University of New Mexico, Albuquerque, NM 87131, USA.

Intraprotein electron transfer (IET) from flavin mononucleotide (FMN) to heme is essential in NO synthesis by NO synthase (NOS). Our previous laser flash photolysis studies provided a direct determination of the kinetics of the FMN-heme IET in a truncated two-domain construct (oxyFMN) of murine inducible NOS (iNOS), in which only the oxygenase and FMN domains along with the calmodulin (CaM) binding site are present (Feng et al. J. Am. Chem. Soc. 128, 3808-3811, 2006). Here we report the kinetics of the IET in a human iNOS oxyFMN construct, a human iNOS holoenzyme, and a murine iNOS holoenzyme, using CO photolysis in comparative studies on partially reduced NOS and a NOS oxygenase construct that lacks the FMN domain. The IET rate constants for the human and murine iNOS holoenzymes are 34 +/- 5 and 35 +/- 3 s(-1), respectively, thereby providing a direct measurement of this IET between the catalytically significant redox couples of FMN and heme in the iNOS holoenzyme. These values are approximately an order of magnitude smaller than that in the corresponding iNOS oxyFMN construct, suggesting that in the holoenzyme the rate-limiting step in the IET is the conversion of the shielded electron-accepting (input) state to a new electron-donating (output) state. The fact that there is no rapid IET component in the kinetic traces obtained with the iNOS holoenzyme implies that the enzyme remains mainly in the input state. The IET rate constant value for the iNOS holoenzyme is similar to that obtained for a CaM-bound neuronal NOS holoenzyme, suggesting that CaM activation effectively removes the inhibitory effect of the unique autoregulatory insert in neuronal NOS.
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http://dx.doi.org/10.1007/s00775-008-0431-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2596912PMC
January 2009

Direct measurement by laser flash photolysis of intraprotein electron transfer in a rat neuronal nitric oxide synthase.

J Am Chem Soc 2007 May 11;129(17):5621-9. Epub 2007 Apr 11.

College of Pharmacy, University of New Mexico, Albuquerque, New Mexico 87131, USA.

Intraprotein interdomain electron transfer (IET) from flavin mononucleotide (FMN) to heme is essential in nitric oxide (NO) synthesis by NO synthase (NOS). Our previous laser flash photolysis studies have provided a direct determination of the kinetics of IET between the FMN and heme domains in truncated oxyFMN constructs of rat neuronal NOS (nNOS) and murine inducible NOS (iNOS), in which only the oxygenase and FMN domains along with the calmodulin (CaM) binding site are present [Feng, C. J.; Tollin, G.; Holliday, M. A.; Thomas, C.; Salerno, J. C.; Enemark, J. H.; Ghosh, D. K. Biochemistry 2006, 45, 6354-6362. Feng, C. J.; Thomas, C.; Holliday, M. A.; Tollin, G.; Salerno, J. C.; Ghosh, D. K.; Enemark, J. H. J. Am. Chem. Soc. 2006, 128, 3808-3811]. Here, we report the kinetics of IET between the FMN and heme domains in a rat nNOS holoenzyme in the presence and absence of added CaM using laser flash photolysis of CO dissociation in comparative studies on partially reduced NOS and a single domain NOS oxygenase construct. The IET rate constant in the presence of CaM is 36 s-1, whereas no IET was observed in the absence of CaM. The kinetics reported here are about an order of magnitude slower than the kinetics in a rat nNOS oxyFMN construct with added CaM (262 s-1). We attribute the slower IET between FMN and heme in the holoenzyme to the additional step of dissociation of the FMN domain from the reductase complex before reassociation with the oxygenase domain to form the electron-transfer competent output state complex. This work provides the first direct measurement of CaM-controlled electron transfer between catalytically significant redox couples of FMN and heme in a nNOS holoenzyme.
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http://dx.doi.org/10.1021/ja068685bDOI Listing
May 2007
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