Faculty Bibliography
Searched for:
person:gouldj04
in-biosketch:true
Total Results:
8
Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial
BACKGROUND:The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported. OBJECTIVE:To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia. DESIGN:Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505). SETTING:46 U.S. and Canadian hospitals. PARTICIPANTS:Patients aged 50 years or older undergoing hip fracture surgery. INTERVENTION:Spinal or general anesthesia. MEASUREMENTS:Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care. RESULTS:A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups. LIMITATION:Missing outcome data and multiple outcomes assessed. CONCLUSION:Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia. PRIMARY FUNDING SOURCE:
PMID: 35696684
ISSN: 1539-3704
CID: 5277802
Are Orthopaedic Trauma Surgeons Adequately Compensated for Longer Procedures? An Analysis of Relative Value Units and Operative Times from the ACS-NSQIP database
BACKGROUND:The physician work Relative Value Unit (wRVU) scale is the primary determinant of compensation. Operative time, technical skill, effort, and surgical complexity contribute to wRVU allocation. The aim of this study is to identify the relationship between these factors and reimbursement for trauma procedures. METHODS:The National Surgical Quality Improvement Program (NSQIP) database was queried for orthopedic trauma procedures from 2016-18. Physician wRVU data was obtained from the 2020 Centers for Medicare & Medicaid Services fee schedule. The primary outcome measured was mean wRVU per minute of operative time (wRVU/min). Wilcoxon rank-sum test and quantile regression were used to determine the association between wRVU, operative time, complication rate, upper or lower extremity procedure, and wRVU/min. RESULTS:63 CPT codes or 107,171 cases queried. Median wRVU/min was significantly lower for longest 50% of procedures (0.119vs0.160, p<0.001) and higher for the top 50% with regard to complication rate (0.161vs0.124, p<0.001). Upper extremity procedures were reimbursed less than lower extremity (0.110vs0.145, p<0.001). Quintile regression showed that adjusted for complication rate, median wRVU/min decreased by 0.0005 (95% CI: 0.0007-0.0003, R1=0.27, p<0.001) for every additional minute of operative time. CONCLUSIONS:The 2020 wRVU scale does not allocate sufficient wRVUs to orthopedic trauma procedures with longer mean operative time or to procedures performed on the upper extremity. There is a negative correlation between operative time and hourly reimbursement, equating to a decrease of $64.96/hour per hour of operation. LEVEL OF EVIDENCE/METHODS:Economic Level III. See Instructions for Authors for a complete description of levels of evidence.
PMID: 34369456
ISSN: 1531-2291
CID: 5034772
Improved Implant Positioning of Cephalomedullary Nail for Trochanteric Fractures Using the Stryker ADAPT Navigation System
BACKGROUND:Tip-apex distance (TAD) of greater than 25 mm increases the risk of cephalomedullary nail (CMN) cutout for trochanteric hip fractures. The Stryker ADAPT navigation system provides intraoperative feedback to guide implant positioning. This study compares lag screw positioning using the ADAPT to conventional methods and investigates if the use of ADAPT impacts operating room efficiency. METHODS:Retrospective review of 82 consecutive patients who underwent Stryker Gamma3 CMN for a peritrochanteric hip fracture. Study groups were assigned based on use of ADAPT navigation. Primary outcome was TAD. Secondary outcomes were lag screw position, operative time, and radiation dose. Univariate analysis of covariance was used to compare primary outcome measures, controlling for fracture classification. RESULTS:41 patients were assigned to each group. When comparing ADAPT and conventional groups mean TAD was 14.45±3.68 and 16.41±3.78 mm (p = 0.023). A higher portion of ADAPT nails (85.4% vs 63.4%, p = 0.024) were center- center within the femoral head compared to conventional methods. There were no significant differences with regards to operative time, fluoroscopy time, or radiation dose. CONCLUSION/CONCLUSIONS:ADAPT navigation provides intraoperative feedback to achieve improved lag screw positioning, leading to improved TAD. The overall improvement in TAD does not likely reach clinical significance. The system requires minimal setup in the operating room, does not impact workflow, and the user interface is straight forward.
PMID: 34311957
ISSN: 1879-0267
CID: 5005842
Engaging patients as partners in a multicentre trial of spinal versus general anaesthesia for older adults
Engaging patients-defined broadly as individuals with lived experience of a given condition, family members, caregivers, and the organisations that represent them-as partners in research is a priority for policymakers, funders, and the public. Nonetheless, formal efforts to engage patients are absent from most studies, and models to support meaningful patient engagement in clinical anaesthesia research have not been previously described. Here, we review our experience in developing and implementing a multifaceted patient engagement strategy within the Regional Versus General Anesthesia for Promoting Independence After Hip Fracture (REGAIN) surgery trial, an ongoing randomised trial comparing spinal vs general anaesthesia for hip fracture surgery in 1600 older adults across 45 hospitals in the USA and Canada. This strategy engaged patients and their representatives at both the level of overall trial oversight and at the level of individual recruiting sites. Activities spanned a continuum ranging from events designed to elicit patients' input on key decisions to longitudinal collaborations that empowered patients to actively participate in decision-making related to trial design and management. Engagement activities were highly acceptable to participants and led to concrete changes in the design and conduct of the REGAIN trial. The REGAIN experience offers a model for future efforts to engage patients as partners in clinical anaesthesia research, and highlights potential opportunities for investigators to increase the relevance of anaesthesia studies by incorporating patient voices and perspectives into the research process.
PMID: 33279102
ISSN: 1471-6771
CID: 5022622
Modification of a Validated Risk Stratification Tool to Characterize Geriatric Hip Fracture Outcomes and Optimize Care in a Post-COVID-19 World
OBJECTIVES:(1) To demonstrate how a risk assessment tool modified to account for the COVID-19 virus during the current global pandemic is able to provide risk assessment for low-energy geriatric hip fracture patients. (2) To provide a treatment algorithm for care of COVID-19 positive/suspected hip fractures patients that accounts for their increased risk of morbidity and mortality. SETTING:One academic medical center including 4 Level 1 trauma centers, 1 university-based tertiary care referral hospital, and 1 orthopaedic specialty hospital. PATIENTS/PARTICIPANTS:One thousand two hundred seventy-eight patients treated for hip fractures between October 2014 and April 2020, including 136 patients treated during the COVID-19 pandemic between February 1, 2020 and April 15, 2020. INTERVENTION:The Score for Trauma Triage in the Geriatric and Middle-Aged ORIGINAL (STTGMAORIGINAL) score was modified by adding COVID-19 virus as a risk factor for mortality to create the STTGMACOVID score. Patients were stratified into quartiles to demonstrate differences in risk distribution between the scores. MAIN OUTCOME MEASUREMENTS:Inpatient and 30-day mortality, major, and minor complications. RESULTS:Both STTGMA score and COVID-19 positive/suspected status are independent predictors of inpatient mortality, confirming their use in risk assessment models for geriatric hip fracture patients. Compared with STTGMAORIGINAL, where COVID-19 patients are haphazardly distributed among the risk groups and COVID-19 inpatient and 30 days mortalities comprise 50% deaths in the minimal-risk and low-risk cohorts, the STTGMACOVID tool is able to triage 100% of COVID-19 patients and 100% of COVID-19 inpatient and 30 days mortalities into the highest risk quartile, where it was demonstrated that these patients have a 55% rate of pneumonia, a 35% rate of acute respiratory distress syndrome, a 22% rate of inpatient mortality, and a 35% rate of 30 days mortality. COVID-19 patients who are symptomatic on presentation to the emergency department and undergo surgical fixation have a 30% inpatient mortality rate compared with 12.5% for patients who are initially asymptomatic but later develop symptoms. CONCLUSION:The STTGMA tool can be modified for specific disease processes, in this case to account for the COVID-19 virus and provide a robust risk stratification tool that accounts for a heretofore unknown risk factor. COVID-19 positive/suspected status portends a poor outcome in this susceptible trauma population and should be included in risk assessment models. These patients should be considered a high risk for perioperative morbidity and mortality. Patients with COVID-19 symptoms on presentation should have surgery deferred until symptoms improve or resolve and should be reassessed for surgical treatment versus definitive nonoperative treatment with palliative care and/or hospice care. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
PMID: 32815845
ISSN: 1531-2291
CID: 4574902
Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective
OBJECTIVES/OBJECTIVE:To examine one health system's response to the essential care of its hip fracture population during the COVID-19 pandemic and report on its effect on patient outcomes. DESIGN/METHODS:Prospective cohort study SETTING:: Seven musculoskeletal care centers with New York City and Long Island. PATIENTS/PARTICIPANTS/METHODS:138 recent and 115 historical hip fracture patients. INTERVENTION/METHODS:Patients with hip fractures occurring between February 1, 2020 and April 15, 2020 or between February 1, 2019 and April 15, 2019 were prospectively enrolled in an orthopedic trauma registry and chart reviewed for demographic and hospital quality measures. Patients with recent hip fractures were identified as COVID positive (C+), COVID suspected (Cs) or COVID negative (C-). MAIN OUTCOME MEASUREMENTS/METHODS:Hospital quality measures, inpatient complications and mortality rates. RESULTS:Seventeen (12.2%) patients were confirmed C+ by testing and another 14 (10.1%) were suspected (Cs) of having had the virus but were never tested. The C+ cohort, when compared to Cs and C- cohorts, had: an increased mortality rate (35.3% vs 7.1% vs 0.9%), increased length of hospital stay, a greater major complication rate and a greater incidence of ventilator need postoperatively. CONCLUSIONS:COVID-19 had a devastating effect on the care of hip fracture patients during the pandemic. Although practice patterns generally remained unchanged, treating physicians need to understand the increased morbidity and mortality in hip fracture patients complicated by COVID-19. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of Levels of Evidence.
PMID: 32482976
ISSN: 1531-2291
CID: 4468782
The pathophysiology of patellofemoral arthritis
Faced with a patient suffering from patellofemoral arthritis, the surgeon must determine the pathophysiology of the condition, because different causes demand different treatments. Possible causes include malalignment, patellofemoral dysplasia, patellofemoral instability, patellofemoral trauma, obesity, osteoarthritis, inflammatory arthritis, and a genetic predisposition. Arthritis secondary to malalignment, dysplasia, instability, or trauma is less likely than arthritis secondary to the other causes to progress to femorotibial arthritis.
PMID: 18602557
ISSN: 0030-5898
CID: 956202
Patellar tilt: the physical examination correlates with MR imaging
Patella malalignment is a recognized cause of knee pain, tilt being one of its more common forms. Although patellar tilt has been described both on the physical examination and on computerized imaging, to date the correlation between the two has not been established. A strong correlation would strengthen the value of each. Moreover, in situations where tilt cannot be clinically assessed (e.g. obesity), CT or MR imaging could be an adequate substitute for the clinical determination of tilt. We propose to correlate the physical examination with the magnetic resonance examination by way of an MR Tilt Angle. This angle is measured in a manner similar to the assessment of tilt on the physical examination, in that a line is drawn across the medial and lateral borders of the patella and referenced off the posterior femoral condyles. Most tilt angles use the slope of the lateral facet as a measure of tilt. These tilt angles paradoxically diminish as patellar tilt increases, a potential source of confusion. In this study, we use an MRI tilt angle that increases in the same direction as the actual tilt, which is more intuitive. We examined 30 patients with tilt and 51 patients without tilt. Patients with significant tilt on the physical examination can be expected to have an MRI Tilt Angle that is 10 degrees or greater whereas an angle of less than 10 degrees is associated with the absence of significant tilt on the physical examination. This MRI Tilt Angle fills the need for an easy, objective, intuitive measure of tilt and is an excellent adjunct to the physical examination
PMID: 18023186
ISSN: 0968-0160
CID: 135317
