Joshua Barrett

Functional abilities of stroke patients in a rehabilitation hospital are recorded every 2 weeks using the Barthel index. For purposes of this study, data were collected retrospectively and prospectively from consecutive records according to predetermined criteria on forms coded for computer analysis. Total scores of 110 patients were correlated with length of stay, placement at discharge and scores in individual functional abilities. Analysis of the data reveals that an initial score over 40 on the Barthel index defines a population with a greater proportion of discharges to home and that patients with initial scores over 60 have a shorter length of stay. Further analysis indicates a predictable progression in the development of functional skills in this population so that with a Barthel score below 40, no one was independent in the mobility skills and fewer than 50% were independent in the very basic skills, such as feeding, grooming and sphincter control. A score of 60 appears to be a pivotal score where patients move from dependency to assisted independence.

Background: Ankle fractures are a common cause of morbidity that have increased in incidence over the past decade. The purpose of this study was to compare the outcomes and prognosis of various fracture subtypes by using 2 validated patient-reported outcome measures: the Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) Computer Adaptive Tests (CATs). Methods: Twelve-month postoperative PF and PI CATs were collected for 126 ankle fracture patients presenting between 2014 and 2017. Patients were stratified by ankle fracture subtype and refined by the presence/absence of concomitant deltoid injury or posterior malleolar fracture. Patients defined as members of vulnerable populations and patients presenting more than 2 weeks from time of injury or with prior acute ipsilateral fracture were excluded. The distribution of PF and PI T scores were assessed via a Shapiro-Wilk test and a 1-way analysis of variance. If significant differences were found between groups, pairwise comparisons were tested via Dwass, Steel, and Critchlow-Fligner multiple comparison analysis. Results: Mean values for the PROMIS PF and PI for each fracture subtype were calculated and compared to reference population mean (SD) T scores of 50 (10): isolated lateral malleolar (PF: 50/PI: 51), isolated medial malleolar (PF: 52/PI: 49), bimalleolar (PF: 48/PI: 50), trimalleoar (PF: 47/PI: 51), isolated posterior malleolar (PF: 53/PI: 44), and isolated syndesmotic injury (PF: 60/PI: 46). Shapiro-Wilk test indicated a nonnormal distribution for the postoperative PROMIS PF T scores across all fracture patients ( P = .0421). Conclusion: Operative fixation of an ankle fracture was able to return most patients to the population mean with regard to PROMIS function and pain regardless of fracture type. Level of Evidence: Level II, prospective comparative study.

Introduction: Cervical spine disease is a leading cause of pain and disability. Degenerative conditions of the spine can result in neurologic compression of the cervical spinal cord or nerve roots and may be surgically treated with an anterior cervical discectomy and fusion (ACDF) in up to 137,000 people per year in the United States. A common sequelae of ACDF is reduced cervical range of motion (CROM) with patient-based complaints of stiffness and neck pain. Currently, tools for assessment of CROM are manual, subjective, and only intermittently utilized during doctor or physical therapy visits. We propose a skin-mountable acousto-mechanic sensor (ADvanced Acousto-Mechanic sensor; ADAM) as a tool for continuous neck motion monitoring in postoperative ACDF patients. We have developed and validated a machine learning neck motion classification algorithm to differentiate between eight neck motions (right/left rotation, right/left lateral bending, flexion, extension, retraction, protraction) in healthy normal subjects and patients. Methods: Sensor data from 12 healthy normal subjects and 5 patients were used to develop and validate a Convolutional Neural Network (CNN). Results: An average algorithm accuracy of 80.0 ± 3.8% was obtained for healthy normal subjects (94% for right rotation, 98% for left rotation, 65% for right lateral bending, 87% for left lateral bending, 89% for flexion, 77% for extension, 50% for retraction, 84% for protraction). An average accuracy of 67.5 ± 5.8% was obtained for patients. Discussion: ADAM, with our algorithm, may serve as a rehabilitation tool for neck motion monitoring in postoperative ACDF patients. Sensor-captured vital signs and other events (extubation, vocalization, physical therapy, walking) are potential metrics to be incorporated into our algorithm to offer more holistic monitoring of patients after cervical spine surgery.

BACKGROUND: Zones 2 and 3 fifth metatarsal fractures are often treated with intramedullary fixation due to an increased risk of nonunion. A previous 3-dimensional (3D) computerized tomography (CT) imaging study by our group determined that the screw should stop short of the bow of the metatarsal and be larger than the commonly used 4.5 millimeter (mm) screw. This study determines how these guidelines translate to operative outcomes, measured using Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Interference (PI) surveys. Radiographic variables measuring the height of the medial longitudinal arch and degree of metatarsus adductus were also obtained to determine if these measurements had any effect on outcomes. And lastly, this study aimed to determine if morphologic differences between males and females affected surgical outcomes. METHODS: We retrospectively identified 23 patients (14 male, 9 female) who met inclusion criteria. Eighteen patients completed PROMIS surveys. Preoperative PROMIS surveys were completed prior to surgery, rather than retroactively. Weightbearing radiographs were also obtained preoperatively to assist with surgical planning and postoperatively to assess interval healing. Correlation coefficients were calculated between PROMIS scores and repair characteristics (hardware characteristics [screw length and diameter] and radiographic measurements of specific morphometric features). T tests determined the relationship between repair characteristics, PROMIS scores, and incidence of operative complications. PROMIS scores and correlation coefficients were also stratified by gender. RESULTS: The average screw length and diameter adhered to guidelines from our previous study. Preoperatively, mean PROMIS PI = 57.26±11.03 and PROMIS PF = 42.27±15.45 after injury. Postoperatively, PROMIS PI = 44.15±7.36 and PROMIS PF = 57.22±10.93. Patients with complications had significantly worse postoperative PROMIS PF scores (p=0.0151) and PROMIS PI scores (p=0.003) compared to patients without complications. Females had non-significantly worse preoperative and postoperative PROMIS scores compared to males and had a higher complication rate (33 percent versus 21 percent, respectively). Metatarsus adductus angle was shown to exhibit a significant moderate inverse relationship with postoperative PROMIS PF scores in the overall cohort (r=-0.478; p=0.045). Metatarsus adductus angle (r=-0.606; p=0.008), lateral talo-1st metatarsal angle (r=-0.592; p=0.01), and medial cuneiform height (r=-0.529; p=0.024) demonstrated significant inverse relationships with change in PROMIS PF scores for the overall cohort. Within the male subcohort, significant relationships were found between the change in PROMIS PF and metatarsus adductus angle (r=-0.7526; p=0.005), lateral talo-1st metatarsal angle (r=-0.7539; p=0.005), and medial cuneiform height (r=-0.627; p=0.029). CONCLUSION: Patients treated according to guidelines from our prior study achieved satisfactory patient reported and radiographic outcomes. Screws larger than 4.5mm did not lead to hardware complications, including screw failure, iatrogenic fractures, or cortical blowouts. Females had non-significantly lower preoperative and postoperative PROMIS scores and were more likely to suffer complications compared to males. Patients with complications, higher arched feet, or greater metatarsus adductus angles had worse functional outcomes. Future studies should better characterize whether patients with excessive lateral column loading benefit from an off-loading cavus orthotic or plantar-lateral plating.

Ankle fractures may require revision surgery for malunion or suboptimal joint congruence results after initial surgical or nonsurgical treatment. There is limited literature on the outcomes of patients undergoing such revision surgery for ankle fracture malunion. In this retrospective case series, we determined clinical and functional outcomes of revision ankle open reduction internal fixation (ORIF) for 7 patients with ankle fracture malunion through patient-reported and radiographic outcomes. Patient-reported Outcomes Measurement Information System physical function and pain interference scores prerevision and postrevision procedure were obtained from 7 patients treated from January 2017 to October 2020. Postoperative complications including persistent pain, infection, hardware removal, hardware failure, and conversion to ankle arthrodesis were analyzed. Seven patients who underwent revision ORIF surgery for ankle fracture malunion between January 2017 and October 2020 were included. The average age was 46.3 12.2 years old; 85.7% of the patients were female; 14.3% were male. The average amount of time between revision ORIF procedure and collection of postoperative Patient-Reported Outcomes Measurement Information System scores was 19.3±5.9 months. Each of the 7 patients showed an increase in physical function after revision surgery (average preoperative physical function score: 30.7; average postoperative physical function score: 48.9). All patients showed a decrease in pain after revision surgery (average preoperative pain interference score: 64.8; average postoperative pain interference score: 55.7). Of the 7 participants who underwent revision ORIF, a majority did not experience any complications at least 1 year postprocedure, including infection, reoperation, or hardware removal. One participant underwent hardware removal for persistent pain and developed overlying cellulitis. For patients with ankle fracture malunion without significant post-traumatic degenerative changes of the ankle joint, revision ankle ORIF can be an effective method for improving physical function, decreasing pain, and preserving ankle joint motion. Level of Evidence: Level IV—case series.