Is tantalum protective against infection in revision total hip arthroplasty?

We hypothesised that the use of tantalum (Ta) acetabular components in revision total hip arthroplasty (THA) was protective against subsequent failure due to infection. We identified 966 patients (421 men, 545 women and 990 hips) who had undergone revision THA between 2000 and 2013. The mean follow up was 40.2 months (3 months to 13.1 years). The mean age of the men and women was 62.3 years (31 to 90) and 65.1 years (25 to 92), respectively. Titanium (Ti) acetabular components were used in 536 hips while Ta components were used in 454 hips. In total, 73 (7.3%) hips experienced subsequent acetabular failure. The incidence of failure was lower in the Ta group at 4.4% (20/454) compared with 9.9% (53/536) in the Ti group (p < 0.001, odds ratio 2.38; 95% CI 1.37 to 4.27). Among the 144 hips (64 Ta, 80 Ti) for which revision had been performed because of infection, failure due to a subsequent infection was lower in the Ta group at 3.1% (2/64) compared with 17.5% (14/80) for the Ti group (p = 0.006). Thus, the use of Ta acetabular components during revision THA was associated with a lower incidence of failure from all causes and Ta components were associated with a lower incidence of subsequent infection when used in patients with periprosthetic joint infection.

Treatment consent capacity in patients with traumatic brain injury across a range of injury severity.

OBJECTIVE: To investigate medical decision-making capacity (MDC) in patients with acute traumatic brain injury (TBI) across a range of injury severity. METHODS: We evaluated MDC cross-sectionally 1 month after injury in 40 healthy controls and 86 patients with TBI stratified by injury severity (28 mild [mTBI], 15 complicated mild [cmTBI], 43 moderate/severe [msevTBI]). We compared group performance on the Capacity to Consent to Treatment Instrument and its 5 consent standards (expressing choice, reasonable choice, appreciation, reasoning, understanding). Capacity impairment ratings (no impairment, mild/moderate impairment, severe impairment) on the consent standards were also assigned to each participant with TBI using cut scores referenced to control performance. RESULTS: One month after injury, the mTBI group performed equivalently to controls on all consent standards. In contrast, the cmTBI group was impaired relative to controls on the understanding standard. No differences emerged between the mTBI and cmTBI groups. The msevTBI group was impaired on almost all standards relative to both control and mTBI groups, and on the understanding standard relative to the cmTBI group. Capacity compromise (mild/moderate or severe impairment ratings) on the 3 clinically complex standards (understanding, reasoning, appreciation) occurred in 10%-30% of patients with mTBI, 50% of patients with cmTBI, and 50%-80% of patients with msevTBI. CONCLUSIONS: One month following injury, MDC is largely intact in patients with mTBI, but is impaired in patients with cmTBI and msevTBI. Impaired MDC is prevalent in acute TBI and is strongly related to injury severity.

Current concepts: diffuse axonal injury-associated traumatic brain injury.

OBJECTIVES: To review the probable physical, physiologic mechanisms that result in the medical and neuropsychologic complications of diffuse axonal injury (DAI)-associated traumatic brain injury (TBI). DATA SOURCES: Various materials were accessed: MEDLINE, textbooks, scientific presentations, and current ongoing research that has been recently reported. STUDY SELECTION: Included were scientific studies involving TBI, particularly direct injury to the axons and glia of the central nervous system (CNS) in both in vitro and in vivo models. These studies include pathologic findings in humans as well as the medical complications and behavioral outcomes of DAI. Studies that addressed animal models of DAI as well as cellular and/or tissue models of neuronal injury were emphasized. The review also covered work on the physical properties of materials involved in the transmission of energy associated with prolonged acceleration-deceleration injuries. DATA EXTRACTION: Studies were selected with regard to those that addressed the mechanism of TBI associated with DAI and direct injury to the axon within the CNS. The material was generally the emphasis of the article and was extracted by multiple observers. Studies that correlate the above findings with the clinical picture of DAI were included. DATA SYNTHESIS: Concepts were developed by the authors based on the current scientific findings and theories of DAI. The synthesis of these concepts involves expertise in physical science, basic science concepts of cellular injury to the CNS, acute medical indicators of DAI, neuropsychologic indicators of DAI, and rehabilitation outcomes from TBI. CONCLUSIONS: The term DAI is a misnomer. It is not a diffuse injury to the whole brain, rather it is predominant in discrete regions of the brain following high-speed, long-duration deceleration injuries. DAI is a consistent feature of TBI from transportation-related injuries as well as some sports injuries. The pathology of DAI in humans is characterized histologically by widespread damage to the axons of the brainstem, parasagittal white matter of the cerebral cortex, corpus callosum, and the gray-white matter junctions of the cerebral cortex. Computed tomography and magnetic resonance imaging scans taken initially after injury are often normal. The deformation of the brain due to plastic flow of the neural structures associated with DAI explains the micropathologic findings, radiologic findings, and medical and neuropsychologic complications from this type of injury mechanism. There is evidence that the types of cellular injury in TBI (DAI, anoxic, contusion, hemorrhagic, perfusion-reperfusion) should be differentiated, as all may involve different receptors and biochemical pathways that impact recovery. These differing mechanisms of cellular injury involving specific biochemical pathways and locations of injury may, in part, explain the lack of success in drug trials to ameliorate TBI.

Long-term neuropsychological outcome after traumatic brain injury.

OBJECTIVE: To describe neuropsychological outcome 5 years after injury in persons with traumatic brain injury (TBI) who received inpatient medical rehabilitation. To determine the magnitude and pattern neuropsychological recovery from 1 year to 5 years after injury. DESIGN: Longitudinal cohort study with inclusion based on the availability of neuropsychological data at 1 year and 5 years after injury. SETTING: National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems of Care. PARTICIPANTS: One hundred eighty-two persons with complicated mild to severe traumatic brain injury. PRIMARY OUTCOME MEASURES: Digits Forward and Backward, Logical Memory I and II, Token Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Trail Making Test, Rey Auditory Verbal Learning Test, Visual Form Discrimination, Block Design, Wisconsin Card Sorting Test, and Grooved Pegboard. RESULTS: Significant variability in outcome was found 5 years after TBI, ranging from no measurable impairment to severe impairment on neuropsychological tests. Improvement from 1 year after injury to 5 years was also variable. Using the Reliable Change Index, 22.2% improved, 15.2% declined, and 62.6% were unchanged on test measures. CONCLUSIONS: Neuropsychological recovery after TBI is not uniform across individuals and neuropsychological domains. For a subset of persons with moderate to severe TBI, neuropsychological recovery may continue several years after injury with substantial recovery. For other persons, measurable impairment remains 5 years after injury. Improvement was most apparent on measures of cognitive speed, visuoconstruction, and verbal memory.

Sertraline to improve arousal and alertness in severe traumatic brain injury secondary to motor vehicle crashes.

OBJECTIVE: To establish whether or not the serotonin reuptake inhibitor (SSRI) sertraline can improve arousal and alertness of patients with traumatic brain injury (TBI) and associated diffuse axonal injury (DAI). Serotonin is a major inhibitory as well an excitatory neurotransmitter, and serotonergic neurons modulate the activity of brain regions responsible for motor control, arousal, attention, and emotional regulation. SETTING: Tertiary care inpatient rehabilitation centre directly attached to a university hospital level-one trauma centre. DESIGN: Prospective placebo-controlled randomized trial utilizing sertraline on admission to acute rehabilitation. DATA SET: Eleven subjects, post-high speed motor vehicle crash and post-severe TBI (GCS < or = 8) with presumed DAI randomized to receive either sertraline 100mg per day or placebo for 2 weeks. All subjects were within 2 weeks of acute injury. Outcome measures recorded were the Orientation Log (daily), Agitated Behaviour Scale (daily), and the Galveston Orientation and Amnesia Test (weekly). RESULTS: Both placebo and active medication groups demonstrated similar rates of improvement on all three scales. There was no difference in the rates of recovery for either study group (p > 0.05, ANOVA with repeated measures). The groups did not demonstrate a statistically significant negative effect on recovery either, although the size is too small for a statistically reliable beta-effect. CONCLUSION: This pilot study fails to establish whether the early use of sertraline may improve alertness, decrease agitation or improve cognitive recall of material. This may be due to the small size of the study group, the brief duration of treatment or by a skewed placebo group. Larger studies will be required to prove any efficacy. There were no complications with its use and sertraline did not demonstrate a detrimental effect on recovery. This indicates that sertraline may be safe to use in the treatment of psychiatric or behavioural complications attributable to TBI.

Outcome after traumatic brain injury: pathway analysis of contributions from premorbid, injury severity, and recovery variables.

OBJECTIVE: To examine the relationship of premorbid variables, injury severity, and cognitive and functional status to outcome 1 year after traumatic brain injury (TBI) and to assess the feasibility of multivariate path analysis as a way to discover those relationships. DESIGN: Prospective, longitudinal. SETTINGS: Level I trauma center, acute inpatient rehabilitation hospital. PATIENTS: One hundred seven subjects (87 men, 20 women; mean age, 33.91 +/- 14.2 yr) who had experienced severe TBI, typically from motor vehicle crashes. INTERVENTIONS: Acute medical and rehabilitation care. MAIN OUTCOME MEASURES: Disability Rating Scale, Community Integration Questionnaire, and return to employment. Evaluated in acute rehabilitation, and at 6 and 12 months' postinjury. RESULTS: Path analyses revealed that premorbid factors had significant relationships with injury severity, functional skills, cognitive status, and outcome; injury severity affected cognitive and functional skills; and cognitive status influenced outcome. No significant relationships were found between injury severity and emotional status, injury severity and outcome, emotional status and outcome, and functional skills and outcome. CONCLUSIONS: Multivariate analysis is important to understanding outcome after TBI. Injury severity, as measured in this study, is less important to 12-month outcome than the premorbid status of the person and the difficulties (particularly cognitive deficits) exhibited at follow-up 6 months after the trauma.

Cognitive and functional recovery at 6 and 12 months post-TBI.

Outcome studies examining recovery from traumatic brain injury (TBI) often fail to provide a clear understanding of the time course of cognitive, emotional, and behavioural recovery. The present study represents an effort to prospectively study individuals with TBI at fixed intervals, specifically 6 and 12 months post-injury with a window of +/- 1 month. Seventy-two individuals with new-onset TBI underwent neuropsychological evaluation and clinical interview at 6 and 12 months post-injury. Results revealed significant improvements in cognitive abilities, including memory, processing speed, language abilities, and constructional skills. There were significant gains in community integration and involvement in productive activities, but limitations in driving activities remained. Although individuals with mild-moderate TBI performed better than individuals with severe TBI, both groups demonstrated equivalent rates of recovery across domains. The results of this study provide important information regarding the time course of TBI recovery.

Validity of the Orientation Log, relative to the Galveston Orientation and Amnesia Test.

OBJECTIVE: To establish the validity of the Orientation Log (O-Log) by comparison with the Galveston Orientation and Amnesia Test (GOAT). DESIGN: Correlation of daily measures of orientation. SETTING: Acute rehabilitation hospital. SUBJECTS: Sixty-eight inpatients receiving rehabilitation following traumatic brain injury (TBI). PRIMARY MEASURES: The O-Log and GOAT. RESULTS: There was a significant correlation between the GOAT and O-Log (r = .901, P<.001). A cutoff of 25 on the O-Log was found to be comparable with the 75 cutoff on the GOAT. The scales were equivalent in measuring duration of posttraumatic amnesia. CONCLUSIONS: The O-Log is a valid measure of orientation for people with TBI and offers some advantages in administration over the GOAT.

Cognitive orientation in rehabilitation and neuropsychological outcome after traumatic brain injury.

This study evaluated the ability of the Orientation Log (O-Log) to predict cognitive outcome at rehabilitation discharge, as well as future neuropsychological outcome. The hypothesis was that patients who demonstrated better orientation upon admission would achieve superior functional cognitive outcome at discharge and on subsequent neuropsychological assessment. Sixty individuals receiving inpatient rehabilitation following a new-onset TBI participated. Orientation data was collected using the O-Log during morning bedside rounds. Outcome data was collected at 6 and 12 months post-injury. Significant correlations were found between the O-log and measures of memory, executive functioning, basic verbal skills, and estimated intellectual ability. When compared to the other predictor variables, step-wise multiple regression analyses revealed that the minimum O-Log score was the primary significant predictor of performance on six neuropsychological and functional outcome measures. Results of this study suggest that evaluating orientation with the O-Log during acute rehabilitation may reflect level of injury severity and aid in predicting cognitive outcome.

Driving following traumatic brain injury: prevalence, exposure, advice and evaluations.

Survivors of traumatic brain injury often have long-term sensory, cognitive and motor deficits that may impair vehicle operation. However, relatively little is known about the driving status and driving characteristics of brain injury survivors. To better understand driving following traumatic brain injury, a survey of driving status, driving exposure, advice received about driving and evaluations of driving competency was administered to a convenience sample of traumatic brain injury survivors (n = 83). The majority of survey participants had experienced either moderate or severe traumatic brain injuries based on the Glasgow Coma Scale. A total of 60% of the survey participants reported that they were currently active drivers. Most individuals (> 60%) who had returned to driving reported driving every day and more than 50 miles per week. Traumatic brain injury survivors frequently received advice about driving from family members, physicians or non-physician health care professionals, but over half (63%) had not been professionally evaluated for driving competency. The presence of high driving exposure, coupled with a lack of widespread driving fitness testing, suggests that some traumatic brain injury survivors have characteristics that may evaluate their risk for vehicle crashes. However, subsequent prospective studies that directly assess driver safety will be needed to confirm this possibility.

Effective serial measurement of cognitive orientation in rehabilitation: the Orientation Log.

OBJECTIVE: To introduce a brief quantitative measure of cognitive orientation (to place, time, and situation) developed for daily use at bedside with rehabilitation inpatients. The Orientation Log (O-Log) is a 10-item scale that allows for partial credit based on responsiveness to logical, multiple-choice, or phonemic cueing. It is formatted for rapid visual analysis of orientation trends that can be used to evaluate pharmacologic and cognitive-behavioral interventions. DESIGN: Descriptive study of the O-Log's reliability (interrater and internal consistency). SETTING: Inpatient rehabilitation center affiliated with a large university medical school. PATIENTS: Fifteen neurorehabilitation inpatients. RESULTS: For individual items, Spearman rho interrater reliability coefficients ranged from .851 to 1.00. The interrater reliability of the total score was .993. O-Log internal consistency (coefficient alpha) was .922. CONCLUSIONS: The O-Log is a reliable and easily administered scale that promises to be a useful tool in monitoring cognitive recovery during rehabilitation.

Neurochemical mechanisms in brain injury and treatment: a review.

This article reviews cellular energy transformation processes and neurochemical events that take place at the time of brain injury and shortly thereafter emphasizing hypoxia-ischemia, cerebrovascular accident, and traumatic brain injury. New interpretations of established concepts, such as diffuse axonal injury, are discussed; specific events, such as free radical production, excess production of excitatory amino acids, and disruption of calcium homeostasis, are reviewed. Neurochemically-based interventions are also presented: calcium channel blockers, excitatory amino acid antagonists, free radical scavengers, and hypothermia treatment. Concluding remarks focus on the role of clinical neuropsychologists in validation of treatment interventions.

Influence of early variables in traumatic brain injury on functional independence measure scores and rehabilitation length of stay and charges.

OBJECTIVE: To determine the relationship between early variables (initial Glasgow Coma Scale [GCS] scores, computed tomography [CT] findings, presence of skeletal trauma, age, length of acute hospitalization) and outcome variables (Functional Independence Measure [FIM] scores, rehabilitation length of stay [LOS], rehabilitation charges) in traumatic brain injury (TBI). DESIGN: Inception cohort. SETTING: University tertiary care rehabilitation center. PATIENTS: 91 patients with TBI. INTERVENTIONS: Inpatient rehabilitation. MAIN OUTCOME MEASURES: FIM, rehabilitation LOS, and rehabilitation charges. RESULTS: Patients in the severely impaired (GCS = 3 to 7) group showed significantly lower (p = .01) mean admission and discharge motor scores (21.26, 39.83) than patients in the mildly impaired (GCS = 13 to 15) group (38.86, 55.29). Cognitive scores were also significantly lower (p < .01) in the severely impaired group on admission (26.73 vs 54.14) and discharge (42.28 vs 66.48). These findings continued to be statistically significant (p < .01) after regression analysis accounted for the other early variables previously listed. Regression analysis also illustrated that longer acute hospitalization LOS was independently associated with significantly lower admission motor (p < .01) and cognitive (p = .05) scores, and significantly higher (p = .01) rehabilitation charges. Patients with CT findings of intracranial bleed with skull fracture had longer total LOS (70.88 vs 43.08 days; p < .05), rehabilitation LOS (30.01 vs 19.68 days; p < .10), and higher rehabilitation charges ($43,346 vs $25,780; p < .05). Paradoxically, those patients in a motor vehicle crash with an extremity bone fracture had significantly higher (p = .002; p = .04 after regression analysis) FIM cognitive scores on admission (48.30 vs 27.28) and discharge (64.74 vs 45.78) than those without a fracture. Finally, data available on rehabilitation admission were used to predict discharge outcomes. The percentage of explained variance for each outcome variable is as follows: discharge FIM motor score, 69.5%; discharge FIM cognitive score, 71.2%; rehabilitation LOS, 54.1%; rehabilitation charges, 61.1%. The most powerful predictor of LOS and charges was the admission FIM motor score (p < .001), followed by CT findings (p = .02) and age (p = .04). CONCLUSION: Information readily available on rehabilitation admission, particularly the FIM motor score, may be useful in predicting discharge FIM scores as well as utilization of medical rehabilitation resources. Earlier transfer to rehabilitation may result in higher functional status and lower rehabilitation charges, as well as lower acute hospitalization charges. The presence of extremity fractures encountered during a motor vehicle crash is associated with a more favorable outcome in TBI as evidenced by higher discharge FIM cognitive scores.

Technique to improve chronic motor deficit after stroke.

The unaffected upper extremity of chronic stroke patients was restrained in a sling during waking hours for 14 days; on ten of those days, these patients were given six hours of practice in using the impaired upper extremity. An attention-comparison group received several procedures designed to focus attention on use of the impaired upper extremity. The restraint subjects improved on each of the laboratory measures of motor function used--in most cases markedly. Extensive improvement, from a multi-year plateau of greatly impaired motor function, was also noted for the restraint group in the life situation and these gains were maintained during a two-year period of follow-up. For the comparison group only one measure showed small to moderate improvement, and this was lost during the follow-up period; there was essentially no overlap between the individuals of the two groups. Thus, prolonged restraint of an unaffected upper extremity and practice of functional movements with the impaired limb proved to be an effective means of restoring substantial motor function in stroke patients with chronic motor impairment identified by the inclusion criteria of this project.

Using the Agitated Behavior Scale to Evaluate Restlessness/Agitation Following Traumatic Brain InjuryA Case Example.

Restlessness and agitation following traumatic brain injury are potential barriers to successful rehabilitation. Although there are several ways to address the problem, including environmental management, physical restraint, and medication, the type of treatment which would be most appropriate under particular circumstances has not been established. Existing treatment studies often suffer from an emphasis on anecdotal information rather than measurement of restlessness/agitation. Use of the Agitated Behavior Scale would help remedy this situation by allowing more consistent decisions about beginning and altering treatment and providing a measurement device to clarify research results, particularly with respect to the use of medications.

The effectiveness of different methods of defining traumatic brain injury in predicting postdischarge adjustment in a spinal cord injury population.

Traumatic brain injury (TBI) can occur concomitantly with spinal cord injury (SCI). Much of the initial work in this area has focused on identifying coincidence rates and risk factors; less has focused on possible long-term implications of TBI when it occurs with SCI. In this study, SCI/TBI and neurologically matched SCI-only groups were formed on the basis of clinicians' ratings of neuropsychologic test scores. SCI/TBI and SCI-only groups were also formed using Halstead Category cutoff scores, presence/absence of loss of consciousness, and clinicians' ratings of severity of TBI. Dependent measures assessed an average of two years postinjury measured personal, social, and family adjustment of the individual with SCI and that of a significant other. Loss of consciousness and nonconsensus clinical ratings of presence/absence of TBI predicted postdischarge adjustment poorly. Severity ratings in the moderate to severe range, and Category cutoff scores did have some predictive value, with patients defined as impaired being more likely to report adjustment difficulties or being described as having adjustment difficulties by a significant other. The difficulty of making unequivocal diagnoses of TBI in this population is discussed and implications for future research delineated.

The disabled driver: an unmet challenge.

A survey was undertaken to determine if driving impairment secondary to a disabling injury is addressed in state licensing laws and training programs. In 35 states drivers submit voluntarily to reevaluation after disabling injuries, but no provision is made for reporting such individuals. Only 15 states authorize physicians to report impaired drivers, and only seven require such reporting. Based on a survey of licensing bureaus in the capital or a major city of every state, clerks (who are likely to be the source of information to injured persons) are generally not aware of reporting requirements and supervisors are only slightly better informed. Of the 100 rehabilitation centers surveyed, only 36 provided on-site training for disabled drivers. Voluntary submission for reevaluation after head injury does not often occur. Despite being asked to do so, none of the 35 head injured patients, followed up to two years post-onset, sought reevaluation, although 21 had resumed regular driving. Two of the 21 were involved in subsequent traffic accidents. Common guidelines need to be established across states to ensure reevaluation of individuals with disabling conditions, delivery of accurate information concerning licensing, and availability of training programs.