Outcomes of Six Specific Types of Post-Hospital Brain Injury Rehabilitation Programs.

OBJECTIVE: Evaluate outcomes of intensive posthospital brain injury rehabilitation programs compared to supported living (SL) programs; explore variations in outcome by diagnostic category (traumatic brain injury, stroke, and other acquired brain injury [ABI]) and specific program type. SETTING: Data were obtained from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and SL programs serving individuals with ABI. PARTICIPANTS: A total of 2120 individuals with traumatic brain injury, stroke, or other ABI participated in this study. MAIN MEASURES: The main measures are sex, age, time since injury, and Mayo-Portland Adaptability Inventory (4th edition; MPAI-4). DESIGN: Retrospective analyses of demographic variables and MPAI-4 Total, index, and subscale Rasch-derived T-scores on admission and discharge. RESULTS: Gains on MPAI-4  Total T-scores were significantly greater for the intensive rehabilitation (IR) group in comparison to stable functioning in the SL group (F = 236.69, P < .001, partial η2 = .101) while controlling for admission/time 1 scores; similar results were found for MPAI-4 indices and subscales. For the IR cohort, discharge scores differed by diagnostic category after controlling for admission scores for the Total MPAI-4 T-score (F = 22.65, P < .001, partial η2 = .025), as well as all indices and subscales. A statistically significant interaction between program type and diagnostic group on discharge MPAI-4 Total T-scores (F = 2.55, P = .018, partial η2 = .01) after controlling for admission scores indicated that differing outcomes across diagnoses also varied by program type. Varying significant main effects and interactions were apparent for MPAI-4 indices and subscales with generally small effect sizes. CONCLUSIONS: Significant gains on MPAI-4 variables across IR program types compared to no change over a comparable period of time for SL programs supports the effectiveness of posthospital brain injury rehabilitation. This finding in the presence of small effect sizes on outcome variables for program type and for significant interactions between program type and diagnostic category suggests that participants generally were appropriately matched to program type and benefited from interventions provided through specific program types.

Distinguishing Characteristics of Admissions to Various Types of Posthospital Brain Injury Rehabilitation Programs.

OBJECTIVE: Describe and compare the demographic characteristics and disability profiles of individuals admitted to 6 types of posthospital brain injury rehabilitation (PHBIR) programs. SETTING: Data from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community Neurorehabilitation, Day Treatment, Outpatient Neurorehabilitation, and Supported Living programs serving individuals with acquired brain injury (ABI). PARTICIPANTS: Two thousand twenty-eight individuals with traumatic brain injury (TBI), stroke, or other ABI. MAIN MEASURES: Sex, age, time since injury, and Mayo-Portland Adaptability Inventory, 4th edition (MPAI-4). DESIGN: Retrospective analyses of demographic variables and MPAI-4 Total, Index, and subscale Rasch-derived T-scores on admission comparing diagnostic categories and program types within diagnostic categories. RESULTS: Participants with TBI were predominantly male, and those with stroke were generally older. Admissions to more intensive and supervised programs (residential neurobehavioral and residential neurorehabilitation) generally showed greater disability than admissions to home and community programs who were more disabled than participants in day treatment and outpatient programs. Residential neurobehavioral and supported living program participants generally were male and had TBI. Home and community admissions tended to be more delayed than residential neurorehabilitation admissions. The majority of those with other ABI were admitted to outpatient rather than more intensive programs. Additional analyses demonstrated significant differences in MPAI-4 profiles among the various program types. CONCLUSIONS: Admissions with TBI, stroke, and other ABI to PHBIR differ in demographic factors and disability profiles. When examined within each diagnostic category, demographic features and disability profiles also distinguish among admissions to the various program types. Results provide insights about decision-making in referral patterns to various types of PHBIR programs, although other factors not available for analysis (eg, participant/family preference, program, and funding availability) likely also contribute to admission patterns.

Rasch Analysis of the Mayo-Portland Adaptability Inventory for Posthospital Brain Injury Rehabilitation.

OBJECTIVES: (1) Reexamine the item structure and reliability of the Mayo-Portland Adaptability Inventory (4th ed; MPAI-4) through Rasch analysis of admission and discharge scores for a large sample of adults with acquired brain injury (ABI) who participated in various types of posthospital brain injury rehabilitation (PHBIR) programs; (2) compare differential item functioning (DIF) for traumatic brain injury (TBI), stroke and other ABI; and (3) explore the viability of more specific subscales in addition to the established indices. SETTING: Data from Residential Neurobehavioral, Residential Neurorehabilitation, Home and Community, Day Treatment, and Outpatient rehabilitation programs serving individuals with ABI. PARTICIPANTS: A total of 2154 individuals with TBI, stroke, or other ABI. DESIGN: Retrospective analysis of de-identified admission and discharge data from the Foundation to Advance Brain Rehabilitation (FABR) consortium database. MAIN MEASURE: MPAI-4. RESULTS: After adjusting 4 misfitting items and eliminating 20 misfitting persons, the MPAI-4 demonstrated real person reliability/separation = 0.93/3.52 and real item reliability/separation = 1.00/24.02. Independent Rasch analyses by diagnostic category found similar reliabilities and separations. Residual item correlations and principal component analysis of residuals (PCAR) indicated areas of local dependence arranged hierarchically reflecting the full-scale item hierarchy and providing the basis for 3 new subscales of Physical Abilities, Cognitive Abilities, and Autonomy. DIF across diagnostic categories revealed differences in item elevations characteristic of typical patients in each category. Measure means and SDs were very similar across categories. CONCLUSIONS: MPAI-4 items demonstrate very good person and item reliabilities for individuals with TBI, stroke, and other ABI at a level that supports individual evaluation. Variations in item calibrations across diagnostic categories reflect the differential characteristics of typical patients within categories. The entire measure provides an overall assessment of common sequalae of ABI, and standard indices used in combination with newly derived subscales provide more specific assessments of rehabilitation needs for treatment planning.

Do hospital-based emergency Medicaid programs benefit trauma centers? A mixed-methods analysis.

INTRODUCTION: Hospital Presumptive Eligibility (HPE) is a temporary Medicaid insurance at hospitalization, which can offset patient costs of care, increase access to postdischarge resources, and provide a path to sustain coverage through Medicaid. Less is known about the implications of HPE programs on trauma centers (TCs). We aimed to describe the association with HPE and hospital Medicaid reimbursement and characterize incentives for HPE participation among hospitals and TCs. We hypothesized that there would be financial, operational, and mission-based incentives. METHODS: We performed a convergent mixed methods study of HPE hospitals in California (including all verified TCs). We analyzed Annual Financial Disclosure Reports from California's Department of Health Care Access and Information (2005-2021). Our primary outcome was Medicaid net revenue. We also conducted thematic analysis of semistructured interviews with hospital stakeholders to understand incentives for HPE participation (n = 8). RESULTS: Among 367 California hospitals analyzed, 285 (77.7%) participate in HPE, 77 (21%) of which are TCs. As of early 2015, 100% of TCs had elected to enroll in HPE. There is a significant positive association between HPE participation and net Medicaid revenue. The highest Medicaid revenues are in HPE level I and level II TCs. Controlling for changes associated with the Affordable Care Act, HPE enrollment is associated with increased net patient Medicaid revenue ( b = 6.74, p < 0.001) and decreased uncompensated care costs ( b = -2.22, p < 0.05). Stakeholder interviewees' explanatory incentives for HPE participation included reduction of hospital bad debt, improved patient satisfaction, and community benefit in access to care. CONCLUSION: Hospital Presumptive Eligibility programs not only are a promising pathway for long-term insurance coverage for trauma patients but also play a role in TC viability. Future interventions will target streamlining the HPE Medicaid enrollment process to reduce resource burden on participating hospitals and ensure ongoing patient engagement in the program. LEVEL OF EVIDENCE: Economic And Value Based Evaluations; Level II.

Lower Extremity Considerations in the Pregnant Patient.

There remains a paucity of literature on musculoskeletal dysfunction, biomechanics, and pathologies of the lower extremity during pregnancy. There are a multitude of physiologic changes that affect a large percentage of patients throughout pregnancy. Podiatric pathologies observed during gestation can be debilitating for this population, ranging from musculoskeletal and biomechanical causes to traumatic injuries and thromboembolic events. This literature review aims to provide an updated review of lower extremity considerations during pregnancy. The authors seek to provide guidance to clinicians based on a review of the available evidence today, and we aim to address deficiencies in research involving the pregnant population.Levels of Evidence: Level V.

The Zadek Osteotomy for Surgical Management of Insertional Achilles Tendinopathy: A Systematic Review.

BACKGROUND: The calcaneal dorsal closing wedge osteotomy, otherwise known as the Zadek or Keck and Kelly osteotomy, is used to treat insertional Achilles tendinopathy. The purpose of this study is to investigate the clinical outcomes affiliated with the Zadek technique for insertional Achilles tendinopathy (IAT) as reported in the literature. METHODS: An English literature search on PubMed was performed yielding 8 level IV retrospective case series. RESULTS: The weighted mean of preoperative and postoperative Victorian Institute of Sports Assessment-Achilles Questionnaire (VISA-A) scores was 52.7 and 87.8, respectively. The weighted mean of preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores was 56.3 and 92.9, respectively. Majority of the reported complications were minor events, including symptomatic hardware (2.8%; n = 7/247), sural nerve paresthesia (2%; n = 5/247), and superficial infection (3.2%; n = 8/247). There was 1 reported event of hardware failure resulting in re-operation. Deep vein thrombosis occurred at a rate of 0.8% (n = 2/247), complex regional pain syndrome at 0.4% (n = 1/247) and nonunion at a rate of 1.2% (n = 3/247). CONCLUSION: The Zadek osteotomy is a viable option for insertional Achilles tendinopathy based on significantly improved outcome measures and minor complication rates. LEVEL OF EVIDENCE: 4.

An Observational Cohort Study of the Role of Level of Effort in Post-Acute Brain Injury Rehabilitation.

OBJECTIVE: To investigate the role of participant level of effort (LoE) on outcome in post-acute brain injury rehabilitation with the hypothesis that greater effort is associated with more positive outcomes. DESIGN: Observational cohort study. SETTING: Comprehensive integrated rehabilitation program for brain injury within a skilled nursing facility. PARTICIPANTS: Consecutive admissions with acquired brain injury (N=101). INTERVENTIONS: Individualized interdisciplinary brain injury rehabilitation; therapist rating of participant LoE with Acquired Brain Injury LoE Scale (ABI-LoES) during physical therapy, occupational therapy, and speech and language pathology sessions. MAIN OUTCOME MEASURES: Mayo-Portland Adaptability Inventory, fourth edition (MPAI-4); Supervision Rating Scale (SRS). RESULTS: Linear regression showed that discharge MPAI-4 Total T scores were significantly associated with mean ABI-LoES rating, admission MPAI-4 Total T scores, age at admission, and days from injury but not with standard deviation of ABI-LoES rating, sex, injury type, length of stay, or treatment before or during the COVID-19 pandemic. Discharge SRS scores were significantly associated with mean ABI-LoES rating, admission SRS scores, and age. A 1-unit increase in mean ABI-LoES rating was associated with 5.1-unit lower discharge MPAI-4 Total T scores and 1.5 lower discharge SRS scores, after controlling for other variables. Logistic regression showed that the odds of achieving a minimal clinically important difference on the MPAI-4 were 8.34 times higher with each 1-unit increase in mean ABI-LoES rating after controlling for other variables. Admission MPAI-4 was negatively associated with mean ABI-LoES rating (ß=-0.07, t=-8.85, P<.0001). CONCLUSIONS: After controlling for nonmodifiable variables, average ABI-LoES rating is positively associated with outcome. Initial level of disability is negatively associated with mean ABI-LoES rating.

Medullary Screw Fixation and the Pilot Hole Technique for the Correction of Hammertoe Deformity.

BACKGROUND: Historically, Kirschner wires have been used for fixation of the interphalangeal joints of the toe. They are still the most popular form of fixation, likely due to training patterns, ease of use, and decreased cost. Recently, numerous medullary fixation devices have become available, including medullary screws. METHODS: After performing various forms of fixation for the correction of toe deformities, the authors have developed a new pilot hole technique for screw fixation advancing on the previously described pilot hole technique for Kirschner wire fixation. RESULTS: The authors have found this method to provide intraoperative confidence that improper hardware placement has not occurred. CONCLUSIONS: The pilot hole technique described in this paper is a safe and effective technique that may be employed by surgeons using screw fixation for the treatment of hammertoe deformities. The technique reduces the possibility of surgeon error and helps to ensure that the screw is properly placed within the phalanges when properly employed.

Comparison of Preoperative MRI With Intraoperative Findings for Peroneal Tendon Pathologies.

Magnetic resonance imaging (MRI) is commonly used to evaluate soft tissue pathology of the foot and ankle. Prior investigations have reported limitations of this modality, however, in evaluation of pathologies related to the peroneal tendons. This article investigates the correlation of pre-operative MRI studies with intraoperative findings. Five board-certified radiologists interpreted MRIs of 80 ankles that subsequently underwent surgical procedures performed by one board-certified foot and ankle surgeon, after which comparison was made between their findings. Statistically significant disagreement was found between radiologist and surgeon findings of a normal peroneus brevis (PB), PB and peroneus longus (PL) tendinosis, PB and PL hypertrophy, PB and PL partial linear tears, PB and PL flattening, PB longitudinal split tears, and the PB attritional spectrum (combined analysis of flattening, partial linear tearing, and longitudinal split tears). These results suggest that given the disconcordance between MRI and intraoperative findings, surgeons should remain cautious in their reliance upon this imaging modality when evaluating this anatomic region.

Cadaveric Analysis of Exposure of the Talar Articular Surface Through the Posteromedial Approach.

The purpose of this cadaveric study is to assess the talar articular surface visible through a modified posterior medial approach to the ankle joint for talar osteochondral defects. Ten fresh frozen cadaveric specimens were included. The talar surface area was outlined utilizing a marker. The talus was removed to measure the medial to lateral length and posterior to anterior length using a flexible ruler. A skin incision was made posterior to the medial malleolus. The incision was deepened through the flexor retinaculum. Dissection was carried between the posterior tibial and flexor digitorum longus tendons through the posterior tibial tendon sheath in order to access the posteromedial ankle joint. The posterior tibiofibular ligament should remain intact. A Hintermann distractor was then inserted to distract the ankle joint. The average articular cartilage visible from medial to lateral was 1.90 (68.6%) centimeters, while from posterior to anterior was 2.00 (43.6%) centimeters. Medial malleolar osteotomy is often required to visualize posteromedial talar osteochondral defects that are difficult to visualize with standard anterior ankle arthroscopy. Our study suggests that the modified posteromedial approach between the posterior tibial and flexor digitorum longus tendons and utilizing a Hintermann distractor allows for visualization of common posterior and central-medial lesions. When considering the anatomic 9-zone grid scheme proposed by Raikin et al, zone 4, 7, and 8 lesions can be assessed with this approach. A clinical study should be undertaken to evaluate the morbidity of this approach.

Opioid prescribing habits of podiatric surgeons following elective foot and ankle surgery.

Prescription of opioids following surgery is commonplace in the United States, but with that has come increases in misuse, overdose and death. Evaluating prescribing habits in efforts to reduce the opioid epidemic is becoming more frequent. The purpose of the present study was to examine the self-reported practices of podiatric surgeons regarding their methods of post-operative pain management in adult, sensate patients, as well as assessing the frequency of use of adjunctive pain control modalities. A survey was created and distributed to Podiatric Surgeons electronically, across the United States. Results of this study show that Podiatric Surgeons prescribe hydrocodone/acetaminophen most commonly after surgery, with most prescribing opioids for less than 2 weeks. With regards to adjunctive pain management, two-thirds of respondents use regional anesthesia blocks, with only 13% using post-anesthesia delivery devices (PADD). Interestingly, those using PADDs prescribed significantly more opioids at the first prescription and were more likely to refill the prescription. Podiatric Surgeons are concerned with various negative outcomes for their patients when taking opioids, including addiction, non-adherence, and motor vehicle accidents. Podiatric Surgeons are less concerned about negative outcomes for themselves when prescribing opioids. This study is in agreement with previously published studies in other medical specialties regarding opioid prescribing habits and concerns. However, further research is needed to fully understand the role PADDs and regional anesthesia blocks play in reducing the amount of opioids prescribed following surgery. The Opioid Epidemic in the United States is multi-faceted, but over-prescription by providers is part of it. Continuing to assess and understand how opioids are prescribed will be paramount to curb the epidemic.

Internal Amputation in Charcot Neuroarthropathy Complicated by Diabetic Foot Osteomyelitis.

Studies have demonstrated the importance of preserving plantar surface area, lever arm length, and plantar soft tissues in affording patients a plantigrade, stable, and functional limb. We describe a case of a patient who underwent internal pedal amputation that was amenable to functional bracing. The purpose of this case study is to present internal pedal amputation as a viable option to eradicate infection and produce a plantigrade, stable foot that is amenable to custom bracing.

Pernio-Induced Toe Pain in the Setting of Onychocryptosis: A Case Report.

Pernio is an inflammatory condition of the skin associated with cold exposure. The dermatologic manifestations may vary, and this entity is frequently misdiagnosed. Its association with systemic disease underscores the importance of accurate diagnosis. The authors describe a case report in which a patient who, after initially presenting with a complaint of pain and an ingrown toenail, was eventually diagnosed with pernio as well.

Conversion of First Metatarsophalangeal Joint Arthrodesis to Interpositional Arthroplasty With Acellular Dermal Matrix for First Ray Ulceration: A Case Report.

The purpose of this study is to report the outcome of the conversion of a first metatarsophalangeal (MTP) joint arthrodesis to an interpositional arthroplasty with an acellular dermal matrix for a chronic nonhealing first ray wound. To our knowledge, this is the first case report converting a first ray arthrodesis to an interpositional arthroplasty to heal a chronic ulceration. A 78-year-old female developed a chronic neuropathic ulceration under the first metatarsal head and hallux after a first MTP joint arthrodesis. The patient failed local wound care and underwent gastrocnemius recession, hallux interphalangeal joint fusion, and an interpositional arthroplasty with the use of an acellular dermal matrix. Bone tunnels were placed proximal to the metatarsal neck, where absorbable sutures affixed to the dermal matrix were passed from plantar to dorsal, and the graft was secured to the reamed metatarsal head and associated capsule. Postoperative radiographs revealed improved alignment of the first MTP joint. Complete reepithelialization of the plantar ulceration occurred within 2 weeks postoperatively. At the 16-month follow-up, the patient was ambulating without restriction and continued to be free of first ray ulceration and infection. This case study details the use of an acellular dermal matrix in an interpositional arthroplasty to offload a chronic nonhealing ulceration secondary to elevated first ray pressure associated with first MTP joint arthrodesis. The goal of this treatment is to reduce pain, heal the ulceration, and prevent its recurrence.

Gouty Achilles Tendinopathy: A Case Report.

Tendinopathy in the presence of gouty arthropathy is relatively common, yet the clinical suspicion for gout involvement in acute tendon pain remains low. A 49-year-old man presented with an acute, tender, erythematous mass to the right posterior heel. A computed tomographic scan was obtained, which revealed a septated fluid collection superficial to the Achilles tendon. The patient was taken to the operating room for an incision and drainage with debridement, and the abscess was found to be filled with caseous material. The diagnosis of gout was confirmed with pathology. The calcaneus was submitted to biopsy, and the results were negative for osteomyelitis. The patient was returned to the operating room for repair of the Achilles tendon with flexor hallucis longus tendon transfer. Postoperatively, the patient was nonweightbearing for 6 weeks. Oral colchicine was used perioperatively, and a steroid taper was administered. The patient was started on allopurinol and colchicine for chronic treatment. At 14 months, the patient was walking without pain or recurrence of the mass. Although the relationship between hyperuricemia and tendinopathy is not completely understood, it is apparent that tendon involvement may be a sequela in patients with gout. When a patient presents with acute tendon pain, gout should be considered in the differential diagnosis.

The Rare Lateral Cuneocuboid Coalition: A Case Report.

Tarsal coalitions typically occur at the talocalcaneal or calcaneonavicular joints. Common findings are pain, limited range of motion, and a pes planus deformity. The focus of this case report includes the presentation, imaging, treatment, and outcomes for a 21-year-old woman diagnosed with a rare lateral cuneocuboid coalition with chronic pain. Clinical and radiographic examinations, typically used to diagnose the common coalition, were unremarkable. Magnetic resonance imaging was diagnostic of the lateral cuneocuboid coalition, which was successfully treated with surgical resection. At 6-year follow-up, she reports resolution of symptoms and has returned to her normal presurgical activity level pain-free. This case is only the third lateral cuneocuboid coalition reported in the literature. The rarity of this coalition and its nonsuspicious clinical presentation make it worthy of acknowledgment.

Intraosseous Epidermal Inclusion Cyst of the Proximal Phalanx of the Fifth Toe and Review of the Literature: A Case Study.

Intraosseous epidermal inclusion cysts (IEpC) are benign bone tumors that often present in the phalanges of the fingers, but rarely are seen in the lower extremity. These tumors often present following surgery, and have a similar clinical and radiographic presentation to osteomyelitis. The lack of defining characteristics makes preoperative diagnosis of these tumors very difficult. It is crucial to differentiate these tumors from malignant lesions with similar presentation. This case study presents our treatment of this osseous tumor and reviews the available literature describing this condition. LEVELS OF EVIDENCE: Level V: Case report.

Chondroid Syringoma.

Chondroid syringoma is a cutaneous sweat gland tumor. Despite its relative rarity, a benign and malignant variant have been described. We present a case report of chondroid syringoma of the foot in a healthy patient. Definitive diagnosis required histopathologic examination, while treatment included wide resection. Surgeons who are presented with a painless, solid nodule in the lower extremities should be cognizant of this neoplasm. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case report.

Monitoring real-time enzymatic hydrolysis of Distillers Dried Grains with Solubles (DDGS) by dielectric spectroscopy following hydrothermal pre-treatment by steam explosion.

Dielectric spectroscopy (DS) has been used to monitor the simultaneous saccharification and fermentation of lignocellulosic biomass by measuring its dielectric state. However, it is unknown whether following steam explosion (SE) pre-treatment, lignocellulose would still maintain a dielectric state, and, if maintained, whether the dissipation during enzymatic hydrolysis could be monitored. Distillers Dried Grains with Solubles (DDGS), pre-treated by SE, was found to have a capacitance (C = 580 kHz) of approximately 24 pF cm(-1). Following addition of full-strength cellulolytic cocktail A (CC-A; R(2) = 0.97) and 1/3 strength cocktail B (CC-B; R(2) = 0.96), a natural logarithmic decay in capacitance was determined. Furthermore, the DS biomass probes quantified the initial linear rate of dissipation in capacitance during hydrolysis. The rate of CC-B was 34% that of CC-A. These data extend scope and utility of DS biomass probes for monitoring the enzymatic hydrolysis of SE-pre-treated lignocellulosic substrates in real-time.

Modelling real-time simultaneous saccharification and fermentation of lignocellulosic biomass and organic acid accumulation using dielectric spectroscopy.

Dielectric spectroscopy (DS) is routinely used in yeast and mammalian fermentations to quantitatively monitor viable biomass through the inherent capacitance of live cells; however, the use of DS to monitor the enzymatic break down of lignocellulosic biomass has not been reported. The aim of the current study was to examine the application of DS in monitoring the enzymatic saccharification of high sugar perennial ryegrass (HS-PRG) fibre and to relate the data to changes in chemical composition. DS was capable of both monitoring the on-line decrease in PRG fibre capacitance (C=580 kHz) during enzymatic hydrolysis, together with the subsequent increase in conductivity (G=580 kHz) resulting from the production of organic acids during microbial growth. Analysis of the fibre fractions revealed >50% of HS-PRG lignocellulose had undergone enzymatic hydrolysis. These data demonstrated the utility of DS biomass probes for on-line monitoring of simultaneous saccharification and fermentation (SSF).