Social deprivation influences the epidemiology and outcome of proximal humeral fractures in adults for a defined urban population of Scotland

Social determinants of outcomes in nonoperatively treated proximal humerus fractures

Background

Proximal humerus fractures (PHFs) are common fractures especially in the elderly, with most fractures being managed nonoperatively. Traditional biomedical factors such as radiological alignment have not been able to meaningfully predict comfort and capability after PHFs. Conversely, recent literature has increasingly recognized the role of psychological factors in determining comfort and capability after PHFs. Nonetheless, less is known about the impact of social factors. Additional study of these potentially modifiable social factors as targets for enhancing recovery from injury is merited. Among people recovering from a nonoperatively- treated proximal humerus fracture (PHF) we studied the social factors associated with patient-reported outcomes at 6 months and 1 year.

Methods

One hundred seventy-one patients who received nonoperative management of a PHF completed baseline measures of sociodemographic characteristics (age, gender, race, employment status, household income, educational level, presence of domestic workers, housing type, and smoking status). Six and 12 months after fracture, participants completed the Oxford Shoulder Score (OSS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and EuroQol-5-Dimensions (EQ5D) measures of comfort and capability. The relationship between capability and social factors was assessed using linear regression modelling, accounting for potential confounding from age, fracture severity assessed using Neer classification, premorbid comorbidities measured by Charlson Comorbidity Index, and premorbid functional status measured by Parker Mobility Index and Barthel Index.

Results

Lower capability (higher QuickDASH scores) 6 months and 1 year after fracture were associated with being unemployed (coef: -5.02 [95% CI: -9.96 to -0.07]; P = .047) and having domestic workers at home (coef: 8.63 [95% CI: 1.39 to 15.86]; P = .020), but not with Neer classification. Both greater shoulder discomfort and magnitude of incapability (lower OSS scores) and worse general quality of life (lower EQ5D scores) were associated with having domestic workers (coef: -4.07 [95% CI: -6.62 to -1.53]; P = .002 and coef: -0.18 [95% CI: -0.29 to -0.07]; P = .001 respectively) or living in an assisted care facility (coef: -14.82 [95% CI: -22.24 to -7.39]; P < .001 and coef: -0.59 [95% CI: -0.90 to -0.29] P < .001).

Conclusions

The finding that people recovering from PHF experience less incapability in proportion to their social independence (employment, absence of a caregiver such as domestic workers at home and living outside care facilities) emphasizes the important associations of social factors to musculoskeletal health, and the utility of accounting for social factors in the development and assessment of care strategies.

Socioeconomic deprivation status predicts both the incidence and nature of Achilles tendon rupture

PURPOSE

The aim of this study was to describe the epidemiology of Achilles tendon rupture (ATR) and its relationship with socioeconomic deprivation status (SEDS). The hypothesis was that ATR occurs more frequently in socioeconomically deprived patients. Secondary aims were to determine variations in circumstances of injury between more and less deprived patients.

METHODS

A 6-year retrospective review of consecutive patients presenting with ATR was undertaken. The health-board population was defined using governmental population data and SEDS was defined using the Scottish Index of Multiple Deprivation. The primary outcome was an epidemiological description and comparison of incidence in more and less deprived cohorts. Secondary outcomes included reporting of the relationship between SEDS and patient and injury characteristics with univariate and binary logistic regression analyses.

RESULTS

There were 783 patients (567 male; 216 female) with ATR. Mean incidence for adults (≥ 18 years) was 18.75/100,000 per year (range 16.56-23.57) and for all ages was 15.26/100,000 per year (range 13.51 to 19.07). Incidence in the least deprived population quintiles (4th and 5th quintiles; 18.07 per 100,000/year) was higher than that in the most deprived quintiles (1st and 2nd; 11.32/100,000 per year; OR 1.60, 95%CI 1.35-1.89; p < 0.001). When adjusting for confounding factors, least deprived patients were more likely to be > 50 years old (OR 1.97; 95%CI 1.24-3.12; p = 0.004), to sustain ATR playing sports (OR 1.72, 95%CI 1.11-2.67; p = 0.02) and in the spring (OR 1.65, 95%CI  1.01-2.70; p = 0.045) and to give a history of preceding tendinitis (OR  4.04, 95%CI 1.49-10.95; p = 0.006). They were less likely to sustain low-energy injuries (OR 0.44, 95%CI 0.23-0.87; p = 0.02) and to be obese (OR 0.25-0.41, 95%CI  0.07-0.90; p ≤ 0.03).

CONCLUSIONS

The incidence of ATR was higher in less socioeconomically deprived populations and the hypothesis was therefore rejected. Significant variations in patient and predisposing factors, mechanisms of injury and seasonality were demonstrated between most and least deprived groups, suggesting that circumstances and nature of ATR may vary with SEDS and these are not a homogenous group of injuries.

LEVEL OF EVIDENCE

Prognostic Study Level III.

Assessing the ability of an instrumental variable causal forest algorithm to personalize treatment evidence using observational data: the case of early surgery for shoulder fracture

Background

Comparative effectiveness research (CER) using observational databases has been suggested to obtain personalized evidence of treatment effectiveness. Inferential difficulties remain using traditional CER approaches especially related to designating patients to reference classes a priori. A novel Instrumental Variable Causal Forest Algorithm (IV-CFA) has the potential to provide personalized evidence using observational data without designating reference classes a priori, but the consistency of the evidence when varying key algorithm parameters remains unclear. We investigated the consistency of IV-CFA estimates through application to a database of Medicare beneficiaries with proximal humerus fractures (PHFs) that previously revealed heterogeneity in the effects of early surgery using instrumental variable estimators.

Methods

IV-CFA was used to estimate patient-specific early surgery effects on both beneficial and detrimental outcomes using different combinations of algorithm parameters and estimate variation was assessed for a population of 72,751 fee-for-service Medicare beneficiaries with PHFs in 2011. Classification and regression trees (CART) were applied to these estimates to create ex-post reference classes and the consistency of these classes were assessed. Two-stage least squares (2SLS) estimators were applied to representative ex-post reference classes to scrutinize the estimates relative to known 2SLS properties.

Results

IV-CFA uncovered substantial early surgery effect heterogeneity across PHF patients, but estimates for individual patients varied with algorithm parameters. CART applied to these estimates revealed ex-post reference classes consistent across algorithm parameters. 2SLS estimates showed that ex-post reference classes containing older, frailer patients with more comorbidities, and lower utilizers of healthcare were less likely to benefit and more likely to have detriments from higher rates of early surgery.

Conclusions

IV-CFA provides an illuminating method to uncover ex-post reference classes of patients based on treatment effects using observational data with a strong instrumental variable. Interpretation of treatment effect estimates within each ex-post reference class using traditional CER methods remains conditional on the extent of measured information in the data.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01663-0.

The Impact of Social Deprivation and Hand Therapy Attendance on Range of Motion After Flexor Tendon Repair

PURPOSE

To examine the influence of social deprivation and hand therapy attendance on active range of motion (AROM) outcomes following flexor tendon repair.

METHODS

We performed a retrospective analysis of patients who underwent primary zone I-III flexor tendon repair between November 2016 and November 2020. Area deprivation index (ADI) was used to quantify social deprivation. Medical record review determined each patient's demographic characteristics, injury details, total hand therapy visits, and final AROM outcome. Active range of motion was converted to Strickland's percentage for analysis. Spearman correlation and simple and multivariable linear regression models were used to assess relationships between explanatory variables and outcomes.

RESULTS

There were a total of 109 patients, with a mean ADI of 53 and mean therapy attendance of 13 visits. Higher ADI and lower therapy attendance were correlated, and each was associated with significantly decreased Strickland's percentage. In the multivariable model, therapy attendance, ADI, zone 2 injury, and age maintained significant associations with Strickland's percentage.

CONCLUSIONS

Socially deprived patients attend fewer therapy sessions and obtain poorer AROM after flexor tendon repair. Social deprivation is likely to contribute to poor outcomes both by its association with decreased therapy attendance and by other potential pathways that make it difficult for deprived patients to achieve good surgical outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The epidemiology of Achilles tendon re-rupture and associated risk factors: male gender, younger age and traditional immobilising rehabilitation are risk factors

PURPOSE

The aim of this study was to describe the epidemiology of Achilles tendon re-rupture. Secondary aims were to identify factors predisposing to increased Achilles tendon re-rupture risk, at the time of primary Achilles tendon rupture.

METHODS

A retrospective review of all patients with primary Achilles tendon rupture and Achilles tendon re-rupture was undertaken. Two separate databases were compiled: the first included all Achilles tendon re-ruptures presenting during the study period and described epidemiology, mechanisms and nature of the re-rupture; the second was a case-control study analysing differences between patients with primary Achilles tendon rupture during the study period, who did, or did not, go on to develop re-rupture, with minimum review period of 1.5 years.

RESULTS

Seven hundred and eighty-three patients (567 males, 216 females) attended with primary Achilles tendon rupture and 48 patients (41 males, 7 females) with Achilles tendon re-rupture. Median time to re-rupture was 98.5 days (IQR 82-122.5), but 8/48 re-ruptures occurred late (range 3 to 50 years) after primary Achilles tendon rupture. Males were affected more commonly (OR = 7.40, 95% CI 0.91-60.15; p = 0.034). Mean Achilles tendon re-rupture incidence was 0.94/100,000/year for all ages and 1.16/100,000/year for adults (≥ 18 years). Age distribution was bimodal for both primary Achilles tendon rupture and re-rupture, peaking in the fifth decade, with secondary peaks in older age. Incidence of re-rupture was higher in less socioeconomically deprived sub-populations (OR = 2.01, 95%CI 1.01-3.97, p = 0.04). The majority of re-ruptures were low-energy injuries. Greater risk of re-rupture was noted for patients with primary rupture aged < 45 years [adjusted odds ratio (aOR) 1.96; p = 0.037] and those treated with traditional cast immobilisation (aOR 2.20; p = 0.050).

CONCLUSION

The epidemiology of Achilles tendon re-rupture is described and known trends (e.g. male predilection) are confirmed, while other novel findings are described, including incidence of a small but significant number of late re-ruptures, occurring years after the primary injury and an increased incidence of re-rupture in less socioeconomically deprived patients. Younger age and traditional immobilising cast treatment of primary Achilles tendon rupture were independently associated with Achilles tendon re-rupture.

LEVEL OF EVIDENCE

III.

Functional Outcome After Nonoperative Treatment of a Proximal Humeral Fracture in Adults

BACKGROUND

The functional outcome following nonoperative treatment of a proximal humeral fracture and the factors that influence it are poorly defined. We aimed to prospectively assess patient-reported outcome measures (PROMs) in a patient cohort at 1 year after the injury.

METHODS

In this study, 774 adult patients sustaining a proximal humeral fracture completed PROM assessments, including the Oxford Shoulder Score (OSS), the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L), and visual analog scale (VAS) assessments of pain, health, and overall treatment satisfaction at 1 year. The mean patient age was 65.6 years, and 73.8% of patients were female. The influences of demographic and fracture measurements and complications on the OSS and EQ-5D-3L were assessed.

RESULTS

The 1-year mean scores were 33.2 points (95% confidence interval [CI], 32.1 to 34.2 points) for the OSS and 0.58 (95% CI, 0.55 to 0.61) for the EQ-5D-3L. There was considerable heterogeneity in the reported scores, and the 3 demographic variables of higher levels of dependency, higher levels of social deprivation, and a history of affective (mood) disorder were most consistently associated with poorer outcomes, accounting for between 37% and 43% of the score variation. The initial fracture translation potentially leading to nonunion accounted for 9% to 15% of the variation, and a displaced tuberosity fracture was also predictive of 1% to 4% of the outcome variation. There was evidence of a ceiling effect for the OSS, with 238 patients (30.8%) having a score of ≥47 points but a mean outcome satisfaction of only 72.9 points, and this effect was more pronounced in younger, active individuals. At the other end of the spectrum, 239 patients (30.9%) reported an OSS of ≤24 points, and 120 patients (15.5%) had a "worse-than-death" EQ-5D-3L score.

CONCLUSIONS

Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, and a substantial proportion of patients have poor perceived functional outcomes. The outcome for the majority of less-displaced fractures is mainly influenced by preexisting patient-related psychosocial factors, although the fracture-related factors of displacement, nonunion, and tuberosity displacement account for a small but measurable proportion of the variation and the poorer outcomes in the minority with more severe injuries.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Non-medical patient-related factor influence in proximal humeral fracture outcomes: a multicentric study

PURPOSE

Age, sex, and type of fracture have traditionally been described as prognostic factors for proximal humeral fractures (PHFs). Some non-medical patient-related factors may play a role in the outcome. This paper evaluates the association of comorbidities and socioeconomic factors with clinical outcomes for PHF.

METHODS

A total of 217 patients with PHF were evaluated according to Neer's classification with X-ray. Comorbidities were assessed through the Charlson comorbidity index and, non-medical patient-related factors were determined with a 52-item questionnaire concerning personal behaviors such as social activities, family support, economic solvency, and leisure-time activities. The clinical outcome was assessed with the Constant-Murley Score (CMS), with a minimum 1-year follow-up. The minimal clinically relevant difference for the CMS was set at 10 points. A multivariable analysis was performed to adjust for comorbidities and non-medical patient-related factors, such as age, sex, fracture classification, and treatment.

RESULTS

One hundred and eighty-three patients completed the initial research protocol, while 126 of them completed the 1-year follow-up. The mean age was 71.6 years (SD ± 13.3), and 79.3% of the patients were women. In the bivariable analysis, age and comorbidities were correlated with the CMS (correlation coefficient: - 0.34 [- 0.49, 0.17] and 0.35 [0.18, 0.50], respectively), as well as non-medical patient-related factors and the fracture pattern (p value ANOVA < 0.001). In the multivariable regression model, the effects of considering oneself socially active, without economic problems, and self-sufficient were associated with a higher CMS than the effect of the fracture pattern (beta coefficient: 11.69 [6.09-17.30], 15.54 [8.32-22.75], and 10.61 [3.34-17.88], respectively).

CONCLUSION

Socioeconomic status had a higher impact on functional outcomes than fracture pattern in patients with PHF.

Evaluating the impact of social deprivation on Press Ganey® Outpatient Medical Practice Survey Scores

Background

Social deprivation has been shown to affect access to health care services, and influences outcomes for a variety of physical and psychological conditions. However, the impact on patient satisfaction remains less clear. The objective of this study was to determine if social deprivation is an independent predictor of patient satisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey (PGOMPS).

Methods

We retrospectively reviewed unique new adult patient (≥ 18 years of age) seen at a tertiary academic hospital and rural/urban outreach hospitals/clinics between January 2014 and December 2017. Satisfaction was defined a priori as achieving a score above the 33rd percentile. The 2015 Area Deprivation Index (ADI) was used to determine social deprivation (lower score signifies less social deprivation). Univariate and multivariable binary logistic regression were used to determine the impact of ADI on PGOMPS total and provider sub-scores while controlling for variables previously shown to impact scores (wait time, patient age, sex, race, specialty type, provider type, and insurance status).

Results

Univariate analysis of PGOMPS total scores revealed a 4% decrease in odds of patient satisfaction per decile increase in ADI (p < 0.001). Patients within the most deprived quartile were significantly less likely to report satisfaction compared to the least deprived quartile (OR 0.79, p < 0.001). Multivariable analysis revealed that the odds of achieving satisfaction decreased 2% for each decile increase in ADI on the Total Score (p < 0.001), independent of other variables previously shown to impact scores. For PGOMPS Provider Sub-Score, univariate analysis showed that patients in the lowest ADI quartile were significantly less likely be satisfied, as compared to the least deprived quartile (OR 0.77; 95% CI 0.70–0.86; p < 0.001). A 5% decrease in a patient being satisfied was observed for each decile increase in ADI (OR 0.95; 95% CI 0.94–0.96; p < 0.001).

Conclusions

Social deprivation was an independent predictor of outpatient visit dissatisfaction, as measured by the Press Ganey® Outpatient Medical Practice Survey. These results necessitate consideration when developing health care delivery policies that serve to minimize inequalities between patients of differing socioeconomic groups.

Prediction of Nonunion After Nonoperative Treatment of a Proximal Humeral Fracture

BACKGROUND

The prevalence of nonunion after a proximal humeral fracture (PHF) and the risk factors for its occurrence are poorly defined. We aimed to estimate the rate of nonunion in nonoperatively treated patients and to produce a clinical model for its prediction.

METHODS

Two thousand two hundred and thirty adult patients (median age, 72 years [range, 18 to 103 years]; 75.5% were female) with a PHF underwent assessment of fracture union using standard clinical evaluation and conventional radiographs. We assessed the prevalence of nonunion and measured the effect of 19 parameters on healing. Best statistical practices were used to construct a multivariate logistic regression model. The PHF assessment of risk of nonunion model (PHARON) was externally validated in a subsequent prospectively collected population of 735 patients, treated by the same protocol in our institution.

RESULTS

Overall, 231 (10.4%) of 2,230 patients developed nonunion. Only 3 (0.8%) of 395 patients with a head-shaft angle (HSA) of >140° developed nonunion; in this cohort, none of the measured candidate variables were independently predictive of nonunion on multivariate logistic regression analysis. In the larger cohort of 1,835 patients with an HSA of ≤140°, 228 (12.4%) developed nonunion. Decreasing HSA, increasing head-shaft translation (HST), and smoking were independently predictive of nonunion on multivariate analysis. The prevalence of nonunion was very low (1%) in the majority with both an HSA of >90° and HST of <50%, whereas the risk was much higher (83.7%) in the 8.3% with an HSA of ≤90° and HST of ≥50%. In both groups, the prevalence of nonunion was much higher in smokers.

CONCLUSIONS

The prevalence of nonunion after PHF is higher than previously reported. Most patients have favorable risk-factor estimates and a very low risk of this complication, but a smaller subgroup is at much higher risk. The risk can be accurately estimated with PHARON, using standard clinical assessment tools.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Psychosocial factors affecting variation in patient-reported outcomes after elbow fractures

BACKGROUND

The purpose of this study was to identify factors associated with limitations in function measured by patient-reported outcome measures (PROMs) 6-9 months after elbow fractures in adults from a range of demographic, injury, psychological, and social variables measured within a week and 2-4 weeks after injury.

METHODS

We enrolled 191 adult patients sustaining an isolated elbow fracture and invited them to complete PROMs at their initial visit to the orthopedic outpatient clinic (within a maximum of 1 week after fracture), between 2 and 4 weeks, and between 6 and 9 months after injury; 183 patients completed the final assessment. Bivariate analysis was performed, followed by multivariable regression analysis accounting for multicollinearity. This was evaluated using partial R², correlation matrices, and variable inflation factor assessment.

RESULTS

There was a correlation between multiple variables within a week of injury and 2-4 weeks after injury with PROMs 6-9 months after injury in bivariate analysis. Kinesiophobia measured within a week of injury and self-efficacy measured at 2-4 weeks were the strongest predictors of limitations 6-9 months after injury in multivariable regression. Regression models accounted for substantial variance in all PROMs at both time points.

CONCLUSIONS

Developing effective coping strategies to overcome fears related to movement and reinjury and finding ways of persevering with activity despite pain within a month of injury may enhance recovery after elbow fractures. Heightened fears around movement and suboptimal coping ability are modifiable using evidence-based behavioral treatments.

Outcome following osteosynthesis or primary arthrodesis of calcaneal fractures: A cross-sectional cohort study

BACKGROUND

Calcaneal fractures are uncommon and have a substantial impact on hindfoot function and quality of life. Several surgical treatment options are available; both in surgical approach and type of operation. The aim of this study was to compare functional outcome and quality of life following ORIF and primary arthrodesis. Furthermore, predictors of worse functional outcome were explored.

METHODS

A retrospective cross-sectional cohort study was performed in patients with surgical fixation of a calcaneal fracture with a minimum follow-up of 18 months. Patients received ORIF through the 1) Extended Lateral Approach (ELA), 2) Sinus Tarsi Approach (STA) or 3) primary arthrodesis via STA. Participants were presented a questionnaire containing demographics, the AOFAS hindfoot scale, Foot Function Index, SF-36, EQ-5D and patient satisfaction.

RESULTS

In total 95 patients participated in this study. The three groups were comparable regarding patient characteristics. A median score of 74.5 points on the AOFAS hindfoot scale and 11.9 on the FFI was found for the entire group. There were no statistically significant differences between patients with ORIF of primary arthrodesis. Patients scored a median of 49.0 on the Physical Component Scale of the SF-36 and 55.4 on the Mental Component Scale. On the EQ-5D patients scored a median of 0.8 points. Again no statistically significant differences were observed between the three subgroups. Socio-economic status was the only statistically significant predictor of worse functional outcome (β: 4.06, 95% CI: 0.50-7.62) after multivariable analysis.

INTERPRETATION

Good midterm outcomes following in terms of functional outcome and in quality of life are observed. We observed no statistical significant difference in functional outcome between patients with ORIF and patients with primary arthrodesis. The only predictor of worse functional outcome is a lower socio-economic status.

Normative data for the lower extremity functional scale (LEFS)

Background and purpose - The lower extremity functional scale (LEFS) is a well-known and validated instrument for measurement of lower extremity function. The LEFS was developed in a group of patients with various musculoskeletal disorders, and no reference data for the healthy population are available. Here we provide normative data for the LEFS. Methods - Healthy visitors and staff at 4 hospitals were requested to participate. A minimum of 250 volunteers had to be included at each hospital. Participants were excluded if they had undergone lower extremity surgery within 1 year of filling out the questionnaire, or were scheduled for lower extremity surgery. Normative values for the LEFS for the population as a whole were calculated. Furthermore, the influence of sex, age, type of employment, socioeconomic status, and history of lower extremity surgery on the LEFS were investigated. Results - 1,014 individuals fulfilled the inclusion criteria and were included in the study. The median score for the LEFS for the whole population was 77 (out of a maximum of 80). Men and women had similar median scores (78 and 76, respectively), and younger individuals had better scores. Participants who were unfit for work had worse scores. There were no statistically significant correlations between socioeconomic status and type of employment on the one hand and LEFS score on the other. A history of lower extremity surgery was associated with a lower LEFS score. Interpretation - High scores were observed for the LEFS throughout the whole population, although they did decrease with age. Men had a slightly higher score than women. There was no statistically significant correlation between socioeconomic status and LEFS score, but people who were unfit for work had a significantly worse LEFS score.

Social deprivation as a risk factor for fractures in childhood

Paediatric fractures are common and can cause significant morbidity. Socioeconomic deprivation is associated with an increased incidence of fractures in both adults and children, but little is known about the epidemiology of paediatric fractures. In this study we investigated the effect of social deprivation on the epidemiology of paediatric fractures. We compiled a prospective database of all fractures in children aged < 16 years presenting to the study centre. Demographics, type of fracture, mode of injury and postcode were recorded. Socioeconomic status quintiles were assigned for each child using the Scottish Index for Multiple Deprivation (SIMD). We found a correlation between increasing deprivation and the incidence of fractures (r = 1.00, p < 0.001). In the most deprived group the incidence was 2420/100 000/yr, which diminished to 1775/100 000/yr in the least deprived group. The most deprived children were more likely to suffer a fracture as a result of a fall (odds ratio (OR) = 1.5, p < 0.0001), blunt trauma (OR = 1.5, p = 0.026) or a road traffic accident (OR = 2.7, p < 0.0001) than the least deprived. These findings have important implications for public health and preventative measures.