Psychometric analysis of measuring functional outcomes in tibial plateau fractures using the Short Form 36 (SF-36), Short Musculoskeletal Function Assessment (SMFA) and the Western Ontario McMaster Osteoarthritis (WOMAC) questionnaires

Quadriceps muscle quality and quantity following tibial plateau fracture repair

PURPOSE

To investigate the qualitative and quantitative changes seen in quadriceps muscles [QM] following tibial plateau fracture and surgery.

METHODS

A consecutive series of patients with an isolated tibial plateau fracture presenting to a single academic center were enrolled and prospectively followed. Bilateral knee MRIs were performed preoperatively and 3 and 12 months postoperatively to assess quantity and quality of the quadriceps muscles. All patients underwent tibial plateau operative repair and were made non-weight-bearing for 10 weeks postoperatively then advanced to weight-bearing as tolerated. Functional status assessed via the short musculoskeletal functional assessment (SMFA); knee range of motion [ROM]; vastus medialis oblique [VMO] and vastus lateralis [VL] muscle quantity (axial width, cross sectional area [CSA] and volume) on injured and contralateral limb; VMO, sartorius, semi-membranous and biceps femoris [BF] muscle quality (fat and water content, and proton density fat fraction). All muscle quantitative and qualitative measurements were compared across all time points.

RESULTS

Ten patients were included in the final analysis, 6 males and 4 females, with average age of 43.62 ± 16.3 years. While the VMO and VL axial width and CSA were significantly decreased at 3 months preoperatively, this was not statistically significant. There was no significant difference between any QM quantitative measurements at any time points. There was no difference in fat content, water content or PDFF at any time point for the VMO, sartorius, semi-membranous and BF muscles. Regression analysis also showed no association between 12-month SMFA scores and knee ROM with VMO/VL CSA at 1 year.

CONCLUSIONS

QM quantity and quality do not significantly change at 3 months and 1 year postoperatively following tibial plateau fracture surgery.

LEVEL OF EVIDENCE

Prognostic Level II.

Minimal Clinically Important Difference (MCID) for the Short Musculoskeletal Function Assessment (SMFA) in Severe Lower Extremity Trauma: Pooled Data from 7 Multicenter, Prospective Clinical Trials

BACKGROUND

The Short Musculoskeletal Function Assessment (SMFA) is a well validated, widely used patient-reported outcome (PRO) measure for orthopaedic patients. Despite its widespread use and acceptance, this measure does not have an agreed upon minimal clinically important difference (MCID). The purpose of the present study was to create distributional MCIDs with use of a large cohort of research participants with severe lower extremity fractures.

METHODS

Three distributional approaches were used to calculate MCIDs for the Dysfunction and Bother Indices of the SMFA as well as all its domains: (1) half of the standard deviation (one-half SD), (2) twice the standard error of measurement (2SEM), and (3) minimal detectable change (MDC). In addition to evaluating by patient characteristics and the timing of assessment, we reviewed these calculations across several injury groups likely to affect functional outcomes.

RESULTS

A total of 4,298 SMFA assessments were collected from 3,185 patients who had undergone surgical treatment of traumatic injuries of the lower extremity at 60 Level-I trauma centers across 7 multicenter, prospective clinical studies. Depending on the statistical approach used, the MCID associated with the overall sample ranged from 7.7 to 10.7 for the SMFA Dysfunction Index and from 11.0 to 16.8 for the SMFA Bother Index. For the Dysfunction Index, the variability across the scores was small (<5%) within the sex and age subgroups but was modest (12% to 18%) across subgroups related to assessment timing.

CONCLUSIONS

A defensible MCID can be found between 7 and 11 points for the Dysfunction Index and between 11 and 17 points for the Bother Index. The precise choice of MCID may depend on the preferred statistical approach and the population under study. While differences exist between MCID values based on the calculation method, values were consistent across the categories of the various subgroups presented.

LEVEL OF EVIDENCE

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

The MCID of the PROMIS physical function instrument for operatively treated tibial plateau fractures

INTRODUCTION

Understanding minimal clinically important differences (MCID) in patient reported outcome measurement are important in improving patient care. The purpose of this study was to determine the MCID of Patient-Reported Outcome Measurement System (PROMIS) Physical Function (PF) domain for patients who underwent operative fixation of a tibial plateau fracture.

METHODS

All patients with tibial plateau fractures that underwent operative fixation at a single level 1 trauma center were identified by Current Procedural Terminology codes. Patients without PROMIS PF scores or an anchor question at two-time points postoperatively were excluded. Anchor-based and distribution-based MCIDs were calculated.

RESULTS

The MCID for PROMIS PF scores was 4.85 in the distribution-based method and 3.93 (SD 14.01) in the anchor-based method. There was significantly more improvement in the score from the first postoperative score (<7 weeks) to the second postoperative time (<78 weeks) in the improvement group 10.95 (SD 9.95) compared to the no improvement group 7.02 (SD 9.87) in the anchor-based method (P < 0.001). The percentage of patients achieving MCID at 7 weeks, 3 months, 6 months, and 1 year were 37-42 %, 57-62 %, 80-84 %, and 95-87 %, respectively.

DISCUSSION

This study identified MCID values for PROMIS PF scores in the tibial plateau fracture population. Both MCID scores were similar, resulting in a reliable value for future studies and clinical decision-making. An MCID of 3.93 to 4.85 can be used as a clinical and investigative standard for patients with operative tibial plateau fractures.

Tibial plateau fractures in older adults are associated with a clinically significant deterioration in health-related quality of life

To investigate health-related quality of life (HRQoL) of older adults (aged ≥ 60 years) after tibial plateau fracture (TPF) compared to preinjury and population matched values, and what aspects of treatment were most important to patients. We undertook a retrospective, case-control study of 67 patients at mean 3.5 years (SD 1.3; 1.3 to 6.1) after TPF (47 patients underwent fixation, and 20 nonoperative management). Patients completed EuroQol five-dimension three-level (EQ-5D-3L) questionnaire, Lower Limb Function Scale (LEFS), and Oxford Knee Scores (OKS) for current and recalled prefracture status. Propensity score matching for age, sex, and deprivation in a 1:5 ratio was performed using patient level data from the Health Survey for England to obtain a control group for HRQoL comparison. The primary outcome was the difference in actual (TPF cohort) and expected (matched control) EQ-5D-3L score after TPF. TPF patients had a significantly worse EQ-5D-3L utility (mean difference (MD) 0.09, 95% confidence interval (CI) 0.00 to 0.16; p < 0.001) following their injury compared to matched controls, and had a significant deterioration (MD 0.140, 95% CI 0 to 0.309; p < 0.001) relative to their preoperative status. TPF patients had significantly greater pre-fracture EQ-5D-3L scores compared to controls (p = 0.003), specifically in mobility and pain/discomfort domains. A decline in EQ-5D-3L greater than the minimal important change of 0.105 was present in 36/67 TPF patients (53.7%). Following TPF, OKS (MD -7; interquartile range (IQR) -1 to -15) and LEFS (MD -10; IQR -2 to -26) declined significantly (p < 0.001) from pre-fracture levels. Of the 12 elements of fracture care assessed, the most important to patients were getting back to their own home, having a stable knee, and returning to normal function. TPFs in older adults were associated with a clinically significant deterioration in HRQoL compared to preinjury level and age, sex, and deprivation matched controls for both undisplaced fractures managed nonoperatively and displaced or unstable fractures managed with internal fixation.

The effects of pain relief on proprioception and muscle strength for tibial plateau fractures: A randomized controlled trial

OBJECTIVES

To investigate the effect of transcutaneous electrical acupoint stimulation (TEAS) combined with proprioceptive neuromuscular facilitation (PNF) on postural stability, muscle strength and pain in patients with tibial plateau fracture.

METHOD

A 3-arm randomized controlled trial was conducted in 60 patients with tibial plateau fracture. Participants received one of the following interventions: standard treatment (ST group, n = 20), ST + PNF training (ST + PNF group, n = 20), ST + PNF training + TEAS intervention (ST + PNF + TEAS group, n = 20). All treatments lasted for six weeks. Participants' postural stability, muscle strength and pain were evaluated at baseline, after 3 and 6 weeks of intervention.

RESULTS

After 3 weeks of intervention, Between-group comparisons showed that both the ST + PNF group and ST + PNF + TEAS group showed significantly greater performance than the ST group in the postural stability measure (P < 0.02) and pain score(P < 0.05). The peak torque of quadriceps extensors and flexors at the velocity of 60°/s was significantly higher in the ST + PNF + TEAS group than in the ST group (P < 0.02). After 6 weeks of intervention, only the ST + PNF + TEAS group was superior to the ST group in postural stability measure(P < 0.04) and in pain score (P < 0.05). The ST + PNF + TEAS group was significantly higher than the ST + PNF group and the ST group in the peak torque of quadriceps extensors at the velocity of 60°/s and 180°/s (P < 0.01).

CONCLUSION

PNF training could improve dynamic postural stability and relieve pain at three weeks, while TEAS combined with PNF was more effective in relieving pain, strengthening muscle strength and improving dynamic postural stability at six weeks post-intervention.

A preliminary study of the surgical approach for posterior tibial plateau fractures: Based on posterior fragment segment classification

PURPOSE

The optimal surgical approach for the posterior tibial plateau fractures (PTPFs) remains controversial. This study aims to establish a method for posterior fragment segment classification to guide the choice of surgical approach and to reveal the outcome of their early reduction and health status.

METHODS

The medical records of 42 PTPFs patients treated with the strategy were collected retrospectively from December 2017 to December 2021. The posterior cortex of the tibial plateau was classified into postero-medial (PM), postero-central (PC), and postero-lateral (PL) segments. A posteromedial inverted L-shaped approach was adopted when the fractures involved the PM segment in the presence or absence of PC. The Frosch approach was performed when the PL segment was concerned. Fractures containing both PM and PL segments were treated by combined approaches. Four factors were measured to evaluate the reduction effect, including medial proximal tibial angle (MPTA), lateral posterior slope angle (LPSA), medial posterior slope angle (MPSA), and articular step-off. The Short Form 36 (SF-36) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were completed at the last follow-up to assess health status and the degree of osteoarthritis.

RESULTS

A posteromedial inverted L-shaped approach was adopted in 16 PTPFs patients, a Frosch approach was adopted in 14 PTPFs patients, and a combined approach was adopted in 12 PTPFs patients. Immediate radiographic results indicated a promising fixation performance with this treatment strategy. The results of SF-36 and WOMAC scores reported good health status in all patients with a mean follow-up time of 34.50 (23-50) months. Two patients developed superficial wound infections, and one patient had liquefaction necrosis in adipose tissue. Although skin numbness occurred in 4 patients, they recovered within 6 months.

CONCLUSION

PTPFs patients treated under the guidance of posterior fragment segment classification achieved encouraging levels of immediate fixation and health status.

Tibial plateau fractures in the elderly have clinical outcomes similar to those in younger patients

BACKGROUND

The purpose of this study was to compare outcomes following surgical treatment of tibial plateau fractures in an elderly (≥ 65y) and non-elderly (< 65) population.

METHODS

Patients with tibial plateau fractures were prospectively followed. Patients were included if they were operatively treated, had an Injury Severity Score of < 16, and had follow-up through 12 months. Clinical, radiographic, and functional outcomes were evaluated at the 3, 6, and 12-month follow-up points.

RESULTS

Mean time to radiographic fracture union was by 4.68 and 5.26 months in young and elderly patients, respectively (p = 0.25). There was no difference in self-reported baseline SMFA (p = 0.617). SMFA scores were better in younger patients at 3 months (p = 0.031), however this did not hold when multivariate modeling controlled for other factors. There was no difference at 6 and 12 months (p = 0.475, 0.392). There was no difference in range of knee motion at 3 months. At 6 and 12 months, young patients had statistically but not clinically better range of knee motion (p = 0.045, 0.007). There were no differences in overall reoperation rates, conversion arthroplasty, post-traumatic osteoarthritis or wound complications.

CONCLUSIONS

Age greater than 65 does not appear to portend poorer outcomes after surgical repair of a tibial plateau fracture. The complication profiles are similar. Elderly and younger patients had similar function at 12 months compared to their baseline. These data suggest that age should not be a disqualifying factor when considering whether a patient with a tibial plateau fracture should be treated operatively.

Comparison of Patient-Reported Outcomes After Suprapatellar Versus Infrapatellar Nailing Techniques for Tibial Shaft Fractures: A Systematic Review and Meta-analysis

OBJECTIVES

To compare patient-reported outcome measures (PROMs) between patients who underwent intramedullary nail (IMN) fixation for tibial shaft fractures using an infrapatellar (IP) or the newer suprapatellar (SP) approach. Secondary outcomes included fluoroscopic radiation exposure, operative time, and radiographic outcomes.

DATA SOURCES

A systematic literature search of the databases Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials Study Selection.

STUDY SELECTION

Level I to III studies in which patients over the age of 18 years with acute tibial shaft fractures who underwent tibial IMN fixation using an IP or SP approach for fracture fixation were assessed for inclusion. Studies with a minimum of 10 patients in each cohort that reported on postoperative patient-reported outcomes with at least 6 months of follow-up were included for analysis.

DATA EXTRACTION AND SYNTHESIS

Twelve studies that reported PROMs and compared IP and SP intramedullary nailing of tibial shaft fractures were analyzed. This included 654 patients who underwent IP IMN fixation and 542 patients who underwent SP IMN fixation. A random-effects model for unadjusted/crude study estimates were pooled using inverse variance (IV) weighting for continuous variable analysis.

CONCLUSIONS

This review found a significant improvement in PROM for patients with tibial shaft fractures when the SP IMN technique was used. In addition, there was a significant decrease in intraoperative fluoroscopy time consistent with other radiographic findings demonstrating improved start point accuracy and reduction with SP IMN fixation of tibial shaft fractures.

LEVEL OF EVIDENCE

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

Responsiveness of the PROMIS physical function measure in orthopaedic trauma patients

OBJECTIVES

To compare the responsiveness of the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) to the 36-Item Short Form Survey Physical Component Score (SF36-PCS) in orthopaedic trauma patients from pre-injury to one year recovery.

DESIGN AND SETTING

Prospective cohort study at a Level 1 trauma centre.

PARTICIPANTS

Patients over the age of 18 with orthopaedic trauma injuries to the pelvis, lower extremity or upper extremity between 2017 and 2018.

MAIN OUTCOMES MEASUREMENTS

The PROMIS-PF and SF36-PCS assessments were conducted at baseline, 3 months, 6 months and 12 months. Responsiveness of each measure was assessed between time points by calculating the standardized response mean (SRM), the proportions of patients exceeding minimal clinically important difference (MCID), and the floor and ceiling effects.

RESULTS

Sixty-eight patients with completed assessments at every timepoint were included: mean age 44.7 years, 39 were male and mean Injury Severity Score (ISS) was 7.4 (range: 4-16). Mean time of completion for the SF-36 at all the time points was 5.6 min vs 1.7 min for the PROMIS-PF (p<0.01). The SRM was comparable between measures at all the time points. Although a greater proportion of patients achieved MCID for SF36-PCS between all the time points, this only approached statistical significance between the 6- and 12-month assessments (47.1% vs 33.8%; p = 0.15). There was a significant ceiling effect demonstrated with the PROMIS-PF at baseline and 12-month assessments, with 34 (50.0%) patients and 7 (10.3%) patients achieving the maximum scores at each time point, respectively.

DISCUSSION AND CONCLUSIONS

PROMIS-PF has a more favourable responder burden based on lower time to completion and comparable responsiveness to the SF-36 PCS. However, there are limitations in responsiveness with the PROMIS-PF in patients who are higher functioning as demonstrated by the ceiling effects in patients at baseline pre-injury and at 12 months post-injury timepoints.

Minimum Clinically Important Difference in Short Musculoskeletal Function Assessment: What Change Matters in Ankle Fractures

Accurate interpretation of the clinical significance of patient-reported outcome (PRO) research requires determination of the threshold where a difference in PRO score represents a clinical benefit to patients, termed the minimum clinically important difference (MCID). The Short Musculoskeletal Function Assessment (SMFA) is one of the most commonly utilized PRO tools in orthopaedics. However, to date, no MCID has been determined. The purpose of this study was to define the MCID for the SMFA. A prospectively collected ankle fracture outcomes registry was reviewed between 2014 and 2016. Inclusion criteria were isolated ankle fracture, treatment with open reduction and internal fixation, and 6-week follow-up with completed SMFA. Two commonly utilized methods to determine the MCID, the anchor and distribution methods, were performed in this study. Overall, 105 patients met inclusion/exclusion criteria. Utilizing both the overall health anchor and the mental and emotional health anchor, the MCID was 7.3 (n = 17 and n = 19, respectively). The distribution method MCID was 7.0 (n = 105). Our study found the MCID values for the SMFA to converge around a value of 7 for the 3 analyses. This indicates that a threshold of 7 should be applied to studies utilizing the SMFA to determine the clinical significance of the results.

Which general functional outcome measure does a better job of capturing change in clinical status in pelvic and acetabular fracture patients? An analysis of responsiveness over the first year of recovery

OBJECTIVE

To compare the responsiveness of the Short Form-36 (SF-36) physical component score (PCS) to the Short Musculoskeletal Function Assessment (SMFA) dysfunction index (DI) in pelvic and acetabular fracture patients over multiple time points in the first year of recovery.

DESIGN

Prospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Four hundred seventy-three patients with surgically treated pelvic and acetabular fractures (Orthopaedic Trauma Association B or C-type pelvic ring disruption or acetabular fracture) were enrolled into the center's prospective orthopaedic trauma database between January 2005 and February 2015. Functional outcome data were collected at baseline, 6 months, and 12 months.

MAIN OUTCOME MEASUREMENTS

Evaluation was performed using the SF-36 Survey and Short Musculoskeletal Function Assessment. Responsiveness was assessed by calculating the standard response mean (SRM), the minimal clinically important difference (MCID), and floor and ceiling effects.

RESULTS

Three hundred five patients had complete data for both outcome scores. SF-36 PCS and SMFA DI scores showed strong correlation for all time intervals (r = -0.55 at baseline, r = -0.78 at 6 months, and r = -0.85 at 12 months). The SRM of the SF-36 PCS was greater in magnitude than the SRM of SMFA DI at all time points; this was statistically significant between baseline and 6 months (P < .001), but not between 6 and 12 months (P = .29). Similarly, the proportion of patients achieving MCID in SF-36 PCS was significantly greater than the proportion achieving MCID in SMFA DI between baseline and 6 months (84.6% vs 69.8%, P < .001), and between 6 and 12 months (48.5% vs 35.7%, P = .01). There were no ceiling or floor effects found for SF-36 PCS at any time intervals. However, 16.1% of patients achieved the highest level of functioning detectable by the SMFA DI at baseline, along with smaller ceiling effects at 6 months (1.3%) and 12 months (3.3%).

CONCLUSIONS

SF-36 PCS is a more responsive measure of functional outcome than the SFMA DI over the first year of recovery in patients who sustain a pelvic ring disruption or acetabular fracture. This superiority was found in using the SRM, proportion of patients meeting MCID, and ceiling effects. Furthermore, the SF-36 PCS correlated with the more disease-specific SMFA DI.

LEVEL OF EVIDENCE

Prognostic Level II.

A comparison of clinical, radiological, and quality-of-life outcomes of double-plate internal and Ilizarov external fixations for Schatzker type 5 and 6 tibia plateau fractures

PURPOSE

To compare clinical, functional, and radiological outcomes in patients with bicondylar tibial fractures treated with either double-plate or Ilizarov external fixation.

METHODS

Patients with Schatzker type 5 and 6 tibial plateau fractures who were treated with double-plate (Group O) and Ilizarov external fixations (Group E) between March 2012 and April 2018 were selected. Demographic data and preoperative, intraoperative, and postoperative variables were analyzed and compared. In the last follow-up, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), Knee Society Score-Knee (KSS-Knee), KSS-Function (KSS-F), and Short-Form Health Survey (SF-36) were used to measure clinical and functional outcomes. Treatment costs and complication rates were also recorded and compared.

RESULTS

A total of 64 patients (43 men and 21 women) were included in the study (group O: 36, group E: 28). WOMAC, KSS-F, KSS-Knee, and OKS scores were similar between the two groups (P > 0.05). The role limitations due to emotional problems, emotional well-being, and social functioning domains of SF-36 were higher in group O (P < 0.001). Three (8.3%) deep infections occurred in group O, whereas no deep infection was observed in group E (P = 0.035). The treatment cost was higher in group O (P < 0.001).

CONCLUSION

In bicondylar tibial plateau fractures, functional outcomes of ORIF and Ilizarov method milar were sibut, role limitations due to emotional problems, emotional well-being and social functioning domains of SF-36 score were higher in ORIF group. However, Ilizarov method is more cost-effective and related with lesser complications.

Comparing the responsiveness of a generic and a musculoskeletal specific functional outcome measure in orthopaedic patients with operative fixation of pelvic ring, acetabulum, or tibia fractures: a comparison between single injury and multiply injured patients

OBJECTIVES

This study compares the responsiveness, or the ability to detect clinical change in a disease, between the generic Short Form-36 (SF-36) and musculoskeletal specific Short Musculoskeletal Functional Assessment (SMFA) patient-reported outcome measures (PROMs) in the orthopaedic trauma population. Stratified analysis was performed to compare whether responsiveness differs between patients with single or multiple orthopaedic injuries.

DESIGN

Prospective case series.

SETTING

Level 1 Trauma Center.

PATIENTS

A total of 659 patients with orthopaedic trauma injuries to the pelvis, acetabulum, or tibia were included for analysis. There were 485 patients with a single isolated injury and 174 patients with multiple orthopaedic injuries.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

Responsiveness was calculated through the standard response mean (SRM), the proportion meeting a minimal clinically important difference, and floor and ceiling effects.

RESULTS

Between baseline and 6 months the magnitude of the SRM for SF-36 was consistently greater than that of SMFA in patients with single (P < .01) and multiple injuries (P < .01). Between 6 and 12 months, there were no differences in SRM across all cohorts. The proportion of patients who achieved minimal clinically important difference was consistently higher when assessed with SF-36 compared with SMFA between baseline and 6 months (81.8% vs 68.1%, P < .0001) and between 6 and 12 months (63.3% vs 55.4%, P = .01).A ceiling effect was only observed at baseline for the SMFA with 16.6% of patients achieving the maximal level of functioning detectable. No floor effects were seen in either PROM.

CONCLUSION

This study demonstrates that SF-36 has superior responsiveness versus SMFA in both polytrauma and isolated injury patients and supports the collection of SF-36 as the primary PROM in prospective orthopaedic trauma studies irrespective of whether the patient has an isolated injury or multiple injuries.

Measurement properties of Patient-Reported Outcome Measures in patients with a tibial shaft fracture; validation study alongside the multicenter TRAVEL study

The aim of this study was to evaluate the measurement properties of the Short Musculoskeletal Function Assessment (SMFA) and Lower Extremity Functional Scale (LEFS) in patients who sustained a tibial shaft fracture, by comparing them with the scores of a general health-related quality of life instrument scale (i.e., EuroQoL-5D). Data of 136 patients participating in a multicenter randomized controlled trial comparing incisions for intramedullary nail entry in adults with a tibial shaft fracture were used. Patients completed the SMFA, LEFS, EQ-5D and an anchor question at 2 and 6 weeks, and at 3, 6 and 12 months. Reliability (internal consistency), construct validity, responsiveness (longitudinal validity), floor and ceiling effects, minimal important change (MIC), and smallest detectable change (SDC) were determined. The SMFA and LEFS (sub)scales showed adequate internal consistency (0.84<α<0.94). Construct and longitudinal validity were also adequate (correctly predicted hypotheses between 83%-100%). Floor effects were not present. Ceiling effects were present at 12 months for the SMFA lower extremity dysfunction and bother subscales (22% and 19%, respectively) and the LEFS (19%). MICs could not be determined with the available data. The SDC was 13.84 points for the SMFA and 38.74 points for the LEFS. This study confirms that the SMFA and LEFS are reliable, valid, and responsive instruments for monitoring functional limitation in patients after sustaining a tibia shaft fracture during at least the first six months post-injury. An anchor-based MIC for the SMFA remains to be determined.

Repair of proximal humerus fracture nonunions using a standardized treatment algorithm: a case series

BACKGROUND

Nonunion of fractures about the proximal humerus represents a rare and complex problem. The purpose of this study was to evaluate the clinical and functional outcomes following proximal humerus fracture (PHF) nonunion repair using a plate and screw construct with a direct comparison to those experienced following operative fixation of acute PHF using a plate and screw construct.

METHODS

Two separate patient cohorts were included in this study. The first consisted of 16 patients diagnosed with a non-united PHF who underwent operative nonunion repair treated with a standard algorithmic approach. The comparison group consisted of 173 patients who achieved union following initial open reduction and internal fixation of an acute PHF treated with a proximal humerus locking plate construct. All patients had at least 12 months of postoperative follow-up. Outcomes were assessed for both groups using American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale (VAS) pain scores, and postoperative shoulder range of motion (ROM). Statistical analyses were used to compare these outcome measures between the two cohorts.

RESULTS

The nonunion repair cohort consisted of eleven surgical neck nonunions and five nonunions of both the surgical neck and greater tuberosity. Ten patients had undergone surgical treatment for their original fracture, while six were initially treated non-operatively. All patients had Boileau type 3 sequelae of their proximal humerus fracture. Union was achieved in all patients at a mean of 5.4 months following nonunion repair. Complications included hardware failure requiring revision in two patients (12.5%) and avascular necrosis requiring conversion to anatomic total shoulder arthroplasty following union in one patient (6.3%). The nonunion repair and acute fracture cohorts did not differ with respect to mean ASES scores, VAS pain scores, or active shoulder ROM at any postoperative time point.

CONCLUSION

Surgical repair of PHF nonunion is a viable treatment strategy that can lead to consistent bony healing with outcomes comparable to those of patients who achieve fracture union following initial surgical repair of an acute proximal humerus fracture. Surgeons should be cognizant of mechanical considerations that may lead to early failure.

Improvement in Functional Outcomes After Elective Symptomatic Orthopaedic Implant Removal

INTRODUCTION

The relative indications for removing symptomatic implants after osseous healing are not fully agreed on. The purpose of this study was to (1) determine whether patients showed improvement in functional outcomes after the removal of symptomatic orthopaedic implants, (2) compare the outcomes between upper and lower extremity implant removal, and (3) determine the rate of implant removal complications.

METHODS

A prospective study was conducted between 2013 and 2016. Patients completed a Short Musculoskeletal Function Assessment outcome questionnaire before implant removal and at the 6-month follow-up. Demographic data were stratified and compared between upper and lower extremity groups and between preimplant removal and 6-month postremoval.

RESULTS

Of the 119 patients included in the study, 85 (71.4%) were lower extremity and 34 (28.6%) were upper extremity. Significant improvement after implant removal was seen in the dysfunction index (P ≤ 0.001), bother index (P ≤ 0.001), and daily activities domain (P ≤ 0.001). Depression or anxiety (P = 0.016) were statistically significant predictors for an improved Short Musculoskeletal Function Assessment dysfunction index score at 6 months. The complication rate was 10.1% (n=12) for the cohort.

DISCUSSION

Implant removal in both the upper and lower extremity presented notable improvement in dysfunction. Complications that require surgical intervention are extremely rare.

Measuring Outcomes Over Time in Distal Radius Fractures: A Comparison of Generic, Upper Extremity-Specific and Wrist-Specific Outcome Measures

Purpose

This study compared the responsiveness of a generic (Short Form-36 [SF-36]), an upper extremity-specific (Disabilities of the Arm, Shoulder, and Hand [DASH]) and a wrist-specific (Patient-Rated Wrist Evaluation [PRWE]) outcome score when evaluating distal radius fractures over time.

Methods

We observed 235 patients who met the inclusion criteria of an isolated distal radius fracture treated surgically or nonsurgically and greater than age 50 years for 12 months in this prospective study. Standardized assessments were performed at baseline and at 6 and 12 months. Exclusion criteria included subjects with concomitant injuries in the ipsilateral limb and follow-up of less than 1 year. Responsiveness was evaluated through the standardized response mean and the proportion who met a minimal clinically important difference. Floor and ceiling effects were also calculated.

Results

The standardized response mean was significantly greatest for the DASH between baseline and 6 months (P < .001), and the PRWE between both baseline and 6 months (P < .01) and 6 and 12 months (P < .01) compared with the SF-36. The proportion of patients who met a minimal clinically important difference between baseline and 6 months was greater in the PRWE, but it did not meet statistical significance (P = .12). The PRWE demonstrated a high ceiling effect at baseline (76.6%) but less so at 12 months (16.9%). The DASH demonstrated similar ceiling effects at baseline (62.9%) and 12 months (18.6%). The SF-36 had no ceiling effect.

Conclusions

In the first 6 months, both the DASH and PRWE have greater responsiveness in assessing change over the SF-36 in distal radius fractures. From 6 to 12 months, the wrist-specific PRWE has greater responsiveness over both the DASH and SF-36. This supports the use of the anatomy- and injury-specific outcome measures over the generic outcome measure in detecting change over a patient's early recovery. However, as the time from injury increases, the absence of a ceiling effect from the generic outcome measure may become more useful.

Clinical relevance

This study demonstrates the responsiveness of the DASH, PRWE, and SF36 in assessing distal radius fractures treated in patients greater than age 50 in the first year. In establishing the most responsive measure, respondent burden can be decreased in future research.

Short or long intramedullary devices for hip fracture? A systematic review of the evidence

Trochanteric hip fractures may be fixed with either sliding hip screws or intramedullary devices. Current UK guidance is that intramedullary fixation should be used for AO/OTA 31A3 fractures but does not stipulate length of nail. We present a systematic review comparing short and long nails for these injuries in older patients. Three studies were randomized, all with methodological concerns. None demonstrated a clinically significant difference in outcome. There is no good evidence to support long over short intramedullary devices in this scenario. Evidence is required to demonstrate whether the potentially increased surgical risk confers any benefits in this group.

Predicting Functional Outcomes Following Fracture Nonunion Repair-Development and Validation of a Risk Profiling Tool

OBJECTIVES

To develop a tool that can be used preoperatively to identify patients at risk of poor functional outcome following operative repair of fracture nonunion.

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Academic medical center.

PATIENTS/PARTICIPANTS

Three hundred twenty-eight patients who underwent operative repair of a fracture nonunion were prospectively followed for a minimum of 12 months post-operatively.

INTERVENTION

After randomization, 223 (68%) patients comprised an experimental cohort and 105 (32%) patients comprised a separate validation cohort. Within the experimental cohort, forward stepwise multivariate logistic regression was applied to 17 independent variables to generate a predictive model identifying patients at risk of having a poor functional outcome [Predicting Risk of Function in Trauma-Nonunion (PRoFiT-NU) Score].

MAIN OUTCOME MEASUREMENTS

Functional outcomes were assessed using the Short Musculoskeletal Function Assessment (SMFA). Poor outcome was defined as an SMFA function index greater than 10 points above the mean at 12 months post-operatively.

RESULTS

Significant predictors of poor outcome were lower extremity nonunion [odds ratio (OR) = 3.082; P = 0.021], tobacco use (OR = 2.994; P = 0.009), worker's compensation insurance (OR = 3.986; P = 0.005), radiographic bone loss (OR = 2.397; P = 0.040), and preoperative SMFA function index (OR = 1.027; P = 0.001). The PRoFiT-NU model was significant and a good predictor of poor functional outcome (χ(5) = 51.98, P < 0.0005; area under the receiver operating curve = 0.79). Within the separate validation cohort, 16% of patients had a poor outcome at a PRoFiT-NU score below 25% (low risk), 39% of patients had a poor outcome at a PRoFiT-NU score between 25% and 50% (intermediate risk), and 63% of patients had a poor outcome at a PRoFiT-NU score above 50% (high risk).

CONCLUSIONS

The PRoFiT-NU score is an accurate predictor of poor functional outcome following fracture nonunion repair.

LEVEL OF EVIDENCE

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

Is PROMIS the new standard for patient-reported outcomes measures in orthopaedic trauma research?

This review describes some of the benefits of the Patient-Reported Outcomes Measurement Information System (PROMIS) architecture, determined how frequently PROMIS measures were used in the current orthopaedic trauma literature, and compared the features of PROMIS instruments with other frequently used patient-reported outcomes measures (PROMs). PROMIS instruments have several unique elements to their architecture, such as item response theory, computerized adaptive testing options, and scaling using T-scores, that differentiate the instruments from many other PROMs. Over the past five years, 108 different PROMs were reported in 319 studies published in high-impact orthopaedic journals. PROMIS measures, including PROMIS Physical Function, Pain Interference, and Upper Extremity Function, were only used in seven studies (2%). PROMIS measures were found to be comparable to other more common PROMs with respect to respondent burden, administration options, and psychometric assessments specific to fracture patients. Likely, the limited familiarity and interpretability of PROMIS measures in the fracture population remain the most substantial barriers to broader adoption in orthopaedic trauma research.

Patient function continues to improve over the first five years following tibial plateau fracture managed by open reduction and internal fixation

Aims

Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients’ long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques.

Methods

In total, 102 patients who sustained a displaced tibial plateau fracture and underwent operative repair by one of three orthopaedic traumatologists at a large, academic medical centre and had a minimum of five-year follow-up were identified. Breakdown of patients by Schatzker classification is as follows: two (1.9%) Schatzker I, 54 (50.9%) Schatzker II, two (1.9%) Schatzker III, 13 (12.3%) Schatzker IV, nine (8.5%) Schatzker V, and 26 (24.5%) Schatzker VI. Follow-up data obtained included: Visual Analogue Scale (VAS) or Numeric Rating Scale (NRS) pain scores, Short Musculoskeletal Functional Assessment (SMFA), and knee range of movement (ROM). Data at latest follow-up were then compared to 12-month data using a paired t-test.

Results

Patient-reported functional outcomes as assessed by overall SMFA were statistically significantly improved at five years (p < 0.001) compared with one-year data from the same patients. Patients additionally reported an improvement in the Standardized Mobility Index (p < 0.001), Standardized Emotional Index (p < 0.001), as well as improvement in Standardized Bothersome Index (p = 0.003) between the first year and latest follow-up. Patient-reported pain and knee ROM were similar at five years to their one-year follow-up. In total, 15 of the patients had undergone subsequent orthopaedic surgery for their knees at the time of most recent follow-up. Of note, only one patient had undergone knee arthroplasty following plateau fixation related to post-traumatic osteoarthritis (OA).

Conclusion

Knee pain following tibial plateau fracture stabilizes at one year. However, PROs continue to improve beyond one year following tibial plateau fracture, at least in a statistical sense, if not also clinically. Patients displayed statistical improvement across nearly all SMFA index scores at their minimum five-year follow-up compared with their one-year follow-up. Cite this article: Bone Joint J 2020;102-B(5):632–637.

Minimal important change in physical function in trauma patients: a study using the short musculoskeletal function assessment

Purpose

The Short Musculoskeletal Function Assessment (SMFA) questionnaire can be used to evaluate physical functioning in patients with traumatic injuries. It is not known what change in score reflects a meaningful change to patients. The aim was to determine minimal important change (MIC) values of the subscales (0–100) of the Dutch SMFA-NL in a sample of patients with a broad range of injuries.

Methods

Patients between 18 and 65 years of age completed the SMFA-NL and the Global Rating of Effect (GRE) questions at 6-week and 12-month post-injury. Anchor-based MIC values were calculated using univariable logistic regression analyses.

Results

A total of 225 patients were included (response rate 67%). The MIC value of the Upper Extremity Dysfunction (UED) subscale was 8 points, with a misclassification rate of 43%. The Lower Extremity Dysfunction subscale MIC value was 14 points, with a misclassification rate of 29%. The MIC value of the Problems with Daily Activities subscale was 25 points, with a misclassification rate of 33%. The MIC value of the Mental and Emotional Problems (MEP) subscale was 7 points, with a misclassification rate 37%.

Conclusion

MIC values of the SMFA-NL were determined. The MIC values aid interpreting whether a change in physical functioning can be considered clinically important. Due to the considerable rates of misclassification, the MIC values of the UED and MEP subscales should be used with caution.

Short Versus Long Cephalomedullary Nails for Pertrochanteric Hip Fractures: A Randomized Prospective Study

OBJECTIVE

To compare functional and clinical outcomes in patients with pertrochanteric hip fractures treated with either a short (SN) or long (LN) cephalomedullary nail.

DESIGN

Prospective, randomized.

SETTING

Clinical investigation was performed at the Mayo Clinic's Level 1 Trauma Center in Rochester, MN.

PATIENTS/PARTICIPANTS

Two hundred twenty patients with intertrochanteric fractures were prospectively randomized to an SN or LN cohort. A total of 168 patients (SN, n = 80; LN, n = 88) had a mean follow-up of 13.9 months. Fifty-two patients did not meet the minimum 3-month follow-up. Demographics were comparable between the cohorts.

MAIN OUTCOME MEASURES

The primary outcome measurement was functional outcome evaluated by Short Form (SF-36) and Harris Hip scores (HHS) at 3 months. Secondary outcomes included implant failure, peri-implant fracture, mortality, operative time, estimated blood loss, and reoperation.

RESULTS

SN and LN cohorts were comparable in all aspects of the SF-36. There was a clinically insignificant difference in the HHS between cohorts. Patients treated in the SN cohort experienced shorter operative times but did not differ in tip-to-apex distance or subtrochanteric fracture extension. There was no difference in implant cutout, deep surgical site infection, or peri-implant fractures.

CONCLUSIONS

Patients treated with SNs or LNs for pertrochanteric femur fractures experienced comparable functional outcomes as measured by SF-36 and HHS. When compared with the LN cohort, SN patients experienced no difference in peri-implant fracture or lag-screw cutout and tolerated up to 3 cm of subtrochanteric fracture line extension.

LEVEL OF EVIDENCE

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

Comparison of Generic, Musculoskeletal-Specific, and Foot and Ankle-Specific Outcome Measures Over Time in Tibial Plafond Fractures

BACKGROUND

This study performed a psychometric analysis assessing and comparing the responsiveness of the relevant components of a generic (Short Form-36 [SF36]), a musculoskeletal-specific (Short Musculoskeletal Functional Assessment [SMFA]), and a foot and ankle-specific (Foot and Ankle Outcome Score [FAOS]) outcome score when evaluating surgically treated tibial plafond fractures over time.

METHODS

Fifty-one patients were followed for 12 months after their tibial plafond fracture. Responsiveness, or the ability to detect clinical change in a disease, was evaluated through the standardized response mean (SRM), the proportion meeting a minimal clinically important difference (MCID), and floor and ceiling effects.

RESULTS

The SRM of the SF36-Physical Component Summary (PCS) was significantly greater than the SMFA-dysfunction index (DI) (P < .01) and FAOS-Activities of Daily Living (ADL) (P = .01) between baseline and 6 months, whereas the SRMs of only SF36-PCS and FAOS-ADL differed (P = .01) between 6 and 12 months. The proportion of patients achieving an MCID for SF36-PCS was higher than FAOS-ADL (P = .03) between baseline and 6 months and higher than SMFA-DI (P = .04) between 6 and 12 months. The FAOS-ADL showed substantial ceiling effects at baseline (88.2%) but much less at 6 months (5.9%) and 12 months (9.8%). Smaller ceiling effects were observed for the SMFA-DI (11.8%) at baseline, whereas none were observed for the SF36-PCS.

CONCLUSIONS

This study found that the SF36-PCS had greater responsiveness in assessing tibial plafond fractures compared to the SMFA-DI and FAOS-ADL, particularly in the first 6 months after surgery. In addition, limitations were revealed in the SMFA-DI and FAOS-ADL. This study illustrates the necessary diligence required for selection of outcome measures, as musculoskeletal and anatomy specific scores are not necessarily superior.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Responsiveness of the EQ-5D-3L in elective shoulder surgery: Does it adequately represent patient experience?

AIM

Generic patient-reported outcome measures (PROMs) allow comparison of health-related quality of life across populations and pathologies. For these comparisons to be valid, the PROM must be responsive; the score must change when the patient's quality of life changes. This study aims to assess the responsiveness of the EQ-5D-three level (3L) in elective shoulder surgery.

METHODS

Pre- and post-operative EQ-5D-3L and Oxford Shoulder Scores (OSS) were prospectively collected across a range of 204 elective shoulder surgeries. Internal responsiveness was assessed through significance testing of mean change scores and standardized response means (SRMs). External responsiveness of the EQ-5D-3L was assessed against the minimal clinically important difference in OSS, using receiver operating characteristic curve and change score correlation.

RESULTS

Both EQ-5D-3L and OSS scores improved significantly over time ( p < 0.05). The SRM for the EQ-5D was 1.27 (95% CI 1.14-1.41) and for OSS 2.36 (2.22-2.52). Area under the curve for EQ-5D was 0.49. Only a weak correlation was found between EQ-5D and OSS change scores ( r = 0.21).

DISCUSSION

The EQ-5D-3L is adequately internally responsive to change following elective shoulder surgery but is unable to differentiate patients demonstrating minimal clinically important change. The EQ-5D therefore only partially reflects patient experience.

Mapping recovery in simple and complex tibial plateau fracture fixation

Aims

The aim of this study was to determine the trajectory of recovery following fixation of tibial plateau fractures up to five-year follow-up, including simple (Schatzker I-IV) versus complex (Schatzker V-VI) fractures.

Patients and Methods

Patients undergoing open reduction and internal fixation (ORIF) for tibial plateau fractures were enrolled into a prospective database. Functional outcome, using the 36-Item Short Form Health Survey Physical Component Summary (SF-36 PCS), was collected at baseline, six months, one year, and five years. The trajectory of recovery for complex fractures (Schatzker V and VI) was compared with simple fractures (Schatzker I to IV). Minimal clinically important difference (MCID) was calculated between timepoints. In all, 182 patients were enrolled: 136 (74.7%) in simple and 46 (25.3%) in complex. There were 103 female patients and 79 male patients with a mean age of 45.8 years (15 to 86).

Results

Mean SF-36 PCS improved significantly in both groups from six to 12 months (p < 0.001) and one to five years (simple, p = 0.008; complex, p = 0.007). In both groups, the baseline scores were not reached at five years. The SF-36 PCS was significantly higher in the simple group compared with the complex group at both six months (p = 0.007) and 12 months (p = 0.01), but not at five years (p = 0.17). Between each timepoint, approximately 50% or more of the patients in each group achieved an MCID in their score change, indicating a significant clinical change in condition. The complex group had a much larger drop off in the first six months, with comparable proportions achieving MCID at the subsequent time intervals.

Conclusion

Tibial plateau fracture recovery was characterized overall by an initial decline in functional outcome from baseline, followed by a steep improvement from six to 12 months, and ongoing recovery up to five years. In simple patterns, patients tended to achieve a higher functional score by six months compared with the complex patterns. However, comparable functional scores between the groups achieved only at the five-year point suggest later recovery in the complex group. Function does not improve to baseline by five years in either group. This information is useful in counselling patients about the course of prospective recovery. Cite this article: Bone Joint J 2019;101-B:1009–1014.

Patient-Reported Outcomes in Foot and Ankle Orthopedics

Patient-reported outcomes (PROs) are a measure of health care quality that reflect the patient's perceptions of their own health status. Recently, there has been a renewed interest in implementation of PROs into everyday clinical practice. There are many dozens of PROs available to foot and ankle surgeons with little consensus on which measures are most appropriate for a given condition. These measures vary widely in length, validity, and content. When integrating PROs into clinical practice, we recommend that clinicians should collect, at a minimum, validated PRO scores that assess pain, function, and general health. Furthermore, concise instruments should be used wherever possible to minimize patient burden, maximize patient engagement, and ensure meaningful data are collected. In the near future, outcomes registries employing computer adaptive testing will facilitate the routine collection of PRO data from all patients.

Level of Evidence

Level V, expert opinion.

Functional outcome of implant removal following fracture fixation below the level of the knee: a prospective cohort study

AIMS

The aim of this study was to evaluate the functional outcome in patients undergoing implant removal (IR) after fracture fixation below the level of the knee.

PATIENTS AND METHODS

All adult patients (18 to 75 years) undergoing IR after fracture fixation below the level of the knee between November 2014 and September 2016 were included as part of the WIFI (Wound Infections Following Implant Removal Below the Knee) trial, performed in 17 teaching hospitals and two university hospitals in The Netherlands. In this multicentre prospective cohort, the primary outcome was the difference in functional status before and after IR, measured by the Lower Extremity Functional Scale (LEFS), with a minimal clinically important difference of nine points.

RESULTS

A total of 179 patients were included with a median age of 50 years (interquartile range (IQR) 37 to 60), of whom 71 patients (39.7%) were male. With a median score of 60 before IR (IQR 45 to 72) and 66 after IR (IQR 51 to 76) on the LEFS, there was a statistically significant improvement in functional outcome (p < 0 .001). A total of 31 surgical site infections (17.3%) occurred.

CONCLUSION

Although IR led to a statistically significant improvement of functional outcome, the minimal clinically important difference was not reached. In conclusion, this study shows that IR does not result in a clinically relevant improvement in functional outcome. These results, in combination with the high complication rate, highlight the importance of carefully reviewing the indication for IR. Cite this article: Bone Joint J 2019;101-B:447-453.

Measuring outcomes following tibial fracture

AIM

The aim of this study was to determine how outcome is measured following adult tibial fracture in the modern era of functional outcome measurement and patient reported outcomes.

METHODS

A systematic review of publications since 2009 was performed, looking specifically at acute, adult tibial shaft fractures. Ovid Medline, Embase, PubMed and PsycINFO databases were searched for relevant titles which were then screened by two authors with adjudication where necessary by a third. Relevant articles were reviewed in full and data was extracted concerning the study participants, study design and any measures that were used to quantify the results following fracture. The results were collated and patient reported outcome measures were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards.

RESULTS

A total of 943 titles and articles were reviewed, with 117 included for full analysis. A wide range of clinical and radiological "outcomes" were described, along with named clinician- and patient-reported outcome measures. There was considerable heterogeneity and lack of detail in the description of the simplest outcomes, such as union, infection or reoperation. Reported clinician and patient reported outcome measures are variably used. None of the identified patient reported outcome measures have been validated for use following tibial fracture.

CONCLUSION

We recommend definition of a core outcome set for use following tibial fracture. This will standardise outcome reporting following these injuries. Furthermore, there is need for a validated patient reported outcome measure to better assess patient important outcomes in this patient group.

The Value of Motion: Patient-Reported Outcome Measures Are Correlated With Range of Motion in Total Ankle Replacement

BACKGROUND

The proposed benefit of total ankle replacement (TAR) over ankle fusion is preserved ankle motion, thus we hypothesized that an increase in range of motion (ROM) is positively correlated with validated patient-reported outcome measures (PROMs) in individuals receiving TAR.

METHODS

Patients undergoing TAR at a single academic medical center between 2007 and 2013 were evaluated in this study. In addition to a minimum of 2-year follow-up, complete preoperative and postoperative outcome measures for the Foot and Ankle Disability Index (FADI), Short Musculoskeletal Function Assessment (SMFA) Bother and Function Indices, Visual Analog Scale (VAS), and 36-Item Short Form Health Survey (SF-36) were requisite for inclusion. Standardized weightbearing maximum dorsiflexion and plantarflexion sagittal radiographs were obtained and previously described ankle and foot measurements were performed to determine ankle ROM.

RESULTS

Eighty-eight patients met inclusion criteria (33 INBONE, 18 Salto-Talaris, 37 STAR). Mean time to final ROM radiographs was 43.8 months (range 24-89 months). All aforementioned PROMs improved between preoperative evaluation and most recent follow-up (  P < .01). Final ankle ROM was significantly correlated with postoperative FADI, SF-36 Mental Component Summary (MCS), SMFA Bother and Function Indices, and VAS. Additionally, dorsiflexion was positively associated with FADI, SF-36 MCS, and SMFA Function (  P < .05) but plantarflexion had no such influence on outcomes. No differences were identified with subset stratification by prosthesis type, fixed versus mobile-bearing design or etiology.

CONCLUSION

In this TAR cohort with prospectively collected outcomes data, radiographic sagittal plane ankle motion was positively correlated with multiple PROMs. Disease-specific and generic health-related quality of life PROMs demonstrated improvement postoperatively in all domains when evaluating final total range of motion. Patients who undergo TAR for end-stage osteoarthritis with improvement in ROM demonstrate a direct correlation with improved patient-centric metrics and outcome scores.

LEVELS OF EVIDENCE

Level III: Retrospective comparative study.

Functional Outcomes of Symptomatic Implant Removal Following Ankle Fracture Open Reduction and Internal Fixation

BACKGROUND

Orthopedic implant removal following open reduction internal fixation of a fracture is a common procedure, especially in the foot and ankle. The purpose of this study was to evaluate functional change after the removal of symptomatic implants following ankle fracture open reduction internal fixation (ORIF) using the Short Musculoskeletal Function Assessment (SMFA) outcome score. We hypothesized that implant removal after ankle fracture would result in improved functional outcomes.

METHODS

Retrospective review of prospectively collected data on patients with a closed ankle fracture between 2013 and 2016 was performed. Inclusion criteria were skeletal maturity, symptomatic ankle implants and completion of the SMFA questionnaire prior to and 6 months after removal. Exclusion criteria were development of a nonunion, prior or current infection, peripheral neuropathy or ongoing litigation surrounding the surgery. The primary outcome was change in SMFA score from baseline to follow-up using Wilcoxon signed-rank test. Additional logistic regression models evaluated the effects of age, sex, body mass index, smoking status, and patient American Society of Anesthesiologists scores.

RESULTS

The study population consisted of 43 patients. There was a statistically significant improvement in function, represented by a decrease in SMFA scores from baseline to the 6-month follow-up period (∆ = -4.1 [95% confidence interval, -7.0, -1.3]; P = .003). Secondary outcome measures of the bother index and daily activities domain also demonstrated significant improvements ( P = .005 and P = .002, respectively). Additional logistical regression models identified no significant effects by assessed covariates for change in SMFA scores.

CONCLUSION

Patients with symptomatic implants following ankle fracture ORIF had a statistically significant improvement in function following implant removal. There appears to be value in removing implants from the ankle in patients who report discomfort during daily activities. Further investigation into the specific indications for implant removal and the impact of injury and fracture pattern on outcomes is warranted.

LEVEL OF EVIDENCE

Level IV, case series.

Patient-related outcomes after proximal tibial fractures

PURPOSE

The purpose of the study was to assess patient-related outcomes at short-term follow-up in patients with a proximal tibial fracture.

METHODS

One hundred sixteen patients (119 fractures) treated at our institution during 2012 were retrospectively reviewed. Follow-up was 1.6 (SD ± 0.4) years post-injury, including the short musculoskeletal function assessment and visual analog scale for pain and satisfaction. Fractures were classified by the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification and divided in two groups: simple and complex.

RESULTS

Patients with simple fractures reported lower short musculoskeletal function assessment indices and less pain on visual analog scale than those with complex fractures. No difference was found in short musculoskeletal function assessment between surgically and non-surgically treated patients. Non-surgically treated patients reported less pain and were more satisfied. The overall complication rate was 30 (25%) of 119 fractures, with surgical treatment carrying a 7.0 (95% CI: 1.5-34) odds ratio for local complications.

CONCLUSIONS

This study provides information about realistic prognosis after proximal tibial fractures. The finding that surgically treated patients had similar outcomes to non-surgically treated ones may indicate that surgery improves the prognosis of complex fractures to a level comparable to the prognosis of less severe ones. However, the risk of complications after surgery should guide treatment when surgery is not clearly indicated.

No Difference Between Bracing and No Bracing After Open Reduction and Internal Fixation of Tibial Plateau Fractures

INTRODUCTION

The use of a postoperative brace may be beneficial after open reduction and internal fixation of tibial plateau fractures. However, bracing has potential drawbacks related to cost, fitting, wound complications, and compliance. We hypothesized that no difference will be found between patients with and without bracing after open reduction and internal fixation of tibial plateau fractures.

METHODS

In this prospective, comparative trial, patients were randomized to 6 weeks of bracing or no bracing after open reduction and internal fixation of tibial plateau fractures. Functional, subjective, and radiographic outcomes were recorded. Patients with an open physis, unstable ligamentous injuries, extensor mechanism disruption, and/or <6 months of prospective outcome data were excluded.

RESULTS

The 24 patients with bracing (average age, 50 ± 16 years; 14 women and 10 men) were compared with the 25 patients without bracing (average age, 51 ± 12 years [P = 0.74]; 9 women and 16 men). No statistically significant differences were found in most of the functional, subjective, and radiographic outcomes, including fracture characteristics, complications, postoperative range of motion, Medical Outcomes Study 36-Item Short Form scores, and union rates. In the nonbraced group, one patient had late joint collapse with valgus malalignment (>10°). Two wound complications occurred in the braced group and four wound complications occurred in the nonbraced group, but this difference was not statistically significant.

DISCUSSION

Improvements in conventional and locking plate technology have allowed more reliable rigid internal fixation of tibial plateau fractures. However, the use of a brace for postoperative rehabilitation after open reduction and internal fixation of tibial plateau fractures continues to be debated.

CONCLUSION

Our prospective study showed no statistically significant difference between bracing and no bracing after open reduction and internal fixation of tibial plateau fractures in terms of functional, subjective, and radiographic outcomes.

LEVEL OF EVIDENCE

Therapeutic level II.

Vitamin D Use and Health Outcomes After Surgery for Hip Fracture

Daily administration of vitamin D is important for maintaining bone homeostasis. The orthopedic community has shown increased interest in vitamin D supplementation and patient outcomes after fracture. The current study used data from a large hip fracture trial to determine the proportion of patients who consistently used vitamin D after hip fracture surgery and to determine whether supplementation was associated with improved health-related quality of life and reduced reoperation rates. The FAITH study is a multicenter trial of elderly patients with femoral neck fracture treated with internal fixation. The current study asked a subset of patients included in the FAITH study about vitamin D supplementation and categorized them as consistent users, inconsistent users, or nonusers. This study also evaluated whether supplementation was associated with improved quality of life and reduced reoperation rates. The final analysis included 573 patients (mean age, 74.1 years; female, 66.3%; nondis-placed fractures, 72.4%). A total of 18.7% of participants reported no use of vitamin D, 35.6% reported inconsistent use, and 45.7% reported consistent use. Adjusted analysis found that consistent supplementation was associated with a 2.42 increase of the Short Form-12 physical component score 12 months postoperatively (P=.033). However, supplementation was not associated with reduced reoperation rates (P=.386). Despite guidelines recommending vitamin D supplementation, a low proportion of elderly patients with hip fracture use vitamin D consistently, suggesting a need for additional strategies to promote compliance. This study found that the use of vitamin D was associated with a statistically significant but not clinically significant improvement in health-related quality of life after hip fracture. Further research is needed to confirm these findings. [Orthopedics. 2017; 40(5):e868-e875.].

Correlation of Physical Performance and Patient-Reported Outcomes Following Total Ankle Arthroplasty

BACKGROUND

Functional recovery following total ankle arthroplasty (TAA) is assessed with patient-reported metrics, but physical performance tests may allow for a more accurate assessment of patient function. We quantified correlations between patient-reported measures and physical performance tests in patients after TAA to determine the usefulness of physical performance tests in post-TAA assessment.

METHODS

In total, 140 patients with end-stage ankle osteoarthritis were assessed prior to TAA and again at 12 and 24 months postoperatively. At each time point, the visual analog scale (VAS), Foot and Ankle Disability Index (FADI), American Orthopaedic Foot & Ankle Society (AOFAS), Short Musculoskeletal Function Assessment (SMFA), and Short-Form 36 (SF-36) scores were collected, as well as walking speed, Four-Square Step Test (FSST) times, and Short Physical Performance Battery (SPPB) balance scores.

RESULTS

All but 1 (SF-36 general health component) of the patient-reported outcomes improved significantly from preoperative assessment to both 1 and 2 years postoperatively ( P < .001 in all cases). Walking speed, FSST times, and balance scores improved significantly across time ( P < .001 in all cases). Walking speed was moderately correlated with total SF-36 scores at both 1 and 2 years postoperatively ( P < .001 in both cases), both components of the SMFA at 1 year postoperatively ( P < .001 in both cases), and total AOFAS scores at 2 years postoperatively ( P = .001).

CONCLUSION

The lack of strong correlations between the 2 sets of metrics indicates that they provide different information about a patient's recovery following TAA. Therefore, it is important to include both sets of metrics in post-TAA assessments to better understand operative success and functional recovery.

LEVEL OF EVIDENCE

Level IV, cohort study.

[Quality of life and job performance resulting from operatively treated tibial plateau fractures]

BACKGROUND

The aim of this article is to present the functional results and the effect on quality of life of surgically treated tibial plateau fractures in physically active and working patients with multiple and serious injuries. In addition, the relationships between functional and radiological outcome were evaluated and compared with activity in daily and professional life.

PATIENTS AND METHODS

In all, 41 injured patients were followed up a mean of 47 months after surgical treatment and examined with radiological, functional, as well as quality of life score.

RESULTS

In the radiological scoring, a mean value of 72 points (max 100 points) was achieved. In the activity score, there was an average of 63.5 points (max 100 points). When evaluating the health-related quality of life, an average score of 69.6 points was achieved. There was a significant relationship between radiological and activity scores and the radiological and life quality scores. Furthermore, the relationship between activity and quality of life scores was considered significant. Surgeon's influence on the functional outcome could be confirmed.

CONCLUSION

The functional and the radiological results were moderate. Quality of life was permanently affected by the consequences of tibial plateau fracture in 12 patients; 11 patients were not re-employed. However, the quality of life was assessed as good or very good and 28 patients had returned to work. The quality of life was firmly linked to the radiological and functional parameters, which tended to be influenced by the quality of the primary surgical treatment when looking at the overall population.

A prospective multi-center study of intramedullary nailing vs casting of stable tibial shaft fractures

Background

The purpose of this study was to determine optimal treatment of stable tibial shaft fractures using intramedullary nailing (IMN) or casting.

Materials and methods

We performed a multi-center prospective study cohort. Patients with stable tibia shaft fractures meeting Sarmiento’s criteria (isolated closed fractures with less than 12 mm of shortening and 10° of angulation) were enrolled prospectively and treated with either a reamed IMN with static interlocking screws or closed reduction followed by long-leg casting. Both groups were weight bearing following surgery. Radiographs were taken until union, and range of motion of knee and ankle joints was assessed. Malalignment (>5°) and malunion (>10°) were determined. Functional outcome measures using short musculoskeletal assessment scores (SMFA) and a knee pain score were scheduled at 6 weeks, 3 months and 6 months.

Results

At 3 months, differences between the casting and IMN groups were noted in return to work (6/15 vs 3/17, P < 0.05); ankle dorsiflexion (7° vs 12°, P < 0.05); plantar flexion (28° vs 39°, P < 0.05); and SMFA domains of Dysfunction Index, Bother Index, daily activities, emotional status, and arm/hand function (P < 0.05). The SMFA mobility function demonstrated a significant trend (P = 0.065). At 6 months, malalignment was present in 3/15 in the casting group and in 1/17 in the IMN group (P = 0.02). Malunion was present in 1/15 in the cast group. One fracture in the casting group went on to nonunion and required late IMN placement at 7 months and eventually healed. There were no differences in ankle motion, SMFA scores, or return to work. There was no difference in knee pain between the groups as measured by VAS and Court-Brown pain scale at 6 months.

Conclusions

Patients with stable tibia fractures treated with intramedullary nailing have improved clinical and functional outcomes at 3 months compared with those treated with casting, but there are no differences in any other outcome measure. Patients treated in a cast may have a higher incidence of malalignment or malunion.

Level of evidence

Level-II prognostic.

Assessment of functional outcomes of surgically managed acetabular fractures

We performed a systematic review of the literature pertaining to the functional outcomes of the surgical management of acetabular fractures. A total of 69 articles met our inclusion criteria, revealing that eight generic outcome instruments were used, along with five specific instruments. The majority of studies reported outcomes using a version of the d’Aubigne and Postel score, which has not been validated for use in acetabular fracture. Few validated outcome measures were reported. No psychometric testing of outcome instruments was performed. The current assessment of outcomes in surgery for acetabular fractures lacks scientific rigour, and does not give reliable outcome data for either scientific comparison or patient counselling.

Take home message: The use of non-validated functional outcome measures is a major limitation of the current literature pertaining to surgical management of acetabular fractures; future studies should use validated outcome measures to ensure the legitimacy of the reported results.

Cite this article: Bone Joint J 2016;98-B:690–5.

Assessment of the minimum clinically important difference in neurological function and quality of life after surgery in cervical spondylotic myelopathy patients: a prospective cohort study

PURPOSE

The purpose of this study was to evaluate the application of the minimum clinically important difference (MCID) concept to postoperative clinical results by using a prospective cohort study in Chinese patients with cervical spondylotic myelopathy (CSM).

METHODS

The sample consisted of 113 patients who underwent surgical treatment for CSM in our hospital between February 2008 and November 2012. The preoperative and 1-year postoperative modified Japanese Orthopaedic Association (mJOA) scores, mJOA score recovery rate, physical component summary (PCS) and mental component summary (MCS) of the Short Form 36 were collected. The MCID of each outcome measurement was calculated by four approaches including average change, minimum detectable change, change difference and receiver operating characteristic curve. The responsiveness of each measurement was then analyzed.

RESULTS

The patients presented a statistically significant improvement (p < 0.01) postoperatively in mJOA, PCS, and MCS. The MCID calculated by four approaches varied from 4.09 to 9.62 for the PCS, 3.11 to 7.41 for the MCS, 1.25 to 3.07 for mJOA score, and 31.37 to 44.02% for mJOA recovery rate. In addition, the improvement of the mJOA score owned the highest responsiveness of the four outcome measurements.

CONCLUSIONS

The threshold value of the MCID was determined by the choice of the assessment approach. In addition, the recovery rate of the mJOA score appeared to be the most valid and responsive measure of effectiveness of surgery in CSM patients.

Psychometric properties of the Musculoskeletal Function Assessment and the Short Musculoskeletal Function Assessment: a systematic review

Objectives:

To investigate the psychometric properties of the Musculoskeletal Function Assessment (MFA) and Short Musculoskeletal Function Assessment (SMFA).

Data sources:

A systematic search of the following databases was undertaken concerning psychometric evidence of the MFA and SMFA: PubMed, Embase, Scopus and Cinahl. References of retrieved articles were inspected for additional data.

Review method:

Articles evaluating the validity, reliability or responsiveness of the MFA or SMFA in patients with musculoskeletal disorders were included in this systematic review. The methodological quality of included articles was critically appraised and the psychometric data were extracted using standardized forms. An established set of criteria were used to synthetize the evidence in order to highlight the strengths and weaknesses of included questionnaires and the gaps in the literature.

Results:

Nine articles on MFA and 24 articles on SMFA met the inclusion criteria. The SMFA fulfilled 75% of the psychometric criteria analyzed, while the MFA fulfilled only 50%. MFA and SMFA have excellent content validity and relative reliability (weighted average intraclass correlation coefficient ⩾ 0.87), and are moderately to highly responsive (standardized response mean between 0.65 and 1.13). Absolute reliability and clinically important difference of both questionnaires need to be defined, while the construct validity of MFA still needs to be established.

Conclusion:

MFA and SMFA are reliable and responsive tools for monitoring the function of patients with various musculoskeletal disorders. Still, research is needed to justify their usage in a clinical setting.

Assessment of health-related quality of life using the SF-36 in Chinese cervical spondylotic myelopathy patients after surgery and its consistency with neurological function assessment: a cohort study

Background

We aimed to calculate the responsiveness and statistically prove the reliability of the Medical Outcomes Study Short Form Health Survey (SF-36) in a prospective cohort study. We investigated the profile of mid-term health-related quality of life (QOL) outcome assessments after surgery for cervical spondylotic myelopathy (CSM) and determined the consistency of the SF-36 assessments of neurological function.

Methods

A total of 142 consecutive patients with CSM who underwent surgery were enrolled in the study. QOL and neurological assessments were evaluated before and at 3 months, 1 year, and more than 2 years postoperatively. We subsequently analyzed the reliability and responsiveness of the SF-36 and the QOL profile for its consistency regarding the neurological function assessment.

Results

(1) Cronbach’s α ranged from 0.73 (for role-emotional) to 0.85 (for physical function). The effect size ranged from 0.57 to 0.93 for SF-36’s eight scales. Minimum clinically important differences (MCIDs) in the physical scores (PCS) and mental scores (MCS) were 5.52 and 3.43, respectively. (2) The scores for all SF-36 scale sections indicated that patients with CSM were significantly impaired compared with healthy adults. SF-36 PCS and MCS peaked at 17.7 and 18.9 months after surgery, respectively. (3) At 3 months after surgery, improvements in the modified Japanese Orthopaedic Association (mJOA) scores significantly correlated only with patients’ physical function and bodily pain scores. At 1 year after surgery, improvements in the mJOA scores significantly correlated with physical function, general health, social function, and role-emotional. At the final follow-up, improvements in the mJOA scores significantly correlated with physical function, vitality, and role-emotional.

Conclusions

SF-36 is reliable and has moderate responsiveness for evaluating patients with CSM, with MCID at 5.52 for the PCS and at 3.43 for the MCS. The preoperative QOL of the CSM patients was severely impaired compared with that of the normal population. Postoperatively, each SF-36 domain improved to a variable degree. During the early stage of recovery the mJOA score improvements correlated with SF-36’s physical component domains, whereas during the later stages the improvements were associated with the mental component domains.

Hip fracture evaluation with alternatives of total hip arthroplasty versus hemiarthroplasty (HEALTH): protocol for a multicentre randomised trial

INTRODUCTION

Hip fractures are a leading cause of mortality and disability worldwide, and the number of hip fractures is expected to rise to over 6 million per year by 2050. The optimal approach for the surgical management of displaced femoral neck fractures remains unknown. Current evidence suggests the use of arthroplasty; however, there is lack of evidence regarding whether patients with displaced femoral neck fractures experience better outcomes with total hip arthroplasty (THA) or hemiarthroplasty (HA). The HEALTH trial compares outcomes following THA versus HA in patients 50 years of age or older with displaced femoral neck fractures.

METHODS AND ANALYSIS

HEALTH is a multicentre, randomised controlled trial where 1434 patients, 50 years of age or older, with displaced femoral neck fractures from international sites are randomised to receive either THA or HA. Exclusion criteria include associated major injuries of the lower extremity, hip infection(s) and a history of frank dementia. The primary outcome is unplanned secondary procedures and the secondary outcomes include functional outcomes, patient quality of life, mortality and hip-related complications-both within 2 years of the initial surgery. We are using minimisation to ensure balance between intervention groups for the following factors: age, prefracture living, prefracture functional status, American Society for Anesthesiologists (ASA) Class and centre number. Data analysts and the HEALTH Steering Committee are blinded to the surgical allocation throughout the trial. Outcome analysis will be performed using a χ(2) test (or Fisher's exact test) and Cox proportional hazards modelling estimate. All results will be presented with 95% CIs.

ETHICS AND DISSEMINATION

The HEALTH trial has received local and McMaster University Research Ethics Board (REB) approval (REB#: 06-151).

RESULTS

Outcomes from the primary manuscript will be disseminated through publications in academic journals and presentations at relevant orthopaedic conferences. We will communicate trial results to all participating sites. Participating sites will communicate results with patients who have indicated an interest in knowing the results.

TRIAL REGISTRATION NUMBER

The HEALTH trial is registered with clinicaltrials.gov (NCT00556842).

Clinical instability of the knee and functional differences following tibial plateau fractures versus distal femoral fractures

BACKGROUND

Fractures of the knee account for about 6% of all trauma admissions. While its management is mostly focused on fracture treatment, it is not the only factor that defines the final outcome.

OBJECTIVES

This study aimed to study objective and subjective outcomes after proximal tibial versus distal femoral fractures in terms of knee instability and health-related quality of life.

PATIENTS AND METHODS

This retrospective, cross-sectional, cohort study was carried out on 80 patients with either isolated proximal tibial (n = 42) or distal femoral (n = 38) fractures, who underwent open reduction and internal fixation. All the fractures were classified based on the Schatzker and AO classification for tibial plateau and distal femoral fractures, respectively. The patients were followed and examined by an orthopedic knee surgeon for clinical assessment of knee instability. In their last follow-up visit, these patients completed a Lysholm knee score and the short-form (SF) 36 health survey.

RESULTS

Among the 42 tibial plateau fractures, 25% were classified as Schatzker type 2. Of the 38 distal femoral fractures, we did not find any type B1 or B3 fractures. The overall prevalence of anterior and posterior instability was 42% and 20%, respectively. Medial Collateral Ligament (MCL) and Lateral Collateral Ligament (LCL) injuries were detected clinically in 50% and 28%, respectively. The incidence rates of ligament injuries in tibial plateau fractures were as follows: Anterior Collateral Ligament (ACL) 26%, Posterior Collateral Ligament (PCL) 7%, MCL 24%, and LCL 14%. Medial collateral ligament injury was the most common in the Schatzker type 2 (50% of the injuries). Distal femoral fractures were associated with ACL injury in 16%, PCL in 13%, MCL in 26% and LCL in 14%. However, final knee range of motion (ROM) and function (Lysholm score) were not associated with fracture location. No statistically significant difference was observed between the two groups, except for the valgus stress test at 30°knee flexion, which was more positive in tibial fractures. All eight domains of SF-36 score in the distal femoral and proximal tibial fractures were significantly different from the normal values; however, there were no statistically significant differences between femoral and tibial fracture scores.

CONCLUSIONS

Although ROM is acceptable in knee joint fractures, instability is common. However, it seems that knee function and quality of life are not associated with the location of the fracture.

Validation of the Short Musculoskeletal Function Assessment in patients with battlefield-related extremity vascular injuries

OBJECTIVE

Vascular extremity injuries can be a significant burden on a patient's long-term quality of life. Currently, no limb-specific surveys have been used to quantify the relation between injury pattern and the resultant physical or psychological impact. The objective of this study was to validate the use of the Short Musculoskeletal Function Assessment (SMFA) in the setting of extremity vascular injury.

METHODS

The Joint Theater Trauma Registry was queried and filtered for U.S. troops with an extremity vascular injury isolated to a single limb. Injury and management data were obtained, and the SMFA was administered after patient contact and consent. Validity was analyzed by characterization of SMFA score distribution, correlation with 36-Item Short Form Health Survey (SF-36) scores, and assessment of its discriminative capability to external measures of injury severity (ie, Injury Severity Score [ISS], Mangled Extremity Severity Score [MESS], and Medicare Part A disability qualification).

RESULTS

At mean follow-up of 5 years, 164 patients (median age, 25 years; interquartile range, 22-31 years) completed both surveys. The overall SMFA Dysfunction Index was 24.8 ± 15.2 (range, 0-78; skewness, 0.60; floor/ceiling effect, 0%-1.2%; and nonresponse, 0%), and the overall Bother Index was 29.4 ± 20.2 (range, 0-96; skewness, 0.58; floor/ceiling effect, 0%-4.3%; and nonresponse, 0.6%). SF-36 physical component summary scores correlated inversely with the Dysfunction Index (r = -0.64; P < .01), whereas mental component summary scores correlated inversely with the Bother Index (r = -0.59; P < .01). No difference was found in reported scores between those considered severely injured (ISS > 15) and those not severely injured (ISS ≤ 15). However, those with mangled extremities (MESS ≥ 7) reported higher Dysfunction and Bother indices than those with lower scores (P < .05). In addition, patients considered disabled (per Medicare Part A qualifications) reported higher Dysfunction and Bother indices compared with those not considered disabled (P < .05).

CONCLUSIONS

Use of the SMFA is validated in those with extremity vascular injuries, and it should be considered an adjunctive tool in evaluating long-term patient outcomes.

Fixation using alternative implants for the treatment of hip fractures (FAITH): design and rationale for a multi-centre randomized trial comparing sliding hip screws and cancellous screws on revision surgery rates and quality of life in the treatment of femoral neck fractures

BACKGROUND

Hip fractures are a common type of fragility fracture that afflict 293,000 Americans (over 5,000 per week) and 35,000 Canadians (over 670 per week) annually. Despite the large population impact the optimal fixation technique for low energy femoral neck fractures remains controversial. The primary objective of the FAITH study is to assess the impact of cancellous screw fixation versus sliding hip screws on rates of revision surgery at 24 months in individuals with femoral neck fractures. The secondary objective is to determine the impact on health-related quality of life, functional outcomes, health state utilities, fracture healing, mortality and fracture-related adverse events.

METHODS/DESIGN

FAITH is a multi-centre, multi-national randomized controlled trial utilizing minimization to determine patient allocation. Surgeons in North America, Europe, Australia, and Asia will recruit a total of at least 1,000 patients with low-energy femoral neck fractures. Using central randomization, patients will be allocated to receive surgical treatment with cancellous screws or a sliding hip screw. Patient outcomes will be assessed at one week (baseline), 10 weeks, 6, 12, 18, and 24 months post initial fixation. We will independently adjudicate revision surgery and complications within 24 months of the initial fixation. Outcome analysis will be performed using a Cox proportional hazards model and likelihood ratio test.

DISCUSSION

This study represents major international efforts to definitively resolve the treatment of low-energy femoral neck fractures. This trial will not only change current Orthopaedic practice, but will also set a benchmark for the conduct of future Orthopaedic trials.

TRIAL REGISTRATION

The FAITH trial is registered at ClinicalTrials.gov (Identifier NCT00761813).