Long-term outcomes after lower extremity trauma

Establishing the Patient Acceptable Symptom State Thresholds for Patient-Reported Outcomes after Operatively Treated Tibial Plateau Fractures

OBJECTIVES

Define patient-acceptable symptom state (PASS) thresholds and factors affecting PASS thresholds for Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Knee Injury and Osteoarthritis Outcome Score (KOOS) following operatively treated tibial plateau fractures.

METHODS

DESIGN

Retrospective cohort.

SETTING

Single Level I academic trauma center.

PATIENT SELECTION CRITERIA

All patients (n = 159) who underwent fixation of a tibial plateau fracture from 2016 to 2021 and completed patient-reported outcome measures (PROMs) at minimum 1-year follow-up were enrolled for the study.

OUTCOME MEASURES AND COMPARISONS

PASS thresholds for global outcome (PASS-Global), pain (PASS-Pain), and function (PASS-Function) were determined using anchor-based questions such as "How satisfied are you today with your injured lower extremity?" with answer choices of very satisfied, satisfied, neutral, unsatisfied, and very unsatisfied. PASS thresholds for each PROM were calculated using 3 methods: (1) 80% specificity, (2) 75th percentile, and (3) Youden Index.

RESULTS

Sixty percent of patients were satisfied with their global outcome and 53% with function. Using 80% specificity, 75th percentile, and Youden Index, PASS-Global thresholds were 48.5, 44.5, and 47.9 for PROMIS-PF and 56.3, 56.2, and 56.3 for KOOS-QOL, respectively. PASS-Pain threshold for KOOS-Pain was 84.4, 80.6, and 80.6, respectively. PASS-Function thresholds were 48.9, 46.8, and 48 for PROMIS-PF and 94.1, 90.2, and 86.8 for KOOS-ADL, respectively. Younger patients and those with bicondylar fractures or infections were associated with significantly lower PASS-Pain thresholds. Schatzker II fractures, lateral column involvement, or isolated lateral approach resulted in significantly higher PASS-Global and PASS-Function thresholds.

CONCLUSIONS

This study defines global, functional, and pain PASS thresholds for tibial plateau fractures. Patients with bicondylar fractures, infections, and medial column involvement were more often unsatisfied. These thresholds are valuable references to identify patients who have attained satisfactory outcomes and to counsel patients with risk factors for unsatisfactory outcomes following tibial plateau fractures.

LEVEL OF EVIDENCE

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

Degree of articular injury as measured by CT cross sectional area is associated with physical function following the treatment of bicondylar tibial plateau fractures

BACKGROUND

Bicondylar tibial plateau fractures are complex injuries that commonly require surgical repair. Long-term clinical outcome has been associated with discrepancies in leg alignment, instability and condylar width abnormalities. While intuitive, the degree of articular damage at time of injury has not been linked to outcomes in patients with bicondylar tibial plateau fractures. The aim of this study was to quantify percentage of articular surface cross sectional area disruption and assess for correlation between the degree of articular injury and patient reported physical function.

METHODS

Retrospective cohort study at two level 1 trauma centers. 57 consecutive patients undergoing surgical repair for bicondylar tibial plateau fractures between 2013 and 2016.

MAIN OUTCOME MEASURE

Preoperative CT scans were reviewed, and the percentage of articular surface disruption cross sectional area was calculated. PROMIS® scores were collected from patients at a minimum of 2 years.

RESULTS

57 patients with an average age of 58 ± 14.3 years were included. The average PROMIS® score was 45.5. There was a correlation between percentage of articular surface disruption and total PROMIS® scores (0.4, CI: 0.2-0.5, p = .007) and the physical function of the PROMIS® score (0.4, CI: 0.2-0.6, p < .001).

CONCLUSION

Our method for calculating articular surface disruption on CT is a simple, reproducible and accurate method for assessing the degree of articular damage in patients with bicondylar tibial plateau fractures. We found that the percentage of cross-sectional articular surface disruption correlates with patient reported outcomes and physical function.

Management of High-Energy Tibial Pilon Fractures

➤ Pilon fractures in the younger patient population are frequently high-energy, intra-articular injuries and are associated with devastating, long-term impacts on patient-reported outcomes and health-related quality of life, as well as high rates of persistent disability.➤ Judicious management of associated soft-tissue injury, including open fractures, is essential to minimizing complications. Optimizing medical comorbidities and negative social behaviors (e.g., smoking) should be addressed perioperatively.➤ Delayed internal fixation with interval temporizing external fixation represents the preferred technique for managing most high-energy pilon fractures presenting with characteristically substantial soft-tissue trauma. In some cases, surgeons elect to utilize circular fixation for these scenarios.➤ Although there have been treatment advances, the results have been generally poor, with high rates of posttraumatic arthritis, despite expert care.➤ Primary arthrodesis may be indicated in cases with severe articular cartilage injury that, in the opinion of the treating surgeon, is likely unsalvageable at the time of the index management.➤ The addition of intrawound vancomycin powder at the time of definitive fixation represents a low-cost prophylactic measure that appears to be effective in reducing gram-positive deep surgical site infections.

Long-term analysis of chronic pain associated with lower extremity injuries

INTRODUCTION

The main objective of this study is to examine chronic pain and limping in relation to lower extremity and pelvic fracture location in addition to fracture combinations if multiple fractures are present on the same leg that have not been previously reported. We hypothesize that fracture pattern and location of lower extremity and pelvis fractures of multiple injured patients influence their long-term pain outcome.

MATERIALS AND METHODS

Retrospective cohort study. Patients with treated multiple lower limb and pelvic fractures at a level 1 trauma center and followed up for at least 10 years postinjury were assessed. Lower leg pain subdivided into persistent, load-dependent and intermittent pain, as well as limping were recorded by using self-administered patient questionnaires and standardized physical examinations performed by a trauma surgeon. Descriptive statistics were used to present comparative measurements between groups.

RESULTS

Fifty-seven percent of patients (n = 301) showed chronic lower limb pain 10 years postinjury. Ten percent of all patients with chronic pain displayed persistent pain, and here the most common fracture combination was tibial shaft fractures in combination with femoral shaft or proximal tibial fractures (13%). One hundred fifty-one patients reported load-dependent pain, with the most common fracture combinations being fractures of the foot in combination with femoral shaft fractures or distal tibial fractures (11%). One hundred twenty patients reported intermittent pain, with the most common fracture combinations involving the shaft of the tibia with either the femoral shaft or distal tibia (9%). Two hundred fifteen patients showed a persistent limp, and here the most common fractures were fractures of the femoral shaft (19%), tibial shaft (17%), and pelvis (15%).

CONCLUSIONS

In multiple injured patients with lower extremity injuries, the combination of fractures and their location are critical factors in long-term outcome. Patients with chronic persistent or load-dependent pain often had underlying femoral shaft fractures in combination with joint fractures.

The impact of upper-extremity injuries on polytrauma patients at a level 1 trauma center

BACKGROUND

Upper-extremity injuries often lead to long-term problems in function and quality of life in patients. However, not much is known about the effects in polytrauma patients. This study aimed to describe the upper-extremity injuries in polytrauma patients and to compare self-reported disability and quality of life in polytrauma patients with vs. without upper-extremity injuries.

METHODS

We performed a retrospective cohort study of adult patients with an Injury Severity Score ≥ 16 admitted to Erasmus MC between January 1, 2007, and December 31, 2016. Patients were asked to complete the Disabilities of the Arm, Shoulder and Hand, Short Form 36, and EuroQol-5D questionnaires. Details on injuries, treatment, and clinical outcome were collected from the national trauma registry and medical files. Characteristics and self-reported outcomes of polytrauma patients with vs. without upper-extremity injuries were compared.

RESULTS

In a cohort of 3469 trauma patients, 1246 (36.5%) had upper-extremity injuries. Of these, 278 (22.0%) had severe injuries (Abbreviated Injury Scale score ≥ 3). Upper-extremity injuries were associated with a longer hospitalization (median, 12 days vs. 8 days; P < .001), longer intensive care unit stay (median, 5 days vs. 4 days; P = .005), and lower mortality rate (14.6% vs. 23.9%, P < .001). Among the 598 patients who completed the questionnaires, no differences in the physical component summary score (47 vs. 48, P = .181) and mental component summary score (54 vs. 53, P = .315) of the Short Form 36 questionnaire, as well as the utility score (0.82 vs. 0.85, P = .101) and visual analog scale score (80 vs. 80, P = .963) of the EuroQol-5D questionnaire, were found. However, patients with upper-extremity injuries showed a minor increase in disability in the Disabilities of the Arm, Shoulder and Hand score (9.2 vs. 4.2, P = .023).

CONCLUSION

Upper-extremity injuries in polytrauma patients are associated with a longer hospitalization, longer intensive care unit stay, and reduced mortality rate, as well as a minor increase in long-term disability.

The 1-Year Economic Impact of Work Productivity Loss Following Severe Lower Extremity Trauma

BACKGROUND

Severe lower extremity trauma among working-age adults is highly consequential for returning to work; however, the economic impact attributed to injury has not been fully quantified. The purpose of this study was to examine work and productivity loss during the year following lower extremity trauma and to calculate the economic losses associated with lost employment, lost work time (absenteeism), and productivity loss while at work (presenteeism).

METHODS

This is an analysis of data collected prospectively across 3 multicenter studies of lower extremity trauma outcomes in the United States. Data were used to construct a Markov model that accumulated hours lost over time due to lost employment, absenteeism, and presenteeism among patients from 18 to 64 years old who were working prior to their injury. Average U.S. wages were used to calculate economic loss overall and by sociodemographic and injury subgroups.

RESULTS

Of 857 patients working prior to injury, 47.2% had returned to work at 1 year. The average number of productive hours of work lost was 1,758.8/person, representing 84.6% of expected annual productive hours. Of the hours lost, 1,542.3 (87.7%) were due to working no hours or lost employment, 71.1 (4.0%) were due to missed hours after having returned, and 145.4 (8.3%) were due to decreased productivity while working. The 1-year economic loss due to injury totaled $64,427/patient (95% confidence interval [CI], $63,183 to $65,680). Of the 1,758.8 lost hours, approximately 88% were due to not being employed (working zero hours), 4% were due to absenteeism, and 8% were due to presenteeism. Total productivity loss was higher among older adults (≥40 years), men, those with a physically demanding job, and the most severe injuries (i.e., those leading to amputation as well as Gustilo type-IIIB tibial fractures and type-III pilon/ankle fractures).

CONCLUSIONS

Patients with severe lower extremity trauma carry a substantial economic burden. The costs of lost productivity should be considered when evaluating outcomes.

Causes of death following discharge after trauma in North Carolina

BACKGROUND

While a "fourth peak" of delayed trauma mortality has been described, limited data describe the causes of death (CODs) for patients in the years following an injury. This study investigates the difference in COD statewide for patients with and without a recent trauma admission.

METHODS

This retrospective cohort study compared COD for trauma and nontrauma patients in North Carolina. Death certificates in NC's death registry were matched with the NC trauma registry between January 2013 and December 2018 using matching on name and date of birth. Patients who died during the index trauma admission were excluded. Underlying COD recorded on the death certificate were used for the primary analysis.

RESULTS

Of 481,415 death records, 19,083 (4.0%) were linked to an alive discharge within the trauma registry during the study period. Prior trauma patients (PTPs) had a higher incidence of mental illness (9.2 vs. 6.1%), Alzheimer's (6.1% vs. 4.2%), and opioid-related (1.8% vs. 1.6%) COD compared to nontrauma patients, p < 0.05. Overall, suicide was higher in the nontrauma cohort (1.5% vs. 1.1%); however, PTP had higher incidences of death by motor vehicle collision and other injury (6.0% vs. 3.8%) and homicide (0.9% vs. 0.6%), p < 0.001. Prior trauma patients had 1.16 increased odds of an opioid-related death (p = 0.009; 95% confidence interval, 1.04-1.29) compared with those without prior trauma. Younger PTP had a much higher rate of death from suicide (12.0%) compared with those 41 to 65 years (2.8%) and older than 65 years (0.2%; p < 0.001). Discharge to skilled nursing facility (odds ratio, 1.87; p < 0.05) and severe injury (odds ratio, 1.93; p < 0.05) were associated with early death after discharge (≤90 days).

CONCLUSION

After hospital discharge, PTPs remain at risk of dying from future trauma and opioid-related conditions. Prevention strategies for PTP should address the increased risk of death from a subsequent traumatic injury and the at-risk populations for early death after discharge.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, Level IV.

A Quantitative Evaluation of Functional Recovery after Traumatic Lower Extremity Salvage

INTRODUCTION

Soft tissue reconstruction is a routine component of lower extremity trauma care and focus is increasingly being directed towards understanding functional outcomes. This study aims to quantify functional recovery and identify variables associated with functional outcomes of patients who undergo traumatic limb salvage.

METHODS

A retrospective review was performed of patients with lower extremity traumatic injuries requiring vascularized soft tissue reconstruction at a Level 1 trauma center between July 2007-December 2015. Postoperatively, patients were administered the 36-Item Short Form Health Survey Version 2 (SF-36v2) and the Lower Extremity Functional Scale (LEFS) questionnaires by telephone. Demographics, perioperative variables, and postoperative outcomes were analyzed by univariate and bivariate analysis.

RESULTS

Forty-two patients with 42 flaps and a mean of 12.7 months follow up were included in the study. Limb salvage was successful in 38 patients (90.5%). Patients ≥ 40 years old had significantly worse SF-36v2 scores in physical functioning (P ≤0.01) and mental health (P ≤0.05) than their younger counterparts. Patients who had pre-existing hypertension demonstrated significantly lower physical functioning (P ≤0.01). Role limitation due to emotional health was significantly lower in patients who were female (P ≤0.01) or required revision surgery (P ≤0.01). The mean LEFS score was 37.7 ± 18.5.

CONCLUSIONS

Patients exhibited poor functional outcomes following major limb trauma with attempted limb salvage based on two validated patient reported outcomes measures (PROMs). Patient characteristics should be considered in evaluating candidates for reconstruction to optimize outcomes and to effectively counsel patients on their functional prognosis.

Results following prolonged recovery show satisfactory functional and patient-reported outcome after intramedullary nailing of a tibial shaft fracture: a prospective 5-year follow-up cohort study

INTRODUCTION

Although a large number of previous studies have investigated the outcome in patients following tibial shaft fractures, the literature provides limited information on prospectively reported patients with mid- to long-term follow-up. The present study aimed to investigate prospectively the 5-year development in patient-reported quality of life after intramedullary nailing of a tibial shaft fracture.

MATERIAL AND METHODS

The design was a prospective, 5-year follow-up cohort study. Quality of life (QOL) was measured with the questionnaire Eq5d-5L and compared to the 1-year outcome reported by the same patients. Secondary outcome measurements were the Knee Injury and Osteoarthritis Outcome Score (KOOS), recordings of pain, gait and muscle strength.

RESULTS

Twenty-nine patients were eligible for participation. Mean patient age at the time of the 5-year follow-up was 46.3 years. The 5-year postoperative mean Eq5d-5L index was 0.864 (95% CI 0.809-0.918). The mean Eq5d-5L VAS was 88.4 (95% CI 83.4-93.5). Compared with the same patients' Eq5d-5L index scores at the 1-year follow-up (0.784), a significant increase was observed (P = 0.014). A comparison to the Danish Eq.5D reference population showed no statistically significant difference.

CONCLUSIONS

Patient-reported quality of life among patients treated with intramedullary nailing following a tibial shaft fracture increased significantly between the 1-year and 5-year follow-up. In contrast to the 1-year patient-reported quality of life, results are comparable to those of a reference population at the 5-year follow-up. In a clinical setting, these results highlight that patients may expect a prolonged period to recover. However, of most importance is that patients can expect a satisfactory outcome years after fracture and treatment.

Self-Reported Feelings of Disability Following Lower Extremity Orthopaedic Trauma

BACKGROUND

Nearly 20% of Americans consider themselves disabled. A common cause of disability is unexpected orthopaedic trauma. The purpose of this current study, assessing common lower extremity trauma, is the following: to assess the prevalence of self-reported feelings of disability following these injuries, to determine if self-reported feelings of disability impact functional outcomes, and to understand patient characteristics associated with self-reported feelings of disability.

METHODS

The functional statuses of patients with tibial plateau fractures and ankle fractures were prospectively assessed. Patient reported feelings of disability (acquired from validated functional outcome surveys), which were compared with overall patient-reported functional outcome and emotional status at each follow-up visit. Additionally, patient demographics were analyzed, to assess associations with feelings of disability.

RESULTS

A total of 710 patients were included in our analysis. At short-term follow-up (3 months), a strong positive correlation existed between self-reported feelings of disability and worse functional outcomes (rs = 0.744, P < 0.001). At long-term follow-up (12-months), a strong positive correlation existed between self-reported feelings of disability and worse functional outcomes (rs = 0.741, P < 0.001). Self-reported feelings of disability were associated with increased age at both short-term (P = 0.015) and long-term (P = 0.003) follow-ups. At short-term follow-up, 41% of males and 59% of females self-reported feelings of disability (P < 0.001) No significant differences existed between genders at long-term follow-up (P = 0.252). Self-reported feelings of disability declined at each follow-up visit, from 48.1% at short-term follow-up to 22.1% at long-term follow-up.

CONCLUSION

Self-reported feelings of disability, following lower extremity trauma, had strong positive correlations with worse outcomes. Orthopaedic trauma surgeons should be aware of the percentage of patients who feel disabled following lower extremity fractures, and know that this is associated with sub-optimal outcomes.

LEVEL OF EVIDENCE

III.

Long-term Functional, Psychological, Emotional, and Social Outcomes in Survivors of Firearm Injuries

Importance

The outcomes of firearm injuries in the United States are devastating. Although firearm mortality and costs have been investigated, the long-term outcomes after surviving a gunshot wound (GSW) remain unstudied.

Objective

To determine the long-term functional, psychological, emotional, and social outcomes among survivors of firearm injuries.

Design, Setting, and Participants

This prospective cohort study assessed patient-reported outcomes among GSW survivors from January 1, 2008, through December 31, 2017, at a single urban level I trauma center. Attempts were made to contact all adult patients (aged ≥18 years) discharged alive during the study period. A total of 3088 patients were identified; 516 (16.7%) who died during hospitalization and 45 (1.5%) who died after discharge were excluded. Telephone contact was made with 263 (10.4%) of the remaining patients, and 80 (30.4%) declined study participation. The final study sample consisted of 183 participants. Data were analyzed from June 1, 2018, through June 20, 2019.

Exposures

A GSW sustained from January 1, 2008, through December 31, 2017.

Main Outcomes and Measures

Scores on 8 Patient-Reported Outcomes Measurement Information System (PROMIS) instruments (Global Physical Health, Global Mental Health, Physical Function, Emotional Support, Ability to Participate in Social Roles and Activities, Pain Intensity, Alcohol Use, and Severity of Substance Use) and the Primary Care PTSD (posttraumatic stress disorder) Screen for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Results

Of the 263 patients who survived a GSW and were contacted, 183 (69.6%) participated. Participants were more likely to be admitted to the hospital compared with those who declined (150 [82.0%] vs 54 [67.5%]; P = .01). Participants had a median time from GSW of 5.9 years (range, 4.7-8.1 years) and were primarily young (median age, 27 years [range, 21-36 years]), black (168 [91.8%]), male (169 [92.3%]), and employed before GSW (pre-GSW, 139 [76.0%]; post-GSW, 113 [62.1%]; decrease, 14.3%; P = .004). Combined alcohol and substance use increased by 13.2% (pre-GSW use, 56 [30.8%]; post-GSW use, 80 [44.0%]). Participants had mean (SD) scores below population norms (50 [10]) for Global Physical Health (45 [11]; P < .001), Global Mental Health (48 [11]; P = .03), and Physical Function (45 [12]; P < .001) PROMIS metrics. Eighty-nine participants (48.6%) had a positive screen for probable PTSD. Patients who required intensive care unit admission (n = 64) had worse mean (SD) Physical Function scores (42 [13] vs 46 [11]; P = .045) than those not requiring the intensive care unit. Survivors no more than 5 years after injury had greater PTSD risk (38 of 63 [60.3%] vs 51 of 119 [42.9%]; P = .03) but better mean (SD) Global Physical Health scores (47 [11] vs 43 [11]; P = .04) than those more than 5 years after injury.

Conclusions and Relevance

This study's results suggest that the lasting effects of firearm injury reach far beyond mortality and economic burden. Survivors of GSWs may have negative outcomes for years after injury. These findings suggest that early identification and initiation of long-term longitudinal care is paramount.

The economic burden of open tibia fractures: A systematic review

BACKGROUND

Open tibia fractures are a common injury following road traffic collisions and place a large economic burden on patients and healthcare systems. Summarising their economic burden is key to inform policy and help prioritise treatment.

METHODS

All studies were identified from a systematic search of Medline, Embase and the Cochrane Central Register of Controlled Trials. We included any human with a diagnosed open tibia fracture, following any intervention. The primary outcome was any costs reported or patient return to work status. Secondary outcomes included average length of stay, wage loss, absenteeism and complications such as infection, amputation and nonunion. Data was extracted and we performed a descriptive narrative summary.

RESULTS

We reviewed 1,204 studies from our searches. A total of 34 studies were included from 14 different countries. The average age was 37.7 years old and 76% of the patients were male. 6.5% were Gustilo I, 12% Gustilo II and 82% Gustilo III. Initial direct hospitalisation costs were reported to be between £356 to £126,479 with an average length of stay of 56 days (3.1-244). 89% of participants were working pre-injury, 60% fully returned to work, 17% returned to work part time or changed profession and 22% did not return to work at one-year. The most common complications reported were 22% infection, 11% nonunion and 16% amputation. Mean follow-up duration for the studies was 25 months.

CONCLUSION

The economic burden of open tibia fractures varies greatly, but it is costly for both hospitals and patients. The current evidence is predominantly from high-income countries (HICs), especially the USA. Further research is required to investigate the costs of open tibia fractures using validated costing tools, especially in low-income countries (LICs), to help inform and direct policy.

Association between Patient-Reported Health Status and Physical Activity Six Months after Upper and Lower Limb Fractures in Working-Aged Adults

INTRODUCTION

Physical activity limitations are common following upper and lower limb fractures in adults of working age. There is a lack of research investigating the factors associated with these limitations, such as pain, mental health problems, and mobility impairments.

OBJECTIVES

To report health status (EQ-5D) 6 months after upper and lower limb fracture in adults of working age (ages 18-69 years), and to determine the association between sedentary behavior (sitting time) and physical activity (steps, moderate-intensity physical activity [MPA]) 2 weeks and 6 months post-fracture with health status 6 months post-fracture.

DESIGN

Prospective cohort study.

SETTING

Major (level I) trauma center.

PARTICIPANTS

Sixty-three adults 18-69 years of age with upper or lower limb fractures who were recruited consecutively.

MAIN OUTCOME MEASURES

Participants wore ActiGraph and activPAL accelerometers for 10 days, 2 weeks and 6 months post-fracture. At 6 months, participants completed the EQ-5D. We used linear mixed-effects multivariable regression analyses to explore associations between EQ-5D domains and sitting time, steps, or physical activity.

RESULTS

Participants with mobility problems (compared to participants without) were highly sedentary at 2 weeks (β = 0.86, P = .04), took fewer steps/d (Ratio of Geometric Means [RGM] = 0.62, P = .02) and engaged in less MPA (RGM = 0.32, P = .01). In addition, they engaged in less MPA at 6 months (RGM = 0.52, P = .02). Participants with self-care problems (compared with participants without) took fewer steps per day at 6 months (RGM = 0.78, P = .04), and engaged in less MPA at 2 weeks (RGM = 0.31, P = .01) and 6 months (RGM = 0.48, P = .02).

CONCLUSIONS

Adults with mobility and self-care problems 6 months post-fracture engaged in high levels of sedentary behavior and low levels of physical activity. These findings can guide clinicians on health problems to target in order to maximize recovery of physical activity following fracture.

Physical Activity and Sedentary Behavior 6 Months After Musculoskeletal Trauma: What Factors Predict Recovery?

BACKGROUND

Physical activity is increasingly recognized as an important marker of functional recovery following fracture.

OBJECTIVE

The objectives of this study were to measure sedentary behavior and physical activity 2 weeks and 6 months following fracture and to determine associated demographic and injury factors.

DESIGN

This was an observational study.

METHODS

Two weeks and 6 months following fracture, 83 adults who were 18 to 69 years old and had upper limb (UL) or lower limb (LL) fractures wore an accelerometer and an inclinometer for 10 days. We calculated sitting time, steps, moderate-intensity physical activity (MPA), and vigorous-intensity physical activity and conducted linear mixed-effects multivariable regression analyses to determine factors associated with temporal changes in activity.

RESULTS

At 6 months versus 2 weeks after fracture, participants sat less, took more steps, and engaged in more MPA. Participants with LL fractures sat 2 hours more, took 66% fewer steps, and engaged in 77% less MPA than participants with UL fractures. Greater reductions in sitting time were observed for participants in the youngest age group and with LL fractures, participants with high preinjury activity, and participants who were overweight or obese. For steps, greater improvement was observed for participants in the youngest and middle-aged groups and those with LL fractures. For MPA, greater improvement was observed for middle-aged participants and those with LL fractures.

LIMITATIONS

Although this study was sufficiently powered for the analysis of major categories, a convenience sample that may not be representative of all people with musculoskeletal trauma was used.

CONCLUSIONS

Working-age adults with LL fractures had lower levels of physical activity 6 months after fracture than those with UL fractures. Older adults showed less improvement over time, suggesting that they are an important target group for interventions aimed at regaining preinjury activity levels.

Effect of Mental Health Conditions on Complications, Revision Rates, and Readmission Rates Following Femoral Shaft, Tibial Shaft, and Pilon Fracture

OBJECTIVES

To evaluate the effect of pre-existing mental health (MH) conditions on 90-day complication, 90-day readmission, and all-time revision surgical intervention rates following femoral, tibial, and pilon fractures.

DESIGN

Data were collected using a commercially available database software for which Current Procedural Terminology codes were used to identify patients who underwent surgical treatment of tibial, femoral, or pilon fractures. These patients were then subdivided into those with and without pre-existing MH condition using International Classification of Disease, Ninth Edition codes. Ninety-day postoperative complications, revision surgery, and 90-day readmission rates were then compared between those with and without MH conditions.

SETTING

National databases of 70 million combined patients from 2007 to 2015.

PATIENTS/PARTICIPANTS

Humana and Medicare insured patients.

INTERVENTION

Surgical treatment of tibial, femoral, and pilon fractures.

MAIN OUTCOME MEASUREMENTS

Ninety-day readmission, 90-day complications, and all-time revision surgical intervention.

RESULTS

The total number of patients for femoral, tibial, and pilon treatment, respectively, included 6207, 6253, and 5940 without MH conditions and 4879, 5247, and 2911 with MH conditions. Femoral, tibial, and pilon readmission rates, revision rates, and complication rates were significantly higher among patients with MH disorders in matched cohorts after controlling for medical comorbidities (P ≤ 0.05 for all).

CONCLUSIONS

Comorbid MH conditions are associated with higher postoperative complication, readmission, and revision surgery rates for treated femoral, tibial, and pilon fractures.

LEVEL OF EVIDENCE

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

Psychiatric Illness Is Common in Elderly Fracture Patients

OBJECTIVES

To (1) describe the prevalence of psychiatric illness in fracture patients ≥70 years of age and (2) investigate the association between psychiatric illness and complications requiring unplanned readmission in elderly patients.

DESIGN

Retrospective cohort study.

PATIENTS/PARTICIPANTS

One thousand one hundred eighty-six patients ≥70 years of age with surgically treated fractures and ≥1-month follow-up treated from 2012 to 2017.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Complication requiring unplanned readmission.

RESULTS

Forty-four percent of patients ≥70 years of age have psychiatric comorbidities, and of those, 34% had >1 diagnosis. There was a higher rate of readmission among patients with psychiatric diagnosis compared with those without psychiatric diagnosis (35% vs. 21%, P < 0.001). There was a higher prevalence of psychiatric illness among patients 70 years of age or older compared with patients less than 70 years of age (44% vs. 39%, P = 0.007). Multivariate regression analysis controlling for age, sex, Charlson Comorbidity Index, dementia, delirium during admission, tobacco use, substance abuse, Injury Severity Score, fracture location, number of procedures, and number of fractures demonstrated an independent association between psychiatric illness and unplanned readmission (adjusted OR 1.54, 95% confidence interval, 1.15-2.07, P = 0.003).

CONCLUSIONS

Almost half of the elderly patients in the present cohort have psychiatric comorbidities. Furthermore, psychiatric illness is an independent predictor of unplanned readmission, which may have substantial consequences for recovery and cost of care. This emphasizes the need for more attention to these issues in geriatric patient populations and the need to identify means to influence the downstream consequences of these comorbidities.

LEVEL OF EVIDENCE

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

Risk factors for complications and adverse outcomes in polytrauma patients with associated upper extremity injuries

Background

In terms of upper extremity fractures by patients with multiple injuires, a lot of studies have assessed the functional outcome following trauma to have less favorable outcomes in regards to functional recovery. We tested the hypothesis that differences in clinical outcome occur between shaft and articular injuries of the upper extremity, when patients that sustained neurologic deficits (e.g. brachial plexus lesions) are excluded.

Methods

We involved Patients with isolated or combined upper extremity fracture, ISS > 16 in a level one trauma center. The follow up was at least 10 years after the initial injury. Both clinical examination (range of motion, instability, contractures, peripheral nerve damage) and radiographic analysis were carried out. We evaluated also the development of heterotopic ossifications. To analyse patients were subdivided into 3 different subgroups (articular [IA], shaft [IS], and combined [C]).

Results

A statistically significant difference was found when ROM was compared between Group IS and C (p = 0.012), for contractures between Groups IA and C (p = 0.009) and full muscle elbow forces between Groups IS and C (p = 0.005) and Group IA and IS (p = 0.021). There was a significantly increased incidence in heterotopic ossifications when articular involvement was present. This applied for the isolated (p < 0.02) and the combined group (Group C vs Group IS, p = 0.003).When Brooker type I/II in group IA and Brooker types III/IV were combined, there was a significant difference (p < 0.001). In group IA (n = 1) and in group C (n = 6), HO developed or worsened after revision surgery, all of which were performed for malunion or nonunion.

Conclusions

In this study, patients with isolated shaft fractures of the upper extremity tend to have a more favorable outcome in comparison with combined to isolated articular fractures in terms of range of motion, pain and the ability to use the arm for everyday activities.In the clinical practice of the treatment of polytraumatized patients with upper extremity injuries, we feel that the relevance of these injuries should not be underestimated. They are especially prone to development of heterotopic ossifications, thus requiring prophylactic measures, if necessary. As their incidence increases with the rate of reoperations, we feel that even during initial care, meticulous surgery is required to avoiding the necessity of revision surgeries. Similar to injuries below the knee, upper extremity injuries, should be treated to avoid any functional disability.

Preliminary radiological result after establishment of hospital-based trauma registry in level-1 trauma hospital in developing country setting, prospective cohort study

Introduction

Injuries are the second most common cause of disability, the fifth most common cause of healthy years of life lost per 1000 people and unfortunately 90% of mortality takes place in low-to middle-income countries. Trauma registries guide policymakers and health care providers in decision making in terms of resource allocation as well as enhancing trauma care outcomes. Furthermore data from these registries inform policy makers to decrease the rate of death and disability occurring as a result of injuries. We present our experience in setting up an orthopedic trauma registry and the first short term follow-up of radiological outcomes.

Materials and methodology

Our study is a non-funded, non-commercial, prospective cohort study that was registered at Research Registry. The primary objectives of our study included assessing pattern of injuries in patients with upper and lower limb skeletal trauma presenting to our tertiary care academic university hospital and their respective outcomes. Data was collected by the musculoskeletal service line team members supervised by an experienced research associate and trauma consultants. The work has been reported in line with the STROCSS criteria.

Results

A total of 177 patients were included in this analysis, of whom 101 (57.1%) patients had lower limb fractures, 64(36.1%) patients ad upper limb fractures and 12 (6.8%) patients had both upper and lower limbs involved. A total of 189 upper and lower limb fracture cases were recorded. 176 patients (93.1%) underwent surgeries and 13(6.9%) were managed nonoperatively. Roentgenographic outcomes were assessed using radiological criteria for each bone fractured.

Conclusion

Establishing a trauma registry assists in identification of the pattern of injuries presenting to the hospital which helps in priority setting, care management and planning. This continuous audit of outcomes in turn, plays a significant role in quality improvement.

The Socioeconomic Implications of Isolated Tibial and Femoral Fractures from Road Traffic Injuries in Uganda

BACKGROUND

The purpose of this study was to determine the socioeconomic implications of isolated tibial and femoral fractures caused by road traffic injuries in Uganda.

METHODS

This prospective longitudinal study included adult patients who were admitted to Uganda's national referral hospital with an isolated tibial or femoral fracture. The primary outcome was the time to recovery following injury. We assessed recovery using 4 domains: income, employment status, health-related quality of life (HRQoL) recovery, and school attendance of the patients' dependents.

RESULTS

The majority of the study participants (83%) were employed, and they were the main income earner for their household (74.0%) at the time of injury, earning a mean annual income of 2,375 U.S. dollars (USD). All of the patients had been admitted with the intention of surgical treatment; however, because of resource constraints, only 56% received operative treatment. By 2 years postinjury, only 63% of the participants had returned to work, and 34% had returned to their previous income level. Overall, the mean monthly income was 62% less than preinjury earnings, and participants had accumulated 1,069 USD in debt since the injury; 41% of the participants had regained HRQoL scores near their baseline, and 62% of school-aged dependents, enrolled at the time of injury, were in school at 2 years postinjury.

CONCLUSIONS

At 2 years postinjury, only 12% of our cohort of Ugandan patients who had sustained an isolated tibial or femoral fracture from a road traffic injury had recovered both economically and physically.

LEVEL OF EVIDENCE

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

The effect of socio-economic status on non-fatal outcome after injury: A systematic review

BACKGROUND

Over the past decades, the number of survivors of injuries has rapidly grown. It has become important to focus more on the determinants of non-fatal outcome. Although socio-economic status (SES) is considered to be a fundamental determinant of health in general, the role of SES as a determinant of non-fatal outcome after injury is largely unknown.

METHODS

An online search was conducted in November 2015 using Embase, Medline, Web of Science, Cinahl, Cochrane, Google scholar and PubMed. Studies examining the relation between SES and a physical or psychological outcome measure, or using SES as a confounder in a general trauma population were included. There were no restrictions regarding study design. The 'Quality in Prognostic Studies tool' was used to assess the methodological quality of the included studies.

RESULTS

The 24 included studies showed large variations in methodological quality. The number of participants ranged from 56 to 4639, and assessments of the measures ranged from immediately to 6year post-injury. Studies used a large number of variables as indicators of SES. Participant's educational level was used most frequently. The majority of the studies used a multivariable technique to analyse the relation between SES and non-fatal outcome after injury. All studies found a positive association (80% of studies significant, n=19) between increased SES and better non-fatal outcome after injury.

CONCLUSION

Although an adequate and valid measure of SES is lacking, the results of this review showed that SES is an important determinant of non-fatal outcome after injury. Future research should focus on the definition and measurement of SES and should further underpin the effect of SES on non-fatal outcome after injury.

Injuries to the upper extremities in polytrauma: limited effect on outcome more than ten years after injury - a cohort study in 629 patients

AIMS

To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients.

PATIENTS AND METHODS

A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients' injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion.

RESULTS

In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC.

CONCLUSION

Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255-60.

[Medication and bone metabolism: Clinical importance for fracture treatment]

INTRODUCTION

The improvement and acceleration of fracture healing has been a component of medical practice since fractures have been treated. The aim is not only to fulfill the basic principles of fracture healing, such as reduction, retention, soft tissue coverage and infection prevention but also to reduce negative influences on fracture healing and promote positive factors. Nicotine, alcohol, diabetes and malnutrition can negatively affect fracture healing and should be appropriately controlled during fracture treatment; however, it is far more difficult to develop medicinal treatment strategies that lead to improvement and acceleration of fracture healing.

AIM

This article provides an overview of pharmacological factors influencing fracture healing. In addition, substances frequently used in clinical practice will be evaluated in terms of the effects on fracture healing processes.

MATERIAL AND METHODS

An extensive literature search was conducted in PubMed based on thematic keywords. The selection of studies and scientific publications focused mainly on results from clinical trials in order to provide practically relevant information.

RESULTS

In this context, preclinical studies have identified several drugs that lead to the acceleration of fracture healing; however, only a very limited number of clinical trials have confirmed this positive effect. Most of these studies dealt with drugs developed for the treatment of osteoporosis, as osteoporotic fractures are common and a positive or negative influence of such drugs are of particular interest in this field. In the field of osteoporosis medication a certain degree of positive effect of parathyroid hormone 1-34 (PTH) on fracture healing has been shown in clinical trials. For other osteoporosis medications no negative influence on fracture healing in clinical settings has been reported; however, there seems to be a positive effect in terms of better implant fixation for patients receiving oral bisphosphonate therapy.

DISCUSSION

Systemic medication to improve fracture healing will not be part of the clinical routine in the foreseeable future as the available data for already approved drugs and drugs under development do not currently justify routine administration. However, the currently known data should encourage the potential of known medications to be completely exhausted in fracture healing studies as well as novel therapy options in the sense of positive effects on fracture healing in order to improve patient care.

One-year development of QOL following orthopaedic polytrauma: a prospective observational cohort study of 53 patients

INTRODUCTION

Most studies of polytrauma examined highly mixed patient groups. The objective of the present study was to report the development of patient-reported quality of life (QOL), in a patient group with musculoskeletal polytrauma, excluding patients with major thoracic, abdominal, and brain injuries.

MATERIALS AND METHODS

The study design was a 1-year cohort follow-up study. Recordings of injury severity were measured with the ISS and NISS. Patient-reported QOL was measured with the questionnaires Eq5d-5L and SF-36 and compared to age-matched reference populations. Moreover, patients return to work status was measured. Data were collected prospectively at discharge, 3, 6, and 12 months.

RESULTS

53 patients were included. The mean age was 42.3 years, ranging from 17 to 78 years. Twelve months after trauma admission, the mean Eq5d-5L index was 0.601 (95 % CI 0.546-0.657). A progressive increasing Eq5d-5L index and SF-36 PCS was observed between the discharge and the 12-month follow-up (p < 0.001). The development in QOL from 6 to 12 months almost shows identically scores. Throughout the study period, patients reported significant worse QOL compared with the established reference population. 32 % of patients have resumed earlier employment status at 1-year follow-up.

CONCLUSIONS

Throughout the 12-month observational period, patients reported worse QOL compared to the age-matched reference population. The development of QOL from 6- to 12-month time points almost showed identically scores with only little improvement. At the end of 1-year follow-up, 32 % of patients had resumed prior employment status.

Decreased QOL and muscle strength are persistent 1 year after intramedullary nailing of a tibial shaft fracture: a prospective 1-year follow-up cohort study

INTRODUCTION

To evaluate the development in patient-reported quality of life (QOL) and muscle strength in the period from surgery to 12 months postoperatively after intramedullary nailing of a tibial shaft fracture.

MATERIALS AND METHODS

The design was a prospective, follow-up cohort study. QOL was measured with the questionnaire Eq5D-5L and compared to norm data from a reference population. Recordings of pain and contralateral muscle strength (isometric maximal voluntary contraction (MVC) for knee flexion and extension were collected at 6 weeks, 3, 6, and 12 months postoperatively. Ipsilateral MVCs were recorded at 6 and 12 months.

RESULTS

Forty-nine patients were included. The mean age at the time of fracture was 43.1 years (18-79 years). Twelve months postoperatively, the mean Eq5D-5L index was 0.792 (95 % CI 0.747-0.837). Throughout the 12 months postoperatively, patients reported worse QOL compared to the reference population. Six and 12 months after surgery patients demonstrated decreased muscle strength in the injured leg compared to the non-injured leg for knee extension and flexion (P < 0.001). Twelve months postoperatively, increasing relative difference in muscle strength during knee extension show a fair correlation to worse QOL (R = 0.541, P < 0.001).

CONCLUSIONS

Throughout the 12 months postoperatively, patients reported worse QOL compared to the reference population. Muscle strength in the non-injured leg improved over time and was higher after 6 and 12 months compared with the injured leg.

Economic loss due to traumatic injury in Uganda: The patient's perspective

INTRODUCTION

Traumatic injury is a growing public health concern globally, and is a major cause of death and disability worldwide. The purpose of this study was to quantify the socioeconomic impact of lower extremity fractures in Uganda.

METHODS

All adult patients presenting acutely to Uganda's national referral hospital with a single long bone lower extremity fracture in October 2013 were recruited. Consenting patients were surveyed at admission and again at six-months and 12-months post-injury. The primary outcome was the cumulative 12-month post-injury loss in income. Secondary outcome measures included the change in health-related quality of life (HRQoL) and the injury's effect on school attendance for the patients' dependents.

RESULTS

Seventy-four patients were recruited during the study period. Sixty-four (86%) of the patients were available for 12-months of follow-up. Compared to pre-injury earnings, patients lost 88.4% ($1822 USD) of their annual income in the 12-months following their injury. To offset this loss in income, patients borrowed an average of 28% of their pre-injury annual income. Using the EuroQol-5D instrument, the mean HRQoL decreased from 0.91 prior to the injury to 0.39 (p<0.0001) at 12-months post-injury. Ninety-three percent of school-aged dependents missed at least one month of school during their guardian's recovery and only 61% had returned to school by 12-months post-injury.

CONCLUSION

This study demonstrates that lower extremity fractures in Uganda had a profound impact on the socioeconomic status of the individuals in our sample population, as well as the socioeconomic health of the family unit.

Health related quality of life and return to work after minor extremity injuries: A longitudinal study comparing upper versus lower extremity injuries

PURPOSE

To investigate the impact on health related quality of life (HRQL) during the first year after minor extremity injury and to determine whether there is a difference in recovery patterns and return to work between upper extremity injuries (UEI) and lower extremity injuries (LEI).

METHOD

A total of 181 adults' age 18 years or older randomly selected from patients admitted to an emergency department with minor injuries were studied. HRQL was measured using the Functional Status Questionnaire (FSQ) at 1-2 weeks, 3, 6, and 12-months post-injury. Pre-injury FSQ scores were measured retrospectively at admission. A quasi-least square (QLS) model was constructed to examine differences of FSQ scores at each measuring point for UEI and LEI.

RESULTS

Fractures of the knee/lower leg (25%) were the most frequently injured body area. Slips or falls (57%) and traffic-related events (22%) were the most common injury causes. The mean ISS was 4.2 (SD 0.86). Both groups had significant declines in the FSQ scores physical and social functioning at 1-2 weeks after injury. Patients with UEI made larger improvements in the first 3 months post-injury versus patients with LEI whose improvements extended over the first 6 months. None of the groups reached the pre-injury FSQ scores during the first post-injury year except in the subscale work performance where UEI exceeded the pre-injury scores. At 12 months post-injury, significant lower FSQ scores remained in the LEI group compared to the UEI group in intermediate activities of daily living (p=0.036, d 0.4) and work performance (p=0.004, d 0.7). The return to work at 3 months and 12 months were 76% and 88% for UEI and 58% and 77% for LEI. No significant differences were found between groups in the FSQ scale mental health and social interaction.

CONCLUSIONS

LEI had the highest impact on HRQL and return to work during the first year which exceeded the consequences of UEI. These findings contribute to the information about the consequences of injury in order to give sufficient prognostic information to patients and different stakeholders. Future investigations should aim to investigate specific minor extremity injuries and identify factors that facilitate recovery and return to work.

Noncontiguous and open fractures of the lower extremity: Epidemiology, complications, and unplanned procedures

INTRODUCTION

Isolated fractures of the lower extremity are relatively common injuries while multifocal injuries resulting from high-energy trauma are less frequently encountered. Our objectives are to characterise patients who sustained multiple noncontiguous fractures and open fractures of the lower extremity, report the incidence of major complications, and identify factors that may contribute to complications and unplanned re-operations.

PATIENTS AND METHODS

A retrospective review of patients was performed at a Level 1 trauma centre from 2000 to 2013. Patients who sustained two or more noncontiguous operative fractures in an ipsilateral lower extremity, with at least one open fracture were included. Noncontiguous was defined as fractures in the same lower limb that were not in continuity on preoperative radiographs or intra-operatively. Demographic, injury characteristics, and hospitalisation data were collected. Primary outcomes included non-union, deep infection, and the need for unplanned surgeries.

RESULTS

257 patients sustained a total of 876 lower extremity fractures with an average of 1.7 open and 2.7 operative fractures in the qualifying limb. Ninety-nine patients (38.5%) sustained bilateral lower extremity injuries. Following their initial stay, 22.6% of patients had planned procedures (definitive fixation, skin, or planned bone grafting). Nearly half (45.9%) required one or more unplanned re-operation. Complications included deep infections (19.5%), non-unions (19.5%), and mal-unions (2.7%). 17.5% of the patients had at least one procedure for removal of painful implants. A deep infection was predictive of having a non-union (odds ratio, OR 7.5). The presence of a Gustilo-type IIIB/IIIC (OR 24.6/16.0) fracture was predictive of having a deep infection. After excluding painful implant removal, a type IIIB fracture was associated with an unplanned procedure (OR 13.8).

CONCLUSIONS

Patients with multiple non-contiguous lower extremity injuries associated with open fractures can expect complications including non-unions, deep infections, and painful implants. Nearly half of the patients will need further operative treatment.

The course of health status and (health-related) quality of life following fracture of the lower extremity: a 6-month follow-up study

PURPOSE

The aim of this prospective study was to describe the course of health status (HS), health-related quality of life, and quality of life (QOL) in patients with lower extremity fractures (LEF) up to 6 months post-fracture.

METHODS

Patients (n = 171; age range 18-100 years) completed the World Health Organization Quality of Life assessment instrument-Bref (WHOQOL-Bref) and the Short Musculoskeletal Function Assessment questionnaire (SMFA) at time of diagnosis (i.e., pre-injury status), 1 week, and 6 months post-fracture. Linear mixed modeling was performed.

RESULTS

Interaction effects of time with treatment were detected for the WHOQOL-Bref facet Overall QOL and General health (p = .002) and Physical health (p = .003). Patients did not return to their pre-injury Physical health, Psychological health, and Environment 6 months post-fracture (p < .05). No effects were found for Social relationships. The SMFA subscale Lower extremity dysfunction showed main effects for time and treatment (p < .0001) with full recovery at 6 months (p = .998). An interaction effect of time with treatment was found for Daily life consequences (p < .0001) with nonoperatively treated patients showing full recovery (p = 1.00), whereas surgically treated patients did not (p = .002).

CONCLUSIONS

Six months after LEF, patients still experienced impaired physical and psychological health on the WHOQOL-Bref compared to their pre-injury status. However, patients showed full recovery on SMFA Lower extremity dysfunction, indicating that the choice of the questionnaire influences the derived conclusions. LEF did not affect satisfaction with social relationships.

Hyperbaric Oxygen in Lower Limb Trauma (HOLLT); protocol for a randomised controlled trial

INTRODUCTION

Open fractures with significant soft tissue injury are associated with high rates of complications, such as non-union, infection, chronic pain and disability. Complications often require further inpatient care, and in many cases, multiple operations and prolonged rehabilitation. Use of hyperbaric oxygen therapy as an adjunct to standard orthopaedic trauma care has the potential to reduce the complications of musculoskeletal injury and thus improve outcomes. Two previous randomised trials have suggested some positive effect, but neither functional measures nor long-term outcomes were reported.

METHODS AND ANALYSIS

An international, multicentre, randomised, open-label, clinical trial. Patients with trauma with an acute open fracture of the tibia with severe soft tissue injury (Gustilo grade 3) and high risk of injury-related complications were recruited from participating major trauma hospitals with hyperbaric facilities. Patients were enrolled with the expectation of commencing 12 sessions of hyperbaric oxygen therapy within 48 h of injury. The primary outcome measure is the incidence of acute complications of the open fracture wound at 14 days. Other short-term outcome measures include amputation, need for fasciotomy, time until wound closure, breakdown of closed wounds, time until definitive orthopaedic fixation, number of operative procedures, intensive care stay and hospital stay. Long-term follow-up will continue for 2 years postinjury.

ETHICS AND DISSEMINATION

Ethics approval was given by The Alfred Health Human Ethics Committee (206/04) and the Monash University Human Research Ethics Committee (CF07/4208). Approval was also obtained from the institutional research ethics committee at each participating site. This study will make a significant contribution to the trauma literature and should answer the question of whether hyperbaric oxygen therapy can significantly improve outcomes in severe lower limb trauma. Collective study results will be published in international journals and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov: NCT00264511; Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12607000559415.

Femur fractures in professional athletes: a case series

OBJECTIVE

To discuss return to play after femur fractures in several professional athletes.

BACKGROUND

Femur fractures are rare injuries and can be associated with significant morbidity and mortality. No reports exist, to our knowledge, on return to play after treatment of isolated femur fractures in professional athletes. Return to play is expected in patients with femur fractures, but recovery can take more than 1 year, with an expected decrease in performance.

TREATMENT

Four professional athletes sustained isolated femur fractures during regular-season games. Two athletes played hockey, 1 played football, and 1 played baseball. Three players were treated with anterograde intramedullary nails, and 1 was treated with retrograde nailing. All players missed the remainder of the season. At an average of 9.5 months (range, 7-13 months) from the time of injury, all athletes were able to return to play. One player required the removal of painful hardware, which delayed his return to sport. Final radiographs revealed that all fractures were well healed. No athletes had subjective complaints or concerns that performance was affected by the injury at an average final follow-up of 25 months (range, 22-29 months).

UNIQUENESS

As the size and speed of players increase, on-field trauma may result in significant injury. All players returned to previous levels of performance or exceeded previous statistical performance levels.

CONCLUSIONS

In professional athletes, return to play from isolated femur fractures treated with either an anterograde or retrograde intramedullary nail is possible within 1 year. Return to the previous level of performance is possible, and it is important to develop management protocols, including rehabilitation guidelines, for such injuries. However, return to play may be delayed by subsequent procedures, including hardware removal.

Decreased muscle strength is associated with impaired long-term functional outcome after intramedullary nailing of femoral shaft fracture

PURPOSE

To examine the long-term outcome after intramedullary nailing of femoral diaphysial fractures measured as disease-specific patient reported function, walking ability, muscle strength, pain and quality of life (QOL).

METHODS

Cross-sectional study. Retrospective review and follow-up with clinical examination of 48 patients treated with intramedullary nailing after femoral shaft fracture between 2007 and 2010. The patients underwent a clinical examination and assessment of walking ability, maximal muscle strength during knee flexion and extension and hip abduction. Hip disability and Osteoarthritis Outcome Score (HOOS) and questionnaire evaluating QOL (Eq5D-5L) were completed by patients.

RESULTS

Fourty-eight patients agreed to participate. Mean time for follow-up was 4.7 years. The mean HOOS scores were 84.9 (Pain), 86.6 (ADL), 85.0 (Symptoms), 72.6 (QOL), and 69.1 (Sport). The mean muscle strength of knee flexion with the injured leg (226.0 N) was significantly lower then knee flexion with the non-injured leg (259.5 N, P < 0.0001). Likewise for knee extension (335.2 vs 406.4 N, P < 0.001) and hip abduction (129.2 vs 156.0 N, P < 0.001). Significant association between HOOS and an increase in the difference in muscle strength were observed as well as between worse HOOS outcome and increasing body mass index.

CONCLUSION

This study showed that decreased muscle strength for knee flexion, knee extension and hip abduction was associated with worse long-term functional outcome measured with a disease-specific questionnaire (HOOS) after intramedullary nailing of femoral shaft fracture.

Functional outcome after tibial plateau fracture osteosynthesis: a mean follow-up of 6 years

BACKGROUND

Tibial plateau fractures often require surgical treatment. Functional outcome depends mainly on the range of knee motion, joint stability, and pain. Only a few studies evaluate the functional outcome of a tibial plateau fracture after operation. The primary aim of this study was to evaluate the results and functional outcome of surgically treated (ORIF) tibial plateau fractures.

METHODS

Between January 2000 and December 2010 all consecutive patients undergoing osteosynthesis of a tibial plateau fracture were included if they were discharged alive and completed the questionnaire. The primary outcome measures were functional outcome ("Knee injury and Osteoarthritis Score" (KOOS) questionnaire) and Health-related quality of life (HrQoL) using the EuroQol-6D (EQ-6D) questionnaire at the end of the study follow-up period (May 2013).

RESULTS

Eighty-two patients were included in the functional outcome and HrQoL analysis. The functional outcome results were concluded as "Fair" for the overall cohort within the sections Symptoms/Pain/Self-care. A significant difference was seen in the Sport/Recreation section (functional outcome: "Poor"). Dividing our cohort in a low-energy and a high-energy-trauma group, significant lower functional outcome score was seen in the KOOS section Pain for the high-energy-trauma patients. The HrQoL of the total study-population was worse in comparison to an age-matched general Dutch population on the EQ-us (difference of 0.15). This decrease in HrQoL was seen in all dimensions of the EuroQol questionnaire.

CONCLUSIONS

Six years after discharge from hospital, patients still alive had a "Fair" functional knee outcome. However, HrQoL was lower in comparison to the general Dutch population.

Limb salvage surgery

The threat of lower limb loss is seen commonly in severe crush injury, cancer ablation, diabetes, peripheral vascular disease and neuropathy. The primary goal of limb salvage is to restore and maintain stability and ambulation. Reconstructive strategies differ in each condition such as: Meticulous debridement and early coverage in trauma, replacing lost functional units in cancer ablation, improving vascularity in ischaemic leg and providing stable walking surface for trophic ulcer. The decision to salvage the critically injured limb is multifactorial and should be individualised along with laid down definitive indications. Early cover remains the standard of care, delayed wound coverage not necessarily affect the final outcome. Limb salvage is more cost-effective than amputations in a long run. Limb salvage is the choice of procedure over amputation in 95% of limb sarcoma without affecting the survival. Compound flaps with different tissue components, skeletal reconstruction; tendon transfer/reconstruction helps to restore function. Adjuvant radiation alters tissue characters and calls for modification in reconstructive plan. Neuropathic ulcers are wide and deep often complicated by osteomyelitis. Free flap reconstruction aids in faster healing and provides superior surface for offloading. Diabetic wounds are primarily due to neuropathy and leads to six-fold increase in ulcerations. Control of infections, aggressive debridement and vascular cover are the mainstay of management. Endovascular procedures are gaining importance and have reduced extent of surgery and increased amputation free survival period. Though the standard approach remains utilising best option in the reconstruction ladder, the recent trend shows running down the ladder of reconstruction with newer reliable local flaps and negative wound pressure therapy.

Assessment of the internal construct validity of the revised High-Level Mobility Assessment Tool for traumatic orthopaedic injuries

OBJECTIVE

To determine whether the revised High-Level Mobility Assessment Tool (HiMAT) was valid for measuring mobility for people with multi-trauma orthopaedic lower limb injuries.

DESIGN

Cross-sectional study.

SUBJECTS

Participants with lower limb multi-trauma orthopaedic injuries.

METHODS

One complete revised HiMAT was obtained for 106 people within 12 weeks of being allowed to fully weight bear. Rasch analysis was used to assess the overall fit of the model for individuals and items, differential item functioning, local dependency, targeting of items and dimensionality.

RESULTS

The mean revised HiMAT score was 10.5 (SD = 6.8) with a range of 5-30. Rasch analysis of revised HiMAT showed adequate overall fit to the model (P = 0.29) with no misfitting items (fit residual SD = 0.69) or persons (fit residual SD = 0.62). The scale showed good internal consistency (Person Separation Index = 0.91). One item (hopping) demonstrated disordered thresholds, however this item had good fit to the model in all other aspects. The revised HiMAT was unidimensional, and no differential item functioning was detected for gender or age. The revised HiMAT was well targeted for this group with a range of items across all ability levels.

CONCLUSION

The results of this study support the internal construct validity of the revised HiMAT as a well-targeted, unidimensional measure of high-level mobility with no ceiling or floor effect for males and females recovering from multi-trauma orthopaedic lower limb injuries.

Development and preliminary validation of a Function IndeX for Trauma (FIX-IT)

BACKGROUND

Assessing fracture healing in clinical trials is subjective. The new Function IndeX for Trauma (FIX-IT) score provides a simple, standardized approach to assess weight-bearing and pain in patients with lower extremity fractures. We conducted an initial validation of the FIX-IT score.

METHODS

We conducted a cross-sectional study involving 50 patients with lower extremity fractures across different stages of healing to evaluate the reliability and preliminary validity of the FIX-IT score. Patients were independently examined by 2 orthopedic surgeons, 1 orthopedic fellow, 2 orthopedic residents and 2 research coordinators. Patients also completed the Short Form-36 version 2 (SF-36v2) questionnaire, and convergent validity was tested with the SF-36v2.

RESULTS

For interrater reliability, the intraclass correlation coefficients ranged from 0.637 to 0.915. The overall interrater reliability for the total FIX-IT score was 0.879 (95% confidence interval 0.828-0.921). The correlations between the FIX-IT score and the SF-36 ranged from 0.682 to 0.770 for the physical component summary score, from 0.681 to 0.758 for the physical function subscale, and from 0.677 to 0.786 for the role-physical subscale.

CONCLUSION

The FIX-IT score had high interrater agreement across multiple examiners. Moreover, FIX-IT scores correlate with the physical scores of the SF-36. Although additional research is needed to fully validate FIX-IT, our results suggest the potential for FIX-IT to be a reliable adjunctive clinician measure to evaluate healing in lower extremity fractures.

LEVEL OF EVIDENCE

Diagnostic Study Level I.

The concurrent validity and responsiveness of the high-level mobility assessment tool for mobility limitations in people with multitrauma orthopedic injuries

OBJECTIVE

To investigate the concurrent validity, responsiveness, and ceiling effect of the revised High-Level Mobility Assessment Tool (HiMAT) in persons after orthopedic multitrauma.

DESIGN

Cross-sectional sample of convenience.

SETTING

A large tertiary rehabilitation hospital.

PARTICIPANTS

Forty-three participants with orthopedic multitrauma lower limb injuries that resulted from motor vehicle accidents.

METHODS

This study compared the concurrent validity, responsiveness, and ceiling effects of the revised HiMAT, motor subsection of the Functional Independence Measure (FIM) instrument. Performances for all participants were concurrently scored on the motor FIM, revised HiMAT, and the Lower Extremity Functional Scale (LEFS) at initial testing, and 6 and 12 weeks after the decision to fully bear weight.

MAIN OUTCOME MEASUREMENTS

Revised HiMAT, motor FIM, and LEFS.

RESULTS

The correlation between the revised HiMAT and the motor FIM was moderate (r = 0.49; P <.001) and partly induced by a ceiling effect in the motor FIM. After 12 weeks of full weight bearing, 51.2% of participants achieved the maximum score on the motor FIM. The correlation between the revised HiMAT and LEFS was weak (r = 0.39; P = .012), which indicated a weak relationship between self-reported mobility problems and actual performance. The revised HiMAT was more responsive than the motor FIM and the LEFS, based on the proportion of persons who exceeded the minimal detectable change score over a period of 6 and 12 weeks.

CONCLUSION

The revised HiMAT is more responsive to change than the LEFS and motor FIM, and less susceptible to a ceiling effect than the motor FIM for persons with orthopedic multitrauma. It has poor-to-moderate concurrent validity with the LEFS and motor FIM, which suggests that it may be measuring a different aspect of mobility.

The multiple meanings of 'disability' in interviews with amputees

The link between having a lower-limb amputation and being disabled might seem self-evident. Indeed, the medical model of disability would suggest that lower-limb amputation causes disability, and that all lower-limb amputees are disabled people. Conversely, social models of disability would argue that limb loss does not determine disability, but that disabilities are rather caused by social structures and prejudices, while the interactional model suggests that there are both individual and social causes of disability. This paper draws on interviews with nine lower-limb amputees to address amputees' own accounts of disability, in order to determine how (if at all) they make links between being an amputee and being disabled. The analysis shows that participants draw on various models of disability, as well as their own lived experiences, to construct subjective and diverse definitions of disability. Three interlinking definitions of disability recurred across the data: disability as a measure of personal (in)abilities; disability as a stigmatizing mask; and disability as an official status. Overall, disability was constructed as a complex, context-dependent label, which could not be reduced to any singular concept.

Health-related quality of life in children and adolescents following traumatic injury: a review

This paper comprehensively reviews the published literature investigating health-related quality of life (HRQOL) following general traumatic injury in individuals between birth and 18 years. Studies were not considered if they primarily compared medical treatment options, evaluated physical function but not other aspects of HRQOL, or focused on non-traumatic wounds. Specific injury types (e.g., burn injury) were also not included. A total of 16 studies met criteria. Participants were age 1-18 years, with 12 studies considering children 5 years of age or older. Males were overrepresented. Injury severity averaged mostly in the moderate range. HRQOL deficits were noted in injured samples in all studies except the two with the longest time to follow-up (6-11 years). Some improvement was seen 6 months to 2 years after injury. Factors associated with HRQOL deficits were investigated, with acute and posttraumatic stress disorder symptoms showing the strongest relationship. Research to date in this area is impressive, particularly the number of studies using prospective longitudinal investigations and validated measures. Challenges remain regarding methodologic differences, assessment of preinjury status, retention of participants, and management of missing data. Suggested future directions include extension of follow-up duration, utilization of pediatric self-report when possible, inclusion of younger children, and development of intervention programs.

Drugs for bone healing

INTRODUCTION

The biological process of fracture healing is complex with influences that are both patient-dependent and related to the trauma experienced and stability of the fracture. Fracture healing complications negatively affect the patient's quality of life, even more when fractures occur in the elderly osteoporotic patients.

AREAS COVERED

In the polytherapy for bone regeneration, a high success rate was obtained with the use of growth factors, osteogenic cells, and osteoconductive factors. There have been high expectations that treatment with drugs active on bone remodeling would be efficient for acceleration of fracture healing. A literature search was undertaken using wording like "drug or pharmacology of fracture healing." This report will review the systemic pharmacological agents for which clinical trials documenting their efficacy on bone healing have been carried out or are underway.

EXPERT OPINION

At present the use of systemic pharmacological agents to enhance fracture healing in the clinical setting is still controversial. However, future clinical trials will offer the possibility to obtain data that will make possible the registration of a drug as a "healer."

Impact of isolated acetabular and lower extremity fractures on long-term outcome

BACKGROUND

The long-term clinical status of surviving patients with multiple injuries has not been well described. The aim of this study was to evaluate the long-term outcome of acetabular and lower limb injuries.

METHODS

Patients treated at a Level I trauma center at least 10 years before participation in this study were invited for a follow-up physical examination. Six hundred thirty-seven patients were examined. Inclusion criteria are as follows: Injury Severity Score ≥16 Points;treatment in a Level I trauma center; and injuries of the lower limb: fractures of the acetabulum, proximal femur, femoral shaft,knee joint, and tibial shaft. Exclusion criteria are as follows: incomplete follow-up examination, amputations, ankle and foot fractures, and patients older than 60 years and younger than 3 years. The follow-up examination included the following parameters:range of motion, pain, limping, successful rehabilitation, and outcome scores.

RESULTS

Of 525 patients with fractures of the acetabulum and lower limb, 229 patients fulfilled the inclusion criteria. Mean age: 24.9 (range,3–60) years; Injury Severity Score: 19.66 (range, 16–43). The most frequent rates of ongoing local pain were stated by patients with fractures of the acetabulum (50%) and the proximal femur (45%). Moreover, the incidence of abnormal gait was significantly lower in patients with femoral shaft fractures when compared with the patients with fractures of the acetabulum (3.7% vs. 35%;p 0.0001), proximal femur (3.7% vs. 20%; p≤ 0.006), and tibial shaft (3.7% vs. 14.7%; p = 0.023).

CONCLUSIONS

Our results demonstrate a better long-term outcome in patients with femur shaft fractures, whereas patients with articular fractures and proximal femur fractures were associated with poorer outcomes. Fracture location is determining factor for long-term outcome

Osteocutaneous pedicle flap transfer for salvage of transtibial amputation after severe lower-extremity injury

BACKGROUND

A conventional transtibial amputation may not be possible when the zone of injury involves the proximal part of the tibia, or in cases of massive tibial bone and/or soft-tissue loss. The purpose of this study was to examine the outcomes of salvage of a transtibial amputation level with a rotational osteocutaneous pedicle flap from the ipsilateral hindfoot.

METHODS

Fourteen patients who had an osteocutaneous pedicle flap from the ipsilateral foot were included in the study. Twelve patients were followed for more than twenty-four months (mean, 60.2 months) and were evaluated with use of the Sickness Impact Profile (SIP), Musculoskeletal Function Assessment (MFA), and a 100-ft (30.48-m) timed walking test.

RESULTS

There were ten men and four women with mean age of 43.2 years. Thirteen patients had a type-IIIB open tibial fracture, and one had extensive soft-tissue loss secondary to a burn. Four patients were treated for infection after the index procedure. There were no nonunions of the tibia to the calcaneus. Three patients underwent late reconstructive procedures to improve prosthetic fit. No patient required subsequent revision to a more proximal amputation level. Mean knee flexion was 139°.

CONCLUSIONS

A novel technique has been developed to salvage a transtibial amputation level with use of a rotational osteocutaneous flap from the hindfoot. In the absence of adequate tibial length and/or soft-tissue coverage to salvage the entire limb or to perform a conventional-length transtibial amputation, this technique is a highly functional alternative that does not require microvascular free tissue transfer.

Difficulties in establishing long-term trauma outcomes data collections. Could trauma outcomes be routinely monitored in New South Wales, Australia: piloting a 3 month follow-up?

Injuries represent a significant health burden in Australia. In New South Wales (NSW), no routine follow-up of post-injury health outcomes is conducted. This article describes the development of a protocol and the conduct of a pilot study to collect information on trauma outcomes at 3 months post-injury at two trauma centres. A modified Victorian model of trauma outcomes monitoring was adopted, with potential participants required to 'opt in' to the collection. Fifty-three percent of individuals contacted consented to opt in, with 75% of these completing an interview. The data items collected were able to provide an indicator of the impact of trauma on individuals. This study has highlighted that there are important methodological issues to be addressed in terms of recruitment in establishing long-term trauma outcomes data collections that are representative of the trauma population. Ultimately, information from a long-term trauma outcomes collection could be linked to data collections to conduct research across the injury continuum.

Subjective results after surgical treatment for displaced intra-articular calcaneal fractures

We present a retrospective study investigating the results of the subjective assessment of displaced intra-articular calcaneal fractures in a selected cohort of 42 patients treated operatively, with a follow-up duration of at least 3 years. The adjusted American Orthopaedic Foot and Ankle Society questionnaire, Foot Function Index, and visual analog scale were used to quantify the subjective evaluations. Our hypothesis was that good subjective results could be predicted and obtained in patients with specific characteristics if anatomic reduction of the fracture was achieved. The results of the study confirmed our hypothesis. A number of specific subgroup analyses were undertaken. The study confirmed that Böhler angle restoration and the quality of reduction of the subtalar joint facet are important prognostic factors related to the outcome. In contrast, gender and Sanders type had less influence at the intermediate-term follow-up results. The main weaknesses of the present study included its retrospective nature, the lack of a control group managed nonoperatively for comparison, and the small sample size. Moreover, the operating surgeon performed the radiographic measurement and categorized the quality of the surgical reconstruction.

Validity of outcome measures used to assess one and six month outcomes in orthopaedic trauma patients

INTRODUCTION

To evaluate the validity of the 12-item Short Form Health Survey (SF-12), Sickness Impact Profile (SIP) and the Short Musculoskeletal Functional Assessment Questionnaire (SMFA) for use in an orthopaedic trauma population.

MATERIALS AND METHODS

A prospective validation trial was completed at a Level 1 adult trauma centre in Melbourne, Australia. One hundred and fifty four patients with orthopaedic trauma managed or followed-up by an orthopaedic unit were prospectively recruited. Patients with pathological fractures related to metastatic disease and/or an isolated orthopaedic injury, a documented history of mental illness or dementia or those for whom follow-up was likely to be difficult were excluded. The SF-12, SIP and SMFA were administered by a trained interviewer at one and six months. Each questionnaire was scored for the physical and mental components and then compared for content and construct validity at each time point.

RESULTS

Complete data were collected for 134 patients at one and six months. The one and six month component scores correlated strongly between the SF-12 physical, SIP physical (r=0.513-0.669) and SMFA dysfunction (r=0.529-0.778); the SF-12 mental, SIP mental (r=0.643-0.719) and SMFA bother (r=0.564-0.602) components. The strength of association was greater for the six month time point compared to the one month measure. The SF-12 demonstrated no ceiling or floor effects, and provided a lower time burden on participants and researchers when compared to the SIP and SMFA.

CONCLUSIONS

For large population-based surveillance research into orthopaedic injury the SF-12 provides a valid and versatile tool.

Anxiety and depression in Brazilian orthopaedics inpatients: a cross sectional study with a clinical sample comparison

There are few studies on the development of anxiety and depression in orthopaedics and trauma (O&T) inpatients. We designed a cross-sectional study aimed at comparing the prevalence of depression and anxiety in 100 O&T inpatients and 100 clinical inpatients in the same hospital. O&T patients were divided into subgroups: trauma and non-trauma (arthroplasty, tumour, and infection sub grouping). We measured anxiety and depression by the Hospital Anxiety and Depression Scale and co-morbidities by the Charlson age-adjusted comorbidity index (CCI). For the trauma subgroup, AO/OTA fracture classification and Gustillo and Anderson grade of open fractures classification was applied. The prevalence of anxiety and depression was 35% and 28%, respectively for the clinical sample, and 44% and 33% for the O&T sample. Compared with the clinical sample, anxiety scores were higher in the O&T sample (p = .047), and in arthroplasty (p = .020) and trauma subgroups (p = .031). In the O&T sample, high CCI scores were associated with high anxiety scores (p = .033).