Steppingstones to the implementation of an inhospital fracture and dislocation registry using the AO/OTA classification: compliance, completeness and commitment

Validity and reliability of the Manchester Oxford Foot Questionnaire (MOXFQ) in one-year postoperative ankle fracture patients-a validation study

BACKGROUND

Ankle fracture patients are a heterogenous group with differences in age, sex, fracture morphology, and treatment provided. With the increased focus on patient-centered treatment, patient-reported outcome measures (PROMs) are increasingly adopted by clinicians to facilitate best clinical practice. The Manchester Oxford Foot Questionnaire (MOXFQ) has demonstrated good measurement properties when used in patients with foot or ankle disease. The PROM has three domains: (1) Pain; (2) Walking/Standing; and (3) Social Interaction. One study found sufficient content validity for the Pain and Walking/Standing domains when used in the evaluation of ankle fracture patients. Another validation study demonstrated acceptable structural validity and reliability for the MOXFQ in ankle fracture patients 12 weeks after injury. The aim of this study is to assess the structural validity and reliability of the Norwegian version of the MOXFQ in the context of an ankle fracture patients one year after surgery and provide patient acceptable symptom state (PASS) estimates.

METHODS

A pragmatic cross-sectional study design was used to collect the one-year MOXFQ follow-up data from patients surgically treated for an ankle fracture in the period 2017 to 2020 at (Stavanger University Hospital). The structural validity and internal consistency were assessed using confirmatory factor analysis. A separate test-retest study including patients at least one year since ankle surgery was used in the assessment of reliability and measurement error.

RESULTS

A confirmatory factor analysis of the three-factor model of the MOXFQ had a good model fit (TLI 0.94; CFI 0.95; RMSEA 0.094; SRMR 0.039). However, the measurement model demonstrated poor discriminant validity of the three factors. A unidimensional model of the 16 items had worse model fit, while a second-order factor model demonstrated strong factor loadings for a second-order factor. A bi-factor model also revealed a strong general factor but also unique variance in the Pain and Social Interaction domain. The domains had good internal consistency (McDonald's omega 0.80 to 0.95) and test-retest reliability (ICC 0.80 to 0.92). The standard errors of measurements for the three domains were between 6.5 and 7.5, and 5.5 for the MOXFQ-Index (scale 0 to 100). PASS estimates for the (sub)scales were: Pain 45; Walking/Standing 39; Social Interaction 19; and MOXFQ-Index 34.

CONCLUSION

The MOXFQ with three domains demonstrated sufficient structural validity and reliability when used in the evaluation of a one-year postoperative ankle fracture population. Reporting the scores of the Pain and Walking/Standing domains was best supported.

Masquelet technique combined with modified Sauve‑Kapandji, negative pressure drainage and flap transplantation for the treatment of a Gustilo‑Anderson III type C open fracture of the forearm: A case report

Gustilo-Anderson III Type C open fracture is a high-energy injury with severe bone defects and extensive soft-tissue and vascular damage. Successful limb salvage remains challenging for surgeons due to the inherent risks of vascular damage, infection, nonunion and even amputation. The present case study reports on a 55-year-old male who presented with a Gustilo-Anderson III type C open fracture, which was successfully salvaged by a combined Masquelet and microsurgical approach. The modified Sauve-Kapandji technique was used to improve wrist mobility. Sufficient preoperative evaluation, a detailed surgical plan, positive revascularization, thorough debridement and prevention of complications are key to successful limb salvage. The range of motion test was excellent one year after surgery. The patient was able to take care of their daily life, return to performing a light-labor job and is satisfied with the function of the limb. Therefore, the Masquelet technique combined with modified Sauve-Kapandji technique, negative pressure drainage and skin-flap transplantation may be a reasonable and effective treatment for Gustilo-Anderson III type C open forearm fracture.

The Swedish Fracture Register - ten years of experience and 600,000 fractures collected in a National Quality Register

BACKGROUND

Before the creation of the Swedish Fracture Register (SFR), there was no national quality register that prospectively collects data regarding all types of fractures regardless of treatment in an emergency setting. Observational data on fractures registered in a sustainable way may provide invaluable tools for quality improvements in health care and research.

DESCRIPTION

Ten years after its implementation, the Swedish Fracture Register has 100% coverage among orthopaedic and trauma departments in Sweden. The completeness of registrations reached in 2020 69-96% for hip fractures at the different departments, with the majority reporting a completeness above 85%. The Swedish Fracture Register is a fully web-based national quality register created and run by orthopaedic professionals, with financial support from public healthcare providers and the government. All users have full access to both the registration platform and all aggregated statistics in real time. The web-based platform was created for use in health quality registers and it has easily gained acceptance among users. The register has gradually developed by the addition of more fracture types and skeletal parts. Research activity is high and 31 scientific publications have been published since 2016. The strategy from the start was to publish validation data and basic epidemiological data. However, over the past few years, publications on outcomes, such as re-operations and mortality, have been published and four register-based, randomised, controlled trials are ongoing.

CONCLUSION

It is possible to create a fracture register, to gain professional acceptance and to collect fracture data in a sustainable way on a national level if the platform is easy to use. Such a platform can also be used as a randomisation platform for prospective studies.

Structured and Systematic Team and Procedure Training in Severe Trauma: Going from 'Zero to Hero' for a Time-Critical, Low-Volume Emergency Procedure Over Three Time Periods

Background

Resuscitative emergency thoracotomy is a potential life-saving procedure but is rarely performed outside of busy trauma centers. Yet the intervention cannot be deferred nor centralized for critically injured patients presenting in extremis. Low-volume experience may be mitigated by structured training. The aim of this study was to describe concurrent development of training and simulation in a trauma system and associated effect on one time-critical emergency procedure on patient outcome.

Methods

An observational cohort study split into 3 arbitrary time-phases of trauma system development referred to as ‘early’, ‘developing’ and ‘mature’ time-periods. Core characteristics of the system is described for each phase and concurrent outcomes for all consecutive emergency thoracotomies described with focus on patient characteristics and outcome analyzed for trends in time.

Results

Over the study period, a total of 36 emergency thoracotomies were performed, of which 5 survived (13.9%). The “early” phase had no survivors (0/10), with 2 of 13 (15%) and 3 of 13 (23%) surviving in the development and mature phase, respectively. A decline in ‘elderly’ (>55 years) patients who had emergency thoracotomy occurred with each time period (from 50%, 31% to 7.7%, respectively). The gender distribution and the injury severity scores on admission remained unchanged, while the rate of patients with signs on life (SOL) increased over time.

Conclusion

The improvement over time in survival for one time-critical emergency procedure may be attributed to structured implementation of team and procedure training. The findings may be transferred to other low-volume regions for improved trauma care.

Supplementary Information

The online version contains supplementary material available at (doi:10.1007/s00268-021-05980-1).

Performance and outcome evaluation of emergency resuscitative thoracotomy in a Norwegian trauma centre: a population-based consecutive series with survival benefits

BACKGROUND

Emergency resuscitative thoracotomy (ERT) is a lifesaving procedure for select indications in severely injured patients. The main body of the literature stem from regions with a high prevalence of penetrating injuries, while data from European institutions remain scarce. We aimed to evaluate a decade of ERT in a Norwegian trauma centre.

METHODS

A prospectively collected series from the institutional trauma registry of all consecutive trauma patients who had an ERT at Stavanger University Hospital (SUH) from 2006 to 2018. Data were extracted using both registry and electronic patient record (EPR) data, including injury profile, demographics and outcomes. Comparison of groups were done by descriptive statistics.

RESULTS

A total of 26 ERTs were performed during the study period, of which 20 were men (75%) and 6 women (25%). Five patients (19%) survived to hospital discharge, of which 3 men and 2 women with a median age of 46 years (range 24-68). All survivors had thoracic injury as location of major injury (LOMI.). Of the five survivors, four suffered blunt injury and one patient penetrating injury. At one-year of follow-up of the survivors, three patients scored 8/8 on Glasgow outcome scale-extended, 1 patient scored 7/8 and one patient 5/8.

CONCLUSION

In this study, ERT conferred good outcome with survival in one of every five procedures. Performing ERT in severely injured patients presenting in extremis appears to be justified even in low-volume centres and in blunt trauma.

Validating a transnational fracture treatment registry using a standardized method

AIM

Subsequent to a three-month pilot phase, recruiting patients for the newly established BFCC (Baltic Fracture Competence Centre) transnational fracture registry, a validation of the data quality needed to be carried out, applying a standardized method.

METHOD

During the literature research, the method of "adaptive monitoring" fulfilled the requirements of the registry and was applied. It consisted of a three-step audit process; firstly, scoring of the overall data quality, followed by source data verification of a sample size, relative to the scoring result, and finally, feedback to the registry on measures to improve data quality. Statistical methods for scoring of data quality and visualisation of discrepancies between registry data and source data were developed and applied.

RESULTS

Initially, the data quality of the registry scored as medium. During source data verification, missing items in the registry, causing medium data quality, turned out to be absent in the source as well. A subsequent adaptation of the score evaluated the registry's data quality as good. It was suggested to add variables to some items in order to improve the accuracy of the registry.

DISCUSSION

The application of the method of adaptive monitoring has only been published by Jacke et al., with a similar improvement of the scoring result following the audit process. Displaying data from the registry in graphs helped to find missing items and discover issues with data formats. Graphically comparing the degree of agreement between the registry and source data allowed to discover systematic faults.

CONCLUSIONS

The method of adaptive monitoring gives a substantiated guideline for systematically evaluating and monitoring a registry's data quality and is currently second to none. The resulting transparency of the registry's data quality could be helpful in annual reports, as published by most major registries. As the method has been rarely applied, further successive applications in established registries would be desirable.

High reliability in classification of tibia fractures in the Swedish Fracture Register

INTRODUCTION

The Swedish Fracture Register (SFR) was started in 2011 and registers fractures of all types, treated either surgically or non-surgically. Twenty-six orthopaedic departments in Sweden are affiliated and a total of 84,000 fractures have been registered. The physician who establishes the diagnosis of the fracture registers and classifies it according to the AO/OTA classification. The accuracy of the classification of fractures is important for the reliability of the data in the SFR. This study aimed to evaluate how accurate the classification of tibia fractures in the register is.

METHODS

Three experienced trauma surgeons (raters) were presented with the radiographs of 114 patients with tibia fractures randomly allocated from the SFR. The raters classified the fractures independently and blinded to clinical patient information in two classification sessions with a time interval of one month. The AO/OTA classification coded by the three expert raters (our predefined gold standard) was compared with the classifications in the SFR. Inter- and intra-observer agreement was evaluated. The degree of agreement was reported using the approach of Landis and Koch.

RESULTS

The accuracy of the SFR, defined as agreement between the SFR and the gold standard classification, was kappa=0.75 for the AO/OTA type and 0.56 for the AO/OTA group, corresponding to substantial and moderate agreement, respectively. Inter-observer agreement across the three expert raters was kappa=0.74 for the AO/OTA type and 0.53 for the AO/OTA group. Intra-observer agreement was kappa=0.74-0.79 for the AO/OTA type and 0.62-0.64 for the AO/OTA group.

CONCLUSION

This study shows that the accuracy of classification of tibia fractures in the SFR was substantial for the AO/OTA type (kappa=0.75) and moderate for the AO/OTA group (kappa=0.56) as defined by Landis and Koch. This degree of accuracy is similar to that in previous studies. We interpret this as meaning that the results of this study demonstrate the high reliability of the data in the SFR and enable the SFR to be used for further scientific analysis.

The Swedish fracture register: 103,000 fractures registered

BACKGROUND

Although fractures consume large social and financial resources, little is known about their actual numbers, treatment methods or outcomes. The scarcity of data calls for a high-quality, population-based register. No previous registers have prospectively collected data and patient-reported outcome measures (PROMs) on fractures of all types. The Swedish Fracture Register was recently created to fill this gap in knowledge. Its purpose is to provide information on fractures of all types, whether treated by surgery or otherwise. The aim of this article is to describe how the register was developed and its current use.

DESCRIPTION

The Swedish Fracture Register was developed during a 4-year period, 2007-2010. Data collection started in 2011. The register currently collects data on all extremity, pelvic and spine fractures in adults who have been diagnosed or treated at the affiliated departments. Data entry is fully web based, including date, cause of injury, classification and treatment. It is performed by the attending physician. Patients fill out PROMs - EQ-5D-3L and the Short Musculoskeletal Function Assessment (SMFA) - relating to health status and level of functioning before the fracture and one year later. Surgeon-reported outcome measures are registered as reoperation rates. The Swedish Fracture Register is now functioning effectively and is used in clinical routine. From January 2011 to September 2015, more than 103,000 fractures have been entered at 26 Swedish orthopedic departments.

CONCLUSIONS

The Swedish Fracture Register is already a well-functioning, population-based fracture register that covers fractures of all types, regardless of treatment, and collects both surgeon- and patient-reported outcome measures. In the future the Swedish Fracture Register will be able to present both results of fracture treatment and valuable epidemiological data.

Analysis of complications of intertrochanteric fracture treated with Gamma 3 intramedullary nail

Whether Gamma 3 fixation system is suitable for all intertrochanteric fractures is inconclusive. This paper analyzed the surgical complications of Gamma 3 intramedullary nail in the treatment of intertrochanteric fractures.

METHODS

A total of 186 cases were enrolled in the study including 115 males and 71 females. The surgical operations were performed in all cases and Gamma 3 intramedullary nail was inserted in medullary cavity.

RESULTS

Anti-rotation screw displacement into the intermuscular space of inner thigh occurred in 1 case, lateral femoral wall defect in 3 cases; refracture of proximal femur shaft during the Gamma 3 nail inserting into the medullary cavity occurred in 5 cases and fractures with a gap or malalignment in closed reduction of A3 type in occurred 6 cases. Fracture union occurred in 3-4 months postoperative. Recovery situations of all patients were evaluated based on Harris scoring system 6 with an average of 87 points. There are indications and shortcomings in the treatment of intertrochanteric fracture with Gamma 3 intramedullary nail.

CONCLUSION

Understanding the surgical indications, standardizing the operation and upgrading skills are the key points to ensure operation successful, reduce complications and improve clinical outcomes.

Atypical femoral fractures in elderly women

An atypical femoral fracture (AFF), with a transverse fracture radiologically through the lateral cortex is a rare but serious condition. In order to improve our ability to identify patients with this condition, we retrospectively surveyed all subtrochanteric, peri-implant and diaphyseal femoral fractures in patients aged ≥ 65 years who underwent surgical treatment at our hospital between 2004 and 2011.

We describe the incidence of atypical fractures and their characteristics, with observational data including a review of the hospital and general practitioner records. Clinical outcomes were evaluated using the Harris hip score (HHS) and the timed up-and-go (TUG) test.

Atypical fractures only occurred in women with an incidence of 9.8 per 100 000 person-years. The incidence in those who were treated with bisphosphonates was 79.0 per 100 000 person-years; eight of 17 fractures occurred around metal implants. There was a high incidence of delayed union and revision surgery. A total of nine patients (ten AFFs) were available for review at a mean follow-up of 36.5 months (10 to 104). The clinical outcome was poor with a mean HHS of 58.9 (95% CI 47.4 to 70.4) and a mean TUG test of 25.7 s (95% CI 12.7 to 38.8).

The delay in diagnosis and treatment of AFF may result from a lack of knowledge of this condition.

Cite this article: Bone Joint J 2014; 96-B:1035–40.

Reliable classification of children's fractures according to the comprehensive classification of long bone fractures by Müller

BACKGROUND AND PURPOSE

Guidelines for fracture treatment and evaluation require a valid classification. Classifications especially designed for children are available, but they might lead to reduced accuracy, considering the relative infrequency of childhood fractures in a general orthopedic department. We tested the reliability and accuracy of the Müller classification when used for long bone fractures in children.

METHODS

We included all long bone fractures in children aged < 16 years who were treated in 2008 at the surgical ward of Stavanger University Hospital. 20 surgeons recorded 232 fractures. Datasets were generated for intra- and inter-rater analysis, as well as a reference dataset for accuracy calculations. We present proportion of agreement (PA) and kappa (K) statistics.

RESULTS

For intra-rater analysis, overall agreement (κ) was 0.75 (95% CI: 0.68-0.81) and PA was 79%. For inter-rater assessment, K was 0.71 (95% CI: 0.61-0.80) and PA was 77%. Accuracy was estimated: κ = 0.72 (95% CI: 0.64-0.79) and PA = 76%.

INTERPRETATION

The Müller classification (slightly adjusted for pediatric fractures) showed substantial to excellent accuracy among general orthopedic surgeons when applied to long bone fractures in children. However, separate knowledge about the child-specific fracture pattern, the maturity of the bone, and the degree of displacement must be considered when the treatment and the prognosis of the fractures are evaluated.