The effects of shared decision making in the conservative management of stable ankle fractures

A Stability-Based Management Protocol for Isolated Lateral Malleolar Ankle Fractures at the Level of the Syndesmosis Reduces the Need for Surgical Intervention

Purpose

The study aimed to establish and subsequently improve the rate of stability assessments of fractures with uncertain stability and the impact on the avoidance of potentially unnecessary surgery.

Methods

Two independent audit cycles were conducted from October 2019 to May 2020. All patients had closed isolated lateral malleolar fractures at the level of the tibiotalar syndesmosis involving skeletally mature bone. A stability-based management protocol was introduced, incorporating an education programme and management guideline.

Results

75 ankles fractures were included. In the initial audit cycle, 13 patients did not undergo stability X-rays within 2 weeks of injury. Interestingly, only one stability assessment was performed for five operated ankles in the first audit, versus a 100% compliance rate in the second cycle. We observed more accurate documentation following education and awareness of clinical importance.

Conclusion

By implementing a stability-based management guideline, there was an improvement in compliance with guidance towards stability assessments of ankle fractures. This potentially led to the avoidance of unnecessary surgery on fractures where stability assessments supported non-operative management.

Patient and Surgeon Ratings of Patient Involvement in Decision-Making Are Not Aligned

BACKGROUND

Specialists want to guide patients toward making informed treatment choices consistent with what matters most to them (their values). One measure of this goal is alignment between patient and surgeon-perceived involvement in decision-making. We performed a cross-sectional survey of patients presenting for musculoskeletal specialty care to determine agreement between patients and surgeons regarding patient involvement in shared decision-making. We also tested (1) factors associated with specialist-perceived involvement, accounting for the patient's perceived involvement in decision-making, and (2) factors associated with patient perception of involvement in decision-making, accounting for ratings of preferred involvement.

METHODS

In this cross-sectional survey, 136 patients seeking musculoskeletal care for conditions involving the upper or lower extremities rated their preferred level of involvement in decision-making (Control Preferences Scale) before the visit and their perceived level of involvement (Modified Control Preferences Scale) after the visit. Participants also completed measures of symptoms of depression and pain self-efficacy. After the visit, the surgeons rated their perception of the patient's involvement in decision-making (Modified Control Preferences Scale).

RESULTS

There was poor agreement between patients and surgeons regarding the extent of patient participation in decision-making (ICC = 0.11). The median difference was 1 point on a 5-point Likert scale (interquartile range: 0 to 1). Accounting for demographic characteristics and personal factors in multivariable analysis, specialists rated patients who did not have a high school diploma as having less involvement in decision-making. Specialist-perceived patient involvement in decision-making was not related to patient-perceived involvement. The only factor associated with higher patient-rated involvement was higher patient-preferred involvement (OR = 3.9; 95% CI = 2.6 to 5.8; p < 0.001).

CONCLUSIONS

The observation that surgeons misperceive patient participation in decision-making emphasizes the need for strategies to ensure patient participation, such as methods to help patients gain awareness of what matters most to them (their values), clinician checklists for identification and reorientation of common misinterpretations of symptoms, and decision aids or motivational interviewing tools that can help to ensure that patient choices are consistent with their values and are unhindered by misconceptions.

Health Literacy and Decisional Preferences in Hand Surgery

PURPOSE

Patients increasingly prefer to be involved in health decisions. Shared decisions are associated with less decisional conflict and improved satisfaction. This study examines the relationship between health literacy and preferred decision-making role in patients seeking care for hand problems.

METHODS

We performed a cross-sectional study of 226 patients who were presenting to a hand service for the first time, who were older than 18 years, not pregnant, and fluent and literate in English. Patient demographic information, work status, and education level were collected from the patient. Diagnosis and insurance status were collected from the medical record. Pain interference, depression, and upper extremity function were measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires administered with computerized adaptive testing. Health literacy and preferred decision-making role were assessed using the Newest Vital Sign Test and Control Preference Scale, respectively. Discordance between preferred and actual decision-making role was assessed using the Control Preference Scale statements with the words "I prefer" omitted. Bivariate and multivariable logistic regressions were used to assess for factors associated with preferred decision-making role and discordance.

RESULTS

Seventy-eight percent of patients preferred an active or collaborative, rather than a passive, role in decision making. Sixty-one percent felt they had achieved their preferred role. Preferred role and achievement of that role were not associated with health literacy, age, race, insurance, work status, diagnosis, pain intensity, symptoms of depression, and magnitude of self-reported activity limitations. More years of education was associated with a more active preferred decision-making role but not with obtaining that preferred role.

CONCLUSIONS

Most people want to participate in decisions about their care even if they have low health literacy.

CLINICAL RELEVANCE

Hand specialists can seek strategies to help people understand and participate in care decisions.

'Getting them on board': Musculoskeletal physiotherapists conceptions of management of persons with low back pain

OBJECTIVE

Low back pain (LBP) is the leading cause of disability worldwide; however, the majority of LBP is non-specific in nature with no clearly identifiable source of pain. Contemporary understanding of LBP highlights the multidimensional nature of LBP and as a result clinical practice and guidelines have evolved and advocate a multidimensional approach to managing persons with LBP. This change in understanding and practice provides challenges for physiotherapists and persons with LBP, many who have biomedical views. The aim of this study was to explore musculoskeletal physiotherapists conceptions towards the management of LBP.

METHOD

The research employed a phenomenographic inspired approach which aims to explore variations in conceptions, beliefs and understanding of a phenomenon. Six participants (physiotherapists) were interviewed via semi-structured interviews to explore their experiences of managing persons with LBP and the data was analysed using a phenomenographic framework.

RESULTS

Three main categories emerged from the participants descriptions: the perceived role of preferences and expectations, therapeutic alliance development and getting the person "on board".

CONCLUSION

Participants descriptions implied a therapist centred view towards the care they provided for persons with LBP. The perceived role of expectations was a significant aspect within the participants descriptions of the management of LBP. Last, the participants described the perceived development of a therapeutic alliance. These categories suggest how the physiotherapists interviewed in this study conceive the management of LBP, and these findings will provide a greater understanding around the physiotherapy management of LBP.

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England

BACKGROUND

Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contact-casting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients.

METHODS

Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence.

RESULTS

Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved.

CONCLUSIONS

Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contact-casting, in line with recent evidence.

Clinical Approach in Youth Sports Medicine: Patients' and Guardians' Desired Characteristics in Sports Medicine Surgeons

INTRODUCTION

Adolescent athletes' and their guardians' preferences for sports medicine surgeon characteristics are unknown.

METHODS

Unique, anonymous surveys regarding preferences in characteristics of sports medicine surgeons were given to both patients (aged 10 to 18 years) and their guardians before being seen by a sports medicine surgeon.

RESULTS

Patients and their guardians reported shared decision making as the most important surgeon characteristic, followed by understanding patients' sports and goals. A higher percentage of male patients than female patients had a surgeon sex preference (P = 0.005); however, for both the groups, this ranked lower than other surgeon qualities. Nearly all respondents reported that the adolescent patient should be involved in medical decision making; yet, physician selection was determined by the guardian 65% of the time.

CONCLUSIONS

Both adolescent patients and their guardians reported shared decision making and understanding patients' sports and goals as surgeon qualities that were more important to them than surgeon sex.

LEVEL OF EVIDENCE

Level IV, cross-sectional study.

Three week versus six week immobilisation for stable Weber B type ankle fractures: randomised, multicentre, non-inferiority clinical trial

OBJECTIVE

To determine whether treatment of isolated stable Weber B type ankle fractures with a cast or a simple orthotic device for three weeks produces non-inferior outcomes compared with conventional immobilisation in a cast for six weeks.

DESIGN

Randomised, pragmatic, non-inferiority, clinical trial with blinded outcome assessment.

SETTING

Two major trauma centres in Finland, 22 December 2012 to 6 June 2016.

PARTICIPANTS

247 skeletally mature patients aged 16 years or older with an isolated Weber B type fibula fracture and congruent ankle mortise in static ankle radiographs.

INTERVENTIONS

Participants were randomly allocated to conventional six week cast immobilisation (n=84) or three week treatment either in a cast (n=83) or in a simple orthosis (n=80).

MAIN OUTCOME MEASURES

The primary, non-inferiority, intention-to-treat outcome was the Olerud-Molander Ankle Score at 12 months (OMAS; range 0-100; higher scores indicate better outcomes and fewer symptoms). The predefined non-inferiority margin for the primary outcome was -8.8 points. Secondary outcomes were ankle function, pain, quality of life, ankle motion, and radiographic outcome. Follow-up assessments were performed at 6, 12, and 52 weeks.

RESULTS

212 of 247 randomised participants (86%) completed the study. At 52 weeks, the mean OMAS was 87.6 (SD 18.3) in the six week cast group, 91.7 (SD 12.9) in the three week cast group, and 89.8 (SD 18.4) in the three week orthosis group. The between group difference at 52 weeks for the three week cast versus six week cast was 3.6 points (95% confidence interval -1.9 to 9.1, P=0.20), and for the three week orthosis versus six week cast was 1.7 points (-4.0 to 7.3, P=0.56). In both comparisons, the confidence intervals did not include the predefined inferiority margin of -8.8 points. The only statistically significant between group differences observed in the secondary outcomes and harms in the two primary comparisons were slight improvement in ankle plantar flexion and incidence of deep vein thrombosis, both in the three week orthosis group versus six week cast group.

CONCLUSION

Immobilisation for three weeks with a cast or orthosis was non-inferior to conventional cast immobilisation for six weeks in the treatment of an isolated stable Weber B type fracture.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01758835.

Surgeons' perspective on shared decision making in trauma surgery. A national survey

OBJECTIVE

This study aimed to answer the following research question: What is the knowledge, opinion, and experience of trauma surgeons with respect to shared decision making (SDM)?

METHODS

An online survey was sent out in September 2016 to all 257 surgeons registered as a trauma surgeon with the Dutch Association of Trauma Surgery, to gather demographic, knowledge, and practice based information regarding their use of SDM. Results were presented according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).

RESULTS

The questionnaire was filled out by 112 (44%) trauma surgeons. Opinions about what SDM entails differed, but 27% described a process that was clearly discordant with current consensus. Eighty-six percent of trauma surgeons regarded SDM as (very) relevant for providing good care. Sixty-two percent reported to encounter problems in achieving SDM.

CONCLUSION AND IMPLICATIONS

The general opinion of Dutch trauma surgeons towards SDM is very positive, but many lack the understanding of what SDM really implies and surgeons report SDM to be difficult to accomplish. To improve the occurrence of SDM in trauma surgery, there is an obvious need for education and training in SDM skills for surgeons.

Stability in ankle fractures: Diagnosis and treatment

Medial column (deltoid ligament) integrity is of key importance when considering the stability of isolated lateral malleolus ankle fractures.Weight-bearing radiographs are the best method of evaluating stability of isolated distal fibula fractures.Computed tomography (CT) scanning is mandatory for the assessment of complex ankle fractures, especially those involving the posterior malleolus.Most isolated trans-syndesmotic fibular fractures (Weber-B, SER, AO 44-B) are stable and can safely be treated non-operatively.Posterior malleolus fractures, regardless of size, should be considered for surgical fixation to restore stability, reduce the need for syndesmosis fixation, and improve contact pressure distribution. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170057.

Activity demands and instability are the most important factors for recommending to treat ACL injuries with reconstruction

PURPOSE

The purpose of the study was to (1) study and compare the factors that Swedish orthopaedic surgeons and physical therapists consider important for recommending ACL reconstruction and, (2) to assess how orthopaedic surgeons and physical therapists consider their own and each others, as well as patients', roles are in the treatment decision.

METHODS

A web-based survey assessing the relevance of 21 predetermined factors, in the choice to recommend ACL reconstruction, was sent to orthopaedic surgeons and physical therapists. Respondents were also asked to rate the importance of the assessment made by themselves, the other clinician (physical therapists rated the importance of surgeons, surgeons rated the importance of physical therapists), and the patients' preferences.

RESULT

Orthopaedic surgeons agreed of eight, and physical therapists of seven factors as important in the choice to recommend ACL reconstruction. The factors both groups reported as important were; "patient's wishes to return to contact/pivoting sports", "instability in physical activity", "instability in activities of daily living despite adequate rehabilitation", "physically demanding occupation", and "young age". Both professions rated their own and each others assessments as well as patient's wishes as important for the decision to recommend ACL reconstruction.

CONCLUSION

Orthopaedic surgeons and physical therapists agree about factors that are important for their decision to recommend ACL reconstruction, showing that both professions share a common ground in perceptions of factors that are important in recommending ACL reconstruction.

LEVEL OF EVIDENCE

Diagnostic study: Level III.

Shared decision making in the management of midshaft clavicular fractures: Nonoperative treatment or plate fixation

INTRODUCTION

Most patients with a displaced midshaft clavicular fracture can be treated either operatively or nonoperatively, with similar long-term outcomes. The treatment choice depends on individual preferences, and is therefore suited for a shared decision making (SDM) approach. However, little is known about SDM in fracture treatment. The purpose of this study was to evaluate the current daily practice of shared decisional behaviour in clavicular fracture treatment, in order to assess the need for improvement and set a baseline level for future research.

PATIENTS AND METHODS

All consecutive adult patients treated in two hospitals for a displaced, midshaft clavicular fracture in 2015 filled out a questionnaire shortly after the decision making moment, that consisted of questions concerning their knowledge and preferences regarding the treatment options; the SDM-Q-9-NL to measure the perceived degree of SDM, and the Control Preferences Scale to measure patients' preferred and actual roles in decision making.

RESULTS

Fifty patients were included. Eighteen percent of the patients were unaware of the treatment options before the consultation, 48% had no preference for either treatment option. The mean score for perceived degree of SDM was 74 out of 100 (SD 23, range 12.5-100). In 68% of patients, the preferred role matched the actual role in making the decision. Sixteen patients (32%) would have preferred either a less (n=8) or a more (n=8) active role.

CONCLUSION

The patient-reported level of SDM in treatment decisions for clavicular fractures was high, but not all patients had the role in this process that they preferred. To improve patients' involvement in the treatment decision making process for clavicular fractures, it is important to create general awareness about SDM, and increase knowledge of orthopaedic trauma surgeons about SDM behaviour.

Current concepts of shared decision making in orthopedic surgery

PURPOSE OF REVIEW

The Shared Decision Making (SDM) model, a collaborative decision making process between the physician and patient to make an informed clinical decision that enhances the chance of treatment success as defined by each patient's preferences and values, has become a new and promising tool in the healthcare process; however, minimal data exists on its application in the orthopedic surgical specialty. Increasing evidence has demonstrated that this once novel idea can be implemented successfully in the orthopedic setting to improve patient outcomes.

RECENT FINDINGS

SDM can be applied without significant increases in the office length. Patients report that a physician that takes the time to listen to them is among the most important factors in their care. When time was focused on the SDM process, there was a direct correlation between the time spent with a patient and patient satisfaction. Patients exposed to a decision aid prior to surgery gained a greater knowledge from baseline to make a higher quality decision that was consistent with their values. Involving family members preoperatively can help all patients adhere to postoperative regimens. Exposing patients to a decision aid can reduce expensive elective surgeries, in favor of non-operative management. Incorporating patient goals into the decision-making process has increased satisfaction, compliance, and outcomes. SDM is a two-way exchange of information that attempts to correct the inequality of power between the patient and physician. Decision-aids are helpful tools that facilitate the decision-making process. Treatment decisions are consistent with patient preferences and values when there may be no "best" therapy. A good patient-physician relationship is essential during the process to reduce decisional conflict and increase overall patient outcomes.

Do Upper Extremity Trauma Patients Have Different Preferences for Shared Decision-making Than Patients With Nontraumatic Conditions?

BACKGROUND

Shared decision-making is a combination of expertise, available scientific evidence, and the preferences of the patient and surgeon. Some surgeons contend that patients are less capable of participating in decisions about traumatic conditions than nontraumatic conditions.

QUESTIONS/PURPOSES

(1) Do patients with nontraumatic conditions have different preferences for shared decision-making when compared with those who sustained acute trauma? (2) Do disability, symptoms of depression, and self-efficacy correlate with preference for shared decision-making?

METHODS

In this prospective, comparative trial, we evaluated a total of 133 patients presenting to the outpatient practices of two university-based hand surgeons with traumatic or nontraumatic hand and upper extremity illnesses or conditions. Each patient completed questionnaires measuring their preferred role in healthcare decision-making (Control Preferences Scale [CPS]), symptoms of depression (Patients' Health Questionnaire), and pain self-efficacy (confidence that one can achieve one's goals despite pain; measured using the Pain Self-efficacy Questionnaire). Patients also completed a short version of the Disabilities of the Arm, Shoulder, and Hand questionnaire and an ordinal rating of pain intensity.

RESULTS

There was no difference in decision-making preferences between patients with traumatic (CPS: 3 ± 2) and nontraumatic conditions (CPS: 3 ± 1 mean difference = 0.2 [95% confidence interval, -0.4 to 0.7], p = 0.78) with most patients (95 versus 38) preferring shared decision-making. More educated patients preferred a more active role in decision-making (beta = -0.1, r = 0.08, p = 0.001); however, differences in levels of disability, pain and function, depression, and pain-related self-efficacy were not associated with differences in patients' preferences in terms of shared decision-making.

CONCLUSIONS

Patients who sustained trauma have on average the same preference for shared decision-making compared with patients who sustained no trauma. Now that we know the findings of this study, clinicians might be motivated to share their expertise about the treatment options, potential outcomes, benefits, and harms with the patient and to discuss their preference as well in a semiacute setting, resulting in a shared decision.