Fix or Replace? Patient Preferences for the Treatment of Geriatric Lower Extremity Fractures: A Discrete Choice Experiment

Introduction

When considering treatment options for geriatric patients with lower extremity fractures, little is known about which outcomes are prioritized by patients. This study aimed to determine the patient preferences for outcomes after a geriatric lower extremity fracture.

Materials and Methods

We administered a discrete choice experiment survey to 150 patients who were at least 60 years of age and treated for a lower extremity fracture at a Level I trauma center. The discrete choice experiment presented study participants with 8 sets of hypothetical outcome comparisons, including joint preservation (yes or no), risk of reoperation at 6 months and 24 months, postoperative weightbearing status, disposition, and function as measured by return to baseline walking distance. We estimated the relative importance of these potential outcomes using multinomial logit modeling.

Results

The strongest patient preference was for maintained function after treatment (59%, P < .001), followed by reoperation within 6 months (12%, P < .001). Although patients generally favored joint preservation, patients were willing to change their preference in favor of joint replacement if it increased function (walking distance) by 13% (SE, 66%). Reducing the short-term reoperation risk (12%, P < .001) was more important to patients than reducing long-term reoperation risk (4%, P = .33). Disposition and weightbearing status were lesser priorities to patients (9%, P < .001 and 7%, P < .001, respectively).

Discussion

After a lower extremity fracture, geriatric patients prioritized maintained walking function. Avoiding short-term reoperation was more important than avoiding long-term reoperation. Joint preservation through fracture fixation was the preferred treatment of geriatric patients unless arthroplasty or arthrodesis provides a meaningful functional benefit. Hospital disposition and postoperative weightbearing status were less important to patients than the other included outcomes.

Conclusions

Geriatric patients strongly prioritize function over other outcomes after a lower extremity fracture.

Infection Rates and Surgical Procedures Associated With Isolated Open Talar Neck and Body Fractures

BACKGROUND

Open fractures of the talar body and neck are uncommon. Previous reports of associated deep infection rates and resulting surgical requirements vary widely. The primary objective of this study is to report the incidence of deep infections for isolated open talar body and neck fractures, and secondarily the incidence and number of total surgeries performed (TSP), secondary salvage procedures (SSPs), and nonsalvage procedures (NSPs).

METHODS

Retrospective case-control study of 32 consecutive isolated open talus fracture patients (22 neck, 10 body) were followed for an average of 39.2 months.

RESULTS

Five (15.6%) fractures developed deep infections. Fifty percent of open body fractures became infected compared with 0% of neck fractures (P < .001). There was no difference between infected group (IG) and uninfected fracture group (UG) with respect to age, sex, body mass index, tobacco, diabetes, vascular disease, open fracture type, wound location, hours to irrigation and debridement, or definitive treatment. The majority (92.6%) of UG fractures used a dual incision with open wound extension. There were more single extensile approaches in the IG group (P = .04). The IG required 5.8 TSP per patient compared with 2.1 in the UG (P = .004). All (100%) of the IG required an SSP compared with 29.6% of the UG (P = .006). All (100%) of the IG required an NSP compared to 40.7% of the UG (P = .043). In the IG, 2.8 NSPs per patient were required after definitive surgery compared with 1.18 in the UG (P = .003). Of those followed 1 year, the incidence of SSP remained higher in the IG (P = .016).

CONCLUSION

The incidence of deep infection following isolated open talar fractures is high and occurs disproportionally in body fractures. Infected fractures required nearly 6 surgeries, and all required SSP.

LEVEL OF EVIDENCE

Level IV, prognostic.

Risk factors for failure of manipulation under anesthesia in posttraumatic knee stiffness

OBJECTIVES

To determine the proportion of patients who fail manipulation under anesthesia (MUA) as a treatment for posttraumatic knee stiffness and determine the risk factors for MUA failure.

METHODS

A retrospective cohort study was performed at a level I trauma center. We identified 213 knees in 199 patients with arthrofibrosis treated by MUA within 1 year of injury from 2007 to 2020. The primary outcome was MUA failure as defined by need for repeat MUA or surgical release after MUA. Multivariable logistic regression was used to determine the association between MUA failure and potential risk factors.

RESULTS

Overall, 111 knees (52%) failed treatment with MUA. An association was demonstrated between MUA failure and delay in treatment >90 days after injury (OR 3.6, p < 0.01), neurologic injury (OR 2.2, p = 0.02), and pre-procedure knee flexion <45° (OR 1.9, p < 0.01). The rate of failure for knees with no risk factors was 0% (0 of 14), 37% for knees with one risk factor (27 of 73), and 67% (84 of 126) for knees with two or more risk factors.

CONCLUSION

For patients whose MUA is delayed beyond 90 days postinjury, pre-manipulation knee flexion is <45°, or those with associated neurologic injury; odds of MUA failing to correct posttraumatic arthrofibrosis are significantly increased. The likelihood of obtaining adequate range of motion (ROM) with MUA alone is lower than reported in other populations, with a higher likelihood of being treated with surgical release or additional MUA to attempt to obtain adequate ROM.

Is External Beam Radiation Therapy Really Associated With Low Rates of Heterotopic Ossification After Acetabular Surgery?

OBJECTIVES

Describe rate of post-operative heterotopic ossification (HO) after acetabular surgery for patients that received external beam radiation (XRT) as HO prophylaxis.

DESIGN

Retrospective.

SETTING

Level I trauma center.Patients/participants: Consecutive series of patients that presented to a single level I academic trauma center over a 10-year period (2008-2018) for surgical fixation of an acetabular fracture. Patients eligible for inclusion were those that underwent surgical fixation of an acetabular fracture via a posterior (Kocher-Langenbeck), combined anterior and posterior, or extensile exposure. Patients were excluded if an isolated anterior approach was performed, or if an acute total hip arthroplasty was performed at the time of index surgery.

INTERVENTION

XRT.

MAIN OUTCOME

Severe HO (Brooker class III or IV).

RESULTS

The severe HO (Brooker class III or IV) rate for entire cohort was 12% (44 / 361 patients). Of these 44 patients, 30 patients were classified as Brooker III and 14 patients were classified as Brooker IV. The Brooker IV rate for the entire cohort was 4% (14/361 patients). Severe HO rates showed a declining trend over the time period examined, with a risk reduction of -1.0% per year (95% CI -2.1 to 0.2%; p=0.10).

CONCLUSION

To our knowledge, this is the largest single consecutive series on acetabular fracture patients that received XRT as HO prophylaxis. The overall severe HO rate was 12%, which is similar to other comparably large series data on patients that did not receive XRT after surgical fixation acetabular fractures. Although these data suggest XRT may not be beneficial when used universally for all patients, comparative studies are required to rule out the benefits of XRT for preventing HO in this population.

LEVEL OF EVIDENCE

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