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

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

OBJECTIVES

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

DESIGN

Prospective case series.

SETTING

Level 1 Trauma Center.

PATIENTS

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

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Polytrauma outcome: implementation of health-related quality of life assessment into the German Trauma Registry

INTRODUCTION

As a result of improvement in polytrauma management within the last years, more patients survive a significant trauma. Trauma registers, such as the TraumaRegister DGU^®, played a role in identifying risk factors of poor outcomes which led to an improvement of survival rates. In recent years the health-related quality of life (HRQoL) after trauma got into the focus of trauma studies.

MATERIALS AND METHODS

Under the sponsorship of the German Society of Trauma Surgery (DGU) the members of the Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) convened intending to identify an assessment tool for implementation into the TraumaRegister DGU^®.

RESULTS

After the conduct of a systematic literature review, the working group decided to choose the 12-item Short-Form Health Survey (SF-12) and five more questions, capturing the satisfaction of treatment, work capacity and trauma-related medical treatment.

CONCLUSION

The data collection of HRQoL and the additional variables started in 2017 in participating clinics as a part of the regular data collection of the TraumaRegister DGU^®.

Patient-Reported Outcomes in Foot and Ankle Orthopedics

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

Level of Evidence

Level V, expert opinion.

Patient-Reported Outcomes in Foot and Ankle Surgery

Patient-reported outcomes (PROs) are a measure of health care quality that empower patients to share their health care perceptions with their providers. In orthopedic foot and ankle surgery, these measures can range from global assessments of pain or satisfaction to complex questionnaires designed to assess the function of specific anatomic regions or the recovery from specific procedures. This article seeks to characterize the use of PROs in foot and ankle surgery, describe some of the most commonly used measures, discuss implementation in everyday clinical practice, and explore the future of PROs in foot and ankle orthopedics.

Long-Term Functional Outcomes after Traumatic Thoracic and Lumbar Spine Fractures

The incidence of thoracolumbar spine fractures in blunt trauma is 4 to 5 per cent. These fractures may lead to neurologic injury, chronic back pain, and disability. Most studies from United States trauma centers focus on neurologic sequelae and/or compare treatment modalities. However, most patients with spine fractures do not have a neurologic deficit. Our primary objective was to determine the long-term outcome of traumatic thoracolumbar spine fractures, specifically addressing quality of life, chronic pain, and employment using a validated patient outcome survey. A chart review of 138 adult blunt trauma patients who sustained a thoracolumbar spine fracture and were admitted to our Level I trauma center from 2008 to 2013 was performed. A phone interview based on the Short-Form 12®, a general health survey, was then conducted. Of the 134 patients who met the inclusion criteria, 46 (34%) completed the survey. The average Short-Form 12® scores were 51.0 for the physical health component score and 52.9 for the mental health component score. These did not differ significantly from the national norm. Furthermore, 83 per cent (38) of the survey respondents returned to work full-time at the same level as before their injury. Majority of the patients (76%) said they did not have pain two to seven years after injury. Despite a commonly held belief that back injury leads to chronic pain and disability, after sustaining a thoracic or lumbar fracture, patients are generally able to return to work and have a comparable quality of life to the general population. This knowledge may be useful in counseling patients regarding expectations for recovery from trauma.

The impact of non weight bearing: A prospective cohort study

BACKGROUND

Patients with lower limb injuries are commonly advised to non weight bear (NWB) on their injured limb as part of treatment. Occasionally, patients complain that offloading one limb, associated with the use of crutches or other mobility aids, may lead to pain on one of the other supporting limbs. This has led to compensation claims (1) but has never been the subject of formal research.

METHODS

A prospective cohort trial was undertaken to address this question. Patients were recruited from two Metropolitan Hospital Orthopaedic Fracture Clinics and Orthopaedic Wards. A survey was administered at two time points; the first at the point of definitive orthopaedic treatment and commencement of the NWB phase. The second after the NWB phase was completed. The surveys included a pain Visual Analogue Scale (VAS), Short Form (SF)12, a pain body chart and a health questionnaire.

RESULTS

A total of 55 patients were enrolled in the study. Seven patients developed new joint pain after a period NWB. These patients scored significantly lower on the follow up SF12 when compared to those who did not develop new pain (p=0.045). Follow up phone calls at least 6 months following completion of the second survey revealed that all initial and new pain areas in these participants had resolved. The main limitation of this study was the limited numbers.

CONCLUSION

This study supports the idea that crutches, prescribed in the short term to allow a limb to be NWB, achieve this aim with minimal impact. Their use may be associated with new other joint pain however it can be anticipated this will resolve after cessation of crutch use.

Utility of repeat head computed tomography after mild head trauma: influence on short- and long-term prognosis and health-related quality of life

The aim of this study was to investigate the utility of repeat head CT in a large population of patients with non-isolated blunt mild head trauma (MTBI), especially in the presence of intracranial injury. This is a study of a cohort of 478 non-isolated MTBI patients admitted to the High Dependency Unit of the Emergency Department of the University-Hospital of Florence from July 2008 to December 2013. Results of initial and subsequent head CT scans, and indications for repeat head CT scan (routine vs. neurologic change) were recorded. The study population was divided into two subgroups: 28 (6 %) patients with neurological change or persistently reduced GCS (group GCS-) and 450 (94 %) patients with normal or improving GCS (group GCS+). After 6 months from the event, a telephone interview using SF12 questionnaire was conducted. Among GCS- patients, the admission CT scan showed intracranial lesions (ICI) in 16 (57 %) patients; only two patients had a TBI-related neurosurgical intervention. Among GCS+ patients, the first CT scan showed an ICI in 133 patients; in a significant proportion of patients with ICI at the first CT scan, the injury worsened (40/133, 30 %, p < 0.0001). However, no GCS+ patient had any neurosurgical intervention. We observed a significant reduction in both MCS and PCS scores after the injury compared with the previous period. The number of repeat CT scan was high in patients who presented ICI at the first CT scan; however, no patient with ICI and normal or improving GCS score needed a neurosurgical intervention.

The efficacy of continuous-flow cryo and cyclic compression therapy after hip fracture surgery on postoperative pain: design of a prospective, open-label, parallel, multicenter, randomized controlled, clinical trial

BACKGROUND

The number of hip fractures and resulting post-surgical outcome are a major public health concern and the incidence is expected to increase significantly. The acute recovery phase after hip fracture surgery in elder patients is often complicated by severe pain, high morphine consumption, perioperative blood loss with subsequent transfusion and delirium. Postoperative continuous-flow cryocompression therapy is suggested to minimize these complications and to attenuate the inflammatory reaction that the traumatic fracture and subsequent surgical trauma encompass. Based on a pilot study in patients undergoing total hip arthroplasty for osteoarthritis, it is anticipated that patients treated with continuous-flow cryocompression therapy will have less pain, less morphine consumption and lower decrease of postoperative hemoglobin levels. These factors are associated with a shorter hospital stay and better long-term (functional) outcome.

METHODS/DESIGN

One hundred and sixty patients with an intra or extracapsular hip fracture scheduled for internal fixation (intramedullary hip nail, dynamic hip screw or cannulated screws) or prosthesis surgery (total hip or hemiarthroplasty) will be included in this prospective, open-label, parallel, multicenter, randomized controlled, clinical superiority trial. Patients will be allocated to two treatment arms: group 'A' will be treated with continuous-flow cryocompression therapy and compared to group 'B' that will receive standard care. Routine use of drains and/or compressive bandages is allowed in both groups. The primary objective of this study is to compare acute pain the first 72 h postoperative, measured with numeric rating scale for pain. Secondary objectives are: (non-) morphine analgesic use; adjusted postoperative hemoglobin level; transfusion incidence; incidence, duration and severity of delirium and use of psychotropic medication; length of stay; location and duration of rehabilitation; functional outcome; short-term patient-reported health outcome; general and cryotherapy related complications and feasibility.

DISCUSSION

This is the first randomized controlled trial that will assess the analgesic efficiacy of continuous-flow cryocompression therapy in the acute recovery phase after hip fracture surgery.

TRIAL REGISTRATION

www.trialregister.nl, NTR4152 (23(rd) of August 2013).

Trampoline related injuries in adults

INTRODUCTION

Trampoline-related injuries in adults are uncommon. Participation in trampolining is increasing following its admission as a sport in the Olympics and the opening of local recreational trampoline centres. The aim of this study was to assess the number and outcomes of adult trampoline-related orthopaedic injuries presenting to four trauma hospitals in Victoria.

METHODS

A cohort study was performed for the period 2007-2013. Adult patients registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) who had sustained a trampolining related injury were included in this study. Descriptive analyses were used to describe the patient population, the injuries sustained and their in-hospital and 6-month outcomes.

RESULTS

There was an increase in trampolining injuries from 2007 (n=3) to 2012 (n=14) and 2013 (n=18). Overall, fifty patients with a median age of 25 (range 16-66) were identified. Thirty-five patients (70%) had lower limb injuries, 20 patients (40%) had spinal injuries and one patient had an upper limb injury. Thirty-nine patients (78%) required surgery. Fractures of the tibia (n=13), ankle fractures (n=12) and cervical spine injuries (n=7) were the most common injuries; all of which required surgery. Complications included death, spinal cord injuries, compartment syndrome and open fractures. At 6 months post injury, more than half (52%) of the patients had not achieved a good recovery, 32% had some form of persistent disability, 14% did not get back to work and overall physical health for the cohort was well below population norms for the SF-12.

CONCLUSION

Adult trampoline-related injuries have increased in the last few years in this cohort identified through VOTOR. Lower limb and spinal injuries are most prevalent. Public awareness and education are important to reduce the risk for people participating in this activity.

Quality of life after mild to moderate trauma

INTRODUCTION

To evaluate potential reduction in health-related quality of life (HRQOL) after a mild to moderate trauma.

MATERIALS AND METHODS

Follow-up study of a cohort of 153 trauma patients admitted to the High Dependency Unit of the Emergency Department of the University-Hospital of Florence from July 2008 to February 2012. After 6 months from the event, a telephone interview using the Physical (PCS) and Mental (MCS) Health Composite Score (SF12) was conducted. Patients reported their HRQOL both at present and before trauma. Scores ≥ 50 represent no disability; 40-49, mild disability; 30-39, moderate disability; and below 30, severe disability.

RESULTS

Before the event 143 (93%) subjects reported a normal PCS and MCS. After the events, a significantly lower proportion of patients maintained a normal PCS and MCS values (52 and 68%, all p<0.01). One, two, three and four PCS items worsened in 14%, 15%, 18% and 38% of the study population, while one, two, three or four MCS dimensions worsened in 12%, 19%, 19% and 24%. We identified 109 subjects (N+), which showed normal PCS and MCS values before trauma, in the absence of any pre-existing medical condition. After the event, we observed a significant PCS (before: 54, standard deviation, SD 6; after 43, SD 11, p<0.0001) and MCS (before: 55, SD 7; after 47, SD 11, p<0.0001) worsening among N+ subjects. Distribution across the four disability categories was 52, 24, 17 and 6% for MCS score and 38, 25, 27 and 11% for PCS score: overall 8 (7%) patients reported a moderate disability and 5 (5%) reported a severe disability in both dimensions. Compared with subjects with preserved values, patients with an abnormal (<39) HRQOL were older, showed a higher prevalence of female gender and pre-existing medical conditions and a worst Sequential Organ Failure Assessment score. An advanced age (OR 1.033, 95% CI 1.010-1.057, p=0.005) and a higher SOFA T1 score (OR 1.500, 95% CI 1.027-2.190, p=0.036) were independently associated with a worsening PCS.

CONCLUSIONS

After a mild trauma, we evidenced a relevant reduction in HRQOL; an advanced age and a higher degree of organ dysfunction were independently associated with HRQOL deterioration.

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

Objectives:

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

Data sources:

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

Review method:

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

Results:

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

Conclusion:

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

Computerized Adaptive Testing Using the PROMIS Physical Function Item Bank Reduces Test Burden With Less Ceiling Effects Compared With the Short Musculoskeletal Function Assessment in Orthopaedic Trauma Patients

PURPOSE

Patient-reported outcomes are important to assess effectiveness of clinical interventions. For orthopaedic trauma patients, the short Musculoskeletal Function Assessment (sMFA) is a commonly used questionnaire. Recently, the Patient-Reported Outcome Measurement Information System (PROMIS) PF Function Computer Adaptive Test (PF CAT) was developed using item response theory to efficiently administer questions from a calibrated bank of 124 PF questions using computerized adaptive testing. In this study, we compared the sMFA versus the PROMIS PF CAT for trauma patients.

METHODS

Orthopaedic trauma patients completed the sMFA and the PROMIS PF CAT on a tablet wirelessly connected to the PROMIS Assessment Center. The time for each test administration was recorded. A 1-parameter item response theory model was used to examine the psychometric properties of the instruments, including precision and floor/ceiling effects.

RESULTS

One hundred fifty-three orthopaedic trauma patients participated in the study. Mean test administration time for PROMIS PF CAT was 44 seconds versus 599 seconds for sMFA (P < 0.05). Both instruments showed extremely high item reliability (Cronbach alpha = 0.98). In terms of instrument coverage, neither instrument showed any floor effect; however, the sMFA revealed 14.4% ceiling effect, whereas the PROMIS PF CAT had no appreciable ceiling effect.

CONCLUSIONS

Administered by electronic means, the PROMIS PF CAT required less than one-tenth the amount of time for patients to complete than the sMFA while achieving equally high reliability and less ceiling effects. The PROMIS PF CAT is a very attractive and innovative method for assessing patient-reported outcomes with minimal burden to patients.

Prognosis and health-related quality of life in elderly patients after a mild to moderate trauma

The aims of this study were to compare outcome after a mild to moderate trauma in three subgroups of patients of increasing age (A1: <50, A2: 50-74, A3: >74 years) and to assess potential health-related quality of life (HRQOL) impairment. This is a follow-up study of a cohort of 418 trauma patients admitted to the High Dependency Unit of the Emergency Department of the University Hospital of Florence from July 2008 to February 2012. Six months after the event, a telephone interview using the Physical component summary (PCS) and Mental component summary (MCS) Health Composite Score (SF12) was conducted. Patients reported their QOL both at present and before trauma. In-hospital mortality was 10 of 418 (2.3 %); overall mortality was 27 of 244 (11 %) patients found at follow-up. No death was observed among A1 patients; overall mortality was (6/76) 7 % in A2 and (21/71) 30 % in A3 patients (p < 0.05 A1 vs A2, A1 vs A3 and A2 vs A3). Before the event, respectively, 94 and 96 % patients reported a normal MCS and PCS score (>39); after the event, the proportion of patients with a normal score value was significantly lower (MCS 70 %, p = 0.002; PCS 58 %, p < 0.0001). All subgroups showed a highly significant reduction in the scores' value due to the trauma. After the event, the proportion of patients with normal scores was significantly lower (all p < 0.0001, except for MCS score in A1 subgroup, who showed p = 0.013) within all subgroups. Elderly patients' prognosis was significantly worse compared with the younger counterpart; despite young patients' optimal outcome, HRQOL was uniformly reduced across all age groups.

Short- and long-term subjective medical treatment outcome of trauma surgery patients: the importance of physician empathy

PURPOSE

To investigate accident casualties' long-term subjective evaluation of treatment outcome 6 weeks and 12 months after discharge and its relation to the experienced surgeon's empathy during hospital treatment after trauma in consideration of patient-, injury-, and health-related factors. The long-term results are compared to the 6-week follow-up outcomes.

PATIENTS AND METHODS

Two hundred and seventeen surgery patients were surveyed at 6 weeks, and 206 patients at 12 months after discharge from the trauma surgical general ward. The subjective evaluation of medical treatment outcome was measured 6 weeks and 12 months after discharge with the respective scale from the Cologne Patient Questionnaire. Physician Empathy was assessed with the Consultation and Relational Empathy Measure. The correlation between physician empathy and control variables with the subjective evaluation of medical treatment outcome 12 months after discharge was identified by means of logistic regression analysis under control of sociodemographic and injury-related factors.

RESULTS

One hundred and thirty-six patients were included within the logistic regression analysis at the 12-month follow-up. Compared to the 6-week follow-up, the level of subjective evaluation of medical treatment outcome was slightly lower and the association with physician empathy was weaker. Compared to patients who rated the empathy of their surgeon lower than 31 points, patients with ratings of 41 points or higher had a 4.2-fold higher probability to be in the group with a better medical treatment outcome (3.5 and above) on the Cologne Patient Questionnaire scale 12 months after discharge from hospital (P=0.009, R (2)=33.5, 95% confidence interval: 1.440-12.629).

CONCLUSION

Physician empathy is the strongest predictor for a higher level of trauma patients' subjective evaluation of treatment outcome 6 weeks and 12 months after discharge from the hospital. Interpersonal factors between surgeons and their patients are possible key levers for improving patient outcomes in an advanced health system. Communication trainings for surgeons might prepare them to react appropriately to their patients' needs and lead to satisfactory outcomes for both parties.