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Joosten PGF, Borgdorff MP, Botman M, Bouman MB, van Embden D, Giannakópoulos GF. Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2024; 50:467-476. [PMID: 37776341 PMCID: PMC11035412 DOI: 10.1007/s00068-023-02366-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/08/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION Guidelines on the management of open tibia fractures recommend timely treatment in a limb reconstruction center which offer joint orthopedic-trauma and plastic surgery services. However, patient's transfer between centers remains inevitable. This review aims to evaluate the clinical outcomes and hospital factors for patients directly admitted and transferred patients to a limb-reconstruction center. METHODS A research protocol adhering to PRISMA standards was established. The search included databases like MEDLINE, EMBASE, and the Cochrane library up until March 2023. Nine articles met the inclusion criteria, focusing on open tibia fractures. Exclusion criteria were experimental studies, animal studies, and case reports. Outcomes of interest were operation and infection rates, nonunion, limb salvage, and the Enneking limb score. RESULTS The analysis involved data from 520 patients across nine studies published between 1990 and 2023, with the majority (83.8%) having Gustilo Anderson type III open tibia fractures. Directly admitted patients showed lower overall infection rates (RR 0.30; 95% CI 0.10-0.90; P = 0.03) and fewer deep infections (RR 0.39; 95% CI 0.22-0.68; P = 0.001) compared to transferred patients. Transferred patients experienced an average five-day delay in soft tissue closure and extended hospital stays by eight days. Patients transferred without initial surgical management underwent fewer total surgical procedures. The direct admission group displayed more favorable functional outcomes. CONCLUSION Low- to moderate-quality evidence indicates worse clinical outcomes for transferred patients compared to directly admitted patients. Early treatment in specialized limb reconstruction units is essential for improved results in the management of open tibia fractures. LEVEL OF EVIDENCE Therapeutic level IIa.
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Affiliation(s)
- Pien Gabriele Francien Joosten
- Trauma Unit, Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
| | - Marieke Paulina Borgdorff
- Trauma Unit, Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands.
- Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam University Medical Center, Meibergdreef 9, J1A-207, 1105AZ, Amsterdam, The Netherlands.
- Amsterdam Movement Sciences, Musculoskeletal Health, Amsterdam, The Netherlands.
| | - Matthijs Botman
- Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam University Medical Center, Meibergdreef 9, J1A-207, 1105AZ, Amsterdam, The Netherlands
| | - Mark-Bram Bouman
- Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam University Medical Center, Meibergdreef 9, J1A-207, 1105AZ, Amsterdam, The Netherlands
| | - Daphne van Embden
- Trauma Unit, Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105AZ, Amsterdam, The Netherlands
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Mirnezami AH, Drami I, Glyn T, Sutton PA, Tiernan J, Behrenbruch C, Guerra G, Waters PS, Woodward N, Applin S, Charles SJ, Rose SA, Denys A, Pape E, van Ramshorst GH, Baker D, Bignall E, Blair I, Davis P, Edwards T, Jackson K, Leendertse PG, Love-Mott E, MacKenzie L, Martens F, Meredith D, Nettleton SE, Trotman MP, van Hecke JJM, Weemaes AMJ, Abecasis N, Angenete E, Aziz O, Bacalbasa N, Barton D, Baseckas G, Beggs A, Brown K, Buchwald P, Burling D, Burns E, Caycedo-Marulanda A, Chang GJ, Coyne PE, Croner RS, Daniels IR, Denost QD, Drozdov E, Eglinton T, Espín-Basany E, Evans MD, Flatmark K, Folkesson J, Frizelle FA, Gallego MA, Gil-Moreno A, Goffredo P, Griffiths B, Gwenaël F, Harris DA, Iversen LH, Kandaswamy GV, Kazi M, Kelly ME, Kokelaar R, Kusters M, Langheinrich MC, Larach T, Lydrup ML, Lyons A, Mann C, McDermott FD, Monson JRT, Neeff H, Negoi I, Ng JL, Nicolaou M, Palmer G, Parnaby C, Pellino G, Peterson AC, Quyn A, Rogers A, Rothbarth J, Abu Saadeh F, Saklani A, Sammour T, Sayyed R, Smart NJ, Smith T, Sorrentino L, Steele SR, Stitzenberg K, Taylor C, Teras J, Thanapal MR, Thorgersen E, Vasquez-Jimenez W, Waller J, Weber K, Wolthuis A, Winter DC, Brangan G, Vimalachandran D, Aalbers AGJ, Abdul Aziz N, Abraham-Nordling M, Akiyoshi T, Alahmadi R, Alberda W, Albert M, Andric M, Angeles M, Antoniou A, Armitage J, Auer R, Austin KK, Aytac E, Baker RP, Bali M, Baransi S, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Bui A, Burgess A, Burger JWA, Campain N, Carvalhal S, Castro L, Ceelen W, Chan KKL, Chew MH, Chok AK, Chong P, Christensen HK, Clouston H, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Damjanovic L, Davies M, Davies RJ, Delaney CP, de Wilt JHW, Deutsch C, Dietz D, Domingo S, Dozois EJ, Duff M, Egger E, Enrique-Navascues JM, Espín-Basany E, Eyjólfsdóttir B, Fahy M, Fearnhead NS, Fichtner-Feigl S, Fleming F, Flor B, Foskett K, Funder J, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Giner F, Ginther N, Glover T, Golda T, Gomez CM, Harris C, Hagemans JAW, Hanchanale V, Harji DP, Helbren C, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Holmström A, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Jenkins JT, Jourand K, Kaffenberger S, Kapur S, Kanemitsu Y, Kaufman M, Kelley SR, Keller DS, Kersting S, Ketelaers SHJ, Khan MS, Khaw J, Kim H, Kim HJ, Kiran R, Koh CE, Kok NFM, Kontovounisios C, Kose F, Koutra M, Kraft M, Kristensen HØ, Kumar S, Lago V, Lakkis Z, Lampe B, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Loria A, Lynch AC, Mackintosh M, Mantyh C, Mathis KL, Margues CFS, Martinez A, Martling A, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, McArthur DR, McCormick JJ, McGrath JS, McPhee A, Maciel J, Malde S, Manfredelli S, Mikalauskas S, Modest D, Morton JR, Mullaney TG, Navarro AS, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, O’Dwyer ST, Paarnio K, Pappou E, Park J, Patsouras D, Peacock O, Pfeffer F, Piqeur F, Pinson J, Poggioli G, Proud D, Quinn M, Oliver A, Radwan RW, Rajendran N, Rao C, Rasheed S, Rasmussen PC, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Seifert G, Selvasekar C, Shaban M, Shaikh I, Shida D, Simpson A, Skeie-Jensen T, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Spasojevic M, Steffens D, Stocchi L, Stylianides NA, Swartling T, Sumrien H, Swartking T, Takala H, Tan EJ, Taylor D, Tejedor P, Tekin A, Tekkis PP, Thaysen HV, Thurairaja R, Toh EL, Tsarkov P, Tolenaar J, Tsukada Y, Tsukamoto S, Tuech JJ, Turner G, Turner WH, Tuynman JB, Valente M, van Rees J, van Zoggel D, Vásquez-Jiménez W, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weiser MR, Westney OL, Wheeler JMD, Wild J, Wilson M, Yano H, Yip B, Yip J, Yoo RN, Zappa MA. The empty pelvis syndrome: a core data set from the PelvEx collaborative. Br J Surg 2024; 111:znae042. [PMID: 38456677 PMCID: PMC10921833 DOI: 10.1093/bjs/znae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/15/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored. METHOD Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition. RESULTS One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed. CONCLUSIONS EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.
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Thwaites S, Abrahams J, Thewlis D, Rickman M. The absence of reporting standards and a lack of objective, performance-based outcomes following intramedullary nailing of tibial shaft fractures: findings from a scoping review into 179 articles. Eur J Trauma Emerg Surg 2024; 50:59-70. [PMID: 37555990 PMCID: PMC10924025 DOI: 10.1007/s00068-023-02338-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/23/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE This scoping review was conducted to summarise the outcome tools reported in the assessment of tibial shaft fractures treated with intramedullary (IM) nailing, with a key focus on knee pain and function, and performance-based outcomes. METHODS PubMed and Embase databases were searched on May 31, 2023. All study designs and populations were included, including ex vivo studies without fracture. Studies with only open or intra-articular fractures, or other fracture fixation, were excluded. Reported outcome tools and pertinent study characteristics were extracted and summarised. RESULTS Of 488 articles identified, 179 met the inclusion criteria. For in vivo studies (n = 152), there were 13,705 fractures; the IM nailing approach not described for 30% of these. There were 133 unique patient outcomes, with a binary assessment of knee pain (29% of studies) and Lysholm score (21%) most common. Only 10/152 (7%) in vivo studies included an objective, performance-based measure of knee function. Fracture union was most frequent (52%) of 81 different clinical outcomes. For ex vivo studies (n = 29), there were 408 tibias included, with nail insertion location most prevalent (66% of studies) of 34 reported outcomes. CONCLUSION The heterogeneity of outcome tools reported limits comparison between studies and the most commonly reported patient outcomes may not be the most appropriate. Future studies should report the IM nailing approach and consider capturing both patient-reported and performance-based outcomes to help inform surgical decision making.
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Affiliation(s)
- Simon Thwaites
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.
| | - John Abrahams
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Dominic Thewlis
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Mark Rickman
- Centre for Orthopaedic and Trauma Research, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Bian X, Jin L, Wang Y, Yuan M, Yao Z, Ning B, Gao W, Guo C. Riboflavin deficiency reduces bone mineral density in rats by compromising osteoblast function. J Nutr Biochem 2023; 122:109453. [PMID: 37788723 DOI: 10.1016/j.jnutbio.2023.109453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 09/05/2023] [Accepted: 09/27/2023] [Indexed: 10/05/2023]
Abstract
Insufficient riboflavin intake has been associated with poor bone health. This study aimed to investigate the effect of riboflavin deficiency on bone health in vivo and in vitro. Riboflavin deficiency was successfully developed in rats and osteoblasts. The results indicated that bone mineral density, serum bone alkaline phosphatase, bone phosphorus, and bone calcium were significantly decreased while serum ionized calcium and osteocalcin were significantly increased in the riboflavin-deficient rats. Riboflavin deficiency also induced the reduction of Runx2, Osterix, and BMP-2/Smad1/5/9 cascade in the femur. These results were further verified in cellular experiments. Our findings demonstrated that alkaline phosphatase activities and calcified nodules were significantly decreased while intracellular osteocalcin and pro-collagen I c-terminal propeptide were significantly increased in the riboflavin-deficient osteoblasts. Additionally, the protein expression of Osterix, Runx2, and BMP-2/Smad1/5/9 cascade were significantly decreased while the protein expression of p-p38 MAPK were significantly increased in the riboflavin-deficient cells compared to the control cells. Blockage of p38 MAPK signaling pathway with SB203580 reversed these effects in riboflavin-deficient osteoblastic cells. Our data suggest that riboflavin deficiency causes osteoblast malfunction and retards bone matrix mineralization via p38 MAPK/BMP-2/Smad1/5/9 signaling pathway.
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Affiliation(s)
- Xiangyu Bian
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, PR China
| | - Lu Jin
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, PR China
| | - Yanxian Wang
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, PR China
| | - Man Yuan
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, PR China
| | - Zhanxin Yao
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, PR China
| | - Baoan Ning
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, PR China
| | - Weina Gao
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, PR China.
| | - Changjiang Guo
- Tianjin Institute of Environmental and Operational Medicine, Tianjin, PR China.
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Aquilina AL, Claireaux H, Aquilina CO, Tutton E, Fitzpatrick R, Costa ML, Griffin XL. What outcomes have been reported on patients following open lower limb fracture, and how have they been measured? Bone Joint Res 2023; 12:138-146. [PMID: 37051811 PMCID: PMC10003018 DOI: 10.1302/2046-3758.122.bjr-2022-0116.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
Open lower limb fracture is a life-changing injury affecting 11.5 per 100,000 adults each year, and causes significant morbidity and resource demand on trauma infrastructures. This study aims to identify what, and how, outcomes have been reported for people following open lower limb fracture over ten years. Systematic literature searches identified all clinical studies reporting outcomes for adults following open lower limb fracture between January 2009 and July 2019. All outcomes and outcome measurement instruments were extracted verbatim. An iterative process was used to group outcome terms under standardized outcome headings categorized using an outcome taxonomy. A total of 532 eligible studies were identified, reporting 1,803 outcomes with 786 unique outcome terms, which collapsed to 82 standardized outcome headings. Overall 479 individual outcome measurement instruments were identified, including 298 outcome definitions, 27 patient- and 18 clinician-reported outcome measures, and six physical performance measures. The most-reported outcome was 'bone union/healing' reported in over 50% of included studies, while health-related quality of life was only measured in 6% of included studies. Outcomes reported for people recovering from open lower limb fracture are heterogeneous, liable to outcome reporting bias, and vary widely in the definitions and the measurement tools used to collect them. Outcomes likely to be important to patients, such as quality of life and measures of physical functioning, have been neglected. This systematic review identifies the need to unify outcome measures reported on patients recovering from open lower limb fracture; this may be addressed by creating a core outcome set.
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Affiliation(s)
- Alexander L Aquilina
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK
| | - Henry Claireaux
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Christian O Aquilina
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK
| | - Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Xavier L Griffin
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
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Functional outcomes and health-related quality of life after reconstruction of segmental bone loss in femur and tibia using the induced membrane technique. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04714-9. [PMID: 36460763 PMCID: PMC10374690 DOI: 10.1007/s00402-022-04714-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION The induced membrane technique (IMT), frequently called Masquelet technique, is an operative, two-staged technique for treatment of segmental bone loss. Previous studies mainly focused on radiological outcome parameters and complication rates, while functional outcomes and health-related quality of life after the IMT were sparsely reported. MATERIALS AND METHODS Retrospective study containing of a chart review as well as a clinical and radiological follow-up examination of all patients treated with the IMT at a single institution. The clinical outcomes were evaluated using the Lower Extremity Functional Scale (LEFS), the Short-Form-36 (SF-36) and the visual analog scale (VAS) for pain. The radiographic evaluation contained of standard anteroposterior and lateral, as well as hip-knee-ankle (HKA) radiographs. RESULTS Seventeen patients were included in the study. All had suffered high-energy trauma and sustained additional injuries. Ten bone defects were localized in the femur and seven in the tibia. Ten patients underwent additional operative procedures after IMT stage 2, among them three patients who contracted a postoperative deep infection. The median LEFS was 59 (15-80), and the SF-36 physical component summary (PCS) and mental component summary (MCS) were 41.3 (24.0-56.1) and 56.3 (13.5-66.2), respectively. The median length of the bone defect was 9 (3-15) cm. In 11 patients, union was obtained directly after IMT stage 2. Bone resorption was observed in two patients. At follow-up, 16 of the 17 bone defects had healed. The median follow-up was 59 months (13-177). CONCLUSION Our results show a high occurrence of complications after IMT stage 2 in segmental bone defects of femur and tibia requiring additional operative procedures. However, fair functional outcomes as well as a good union rate were observed at follow-up.
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Effect of Ultrasound Image-Guided Nerve Block on the Postoperative Recovery Quality of Patients with Tibial Fractures Using the Concept of Enhanced Recovery after Surgery. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:4428883. [PMID: 36045945 PMCID: PMC9424038 DOI: 10.1155/2022/4428883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/28/2022] [Accepted: 08/03/2022] [Indexed: 11/24/2022]
Abstract
This study was aimed at investigating the clinical effect of ultrasound-guided nerve block based on the concept of enhanced recovery after surgery (ERAS) for postoperative anesthesia in patients with tibial fractures. The noise-reduction processing was introduced in ultrasound images to adjust the ultrasound clarity of the patient. A total of 177 patients with tibial fractures in our hospital were retrospectively analyzed and divided into OG group (general anesthesia combined with nerve block, 78 cases), C1 group (simple general anesthesia, 27 cases), C2 group (ultrasound-guided nerve block combined with general anesthesia, 10 cases), and C3 group (62 cases of spinal-epidural anesthesia). The effect of anesthesia and postoperative recovery time of patients in each group were analyzed. The wake-up time of the OG group was significantly shorter than that of the other three groups (P < 0.05). The doses of propofol and remifentanil in the OG group were much lower than those in the other groups (P < 0.05). After the ultrasound image was processed with noise reduction, the image showed the lesion more clearly. The excellent and good rates of OG group, C1 group, C2 group, and C3 group were 89.86%, 62.73%, 75.37%, and 61.07%, respectively. The Ramsay sedation score and anesthesia satisfaction in the OG group were obviously higher than those in the other groups, but there was no significant difference (P > 0.05). The visual analogue scale (VAS) scores of the OG group at 12 h, 24 h, and 36 h after the surgery were 4.52 ± 0.41, 4.72 ± 0.24, and 4.81 ± 0.74, respectively, which were significantly higher than those of the other three groups (P < 0.05). On the basis of ERAS, ultrasound-guided nerve block combined with general anesthesia can improve the perioperative pain in patients with tibial fractures and significantly shorten the time for the wake-up time. In addition, it was safe and reliable, so it was worthy of clinical promotion.
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Ratter J, Pellekooren S, Wiertsema S, van Dongen JM, Geleijn E, de Groot V, Bloemers FW, Jansma E, Ostelo RWJG. Content validity and measurement properties of the Lower Extremity Functional Scale in patients with fractures of the lower extremities: a systematic review. J Patient Rep Outcomes 2022; 6:11. [PMID: 35092528 PMCID: PMC8800956 DOI: 10.1186/s41687-022-00417-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/17/2022] [Indexed: 11/29/2022] Open
Abstract
Background Fractures of lower extremities are common trauma-related injuries, and have major impact on patients' functional status. A frequently used Patient-Reported Outcome Measure (PROM) to evaluate patients’ functional status with lower extremity fractures is the Lower Extremity Functional Scale (LEFS). However, there is no systematic review regarding content validity and other measurement properties of the LEFS in patients with lower extremity fractures. Methods A search was performed in PubMed, Embase, Scopus, and Cochrane Library from inception until November 2020. Studies on development of the LEFS and/or the evaluation of one or more measurement properties of the LEFS in patients with lower extremity fractures were included, and independently assessed by two reviewers using COSMIN guidelines. Results Seven studies were included. Content validity of the LEFS was rated 'inconsistent', supported by very low quality of evidence. Structural validity was rated ‘insufficient’ supported by doubtful methodological quality. Internal consistency, measurement error, and responsiveness were rated 'indeterminate' supported by inadequate to adequate methodological quality. The methodological quality of the construct validity (hypotheses testing) assessment was rated as 'inadequate'. Conclusion The LEFS has several shortcomings, the lack of sufficient content validity being the most important one as content validity is considered the most crucial measurement property of a PROM according to the COSMIN guidelines. In interpreting the outcomes, one should therefore be aware that not all relevant aspects of physical functioning may be accounted for in the LEFS. Further validation in a well-designed content validity study is needed, including a clearly defined construct and patient involvement during the assessment of different aspects of content validity. Plain English summary Bone fractures of the lower extremities are a common injury. During rehabilitation it is essential to evaluate how patients experience their physical functioning, in order to monitor the progress and to optimize treatment. To measure physical functioning often questionnaires (also known as Patient Reported Outcome Measures) are used, such as the Lower Extremity Functional Scale (LEFS). However, it is not clear if the LEFS actually measures physical function, and if its other measurement properties are sufficient for using this questionnaire among patients with fractures in the lower extremities. Therefore, we systematically searched and assessed scientific papers on the development of the LEFS (i.e., its ability to measure physical functioning), and papers on the performance of the LEFS with regard to several measurement properties to identify possible factors that may cause measurement errors. Hereby we have assessed the quality of the studies included. Our main finding was that the LEFS may not measure all aspects of physical function. Given the low quality of the papers included in our study, these findings come with considerable uncertainty. As the LEFS was developed more than 20 years ago, it may not represent physical functioning as we currently conceptualize this. Therefore, we recommend to perform a study in which the content of the LEFS will be evaluated by experts in the field as well as patients, and modify the questionnaire as needed.
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Affiliation(s)
- Julia Ratter
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HZ, Amsterdam, The Netherlands.
| | - Sylvia Pellekooren
- Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Suzanne Wiertsema
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HZ, Amsterdam, The Netherlands
| | - Johanna M van Dongen
- Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Edwin Geleijn
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HZ, Amsterdam, The Netherlands
| | - Vincent de Groot
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HZ, Amsterdam, The Netherlands
| | - Frank W Bloemers
- Department of Trauma Surgery, Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Elise Jansma
- Department of Epidemiology and Data Science, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Health Sciences, Faculty of Science, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Epidemiology and Data Science, Location VUmc, Amsterdam Movement Sciences, Amsterdam UMC, De Boelelaan 1117, Amsterdam, The Netherlands
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Larsen P, Eriksen CB, Stokholm R, Elsoe R. 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. Arch Orthop Trauma Surg 2021; 141:1303-1310. [PMID: 32951059 DOI: 10.1007/s00402-020-03608-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/09/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Peter Larsen
- Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg, Denmark. .,Department of Orthopaedic Trauma Surgery, Aalborg University Hospital, 18-22 Hobrovej, 9000, Aalborg, Denmark.
| | - Christian Berre Eriksen
- Department of Orthopaedic Trauma Surgery, Aalborg University Hospital, 18-22 Hobrovej, 9000, Aalborg, Denmark
| | - Rasmus Stokholm
- Department of Orthopaedic Trauma Surgery, Aalborg University Hospital, 18-22 Hobrovej, 9000, Aalborg, Denmark
| | - Rasmus Elsoe
- Department of Orthopaedic Trauma Surgery, Aalborg University Hospital, 18-22 Hobrovej, 9000, Aalborg, Denmark
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Pallister I, Handley GJ, Maggs S, Davies AM, Kyle A, Bodger O, Dafydd H. Measuring recovery after open lower limb fractures: combined objective functional tests and global perceived recovery outperform narrower metrics and a standard generic patient reported outcome measure. BMC Musculoskelet Disord 2021; 22:539. [PMID: 34118896 PMCID: PMC8199836 DOI: 10.1186/s12891-021-04356-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Open lower limb fractures are serious injuries requiring combined ortho-plastic surgery and have significantly worse outcomes than similar closed fractures. There is little objective published data to determine which functional outcome measures best reflect progress or completeness of physical recovery. Our hypothesis was that objective measures combining strength, mobility and balance would better reflect recovery than isolated parameters (e.g. range of motion ROM) and would compare well to patients' perceived recovery. METHODS Adult open lower limb fracture patients were reviewed 6 and 12 weeks, 6, 9 and 12 months post-injury. The mechanism, injury pattern, age, gender and treatment were recorded. Isolated parameter objective functional outcome measures (OFOMs) (ROM and MRC strength grade) were compared to combined OFOMs (timed up and go, comfortable gait speed and fast gait speed, Edgren Side Step Test (TUAG, CGS, FGS, ESST) and Single Leg balance. Patient reported outcomes were recorded (Global Perceived Effect (GPE) score and Disability Rating Index (DRI)). Statistical analysis used non-parametric tests (e.g. Spearman correlation) compared each with time since injury. RESULTS Sixty-eight patients (54 male) with a median age of 45(20-75) years. Of the 19 isolated OFOMs, only knee flexion and ankle plantar flexion ROM and strength improved with time (Spearman correlation p = 0.042, 0.008, 0.032, 0.036 respectively). TUAG, ESST, CGS, FGS and GPE scores showed significant improvement (Spearman correlation p < 0.001). Patients' estimation of recovery paralleled these measures (Spearman correlation p < 0.001) with all but 2 patients achieving the minimum clinical important difference in DRI by 12 months compared to baseline. However, the GPE score had a higher proportion of improving responses than DRI at each time-point. DISCUSSION Functional recovery is a key determinant in patients returning to work, providing for themselves and their family or resuming independent living for older patients. This study has demonstrated time-related improvements in combined OFOMs measuring mobility, strength, agility and balance paralleling patients' perception of recovery in the 12 months after open lower limb fractures. Over the same time-frame, the simple GPE score compared favourably with the DRI. Such parameters could become part of a defined core outcomes set. Focussing rehabilitation towards these combined OFOMs may help hasten recovery. TRIAL REGISTRATION South West Wales REC 06/WMW02/10).
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Affiliation(s)
- Ian Pallister
- Department of Trauma & Orthopaedics, Swansea University Medical School, c/o Morriston Hospital, Swansea, SA6 6NL, UK.
| | | | - Sharon Maggs
- Department of Physiotherapy, Morriston Hospital, Swansea, UK
| | | | - Amanda Kyle
- Department of Occupational Therapy, Morriston Hospital, Swansea, UK
| | - Owen Bodger
- Senior Lecturer Statistician, Swansea University Medical School, Swansea, UK
| | - Hywel Dafydd
- Department of Wales Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK
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Prediction of delayed union of tibial shaft fracture treated with intramedullary nailing: multicenter-study analysis and literature review -the TRON study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:129-135. [PMID: 33760997 DOI: 10.1007/s00590-021-02939-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE We aimed to 1) identify predictors of delayed and nonunion of tibial shaft fractures in patients treated with intramedullary nailing (IMN), including patient demographics and surgical factors, and 2) determine whether the nail/shaft ratio is associated with delayed and nonunion. METHODS This retrospective, multicenter study included 315 patients with tibial shaft fracture treated with IMN between 2014 and 2019 and excluded patients with insufficient follow-up for 12 months, lost data and inadequate radiographs. Finally, we analyzed 258 patients (184 males; 74 females). Main outcome measurements were delayed union at 6 and nonunion at 12 months after surgery as determined on anteroposterior and lateral radiographs. We extracted the following as risk factors of delayed and nonunion: age, sex, BMI, fracture site, fracture type, injury energy, smoking history, and nail/shaft ratio. We conducted logistic regression analysis to investigate risk factors of delayed and nonunion using these extracted items as explanatory variables. RESULTS Type C fracture was independently associated with delayed union (odds ratio 2.9, 95% confidential interval: 1.04-8.09, P = 0.04). Nail/shaft ratio was not an independent factor of delayed union. No independent explanatory factors were related to nonunion. CONCLUSIONS Type C fractures, which were unstable and fragmented, was associated with delayed union in tibia fractures treated with IMN, whereas nail thickness was not associated with delayed or nonunion fractures.
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Mott A, Mitchell A, McDaid C, Harden M, Grupping R, Dean A, Byrne A, Doherty L, Sharma H. Systematic review assessing the evidence for the use of stem cells in fracture healing. Bone Jt Open 2020; 1:628-638. [PMID: 33215094 PMCID: PMC7659646 DOI: 10.1302/2633-1462.110.bjo-2020-0129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIMS Bone demonstrates good healing capacity, with a variety of strategies being utilized to enhance this healing. One potential strategy that has been suggested is the use of stem cells to accelerate healing. METHODS The following databases were searched: MEDLINE, CENTRAL, EMBASE, Cochrane Database of Systematic Reviews, WHO-ICTRP, ClinicalTrials.gov, as well as reference checking of included studies. The inclusion criteria for the study were: population (any adults who have sustained a fracture, not including those with pre-existing bone defects); intervention (use of stem cells from any source in the fracture site by any mechanism); and control (fracture healing without the use of stem cells). Studies without a comparator were also included. The outcome was any reported outcomes. The study design was randomized controlled trials, non-randomized or observational studies, and case series. RESULTS In all, 94 eligible studies were identified. The clinical and methodological aspects of the studies were too heterogeneous for a meta-analysis to be undertaken. A narrative synthesis examined study characteristics, stem cell methods (source, aspiration, concentration, and application) and outcomes. CONCLUSION Insufficient high-quality evidence is available to determine the efficacy of stem cells for fracture healing. The studies were heterogeneous in population, methods, and outcomes. Work to address these issues and establish standards for future research should be undertaken.Cite this article: Bone Joint Open 2020;1-10:628-638.
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Affiliation(s)
- Andrew Mott
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Alex Mitchell
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Catriona McDaid
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Melissa Harden
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Rachael Grupping
- Department of Trauma and Orthopaedics, Hull University Teaching Hospitals, Hull, UK
| | - Alexandra Dean
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Ailish Byrne
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Laura Doherty
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Hemant Sharma
- Department of Trauma and Orthopaedics, Hull University Teaching Hospitals, Hull, UK
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DeCoster TA. CORR Insights®: Delays to Surgery and Coronal Malalignment Are Associated with Reoperation after Open Tibia Fractures in Tanzania. Clin Orthop Relat Res 2020; 478:1836-1838. [PMID: 32732564 PMCID: PMC7371048 DOI: 10.1097/corr.0000000000001301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/22/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Thomas A DeCoster
- T. A. DeCoster, Professor, University of New Mexico, Department of Orthopaedics, Albuquerque, NM, USA
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Trickett RW, Mudge E, Price P, Pallister I. The development of a novel patient-derived recovery scale for open tibial fractures. Bone Joint J 2020; 102-B:17-25. [PMID: 31888370 DOI: 10.1302/0301-620x.102b1.bjj-2019-0303.r2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AIMS The aim of this study was to develop a psychometrically sound measure of recovery for use in patients who have suffered an open tibial fracture. METHODS An initial pool of 109 items was generated from previous qualitative data relating to recovery following an open tibial fracture. These items were field tested in a cohort of patients recovering from an open tibial fracture. They were asked to comment on the content of the items and structure of the scale. Reduction in the number of items led to a refined scale tested in a larger cohort of patients. Principal components analysis permitted further reduction and the development of a definitive scale. Internal consistency, test-retest reliability, and responsiveness were assessed for the retained items. RESULTS The initial scale was completed by 35 patients who were recovering from an open tibial fracture. Subjective and objective analysis permitted removal of poorly performing items and the addition of items suggested by patients. The refined scale consisted of 50 Likert scaled items and eight additional items. It was completed on 228 occasions by a different cohort of 204 patients with an open tibial fracture recruited from several UK orthoplastic tertiary referral centres. There were eight underlying components with tangible real-life meaning, which were retained as sub-scales represented by ten Likert scaled and eight non-Likert items. Internal consistency and test-retest reliability were good to excellent. CONCLUSION The Wales Lower Limb Trauma Recovery (WaLLTR) Scale is the first tool to be developed from patient data with the potential to assess recovery following an open tibial fracture. Cite this article: Bone Joint J 2020;102-B(1):17-25.
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Affiliation(s)
- Ryan W Trickett
- Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Elizabeth Mudge
- Department of Wound Healing, Cardiff University School of Medicine, Cardiff, UK
| | | | - Ian Pallister
- Abertawe Bro Morgannwg University Health Board, Morriston Hospital, Swansea, UK
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Craxford S, Deacon C, Myint Y, Ollivere B. Assessing outcome measures used after rib fracture: A COSMIN systematic review. Injury 2019; 50:1816-1825. [PMID: 31353094 DOI: 10.1016/j.injury.2019.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The incidence of invasive treatment of rib fracture has increased significantly over the last decade however the evidence of improved patient outcomes to support this is lacking. A systematic review was performed to identify patient reported outcome measures (PROMs) used in the assessment of outcomes following chest wall injury. The quality of evidence for the psychometric properties of the identified PROMs was graded using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. METHODS Rib fracture studies measuring patient reported outcomes were identified using PubMed/Medline, EMBASE, AMED and PsycINFO. Methodological quality of measurement properties was evaluated with the COnsensus-based Standards for selection of health status Measurement INstruments (COSMIN) checklist. RESULTS A total of 64 studies were identified including 19 different PROM instruments. Domains included in the reported PROMs included pain, breathlessness, general health quality of life, physical function and physiological health. No rib fracture specific PROM was identified. The most frequently reported instrument was the SF-36 reporting overall quality of life (HRQoL) although there was very low quality evidence for its content validity. There was low quality evidence to support good content validity for the Medical Research Council (MRC) dyspnoea scale, Brief Pain Index (BPI) and McGill Pain Questionnaire (MPQ). No PROM had undergone validation in a rib fracture population. The overall quality of the PROM development studies was poor. While we were unable to identify a clear "gold standard", based on the limited current evidence, we recommend that the EQ-5D-5L is used in combination with the MRC and BPI or MPQ for future rib fracture studies. CONCLUSION The lack of validated outcome measures for rib fracture patients is a significant limitation of the current literature. Further studies are needed to provide validated outcome measures to ensure accuracy of the reported results and conclusions. As interventions for rib fractures have become more common in both research and clinical practice this has become an urgent priority.
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Affiliation(s)
| | - Christopher Deacon
- Department of Trauma and Orthopaedics, Queens Medical Centre, Nottingham, UK
| | - Yulanda Myint
- Department of Trauma and Orthopaedics, Queens Medical Centre, Nottingham, UK
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