The Longitudinal Short-, Medium-, and Long-Term Functional Recovery After Unstable Pelvic Ring Injuries

Trajectory of Recovery following ORIF for Distal Radius Fractures

Background  Distal radius fractures are commonly seen among the elderly, though studies examining their long-term outcomes are limited. Purpose  The aim of this study was to describe the 5-year trajectory of recovery of distal radius fractures treated with open reduction and internal fixation (ORIF). Methods  Patients with distal radius fractures (AO/OTA 23.A-C) treated by ORIF were prospectively studied. Patient-Rated Wrist Evaluation (PRWE) score was measured at baseline (preinjury recall) and postoperatively at 6 months, 1 year, and 5 years. Clinically relevant change in PRWE score was assessed using the minimal clinically important difference (MCID). Results  A total of 390 patients were included, of which 75% completed 5-year follow-up. Mean baseline PRWE score was 1.25 (standard deviation, SD: 2.9). At 6 months, mean PRWE score was at its highest up to 20.2 (SD: 18.4; p  < 0.01). A significant improvement in mean PRWE score was observed at 1 year down to 15.2 (SD: 17.6; p  < 0.01); 44% of patients were still one MCID outside of their baseline PRWE score at 1 year. Further significant improvement in mean PRWE score occurred at 5 years down to 9.4 (SD: 13.4; p  < 0.01); 29% of patients remained one MCID outside of their baseline PRWE score at 5 years. Conclusion  Recovery after ORIF for distal radius fractures showed significant worsening after surgery, followed by significant improvements up to 1 year and between years 1 and 5, albeit to a lesser extent. Statistically and clinically relevant wrist pain and disability persisted at 5 years. Future research should examine different treatment modalities and include a nonoperative treatment arm for comparison. Level of Evidence  Prognostic level II.

Long-Term Follow-Up after Iliosacral Screw Fixation of Unstable Pelvic Ring Fractures

(1) Background: High-energy injuries of the pelvic ring are rare. The wide application of iliosacral screw fixation of the posterior pelvic ring is relatively new. The aim of the present study was to evaluate the long-term quality of life. (2) Methods: All patients treated with an iliosacral screw for a posterior pelvic ring stabilization after high-energy trauma at a level 1 trauma center between 2005 and 2015 were included. Pelvic ring injuries were classified according to the Tile classification adapted by AO/ASIF. The clinical evaluation included the patient-oriented questionnaires surveys of the Majeed Score, Iowa Pelvic Score (IPS), Work Ability Index (WAI), SF-36, EQ5D-5L. (3) Results: A total of 84 patients were included with a median follow-up of 130.1 months (IQR 95.0-162.0 months). The median ISS was 22.5 (IQR 16.0-29.0), mean Majeed Score 83.32 (SD ± 19.26), IPS 77.88 (SD ± 13.96), WAI 32.71 (SD ± 11.31), SF-36 PF 71.25 (SD ± 29.61) and EQ5D-5L 0.83 (SD ± 0.21). There was a notably difference between uni- and bilateral pelvic fractures (p = 0.033) as well as a correlation with the ISS (p = 0.043) with inferior functional outcome measured by IPS. (4) Conclusions: Long-term follow-up of iliosacral screw fixation of unstable pelvic ring fractures showed a good quality of life and functional outcome with equal EQ5D-5L results and inferior SF-36 physical functioning compared to the German population.

Evaluation of the trajectory of recovery following surgically treated acetabular fractures

Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Methods

Eligible patients at a level I trauma centre were recruited into a longitudinal registry of surgical acetabular fractures between June 2004 and August 2019. Patient-reported outcome measures (PROMs), including the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS), were recorded at baseline pre-injury recall and six months, one year, two years, and five years postoperatively. Comparative analyses were performed for elementary and associated fracture patterns. The proportion of patients achieving minimal clinically important difference (MCID) was determined. The rate of, and time to, conversion to total hip arthroplasty (THA) was also established.

Results

We recruited 251 patients (253 fractures), with a 4:1 male to female ratio and mean age of 46.1 years (SD 16.4). Associated fracture patterns accounted for 56.5% of fractures (n = 143). Trajectory analysis showed all timepoints had significant disability versus baseline, including final follow-up (p < 0.001). Elementary fractures had higher SF-36 PCS at six months (p = 0.023) and one year (p = 0.007) compared to associated fractures, but not at two years (p = 0.135) or five years (p = 0.631). The MCID in SF-36 PCS was observed in 37.3% of patients (69/185) between six months and one year, 26.9% of patients (39/145) between one and two years, and 23.3% of patients (20/86) between two and five years, highlighting the long recovery potential of these injuries. A significant proportion of patients failed to attain the MCID after five years (38.1%; 40/105). Conversion to THA occurred in 13.1% of patients (11/110 elementary and 22/143 associated fractures). Approximately two-thirds of THAs (21/33 patients; 63.6%) were performed within two years of index surgery.

Conclusion

Acetabular fractures significantly impact physical function. Recovery trajectory is often elongated beyond one year, with two-thirds of our patients displaying persistent clinically relevant long-term disability.

Complications of surgically treated pelvic ring injuries with associated genitourinary injuries

OBJECTIVE

Pelvic ring injuries are often associated with vascular and intrapelvic organ injuries including damage to the genitourinary system. The purpose of this study was to examine the relationship between surgically treated pelvic ring injuries and genitourinary injuries. The primary outcome was to determine the rate of post-operative complications including infection, urinary dysfunction, and sexual dysfunction. The secondary outcome was to determine if the time to surgery was associated with post-operative complications.

METHODS

Retrospective chart review from September 1, 2015 to December 31, 2019 of patients who sustained a pelvic ring injury which required surgical intervention. All patients with closed triradiate cartilage were included.

RESULTS

A total of 115 patients met the inclusion criteria, 12 patients with an associated genitourinary (GU) injury were included in the GU group and 103 without GU injury were placed in the non-GU group. The median (range) age of patients in the GU group was 49.5 years (20, 64) and 48 years (15, 92) in the control group (p = 0.92). Demographic characteristics including age, Injury Severity Score and Elixhauser comorbidity score were similar between groups. Within the GU group, five patients had an injury to their bladder, four to their urethra and three had an injury to their kidney. In the GU group, one patient developed a wound dehiscence and one developed a urinary tract infection with subsequent sepsis (17%), while in the non-GU group, one patient (1%) developed erectile dysfunction (p = 0.028). Regression analysis demonstrated that having concomitant pelvic ring and GU injuries, as well as the number of surgeries were variables associated with post-operative complications, while time to surgery was not.

DISCUSSION AND CONCLUSIONS

Pelvic ring injuries with concomitant genitourinary injuries were associated with increased odds of post-operative complications. No differences were noted in complication rates due to the time to surgery between groups.

Prospective Characterization of Pain and Function in Patients With Unstable Pelvic Fractures Treated With Posterior Screw Fixation

OBJECTIVES

Describe patient-reported pain and function within 24 months of a pelvic fracture treated with posterior screw fixation and identify factors associated with increased pain.

DESIGN

Prospective case series.

SETTING

Academic trauma center.

PATIENTS/INTERVENTION

Eighty-eight patients with adult pelvic fracture treated with sacroiliac or transiliac screws.

MAIN OUTCOME MEASURES

Average pain measured with the Brief Pain Inventory (BPI); function measured with the Majeed Pelvic Outcome Score from 6 to 24 months postinjury.

RESULTS

The mean pain from 6 to 24 months postinjury was 2.22 on the 10-point BPI scale (95% CI, 0.64-3.81). Sixty-nine patients (78.4%) reported mild to no pain at 6 months; 12 (13.6%) patients had severe pain. Two years after injury, 71 patients (80.6%) exhibited mild to no pain. Within 24 months of injury, the mean pelvic function was 71 on the 100-point Majeed scale (95% CI, 60-82). Half of the sample (n = 44) had good to excellent pelvis function by 6 months postinjury; 55 patients (62.5%) attained this level of function by 24 months. A history of chronic pain (1.31; 95% CI, 0.26-2.37; P = 0.02), initial fracture displacement (≥5 mm) (0.99; 95% CI, 0.23-1.69; P = 0.01), and socioeconomic deprivation (0.28; 95% CI, 0.11-0.44; P < 0.01) were significantly associated with increased pain.

CONCLUSION

Our findings suggest that most patients with unstable pelvic ring fractures treated with posterior screw fixation achieve minimal to no pelvis pain and good to excellent pelvic function 6-24 months after injury.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-Term Trajectory of Recovery Following Pilon Fracture Fixation

OBJECTIVES

To describe the trajectory of recovery following fixation of pilon fractures from baseline to 5-year follow-up.

DESIGN

Prospective cohort study.

SETTING

Level-1 trauma center.

PATIENTS/PARTICIPANTS

Patients with pilon fractures (OTA/AO 43.C) treated with open reduction and internal fixation.

INTERVENTION

None.

MAIN OUTCOMES MEASURES

Patient-reported outcome measures were measured at baseline, 6 months, 1 year, and 5 years using the Short-Form 36 Health Survey (SF-36) Physical Component Score and Mental Component Score, Short Musculoskeletal Functional Assessment, and the Foot and Ankle Outcome Score.

RESULTS

One hundred two patients were enrolled: mean age was 42.6 years; 69% were males; 88% had an injury severity score of 9; 74 patients (73%) completed 1-year follow-up; 40 patients (39%) completed 5-year follow-up. Trajectory of recovery of physical function showed a significant decline between baseline and 6 months, with significant improvement between 6 months and 1 year and then ongoing but slower improvement between 1 year and 5 years. Sixty-four patients returned to baseline SF-36 Physical Component Score at 5 years. Pain was a persistent issue and remained significantly worse at 5 years when compared with baseline. Psychological well-being (SF-36 Mental Component Score) did not significantly change from baseline at 5 years.

CONCLUSION

Functional recovery following open reduction and internal fixation for pilon fractures was characterized by an initial decrease in function from baseline, followed by an increase between 6 months and 1 year, and then slower but continued increases from 1 year to 5 years. Function did not return to baseline levels, pain was a persistent issue, and mental well-being showed no change from baseline at 5 years. This information may be useful when counselling patients.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Quantifying Urinary and Sexual Dysfunction After Pelvic Fracture

OBJECTIVES

To quantify the severity of urinary and sexual dysfunction and to evaluate the relationship between urinary and sexual dysfunction, injury, and treatment factors in patients with pelvic fracture.

DESIGN

Prospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

One hundred thirteen patients with surgically treated pelvic fracture (65.5% OTA/AO 61B fractures; 7 open fractures; 74 men).

INTERVENTIONS

Surgical pelvic stabilization.

MAIN OUTCOME MEASURES

The 36-Item Short Form Health Survey and International Consultation Incontinence Questionnaire responses were collected at baseline, 6 months, and 1, 2, and 5 years. Patients were scored on symptoms of voiding and incontinence, and filling (for women), to derive urinary function. Sexual function was scored as a single domain. Both genders reported urinary and sexual bothersome symptoms. Regression analysis was used to isolate the importance of predictive factors on urinary and sexual function, urinary and sexual bother, and their impact on quality of life.

RESULTS

Patients with pelvic fracture have significant urinary and sexual dysfunction, which is sustained or worsens over time. Male urinary function was predicted by Injury Severity Score (P = 0.03) and 61C fracture (odds ratio: 3.23, P = 0.04). Female urinary function was predicted by urinary tract injury at admission (odds ratio: 7.57, P = 0.03). Neurologic injury and anterior fixation were identified as significant predictors for male sexual function and sexual bother, whereas urological injuries were important in predicting female urinary and sexual bother (P < 0.01). Sexual function (P = 0.02) and sexual bother (P < 0.001) were important predictors of overall mental well-being in men.

CONCLUSIONS

Urinary and sexual dysfunction are prevalent and sustained in men and women and do not follow the prolonged slow recovery trajectory seen in physical function. Male urinary and sexual dysfunction was closely tied to neurologic injury, whereas female urinary and sexual dysfunction was predicted by the presence of a urinary tract injury. Urinary and sexual dysfunction were important to overall mental well-being in men.

LEVEL OF EVIDENCE

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

Effect of Percutaneous Posterior Pelvic Ring Reduction and Fixation on Patient-Reported Outcomes

OBJECTIVES

The purpose of this study was to assess patient outcomes using Patient-Reported Outcomes Measurements Information System (PROMIS) scores after closed reduction and percutaneous fixation (CRPF) of the posterior pelvic ring and determine whether quality of reduction affects the outcomes.

DESIGN

This is a retrospective cohort study.

SETTING

The study involved a Level I trauma center.

PATIENTS

The study included 46 adult patients with operatively treated pelvic ring injuries (63% OTA/AO 61-B) who underwent CRPF between 2014 and 2018 at a single institution.

INTERVENTION

The intervention involved closed reduction and percutaneous posterior pelvic ring fixation.

MAIN OUTCOME MEASUREMENTS

The main outcome measurements were postoperative patient PROMIS scores, including physical function, pain interference, anxiety, and depression, and radiographic measurements of postoperative displacement and pelvic deformity.

RESULTS

After CRPF, PROMIS scores of physical function, pain interference, and anxiety were significantly improved at the time of final follow-up when compared with the first postoperative visit. The amount of malreduction or pelvic deformity did not significantly affect outcome scores; however, results were limited by small sample size.

CONCLUSIONS

CRPF of posterior pelvic ring injuries results in good functional and radiographic outcomes. Degree of malreduction may not affect outcomes as much as previously believed.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Fallacy of Follow-up: When Orthopaedic Trauma Patients Actually Return to Clinic

BACKGROUND

Clinical follow-up in orthopaedic trauma is challenging, yet expectations exist that a 1-year follow-up is the minimum requirement for clinical trials and research publications. The primary purpose of our study was to evaluate the rate of follow-up after operative orthopaedic trauma care and the relationship to clinical care. Our secondary aim was to identify any independent risk factors regarding follow-up completion.

METHODS

A chart review of patients operatively treated for a traumatic injury during the months of January and July 2016 was conducted. Patient demographic characteristics, injury type, severity, and patient distance from the hospital were collected. The final clinical instructions and whether a return visit was requested or as needed were recorded.

RESULTS

There were 293 patients in this study, of whom 84 (29%) had follow-up of at least 1 year and 52 (18%) were instructed to follow up only as needed at their last visit prior to the 1-year mark. When removing the latter 52 patients, the 1-year follow-up rate was 35% (84 of 241 patients). Of these 241 patients, 157 (65%) were requested to return for additional clinical care but failed to return prior to 1 year. Logistic regression identified tobacco use (odds ratio [OR], 0.34 [95% confidence interval (CI), 0.15 to 0.77]; p = 0.010), final appointment status (OR, 6.3 [95% CI, 3.4 to 11.6]; p < 0.001), isolated compared with multiple fractures (OR, 2.2 [95% CI, 1.2 to 4.1]; p = 0.013), and distance from the trauma center per mile as a continuous variable (OR, 0.999 [95% CI, 0.998 to 1.0]; p = 0.03) as significant predictors.

CONCLUSIONS

Our data suggest that a 1-year clinic follow-up requirement may not be feasible. We observed a low rate of patients with a minimum 1-year clinical follow-up. Clinical care had been completed in 18% of patients prior to 1 year. Journal and grant reviewers may need to consider the feasibility and clinical relevance of these follow-up expectations.

Outcomes following pelvic ring fractures in the paediatric population: A systematic review

BACKGROUND

Pelvic fractures represent a small proportion of all paediatric fractures, but are likely to be associated with a high-energy mechanism, multiple injuries, and significant morbidity and mortality. Operative fixation of unstable pelvic fractures is accepted. However, there remains a paucity of data on functional outcomes and complications following pelvic fractures in the skeletally immature.

METHODS

A PRISMA-compliant systematic review was performed, searching Medline, Embase, and Cochrane central review. The primary outcome was functional outcome after pelvic fractures in the paediatric population following operative or non-operative treatment. Secondary outcomes included mechanism of injury, associated injuries, mortality rate, and method of surgical fixation if required. Where possible, weighted totals of the data set were performed.

RESULTS

In total, 23 studies were included in this review. Only eight studies reported functional outcomes, with limb length discrepancy and limp being the most common complication. Only 8.8% of all pelvic fractures underwent surgical fixation. Motor vehicle collision was the most common cause of injury, and extremity fracture was the most common associated injury.

CONCLUSION

Paediatric pelvic fractures are caused by high-energy mechanisms and have significant morbidity and mortality. There remains a paucity of information on functional outcomes after these injuries.