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Richards JT, O’Hara NN, Healy K, Zingas N, McKibben N, Benzel C, Slobogean GP, O’Toole RV, Sciadini MF. Fix or Replace? Patient Preferences for the Treatment of Geriatric Lower Extremity Fractures: A Discrete Choice Experiment. Geriatr Orthop Surg Rehabil 2024; 15:21514593241236647. [PMID: 38426150 PMCID: PMC10903189 DOI: 10.1177/21514593241236647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 12/20/2023] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction When considering treatment options for geriatric patients with lower extremity fractures, little is known about which outcomes are prioritized by patients. This study aimed to determine the patient preferences for outcomes after a geriatric lower extremity fracture. Materials and Methods We administered a discrete choice experiment survey to 150 patients who were at least 60 years of age and treated for a lower extremity fracture at a Level I trauma center. The discrete choice experiment presented study participants with 8 sets of hypothetical outcome comparisons, including joint preservation (yes or no), risk of reoperation at 6 months and 24 months, postoperative weightbearing status, disposition, and function as measured by return to baseline walking distance. We estimated the relative importance of these potential outcomes using multinomial logit modeling. Results The strongest patient preference was for maintained function after treatment (59%, P < .001), followed by reoperation within 6 months (12%, P < .001). Although patients generally favored joint preservation, patients were willing to change their preference in favor of joint replacement if it increased function (walking distance) by 13% (SE, 66%). Reducing the short-term reoperation risk (12%, P < .001) was more important to patients than reducing long-term reoperation risk (4%, P = .33). Disposition and weightbearing status were lesser priorities to patients (9%, P < .001 and 7%, P < .001, respectively). Discussion After a lower extremity fracture, geriatric patients prioritized maintained walking function. Avoiding short-term reoperation was more important than avoiding long-term reoperation. Joint preservation through fracture fixation was the preferred treatment of geriatric patients unless arthroplasty or arthrodesis provides a meaningful functional benefit. Hospital disposition and postoperative weightbearing status were less important to patients than the other included outcomes. Conclusions Geriatric patients strongly prioritize function over other outcomes after a lower extremity fracture.
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Affiliation(s)
- John T. Richards
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Author’s name insert query plzJ. T. Richards is an employee of the US Government. This work was prepared as part of their official duties. Title 17 U.S.C.§105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. §101 defined a US Government work as a work prepared by a military service member or employees of the US Government as part of that person’s official duties. The opinions or assertions contained in this paper are the private views of the authors and are not to be construed as reflecting the views, policy or positions of the Department of the Navy, Department of Defense nor the US Government
| | - Nathan N. O’Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Author’s name insert query plzJ. T. Richards is an employee of the US Government. This work was prepared as part of their official duties. Title 17 U.S.C.§105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. §101 defined a US Government work as a work prepared by a military service member or employees of the US Government as part of that person’s official duties. The opinions or assertions contained in this paper are the private views of the authors and are not to be construed as reflecting the views, policy or positions of the Department of the Navy, Department of Defense nor the US Government
| | - Kathleen Healy
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Author’s name insert query plzJ. T. Richards is an employee of the US Government. This work was prepared as part of their official duties. Title 17 U.S.C.§105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. §101 defined a US Government work as a work prepared by a military service member or employees of the US Government as part of that person’s official duties. The opinions or assertions contained in this paper are the private views of the authors and are not to be construed as reflecting the views, policy or positions of the Department of the Navy, Department of Defense nor the US Government
| | - Nicolas Zingas
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Author’s name insert query plzJ. T. Richards is an employee of the US Government. This work was prepared as part of their official duties. Title 17 U.S.C.§105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. §101 defined a US Government work as a work prepared by a military service member or employees of the US Government as part of that person’s official duties. The opinions or assertions contained in this paper are the private views of the authors and are not to be construed as reflecting the views, policy or positions of the Department of the Navy, Department of Defense nor the US Government
| | - Natasha McKibben
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Author’s name insert query plzJ. T. Richards is an employee of the US Government. This work was prepared as part of their official duties. Title 17 U.S.C.§105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. §101 defined a US Government work as a work prepared by a military service member or employees of the US Government as part of that person’s official duties. The opinions or assertions contained in this paper are the private views of the authors and are not to be construed as reflecting the views, policy or positions of the Department of the Navy, Department of Defense nor the US Government
| | - Caroline Benzel
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Author’s name insert query plzJ. T. Richards is an employee of the US Government. This work was prepared as part of their official duties. Title 17 U.S.C.§105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. §101 defined a US Government work as a work prepared by a military service member or employees of the US Government as part of that person’s official duties. The opinions or assertions contained in this paper are the private views of the authors and are not to be construed as reflecting the views, policy or positions of the Department of the Navy, Department of Defense nor the US Government
| | - Gerard P. Slobogean
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Author’s name insert query plzJ. T. Richards is an employee of the US Government. This work was prepared as part of their official duties. Title 17 U.S.C.§105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. §101 defined a US Government work as a work prepared by a military service member or employees of the US Government as part of that person’s official duties. The opinions or assertions contained in this paper are the private views of the authors and are not to be construed as reflecting the views, policy or positions of the Department of the Navy, Department of Defense nor the US Government
| | - Robert V. O’Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Author’s name insert query plzJ. T. Richards is an employee of the US Government. This work was prepared as part of their official duties. Title 17 U.S.C.§105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. §101 defined a US Government work as a work prepared by a military service member or employees of the US Government as part of that person’s official duties. The opinions or assertions contained in this paper are the private views of the authors and are not to be construed as reflecting the views, policy or positions of the Department of the Navy, Department of Defense nor the US Government
| | - Marcus F. Sciadini
- Marcus F. Sciadini, MD, Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
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Duvvuri P, Trout SM, Bub CD, Goldman AT. Use of a Hindfoot Nail Without Separate Subtalar and Tibiotalar Joint Preparation to Treat Geriatric Ankle and Distal Tibia Fractures: A Case Series. Geriatr Orthop Surg Rehabil 2023; 14:21514593231195239. [PMID: 37581176 PMCID: PMC10423445 DOI: 10.1177/21514593231195239] [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: 08/10/2022] [Revised: 07/15/2023] [Accepted: 07/28/2023] [Indexed: 08/16/2023] Open
Abstract
Introduction Ankle fractures in geriatric patients can be devastating injuries, as they limit an individual's mobility, autonomy, and quality of life. This study examines the functional outcomes and complications related to hindfoot nails (HFN) in geriatric patients who have suffered an ankle malleolar or distal tibia fracture. Materials and Methods This is a single-surgeon case-series of patients who underwent HFN for acute fixation or delayed reconstruction after an ankle or distal tibia fracture. Demographic information, comorbidities, baseline functional status, AO/OTA classification, surgical indications, need for external fixation, total operative time, length of stay (LOS), ambulation at discharge, and discharge disposition were recorded. Primary outcomes included 30-day complications, ambulation at follow-up, and time to fracture union and fusion. Results There were 22 patients, with average age 80.8 years. Mean LOS was 7.0 days, and 68.2% were discharged to subacute rehabilitation. Within 30 days, 1 patient developed a deep vein thrombosis and bilateral pulmonary emboli, and 2 experienced wound dehiscence requiring antibiotics. At 6-weeks, 1 patient sustained a fall with periprosthetic fracture requiring HFN revision, and another developed cellulitis necessitating hardware removal. Fracture healing was seen in 72.7% at 19.4 weeks, while radiographic fusion occurred in 18.2% at 43.0 weeks. 72.7% were ambulating with an assistive device at discharge, and 100.0% at 12-weeks post-operatively or last follow-up. Upon final examination, all patients were ambulating without pain. Discussion HFNs provide a reliable alternative to traditional open reduction internal fixation and have the ability to improve quality of life for geriatric patients through a faster return to weight-bearing. Additionally, radiographic fusion rates show that patients have favorable functional outcomes even without formal arthrodesis. Conclusion HFN is beneficial for elderly patients with low functional demand and complex medical comorbidities, as it allows for early mobility after sustaining an ankle or distal tibia fracture.
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Affiliation(s)
- Priya Duvvuri
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sally May Trout
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Christine Decker Bub
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Ariel Tenny Goldman
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, New Hyde Park, NY, USA
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Zhao W, Wang Q, Cui Z, Yue Z, Hu Z, Zeng L, Xin D, Tang Y, Tang D. A retrospective assessment of the clinical efficacy of different internal fixation methods in the treatment of distal fibula fractures in the elderly. Medicine (Baltimore) 2022; 101:e30973. [PMID: 36316934 PMCID: PMC9622573 DOI: 10.1097/md.0000000000030973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
An ankle fracture is a fracture of the distal tibia or fibula that forms the ankle joint, usually associated with ligament and soft tissue injury, and is a common type of lower limb fracture and one of the most common types of fracture in the elderly. Although ankle fractures are one of the most common injuries seen by orthopedic trauma surgeons, there is no uniform protocol for the diagnosis and treatment of ankle fractures in the elderly, and there are many controversial indications for surgery. The aim of this study is to assess the clinical efficacy of different internal fixation methods in the treatment of distal fibular fractures in the elderly, in an effort to improve the rational selection and application of clinical acts. A retrospective analysis was performed on 68 cases of patients who suffered an ankle fracture and were treated with different internal fixation methods according to the fracture types and individual differences in distal fibula fractures. The postoperative therapeutic effect assessment was performed in terms of clinical examination, imaging evaluation, and AOFAS ankle-hind foot function scoring. There was no unhealed bone, ankle instability and loose/fractured internal fixation. Fracture healing time was 2.7 to 4.0 months (average 3.2 months). AOFAS score was 88.3 ± 6.2, of which, 34 excellent cases, 30 good cases, and 4 fair cases. Ankle activity dorsiflexion 6º~18º, average 15º; plantar flexion 26º~47º, average 37º. A good clinical efficacy could be achieved from the most appropriate individualized internal fixation for distal fibula fractures of elderly patients.
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Affiliation(s)
- Wenhai Zhao
- Department of Orthopedics, Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin, China
- *Correspondence: Wenhai Zhao, Department of Orthopedics, Affiliated Hospital to Changchun University of Chinese Medicine, 130117 Changchun, Jilin, China (e-mail: )
| | - Qian Wang
- Department of Orthopedics, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhenhai Cui
- Department of Orthopedics, Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Zhenshuang Yue
- Department of Orthopedics, Xiao Shan TCM Hospital, Hangzhou, Zhejiang, China
| | - Zhongqing Hu
- Department of Orthopedics, Xiao Shan TCM Hospital, Hangzhou, Zhejiang, China
| | - Linru Zeng
- Department of Orthopedics, Xiao Shan TCM Hospital, Hangzhou, Zhejiang, China
| | - Dawei Xin
- Department of Orthopedics, Xiao Shan TCM Hospital, Hangzhou, Zhejiang, China
| | - Yanghua Tang
- Department of Orthopedics, Xiao Shan TCM Hospital, Hangzhou, Zhejiang, China
| | - Dezhi Tang
- Department of Orthopedics, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Large TM, Kaufman AM, Frisch HM, Bankieris KR. High-risk ankle fractures in high-risk older patients: to fix or nail? Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04574-3. [PMID: 35947171 DOI: 10.1007/s00402-022-04574-3] [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: 02/21/2022] [Accepted: 07/31/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Optimal treatment of high-risk ankle fractures in older, comorbid patients is unknown. Results of open reduction internal fixation (ORIF) versus tibiotalocalcaneal (TTC) fusion nailing for the treatment of high-risk geriatric ankle fractures were investigated. MATERIALS AND METHODS Results of ORIF versus TTC fusion nailing were evaluated via retrospective case-control cohort study of 60 patients over age 50 with an open ankle fracture or one with at least 50% talar subluxation and at least 1 high-risk comorbidity: diabetes mellitus (DM), peripheral vascular disease, immunosuppression, active smoking, or a BMI > 35. The primary outcome was reoperation rate within 1-year post-surgery. Secondary outcomes include infection, peri-implant fracture, malunion/nonunion, mortality, length of stay, disposition, and hospital acquired complications. RESULTS Mean age was 71 (ORIF) and 68 (TTC). 12/47 (25.5%) ORIF cases were open fractures versus 4/14 (28.6%) with TTC. There were no significant differences between ORIF and TTC in 1-year reoperation rates (17% vs 21.4%), infection rates (12.8% vs 14.3%), or union rates (76.% vs 85.7%), respectively. One TTC patient sustained a peri-implant fracture treated nonoperatively. There were no significant differences in medical risk factors between groups other than a higher rate of DM in the TTC group, 42.6% vs 78.6%, p = 0.02. Incomplete functional outcome data in this challenging patient cohort precluded drawing conclusions. CONCLUSION ORIF and TTC fusion nailing result in comparable and acceptable reoperation, infection, and union rates in treating high-risk ankle fractures in patients over 50 with at least 1 major comorbidity for increased complications; further study is warranted.
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Affiliation(s)
- Thomas M Large
- Department of Orthopaedic Surgery, Emory University, Grady Memorial Hospital, 80 Jesse Hill Jr Dr SE, Atlanta, GA, 30303, USA.
| | - Adam M Kaufman
- Orthopaedic Trauma Services, Mission Hospital, Asheville, NC, USA
| | - Harold M Frisch
- Orthopaedic Trauma Services, Mission Hospital, Asheville, NC, USA
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