The Short Musculoskeletal Function Assessment: a study of the reliability, construct validity and responsiveness in patients sustaining trauma

Is patient-reported outcome after treatment of unstable pelvic ring injuries related to pelvic symmetry? A prospective study

PURPOSE

To determine the relation between pelvic symmetry, as measured by the cross-measurement technique, and patient-reported outcome measures (PROMs) in terms of functional status and health-related quality of life.

METHODS

In this prospective cohort study, X and Y measurements were taken according to the cross-measurement technique on AP radiographs of patients who were treated for an unstable pelvic ring injury in a level-1 trauma center. Patients completed PROMs at the time of admission (recalled pre-injury score) and one year following their injury, reporting their functional status with the Short Musculoskeletal Function Assessment (SMFA-NL), specifically the lower extremity dysfunction (LED), problems with daily activities (PDA) and mental and emotional problems (MEP) subscales, and quality of life with EuroQol-5D (EQ-5D). Subgroup analyses were also performed. PROMs were used to analyze the relation between pelvic symmetry and patient-reported outcome, using Spearman's Rank correlation coefficients.

RESULTS

A total of 130 patients (mean age 58 (SD18) years) with an unstable pelvic ring injury were included, of which 95 (73%) sustained type-B injuries and 35 (27%) type-C injuries. Sixty-three (49%) patients were treated operatively. The median pelvic symmetry ratio was 1.01 (IQR: 0.05). Weak or no correlations were found between the pelvic symmetry scores and the outcome measurements (Spearman's correlation coefficients: LED r = 0.09; PDA r = 0.11; MEP r=-0.02; and EQ-5D r=-0.08). Subgroup analyses revealed no correlations.

CONCLUSIONS

No significant relation was found between pelvic symmetry, measured radiologically, and functional status and health-related quality of life, one year following an unstable pelvic ring injury.

Socioeconomic factors associated with poor patient-reported outcomes of 17,478 patients after a distal radial fracture

This study aimed to investigate the association of socioeconomic factors, country of birth and comorbidities with poor patient-reported outcome 1 year after a distal radial fracture. The patient population was obtained from the Swedish Fracture Register. In the study, 17,468 patients 18 years or older were included. Poor outcome was the dependent variable in a multivariate logistic regression analysis. The factors with the strongest association with poor outcome were country of birth outside the European Union (odds ratio (OR) = 2.28; 95% CI = 1.91-2.73), high-energy trauma mechanism (OR = 1.76; 95% CI = 1.46-2.12), a history of anxiety or depression (OR = 1.46; 95% CI = 1.26-1.70), and a Charlson comorbidity index ≥3 (OR = 1.51; 95% CI = 1.17-1.94). Alleviating the effects of these factors could potentially decrease the proportion of patients with a disability after a distal radial fracture.Level of evidence: III.

Virtual Reality for Subacute Pain After Orthopedic Traumatic Musculoskeletal Injuries: A Mixed Methods Pilot Study

OBJECTIVES

Acute orthopedic traumatic musculoskeletal injuries are prevalent, costly, and often lead to persistent pain and functional limitations. Psychological risk factors (eg, pain catastrophizing and anxiety) exacerbate these outcomes but are often overlooked in acute orthopedic care. Addressing gaps in current treatment approaches, this mixed-methods pilot study explored the use of a therapeutic virtual reality (VR; RelieVRx ), integrating principles of mindfulness and cognitive-behavioral therapy, for pain self-management at home following orthopedic injury.

METHODS

We enrolled 10 adults with acute orthopedic injuries and elevated pain catastrophizing or pain anxiety from Level 1 Trauma Clinics within the Mass General Brigham health care system. Participants completed daily RelieVRx sessions at home for 8 weeks, which included pain education, relaxation, mindfulness, games, and dynamic breathing biofeedback. Primary outcomes were a priori feasibility, appropriateness, acceptability, satisfaction, and safety. Secondary outcomes were pre-post measures of pain, physical function, sleep, depression, and hypothesized mechanisms (pain self-efficacy, mindfulness, and coping).

RESULTS

The VR and study procedures met or exceeded all benchmarks. We observed preliminary improvements in pain, physical functioning, sleep, depression, and mechanisms. Qualitative exit interviews confirmed high satisfaction with RelieVRx and yielded recommendations for promoting VR-based trials with orthopedic patients.

DISCUSSION

The results support a larger randomized clinical trial of RelieVRx versus a sham placebo control to replicate the findings and explore mechanisms. There is potential for self-guided VR to promote evidence-based pain management strategies and address the critical mental health care gap for patients following acute orthopedic injuries.

Enhancing the Evaluation of Physical Function Following Orthopaedic Trauma Care: Comparison of PROMIS Computerized Adaptive Testing and Short Musculoskeletal Function Assessment

OBJECTIVES

To compare measurement properties of Patient-Reported Outcomes Measurement Information System (PROMIS) (physical function [PF] and pain interference [PI]) computerized adaptive testing to traditional Short Musculoskeletal Function Assessment (SMFA) (dysfunction index [DI] and bother index [BI]). To explore factors associated with PROMIS scores.

METHODS

DESIGN

Cross-sectional study.

SETTING

Level I Trauma Center.

PATIENT SELECTION CRITERIA

Isolated upper/lower extremity fracture patients were recruited from the orthopaedic trauma outpatient clinic (October 1, 2021 to January 1, 2023).

OUTCOME MEASURES

Correlations (Pearson), reliability (standard error [SE] [T score]), efficiency (amount of information per item [1 - SE2/Nitems]), and floor/ceiling effects were assessed. An r > 0.7 represented high correlation, and SE ≤ 2.2 represented sufficient reliability. Factors associated with worse PROMIS scores were also identified.

RESULTS

In total, 202 patients completed PROMs at median 98 days follow-up. Correlations between PROMIS-PF and SMFA-DI, and PROMIS-PI and SMFA-BI were -0.84 and 0.65. Reliability was very high for both instruments (mean SE 2.0 [PROMIS-PF], SE 2.1 [PROMIS-PI], and SE 1.2 [SMFA-DI], SE 1.8 [SMFA-BI]). Relative efficiency for PROMIS-PF versus SMFA-DI, and PROMIS-PI versus SMFA-BI was 7.8 (SD 2.5) and 4.1 (SD 1.7), respectively. Neither PROMIS nor SMFA exhibited floor/ceiling effects. In the multivariable regression analyses, elevated levels of depression, among other factors, showed an (independent) association with worse PROMIS-PF and PROMIS-PI scores.

CONCLUSIONS

PROMIS-PF and PROMIS-PI CATs showed a (high and moderate) correlation with SMFA and hence measure a comparable construct of physical function and discomfort. As computerized adaptive tests are much more efficient to administer, they present a compelling alternative to SMFA for evaluating impact of fracture treatment. The relation between symptoms of depression and PROMIS scores emphasizes the importance of psychosocial aspects of health in orthopaedic trauma patients.

LEVEL OF EVIDENCE

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

Patients with more complex ankle fractures are associated with poorer patient-reported outcome: an observational study of 11,733 patients from the Swedish Fracture Register

BACKGROUND AND PURPOSE

Patient-reported outcome measures (PROMs) following ankle fractures, including all fracture types, have not been reported. It is therefore unclear whether fracture morphology correlates with outcome. We aimed to analyze PROMs in patients with an ankle fracture in relation to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) fracture classification using population-based register data from the Swedish Fracture Register (SFR).

METHODS

All patients aged ≥ 18 years with an ankle fracture (AO/OTA 44A1-C3) registered in the SFR between 2012 and 2019 were retrieved from the register. Patients with completed PROM questionnaires (Short Musculoskeletal Function Assessment and EuroQol-Visual Analogue Scale) on both day 0 (pre-trauma) and 1-year post-trauma were included. The difference in PROMs between day 0 and 1 year was calculated for each patient (delta value) and mean delta values were calculated at group level, based on the AO/OTA fracture classification.

RESULTS

11,733 patients with 11,751 fractures with complete PROMs were included. According to the AO/OTA classification, 21% were A fractures, 67% were B fractures and 12% were C fractures. All groups of patients, regardless of fracture class (A1-C3), displayed an impairment in PROMs after 1 year compared with day 0. Type C fractures displayed a larger impairment in PROMs at group level than type B, which in turn had a greater impairment than type A. The same pattern was seen in groups 3, 2, and 1 for A and B fractures.

CONCLUSION

We found that the AO/OTA classification is prognostic, where more complex fractures were associated with poorer PROMs.

Associations of musculoskeletal dysfunction, time to brake, and patient reported outcomes following lower extremity trauma

INTRODUCTION

Inability to drive a motor vehicle due to lower extremity injury is a major inconvenience. Timing of safe return to driving has not been much studied. Objective measurements such as time to brake (TTB) have been proposed; however, utility and concordance of functional outcome measurements have not been previously evaluated. The purpose of this project is to measure these parameters and to assess for associations with ability to safely return to driving, improving the ability of clinicians to assess for measurements of driving readiness without specifically measuring TTB.

METHODS

A prospective, cohort study of 232 patients with complex lower extremity injuries to the pelvis, acetabulum, hip, femur, knee, tibia, ankle, and foot was performed. Time to brake (TTB) was measured once weightbearing was allowed. Function was assessed by the Musculoskeletal Function Assessment (MFA) questionnaire, and pain, mobility, and physical functions, via patient reported outcome measurement information system (PROMIS) surveys.

RESULTS

Patients with longer TTB had significantly elevated MFA scores indicating increased musculoskeletal dysfunction post-injury. As the MFA score increased by 1 point, TTB increased by 0.013 s (p<0.001). PROMIS metrics were also significantly associated with patients experiencing more pain and worse mobility as TTB increased.

DISCUSSION

Many patients continue to exhibit musculoskeletal dysfunction several months post-treatment for complex lower extremity injuries. Patients with better PROMIS metrics and MFA scores, and shorter TTB are more appropriate to return to driving. Surgeons may be better informed about safe driving ability by considering these measurements.

LEVEL OF EVIDENCE

II.

Functional Outcomes After High-Energy Lisfranc Injuries

BACKGROUND

Midfoot fractures and dislocations are infrequent and functional outcomes following Lisfranc injuries have not been well described. The purpose of this project was to explore functional outcomes following operative treatment of high-energy Lisfranc injury.

METHODS

A retrospective cohort of 46 adults with tarsometatarsal fractures and dislocations treated at a single Level 1 trauma center were reviewed. Demographic, medical, social, and injury features of these patients and their injuries were recorded. Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA) surveys were collected after mean 8.7 years' follow-up. Multiple linear regression was performed to identify independent predictors of outcome.

RESULTS

Forty-six patients with mean age 39.7 years completed functional outcome surveys. Mean SMFA scores were 29.3 (dysfunction) and 32.6 (bothersome). Mean FFI scores were 43.1 (pain), 43.0 (disability), and 21.7 (activity), with a mean total score of 35.9. FFI pain scores were worse than published values for fractures of the plafond (33, P = .04), distal tibia (33, P = .04), and talus (25.3, P = .001). Lisfranc injury patients reported worse disability (43.0 vs 29, P = .008) and total FFI scores (35.9 vs 26, P = .02) compared with distal tibia fractures. Tobacco smoking was an independent predictor of worse FFI (P < .05) and SMFA emotion and bothersome scores (P < .04). Chronic renal disease was a predictor of worse FFI disability (P = .04) and SMFA subcategory scores (P < .04). Male sex was associated with better scores in all SMFA categories (P < .04). Age, obesity, or open injury did not affect functional outcomes.

CONCLUSION

Patients reported worse pain by FFI after Lisfranc injury compared to other injuries about the foot and ankle. Tobacco smoking, female sex, and preexisting chronic renal disease are predictive of worse functional outcome scores, warranting further study in a larger sample, as well as counseling of long-term consequences of this injury.

LEVEL OF EVIDENCE

Level IV, retrospective, prognostic.

Assessing independence in mobility activities in trauma care: Validity and reliability of the Activity Independence Measure-Trauma (AIM-T) in humanitarian settings

The importance of measuring outcomes after injury beyond mortality and morbidity is increasingly recognized, though underreported in humanitarian settings. To address shortcomings of existing outcome measures in humanitarian settings, the Activity Independence Measure-Trauma (AIM-T) was developed, and is structured in three subscales (i.e., core, lower limb, and upper limb). This study aimed to assess the AIM-T construct validity (structural validity and hypothesis testing) and reliability (internal consistency, inter-rater reliability and measurement error) in four humanitarian settings (Burundi, Iraq, Cameroon and Central African Republic). Patients with acute injury (n = 195) were assessed using the AIM-T, the Barthel Index (BI), and two pain scores. Structural validity was assessed through confirmatory factor analysis. Hypotheses were tested regarding correlations with BI and pain scores using Pearson correlation coefficient (PCC) and differences in AIM-T scores between patients' subgroups, using standardized effect size Cohen's d (d). Internal consistency was assessed with Cronbach's alpha (α). AIM-T was reassessed by a second rater in 77 participants to test inter-rater reliability using intraclass correlation coefficient (ICC). The results showed that the AIM-T structure in three subscales had an acceptable fit. The AIM-T showed an inverse weak to moderate correlation with both pain scores (PCC<0.7, p≤0.05), positive strong correlation with BI (PCC≥0.7, p≤0.05), and differed between all subgroups (d≥0.5, p≤0.05). The inter-rater reliability in the (sub)scales was good to excellent (ICC 0.86-0.91) and the three subscales' internal consistency was adequate (α≥0.7). In conclusion, this study supports the AIM-T validity in measuring independence in mobility activities and its reliability in humanitarian settings, as well as it informs on its interpretability. Thus, the AIM-T could be a valuable measure to assess outcomes after injury in humanitarian settings.

Lower limb post-traumatic osteomyelitis: a systematic review of clinical outcomes

PURPOSE

The aim of this study was to examine the patient-reported outcomes of patients presenting with post-traumatic osteomyelitis (PTOM) of the lower limb over the past 15 years. This period was chosen to reflect modern treatment principles and increased centralisation of care.

METHODS

An electronic literature search of the relevant databases (PubMed, Ovid Medline, Embase, and the Cochrane library) was conducted to identify studies published between January 2006 and July 2021 reporting series of greater than 10 patients with PTOM of the tibia or femur at the site of a previous fracture. Studies reporting septic non-union were excluded.

RESULTS

Sixteen eligible studies were identified and included in the final report. Remission of infection was achieved in 93.2% of cases (range 70-100%), whilst amputation was reported in 1-7% of cases. A variety of patient-reported outcome measures were utilised including the lower extremity functional scale, short musculoskeletal functional assessment, Enneking score, and EQ-5D-3L. Limb-specific functional outcomes returned to levels similar to that of the general population although poorer outcomes were noted in specific cohorts including those with complex anatomic disease and active medical comorbidities.

CONCLUSION

Infection following fracture fixation remains a difficult problem to treat. Regardless, using modern treatments and techniques patients can have comparable functional outcomes to that of the general population. High-quality studies are required to advance our knowledge into which types of treatments offer a benefit and how to further improve outcomes.

Illicit drug and alcohol use and measures of musculoskeletal function and mental health in orthopaedic trauma patients

Objectives

The objective of this study was to describe the relationship between positive toxicology screens and measures of preinjury mental health and physical function in an orthopaedic trauma population.

Design

This was a cross-sectional study.

Setting

Urban Level 1 trauma center.

Patients

A total of 125 trauma patients gave written consent for this study.

Main Outcome Measurements

Questionnaires such as, Patient Health Questionnaire-9, General Anxiety Disorder-7, PCL-5, and Short Musculoskeletal Function Assessment, were used to survey patients after surgical intervention.

Results

Patient Health Questionnaire-9 (P = 0.05) and PCL-5 (P = 0.04) were not found to have significant differences between positive and negative toxicology screens. Both General Anxiety Disorder-7 (P = 0.004) and Short Musculoskeletal Function Assessment function (P = 0.006) were significantly higher in patients with positive toxicology screens.

Conclusions

Positive toxicology seems to be associated with preinjury anxiety. Patient reported preinjury function was not adversely affected by the presence of illicit substances or alcohol, nor were levels of post-traumatic stress disorder and depression found to be higher in patients with positive toxicology screens.

Level of Evidence

Level IV Cross-Sectional Study.

Monitoring independence in daily life activities after trauma in humanitarian settings: Item reduction and assessment of content validity of the Activity Independence Measure-Trauma (AIM-T)

A standardized set of measures to assess functioning after trauma in humanitarian settings has been called for. The Activity Independence Measure for Trauma (AIM-T) is a clinician-rated measure of independence in 20 daily activities among patients after trauma. Designed in Afghanistan, it has since been used in other contexts. Before recommending the AIM-T for wider use, its measurement properties required confirmation. This study aims at item reduction followed by content validity assessment of the AIM-T. Using a two-step revision process, first, routinely collected data from 635 patients at five facilities managing patients after trauma in Haiti, Burundi, Yemen, and Iraq were used for item reduction. This was performed by analyzing inter-item redundancy and distribution of the first version of the AIM-T (AIM-T1) item scores, resulting in a shortened version (AIM-T2). Second, content validity of the AIM-T2 was assessed by item content validity indices (I-CVI, 0-1) based on structured interviews with 23 health care professionals and 60 patients in Haiti, Burundi, and Iraq. Through the analyses, nine pairs of redundant items (r≥0.90) were identified in the AIM-T1, leading to the removal of nine items, and resulting in AIM-T2. All remaining items were judged highly relevant, appropriate, clear, feasible and representative by most of participants (I-CVI>0.5). Ten items with I-CVI 0.5-0.85 were revised to improve their cultural relevance or appropriateness and one item was added, resulting in the AIM-T3. In conclusion, the proposed 12-item AIM-T3 is overall relevant, clear, and representative of independence in daily activity after trauma and it includes items appropriate and feasible to be observed by clinicians across different humanitarian settings. While some additional measurement properties remain to be evaluated, the present version already has the potential to serve as a routine measure to assess patients after trauma in humanitarian settings.

The effect of age on resilience of health-related quality of life among polytrauma patients: a cross-sectional multicenter study

Purpose

The aim of this study was to determine the impact of age on patient-reported health-related quality of life (HRQoL) and the capacity to show resilience—i.e., the ability to adapt to stressful adverse events—after sustaining a polytrauma.

Methods

A cross-sectional multicenter cohort was conducted between 2013 and 2016 that included surviving polytrauma patients (ISS ≥ 16). HRQoL was obtained by the Short Musculoskeletal Function assessment and EuroQol (SMFA and EQ-5D-5L). The effect of age on HRQoL was tested with linear regression analysis. Next, the individual scores were compared with age- and sex-matched normative data to determine whether they showed resilience. Multivariate binary logistic regression was used to assess the effect of age on reaching the normative threshold of the surveys, correcting for several confounders.

Results

A total of 363 patients responded (57%). Overall, patients had a mean EQ-5D-5L score of 0.73. With higher age, scores on the SMFA subscales “upper extremity dysfunction,” “lower extremity dysfunction” and “daily activities” significantly dropped. Only 42% of patients were classified as being resilient, based on the EQ-5D-5L score. Patients aged 60–69 showed the highest resilience (56%), and those aged 80 + showed the lowest resilience (0%).

Conclusion

Sustaining a polytrauma leads to a serious decline in HRQoL. Aging is associated with a decline in the physical components of HRQoL. No clear relationship with age was seen on the non-physical components of quality of life. Octogenarians, and to a lesser extent septuagenarians and tricenarians, showed to be very vulnerable groups, with low rates of resilience after surviving a polytrauma.

The effects of pelvic ring injuries on quality of life, physical, and mental health: results of a 2-year prospective cohort study

Purpose

Pelvic ring injuries are known to affect the patients’ daily life in terms of physical functioning and quality of life (QoL). Still, prospective studies on the patient’s perception over the first 2 years of rehabilitation are lacking. Therefore, patients cannot be properly informed about whether or when they will return to their pre-existing level of physical functioning and QoL.

Methods

A prospective longitudinal cohort study was performed over a 4-year period including all consecutive patients above 18 years who sustained a pelvic ring injury in a level 1 trauma center. Validated patient-reported outcome measures (PROMs) were used to assess physical functioning (SMFA) and QoL (EQ-5D) at baseline (recalled pre-injury score), 6 weeks, 3 months, 6 months, 1 year and 2 years after the injury. It was assessed whether patients had fully recovered by comparing follow-up scores to baseline PROMs. Binary logistic regression analysis was used to identify independent predictors for patients who did not fully recover. Most experienced difficulties at 3 months and 1 year were identified by analyzing the highest reported scores on individual items of the SMFA.

Results

A total of 297 patients with a pelvic ring injury were identified of which 189 were eligible for follow-up and 154 (82%) responded. Median SMFA function score at 3 months, 1 and 2 years was 70, 78 and 88, respectively, compared to 96 out of 100 before the injury. Median SMFA bother score was 67, 79 and 88, respectively. Median EQ-5D score at 3 months, 1 and 2 years was 0.61, 0.81 and 0.85, respectively, compared to 1 (maximum achievable) before the injury. After 1 and 2 years of follow-up, 61% and 75% of the patients fully “recovered” in physical functioning and 52% and 71% fully recovered in terms of QoL. Female gender and high-energy trauma were independent predictors for not fully recovering after 1 year. After 3 months of follow-up, 54% of patients reported severe difficulties with recreational activities, whereas after 1 year, most experienced difficulties (31% of patients) concerned heavy house or yard work. Moreover, after 3 months and 1 year, 44% and 27% of patients reported feeling physically disabled.

Conclusion

Pelvic ring injuries have a large impact on the patients’ daily life in the first 2 years of rehabilitation. Directly after the injury, physical functioning and QoL decrease strongly but then gradually improve over a 2-year period with about 75% of patients fully recovering. Female gender and high-energy trauma are shown to be independent predictors for not fully recovering. After 3 months, patients experience difficulties with both the physical and mental effects of the injury which continue to be present after 1 year.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01893-3.

Are Sarcopenia and Myosteatosis in Elderly Patients with Pelvic Ring Injury Related to Mortality, Physical Functioning and Quality of Life?

The purpose of this study was to evaluate the prevalence of sarcopenia and/or myosteatosis in elderly patients with pelvic ring injuries and their influence on mortality, patient-perceived physical functioning and quality of life (QoL). A multicenter retrospective cohort study was conducted including elderly patients aged ≥ 65 treated for a pelvic ring injury. Cross-sectional computed tomography (CT) muscle measurements were obtained to determine the presence of sarcopenia and/or myosteatosis. Kaplan–Meier analysis was used for survival analysis, and Cox proportional hazards regression analysis was used to determine risk factors for mortality. Patient-reported outcome measures for physical functioning (SMFA) and QoL (EQ-5D) were used. Multivariable linear regression analyses were used to determine the effect of sarcopenia and myosteatosis on patient-perceived physical functioning and QoL. Data to determine sarcopenia and myosteatosis were available for 199 patients, with a mean follow-up of 2.4 ± 2.2 years: 66 patients (33%) were diagnosed with sarcopenia and 65 (32%) with myosteatosis, while 30 of them (15%) had both. Mortality rates in patients at 1 and 3 years without sarcopenia and myosteatosis were 13% and 21%, compared to 11% and 36% in patients with sarcopenia, 17% and 31% in patients with myosteatosis and 27% and 43% in patients with both. Higher age at the time of injury and a higher Charlson Comorbidity Index (CCI) were independent risk factors for mortality. Patient-reported mental and emotional problems were significantly increased in patients with sarcopenia.

Measurement properties of Patient-Reported Outcome Measures in patients with a tibial shaft fracture; validation study alongside the multicenter TRAVEL study

The aim of this study was to evaluate the measurement properties of the Short Musculoskeletal Function Assessment (SMFA) and Lower Extremity Functional Scale (LEFS) in patients who sustained a tibial shaft fracture, by comparing them with the scores of a general health-related quality of life instrument scale (i.e., EuroQoL-5D). Data of 136 patients participating in a multicenter randomized controlled trial comparing incisions for intramedullary nail entry in adults with a tibial shaft fracture were used. Patients completed the SMFA, LEFS, EQ-5D and an anchor question at 2 and 6 weeks, and at 3, 6 and 12 months. Reliability (internal consistency), construct validity, responsiveness (longitudinal validity), floor and ceiling effects, minimal important change (MIC), and smallest detectable change (SDC) were determined. The SMFA and LEFS (sub)scales showed adequate internal consistency (0.84<α<0.94). Construct and longitudinal validity were also adequate (correctly predicted hypotheses between 83%-100%). Floor effects were not present. Ceiling effects were present at 12 months for the SMFA lower extremity dysfunction and bother subscales (22% and 19%, respectively) and the LEFS (19%). MICs could not be determined with the available data. The SDC was 13.84 points for the SMFA and 38.74 points for the LEFS. This study confirms that the SMFA and LEFS are reliable, valid, and responsive instruments for monitoring functional limitation in patients after sustaining a tibia shaft fracture during at least the first six months post-injury. An anchor-based MIC for the SMFA remains to be determined.

Patient function continues to improve over the first five years following tibial plateau fracture managed by open reduction and internal fixation

Aims

Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients’ long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques.

Methods

In total, 102 patients who sustained a displaced tibial plateau fracture and underwent operative repair by one of three orthopaedic traumatologists at a large, academic medical centre and had a minimum of five-year follow-up were identified. Breakdown of patients by Schatzker classification is as follows: two (1.9%) Schatzker I, 54 (50.9%) Schatzker II, two (1.9%) Schatzker III, 13 (12.3%) Schatzker IV, nine (8.5%) Schatzker V, and 26 (24.5%) Schatzker VI. Follow-up data obtained included: Visual Analogue Scale (VAS) or Numeric Rating Scale (NRS) pain scores, Short Musculoskeletal Functional Assessment (SMFA), and knee range of movement (ROM). Data at latest follow-up were then compared to 12-month data using a paired t-test.

Results

Patient-reported functional outcomes as assessed by overall SMFA were statistically significantly improved at five years (p < 0.001) compared with one-year data from the same patients. Patients additionally reported an improvement in the Standardized Mobility Index (p < 0.001), Standardized Emotional Index (p < 0.001), as well as improvement in Standardized Bothersome Index (p = 0.003) between the first year and latest follow-up. Patient-reported pain and knee ROM were similar at five years to their one-year follow-up. In total, 15 of the patients had undergone subsequent orthopaedic surgery for their knees at the time of most recent follow-up. Of note, only one patient had undergone knee arthroplasty following plateau fixation related to post-traumatic osteoarthritis (OA).

Conclusion

Knee pain following tibial plateau fracture stabilizes at one year. However, PROs continue to improve beyond one year following tibial plateau fracture, at least in a statistical sense, if not also clinically. Patients displayed statistical improvement across nearly all SMFA index scores at their minimum five-year follow-up compared with their one-year follow-up. Cite this article: Bone Joint J 2020;102-B(5):632–637.

Minimal important change in physical function in trauma patients: a study using the short musculoskeletal function assessment

Purpose

The Short Musculoskeletal Function Assessment (SMFA) questionnaire can be used to evaluate physical functioning in patients with traumatic injuries. It is not known what change in score reflects a meaningful change to patients. The aim was to determine minimal important change (MIC) values of the subscales (0–100) of the Dutch SMFA-NL in a sample of patients with a broad range of injuries.

Methods

Patients between 18 and 65 years of age completed the SMFA-NL and the Global Rating of Effect (GRE) questions at 6-week and 12-month post-injury. Anchor-based MIC values were calculated using univariable logistic regression analyses.

Results

A total of 225 patients were included (response rate 67%). The MIC value of the Upper Extremity Dysfunction (UED) subscale was 8 points, with a misclassification rate of 43%. The Lower Extremity Dysfunction subscale MIC value was 14 points, with a misclassification rate of 29%. The MIC value of the Problems with Daily Activities subscale was 25 points, with a misclassification rate of 33%. The MIC value of the Mental and Emotional Problems (MEP) subscale was 7 points, with a misclassification rate 37%.

Conclusion

MIC values of the SMFA-NL were determined. The MIC values aid interpreting whether a change in physical functioning can be considered clinically important. Due to the considerable rates of misclassification, the MIC values of the UED and MEP subscales should be used with caution.