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Kibble KM, Cunningham BP, Rivard RL, Vang S, Nguyen MP. Ankle fractures: High implant cost is not associated with better patient reported outcomes. Injury 2023; 54:110963. [PMID: 37542790 DOI: 10.1016/j.injury.2023.110963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 07/12/2023] [Accepted: 07/25/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Ankle fractures comprise 9% of all fractures and are among the most common fractures requiring operative management. Open reduction and internal fixation (ORIF) with plates and screws is the gold standard for the treatment of unstable, displaced ankle fractures. While performing ORIF, orthopaedic surgeons may choose from several fixation methods including locking versus nonlocking plating and whether to use screws or suture buttons for syndesmotic injuries. Nearly all orthopaedic surgeons treat ankle fractures but most are unfamiliar with implant costs. No study to date has correlated the cost of ankle fracture fixation with health status as perceived by patients through patient reported outcomes (PROs). The purpose of this study was to determine whether there is a relationship between increasing implant cost and PROs after a rotational ankle fracture. METHODS All ankle fractures treated with open reduction internal fixation (ORIF) at a level I academic trauma center from January 2018 to December 2022 were identified. Inclusion criteria included all rotational ankle fractures with a minimum 6-month follow-up and completed 6-month PRO. Patients were excluded for age <18, polytrauma and open fracture. Variables assessed included demographics, fracture classifications, Foot and Ankle Ability Measure-Activities of Daily Living (FAAM-ADL) score, implant type, and implant cost. RESULTS There was a statistically significant difference in cost between fracture types (p < 0.0001) with trimalleolar fractures being the most expensive. The mean FAAM-ADL score was lowest for trimalleolar fractures at 78.9, 95% CI [75.5, 82.3]. A diagnosis of osteoporosis/osteopenia was associated with a decrease in cost of $233.3, 95% CI [-411.8, -54.8]. There was no relationship between syndesmotic fixation and implant cost, $102.6, 95% CI [-74.9, 280.0]. There was no correlation between implant cost and FAAM-ADL score at 6 months (p = 0.48). CONCLUSIONS The utilization of higher cost ankle fixation does not correlate with better FAAM-ADL scores. Orthopaedic surgeons may choose less expensive implants to improve the value of ankle fixation without impacting patient reported outcomes.
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Affiliation(s)
- Kendra M Kibble
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, Park Nicollet Methodist Hospital, St. Louis Park, MN, United States of America; Department of Orthopaedic Surgery, TRIA Orthopaedic Institute, Bloomington, MN, United States of America
| | - Rachael L Rivard
- Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Sandy Vang
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America
| | - Mai P Nguyen
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, MN, United States of America; Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN, United States of America.
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Guedes S, Sousa-Pinto B, Torres J. Radiological outcomes of bimalleolar fractures: Are timing of surgery and type of reconstruction important? Orthop Traumatol Surg Res 2022; 108:103314. [PMID: 35568298 DOI: 10.1016/j.otsr.2022.103314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 09/06/2021] [Accepted: 01/31/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The goal of open reduction and internal fixation (ORIF) of bimalleolar ankle fractures is to reconstitute ankle anatomy. The most commonly used radiological parameters to assess adequacy of reduction are talocrural angle (TCA), medial clear space (MCS), tibiofibular overlap (TFO) and tibiofibular clear space (TFCS). There is little research about the radiological outcomes of surgery in bimalleolar fractures. We aimed at assessing the adequacy of ORIF and the factors involved in anatomical restoration (specifically time to surgery), postoperatively and at follow-up. METHODS TCA, MCS, TFO and TFCS were measured in preoperative and postoperative radiographs of 107 bimalleolar ankle fractures and in 83 follow-up radiographs, accounting for a total of 297 radiographs and 1182 measurements. Preoperative radiographs were categorized according to Danis-Weber classification. For all included cases, basic demographic data, dates of radiographs and surgery, and type of fixation used were acquired. Variables associated with postoperative and follow-up total anatomical reconstitution (i.e., when the four assessed radiological parameters were normalized), normalization of each radiological parameter, and improvement in the number of normalized radiological parameters were identified through univariable Cox regression analysis. RESULTS In our sample, 23.8% of the ankle fractures in postoperative radiographs and 28% in follow-up radiographs achieved a complete anatomical restoration. Type C fractures (hazard ratio [HR]=0.1, 95% confidence interval [CI]=0.02-0.7, P=0.021) were associated with lower chances of total anatomical reconstitution. The use of reconstruction plates (HR=0.1, 95% CI=0.03-0.7, P=0.014) and one third tubular plates (HR=0.2, 95% CI=0.03-0.8, P=0.026) decreased the chances of improving the number of normalized radiological parameters. Waiting days until surgery impaired total anatomical reconstitution (HR=0.8, 95% CI=0.6-0.9, P=0.012) and also reduced the chances of improving the number of normalized radiological parameters (HR=0.9, 95% CI=0.9-1.0, P=0.045). CONCLUSION The radiological results for the treatment of bimalleolar fractures are time sensitive, and surgery should thus be performed as soon as possible, using adequate fixation materials, in order to achieve a better restoration of ankle anatomy. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- Sara Guedes
- Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Bernardo Sousa-Pinto
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal; MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Torres
- Faculty of Medicine, University of Porto, Porto, Portugal; Orthopaedics and Traumatology Department, Centro Hospitalar de São João, E.P.E., Porto, Portugal
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Abstract
BACKGROUND Several studies have reported on potential negative predictive factors of functional outcomes after ankle fracture fixation. However, there is minimal patient-reported data on long-term outcomes. This study aimed to evaluate potential risk factors leading to a poor patient-reported functional outcome at 2 and 5 years following ankle fracture fixation. METHODS We conducted a prospective cohort study over a 5-year period on patients undergoing open reduction and internal fixation for unstable ankle fractures. Patient demographics, medical comorbidities, fracture pattern, and fixation quality were recorded and analyzed. Patients were followed up at 2 and 5 years. Data collected include the Olerud-Molander Ankle Score (OMAS), Lower Extremity Functional Scale (LEFS), ongoing issues, and the need for further intervention. A P value <.05 was considered statistically significant. RESULTS Out of 180 patients, follow-up data were available for 82 (46%) patients at 2 years and 94 (52%) patients at 5 years. At 2 years, age ≥60 years was a predictor of worse LEFS, while a body mass index ≥30 was a predictor of worse OMAS. Severely deformed ankle at presentation showed worse OMAS and LEFS score. However, these predictive factors were not significant at 5 years. An anatomically reduced ankle fracture fixation was more likely to have a better functional outcome at the 2- and 5-year follow-ups. A reduction in OMAS at 2 years was predictive of possible ongoing issues following surgery, which in turn increased the odds of worsening OMAS at 5 years. CONCLUSION Achieving adequate fracture reduction during fixation is crucial for better ankle functional recovery postinjury. In this cohort, we found that patients who undergo ankle fracture fixation will have an ongoing negative impact on their functional and physical capacity at both 2 and 5 years postoperatively. Appropriate patient counseling is necessary to prepare them for the expected functional outcomes. LEVEL OF EVIDENCE Level II, prognostic.
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Affiliation(s)
- Han Hong Chong
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Pranav Mishra
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Paul Rai
- University Hospitals of Leicester NHS Trust, Leicester, UK
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Elmajee M, Gabr A, Aljawadi A, Strang M, Khan S, Munuswamy S, Pillai A, Sprott D. Treatment of fragility ankle fractures using hindfoot nail, systemic review. J Orthop 2020; 22:559-564. [PMID: 33208992 DOI: 10.1016/j.jor.2020.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 11/01/2020] [Indexed: 11/19/2022] Open
Abstract
With an aging population, the prevalence of fragility ankle fractures is rising. The surgical management of these injuries is challenging and associated with high rates of complications. An extensive literature review (inception of data until September 2019) was undertaken to locate previous studies that have addressed the same topic. Seven studies met the inclusion criteria. The post-operative Olerud and Molander scores were comparable/slightly lower than pre-injury scores. Bony union was achieved in 90.3%-100% of cases. Hindfoot nails, when used to treat fragility ankle fractures, can facilitate early rehabilitation and restoration of function among elderly osteoporotic patients.
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Affiliation(s)
- Mohammed Elmajee
- ST4 Spine Department, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, B31 2AP, UK
| | - Abdullah Gabr
- Salford Royal NHS Foundation Trust, Manchester, M6 8HD, UK
| | - Ahmed Aljawadi
- Trauma and Orthopaedics, Wythenshawe Hospital, Manchester, M23 9LT, UK
| | - Matthew Strang
- Trauma and Orthopaedics, North Manchester General Hospital, Manchester, M8 5RB, UK
| | - Shoaib Khan
- ST4 Trauma and Orthopaedics, Warrington Hospital, Warrington, WA5 1QG, UK
| | | | - Anand Pillai
- Trauma and Orthopaedics, Wythenshawe Hospital, Manchester, M23 9LT, UK
| | - Dominic Sprott
- Salford Royal NHS Foundation Trust, Manchester, M6 8HD, UK
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Keene DJ, Costa ML, Tutton E, Hopewell S, Barber VS, Dutton SJ, Redmond AC, Willett K, Lamb SE. Progressive functional exercise versus best practice advice for adults aged 50 years or over after ankle fracture: protocol for a pilot randomised controlled trial in the UK - the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study. BMJ Open 2019; 9:e030877. [PMID: 31678945 PMCID: PMC6830709 DOI: 10.1136/bmjopen-2019-030877] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Ankle fractures result in significant morbidity in adults, with prognosis worsening with increasing age. Previous trials have not found evidence supporting supervised physiotherapy sessions, but these studies have not focused on older adults or tailored the exercise interventions to the complex needs of this patient group. The Ankle Fracture Treatment: Enhancing Rehabilitation study is a pilot randomised controlled trial to assess feasibility of a later definitive trial comparing best-practice advice with progressive functional exercise for adults aged 50 years and over after ankle fracture.The main objectives are to assess: (i) patient engagement with the trial, measured by the participation rate of those eligible; (ii) establish whether the interventions are acceptable to participants and therapists, assessed by intervention adherence levels, participant interviews and a therapist focus group; (iii) participant retention in the trial, measured by the proportion of participants providing outcome data at 6 months; (iv) acceptability of measuring outcomes at 3 and 6 month follow-up. METHODS AND ANALYSIS A multicentre pilot randomised controlled trial with an embedded qualitative study. At least 48 patients aged 50 years and over with an ankle fracture requiring surgical management, or non-operative management by immobilisation for at least 4 weeks, will be recruited from a minimum of three National Health Service hospitals in the UK. Participants will be allocated 1:1 via a central web-based randomisation system to: (i) best-practice advice (one session of face-to-face self-management advice delivered by a physiotherapist and up to two optional additional sessions) or (ii) progressive functional exercise (up to six sessions of individual face-to-face physiotherapy). An embedded qualitative study will include one-to-one interviews with up to 20 participants and a therapist focus group. ETHICS AND DISSEMINATION Hampshire B Research Ethics Committee (18/SC/0281) gave approval on 2nd July 2018. TRIAL REGISTRATION NUMBER ISRCTN16612336.
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Affiliation(s)
- David J Keene
- 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
| | - Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Vicki S Barber
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Anthony C Redmond
- Leeds Institute of Rheumatology and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Keith Willett
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
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Noto-Bell L, Vogel BN, Senn DE. Effects of Post-Isometric Relaxation on Ankle Plantarflexion and Timed Flutter Kick in Pediatric Competitive Swimmers. J Osteopath Med 2019; 119:569-577. [PMID: 31449303 DOI: 10.7556/jaoa.2019.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Context Ankle plantarflexion is thought to play an important role in swimming performance; thus, coaches and swimmers often seek ways to increase range of motion (ROM) in the ankles. Objective To assess whether osteopathic manipulative treatment (OMT), specifically applying the muscle energy technique (MET) principle of post-isometric relaxation, increases ankle plantarflexion and therefore improves swimming performance. Methods Healthy young male and female competitive swimmers were randomly assigned to either a control, sham, or MET group. At baseline, ankle plantarflexion was measured via goniometer, and a 25-yard flutter kick swim with a kickboard was timed. After receiving the ascribed intervention, the ankle plantarflexion measurements and timed flutter kick were repeated. The initial plantarflexion measurement was retrospectively used to determine the presence of somatic dysfunction, by way of restricted motion, with reference to expected normal ranges based on age and gender. Paired t tests were used to analyze the pre- to postintervention changes in ROM and flutter kick speed within each group. Results Fifty-five swimmers (32 girls and 23 boys; mean age, 12 years) participated in this study. Sixteen participants were in the control group, 17 in the sham group, and 22 in the MET intervention group. Among participants with restricted ROM, those in the MET group showed a statistically significant increase in ankle plantarflexion for the left and right ankles (P=.041 and P=.011, respectively). There was no significant difference in ROM of the control or sham groups. For flutter kick speed, there was no significant pre- to postintervention difference in any group. Conclusion Although a single application of MET, using post-isometric relaxation, on participants with restricted ROM immediately significantly increased swimmers' ROM for bilateral ankle plantarflexion, it did not immediately improve their swimming performance.
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Ankle fractures: Getting it right first time. Foot (Edinb) 2018; 34:48-52. [PMID: 29287221 DOI: 10.1016/j.foot.2017.11.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/22/2017] [Accepted: 11/24/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Ankle fractures are common injuries presenting to trauma departments and ankle open reduction and internal fixation (ORIF2) is one of the first procedures targeted in early orthopaedic training. Failure to address the fracture pattern with the appropriate surgical technique and hardware may lead to early failure, resulting in revision procedures or premature degenerative change. Patients undergoing revision ORIF are known to be at much greater risk of complications and many of these secondary procedures may be preventable. METHOD A retrospective analysis of all patients attending our unit for ankle ORIF over a two year period was undertaken. Patients were identified from our Bluespier database and a review of x-rays was undertaken. All patients undergoing re-operation within eight weeks of the primary procedure were studied. The cause of primary failure was established and potential contributing patient and surgical factors were recorded. RESULTS 236 patients undergoing ankle ORIF were identified. 13 patients (5.5%) returned to theatre for a secondary procedure within eight weeks. Within this group, seven (54%) patients returned for treatment of a neglected or under treated syndesmotic injury, three (23%) for complete failure of fixation, two (15%) with wound problems and one (8%) for medial malleolus mal-reduction. Of the patient group, five (39%) were known type 2 diabetics. Consultants performed two (15%) procedures, supervised registrars five (39%) and unsupervised registrars six (46%) operations. CONCLUSION Errors are being made at all levels of training in applying basic principles such as restoring fibula length and screening the syndesmosis intra-operatively. Appropriate placement and selection of hardware is not always being deployed in osteopenic bone resulting in premature failure of fixation and fracture patterns are not being fully appreciated. Patients are undergoing preventable secondary procedures in the operative treatment of ankle fractures.
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Keene DJ, Mistry D, Nam J, Tutton E, Handley R, Morgan L, Roberts E, Gray B, Briggs A, Lall R, Chesser TJ, Pallister I, Lamb SE, Willett K. The Ankle Injury Management (AIM) trial: a pragmatic, multicentre, equivalence randomised controlled trial and economic evaluation comparing close contact casting with open surgical reduction and internal fixation in the treatment of unstable ankle fractures in patients aged over 60 years. Health Technol Assess 2018; 20:1-158. [PMID: 27735787 DOI: 10.3310/hta20750] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Close contact casting (CCC) may offer an alternative to open reduction and internal fixation (ORIF) surgery for unstable ankle fractures in older adults. OBJECTIVES We aimed to (1) determine if CCC for unstable ankle fractures in adults aged over 60 years resulted in equivalent clinical outcome compared with ORIF, (2) estimate cost-effectiveness to the NHS and society and (3) explore participant experiences. DESIGN A pragmatic, multicentre, equivalence randomised controlled trial incorporating health economic evaluation and qualitative study. SETTING Trauma and orthopaedic departments of 24 NHS hospitals. PARTICIPANTS Adults aged over 60 years with unstable ankle fracture. Those with serious limb or concomitant disease or substantial cognitive impairment were excluded. INTERVENTIONS CCC was conducted under anaesthetic in theatre by surgeons who attended training. ORIF was as per local practice. Participants were randomised in 1 : 1 allocation via remote telephone randomisation. Sequence generation was by random block size, with stratification by centre and fracture pattern. MAIN OUTCOME MEASURES Follow-up was conducted at 6 weeks and, by blinded outcome assessors, at 6 months after randomisation. The primary outcome was the Olerud-Molander Ankle Score (OMAS), a patient-reported assessment of ankle function, at 6 months. Secondary outcomes were quality of life (as measured by the European Quality of Life 5-Dimensions, Short Form questionnaire-12 items), pain, ankle range of motion and mobility (as measured by the timed up and go test), patient satisfaction and radiological measures. In accordance with equivalence trial US Food and Drug Administration guidance, primary analysis was per protocol. RESULTS We recruited 620 participants, 95 from the pilot and 525 from the multicentre phase, between June 2010 and November 2013. The majority of participants, 579 out of 620 (93%), received the allocated treatment; 52 out of 275 (19%) who received CCC later converted to ORIF because of loss of fracture reduction. CCC resulted in equivalent ankle function compared with ORIF at 6 months {OMAS 64.5 points [standard deviation (SD) 22.4 points] vs. OMAS 66.0 points (SD 21.1 points); mean difference -0.65 points, 95% confidence interval (CI) -3.98 to 2.68 points; standardised effect size -0.04, 95% CI -0.23 to 0.15}. There were no differences in quality of life, ankle motion, pain, mobility and patient satisfaction. Infection and/or wound problems were more common with ORIF [29/298 (10%) vs. 4/275 (1%)], as were additional operating theatre procedures [17/298 (6%) vs. 3/275 (1%)]. Malunion was more common with CCC [38/249 (15%) vs. 8/274 (3%); p < 0.001]. Malleolar non-union was lower in the ORIF group [lateral: 0/274 (0%) vs. 8/248 (3%); p = 0.002; medial: 3/274 (1%) vs. 18/248 (7%); p < 0.001]. During the trial, CCC showed modest mean cost savings [NHS mean difference -£644 (95% CI -£1390 to £76); society mean difference -£683 (95% CI -£1851 to £536)]. Estimates showed some imprecision. Incremental quality-adjusted life-years following CCC were no different from ORIF. Over common willingness-to-pay thresholds, the probability that CCC was cost-effective was very high (> 95% from NHS perspective and 85% from societal perspective). Experiences of treatments were similar; both groups endured the impact of fracture, uncertainty regarding future function and the need for further interventions. LIMITATIONS Assessors at 6 weeks were necessarily not blinded. The learning-effect analysis was inconclusive because of limited CCC applications per surgeon. CONCLUSIONS CCC provides a clinically equivalent outcome to ORIF at reduced cost to the NHS and to society at 6 months. FUTURE WORK Longer-term follow-up of trial participants is under way to address concerns over potential later complications or additional procedures and their potential to impact on ankle function. Further study of the patient factors, radiological fracture patterns and outcomes, treatment responses and prognosis would also contribute to understanding the treatment pathway. TRIAL REGISTRATION Current Controlled Trials ISRCTN04180738. FUNDING The National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 75. See the NIHR Journals Library website for further project information. This report was developed in association with the National Institute for Health Research Oxford Biomedical Research Unit funding scheme. The pilot phase was funded by the AO Research Foundation.
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Affiliation(s)
- David J Keene
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Julian Nam
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Elizabeth Tutton
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Royal College of Nursing Research Institute, University of Warwick, Coventry, UK
| | - Robert Handley
- Oxford Trauma Service, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lesley Morgan
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Emma Roberts
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Bridget Gray
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Briggs
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Tim Js Chesser
- Department of Orthopaedic Surgery, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Ian Pallister
- Department of Orthopaedic Surgery, Morriston Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Sarah E Lamb
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Keith Willett
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Şahin E, Kalem M. Utility of Third-Week Postoperative Radiographs in the Management of Ankle Fractures. Foot Ankle Spec 2018; 11:1938640017751188. [PMID: 29310461 DOI: 10.1177/1938640017751188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the costs and efficacy of radiographs taken in the third week after fixation of bimalleolar and trimalleolar fractures. PATIENTS AND METHOD A retrospective evaluation was made of patients who underwent surgical fixation because of bimalleolar and trimalleolar fractures between January 1, 2008, and October 1, 2013. Patient demographics (age, gender, body mass index), fracture type, follow-up periods, and fixation methods were recorded, and the radiographs taken on postoperative day 1, at 3 weeks, 6 weeks, and the final follow-up were examined by 2 orthopedists. Measurements were taken of the medial clear space (MCS ≤ 4 mm), the tibiofibular clear space (TFCS < 5 mm), and the talocrural angle (TCA = 83° ± 4°) on the mortise radiograph and of the overlap between the tibial tubercle and fibula (TFO > 10 mm) on the anteroposterior radiograph; residual step (mm) was measured on the lateral radiograph. RESULTS A total of 263 patients were examined, and of these, 112 were included for evaluation. In the measurements of postoperative day 1, third week, and sixth week and the final radiographs, no statistically significant difference was determined in the MCS, TFCS, TCA, TFO, and residual step values. Because the cost of a series of 3-way ankle radiographs in Turkey is US$3.81 per patient, the cost of the control series for the 112 patients in this study was US$ 427.3. CONCLUSIONS In patients treated surgically for bimalleolar and trimalleolar fractures, the radiographs taken in the third week rarely resulted in a change of patient management. Therefore, it simply constitutes an additional cost for the patient or the hospital. LEVELS OF EVIDENCE Level III: Retrospective Cohort study.
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Affiliation(s)
- Ercan Şahin
- Faculty of Medicine, Department of Orthopedics and Traumatology, Bülent Ecevit University, Zonguldak, Turkey (ES)
- Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey (MK)
| | - Mahmut Kalem
- Faculty of Medicine, Department of Orthopedics and Traumatology, Bülent Ecevit University, Zonguldak, Turkey (ES)
- Faculty of Medicine, Department of Orthopedics and Traumatology, Ankara University, Ankara, Turkey (MK)
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Patients’ perceptions of repair, rehabilitation and recovery after major orthopaedic trauma: a qualitative study. Physiotherapy 2017; 103:322-329. [DOI: 10.1016/j.physio.2015.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 11/02/2015] [Indexed: 11/22/2022]
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Costa ML, Jameson SS, Reed MR. Do large pragmatic randomised trials change clinical practice?: assessing the impact of the Distal Radius Acute Fracture Fixation Trial (DRAFFT). Bone Joint J 2016; 98-B:410-3. [PMID: 26920968 DOI: 10.1302/0301-620x.98b3.36730] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Our aim, using English Hospital Episode Statistics data before during and after the Distal Radius Acute Fracture Fixation Trial (DRAFFT), was to assess whether the results of the trial affected clinical practice. PATIENTS AND METHODS Data were grouped into six month intervals from July 2005 to December 2014. All patient episodes in the National Health Service involving emergency surgery for an isolated distal radial fracture were included. RESULTS Clinical practice in England had not changed in the five years before DRAFFT: 75% of patients were treated with plate fixation versus 12% with Kirschner (K)-wires. After the publication of the trial, the proportion of patients having K-wire fixation rose to 42% with a concurrent fall in the proportion having fixation with a plate to 48%. The proportion of 'other' procedures stayed the same. TAKE HOME MESSAGE It appears that surgeons in the United Kingdom do change their practice in response to large, pragmatic, multicentre clinical trials in musculoskeletal trauma.
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Affiliation(s)
- M L Costa
- The Kadoorie Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - S S Jameson
- South Tees Hospitals NHS Foundation Trust, Marton Road, Middlesbrough, TS4 3BW, UK
| | - M R Reed
- Newcastle University and Northumbria Healthcare, Northumbria, NE63 9JJ, UK
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12
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Abstract
Hip fracture is a common injury associated with high mortality, long-term disability and huge socio-economic burden. Yet there has been relatively little research into best treatment, and evidence that has been generated has often been criticised for its poor quality. Here, we discuss the advances made towards overcoming these criticisms and the future directions for hip fracture research: how co-ordinating existing national infrastructures and use of now established clinical research networks will likely go some way towards overcoming the practical and financial challenges of conducting large trials. We highlight the importance of large collaborative pragmatic trials to inform decision/policy makers and the progress made towards reaching a consensus on a core outcome set to facilitate data pooling for evidence synthesis and meta-analysis. These advances and future directions are a priority in order to establish the high-quality evidence base required for this important group of patients.
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Affiliation(s)
- M A Fernandez
- University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Rd, Coventry, CV2 2DX, UK
| | - X L Griffin
- University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
| | - M L Costa
- University of Oxford, Headley Way, Oxford, OX3 9DU, UK
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