There are more things in physical function and pain: a systematic review on physical, mental and social health within the orthopedic fracture population using PROMIS

Novel 3D MRI-based volumetric assessment of rotator cuff musculature demonstrates stronger correlation with preoperative functional status when compared to the Goutallier grading scheme

BACKGROUND

The Goutallier classification (GC) is used to assess fatty atrophy in rotator cuff (RC) tears, yet limitations exist. A battery of 3-dimensional (3D) magnetic resonance imaging (MRI) volumetric scores (VSs) was developed to provide comprehensive characterization of RC pathology. The purposes of this study were to (1) describe the correlation between GC and VSs for supraspinatus changes in RC tears, (2) characterize the chronicity of RC tears using a battery of 12 VS measurements, and (3) compare GC and VSs to determine which method most closely corresponds with preoperative patient-reported outcome measures (PROMs).

METHODS

Preoperative shoulder MRIs were reviewed after arthroscopic RC repair. Preoperative GC stage and Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) scores were collected. The battery of VSs included fat infiltration (FIS), muscle size (MSS), and relative volume contribution (RCS) for each RC muscle. Backward linear regression was performed to compare GC stage with preoperative PROMIS PF and PI to determine which VS measurement most closely correlated with preoperative PROMs.

RESULTS

Eighty-two patients underwent RC repair (mean age 55 ± 8.2 years, 63% male, 68% GC stage ≤1). In evaluation of the supraspinatus, there was a moderate positive correlation between GC and FIS (r = 0.459, P < .001); strong negative correlations were observed between MSS (r = -0.800, P < .001) and RCS (r = -0.745, P < .001) when compared to GC. A negligible linear correlation was observed between GC and preoperative PROMIS PF (r = -0.106, P = .343) and PI (r = -0.071, P = .528). On multivariate analysis, subscapularis MSS (β >0, P = .064) was a positive predictor and subscapularis FIS (β <0, P = .137), teres minor MSS (β <0, P = .141), and FIS (β <0, P = .070) were negative predictors of preoperative PF (r = 0.343, P = .044); in contrast, supraspinatus MSS (β >0, P = .009) and FIS (β >0, P = .073), teres minor FIS (β >0, P = .072), and subscapularis FIS (β >0, P = .065) were positive predictors of preoperative PI (r = 0.410, P = .006).

CONCLUSION

Although the criterion standard in evaluation of RC pathology, GC demonstrated negligible correlation with preoperative functional disability. Alternatively, a battery of 3D VSs showed strong correlation with GC through a quantitative, comprehensive evaluation of the RC unit including several moderate predictors of preoperative functional disability.

Utilization of patient reported outcomes measurement information system in plastic and reconstructive surgery research

BACKGROUND

The patient-reported outcomes measurement information system (PROMIS) was developed by investigators funded by the National Institutes of Health as a standardized means of directly assessing the patients' perspectives across domains. PROMIS domains include physical function, pain, fatigue, emotional distress, and social health. Various studies have reported increased utilization of PROMIS in research articles in specific specialties; however, the extent to which PROMIS has been employed in the field of plastic and reconstructive surgery remains unclear. The goal of the present study was to characterize the prevalence and trends of PROMIS within plastic and reconstructive surgery articles.

METHODS

Literature search was conducted across multiple databases for PROMIS studies within plastic surgery literature. We identified 136 articles and the following data were extracted: author name, journal, impact factor, country of origin, year of publication, publication type, subspecialty, study size, and PROMIS measures used.

RESULTS

In this study, 136 studies met the inclusion criteria. There was an overall increasing trend in the number of PROMIS studies published. The most common subspecialties that used PROMIS measures were general reconstruction (n = 24), hand (n = 9), and burn (n = 5). The most used PROMIS measures were the pain interference (n = 26), pain intensity (n = 15), and depression (n = 13). A total of 24 journals included PROMIS studies with a mean impact factor of 3.73 (SD = 3.2). The most common country of origin was the United States (n = 42).

CONCLUSION

The data demonstrated an increasing use of PROMIS within plastic surgery across a wide variety of subspecialities and study designs. The characterization of these trends allows researchers and clinicians alike to gain a greater understanding of this powerful tool in measuring patient care.

Prevalence, resources, provider insights, and outcomes: a review of patient mental health in orthopaedic trauma

This literature review examines the impact of orthopaedic trauma on patient mental health. It focuses on patient outcomes, available resources, and healthcare provider knowledge and education. Orthopaedic trauma represents a significant physical and psychological burden for patients, often resulting in long-term disability, pain, and functional limitations. Understanding the impact of orthopaedic trauma on patient mental health is crucial for improving patient care, and optimizing recovery and rehabilitation outcomes. In this review, we synthesize the findings of empirical studies over the past decade to explore the current understanding of mental health outcomes in patients with orthopaedic trauma. Through this analysis, we identify gaps in existing research, as well as potential avenues for improving patient care and mental health support for patients with severe orthopaedic injuries. Our review reveals the pressing need for collaboration between healthcare providers, mental health professionals, and social support systems to ensure comprehensive mental care for patients with traumatic orthopaedic injuries.

Resilience Improves Patient-Reported Outcomes After Orthopaedic Trauma

OBJECTIVES

To analyze the relationship between patient resilience and patient-reported outcomes after orthopaedic trauma.

METHODS

DESIGN

Retrospective analysis of prospectively collected data.

SETTING

Single Level 1 Trauma Center.

PATIENT SELECTION CRITERIA

Patients were selected based on completion of the Patient-Reported Outcomes Measurement Information System (PROMIS) and Brief Resilience Scale (BRS) surveys 6 months after undergoing operative fracture fixation following orthopaedic trauma. Patients were excluded if they did not complete all PROMIS and BRS surveys.

OUTCOME MEASURES AND COMPARISONS

Resilience, measured by the BRS, was analyzed for its effect on patient-reported outcomes, measured by PROMIS Global Physical Health, Physical Function, Pain Interference, Global Mental Health, Depression, and Anxiety. Variables collected were demographics (age, gender, race, body mass index), injury severity score, and postoperative complications (nonunion, infection). All variables were analyzed with univariate for effect on all PROMIS scores. Variables with significance were included in multivariate analysis. Patients were then separated into high resilience (BRS >4.3) and low resilience (BRS <3.0) groups for additional analysis.

RESULTS

A total of 99 patients were included in the analysis. Most patients were male (53%) with an average age of 47 years. Postoperative BRS scores significantly correlated with PROMIS Global Physical Health, Pain Interference, Physical Function, Global Mental Health, Depression, and Anxiety ( P ≤ 0.001 for all scores) at 6 months after injury on both univariate and multivariate analyses. The high resilience group had significantly higher PROMIS Global Physical Health, Physical Function, and Global Mental Health scores and significantly lower PROMIS Pain Interference, Depression, and Anxiety scores ( P ≤ 0.001 for all scores).

CONCLUSIONS

Resilience in orthopaedic trauma has a positive association with patient outcomes at 6 months postoperatively. Patients with higher resilience report higher scores in all PROMIS categories regardless of injury severity. Future studies directed at increasing resilience may improve outcomes in patients who experience orthopaedic trauma.

LEVEL OF EVIDENCE

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

Risk of Fracture and Complications After Fixation in Patients With Pre-injury Psychiatric Illness: A Propensity-Matched Cohort Study

OBJECTIVES

The purpose was to describe the frequency of orthopaedic trauma and postsurgical complications associated with psychiatric diagnoses.

METHODS

DESIGN

Query of TriNetx Analytics Network.

SETTING

Participating hospitals.

PATIENT SELECTION CRITERIA

Those ≥18 years old with psychiatric illness and orthopaedic trauma.

OUTCOME MEASURES AND COMPARISONS

Fractures and postoperative complications were described. A 1:1 propensity score matching function was used. Odds ratios compared intercohort complications.

RESULTS

A total of 11,266,415 patients were identified with a psychiatric diagnosis, including bipolar disorder (8.9%), schizophrenia (3.3%), major depression (12.4%), stress-related disorder (9.6%), anxiety disorder (64.5%), borderline personality disorder (1.1%), or antisocial personality (0.2%). Prevalence of 30.2% was found for a fracture and at least 1 psychiatric diagnosis. Antisocial personality disorder had the highest risk ratio relative to people without that mental disorder (relative risk [RR] = 5.09) of having 1 or more associated fracture, followed by depression (RR = 3.03), stress-related disorders (RR = 3.00), anxiety disorders (RR = 2.97), borderline personality disorder (RR = 2.92), bipolar disorder (RR = 2.80), and schizophrenia (RR = 2.69). Patients with at least 1 psychiatric comorbidity had greater risk of pulmonary embolism, superficial and deep surgical site infections, pneumonia, urinary tract infection, deep venous thrombosis, osteonecrosis, and complex regional pain syndrome by 1 month after fixation, when compared with patients without psychiatric disorder. By 1 year, they were also at an increased risk for stroke and myocardial infarction.

CONCLUSIONS

All psychiatric comorbidities were associated with increased RR of fracture and higher odds of complications compared with patients without psychiatric comorbidities. Providers should be aware of preexisting psychiatric diagnoses during treatment of acute injuries because of these risks.

LEVEL OF EVIDENCE

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

Using PROM(I)S to measure health-related quality of life in patients with a bone fracture: An observational cohort study

INTRODUCTION

The incidence of patients with fractures is increasing and so is the impact on health care systems and society. To improve patient care, measurement of disabilities and impaired health experiences after traumatic musculoskeletal injuries are important. Next to objective clinical parameters, PROM(I)S can be used to map health domains important to patients. We aimed to objectify different aspects of (health-related) quality of life in fracture patients, including the ability to participate in social roles and activities using PROMIS among other PROMs.

METHODS

An observational cohort study was performed in which health-related quality of life in fracture patients was measured. Patients aged 18 year and older either treated conservatively or surgically between November 2020 and June 2022 were included. Participants were followed for a maximum of one year and completed the following PROMs: PROMIS-CAT physical function, PROMIS-CAT pain interference, PROMIS-CAT ability to participate in social roles and activities and LEFS or QDASH. We applied a univariate linear mixed model to evaluate significance of improvement.

RESULTS

Seven hundred-forty six patients with a mean age of 54.4 years were included. Mean PROMIS scores were structurally inferior in the lower extremity (LE) fracture group in comparison with the upper extremity (UE) fracture group. For "PROMIS physical function", UE fracture patients performed better and showed physical progression earlier. For "PROMIS pain interference", UE fracture patients experienced fewer limitations, but it took longer to experience improvement in this group. For "PROMIS ability to participate in social roles", significant improvement was only seen in the UE fracture group at one year follow up.

CONCLUSION

Upper -and lower extremity fractures can have a significant impact on physical function and social health. Patients with UE fractures tend to have fewer limitations compared to LE fracture patients. Physical function and pain interference is most impaired shortly after the injury in all fracture patients and show significant changes over time, social health improves less over time. Moment of measurement should be based on type of fracture and can differ between individual patients, but when generic measures and outcomes are desirable, PROMIS questionnaires can potentially be used measurement.

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.

From numbers to meaningful change: Minimal important change by using PROMIS in a cohort of fracture patients

INTRODUCTION

use of the Patient-Reported Outcomes measurement Information System (PROMIS®) is slowly increasing in patients with a fracture. Yet, minimal important change of PROMIS in patients with fractures has been addressed in a very limited number of studies. As the minimal important change (MIC) is important to interpret PROMIS-scores, the goal is to estimate the MIC for PROMIS physical function (PF), PROMIS pain interference (PI) and PROMIS ability to participate in social roles and activities (APSRA) in patients with a fracture. Secondly, the smallest detectable change was determined.

MATERIALS AND METHODS

A longitudinal cohort study on patients ≥ 18 years receiving surgical or non-surgical care for fractures was conducted. Patients completed PROMIS PF V1.1, PROMIS PI V1.1 and PROMIS APSRA V2.0. For follow-up, patients completed three additional anchor questions evaluating patient-reported improvement on a seven point rating scale. The predictive modeling method was used to estimate the MIC value of all three PROMIS questionnaires.

RESULTS

Hundred patients with a mean age of 55.4 ± 12.6 years were included of which sixty (60%) were female. Seventy-two (72%) patients were recovering from a surgical procedure. PROMIS-CAT T-scores of all PROMIS measures showed significant correlations with their anchor questions. The predictive modeling method showed a MIC value of +2.4 (n = 98) for PROMIS PF, -2.9 (n = 96) for PROMIS PI and +3.2 (n = 91) for PROMIS APSRA.

CONCLUSION

By using the anchor based predictive modeling method, PROMIS MIC-values for improvement of respectively +2.4 points on a T-score metric for PROMIS-PF, -2.9 for PROMIS-PI and +3.2 for PROMIS APSRA give the impression of being meaningful to patients. These values can be used in clinical practice for managing patient expectations; to inform on treatment results; and to assess if patients experience significant change. This in order to encourage patient centered care.

Functional outcomes and complications after treatment of distal radius fracture in patients sixty years and over: A systematic review and network meta-analysis

AIM

This network meta-analysis aims to compare functional outcomes and complications between conservative treatment and surgery for distal radius fractures in patients aged 60 years and over.

METHODS

We searched the PubMed, EMBASE, and Web of Science databases for randomized controlled trials (RCTs) assessing the effect of conservative treatment and surgery for distal radius fractures in patients aged 60 years and over. Primary outcomes included grip strength and overall complications. Secondary outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH) scores, Patient-Rated Wrist Evaluation (PRWE) scores, wrist range of motion and forearm rotation, and radiographic assessment. All continuous outcomes were assessed using standardized mean differences (SMDs) with 95% confidence intervals (CIs), and binary outcomes were assessed using odds ratio (OR) with 95% CIs. The surface under the cumulative ranking curve (SUCRA) was used to determine a hierarchy of treatments. Cluster analysis was performed for grouping treatments based on the SUCRA values of primary outcomes.

RESULTS

Fourteen RCTs were included to compare conservative treatment, volar lockedplate (VLP), K-wires fixation, and external-fixation. VLP outperformed conservative treatment for 1-year and minimum 2-year grip strength (SMD; 0.28 [0.07 to 0.48] and 0.27 [0.02 to 0.53], respectively). VLP yielded the optimal grip strength at 1-year and minimum 2-year follow-up (SUCRA; 89.8% and 86.7%, respectively). In a subgroup analysis of patients aged 60 to 80 years old, VLP outperformed conservative treatment in DASH and PRWE scores (SMD, 0.33 [0.10, 0.56] and 0.23 [0.01, 0.45], respectively). In addition, VLP had the fewest complications (SUCRA = 84.3%). Cluster analysis suggested that VLP and K-wire fixation were more effective treatment groups.

CONCLUSION

Evidence to date demonstrates that VLP provides measurable benefits in grip strength and fewer complications to those 60 years of age and over, and that benefit is not reflected in current practice guidelines. There is a subgroup of patients where K-wire fixation outcomes are similar to those of VLP; defining this subgroup may yield substantial societal benefits.

Early postoperative step count and walking time have greater impact on lower limb fracture outcomes than load-bearing metrics

INTRODUCTION

Weight-bearing protocols for rehabilitation of lower extremity fractures are the gold standard despite not being data-driven. Additionally, current protocols are focused on the amount of weight placed on the limb, negating other patient rehabilitation behaviors that may contribute to outcomes. Wearable sensors can provide insight into multiple aspects of patient behavior through longitudinal monitoring. This study aimed to understand the relationship between patient behavior and rehabilitation outcomes using wearable sensors to identify the metrics of patient rehabilitation behavior that have a positive effect on 1-year rehabilitation outcomes.

METHODS

Prospective observational study on 42 closed ankle and tibial fracture patients. Rehabilitation behavior was monitored continuously between 2 and 6 weeks post-operative using a gait monitoring insole. Metrics describing patient rehabilitation behavior, including step count, walking time, cadence, and body weight per step, were compared between patient groups of excellent and average rehabilitation outcomes, as defined by the 1-year Patient Reported Outcome Measure Physical Function t-score (PROMIS PF). A Fuzzy Inference System (FIS) was used to rank metrics based on their impact on patient outcomes. Additionally, correlation coefficients were calculated between patient characteristics and principal components of the behavior metrics.

RESULTS

Twenty-two patients had complete insole data sets, and 17 of which had 1-year PROMIS PF scores (33.7 ± 14.5 years of age, 13 female, 9 in Excellent group, 8 in Average group). Step count had the highest impact ranking (0.817), while body weight per step had a low impact ranking (0.309). No significant correlation coefficients were found between patient or injury characteristics and behavior principal components. General patient rehabilitation behavior was described through cadence (mean of 71.0 steps/min) and step count (logarithmic distribution with only ten days exceeding 5,000 steps/day).

CONCLUSION

Step count and walking time had a greater impact on 1-year outcomes than body weight per step or cadence. The results suggest that increased activity may improve 1-year outcomes for patients with lower extremity fractures. The use of more accessible devices, such as smart watches with step counters combined with patient reported outcome measures may provide more valuable insights into patient rehabilitation behaviors and their effect on rehabilitation outcomes.