The socioeconomic impact of orthopaedic trauma: A systematic review and meta-analysis

Spanish Translation and Validation of the LIMB-Q: A Patient-reported Outcome Measure for Lower Extremity Trauma

Background

Hispanic patients represent a notable portion of the adult trauma population in the United States, yet their participation in studies collecting patient-reported outcome measure data following lower extremity injuries is limited. This study aims to translate and linguistically validate the LIMB-Q in Spanish for use in this population.

Methods

We followed guidelines from the World Health Organization and the Professional Society for Health Economics and Outcomes Research to conduct this translation. Two independent translators conducted a blind forward translation of the LIMB-Q from English to Spanish, followed by a back translation to confirm the conceptual preservation of each LIMB-Q item. Five patients then participated in cognitive debriefing interviews to collect feedback on comprehension, interpretation, and language.

Results

Translators occasionally differed in the vocabulary they used in their forward translations. All conflicts were resolved by discussion and selection of the option with the greatest colloquial recognition and medical relevance. Back translation identified 25 differences, including items that did not fully convey semantics (n = 12), were missing parts (n = 9), or were listed out of order (n = 4). All items with inadequate semantics were revised to ensure full retention of their original meaning. Five patients participated in cognitive debriefing interviews, resulting in 5 revisions for diction and syntax.

Conclusions

The Spanish (US) translation of LIMB-Q is now available. This instrument may be used in both clinical and research settings to better understand the quality of life and satisfaction of Hispanic patients after traumatic lower extremity injury.

Nanostructures in Orthopedics: Advancing Diagnostics, Targeted Therapies, and Tissue Regeneration

Nanotechnology, delving into the realm of nanometric structures, stands as a transformative force in orthopedics, reshaping diagnostics, and numerous regenerative interventions. Commencing with diagnostics, this scientific discipline empowers accurate analyses of various diseases and implant stability, heralding an era of unparalleled precision. Acting as carriers for medications, nanomaterials introduce novel therapeutic possibilities, propelling the field towards more targeted and effective treatments. In arthroplasty, nanostructural modifications to implant surfaces not only enhance mechanical properties but also promote superior osteointegration and durability. Simultaneously, nanotechnology propels tissue regeneration, with nanostructured dressings emerging as pivotal elements in accelerating wound healing. As we navigate the frontiers of nanotechnology, ongoing research illuminates promising avenues for further advancements, assuring a future where orthopedic practices are not only personalized but also highly efficient, promising a captivating journey through groundbreaking innovations and tailored patient care.

May the Symptomatic Subtalar Joint Be Conservatively Treated With Intra-Articular Hyaluronic Acid Injections After a Calcaneus Fracture?

BACKGROUND

Subtalar pain following intra-articular calcaneus fractures may be associated with disability, pain, and a negative impact on the quality of life. Salvage procedures as subtalar fusion are associated with further consequences as stiffness, altered ankle biomechanics, and adjacent articular overloading with degenerative changes. The objective of the present study is to evaluate the short-term effects of viscosupplementation with intra-articular hyaluronic acid (HA) on function and pain, in patients with painful subtalar joint after calcaneus fracture.

METHODS

We searched for patients who underwent osteosynthesis of intra-articular calcaneus fracture between January 2011 and July 2015 and were diagnosed during the follow-up with pain and subtalar osteoarthritis. Between January and December of 2018, 13 patients (50 ± 10 years) accepted to participate in this study and received intra-articular HA injections. Three consecutive doses of 20 mg of HA were administered within a week interval, through anterolateral injections into the subtalar joint. We prospectively evaluated the function using the ankle/hindfoot American Orthopaedic Foot & Ankle Society score (AOFAS) and level of pain using the visual analog scale (VAS) before the intervention and 4, 12, and 24 weeks after the first injection.

RESULTS

Hindfoot function improved with an increase of AOFAS from 55 ± 19 before the intervention to 88 ± 20 at the 24th week (P = .001). Similarly, we observed relief of pain during the 24 weeks following intra-articular hyaluronic acid injection, with a decrease in VAS from 8.3 ± 1.3 before treatment to 2.2 ± 3.0 at the 24th week (P = .001).

CONCLUSION

For patients experiencing pain and dysfunction with subtalar osteoarthritis after intra-articular calcaneus fracture, viscosupplementation with intra-articular HA may be associated with improvement in function and pain in the short term. Furthermore, patients with higher grades of osteoarthritis may have limited benefit in pain relief and function improvement.

LEVEL OF EVIDENCE

IV, Case series.

Resuming work roles after injury in a low-income context: Multiple factors influencing the return to work outcomes

BACKGROUND

Return to work (RTW) is an important outcome indicator for the effectiveness of rehabilitation services, and the functional status and overall recovery among individuals who have experienced injury. Despite the rising incidence of traumatic injury among economically productive citizens in Ethiopia, there is a paucity of evidence about the RTW status of injury survivors. This study examined factors associated with RTW success and determinants of time to RTW after injury in Ethiopia.

METHODS

An institution-based cross-sectional study was conducted to collect data retrospectively one year after patients arrived at the study setting due to traumatic injuries. Medical records of all patients who visited the emergency room of a large public hospital in Addis Ababa were reviewed. Data were collected from survivors of traumatic injury, interviewed by telephone one year post-injury. Multivariable logistic regression and survival analysis were carried out to explore factors.

RESULTS

Of the 251 participants, 75% were young adults (age

CONCLUSION

The study uncovers factors crucial to RTW planning and interventions, and provides insights to minimize barriers, foster a smooth transition to employment, and optimize survivors' lives after injury.

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MESH Headings

• Humans
• Male
• Female
• Adult
• Return to Work/statistics & numerical data
• Ethiopia/epidemiology
• Wounds and Injuries/epidemiology
• Wounds and Injuries/rehabilitation
• Cross-Sectional Studies
• Young Adult
• Middle Aged
• Poverty
• Adolescent
• Retrospective Studies

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Grants

• University of Gondar

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Affiliation(s)

Ansha Nega Ahmed School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
Marcia Finlayson School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
Adamu Addissie School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
Ayalew Zewdie Addis Ababa Burn, Emergency and Trauma Hospital, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
Rosemary Lysaght School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada

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Development of a vocational rehabilitation intervention to support return-to-work and well-being following major trauma: a person-based approach

OBJECTIVES

Major trauma centres (MTCs) save lives but rehabilitation to support return-to-work (RTW) is lacking. This paper describes development of a vocational rehabilitation intervention (the ROWTATE intervention) to support RTW following traumatic injury.

DESIGN

Sequential and iterative person-based approach in four stages-Stage 1: review of evidence about the efficacy and mechanisms of RTW interventions; Stage 2: interviews (n=38) and focus groups (n=25) with trauma survivors and service providers in five UK MTCs to identify the issues, and challenges faced postinjury; Stage 3: codesign workshops (n=43) with trauma stakeholders in MTCs to conceptually test and identify intervention delivery barriers/enablers; Stage 4: meetings (n=7) with intervention development working group (IDWG) to: (1) generate guiding principles, (2) identify key intervention features (process, components, mechanisms) to address unmet rehabilitation needs; (3) generate a logic model and programme theory to illustrate how the intervention works; and (4) develop a training package to support delivery.

RESULTS

Trauma survivors described unmet needs relating to early advice about RTW; psychological support; pain management; hidden disabilities (eg, fatigue); estimating recovery; and community, amputee and musculoskeletal rehabilitation. Mechanisms of effective interventions identified in the review included early intervention, colocation, employer engagement, case coordination and work accommodations. Intervention features identified by IDWG members (n=13) from stages 1 and 2 were use of stepped-care approaches by occupational therapists (OTs) and clinical psychologists (CPs), OT/CP formulation for complex cases, assessment of mental health problems, individually tailored rehabilitation including vocational goal setting, cross-sector coordination/communication, employer engagement, phased RTW, education/advice for family/employers, exploration of work alternatives, ongoing review of physical and mental health needs, work stability monitoring. Conceptual testing ratified the logic model. Geography and long waiting lists were identified as potential delivery barriers.

CONCLUSIONS

Real-world testing of the intervention is underway in a randomised controlled trial.

The economic impact of open lower limb fractures in the Netherlands: a cost-of-illness study

PURPOSE

To estimate the one-year sum of direct costs related to open lower limb fracture treatment in an academic setting in the Netherlands. The secondary objective was to estimate the impact of deep infection and nonunion on one-year total direct costs.

METHODS

A multi-center, retrospective cost analysis of open lower limb fractures treated in an academic setting in the Netherlands, between 1 January 2017 and 31 December 2018, was conducted. The costing methodology was based on patient level aggregation using a bottom-up approach. A multiple linear regression model was used to predict the total costs based on Fracture-related-infections, multitrauma, intensive care unit (ICU) admission, Gustilo-Anderson grade and nonunion.

RESULTS

Overall, 70 fractures were included for analysis, the majority Gustilo-Anderson grade III fractures (57%). Median (IQR) one-year hospital costs were €31,258 (20,812-58,217). Costs were primarily attributed to the length of hospital stay (58%) and surgical procedures (30%). The median length of stay was 16 days, with an increase to 50 days in Fracture-related infections. Subsequent costs (46,075 [25,891-74,938] vs. 15,244 [8970-30,173]; p = 0.002), and total hospital costs (90,862 [52,868-125,004] vs. 29,297 [21,784-40,677]; p < 0.001) were significantly higher for infected cases. It was found that Fracture-related infection, multitrauma, and Gustilo-Anderson grade IIIA-C fractures were significant predictors of increased costs.

CONCLUSION

In treatment of open lower limb fractures, deep infection, higher Gustilo-Anderson classification, and multitrauma significantly increase direct hospital costs. Considering the impact of infection on morbidity and total healthcare costs, future research should focus on preventing Fracture-related infections.

Factors that Promote and Protect Against Financial Toxicity after Orthopaedic Trauma: A Qualitative Study

INTRODUCTION

Financial toxicity is highly prevalent in patients after an orthopaedic injury. However, little is known regarding the conditions that promote and protect against this financial distress. Our objective was to understand the factors that cause and protect against financial toxicity after a lower extremity fracture.

METHODS

A qualitative study was conducted using semi-structured interviews with 20 patients 3 months after surgical treatment of a lower extremity fracture. The interviews were audio-recorded, transcribed verbatim, and analyzed using thematic analysis to identify themes and subthemes. Data saturation occurred after 15 interviews. The percentage of patients who described the identified themes are reported.

RESULTS

A total of 20 patients (median age, 44 years [IQR, 38 to 58]; 60% male) participated in the study. The most common injury was a distal tibia fracture (n = 8; 40%). Eleven themes that promoted financial distress were identified, the most common being work effects (n = 14; 70%) and emotional health (n = 12; 60%). Over half (n = 11; 55%) of participants described financial toxicity arising from an inability to access social welfare programs. Seven themes that protected against financial distress were also identified, including insurance (n = 17; 85%) and support from friends and family (n = 17; 85%). Over half (n = 13; 65%) of the participants discussed the support they received from their healthcare team, which encompassed expectation setting and connections to financial aid and other services. Employment protection and workplace flexibility were additional protective themes.

CONCLUSION

This qualitative study of orthopaedic trauma patients found work and emotional health-related factors to be primary drivers of financial toxicity after injury. Insurance and support from friends and family were the most frequently reported protective factors. Many participants described the pivotal role of the healthcare team in establishing recovery expectations and facilitating access to social welfare programs.

Duration of sick leave after operated and non-operated distal radial fracture: a Finnish cohort study of 19,995 patients

The purpose of this study was to investigate whether operative treatment for distal radial fracture reduces the length of sick leave and the costs of treatment. We identified 19,995 patients from a registry who received a state sick leave allowance between 2010 and 2019 owing to distal radial fractures. We compared these patients to a registry of operations and identified 4346 operated patients. Operated patients had a mean sick leave of 75 days, whereas non-operated patients had a sick leave of 63 days. In the operated group, the cost of sick leave was €7505 (UK£6419; US$8070), which was 34% higher than in the non-operated group. Over the analysed period, the duration of sick leave decreased. Although several studies have shown better early functional outcomes after operation, this does not seem to shorten sick leave.Level of evidence: III.

Peer-reviewed publications in orthopaedic surgery from lower income countries: A comparative analysis

INTRODUCTION

Musculoskeletal (MSK) disease is a substantial global burden, especially in lower income countries. However, limited research has been published on MSK health by scholars from these countries. We aimed to study the distribution of authorships, including trends in peer-reviewed orthopaedic publications based on each author's affiliated institution's country income status.

METHODS

Based on a bibliometric search, 119 orthopaedic-related journals were identified using the Journal Citation Reports database. Details of all scientific articles published in these journals between 2012 and 2021 were used to study trends and association between each of the author's affiliated institution's country income status, using the World Bank Classification.

RESULTS

Of the 133,718 unique articles, 87.6% had at least one author affiliation from a high-income country (HIC), 7.0% from an upper-middle income country (UMIC), 5.2% from a lower-middle income country (LMIC), and 0.2% from a low-income country (LIC). Overall, these articles were cited 1,825,365 times, with 92.5% of citations from HIC-affiliated authors and < 0.1% from LIC-affiliated authors. Over the 10-year study period, HIC-affiliated articles demonstrated the largest increase in the number of publications (9107-14,619), compared to UMIC-affiliated (495-1214), LMIC-affiliated (406-874), and LIC-affiliated articles (4-28).

CONCLUSIONS

There are large and persistent disparities in orthopaedic research publications based on the country income status of the author's affiliated institution, especially in the higher impact orthopaedic journals. Efforts should be made to increase opportunities for scholars from LICs and LMICs to publish their research in high-impact orthopaedic journals.

Assessment of Health-Related Quality of Life in Patients With Traumatic Fractures Following Thoracolumbar Fusion: Short-Term Results

INTRODUCTION

Thoracolumbar vertebral fractures (TVFs) constitute frequent injuries with specific therapeutic challenges and remarkable implications for affected individuals. The aim of this study is to investigate the alteration of overall health-related quality of life (HRQoL) in patients with traumatic TVFs undergoing thoracolumbar fusion surgery.

MATERIALS AND METHODS

A total of 72 patients with single-level traumatic thoracic or lumbar vertebral fractures (AO type A3 or A4) were enrolled in this prospective cohort study. All patients were subjected to thoracolumbar spinal fusion surgery with or without posterior decompression, being followed up for a two-year period. Clinical assessment was conducted via the implementation of the Visual Analog Scale (VAS) and 36-item Short-Form Survey Questionnaire (SF-36) for the evaluation of pain and HRQoL, respectively. Patient assessment was performed in determined postoperative follow-up intervals.

RESULTS

Recorded values of assessed outcome measures demonstrated a statistically significant improvement during the entire two-year follow-up period. This improvement was more pronounced throughout the first three to six postoperative months, subsequently demonstrating a plateau. No statistically significant correlation between age, SF-36, and VAS was found, with the exception of the bodily pain index, the improvement of which was observed to be positively correlated with age. Transient causalgia and cerebrospinal fluid leak were recorded in 5% of evaluated individuals.

CONCLUSIONS

Thoracolumbar fusion constitutes a safe and efficient option for the surgical management of single-level traumatic vertebral fractures. Nevertheless, rehabilitation is a lasting procedure that may last over six months until final amelioration is observed. Clinical improvement may be more pronounced in older patients, potentially due to different expectations.

The Relation Between Osteoporosis and Bone Fractures and Health-Related Quality of Life in Post-menopausal Saudi Women in the Jazan Region: A Cross-Sectional Study

INTRODUCTION

Osteoporosis is a significant health concern, often leading to fragility fractures and severely impacting the quality of life in post-menopausal women. Studies evaluating the effects of osteoporosis and resultant fractures on health-related quality of life (HRQoL) in Saudi women are lacking. This study aimed to assess the relationship between osteoporosis and fracture and physical, psychological, social, and environmental HRQoL domains in post-menopausal Saudi women.

METHODS

In this cross-sectional study conducted in Jazan, Saudi Arabia, 158 post-menopausal Saudi women completed HRQoL surveys using the validated Arabic WHOQOL-BREF questionnaire. Data on socioeconomics, comorbidities, and fracture history were gathered. Descriptive statistics delineated sample characteristics. Analysis of variance (ANOVA) and post-hoc tests identified differences in HRQoL across socioeconomic and clinical categories. Multivariate regression analyses determined factors independently related to HRQoL.

RESULTS

Of 158 women surveyed, 39% had a history of osteoporotic fracture. Foot (35%), hand (31%), and vertebral (10%) fractures were the most frequent. Women over 70 had significantly lower physical HRQoL than those aged 45-55 (p<0.001). Unemployed and lower-income women showed poorer HRQoL across domains (p<0.01). Vertebral and hand fractures were negatively related to physical and psychological health (p<0.05). Chronic diseases like hypertension and rheumatoid arthritis reduced HRQoL (p<0.01). In regression analyses, older age, vertebral fracture, physical inactivity, long-term hormone therapy, and unemployment emerged as determinants of poorer HRQoL (p<0.05).

CONCLUSION

Osteoporosis and resultant fragility fractures, especially in vertebral and hand bones, led to substantial impairments in physical, social, psychological, and environmental HRQoL in Saudi women. Modifiable risk factors like physical inactivity and long-term hormone use also affected HRQoL. Targeted screening and multidomain interventions for disadvantaged women with osteoporosis are warranted to improve functioning and quality of life.

Work Productivity Loss After Minimally Displaced Complete Lateral Compression Pelvis Fractures

OBJECTIVE

To quantify work impairment and economic losses due to lost employment, lost work time (absenteeism), and lost productivity while working (presenteeism) after a lateral compression pelvic ring fracture. Secondarily, productivity loss of patients treated with surgical fixation versus nonoperative management was compared.

METHODS

DESIGN

Secondary analysis of a prospective, multicenter trial.

SETTING

Two level I academic trauma centers.

PATIENT SELECTION CRITERIA

Adult patients with a lateral compression pelvic fracture (OTA/AO 61-B1/B2) with a complete posterior pelvic ring fracture and less than 10 mm of initial displacement. Excluded were patients who were not working or non-ambulatory before their pelvis fracture or who had a concomitant spinal cord injury.

OUTCOME MEASURES AND COMPARISONS

Work impairment, including hours lost to unemployment, absenteeism, and presenteeism, measured by Work Productivity and Activity Impairment assessments in the year after injury. Results after non-operative and operative treatment were compared.

RESULTS

Of the 64 included patients, forty-seven percent (30/64) were treated with surgical fixation, and 53% (30/64) with nonoperative management. 63% returned to work within 1 year of injury. Workers lost an average of 67% of a 2080-hour average work year, corresponding with $56,276 in lost economic productivity. Of the 1395 total hours lost, 87% was due to unemployment, 3% to absenteeism, and 10% to presenteeism. Surgical fixation was associated with 27% fewer lost hours (1155 vs. 1583, P = 0.005) and prevented $17,266 in average lost economic productivity per patient compared with nonoperative management.

CONCLUSIONS

Lateral compression pelvic fractures are associated with a substantial economic impact on patients and society. Surgical fixation reduces work impairment and the corresponding economic burden.

LEVEL OF EVIDENCE

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

Social determinants of health in patients undergoing hemiarthroplasty: are they associated with medical complications, healthcare utilization, and payments for care?

INTRODUCTION

Social determinants of health (SDOH) have previously been shown to impact orthopedic surgery outcomes. This study assessed whether greater socioeconomic disadvantage in patients undergoing hemiarthroplasty following femoral neck fracture was associated with differences in (1) medical complications, (2) emergency department (ED) utilization, (3) readmission rates, and (4) payments for care.

METHODS

A US nationwide database was queried for hemiarthroplasties performed between 2010 and 2020. Area Deprivation Index (ADI), a validated measure of socioeconomic disadvantage reported on a scale of 0-100, was used to compare two cohorts of greater and lesser deprivation. Patients undergoing hemiarthroplasty from high ADI (95% +) were 1:1 propensity score matched to a comparison group of lower ADI (0-94%) while controlling for age, sex, and Elixhauser Comorbidity Index. This yielded 75,650 patients evenly distributed between the two cohorts. Outcomes studied were 90-day medical complications, ED utilizations, readmissions, and payments for care. Multivariate logistic regression models were utilized to calculate odds ratios (ORs) of the relationship between ADI and outcomes. p Values < 0.05 were significant.

RESULTS

Patients of high ADI developed greater medical complications (46.74% vs. 44.97%; OR 1.05, p = 0.002), including surgical site infections (1.19% vs. 1.00%; OR 1.20, p = 0.011), cerebrovascular accidents (1.64% vs. 1.41%; OR 1.16, p = 0.012), and respiratory failures (2.27% vs. 2.02%; OR 1.13, p = 0.017) compared to patients from lower ADIs. Although comparable rates of ED visits (2.92% vs. 2.86%; OR 1.02, p = 0.579), patients from higher ADI were readmitted at diminished rates (10.57% vs. 11.06%; OR 0.95, p = 0.027). Payments were significantly higher on the day of surgery ($7,570 vs. $5,974, p < 0.0001), as well as within 90 days after surgery ($12,700 vs. $10,462, p < 0.0001).

CONCLUSIONS

Socioeconomically disadvantaged patients experience increased 90-day medical complications and payments, similar ED utilizations, and decreased readmissions. These findings can be used to inform healthcare providers to minimize disparities in care.

LEVEL OF EVIDENCE

III.

[Analysis of Sickness-Related Days of Absence among Soldiers of the German Armed Forces from 2008 to 2018 Part 1: Retrospective Analysis with Comparison to the Statutory Health Insurance System]

BACKGROUND

Sickness-related absences are of particular importance both in the German armed forces and in the civilian sector.

THE AIM OF THIS STUDY

was to analyze the incidence of sick leave among soldiers in comparison to the working population covered by the statutory health insurance (SHI) system.

METHOD

According to the systematics of the SHI, the key figures on incapacity to work in the period 2008-2018 are calculated in an age- and gender-standardized manner. Likewise, a list of the TOP 20 ICD-10 diagnoses in relation to incapacity to work was determined, and their average annual rates of change were calculated for trend analysis.

RESULTS

The annual rate of sick leave among soldiers was between 1.5 and 2.3%, which was lower than that of the SHI (3.1 to 5.0%). The duration of illness (sick days per case) among soldiers was between 9.0-15.6 days per year, compared with 10.9-14.4 days in the SHI system. The sickness frequency (cases per 100 persons) was lower among soldiers (48.2-75.0 cases) than in the SHI (96.8-131.0 cases). Most days of absence among soldiers were due to "respiratory infections (J06)" with 13.2%, "stress reactions (F43)" with 8.7%, "other infectious gastroenteritis and colitis (A09)" with 6.5%, "back pain (M54)" with 4.4% and "depressive episode (F32)" with 4.0% of all days of absence and were comparable to the values in SHI. "Depressive episode (F32)", "injuries (T14)", sreactions (F43)", "respiratory infections (J06)" and "pregnancy complaints (O26)" showed the highest rates of increase of+6.1% to+3.6% of days off work.

CONCLUSION

For the first time, it was possible to compare the sickness rate of soldiers with that of the general population in Germany, which may also provide indications for further measures for primary, secondary and tertiary prevention. The lower sickness rate among soldiers compared with the general population is mainly due to a lower incidence of illness, with a similar duration and pattern of illness, but with an overall upward trend. The ICD-10 diagnoses "Depressive episode (F32)," "injuries (T14)," "stress reactions (F43)," "acute upper respiratory tract infections (J06)" and "pregnancy complaints (O26)," which are increasing at an above-average rate in relation to the number of days absent, require further analysis. This approach seems promising, for example, to generate hypotheses and ideas for further improvement of health care.

Social Determinants of Health and Patients With Traumatic Injuries: Is There a Relationship Between Social Health and Orthopaedic Trauma?

BACKGROUND

Although economic stability, social context, and healthcare access are well-known social determinants of health associated with more challenging recovery after traumatic injury, little is known about how these factors differ by mechanism of injury. Our team sought to use the results of social determinants of health screenings to better understand the population that engaged with psychosocial support services after traumatic musculoskeletal injury and fill a gap in our understanding of patient-reported social health needs.

QUESTION/PURPOSE

What is the relationship between social determinants of health and traumatic musculoskeletal injury?

METHODS

Trauma recovery services is a psychosocial support program at our institution that offers patients and their family members resources such as professional coaching, peer mentorship, post-traumatic stress disorder screening and treatment, educational resources, and more. This team engages with any patient admitted to, treated at, and released from our institution. Their primary engagement population is individuals with traumatic injury, although not exclusively. Between January 2019 and October 2021, the trauma recovery services team interacted with 6036 patients. Of those who engaged with this service, we considered only patients who experienced a traumatic musculoskeletal injury and had a completed social determinants of health screening tool. During the stated timeframe, 13% (814 of 6036) of patients engaged with trauma recovery services and had a complete social determinants of health screening tool. Of these, 53% (428 of 814) had no physical injury. A further 26% (99 of 386) were excluded because they did not have traumatic musculoskeletal injuries, leaving 4.8% (287) for analysis in this cross-sectional study. The study population included patients who interacted with trauma recovery services at our institution after a traumatic orthopaedic injury that occurred between January 2019 and October 2021. Social determinants of health risk screening questionnaires were self-administered prospectively using a screening tool developed by our institution based on Centers for Medicare and Medicaid Services social determinants of health screening questions. Mechanisms of injury were separated into intentional (physical assault, sexual assault, gunshot wound, or stabbing) and unintentional (fall, motor vehicle collision, or motorcycle crash). During the study period, 287 adult patients interacted with trauma recovery services after a traumatic musculoskeletal injury and had complete social determinant of health screening; 123 injuries were unintentional and 164 were intentional. Patients were primarily women (55% [159 of 287]), single (73% [209 of 287]), and insured by Medicaid or Medicare (78% [225 of 287]). Mechanism category was determined after a thorough medical record review to verify the appropriate category. An initial exploratory univariate analysis was completed for the primary outcome variable using the Pearson chi-squared test for categorical variables and a two-tailed independent t-test for continuous variables. All demographic variables and social determinants of health with p < 0.20 in the univariate analysis were included in a multivariate binary regression analysis to determine independent associations with injury mechanism. All variables with p < 0.05 in the multivariate analysis were considered statistically significant.

RESULTS

After controlling for potential demographic confounders, younger age (odds ratio [OR] 0.93 [95% confidence interval (CI) 0.90 to 0.96]; p < 0.001), Black race (compared with White race, OR 2.71 [95% CI 1.20 to 6.16]; p = 0.02), Hispanic ethnicity (compared with White race, OR 5.32 [95% CI 1.62 to 17.47]; p = 0.006), and at-risk status for food insecurity (OR 4.27 [95% CI 1.18 to 15.39]; p = 0.03) were independently associated with intentional mechanisms of injury.

CONCLUSION

There is a relationship between the mechanism of traumatic orthopaedic injury and social determinants of health risks. Specifically, data showed a correlation between food insecurity and intentional injury. Healthcare systems and providers should be cognizant of this, as well as the additional challenges patients may face in their recovery journey because of social needs. Screening for needs is only the first step in addressing patient's social health needs. Healthcare systems should also allocate resources for personnel and programs that support patients in meeting their social health needs. Future studies should evaluate the impact of such programming in responding to social needs that impact health outcomes and improve health disparities.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Insurance churn after adult traumatic injury: A national evaluation among a large private insurance database

BACKGROUND

Traumatic injury leads to significant disability, with injured patients often requiring substantial health care resources to return to work and baseline health. Temporary disability or inability to work can result in changes or loss of employer-based private insurance coverage, which may significantly impact health care access and outcomes. Among privately insured patients, we hypothesized increased instability in insurance coverage for patients with higher severity of injury.

METHODS

Adults 18 years and older presenting to a hospital with traumatic injury were evaluated for insurance churn using Clinformatics Data Mart private-payer claims. Insurance churn was defined as cessation of enrollment in the patient's private health insurance plan. Using Injury Severity Score (ISS), we compared insurance churn over the year following injury between patients with mild (ISS, <9), moderate (ISS, 9-15), severe (ISS, 16-24), and very severe (ISS, >24) injuries. Kaplan-Meier analysis was used to compare time with insurance churn by ISS category. Flexible parametric regression was used to estimate hazard ratios for insurance churn.

RESULTS

Among 750,862 privately insured patients suffering from a traumatic injury, 50% experienced insurance churn within 1 year after injury. Compared with patients who remained on their insurance plan, patients who experienced insurance churn were younger and more likely male and non-White. The median time to insurance churn was 7.7 months for those with mild traumatic injury, 7.5 months for moderately or severely injured, and 7.1 months for the very severely injured. In multivariable analysis, increasing injury severity was associated with higher rates of insurance churn compared with mild injury, up to 14% increased risk for the very severely injured.

CONCLUSION

Increasing severity of traumatic injury is associated with higher levels of health coverage churn among the privately insured. Lack of continuous access to health services may prolong recovery and further aggravate the medical and social impact of significant traumatic injury.

LEVEL OF EVIDENCE

Economic and Value Based Evaluations; Level III.

Feasibility of Capturing Orthopaedic Trauma Research Outcomes Using Personal Mobile Devices

INTRODUCTION

Patients with orthopaedic trauma are frequently lost to follow-up. Personal mobile devices have been used to ascertain clinical research outcomes. The prevalence of mobile device ownership, use patterns, and attitudes about research among patients with orthopaedic trauma would inform clinical research strategies in this population.

METHODS

A total of 1,434 consecutive unique adults scheduled for an orthopaedic trauma outpatient clinic from December 2019 through February 2020 at a metropolitan level 1 trauma center were identified. Associations of demographic data with clinic attendance and mobile phone registration were explored by logistic regression. One hundred one patients attending clinic were then prospectively surveyed from June 2021 through August 2021 about housing stability, personal mobile device ownership, capabilities, use patterns, and openness to communicating via the device with for orthopaedic care and research.

RESULTS

The prevalence of personal mobile device ownership was 91% by registration data and 90% by a survey. Ninety-nine percent of survey respondents with mobile devices reported cell service always or most of the time. Ninety-three percent kept their devices charged always or most of the time. Ninety-two percent reported e-mail access. Eighty-three percent reported video capability. Ninety-one percent would communicate with their orthopaedic trauma care team by text message. Eighty-seven percent would answer research questions by phone call, 79% by text, and 61% by video. Eighty-five percent reported stable housing, which was not associated with mobile device ownership or use, but was associated with clinic nonattendance (29% vs. 66%, P < 0.01) and changing phone number at least once in the previous year (28% vs. 58%, P = 0.04).

DISCUSSION

Personal mobile devices represent a feasible platform for screening and collecting outcomes from patients with orthopaedic trauma. Nine in 10 patients own personal mobile devices, keep them charged, have text and e-mail service, and would use the device to participate in research. Housing instability was not associated with mobile device ownership or use patterns.

Microbial resistance to nanotechnologies: An important but understudied consideration using antimicrobial nanotechnologies in orthopaedic implants

Microbial resistance to current antibiotics therapies is a major cause of implant failure and adverse clinical outcomes in orthopaedic surgery. Recent developments in advanced antimicrobial nanotechnologies provide numerous opportunities to effective remove resistant bacteria and prevent resistance from occurring through unique mechanisms. With tunable physicochemical properties, nanomaterials can be designed to be bactericidal, antifouling, immunomodulating, and capable of delivering antibacterial compounds to the infection region with spatiotemporal accuracy. Despite its substantial advancement, an important, but under-explored area, is potential microbial resistance to nanomaterials and how this can impact the clinical use of antimicrobial nanotechnologies. This review aims to provide a better understanding of nanomaterial-associated microbial resistance to accelerate bench-to-bedside translations of emerging nanotechnologies for effective control of implant associated infections.

Percutaneous-Reinforced Osteoplasty: A Review of Emerging Treatment Strategies for Bone Interventions

Percutaneous-reinforced osteoplasty is currently being investigated as a possible therapeutic procedure for fracture stabilization in high-risk patients, primarily in patients with bone metastases or osteoporosis. For these patients, a percutaneous approach, if structurally sound, can provide a viable method for treating bone fractures without the physiologic stress of anesthesia and open surgery. However, the low strength of fixation is a common limitation that requires further refinement in scaffold design and selection of materials, and may potentially benefit from tissue-engineering-based regenerative approaches. Scaffolds that have tissue regenerative properties and low inflammatory response promote rapid healing at the fracture site and are ideal for percutaneous applications. On the other hand, preclinical mechanical tests of fracture-repaired specimens provide key information on restoration strength and long-term stability and enable further design optimization. This review presents an overview of percutaneous-reinforced osteoplasty, emerging treatment strategies for bone repair, and basic concepts of in vitro mechanical characterization.

International Lower Limb Collaborative (INTELLECT) study: a multicentre, international retrospective audit of lower extremity open fractures

Sixty-two centres in 16 countries contributed with 2,694 open fractures cases to an international, multi-centric, retrospective cohort study involving different healthcare settings. The INTELLECT study results show that there are significant disparities on the management of open lower limb fractures internationally. A timely, multidisciplinary, guideline-directed care is a protective factor for developing infective complications, non-union and requiring an amputation.

Synergistic effects of nanoattapulgite and hydroxyapatite on vascularization and bone formation in a rabbit tibia bone defect model

Hydroxyapatite (HA) is a promising scaffold material for the treatment of bone defects. However, the lack of angiogenic properties and undesirable mechanical properties (such as fragility) limits the application of HA. Nanoattapulgite (ATP) is a nature-derived clay mineral and has been proven to be a promising bioactive material for bone regeneration due to its ability to induce osteogenesis. In this study, polyvinyl alcohol/collagen/ATP/HA (PVA/COL/ATP/HA) scaffolds were printed. Mouse bone marrow mesenchymal stem/stromal cells (BMSCs) and human umbilical vein endothelial cells (HUVECs) were used in vitro to assess the biocompatibility and the osteogenesis and vascularization induction potentials of the scaffolds. Subsequently, in vivo micro-CT and histological staining were carried out to evaluate new bone formation in a rabbit tibial defect model. The in vitro results showed that the incorporation of ATP increased the printing fidelity and mechanical properties, with values of compressive strengths up to 200% over raw PC-H scaffolds. Simultaneously, the expression levels of osteogenic-related genes and vascularization-related genes were significantly increased after the incorporation of ATP. The in vivo results showed that the PVA/COL/ATP/HA scaffolds exhibited synergistic effects on promoting vascularization and bone formation. The combination of ATP and HA provides a promising strategy for vascularized bone tissue engineering.

Quantifying balance deficit in people with ankle fracture six months after surgical intervention through the Y-Balance test

BACKGROUND

Ankle fractures are among the most common traumatic fractures and have a great socio-economic impact. Consequences of an ankle fracture requiring surgical treatment (e.g. pain, reduced ankle range of motion (ROM), muscle weakness, etc.) lead to balance deterioration, which has a profound impact on activities of daily living. However, to the best of the authors' knowledge, no reliable clinical tests are available to monitor balance in patients after ankle surgery.

OBJECTIVES

To quantify single-leg dynamic balance in patients with bimalleolar ankle fracture through the Y-Balance test (YBT). The second objective was to analyze the impact of ankle dorsiflexion ROM and hip strength on balance to optimize balance rehabilitation programs.

DESIGN

Cross-sectional study.

METHODS

22 participants, who had undergone surgery after bimalleolar ankle fractures, were assessed for ankle ROM, hip strength, and dynamic balance six-months after the surgical intervention. The within-session reliability of YBT was calculated through the intraclass correlation coefficient (ICC) and the standard error of measurement (SEM). Student's t-tests were used to assess leg differences. A multiple regression analysis was performed to evaluate the role of ankle dorsiflexion ROM and hip abductor and adductor strength in predicting balance performance.

RESULTS

YBT showed high-to-excellent within-session relative reliability (Healthy leg: 0.85 ≤ ICC≤0.96; Operated leg: 0.84 ≤ ICC≤0.96). SEM values were below 3.3 %. The operated leg showed significant lower YBT scores for anterior reach direction (-9.0 %; g=-0.70) and composite score (-4.5 %; g=-0.34). Multiple regression analysis showed that both, ankle dorsiflexion and hip abductor and adductor strength explained 66 % of the variance in the YBT anterior direction of the operated leg.

CONCLUSIONS

The YBT is a reliable tool that allows the quantification of single-leg dynamic balance impairments from 6-months after surgery in patients with bimalleolar ankle fracture. Between-leg YBT differences in the anterior direction can be used as reference scores (3.3 %) for balance restoration. Balance rehabilitation programs should focus on improving ankle functionality and reducing hip muscle weakness with specific hip strength exercises and balance exercises with similar demands to the reaching tasks of the YBT to promote a faster recovery.

Measuring Recovery and Understanding Long-Term Deficits in Balance, Ankle Mobility and Hip Strength in People after an Open Reduction and Internal Fixation of Bimalleolar Fracture and Their Impact on Functionality: A 12-Month Longitudinal Study

To analyze how balance and other physical capacities evolved after surgery in patients with a bimalleolar fracture and how these capacities and clinical variables (immobilization or unloading time) contribute to restoring patients’ functionality, 22 patients and 10 healthy people (HC) were assessed for static and dynamic balance (Y-Balance test, YBT), dorsiflexion ankle mobility (ADFROM) and hip strength at 6 and 12 months after surgery. Patients’ functional status was assessed through the Olerud Molander Ankle Score (OMAS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Twenty-one patients with ankle fractures who completed the study showed a worse static and dynamic balance at 6 months. The YBT in the anterior direction (YBTA) revealed balance deficits in the operated limb at 12 months compared to the non-operated limb (−5.6%) and the HC (−6.7%). They also showed a decreased ADFROM compared to the non-operated limb (−7.4°) and the HC (−11°). In addition, medium-term (6 months) deficits in abductor strength hip but no hip strength deficits were found at 12 months after surgery. Relative weight analyses showed that ADFROM and hip strength explained 35–63% of the YBTA variance and AOFAS/OMAS scores. Balance, hip strength and ADFROM seem to be reliable indexes for assessing the functional status of these patients. These results could help to understand the relationship between these physical capacities and the patients’ perceived functional status.

The 1-Year Economic Impact of Work Productivity Loss Following Severe Lower Extremity Trauma

BACKGROUND

Severe lower extremity trauma among working-age adults is highly consequential for returning to work; however, the economic impact attributed to injury has not been fully quantified. The purpose of this study was to examine work and productivity loss during the year following lower extremity trauma and to calculate the economic losses associated with lost employment, lost work time (absenteeism), and productivity loss while at work (presenteeism).

METHODS

This is an analysis of data collected prospectively across 3 multicenter studies of lower extremity trauma outcomes in the United States. Data were used to construct a Markov model that accumulated hours lost over time due to lost employment, absenteeism, and presenteeism among patients from 18 to 64 years old who were working prior to their injury. Average U.S. wages were used to calculate economic loss overall and by sociodemographic and injury subgroups.

RESULTS

Of 857 patients working prior to injury, 47.2% had returned to work at 1 year. The average number of productive hours of work lost was 1,758.8/person, representing 84.6% of expected annual productive hours. Of the hours lost, 1,542.3 (87.7%) were due to working no hours or lost employment, 71.1 (4.0%) were due to missed hours after having returned, and 145.4 (8.3%) were due to decreased productivity while working. The 1-year economic loss due to injury totaled $64,427/patient (95% confidence interval [CI], $63,183 to $65,680). Of the 1,758.8 lost hours, approximately 88% were due to not being employed (working zero hours), 4% were due to absenteeism, and 8% were due to presenteeism. Total productivity loss was higher among older adults (≥40 years), men, those with a physically demanding job, and the most severe injuries (i.e., those leading to amputation as well as Gustilo type-IIIB tibial fractures and type-III pilon/ankle fractures).

CONCLUSIONS

Patients with severe lower extremity trauma carry a substantial economic burden. The costs of lost productivity should be considered when evaluating outcomes.

Screws-Only Primary Subtalar Arthrodesis for Calcaneus Fractures

BACKGROUND

The management of displaced intraarticular calcaneus fractures (DIACFs) is a difficult problem with disappointing results from open reduction internal fixation (ORIF). Alternatively, ORIF with primary subtalar arthrodesis (PSTA) has gained increasing popularity. The purpose of this study is to review patient-centered and radiographic outcomes of ORIF plus PSTA using only screws through a sinus tarsi approach.

METHODS

A retrospective study of patients who underwent ORIF+PSTA for DIACFs was conducted. The same surgical technique was used in all cases consisting of only screws; no plates were used. Delayed surgeries past 8 weeks were excluded. Demographic and radiographic data were collected including worker's compensation claims. Plain radiographs were used to characterize injuries and review outcomes.

RESULTS

Seventy-nine DIACFs underwent PSTA with a median follow-up of 200 days (n = 69 patients). Median time to weightbearing was 57.5 days postoperatively. Ten fractures were documented as Sanders II, 36 as Sanders III, and 32 as Sanders IV. Sixty-eight fractures (86.1%) achieved fusion on radiographs at a median of 126.5 (range, 54-518) days. Thirty-nine fractures (57.3%) demonstrated radiographic fusion in all 3 predefined locations. Nine of the 14 worker's compensation patients returned to work within the period of observation. There were 8 complications: 3 requiring a secondary operation. Eleven of 79 fractures treated did not go on to achieve radiographic union.

CONCLUSION

In this retrospective case series, we found that screws-only primary subtalar arthrodesis for the treatment of DIACFs through a sinus tarsi approach was associated with relatively high rates of return to work and radiographic fusion.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Six-months outcome after fracture for working-age persons analyzed using the International Classification of Functioning, Disability, and Health - a prospective cohort observational study

BACKGROUND

Fractures following trauma affect physical and mental health for working-age persons, and the International Classification of Functioning, Disability, and Health (ICF) can help therapists understand the fractures' impact on daily lives.

PURPOSE

To examine self-reported functioning and outcomes six months after upper and lower body fractures and compare limitations using the ICF.

METHODS

Data were collected from 160 patients with fractures as part of a prospective cohort study. The primary outcome measure was the Short Musculoskeletal Function Assessment questionnaire that covers all domains of the ICF. Moreover, sick leave, sense of coherence, and physical activity were reported.

RESULTS

Six months after the injury, function had improved significantly, but patients reported problems on all domains in the ICF with few differences between the upper and lower body groups. Leisure activities caused problems for 63 (38.8%) of the patients and bothered 86 (53.8%). Problems performing work bothered 63 (39.4%) with no significant difference between the groups, although a significantly higher proportion in the upper body group had returned to work within two months (p < .001).

CONCLUSION

Six months after fractures, adults reported problems on all ICF domains, especially on the participation dimension, which therapists should address in the rehabilitation process.

Return to work and sport after a humeral shaft fracture

Aims

The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS.

Methods

From 2008 to 2017, all patients with a humeral diaphyseal fracture were retrospectively identified. Patient demographics and injury characteristics were recorded. Details of pre-injury employment, sporting participation, and levels of return post-injury were obtained via postal questionnaire. The University of California, Los Angeles (UCLA) Activity Scale was used to quantify physical activity among active patients. Regression was used to determine factors independently associated with failure to RTW or RTS.

Results

The Work Group comprised 177 patients in employment prior to injury (mean age 47 years (17 to 78); 51% female (n = 90)). Mean follow-up was 5.8 years (1.3 to 11). Overall, 85% (n = 151) returned to work at a mean of 14 weeks post-injury (0 to 104), but only 60% (n = 106) returned full-time to their previous employment. Proximal-third fractures (adjusted odds ratio (aOR) 4.0 (95% confidence interval (CI) 1.2 to 14.2); p = 0.029) were independently associated with failure to RTW. The Sport Group comprised 182 patients involved in sport prior to injury (mean age 52 years (18 to 85); 57% female (n = 104)). Mean follow-up was 5.4 years (1.3 to 11). The mean UCLA score reduced from 6.9 (95% CI 6.6 to 7.2) before injury to 6.1 (95% CI 5.8 to 6.4) post-injury (p < 0.001). There were 89% (n = 162) who returned to sport: 8% (n = 14) within three months, 34% (n = 62) within six months, and 70% (n = 127) within one year. Age ≥ 60 years was independently associated with failure to RTS (aOR 3.0 (95% CI 1.1 to 8.2); p = 0.036). No other factors were independently associated with failure to RTW or RTS.

Conclusion

Most patients successfully return to work and sport following a humeral shaft fracture, albeit at a lower level of physical activity. Patients aged ≥ 60 yrs and those with proximal-third diaphyseal fractures are at increased risk of failing to return to activity.

Cite this article: Bone Jt Open 2022;3(3):236–244.

Pain Management Strategies After Orthopaedic Trauma: A Mixed-Methods Study with a View to Optimizing Practices

PURPOSE

To examine 1) pain management strategies within the care trajectory of orthopaedic trauma patients and patients' perception of their effectiveness, 2) adverse effects (AEs) associated with pharmacological treatments, particularly opioids and cannabis, and 3) patients' perceptions of strategies that should be applied after an orthopaedic trauma and support that they should obtain from health professionals for their use.

PATIENTS AND METHODS

This study was conducted with orthopaedic trauma patients in a level 1 trauma center. A convergent mixed-methods design was used. Data on pain experience, pain management strategies used and AEs were collected with self-administered questionnaires at hospital discharge (T1) and at 3 months after injury (T2). Patients' preferences about the pain management strategies used, the required support and AEs were further examined through semi-structured individual interviews at the same time measures. Descriptive statistics and thematic analyses were performed.

RESULTS

Seventy-one patients were recruited and 30 individual interviews were undertaken. Pharmacological pain management strategies used at T1 and T2 were mainly opioids (95.8%; 20.8%) and acetaminophen (91.5%; 37.5%). The most frequently applied non-pharmacological strategies were sleep (95.6%) and physical positioning (89.7%) at T1 and massage (46.3%) and relaxation (32.5%) at T2. Findings from quantitative and qualitative analyses highlighted that non-pharmacological strategies, such as comfort, massage, distraction, and physical therapy, were perceived as the most effective by participants. Most common AEs related to opioids were dry mouth (78.8%) and fatigue (66.1%) at T1 and insomnia (30.0%) and fatigue (20.0%) at T2. Dry mouth (28.6%) and drowsiness (14.3%) were the most reported AEs by patients using recreational cannabis. An important need for information at hospital discharge and for a personalized follow-up was identified by participants during interviews.

CONCLUSION

Despite its AEs, we found that opioids are still the leading pain management strategy after an orthopaedic trauma and that more efforts are needed to implement non-pharmacological strategies. Cannabis was taken for recreational purposes but patients also used it for pain relief. Support from health professionals is needed to promote the adequate use of these strategies.

Systematic Review of Biopsychosocial Prognostic Factors for Return to Work After Acute Orthopedic Trauma: A 2020 Update

OBJECTIVE

To provide updated evidence on prognostic factors for return to work (RTW) in the early and late phases after acute orthopedic trauma from a biopsychosocial perspective.

METHODS

A systematic review of articles indexed in the MEDLINE, CINAHL, and Embase databases between 2010 and 2020 was performed. The inclusion criteria were cohort studies of employed populations sustaining acute orthopedic trauma with follow-up data on RTW. Biopsychosocial prognostic factors for RTW must be reported in the multiple regression models and divided into early (≤ 6 months) and late phases (> 6 months) postinjury. Two reviewers performed study selection, assessed the risk of bias and quality using the Quality in Prognosis Studies (QUIPS) tool and the Newcastle-Ottawa Scale (NOS), and extracted data independently.

RESULTS

Thirty articles were included with a follow-up period of 1-58 months. Based on the QUIPS tool, 7 studies (23%) were considered to have a low risk of bias, and 21 studies (70%) were considered to have a moderate risk of bias. Based on the NOS, the quality was high in 87% of the included studies. The RTW rates ranged from 22% to 74% in the early phase and from 44% to 94% in the late phase. In the early phase, strong evidence was found for injury severity. In the late phase, strong evidence was found for age, injury severity, level of pain, self-efficacy, educational level, blue-collar work, and compensation status; moderate evidence was found for recovery expectations and physical workload. There was limited or inconsistent evidence for the other factors.

CONCLUSION

Based on the levels of evidence, injury severity should be considered as one of the key barriers to RTW in the early and late phases postinjury. This finding underlines the need for serious injury prevention efforts. Our results also emphasize the multifaceted actions of the biopsychosocial model to facilitate RTW: promoting policies for older injured workers, improving access to medical and rehabilitation facilities, and adapting physical workload. Multiple other factors are likely important but require additional high-quality studies to assess their role in the RTW process.

Surgical Treatment of Radial Nerve Injuries Associated With Humeral Shaft Fracture-A Single Center Experience

Radial nerve injuries are often associated with humeral shaft fractures. The results of treatment of these injuries, by contemporary surgical approaches, remain diverse. In this paper we presented the outcomes and analyzed the patient, clinical, and surgical procedure related characteristics and factors that may influence the outcome overall, in 77 patients treated at Clinic for Neurosurgery, Clinical Center of Serbia during a 20 years period. The nerve injuries were verified by US and EMNG. The majority of patients were treated by neurolysis or sural nerve grafting, while only few were treated by direct suture. The final recovery was evaluated by muscle strength assessment and classified using MRC. We analyzed extension of the wrist, extension of the fingers including the thumb, and abduction of the thumb. There was a significant statistical difference in MRC grade following the treatment. The total rate of useful functional recovery was achieved in 69 (89.61%) out of all studied patients, out of whom 20 (28.99%) achieved excellent recovery, 26 (37.68%) achieved good recovery and 23 (33.33%) achieved fair recovery. Only 8 (10.39%) out of all studied patients achieved poor recovery. The injured nerves, that were preserved in continuity, acquired by a low-energy trauma, and treated earlier than the 6 months were associated with better functional outcome following the surgery. In addition, there was a trend of better functional improvement with aging, keeping in mind that the old were subjected to lower energy trauma. The expectant management followed by surgery of radial nerve injury associated with humeral shaft fracture should be around 3 months, and the surgical nerve repair should not be performed later than the 6 months after injury. The energy of trauma may be a factor predicting patient's final recovery following the treatment.

The Impact of Musculoskeletal Injuries Sustained in Road Traffic Crashes on Work-Related Outcomes: A Systematic Review

Musculoskeletal injuries occur frequently after road traffic crashes (RTCs), and the effect on work participation is not fully understood. The primary aim of this review was to determine the impact of sustaining a musculoskeletal injury during an RTC on the rate of return to work (RTW), sick leave, and other work outcomes. The secondary aim was to determine factors associated with these work-related outcomes. An electronic search of relevant databases to identify observational studies related to work and employment, RTC, and musculoskeletal injuries was conducted. Where possible, outcome data were pooled by follow-up period to answer the primary aim. Fifty-three studies were included in this review, of which 28 were included in meta-analyses. The pooled rate of RTW was 70% at 1 month, 67% at 3 months, 76% at 6 months, 83% at 12 months, and 70% at 24 months. Twenty-seven percent of participants took some sick leave by one month follow-up, 13% by 3 months, 23% by 6 months, 36% by 12 months, and 22% by 24 months. Most of the factors identified as associated with work outcomes were health-related, with some evidence also for sociodemographic factors. While 70% of people with RTC-related musculoskeletal injury RTW shortly after accident, many still have not RTW two years later.

American Academy of Orthopaedic Surgeons Appropriate Use Criteria: Early Screening for Psychosocial Risk and Protective Factors

The Major Extremity Trauma and Rehabilitation Consortium and the American Academy of Orthopaedic Surgeons (AAOS) have developed Appropriate Use Criteria for the Early Screening for Psychosocial Risk and Protective Factors. Evidence and clinical expertise were used to develop criteria for addressing mental and social health opportunities to help people recover from musculoskeletal injuries to the extremity, spine, and pelvis. The criteria were developed by identifying observable symptoms and results of screening that suggest mental and social health challenges among patients with lower extremity trauma in clinical practice. The 32 patient scenarios and three interventions (evaluate for psychological distress, evaluate for social health opportunities, and evaluate coping and resilience strategies) were developed by the writing panel of clinicians who are specialists in mental and social health in musculoskeletal illness. Next, a separate, multidisciplinary, voting panel made up of specialists and nonspecialists rated the appropriateness of treatment for each patient scenario using a 9-point scale to designate a treatment as "appropriate" (median rating, 7 to 9), "may be appropriate" (median rating, 4 to 6), or "rarely appropriate" (median rating, 1 to 3). Notably, with a high level of agreement, the voting panel determined that interventions to address mental and social health were appropriate in all scenarios as follows: 86% were rated appropriate, 14% were rated possibly appropriate, and none were rated rarely appropriate.

Patients Place More of an Emphasis on Physical Recovery Than Return to Work or Financial Recovery

BACKGROUND

Value-based healthcare models aim to incentivize healthcare providers to offer interventions that address determinants of health. Understanding patient priorities for physical and socioeconomic recovery after injury can help determine which services and resources are most useful to patients.

QUESTIONS/PURPOSES

(1) Do trauma patients consistently identify a specific aspect/domain of recovery as being most important at 6 weeks, 6 months, and 12 months after an injury? (2) Does the relative importance of those domains change within the first year after injury? (3) Are differences in priorities greater between patients than for a given patient over time? (4) Are different recovery priorities associated with identifiable biopsychosocial factors?

METHODS

Between June 2018 and December 2018, 504 adult patients with fractures of the extremities or pelvis were surgically treated at the study site. For this prospective longitudinal study, we purposefully sampled patients from 6 of the 12 orthopaedic attendings' postoperative clinics. The participating surgeons surgically treated 243 adult patients with fractures of the extremities or pelvis. Five percent (11 of 243) of patients met inclusion criteria but missed their appointments during the 6-week recruitment window and could not be consented. We excluded 4% (9 of 243) of patients with a traumatic brain injury, 1% (2) of patients with a spinal cord injury, and 5% (12) of non-English-speaking patients (4% Spanish speaking [10]; 1% other languages [2]). Eighty-six percent of eligible patients (209 of 243) were approached for consent, and 5% (11 of 209) of those patients refused to participate. All remaining 198 patients consented and completed the baseline survey; 83% (164 of 198 patients) completed at least 6 months of follow-up, and 68% (134 of 198 patients) completed the 12-month assessment. The study participants' mean age was 44 ± 17 years, and 63% (125 of 198) were men. The primary outcome was the patient's recovery priorities, assessed at 6 weeks, 6 months, and 12 months after fracture using a discrete choice experiment. Discrete choice experiments are a well-established method for eliciting decisional preferences. In this technique, respondents are presented with a series of hypothetical scenarios, described by a set of plausible attributes or outcomes, and asked to select their preferred scenario. We used hierarchical Bayesian modeling to calculate individual-level estimates of the relative importance of physical recovery, work-related recovery, and disability benefits, based on the discrete choice experiment responses. The hierarchical Bayesian model improves upon more commonly used regression techniques by accounting for the observed response patterns of individual patients and the sequence of scenarios presented in the discrete choice experiment when calculating the model estimates. We computed the coefficient of variation for the three recovery domains and compared the between-patient versus within-patient differences using asymptotic tests. Separate prognostic models were fit for each of the study's three recovery domains to assess marginal changes in the importance of the recovery domain based on patient characteristics and factors that remained constant over the study (such as sex or preinjury work status) and patient characteristics and factors that varied over the study (including current work status or patient-reported health status). We previously published the 6-week results. This paper expands upon the prior publication to evaluate longitudinal changes in patient recovery priorities.

RESULTS

Physical recovery was the respondents' main priority at all three timepoints, representing 60% ± 9% of their overall concern. Work-related recovery and access to disability benefits were of secondary importance and were associated with 27% ± 6% and 13% ± 7% of the patients' concern, respectively. The patients' concern for physical recovery was 6% (95% CrI 4% to 7%) higher at 12 months after fracture that at 6 weeks postfracture. The mean concern for work-related recovery increased by 7% (95% CrI 6% to 8%) from 6 weeks to 6 months after injury. The mean importance of disability benefits increased by 2% (95% CrI 1% to 4%) from 6 weeks to 6 months and remained 2% higher (95% CrI 0% to 3%) at 12 months after the injury. Differences in priorities were greater within a given patient over time than between patients as measured using the coefficient of variation (physical recovery [245% versus 7%; p < 0.001], work-related recovery [678% versus 12%; p < 0.001], and disability benefits [620% versus 33%; p < 0.001]. There was limited evidence that biopsychosocial factors were associated with variation in recovery priorities. Patients' concern for physical recovery was 2% higher for every 10-point increase in their Patient-reported Outcome Measure Information System (PROMIS) physical health status score (95% CrI 1% to 3%). A 10-point increase in the patient's PROMIS mental health status score was associated with a 1% increase in concern for work-related recovery (95% CrI 0% to 2%).

CONCLUSION

Work-related recovery and accessing disability benefits were a secondary concern compared with physical recovery in the 12 months after injury for patients with fractures. However, the importance of work-related recovery was elevated after the subacute phase. Priorities were highly variable within a given patient in the year after injury compared with between-patient differences. Given this variation, orthopaedic surgeons should consider assessing and reassessing the socioeconomic well-being of their patients throughout their continuum of care.

LEVEL OF EVIDENCE

Level II, therapeutic study.

What Factors Are Associated with Increased Financial Burden and High Financial Worry For Patients Undergoing Common Hand Procedures?

BACKGROUND

Few studies have examined whether orthopaedic surgery, including hand surgery, is associated with patients' financial health. We sought to understand the level of financial burden and worry for patients undergoing two common hand procedures-carpal tunnel release and open reduction and internal fixation for a distal radius fracture-as well as to determine factors associated with a higher financial burden and worry.

QUESTIONS/PURPOSES

In patients undergoing operative treatment for isolated carpal tunnel syndrome with carpal tunnel release or open reduction and internal fixation for a distal radius fracture, we used validated financial burden and worry questionnaires to ask: (1) What percentage of patients report some level of financial burden, and what is the median financial burden composite score? (2) What percentage of patients report some level of financial worry, and what percentage of patients report a high level of financial worry? (3) When accounting for other assessed factors, what patient- and condition-related factors are associated with financial burden? (4) When accounting for other assessed factors, what patient- and condition-related factors are associated with high financial worry?

METHODS

In this cross-sectional survey study, a hand and upper extremity database at a single tertiary academic medical center was reviewed for patients 18 years or older undergoing operative treatment in our hand and upper extremity division for an isolated distal radius fracture between October 2017 and October 2019. We then selected all patients undergoing carpal tunnel release during the first half of that time period (given the frequency of carpal tunnel syndrome, a 1-year period was sufficient to ensure comparable patient groups). A total of 645 patients were identified (carpal tunnel release: 60% [384 of 645 patients]; open reduction and internal fixation for a distal radius fracture: 40% [261 of 645 patients). Of the patients who underwent carpal tunnel release, 6% (24 of 384) were excluded because of associated injuries. Of the patients undergoing open reduction and internal fixation for a distal radius fracture, 4% (10 of 261) were excluded because of associated injuries. All remaining 611 patients were approached. Thirty-six percent (223 of 611; carpal tunnel release: 36% [128 of 360]; open reduction and internal fixation: 38% [95 of 251]) of patients ultimately completed two validated financial health surveys: the financial burden composite and financial worry questionnaires. Descriptive statistics were calculated to report the percentage of patients who had some level of financial burden and worry. Further, the median financial burden composite score was determined. The percentage of patients who reported a high level of financial worry was calculated. A forward stepwise regression model approach was used; thus, variables with p values < 0.10 in bivariate analysis were included in the final regression analyses to determine which patient- and condition-related factors were associated with financial burden or high financial worry, accounting for all other measured variables.

RESULTS

The median financial burden composite score was 0 (range 0 [lowest possible financial burden] to 6 [highest possible financial burden]), and 13% of patients (30 of 223) reported a high level of financial worry. After controlling for potentially confounding variables like age, insurance type, and self-reported race, the number of dependents (regression coefficient 0.15 [95% CI 0.008 to 0.29]; p = 0.04) was associated with higher levels of financial burden, while retired employment status (regression coefficient -1.24 [95% CI -1.88 to -0.60]; p < 0.001) was associated with lower levels of financial burden. In addition, the number of dependents (odds ratio 1.77 [95% CI 1.21 to 2.61]; p = 0.004) and unable to work or disabled employment status (OR 3.76 [95% CI 1.25 to 11.28]; p = 0.02) were associated with increased odds of high financial worry.

CONCLUSION

A notable number of patients undergoing operative hand care for two common conditions reported some degree of financial burden and worry. Patients at higher risk of financial burden and/or worry may benefit from increased resources during their hand care journey, including social work consultation and financial counselors. This is especially true given the association between number of dependents and work status on financial burden and high financial worry. However, future research is needed to determine the return on investment of this resource utilization on patient clinical outcomes, overall quality of life, and well-being.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Patient Perspectives on Key Outcomes for Vocational Rehabilitation Interventions Following Traumatic Injury

Returning to work after traumatic injury can have a range of benefits, but there is currently little research that incorporates patient perspectives to identify outcomes of vocational rehabilitation interventions that are important to survivors. Trauma survivors (n = 17) participated in in-depth semi-structured interviews or focus groups exploring outcomes that were important to them for recovery and return to work. Data were analysed using thematic analysis. Participants identified a range of outcomes that they considered important and necessary to facilitate a successful and sustainable return to work: physical and psychological recovery, purposeful life engagement, managing expectations of recovery, managing expectations about return to work, and employers’ expectations. Our participants advocated for a multifaceted and biopsychosocial understanding of recovery and outcomes that need to be captured for vocational rehabilitation interventions. Implications for practice and research are discussed, and recommendations are given based on the findings.

Analysis of Patient Income in the 5 Years Following a Fracture Treated Surgically

Importance

Orthopedic injury is assumed to bear negative socioeconomic consequences. However, the magnitude and duration of a fracture's impact on patient income and social insurance benefits remain poorly quantified.

Objective

To characterize the association between orthopedic injury and patient income using state tax records.

Design, Setting, and Participants

This cohort study included adult patients surgically treated for an orthopedic fracture at a US academic trauma center from January 2003 through December 2014. Hospital data were linked to individual-level state tax records using a difference-in-differences analysis performed from November 2019 through August 2020. The control group comprised of data resampled from fracture patients at least 6 years prior to injury.

Exposures

An operatively treated fracture of the appendicular skeleton.

Main Outcomes and Measures

The primary outcome was individual annual earnings up to 5 years postinjury. Secondary outcomes included annual household income and US Social Security benefits for 5 years postinjury and catastrophic wage loss within 2 years of injury.

Results

A total of 9997 fracture patients (mean [SD] age, 44.6 [18.9] years; 6725 [67.3%] men) to 34 570 prefracture control participants (mean [SD] age, 40.0 [20.5] years; 21 666 [62.7%] men). The median (interquartile range) of preinjury wage earnings was $16 847 ($0 to $52 221). The mean annual decline in individual earnings during the 5 years following injury was $9865 (95% CI, -$10 686 to -$8862). Annual household income declined by $5259 (95% CI, -$6337 to -$4181) over the same period. A fracture was associated with a $206 (95% CI, $147 to $265) mean annual increase in Social Security benefits in the 5 years after injury. An injury increased the risk of catastrophic wage loss by 11.6% (95% CI, 10.5% to 12.7%). Substantial relative income loss was observed in patients with preinjury earnings in the top 3 quartiles, but changes in income were negligible for patients with preinjury earnings in the bottom quartile (19%; 95% CI, -4% to 48%).

Conclusions and Relevance

In this cohort study of patients surgically treated for an orthopedic fracture at a US academic trauma center, fractures were associated with substantial individual and household income loss up to 5 years after injury, and 1 in 5 patients sustained catastrophic income loss in the 2 years after fracture. Gains in Social Security benefits offset less than 10% of annual income losses.

Traumatic stress sufferers: work as therapy or trigger?

Purpose

While a return to work following trauma exposure can be therapeutic, this is not always so. As with many topics related to traumatic stress in organizations, several contingency factors complicate the effort to draw an overarching conclusion about whether returning to work is therapeutic. The purpose of this paper is to present important determinants of whether work is therapeutic or triggering for those with traumatic stress conditions. The need for contingency approaches in the study of traumatic stress in organizations is illustrated.

Design/methodology/approach

Literature on traumatic stress in organizations is reviewed.

Findings

Three of the key determinants of whether a return to work is therapeutic or triggering for traumatic stress sufferers are trauma-type contingencies, condition-type contingencies and work-setting contingencies. For instance, human-caused and task-related traumas are more likely than natural disasters to make a return-to-work triggering. Additionally, the time since developing a traumatic stress condition is inversely related to the degree of improvement in that condition through the experience of working. Moreover, managerial actions can affect how therapeutic an employee’s return to work is.

Practical implications

These findings suggest the challenges of reintegrating a traumatized employee to the workplace can be highly situation-specific. Careful consideration of the traumatic event suffered by each traumatic stress victim, their traumatic stress condition, and the work setting to which they would return are recommended.

Social implications

Promoting mental health in organizations can contribute to employers’ social performance.

Originality/value

Examination of the factors that complicate predicting whether work is therapeutic posttrauma demonstrates how contingency approaches can advance research on trauma in organizations.