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Bretherton CP, Kotwal T, Sandhu H, Baird J, Griffin XL. Patient experiences and desires for recovery after ankle fracture surgery. Injury 2024; 55:111763. [PMID: 39106533 DOI: 10.1016/j.injury.2024.111763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 07/18/2024] [Accepted: 07/29/2024] [Indexed: 08/09/2024]
Abstract
OBJECTIVE This study investigates patients' experiences of commencing weight-bearing after ankle fracture surgery and their recovery priorities to inform a new rehabilitation intervention. METHODS Embedded within the Weight bearing in Ankle Fractures (WAX) trial, this qualitative study conducted semi-structured interviews with patients following ankle fracture surgery. The Behaviour Change Wheel (BCW) framework guided the interview questions to ensure comprehensive domain coverage. A purposive, maximum variation sampling strategy was used for participant selection. Data analysis employed a combined deductive and inductive approach. RESULTS A total of 29 patients were interviewed, revealing five key themes: understanding the recovery journey, navigating the healthcare system, understanding personal physical capabilities, building confidence for weight-bearing, and resuming daily activities. Themes emphasised the variability in healthcare access, the impact of non-weight-bearing on independence, and the role of self-efficacy in recovery. CONCLUSIONS The study highlighted the diversity in patient experiences and recovery challenges post-ankle fracture surgery. Patients' recovery was influenced by access to consistent healthcare advice, self-efficacy, and the physical and psychological impact of non-weight-bearing. The findings suggest a need for tailored, patient-centred rehabilitation interventions that consider individual recovery trajectories and promote self-management. These insights provide a foundational understanding for developing interventions that more effectively address patient priorities and barriers to recovery.
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Affiliation(s)
- Christopher P Bretherton
- Bone and Joint Health, Blizard Institute, Queen Mary University London, 4 Newark Street, London, E1 2AT, United Kingdom; Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, E1 1BB, United Kingdom.
| | - Tejas Kotwal
- Bone and Joint Health, Blizard Institute, Queen Mary University London, 4 Newark Street, London, E1 2AT, United Kingdom
| | - Harbinder Sandhu
- Division of Health Sciences, Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL, United Kingdom
| | - Janis Baird
- Centre for Developmental Origins of Health and Disease, University of Southampton, Southampton, SO17 1BJ, United Kingdom
| | - Xavier L Griffin
- Bone and Joint Health, Blizard Institute, Queen Mary University London, 4 Newark Street, London, E1 2AT, United Kingdom; Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, E1 1BB, United Kingdom
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Bretherton C, Al-Saadawi A, Thomson F, Sandhu H, Baird J, Griffin X. Effectiveness of behavior change in rehabilitation interventions to improve functional recovery after lower limb fracture: a systematic review. Musculoskelet Surg 2024:10.1007/s12306-024-00845-x. [PMID: 38955960 DOI: 10.1007/s12306-024-00845-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 06/21/2024] [Indexed: 07/04/2024]
Abstract
Ankle fractures are common injuries that can significantly impact mobility and quality of life. Rehabilitation following ankle fracture treatment is crucial for recovery, yet adherence to regimens remains a challenge. Behaviour Change Techniques (BCTs) have been suggested to improve adherence, but their effectiveness in ankle fracture rehabilitation is not well established. This review aimed to evaluate the effectiveness of BCTs in the rehabilitation of ankle fracture patients. We conducted a comprehensive search across multiple databases, including MEDLINE and EMBASE, focusing on Randomised Controlled Trials (RCTs) that incorporated BCTs into rehabilitation interventions. The effectiveness of BCTs on patient-reported outcomes (PROMs), quality of life, and adverse events was analysed. Nine RCTs met the inclusion criteria, encompassing a range of interventions that employed BCTs, most commonly including goal setting and instruction on how to perform behaviours, specifically physiotherapy exercises. The review found limited evidence supporting their effectiveness in improving PROMs. Only one study showed a significant positive effect, but it was deemed at high risk of bias. The lack of integration of behavioural theory in the design of rehabilitation interventions and the varied nature of the BCTs employed across studies may contribute to these findings. The use of BCTs in ankle fracture rehabilitation is prevalent, but this review highlights a significant gap their role of enhancing patient outcomes. Future research should incorporate a theory-based approach to intervention design, utilising a broader range of BCTs, to fully evaluate their potential in improving rehabilitation adherence and outcomes following ankle fracture .
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Affiliation(s)
- Christopher Bretherton
- Bone and Joint Health, Blizard Institute, Queen Mary University London, 4 Newark Street, London, E1 2AT, UK.
- Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, E1 1BB, UK.
| | - Ahmed Al-Saadawi
- School of Medicine, Faculty of Medicine and Dentistry, Queen Mary University of London, London, England, UK
| | - Fraser Thomson
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Harbinder Sandhu
- Division of Health Sciences, Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL, UK
| | - Janis Baird
- Centre for Developmental Origins of Health and Disease, University of Southampton, Southampton, SO17 1BJ, UK
| | - Xavier Griffin
- Bone and Joint Health, Blizard Institute, Queen Mary University London, 4 Newark Street, London, E1 2AT, UK
- Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, E1 1BB, UK
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Bretherton CP, Achten J, Jogarah V, Petrou S, Peckham N, Achana F, Appelbe D, Kearney R, Claireux H, Bell P, Griffin XL. Early versus delayed weight-bearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomised controlled trial. Lancet 2024; 403:2787-2797. [PMID: 38848738 DOI: 10.1016/s0140-6736(24)00710-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/24/2024] [Accepted: 04/05/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND After surgery for a broken ankle, patients are usually instructed to avoid walking for 6 weeks (delayed weight-bearing). Walking 2 weeks after surgery (early weight-bearing) might be a safe and preferable rehabilitation strategy. This study aimed to determine the clinical and cost effectiveness of an early weight-bearing strategy compared with a delayed weight-bearing strategy. METHODS This was a pragmatic, multicentre, randomised, non-inferiority trial including 561 participants (aged ≥18 years) who received acute surgery for an unstable ankle fracture in 23 UK National Health Service (NHS) hospitals who were assigned to either a delayed weight-bearing (n=280) or an early weight-bearing rehabilitation strategy (n=281). Patients treated with a hindfoot nail, those who did not have protective ankle sensation (eg, peripheral neuropathy), did not have the capacity to consent, or did not have the ability to adhere to trial procedures were excluded. Neither participants nor clinicians were masked to the treatment. The primary outcome was ankle function measured using the Olerud and Molander Ankle Score (OMAS) at 4 months after randomisation, in the per-protocol population. The pre-specified non-inferiority OMAS margin was -6 points and superiority testing was included in the intention-to-treat population in the event of non-inferiority. The trial was prospectively registered with ISRCTN Registry, ISRCTN12883981, and the trial is closed to new participants. FINDINGS Primary outcome data were collected from 480 (86%) of 561 participants. Recruitment was conducted between Jan 13, 2020, and Oct 29, 2021. At 4 months after randomisation, the mean OMAS score was 65·9 in the early weight-bearing and 61·2 in the delayed weight-bearing group and adjusted mean difference was 4·47 (95% CI 0·58 to 8·37, p=0·024; superiority testing adjusted difference 4·42, 95% CI 0·53 to 8·32, p=0·026) in favour of early weight-bearing. 46 (16%) participants in the early weight-bearing group and 39 (14%) in the delayed weight-bearing group had one or more complications (adjusted odds ratio 1·18, 95% CI 0·80 to 1·75, p=0·40). The mean costs from the perspective of the NHS and personal social services in the early and delayed weight-bearing groups were £725 and £785, respectively (mean difference -£60 [95% CI -342 to 232]). The probability that early weight-bearing is cost-effective exceeded 80%. INTERPRETATION An early weight-bearing strategy was found to be clinically non-inferior and highly likely to be cost-effective compared with the current standard of care (delayed weight-bearing). FUNDING National Institute for Health and Care Research (NIHR), NIHR Barts Biomedical Research Centre, and NIHR Applied Research Collaboration Oxford and Thames Valley.
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Affiliation(s)
- Christopher Patrick Bretherton
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK; Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, UK.
| | - Juul Achten
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
| | - Vidoushee Jogarah
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nicholas Peckham
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
| | - Felix Achana
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
| | - Rebecca Kearney
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Clifton, Bristol, UK
| | - Harry Claireux
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie Centre, University of Oxford, Oxford, UK
| | - Philip Bell
- Patient and Public Representative, Anglesey, UK
| | - Xavier L Griffin
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK; Department of Trauma and Orthopaedic Surgery, Royal London Hospital, Barts Health NHS Trust, London, UK
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Keene DJ, Achten J, Forde C, Png ME, Grant R, Draper K, Appelbe D, Tutton E, Peckham N, Dutton SJ, Lamb SE, Costa ML. Effectiveness of supervised versus self-directed rehabilitation for adults aged 50 years and over with ankle fractures: protocol for the AFTER trial. Bone Jt Open 2024; 5:499-513. [PMID: 38898823 PMCID: PMC11187601 DOI: 10.1302/2633-1462.56.bjo-2023-0183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
Aims Ankle fractures are common, mainly affecting adults aged 50 years and over. To aid recovery, some patients are referred to physiotherapy, but referral patterns vary, likely due to uncertainty about the effectiveness of this supervised rehabilitation approach. To inform clinical practice, this study will evaluate the effectiveness of supervised versus self-directed rehabilitation in improving ankle function for older adults with ankle fractures. Methods This will be a multicentre, parallel-group, individually randomized controlled superiority trial. We aim to recruit 344 participants aged 50 years and older with an ankle fracture treated surgically or non-surgically from at least 20 NHS hospitals. Participants will be randomized 1:1 using a web-based service to supervised rehabilitation (four to six one-to-one physiotherapy sessions of tailored advice and prescribed home exercise over three months), or self-directed rehabilitation (provision of advice and exercise materials that participants will use to manage their recovery independently). The primary outcome is participant-reported ankle-related symptoms and function six months after randomization, measured by the Olerud and Molander Ankle Score. Secondary outcomes at two, four, and six months measure health-related quality of life, pain, physical function, self-efficacy, exercise adherence, complications, and resource use. Due to the nature of the interventions, participants and intervention providers will be unblinded to treatment allocation. Conclusion This study will assess whether supervised rehabilitation is more effective than self-directed rehabilitation for adults aged 50 years and older after ankle fracture. The results will provide evidence to guide clinical practice. At the time of submission, the trial is currently completing recruitment, and follow-up will be completed in 2024.
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Affiliation(s)
- David J. Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Exeter Medical School, University of Exeter, Exeter, UK
| | - Juul Achten
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Colin Forde
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - May E. Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Kylea Draper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Duncan Appelbe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nicholas Peckham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J. Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E. Lamb
- Exeter Medical School, University of Exeter, Exeter, UK
| | - Matthew L. Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Phelps EE, Tutton E, Costa ML, Achten J, Gibson P, Moscrop A, Perry DC. Being recovered: a qualitative study of parents' experience of their child's recovery up to a year after a displaced distal radius fracture. Bone Jt Open 2024; 5:426-434. [PMID: 38770597 PMCID: PMC11107374 DOI: 10.1302/2633-1462.55.bjo-2024-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Aims The aim of this study was to explore parents' experience of their child's recovery, and their thoughts about their decision to enrol their child in a randomized controlled trial (RCT) of surgery versus non-surgical casting for a displaced distal radius fracture. Methods A total of 20 parents of children from 13 hospitals participating in the RCT took part in an interview five to 11 months after injury. Interviews were informed by phenomenology and analyzed using thematic analysis. Results Analysis of the findings identified the theme "being recovered", which conveyed: 1) parents' acceptance and belief that their child received the best treatment for them; 2) their memory of the psychological impact of the injury for their child; and 3) their pride in how their child coped with their cast and returned to activities. The process of recovery was underpinned by three elements of experience: accepting the treatment, supporting their child through challenges during recovery, and appreciating their child's resilience. These findings extend our framework that highlights parents' desire to protect their child during early recovery from injury, by making the right decision, worrying about recovery, and comforting their child. Conclusion By one year after injury, parents in both treatment groups considered their child "recovered". They had overcome early concerns about healing, the appearance of the wrist, and coping after cast removal. Greater educational support for families during recovery would enable parents and their child to cope with the uncertainty of recovery, particularly addressing the loss of confidence, worry about reinjury, and the appearance of their wrist.
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Affiliation(s)
- Emma E. Phelps
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie, Oxford Trauma and Emergency Care, Oxford University, Oxford, UK
| | - Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie, Oxford Trauma and Emergency Care, Oxford University, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Matthew L. Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie, Oxford Trauma and Emergency Care, Oxford University, Oxford, UK
| | - Juul Achten
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie, Oxford Trauma and Emergency Care, Oxford University, Oxford, UK
| | - Phoebe Gibson
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Amy Moscrop
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Daniel C. Perry
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Kadoorie, Oxford Trauma and Emergency Care, Oxford University, Oxford, UK
- Department of Child Health, University of Liverpool, Alder Hey Hospital, Liverpool, UK
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Achten J, Marques EMR, Pinedo-Villanueva R, Whitehouse MR, Eardley WGP, Costa ML, Kearney RS, Keene DJ, Griffin XL. The FAME trial study protocol: In younger adults with unstable ankle fractures treated with close contact casting, is ankle function not worse than those treated with surgical intervention? Bone Jt Open 2024; 5:184-201. [PMID: 38447595 PMCID: PMC10924289 DOI: 10.1302/2633-1462.53.bjo-2023-0099.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Aims Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of function and quality of life (Qol) is considerable. Non-surgical treatment is an alternative to surgery and involves applying a cast carefully shaped to the patient's ankle to correct and maintain alignment of the joint with the key benefit being a reduction in the frequency of common complications of surgery. The main potential risk of non-surgical treatment is a loss of alignment with a consequent reduction in ankle function. This study aims to determine whether ankle function, four months after treatment, in patients with unstable ankle fractures treated with close contact casting is not worse than in those treated with surgical intervention, which is the current standard of care. Methods This trial is a pragmatic, multicentre, randomized non-inferiority clinical trial with an embedded pilot, and with 12 months clinical follow-up and parallel economic analysis. A surveillance study using routinely collected data will be performed annually to five years post-treatment. Adult patients, aged 60 years and younger, with unstable ankle fractures will be identified in daily trauma meetings and fracture clinics and approached for recruitment prior to their treatment. Treatments will be performed in trauma units across the UK by a wide range of surgeons. Details of the surgical treatment, including how the operation is done, implant choice, and the recovery programme afterwards, will be at the discretion of the treating surgeon. The non-surgical treatment will be close-contact casting performed under anaesthetic, a technique which has gained in popularity since the publication of the Ankle Injury Management (AIM) trial. In all, 890 participants (445 per group) will be randomly allocated to surgical or non-surgical treatment. Data regarding ankle function, QoL, complications, and healthcare-related costs will be collected at eight weeks, four and 12 months, and then annually for five years following treatment. The primary outcome measure is patient-reported ankle function at four months from treatment. Anticipated impact The 12-month results will be presented and published internationally. This is anticipated to be the only pragmatic trial reporting outcomes comparing surgical with non-surgical treatment in unstable ankle fractures in younger adults (aged 60 years and younger), and, as such, will inform the National Institute for Health and Care Excellence (NICE) 'non-complex fracture' recommendations at their scheduled update in 2024. A report of long-term outcomes at five years will be produced by January 2027.
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Affiliation(s)
- Juul Achten
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Rafael Pinedo-Villanueva
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | | | - Matthew L. Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - David J. Keene
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Xavier L. Griffin
- Barts Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
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Becerra E, Castro M, Ruiz-Riquelme P. Results of prophylactic simple fasciocutaneous advancement in the initial management of acute ankle fractures with high risk of operative wound complication. Foot Ankle Surg 2024; 30:37-43. [PMID: 37730458 DOI: 10.1016/j.fas.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 08/24/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023]
Abstract
Ankle fracture is the third most prevalent fracture in older adults. Wound dehiscence is the most frequent complication. Our objective is to determine the operative wound complication rate in patients with unstable ankle fracture in whom a prophylactic simple fasciocutaneous advancement was used. METHODS Prospective registry of patients with unstable ankle fracture, in whom a prophylactic fasciocutaneous advancement was performed between August 2020 and July 2021. Demographic variables, time spent in performing the flap, cost of osteosynthesis, minor and major complications of the surgical wound, readmission or reoperation were registered. RESULTS 42 older adults with ankle fracture were included. Median age 69 (60-94). 31% diabetics and 21.5% active smokers. A 40% trimalleolar fracture pattern. There were 7% of superficial complications of the surgical wound. No major complications, no reoperations. CONCLUSIONS Prophylactic fasciocutaneous advancement at the beginning of traumatological surgery is technically simple, reproducible, cheap and with low complications. LEVEL OF EVIDENCE Level IV, cross-sectional study.
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Affiliation(s)
- Eduardo Becerra
- Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Clínico La Florida, Santiago, Chile; Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Carabineros de Chile, Santiago, Chile
| | - Magdalena Castro
- School of Medicine, Finis Terrae University, Santiago, Chile; Clinical Epidemiology and Research Unit, School of Medicine, Finis Terrae University, Santiago, Chile
| | - Pablo Ruiz-Riquelme
- Foot and Ankle Surgery Unit, Department of Orthopedic and Traumatology, Hospital Clínico La Florida, Santiago, Chile; School of Medicine, Finis Terrae University, Santiago, Chile; Foot and Ankle Surgery Unit, Department of Orthopedics and Traumatology, Clinic Las Condes, Santiago, Chile.
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Vabo S, Kjerstad E, Hunskaar S, Steen K, Brudvik C, Morken T. Acute management of fractures in primary care - a cost minimisation analysis. BMC Health Serv Res 2023; 23:1291. [PMID: 37996824 PMCID: PMC10668448 DOI: 10.1186/s12913-023-10297-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND In Norway, primary healthcare has first-line responsibility for all medical emergencies, including traumas and fractures. Normally, patients with suspected fractures are referred to specialist care in hospitals. However, the cooperating municipalities of Bykle and Valle have X-ray facilities and handle minor fractures locally. The aim of this study was to estimate the costs of X-ray diagnosis and initial treatment of fractures at the local primary care centre compared with initial transport and treatment in hospital. METHODS We conducted a cost minimisation analysis by comparing expected costs of initial examination with X-ray and treatment of patients with fractures or suspected fractures at two possible sites, in the local municipality or at the hospital. A cost minimisation analysis is an economic evaluation based on the assumption that the outcomes of the two treatment procedure regimens are equal. Costs were estimated in Euros (EUR) using 2021 mean exchange rates. RESULTS In 2019, we identified a total of 403 patients with suspected fractures in the two municipalities. Among these, 12 patients bypassed the primary care system as they needed urgent hospital care. A total of 391 injured patients were assessed with X-ray at the primary health care centres, 382 received their initial treatment there, and nine were referred to hospital. In an alternative hospital model, without X-ray and treatment possibilities in the municipality, the 382 patients would have been sent directly to hospital for radiological imaging and treatment. The total cost was estimated at EUR 367,756 in the hospital model and at EUR 69,835 in the primary care model, a cost saving of EUR 297,921. CONCLUSION Based on cost minimisation analysis, this study found that radiological diagnosis of suspected fractures and initial treatment of uncomplicated fractures in primary care cost substantially less than transport to and treatment in hospital.
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Affiliation(s)
- Stein Vabo
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Box 22, Nygårdstangen, Bergen, NO-5838, Norway.
- Vennesla Health Care Centre, Sentrumsvegen 41, Vennesla, NO-4700, Norway.
| | - Egil Kjerstad
- Department of Social Science and Health, Health Services and Health Economics Research Group, NORCE Norwegian Research Centre, Nygårdsgaten 112, Bergen, NO-5008, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Box 22, Nygårdstangen, Bergen, NO-5838, Norway
- Department of Global Public Health and Primary Care, University of Bergen, P.O. Box 7800, Bergen, NO-5020, Norway
| | - Knut Steen
- Minor Injury Department, Orthopaedic Division, Haukeland University Hospital, Bergen, Norway
| | - Christina Brudvik
- Department of Clinical Medicine, University of Bergen, P.O. Box 7800, Bergen, NO-5020, Norway
| | - Tone Morken
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Box 22, Nygårdstangen, Bergen, NO-5838, Norway
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Makaram NS, Simpson AHRW. Explanatory and pragmatic trials in orthopaedics - Have we done the right studies? Injury 2023; 54 Suppl 5:110905. [PMID: 37400326 DOI: 10.1016/j.injury.2023.110905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 07/05/2023]
Abstract
Recent decades have seen marked advances in the quality of clinical orthopaedic trauma research, and with this has come a rise in the number of randomised clinical trials (RCTs) being conducted in orthopaedic trauma. These trials have been largely valuable in driving evidence-based management of injuries which previously had clinical equipoise. However, though RCTs are traditionally seen as the 'gold standard' of high-quality research, this research method is comprised primarily of two entities, explanatory and pragmatic designs, each with its own strengths and limitations. Most orthopaedic trials lie within a continuum between these designs, with varying degrees of both pragmatic and explanatory features. In this narrative review we provide a summary of the nuances within orthopaedic trial design, the advantages and limitations of such designs, and suggest tools which may aid clinicians in the appropriate selection and evaluation of trial designs.
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Affiliation(s)
- N S Makaram
- Specialty Registrar (StR) in Trauma and Orthopaedics, Edinburgh Orthopaedics, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SU, United Kingdom.
| | - A Hamish R W Simpson
- Professor of Orthopaedics and Trauma, Edinburgh Orthopaedics, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SU, United Kingdom
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Corin N, Pearkes T, Hristova K, Nagaraj P, Bassett J, Riddick A, Harries W, Hepple S, Winson I, Robinson P. The Use of Hindfoot Nails for Elderly Complex Distal Tibial and Ankle Fractures. J Foot Ankle Surg 2023; 62:797-801. [PMID: 37086906 DOI: 10.1053/j.jfas.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 03/15/2023] [Accepted: 03/29/2023] [Indexed: 04/24/2023]
Abstract
Elderly patients who sustain complex ankle or distal tibial fractures are often frail and comorbid and need surgery to contain the talus underneath the tibia in order to protect the soft tissue envelope and allow early unrestricted weightbearing. We performed a retrospective observational review of patients >65 years old who underwent a hindfoot nail fixation of an ankle or distal tibial fracture in our institution. Data collected included: injury sustained, open or closed injury, ASA grade, age at time of surgery, length of stay, postoperative mortality, complications, and further treatment. The primary outcome was reoperation. Secondary outcomes were infection and 1 year mortality. Seventy hind foot nailing procedures were undertaken. Sixty-three out of 70 patients were female. The average age of those who died within 1 year of surgery was 84 years. Forty-five out of 70 were open injuries. Eleven out of 70 patients died with 1 year of surgery (range 1-358 days postsurgery). Five out of 70 (7%) patients developed an infection. Four out of 5 of these injuries were open. Three out of 5 underwent removal of the nail due to infection. Two out of 5 had the infection suppressed with antibiotics. Ten out of 70 (14%) patients underwent locking bolt removal due to it backing out or being prominent and causing wound healing issues. Two out of 70 (3%) patients went on to have below knee amputations. Both were due to ongoing wound problems following open fractures. The hindfoot nail is an important implant when treating complex ankle and distal tibial fractures in an elderly population. It facilitates early mobilization to avoid deconditioning and other medical complications.
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Affiliation(s)
- Nicole Corin
- Department of Trauma and Orthopaedics, Southmead Hospital, Bristol, United Kingdom.
| | - Timothy Pearkes
- Department of Trauma and Orthopaedics, Southmead Hospital, Bristol, United Kingdom
| | - Kalina Hristova
- Department of Trauma and Orthopaedics, Southmead Hospital, Bristol, United Kingdom
| | - Prashanth Nagaraj
- Department of Trauma and Orthopaedics, Southmead Hospital, Bristol, United Kingdom
| | - James Bassett
- Department of Trauma and Orthopaedics, Southmead Hospital, Bristol, United Kingdom
| | - Andrew Riddick
- Department of Trauma and Orthopaedics, Southmead Hospital, Bristol, United Kingdom
| | - William Harries
- Department of Trauma and Orthopaedics, Southmead Hospital, Bristol, United Kingdom
| | - Steven Hepple
- Department of Trauma and Orthopaedics, Southmead Hospital, Bristol, United Kingdom
| | - Ian Winson
- Department of Trauma and Orthopaedics, Southmead Hospital, Bristol, United Kingdom
| | - Peter Robinson
- Department of Trauma and Orthopaedics, Southmead Hospital, Bristol, United Kingdom
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11
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Morcos Z, Yousaf A, Duggleby L, Koç T. A Stability-Based Management Protocol for Isolated Lateral Malleolar Ankle Fractures at the Level of the Syndesmosis Reduces the Need for Surgical Intervention. Indian J Orthop 2023; 57:1296-1301. [PMID: 37525731 PMCID: PMC10386987 DOI: 10.1007/s43465-023-00926-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 06/05/2023] [Indexed: 08/02/2023]
Abstract
Purpose The study aimed to establish and subsequently improve the rate of stability assessments of fractures with uncertain stability and the impact on the avoidance of potentially unnecessary surgery. Methods Two independent audit cycles were conducted from October 2019 to May 2020. All patients had closed isolated lateral malleolar fractures at the level of the tibiotalar syndesmosis involving skeletally mature bone. A stability-based management protocol was introduced, incorporating an education programme and management guideline. Results 75 ankles fractures were included. In the initial audit cycle, 13 patients did not undergo stability X-rays within 2 weeks of injury. Interestingly, only one stability assessment was performed for five operated ankles in the first audit, versus a 100% compliance rate in the second cycle. We observed more accurate documentation following education and awareness of clinical importance. Conclusion By implementing a stability-based management guideline, there was an improvement in compliance with guidance towards stability assessments of ankle fractures. This potentially led to the avoidance of unnecessary surgery on fractures where stability assessments supported non-operative management.
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Affiliation(s)
- Zeid Morcos
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth, PO6 3LY UK
| | - Ali Yousaf
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth, PO6 3LY UK
| | - Luke Duggleby
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth, PO6 3LY UK
| | - Togay Koç
- Department of Trauma and Orthopaedics, Queen Alexandra Hospital, Portsmouth, PO6 3LY UK
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12
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Peng H, Guo XB, Zhao JM. Influence of Patient-Reported Outcome Measures by Surgical Versus Conservative Management in Adult Ankle Fractures: A Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1152. [PMID: 37374356 DOI: 10.3390/medicina59061152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023]
Abstract
Background and Objective: This meta-analysis was performed to compare the effectiveness of surgical treatment and conservative treatment in adult ankle fractures. Methods: Pubmed, Embase, and Cochrane-Library databases were searched to retrieve prospective randomized-controlled studies that compared the efficacy of surgical treatment and conservative treatment in adult ankle fractures. The meta package in R language was used to organize and analyze the obtained data. Results: A total of eight studies involving 2081 patients was considered eligible, including 1029 patients receiving surgical treatment and 1052 receiving conservative treatment. This systematic review and meta-analysis was prospectively registered on PROSPERO, and the registration number is CRD42018520164. Olerud and Molander ankle-fracture scores (OMAS) and the health survey 12-item Short-Form (SF-12) were used as main outcome indicators, and the follow-up outcomes were grouped according to the follow-up time. Meta-analysis results showed significantly higher OMAS scores in patients receiving surgical treatment than those with conservative treatment at six months (MD = 1.50, 95% CI: 1.07; 1.93) and over 24 months (MD = 3.10, 95% CI: 2.46; 3.74), while this statistical significance was absent at 12-24 months (MD = 0.08, 95% CI: -5.80; 5.96). At six months and 12 months after treatment, patients receiving surgical treatment exhibited significantly higher SF12-physical results than those receiving conservative treatment (MD = 2.40, 95% CI: 1.89; 2.91). The MD of SF12-mental data at six months after meta-analysis was -0.81 (95% CI: -1.22; 0.39), and the MD of SF12-mental data at 12+ months was -0.81 (95% CI: -1.22; 0.39). There was no significant difference in SF12-mental results between the two treatment methods after six months, but after 12 months, the SF12-mental results of patients receiving surgical treatment were significantly lower than those of conservative treatment. Conclusions: In the treatment of adult ankle fractures, surgical treatment is more efficacious than conservative treatment in improving early and long-term joint function and physical health of patients, but it is associated with long-term adverse mental health.
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Affiliation(s)
- Hui Peng
- Department of Trauma Orthopedics and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
- Minzu Hospital of Guangxi Zhuang Autonomous Region, Nanning 530000, China
| | - Xiao-Bo Guo
- Department of Trauma Orthopedics and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
| | - Jin-Min Zhao
- Department of Trauma Orthopedics and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning 530021, China
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13
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Martínez-Barro D, Escalante-Montes PK, Contreras-del Carmen N, Cortes-Aguirre CS, Peralta-Ildefonso D, Hernández-Amaro H, Rojano-Mejía D. [Factors associated with functionality in patients with closed ankle fracture]. REVISTA MEDICA DEL INSTITUTO MEXICANO DEL SEGURO SOCIAL 2023; 61:283-288. [PMID: 37216426 PMCID: PMC10437224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/19/2022] [Indexed: 05/24/2023]
Abstract
Background Ankle fractures are among the most frequent fractures in the lower limb, predominantly affecting young people and representing approximately 9% of all fractures. Objective To identify the factors associated with functionality in patients with closed ankle fracture. Material and methods Observational and retrospective study. Records of people with a diagnosis of ankle fractures admitted to rehabilitation between January to December 2020 in a Physical Medicine and Rehabilitation Unit of a third level hospital were included. Age, sex, body mass index (BMI), days of disability, mechanism of injury, type of treatment, length of stay in rehabilitation, type of fracture and functionality were captured. Chi-squared and Student's t test were used to determine the association. Subsequently a multivariate analysis with binary logistic regression was performed. Results The average age of the subjects was 44.8 years, the female sex was presented in 54.7%, the average BMI was 28.8%, 66% carried out a paid work activity, 65% received surgical treatment, the average time of disability was 140 days, the factors associated with functionality independently were age, pain, dorsiflexion and plantar flexion upon admission to rehabilitation. Conclusions Ankle fractures occur in a young population and the factors associated with functionality were age, dorsiflexion, plantar flexion, and pain upon admission to rehabilitation.
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Affiliation(s)
- Daniel Martínez-Barro
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 6 “Ignacio García Tellez”, Servicio de Rehabilitación. Ciudad Madero, Tamaulipas, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Perla Karina Escalante-Montes
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 270, Servicio de Rehabilitación. Ciudad Reynosa, Tamaulipas, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Nallely Contreras-del Carmen
- Instituto Mexicano del Seguro Social, Hospital General Regional No. 220, Servicio de Rehabilitación. Toluca, Estado de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Claudia Stephane Cortes-Aguirre
- Instituto Mexicano del Seguro Social, Centro Médico Nacional La Raza, Hospital General “Dr. Gaudencio González Garza”, Servicio de Rehabilitación Integral. Ciudad de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Diana Peralta-Ildefonso
- Instituto Mexicano del Seguro Social, Centro Médico Nacional La Raza, Hospital General “Dr. Gaudencio González Garza”, Servicio de Rehabilitación Integral. Ciudad de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - Hermelinda Hernández-Amaro
- Instituto Mexicano del Seguro Social, Unidad Médica de Alta Especialidad de Traumatología, Ortopedia y Rehabilitación “Dr. Victorio de la Fuente Narváez”, Unidad de Medicina Física y Rehabilitación Norte, División de Educación. Ciudad de México. MéxicoInstituto Mexicano del Seguro SocialMéxico
| | - David Rojano-Mejía
- Instituto Mexicano del Seguro Social, Centro Médico Nacional Siglo XXI, Coordinación de Investigación en Salud. Ciudad de México, MéxicoInstituto Mexicano del Seguro SocialMéxico
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Davies PSE, Pennington R, Dhadwal AS, Chokotho L, Nyamulani N, Mpanga C, Graham SM. Clinical outcomes of ankle fractures in sub-Saharan Africa: a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:547-557. [PMID: 36242674 PMCID: PMC10036281 DOI: 10.1007/s00590-022-03397-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/16/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Ankle fractures may cause disability and socioeconomic challenges, even when managed in a high-resource setting. The outcomes of ankle fractures in sub-Saharan Africa are not widely reported. We present a systematic review of the patient-reported outcomes and complications of patients treated for ankle fractures in sub-Saharan Africa. METHODS Medline, Embase, Google Scholar and the Cochrane Central Register of Controlled Trials were searched, utilising MeSH headings and Boolean search strategies. Ten papers were included. Data included patient demographics, surgical and non-surgical management, patient-reported outcome measures and evidence of complications. RESULTS A total of 555 patients with ankle fractures were included, 471 of whom were followed up (range 6 weeks-73 months). A heterogenous mix of low-quality observational studies and two methodologically poor-quality randomised trials demonstrated mixed outcomes. A preference for surgical management was found within the published studies with 87% of closed fractures being treated operatively. A total of five different outcome scoring systems were used. Most studies included in this review were published by well-resourced organisations and as such are not representative of the actual clinical practice taking place. CONCLUSION The literature surrounding the clinical outcomes of ankle fractures in sub-Saharan Africa is sparse. There appears to be a preference for surgical fixation in the published literature and considering the limitations in surgical resources across sub-Saharan Africa this may not be representative of real-life care in the region.
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Affiliation(s)
- Peter Samuel Edward Davies
- Department of Trauma and Orthopaedics, Ninewells Teaching Hospital, Dundee, Scotland, UK
- The University of Dundee, Dundee, Scotland, UK
| | | | - Anil Singh Dhadwal
- Liverpool Orthopaedic and Trauma Service, Liverpool University Teaching Hospital Trust, Liverpool, UK
| | - Linda Chokotho
- Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi
| | - Nohakhelha Nyamulani
- Trauma and Orthopaedics, Queen Elizabeth Central Hospital, BOX 95, Blantyre, Malawi
| | - Chiku Mpanga
- Trauma and Orthopaedics, Queen Elizabeth Central Hospital, BOX 95, Blantyre, Malawi
| | - Simon Matthew Graham
- Liverpool Orthopaedic and Trauma Service, Liverpool University Teaching Hospital Trust, Liverpool, UK.
- Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK.
- Division of Orthopaedic Surgery, Groote Schuur Hospital, Cape Town, South Africa.
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15
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Pearson NA, Tutton E, Gwilym SE, Joeris A, Grant R, Keene DJ, Haywood KL. Understanding patient experience of distal tibia or ankle fracture: a qualitative systematic review. Bone Jt Open 2023; 4:188-197. [PMID: 37051834 PMCID: PMC10031546 DOI: 10.1302/2633-1462.43.bjo-2022-0115.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
To systematically review qualitative studies of patients with distal tibia or ankle fracture, and explore their experience of injury and recovery. We undertook a systematic review of qualitative studies. Five databases were searched from inception to 1 February 2022. All titles and abstracts were screened, and a subset were independently assessed. Methodological quality was appraised using the Critical Appraisal Skills Programme (CASP) checklist. The GRADE-CERQual checklist was used to assign confidence ratings. Thematic synthesis was used to analyze data with the identification of codes which were drawn together to form subthemes and then themes. From 2,682 records, 15 studies were reviewed in full and four included in the review. A total of 72 patients were included across the four studies (47 female; mean age 50 years (17 to 80)). Methodological quality was high for all studies, and the GRADE-CERQual checklist provided confidence that the findings were an adequate representation of patient experience of distal tibia or ankle fracture. A central concept of 'being the same but different' conveyed the substantial disruption to patients' self-identity caused by their injury. Patient experience of 'being the same but different' was expressed through three interrelated themes, with seven subthemes: i) being proactive where persistence, doing things differently and keeping busy prevailed; ii) living with change including symptoms, and living differently due to challenges at work and leisure; and iii) striving for normality, adapting while lacking in confidence, and feeling fearful and concerned about the future. Ankle injuries were disruptive, draining, and impacted on patients' wellbeing. Substantial short- and longer-term challenges were experienced during recovery. Rehabilitation and psychosocial treatment strategies may help to ameliorate these challenges. Patients may benefit from clinicians being cognisant of patient experience when assessing, treating, and discussing expectations and outcomes with patients.
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Affiliation(s)
- Nathan A Pearson
- Warwick Research in Nursing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Elizabeth Tutton
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Major Trauma Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Stephen E Gwilym
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alexander Joeris
- AO ITC, Clinical Science, AO Foundation, Strettbacherstrausse 6, 8600, Dubendorf, Switzerland
| | - Richard Grant
- National Institute for Health Research, Applied Research Collaboration, West Midlands; Warwick Medical School, User Teaching and Research Action Partnership; Fragility Fracture Network; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David J Keene
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Kirstie L Haywood
- Warwick Research in Nursing, Warwick Medical School, University of Warwick, Coventry, UK
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Haque A, Parsons H, Parsons N, Costa ML, Redmond AC, Mason J, Nwankwo H, Kearney RS. Use of cast immobilization versus removable brace in adults with an ankle fracture: two-year follow-up of a multicentre randomized controlled trial. Bone Joint J 2023; 105-B:382-388. [PMID: 36924175 DOI: 10.1302/0301-620x.105b4.bjj-2022-0602.r3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
The aim of this study was to compare the longer-term outcomes of operatively and nonoperatively managed patients treated with a removable brace (fixed-angle removable orthosis) or a plaster cast immobilization for an acute ankle fracture. This is a secondary analysis of a multicentre randomized controlled trial comparing adults with an acute ankle fracture, initially managed either by operative or nonoperative care. Patients were randomly allocated to receive either a cast immobilization or a fixed-angle removable orthosis (removable brace). Data were collected on baseline characteristics, ankle function, quality of life, and complications. The Olerud-Molander Ankle Score (OMAS) was the primary outcome which was used to measure the participant's ankle function. The primary endpoint was at 16 weeks, with longer-term follow-up at 24 weeks and two years. Overall, 436 patients (65%) completed the final two-year follow-up. The mean difference in OMAS at two years was -0.3 points favouring the plaster cast (95% confidence interval -3.9 to 3.4), indicating no statistically significant difference between the interventions. There was no evidence of differences in patient quality of life (measured using the EuroQol five-dimension five-level questionnaire) or Disability Rating Index. This study demonstrated that patients treated with a removable brace had similar outcomes to those treated with a plaster cast in the first two years after injury. A removable brace is an effective alternative to traditional immobilization in a plaster cast for patients with an ankle fracture.
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Affiliation(s)
- Aminul Haque
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Helen Parsons
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Nick Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew L Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Rheumatology, Musculoskeletal and Orthopaedic Sciences, University of Oxford, Oxford, UK
| | - Anthony C Redmond
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - James Mason
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Henry Nwankwo
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
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Tutton E, Gould J, Lamb SE, Costa ML, Keene DJ. 'It Makes Me Feel Old': Understanding the Experience of Recovery From Ankle Fracture at 6 Months in People Aged 50 Years and Over. QUALITATIVE HEALTH RESEARCH 2023; 33:308-320. [PMID: 36745107 PMCID: PMC10061622 DOI: 10.1177/10497323231153605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Ankle fracture is a common injury, and depending on injury severity, treatment may be a support boot, cast or surgery. Older people, particularly those with severe injuries who are asked to restrict weight bearing, struggle with early recovery. To elicit older peoples' experience of recovery 6 months after injury, we drew on a phenomenological approach using interviews. Findings revealed that getting on with life was a way of accepting what it feels like to 'be vulnerable', needing to 'be safe' while determinedly working hard to 'be myself'. Being vulnerable identified endurance of inactivity, loneliness and dependency in the non-weight bearing period of recovery, followed by a struggle to weight bear while lacking confidence and being fearful of falling and causing further damage. Being safe conveyed fragility where sensations, pain and stiffness acted as bodily reminders of injury. Lack of function and awareness of danger led to carefulness where planning or curtailing of activities ensured their safety. Being myself showed a determination to push away from a disrupted self-identify of being older or disabled while being challenged by the continuous process of learning to be more mobile. A lack of readiness for old age created a drive to age well. Despite loss of ability, participants hoped to regain their pre-injury way of living. This study challenges practice that disregards the hard work required to recover from ankle fracture. As comorbidity increases with age, failure to consider this aspect may contribute to frailty in this group of older people.
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Affiliation(s)
- Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Major Trauma Centre, Oxford UniversityHospitals NHS Foundation Trust, Oxford, UK
| | - Jenny Gould
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E. Lamb
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Matthew L. Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David J. Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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18
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Barlow C, Duggleby L, Barton T. Early weight bearing in elderly patients with ankle fractures reduces care needs and maintains independence. Foot Ankle Surg 2023; 29:63-66. [PMID: 36175269 DOI: 10.1016/j.fas.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/02/2022] [Accepted: 09/19/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Ankle fractures in the elderly are increasingly prevalent and are associated with significant morbidity and loss of independence. METHOD Patients over the age of 70 suffering ankle fracture were identified using ICD-9-CM patient coding. Fracture stability was assessed using patient records and radiographic evidence. Management strategy, length of inpatient stay, time non-weight bearing, pre-admission residence, discharge destination and discharge care needs were studied. RESULTS 169 patients with a mean age 80.3 years were studied. Management strategy was shown to have a significant effect on a patient's care requirements (p = 0.012) and ability to return to their primary residence (p = 0.014). Management via an intramedullary rod was associated with the lowest rates of increased care needs (29.7%) and the highest rate of returning home on discharge (88.9%). CONCLUSIONS Early weight bearing had a significant effect on a patient's ability to maintain independent living and were more likely to return to their own home.
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Affiliation(s)
- Ciaran Barlow
- Department of Trauma and Orthopaedics, Royal United Hospital Bath NHS Trust, Combe Park, Bath BA1 3NG, UK.
| | - Luke Duggleby
- Department of Trauma and Orthopaedics, Royal United Hospital Bath NHS Trust, Combe Park, Bath BA1 3NG, UK.
| | - Tristan Barton
- Department of Trauma and Orthopaedics, Royal United Hospital Bath NHS Trust, Combe Park, Bath BA1 3NG, UK.
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19
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Keene DJ, Costa ML, Peckham N, Tutton E, Barber VS, Dutton SJ, Hopewell S, Redmond AC, Willett K, Lamb SE. Progressive exercise versus best practice advice for adults aged 50 years or over after ankle fracture: the AFTER pilot randomised controlled trial. BMJ Open 2022; 12:e059235. [PMID: 36424115 PMCID: PMC9693648 DOI: 10.1136/bmjopen-2021-059235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE The aim of the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study, a multicentre external pilot parallel-group randomised controlled trial (RCT), was to assess feasibility of a definitive trial comparing rehabilitation approaches after ankle fracture. SETTING Five UK National Health Service hospitals. PARTICIPANTS Participants were aged 50 years and over with an ankle fracture requiring immobilisation for at least 4 weeks. INTERVENTIONS Participants were allocated 1:1 via a central web-based randomisation system to: (1) best practice advice (one session of physiotherapy, up to two optional additional advice sessions) or (2) progressive exercise (up to six sessions of physiotherapy). PRIMARY OUTCOME MEASURES Feasibility: (1) participation rate, (2) intervention adherence and (3) retention. RESULTS Sixty-one of 112 (54%) eligible participants participated, exceeding progression criteria for participation of 25%. Recruitment progression criteria was 1.5 participants per site per month and 1.4 was observed. At least one intervention session was delivered for 28/30 (93%) of best practice advice and 28/31 (90%) of progressive exercise participants, exceeding the 85% progression criteria. For those providing follow-up data, the proportion of participants reporting performance of home exercises in the best practice advice and the progressive exercise groups at 3 months was 20/23 (87%) and 21/25 (84%), respectively. Mean time from injury to starting physiotherapy was 74.1 days (95% CI 53.9 to 94.1 days) for the best practice advice and 72.7 days (95% CI 54.7 to 88.9) for the progressive exercise group. Follow-up rate (6-month Olerud and Molander Ankle Score) was 28/30 (93%) for the best practice advice group and 26/31 (84%) in the progressive exercise group with an overall follow-up rate of 89%. CONCLUSIONS This pilot RCT demonstrated that a definitive trial would be feasible. The main issues to address for a definitive trial are intervention modifications to enable earlier provision of rehabilitation and ensuring similar rates of follow-up in each group. TRIAL REGISTRATION NUMBER ISRCTN16612336.
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Affiliation(s)
- David J Keene
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Matthew L Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nicholas Peckham
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Elizabeth Tutton
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Kadoorie Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vicki S Barber
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Sally Hopewell
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Anthony C Redmond
- Leeds Institute of Rheumatology and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Keith Willett
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
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Quan T, Malyavko A, Ifarraguerri AM, Kim Y, Mcdaniel L, Manzi JE, Agarwal AR, Chen FR, Gu A, Tabaie S. Evaluating the Association of Anesthesia Type With Postoperative Complications in Patients Undergoing Ankle Fracture Repair. J Foot Ankle Surg 2022; 61:1086-1090. [PMID: 35183454 DOI: 10.1053/j.jfas.2022.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/05/2022] [Accepted: 01/15/2022] [Indexed: 02/03/2023]
Abstract
General and neuraxial anesthesia are both successful anesthesia techniques used in many orthopedic procedures. The purpose of this study was to compare the complications and length of hospital stay between patients who underwent general anesthesia versus neuraxial anesthesia during the repair of ankle fractures. Patients undergoing open reduction and internal fixation for ankle fracture from 2014 to 2018 were identified in the National Surgical Quality Improvement Program database. Patients were stratified into 2 cohorts: general anesthesia and neuraxial anesthesia. In this analysis, demographics data, comorbidities, and postoperative complications were collected and compared between the two cohorts. Bivariate analyses and multivariable logistical regression were performed. Of 3585 patients who underwent operative treatment for ankle fracture, 3315 patients (92.5%) had general anesthesia and 270 (7.5%) had neuraxial anesthesia. On bivariate analyses, patients who had neuraxial anesthesia were more likely to develop pulmonary complications (p = .173) or extended length of stay more than 5 days (p = .342) compared to the general anesthesia group. Following adjustment on multivariate analyses, the neuraxial anesthesia cohort no longer had increased likelihood of pulmonary complications or extended length of stay compared to the general anesthesia group. Healthy ankle fracture patients could also benefit from neuraxial anesthetic methods, and they should be considered for this anesthetic type regardless of their lack of comorbidities.
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Affiliation(s)
- Theodore Quan
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Alisa Malyavko
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Anna M Ifarraguerri
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Yumin Kim
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Lea Mcdaniel
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Amil R Agarwal
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Frank R Chen
- Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Alex Gu
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Sean Tabaie
- Department of Orthopaedic Surgery, Children's National Health System, Washington, DC
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21
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Ling X, Gabrio A, Mason A, Baio G. A Scoping Review of Item-Level Missing Data in Within-Trial Cost-Effectiveness Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1654-1662. [PMID: 35341690 DOI: 10.1016/j.jval.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 02/02/2022] [Accepted: 02/16/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Cost-effectiveness analysis (CEA) alongside randomized controlled trials often relies on self-reported multi-item questionnaires that are invariably prone to missing item-level data. The purpose of this study is to review how missing multi-item questionnaire data are handled in trial-based CEAs. METHODS We searched the National Institute for Health Research journals to identify within-trial CEAs published between January 2016 and April 2021 using multi-item instruments to collect costs and quality of life (QOL) data. Information on missing data handling and methods, with a focus on the level and type of imputation, was extracted. RESULTS A total of 87 trial-based CEAs were included in the review. Complete case analysis or available case analysis and multiple imputation (MI) were the most popular methods, selected by similar numbers of studies, to handle missing costs and QOL in base-case analysis. Nevertheless, complete case analysis or available case analysis dominated sensitivity analysis. Once imputation was chosen, missing costs were widely imputed at item-level via MI, whereas missing QOL was usually imputed at the more aggregated time point level during the follow-up via MI. CONCLUSIONS Missing costs and QOL tend to be imputed at different levels of missingness in current CEAs alongside randomized controlled trials. Given the limited information provided by included studies, the impact of applying different imputation methods at different levels of aggregation on CEA decision making remains unclear.
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Affiliation(s)
- Xiaoxiao Ling
- Department of Statistical Science, University College London, London, England, UK.
| | - Andrea Gabrio
- Department of Methodology and Statistics, Faculty of Health Medicine and Life Science, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Alexina Mason
- London School of Hygiene and Tropical Medicine, London, England, UK
| | - Gianluca Baio
- Department of Statistical Science, University College London, London, England, UK
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22
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Odeh A, Archer J, Budair B, Marsh A, Fenton P. Management of Open Ankle Fractures in Elderly Patients With a Fibula Nail is a Safe and Reliable Technique. Foot Ankle Spec 2022:19386400221099660. [PMID: 35770327 DOI: 10.1177/19386400221099660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ankle fractures are becoming more common in the elderly and their management is frequently challenging. There is increasing evidence of good outcomes following fibula nail fixation in the management of ankle fractures. The use of a fibula nail in open fractures comes with potential advantages such as minimal soft tissue dissection, early rehabilitation, and decreased wound complications. We aimed to assess their use in the management of open ankle fractures in the elderly. METHODS A review of patients aged 60 years or older with an open ankle fracture treated with a fibular nail at a major trauma center was conducted. All patients were managed with joint Orthopaedic and Plastic Surgical input to determine their optimal management. Functional outcome scores, postoperative complications, and re-operation rates were determined. RESULTS Fifteen patients were identified with a mean age of 76 years. Patient-reported outcomes (Olerud and Molander Score) were calculated in 73% of patients. Our results demonstrated excellent outcome scores (>91) in 1 patient, good outcome scores (61-90) in 7 patients, and fair outcome scores (31-60) in 3 patients. There were no postoperative complications or re-operations within our study group. CONCLUSION This article is the largest series presenting the outcomes of fibula nails in the management of open ankle fractures in elderly patients. We conclude that it can be used as a treatment option to safely manage open ankle fractures in the elderly. It provides a stable fixation, early weight-bearing, low risk of postoperative complications while maintaining good patient-reported functional outcomes. LEVEL OF EVIDENCE Level 4.
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23
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Phelps EE, Tutton E, Costa ML, Achten J, Moscrop A, Perry DC. Protecting my injured child: a qualitative study of parents' experience of caring for a child with a displaced distal radius fracture. BMC Pediatr 2022; 22:270. [PMID: 35549910 PMCID: PMC9097445 DOI: 10.1186/s12887-022-03340-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background Childhood fractures can have a significant impact on the daily lives of families affecting children’s normal activities and parent’s work. Wrist fractures are the most common childhood fracture. The more serious wrist fractures, that can look visibly bent, are often treated with surgery to realign the bones; but this may not be necessary as bent bones straighten in growing children. The children’s radius acute fracture fixation trial (CRAFFT) is a multicentre randomised trial of surgery versus a cast without surgery for displaced wrist fractures. Little is known about how families experience these wrist fractures and how they manage treatment uncertainty. This study aimed to understand families’ experience of this injury and what it is like to be asked to include their child in a clinical trial. Methods Nineteen families (13 mothers, 7 fathers, 2 children) from across the UK participated in telephone interviews. Interviews were audio recorded, transcribed and analysed using reflexive thematic analysis. Results Our findings highlight parents’ desire to be a good parent through the overarching theme “protecting my injured child”. To protect their child after injury, parents endeavoured to make the right decisions about treatment and provide comfort to their child but they experienced ongoing worry about their child’s recovery. Our findings show that parents felt responsible for the decision about their child’s treatment and their child’s recovery. They also reveal the extent to which parents worried about the look of their child’s wrist and their need for reassurance that the wrist was healing. Conclusion Our findings show that protecting their child after injury can be challenging for parents who need support to make decisions about treatment and confidently facilitate their child’s recovery. They also highlight the importance of providing information about treatments, acknowledging parents’ concerns and their desire to do the right thing for their child, reassuring parents that their child’s wrist will heal and ensuring parents understand what to expect as their child recovers.
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Affiliation(s)
- E E Phelps
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - E Tutton
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - M L Costa
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - J Achten
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A Moscrop
- Parent Representative, Liverpool, UK
| | - D C Perry
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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24
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Conombo B, Guertin JR, Tardif PA, Gagnon MA, Duval C, Archambault P, Berthelot S, Lauzier F, Turgeon AF, Stelfox HT, Chassé M, Hoch JS, Gabbe B, Champion H, Lecky F, Cameron P, Moore L. Economic Evaluation of In-Hospital Clinical Practices in Acute Injury Care: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:844-854. [PMID: 35500953 DOI: 10.1016/j.jval.2021.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 08/27/2021] [Accepted: 10/31/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Underuse of high-value clinical practices and overuse of low-value practices are major sources of inefficiencies in modern healthcare systems. To achieve value-based care, guidelines and recommendations should target both underuse and overuse and be supported by evidence from economic evaluations. We aimed to conduct a systematic review of the economic value of in-hospital clinical practices in acute injury care to advance knowledge on value-based care in this patient population. METHODS Pairs of independent reviewers systematically searched MEDLINE, Embase, Web of Science, and Cochrane Central Register for full economic evaluations of in-hospital clinical practices in acute trauma care published from 2009 to 2019 (last updated on June 17, 2020). Results were converted into incremental net monetary benefit and were summarized with forest plots. The protocol was registered with PROSPERO (CRD42020164494). RESULTS Of 33 910 unique citations, 75 studies met our inclusion criteria. We identified 62 cost-utility, 8 cost-effectiveness, and 5 cost-minimization studies. Values of incremental net monetary benefit ranged from international dollars -467 000 to international dollars 194 000. Of 114 clinical interventions evaluated (vs comparators), 56 were cost-effective. We identified 15 cost-effective interventions in emergency medicine, 6 in critical care medicine, and 35 in orthopedic medicine. A total of 58 studies were classified as high quality and 17 as moderate quality. From studies with a high level of evidence (randomized controlled trials), 4 interventions were clearly dominant and 8 were dominated. CONCLUSIONS This research advances knowledge on value-based care for injury admissions. Results suggest that almost half of clinical interventions in acute injury care that have been studied may not be cost-effective.
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Affiliation(s)
- Blanchard Conombo
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada; Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Jason R Guertin
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada
| | - Pier-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Marc-Aurèle Gagnon
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada; Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Cécile Duval
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada; Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Québec, Canada; VITAM-Centre de recherche en santé durable, Université Laval, Québec City, Québec, Canada; Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Université Laval, Québec City, Québec, Canada
| | - Simon Berthelot
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Alexis F Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Michaël Chassé
- Department of Medicine, Université de Montréal, Québec City, Québec, Canada
| | - Jeffrey S Hoch
- Division of Health Policy and Management, Department of Public Health Sciences, University of California, Davis, Davis, CA, USA
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine at Monash University, Melbourne, Victoria, Australia
| | - Howard Champion
- Uniformed Services University of the Health Sciences Annapolis, Bethesda, MD, USA
| | - Fiona Lecky
- School of Health and Related Research, Sheffield, England, UK
| | - Peter Cameron
- School of Public Health and Preventive Medicine at Monash University, Melbourne, Victoria, Australia
| | - Lynne Moore
- Department of Social and Preventative Medicine, Université Laval, Québec City, Québec, Canada; Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Centre de Recherche du CHU de Québec (Hôpital de l'Enfant-Jésus), Université Laval, Québec City, Québec, Canada.
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25
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Mohanty K, Agarwal R. Trauma. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1007/978-3-030-78529-1_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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26
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Neubert A, Jaekel C, Metzendorf MI, Richter B. Surgical versus non-surgical interventions for treating ankle fractures in adults. Hippokratia 2021. [DOI: 10.1002/14651858.cd014930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Anne Neubert
- Department of Orthopaedics and Traumatology; Medical Faculty of the Heinrich-Heine-University Düsseldorf; Düsseldorf Germany
| | - Carina Jaekel
- Department of Orthopaedics and Traumatology; Medical Faculty of the Heinrich-Heine-University Düsseldorf; Düsseldorf Germany
| | | | - Bernd Richter
- Cochrane Metabolic and Endocrine Disorders Group; Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf; Düsseldorf Germany
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27
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Davies L, Beard D, Cook JA, Price A, Osbeck I, Toye F. The challenge of equipoise in trials with a surgical and non-surgical comparison: a qualitative synthesis using meta-ethnography. Trials 2021; 22:678. [PMID: 34620194 PMCID: PMC8495989 DOI: 10.1186/s13063-021-05403-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 06/26/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Randomised controlled trials in surgery can be a challenge to design and conduct, especially when including a non-surgical comparison. As few as half of initiated surgical trials reach their recruitment target, and failure to recruit is cited as the most frequent reason for premature closure of surgical RCTs. The aim of this qualitative evidence synthesis was to identify and synthesise findings from qualitative studies exploring the challenges in the design and conduct of trials directly comparing surgical and non-surgical interventions. METHODS A qualitative evidence synthesis using meta-ethnography was conducted. Six electronic bibliographic databases (Medline, Central, Cinahl, Embase and PsycInfo) were searched up to the end of February 2018. Studies that explored patients' and health care professionals' experiences regarding participating in RCTs with a surgical and non-surgical comparison were included. The GRADE-CERQual framework was used to assess confidence in review findings. RESULTS In total, 3697 abstracts and 49 full texts were screened and 26 published studies reporting experiences of patients and healthcare professionals were included. The focus of the studies (24/26) was primarily related to the challenge of recruitment. Two studies explored reasons for non-compliance to treatment allocation following randomisation. Five themes related to the challenges to these types of trials were identified: (1) radical choice between treatments; (2) patients' discomfort with randomisation: I want the best treatment for me as an individual; (3) challenge of equipoise: patients' a priori preferences for treatment; (4) challenge of equipoise: clinicians' a priori preferences for treatment and (5) imbalanced presentation of interventions. CONCLUSION The marked dichotomy between the surgical and non-surgical interventions was highlighted in this review as making recruitment to these types of trials particularly challenging. This review identified factors that increase our understanding of why patients and clinicians may find equipoise more challenging in these types of trials compared to other trial comparisons. Trialists may wish to consider exploring the balance of potential factors influencing patient and clinician preferences towards treatments before they start recruitment, to enable issues specific to a particular trial to be identified and addressed. This may enable trial teams to make more efficient considered design choices and benefit the delivery of such trials.
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Affiliation(s)
- Loretta Davies
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK.
| | - David Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK
| | - Andrew Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, OX3 7LD, UK
| | | | - Francine Toye
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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28
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Fonkoue L, Sarr L, Muluem KO, Gueye AB, Dembele B, Fon C, Ngongang O, Dieme CB, Sané AD. Early posttraumatic ankle osteoarthritis following ankle fracture-dislocations in a sub-Saharan African setting. Orthop Traumatol Surg Res 2021; 107:102996. [PMID: 34198007 DOI: 10.1016/j.otsr.2021.102996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Ankle fracture-dislocation (AFD) represents a major threat to the joint and a potential source of complication and functional disability. This study was performed to assess the outcome of AFD in a resource-limited setting and factors associated with the posttraumatic ankle osteoarthritis (PTAOA). We hypothesized that conservative treatment after AFD was associated with higher risk of PTAOA compared to surgical treatment. PATIENTS AND METHODS Data from 52 consecutive patients (mean age 37.2±11.1years, with 57.7% n=30, males) who were treated and followed in a teaching hospital for AFD during a period of six years were collected. Forty-four of these patients were obtained at the time of the study for a retrospective evaluation. Functional outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS), ankle-hindfoot scale, and the patient's global satisfaction index. Radiographs were performed and analyzed for PTAOA. Logistic regression was used to determine factors associated with the presence of PTAOA. RESULTS PTAOA was found in 19 (43.2%) patients after an average follow-up period of 27.2±18.3months. Anatomic fracture reduction was achieved in 22 (50%) patients, while the talus was centered in the mortise in 30 (68.2%) patients. Despite these poor anatomical results, the clinical outcome was good to excellent in 33 (75%) patients, and 88.6% was satisfied or very satisfied. Factors associated with the presence of PTAOA were the non-anatomical reduction (OR=11.07; p=0.007, 95% CI: 2.096-58.77) and the time elapsed since trauma (OR=1.073; p=0.007, 95% CI: 1.109-1.129). CONCLUSION This study indicates that AFDs are associated with high rate of early and severe PTAOA. Non-anatomical realignment and a delay since trauma were positive predictors of PTAOA. There was no difference regarding the occurrence of PTAOA after AFD whatever the type of treatment, surgical or conservative. LEVEL OF EVIDENCE IV; retrospective cohort study.
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Affiliation(s)
- Loïc Fonkoue
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal; Department of orthopaedics and trauma, national emergency centre, Yaoundé, Cameroon; University of Yaoundé 1, department of surgery and specialities, Yaoundé, Cameroon.
| | - Lamine Sarr
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal
| | - Kennedy Olivier Muluem
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal; University of Yaoundé 1, department of surgery and specialities, Yaoundé, Cameroon
| | - Alioune Badara Gueye
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal
| | - Badara Dembele
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal
| | - Clovis Fon
- University of Yaoundé 1, department of surgery and specialities, Yaoundé, Cameroon
| | - Olivier Ngongang
- Department of orthopaedics and trauma, national emergency centre, Yaoundé, Cameroon; University of Yaoundé 1, department of surgery and specialities, Yaoundé, Cameroon
| | - Charles Bertin Dieme
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal
| | - André-Daniel Sané
- Department of orthopaedics and trauma, Aristide-Le-Dantec university teaching hospital, Dakar, Senegal
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29
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Brewer P, Murray J, Barr L, Headon E, Davies H, Chadwick C, Blundell C, Davies M. Fibula nail fixation in ankle fractures with significant soft tissue compromise: a retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1257-1263. [PMID: 34420150 DOI: 10.1007/s00590-021-03088-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Intramedullary fixation of lateral malleolar fractures has increased in popularity recently with the introduction of the fibula nail. It has been proposed as an alternative fixation method in fractures to minimise soft tissue injury. The aim of this study was to evaluate the clinical and patient-reported outcomes of those who had an ankle fracture with concurrent significant soft tissue damage, treated with a fibula nail. METHODS Details of patients who were managed at our institution using a fibula nail were obtained from the trauma database. The Acumed Fibula Rod System (FRS) was used in all cases. Those who were less than 12 months following injury were excluded. Patients attended a follow-up clinic for measurement of range of movement, radiographs, and to complete MOX-FQ and EQ-5D questionnaires. RESULTS Twenty patients were identified. Eleven attended for review in person, and a further eight completed questionnaires (questionnaire response rate 95%). The mean age was 59 years (range 19-91). Twelve fractures were open, all of which were initially managed using an external fixator. One patient developed deep infection necessitating fusion. The mean MOX-FQ and EQ-5D scores were 53.6 and 0.649, respectively, at a median of 40 months post-injury. The mean EQ-VAS was 70. The range of movement of the affected side was significantly less than the unaffected side (p < 0.001 on paired t-test). CONCLUSION This study suggests that the FRS offers a reliable and acceptable alternative fixation technique for patients who have significant soft tissue injuries.
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Affiliation(s)
- Paul Brewer
- Orthopaedic Department, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - James Murray
- Orthopaedic Department, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK.
| | - Lynne Barr
- The Orthopaedic Department, East Suffolk and North Essex NHS Foundation Trust, Colchester, UK
| | - Elizabeth Headon
- Orthopaedic Department, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Howard Davies
- Orthopaedic Department, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Carolyn Chadwick
- Orthopaedic Department, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Chris Blundell
- Orthopaedic Department, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Mark Davies
- Orthopaedic Department, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
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30
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Bretherton CP, Claireaux HA, Achten J, Athwal A, Dutton SJ, Peckham N, Petrou S, Kearney RS, Appelbe D, Griffin XL. Protocol for the Weight-bearing in Ankle Fractures (WAX) trial: a multicentre prospective non-inferiority trial of early versus delayed weight-bearing after operatively managed ankle fracture. BMC Musculoskelet Disord 2021; 22:672. [PMID: 34372803 PMCID: PMC8353856 DOI: 10.1186/s12891-021-04560-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/12/2021] [Indexed: 01/26/2023] Open
Abstract
Background Unstable ankle fractures represent a substantial burden of disease, accounting for a mean hospital stay of nine days, a mean cost of £4,491 per patient and 20,000 operations per year. There is variation in UK practice around weight-bearing instructions after operatively managed ankle fracture. Early weight-bearing may reduce reliance on health services, time off work, and improve functional outcomes. However, concerns remain about the potential for complications such as implant failure. This is the protocol of a multicentre randomised non-inferiority clinical trial of weight-bearing following operatively treated ankle fracture. Methods Adults aged 18 years and over who have been managed operatively for ankle fracture will be assessed for eligibility. Baseline function (Olerud and Molander Ankle Score [OMAS]), health-related quality of life (EQ-5D-5L), and complications will be collected after informed consent has been obtained. A randomisation sequence has been prepared by a trial statistician to allow for 1:1 allocation to receive either instruction to weight-bear as pain allows from the point of randomisation, two weeks after the time of surgery (‘early weight-bearing’ group) or to not weight-bear for a further four weeks (‘delayed weight -bearing’ group). All other treatment will be as per the guidance of the treating clinician. Participants will be asked about their weight-bearing status weekly until four weeks post-randomisation. At four weeks post-randomisation complications will be collected. At six weeks, four months, and 12 months post-randomisation, the OMAS, EQ-5D-5L, complications, physiotherapy input, and resource use will be collected. The primary outcome measure is ankle function (OMAS) at four months post-randomisation. A minimum of 436 participants will be recruited to obtain 80% power to detect a non-inferiority margin of -6 points on the OMAS 4 months post-randomisation. A within-trial health economic evaluation will be conducted to estimate the cost-effectiveness of the treatment options. Discussion The results of this study will inform national guidance with regards to the most clinically and cost-effective strategy for weight-bearing after surgery for unstable ankle fractures. Trial registration ISRCTN12883981, Registered 02 December 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04560-7.
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Affiliation(s)
- C P Bretherton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - H A Claireaux
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - J Achten
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A Athwal
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - S J Dutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - N Peckham
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - S Petrou
- Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - R S Kearney
- Department of Musculoskeletal Rehabilitation, University of Warwick, Coventry, UK
| | - D Appelbe
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - X L Griffin
- Trauma and Orthopaedic Surgery, Division of Orthopaedics, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Hancock DW, Hainsworth L, Pentlow AK. A novel fixation method for unstable ankle fractures in the elderly using dual percutaneous tibiotalar cannulated screws. J Surg Case Rep 2021; 2021:rjab311. [PMID: 34316350 PMCID: PMC8310683 DOI: 10.1093/jscr/rjab311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/03/2021] [Accepted: 06/24/2021] [Indexed: 11/14/2022] Open
Abstract
Ankle fractures in the elderly are often complicated by osteoporosis and poor skin quality, resulting in poorer outcomes. This retrospective case-series describes a novel minimally invasive fixation method for managing unstable ankle fractures in the high-risk elderly patient. Six elderly patients who underwent dual tibiotalar cannulated screw fixation for unstable ankle fractures between January 2019 and 2020 were identified. Data on post-operative pain scores, mobility and complications were collected. Pre- and post-operative radiographs were analysed for fracture type and complications. Functional outcomes were excellent with 83.3% of patients pain free, and 100% ambulatory with walking-aids at 10.25 months follow-up. Four of the six patients (66.7%) had satisfactory post-operative radiographs, and there were no soft tissue injury or infections due to the surgery. Dual percutaneous tibiotalar cannulated screws can be used to manage unstable ankle fractures in the low demand elderly patient, resulting in excellent functional outcomes.
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Affiliation(s)
- Daniel W Hancock
- Department of Trauma & Orthopaedics, Weston General Hospital, Grange Road, Uphill, Weston-Super-Mare, Somerset BS23 4TQ, UK
| | - Louis Hainsworth
- Department of Trauma & Orthopaedics, Weston General Hospital, Grange Road, Uphill, Weston-Super-Mare, Somerset BS23 4TQ, UK
| | - Alanna K Pentlow
- Department of Trauma & Orthopaedics, Weston General Hospital, Grange Road, Uphill, Weston-Super-Mare, Somerset BS23 4TQ, UK
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32
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Fenelon C, Galbraith JG, Fahey T, Kearns SR. The Operative Treatment of Ankle Fractures: A 10-Year Retrospective Study of 1529 Patients. J Foot Ankle Surg 2021; 60:663-668. [PMID: 33509713 DOI: 10.1053/j.jfas.2020.03.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 03/19/2020] [Accepted: 03/29/2020] [Indexed: 02/03/2023]
Abstract
Ankle fractures are the second most common fracture of the lower limb and account for nearly 10% of all fractures. They range from simple to complex injuries and approximately 40% require surgical intervention. The aim of our study was to provide an up-to-date reference of the epidemiology, fracture, and fixation characteristics of operatively treated ankle fractures. We also sought to determine the number of patients undergoing further surgery through revision, implant removal, or ankle fusion. A retrospective observational study was conducted of 1529 consecutive patients that underwent operative intervention for an unstable ankle fracture between 2007 and 2017. Fractures of the distal tibia and pilon injuries were excluded. The mean age of patients was 41.8 years with 50.7% male. Unimalleolar fixation was performed in 60.1%, while bimalleolar and trimalleolar fixation was performed in 31.2% and 5%, respectively. Isolated syndesmotic fixation was performed in 3.8%. A posterior malleolus fracture was present in 28.6%, of which 31.6% underwent fixation. A further procedure was performed in 234 (15.3%) patients. Revision open reduction internal fixation was required in 1.4% and 0.8% underwent future ankle fusion. Treatment of ankle fractures makes up a sizeable part of orthopedic trauma practice with more than 1 in 7 patients requiring a second procedure. More complex fractures were predominantly seen in older females, while patients who suffered trimalleolar fractures have an increased likelihood of requiring future ankle fusion or revision. Despite this the rate of ankle fusion was <1%.
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Affiliation(s)
- Christopher Fenelon
- Orthopaedic Registrar, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland.
| | - John G Galbraith
- Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
| | - Tom Fahey
- Professor of General Practice, Department of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Stephen R Kearns
- Professor and Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Galway University Hospital, Galway, Ireland
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33
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Kearney R, McKeown R, Parsons H, Haque A, Parsons N, Nwankwo H, Mason J, Underwood M, Redmond AC, Brown J, Kefford S, Costa M. Use of cast immobilisation versus removable brace in adults with an ankle fracture: multicentre randomised controlled trial. BMJ 2021; 374:n1506. [PMID: 34226192 PMCID: PMC8256800 DOI: 10.1136/bmj.n1506] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To assess function, quality of life, resource use, and complications in adults treated with plaster cast immobilisation versus a removable brace for ankle fracture. DESIGN Multicentre randomised controlled trial. SETTING 20 trauma units in the UK National Health Service. PARTICIPANTS 669 adults aged 18 years and older with an acute ankle fracture suitable for cast immobilisation: 334 were randomised to a plaster cast and 335 to a removable brace. INTERVENTIONS A below the knee cast was applied and ankle range of movement exercises started on cast removal. The removable brace was fitted, and ankle range of movement exercises were started immediately. MAIN OUTCOME MEASURES Primary outcome was the Olerud Molander ankle score at 16 weeks, analysed by intention to treat. Secondary outcomes were Manchester-Oxford foot questionnaire, disability rating index, quality of life, and complications at 6, 10, and 16 weeks. RESULTS The mean age of participants was 46 years (SD 17 years) and 381 (57%) were women. 502 (75%) participants completed the study. No statistically significant difference was found in the Olerud Molander ankle score between the cast and removable brace groups at 16 weeks (favours brace: 1.8, 95% confidence interval -2.0 to 5.6). No clinically significant differences were found in the Olerud Molander ankle scores at other time points, in the secondary unadjusted, imputed, or per protocol analyses. CONCLUSIONS Traditional plaster casting was not found to be superior to functional bracing in adults with an ankle fracture. No statistically difference was found in the Olerud Molander ankle score between the trial arms at 16 weeks. TRIAL REGISTRATION ISRCTN registry ISRCTN15537280.
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Affiliation(s)
- Rebecca Kearney
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Rebecca McKeown
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Helen Parsons
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Aminul Haque
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Nick Parsons
- Warwick Medical School, University of Warwick, Warwick, UK
| | - Henry Nwankwo
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - James Mason
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | | | - Anthony C Redmond
- Leeds Institute for Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Jaclyn Brown
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Siobhan Kefford
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Matthew Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Rheumatology, Musculoskeletal and Orthopaedic Sciences, University of Oxford, Oxford, UK
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34
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Yu T, Ying J, Liu J, Huang D, Yan H, Xiao B, Zhuang Y. Percutaneous posteroanterior screw fixation for Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture: Operative technique and randomized clinical results. J Orthop Surg (Hong Kong) 2021; 29:2309499021997996. [PMID: 33641534 DOI: 10.1177/2309499021997996] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The study described a novel surgical treatment of Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture and patient outcomes at intermediate period follow-up. METHODS All patients from January 2015 to December 2017 with tri-malleolar fracture of which posterior malleolar fractures were Haraguchi type 1, were surgically treated in this prospective study. Lateral and medial malleolar fractures were managed by open reduction and internal fixation through dual incision approaches. 36 cases of Haraguchi type 1 posterior malleolar fractures were randomly performed by percutaneous posteroanterior screw fixation with the aid of medial exposure (group 1). And 40 cases were performed by percutaneous anteroposterior screw fixation (group 2). Clinical outcomes, radiographic outcomes and patient-reported outcomes were recorded. RESULTS Seventy-six patients with mean follow-up of 30 months were included. There were no significant differences in the mean operation time (81.0 ± 11.3 vs. 77.2 ± 12.4), ankle function at different periods of follow-up, range of motions and visual analog scale (VAS) at 24 months between the two groups (p > 0.05). However, the rate of severe post-traumatic arthritis (Grade 2 and 3) and the rate of step-off rather than gap in radiological evaluation were lower in group 1 than that in group 2 (p < 0.05). CONCLUSION Using our surgical technique, more patients had good outcome with a lower rate of severe post-traumatic arthritis, compared with the group of percutaneous anteroposterior screw fixation. Percutaneous posteroanterior screw fixation can be a convenient and reliable alternative in treating Haraguchi type 1 posterior malleolar fracture.
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Affiliation(s)
- Tianming Yu
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Jichong Ying
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Jianlei Liu
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Dichao Huang
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Hailin Yan
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Baiping Xiao
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
| | - Yunqiang Zhuang
- Department of Traumatic Orthopedics, 105854Ningbo No. 6 Hospital, Ningbo, Zhejiang, P.R. China
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35
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Eyre-Brook AI, Ring J, Chadwick C, Davies H, Davies M, Blundell C. A Comparison of Fibula Pro-Tibia Fixation Versus Hindfoot Nailing for Unstable Fractures of the Ankle in Those Older Than 60 Years. Foot Ankle Spec 2021; 16:135-144. [PMID: 34176315 DOI: 10.1177/19386400211017373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ankle fractures in the elderly are an increasing problem, with poor outcomes reported. Operative options for patients with suspected osteoporosis and needing to bear weight to ambulate can include hindfoot intramedullary nail (IMN) or fibula pro-tibia fixation (FPT). FPT involves passing 2 or more screws through a lateral fibula plate, crossing the fibular into the tibia, with 1 or more screws proximal to the incisura. We compared the outcomes of these 2 techniques. METHOD A retrospective review identified 68 patients aged over 60 years with unstable ankle fractures, treated with IMN or FPT. Primary outcome was surgical reoperation/revision rate, secondary outcomes included complications, length of stay, and functional status. Results: There were no significant differences in demographics between IMN and FPT. Revision rates were higher in IMN compared with FPT (P < .0001). IMN patients postoperatively had longer hospital stays (P = .02), longer follow-up times (P = .008), and higher rates of delayed wound healing (P = .03) and nonunion (P = .001). Multivariate analysis identified fixation and age to affect revision rates. CONCLUSION Outcomes were worse in the IMN group compared with FPT. We believe both techniques have a role in the management of elderly ankle fractures, but patient selection is key. We suggest that FPT should be the first-choice technique when soft tissues permit. LEVELS OF EVIDENCE Level III.
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36
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Papiez K, Tutton E, Phelps EE, Baird J, Costa ML, Achten J, Gibson P, Perry DC. A qualitative study of parents' and their child's experience of a medial epicondyle fracture. Bone Jt Open 2021; 2:359-364. [PMID: 34078095 PMCID: PMC8244794 DOI: 10.1302/2633-1462.26.bjo-2020-0186.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
AIMS The aim of this study was to explore parents and young people's experience of having a medial epicondyle fracture, and their thoughts about the uncertainty regarding the optimal treatment. METHODS Families were identified after being invited to participate in a randomized controlled trial of surgery or no surgery for displaced medial epicondyle fractures of the humerus in children. A purposeful sample of 25 parents (22 females) and five young people (three females, mean age 11 years (7 to 14)) from 15 UK hospitals were interviewed a mean of 39 days (14 to 78) from injury. Qualitative interviews were informed by phenomenology and themes identified to convey participants' experience. RESULTS The results identify parents' desire to do the best for their child expressed through two themes: 1) 'uncertainty' (being uncertain about the best treatment option); and 2) 'facilitating recovery' (sharing the experience). Parents and young people were shocked when confronted with uncertainty about treatment and they felt responsible for the decision. They searched for further information, drew on their own experience, and struggled to weigh up risks of the treatments. Discussion with surgeons provided crucial support for decision-making, and young people were involved to a varying degree. In facilitating recovery, parents balanced increasing activity with protecting their child, but lacked knowledge about pain management, and how to improve strength and function of the arm. They hoped for a return to normal, including competitive sports. CONCLUSION Surgeons are aware of the impact of injury on children and their parents; however, they may be less aware of the turmoil created by treatment uncertainty. Confident surgeons who appreciate and contextualize the importance of pre-existing experience and beliefs are best placed to help the family develop confidence to embrace uncertainty, particularly regarding participation in clinical trials. Cite this article: Bone Jt Open 2021;2(6):359-364.
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Affiliation(s)
- Kinga Papiez
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, UK
| | - Elizabeth Tutton
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, UK,Trauma and Major Trauma Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK,Correspondence should be sent to Elizabeth Tutton. E-mail:
| | - Emma E. Phelps
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, UK
| | - Janis Baird
- Epidemiology Unit, Southampton University, Southampton, UK
| | - Matthew L. Costa
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, UK
| | - Juul Achten
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, UK
| | - Phoebe Gibson
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Daniel C. Perry
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University, Oxford, UK
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37
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Karkkola S, Kortekangas T, Pakarinen H, Flinkkilä T, Niinimäki J, Leskelä HV. Stability-Based Classification of Ankle Fractures-The Long-Term Outcome After 11-13 Years of Follow-up. J Orthop Trauma 2021; 35:227-233. [PMID: 32925451 DOI: 10.1097/bot.0000000000001959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the long-term functional and radiological outcome, as well as complications and reoperations of ankle fracture patients treated based on stability classification. DESIGN Retrospective. SETTING Main Trauma Center, University Hospital. PATIENTS AND INTERVENTIONS One hundred sixty patients were treated based on stability classification. After a mean follow-up of 12 years, 102 patients were assessed; 67 visited the outpatient clinic, and standard standing ankle radiographs were taken; osteoarthritis (OA) was graded according to Kellgren-Lawrence classification. The remaining patients (n = 35) were followed up via mail or telephone. The complications and reoperations of all 160 patients were collected from electronic patient records. MAIN OUTCOME MEASURES Olerud-Molander ankle score, foot and ankle outcome score, visual analog scale, RAND-36 item health survey, range-of-motion measurements, and Kellgren-Lawrence OA classification. RESULTS Very good to excellent ankle functional outcome was reported by 96% of the stable fracture group [mean Olerud-Molander ankle score (OMAS), 92; range, 20-100] and 82% of the unstable group (mean OMAS, 86; range, 30-100). For patients with an unstable fracture, OMAS and VAS pain scores significantly improved from 2 to 12 years, even though higher grades of radiologic OA were found. No patients with fractures deemed stable needed operative intervention even in the long-term follow-up. Instead, 30% of the operatively treated patients underwent reoperation during the long follow-up. CONCLUSIONS The treatment of ankle fractures based on stability-based classification led to predictable, functionally good outcomes even during long-term follow-up. Ankle fractures can reliably be deemed stable based on this classification and treated without failures in the long term. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sini Karkkola
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center, University of Oulu, Oulu, Finland
| | - Tero Kortekangas
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
- Medical Research Center, University of Oulu, Oulu, Finland
| | - Harri Pakarinen
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Tapio Flinkkilä
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Jaakko Niinimäki
- Department of Diagnostic Radiology, Oulu University Hospital, Oulu, Finland; and
| | - Hannu-Ville Leskelä
- Division of Orthopedic and Trauma Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland
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38
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Hing CB, Tutton E, Smith TO, Glaze M, Stokes JR, Cook J, Dritsaki M, Phelps E, Cooper C, Trompeter A, Pearse M, Law M, Costa ML. Reamed intramedullary nailing versus circular frame external fixation for segmental tibial fractures (STIFF-F): a mixed methods feasibility study. Pilot Feasibility Stud 2021; 7:93. [PMID: 33838694 PMCID: PMC8035735 DOI: 10.1186/s40814-021-00821-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 03/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Segmental tibial fractures are fractures in two or more areas of the tibial diaphysis resulting in a separate intercalary segment of the bone. Surgical fixation is recommended for patients with segmental tibial fractures as non-operative treatment outcomes are poor. The most common surgical interventions are intramedullary nailing (IMN) and circular frame external fixation (CFEF), but evidence about which is better is of poor quality. An adequately powered randomised controlled trial (RCT) to determine optimum treatment is required. STIFF-F aimed to assess the feasibility of a multicentre RCT comparing IMN with CFEF for segmental tibial fracture. METHODS STIFF-F was a mixed-methods feasibility study comprising a pilot RCT conducted at six UK Major Trauma Centres, qualitative interviews drawing on Phenomenology and an online survey of rehabilitation. The primary outcome was recruitment rate. Patients, 16 years and over, with a segmental tibial fracture (open or closed) deemed suitable for IMN or CFEF were eligible to participate. Randomisation was stratified by site using random permuted blocks of varying sizes. Participant or assessor blinding was not possible. Interviews were undertaken with patients about their experience of injury, treatment, recovery and participation. Staff were interviewed to identify contextual factors affecting trial processes, their experience of recruitment and the treatment pathway. An online survey was developed to understand the rehabilitation context of the treatments. RESULTS Eleven patients were screened and three recruited to the pilot RCT. Nineteen staff and four patients participated in interviews, and 11 physiotherapists responded to the survey. This study found the following: (i) segmental tibial fractures were rarer than anticipated, (ii) the complexity of the injury, study setup times and surgeon treatment preferences impeded recruitment, (iii) recovery from a segmental tibial fracture is challenging, and rehabilitation protocols are inconsistent and (iv) despite the difficulty recruiting, staff valued this research question and strived to find a way forward. CONCLUSION The proposed multicentre RCT comparing IMN with CFEF is not feasible. This study highlighted the difficulty of recruiting patients to an RCT of a complex rare injury over a short time period. TRIAL REGISTRATION The study was registered with the International Standard Randomised Controlled Trials Number Registry: ISRCTN11229660.
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Affiliation(s)
- Caroline B Hing
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK.
| | - Elizabeth Tutton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Toby O Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, Norfolk, UK
| | - Molly Glaze
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jamie R Stokes
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Jonathan Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Emma Phelps
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cushla Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alex Trompeter
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Michael Law
- Department of Trauma and Orthopaedics, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Matthew L Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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39
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Realpe AX, Foster NE, Dickenson EJ, Jepson M, Griffin DR, Donovan JL. Patient experiences of receiving arthroscopic surgery or personalised hip therapy for femoroacetabular impingement in the context of the UK fashion study: a qualitative study. Trials 2021; 22:211. [PMID: 33726810 PMCID: PMC7962311 DOI: 10.1186/s13063-021-05151-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 02/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND UK FASHIoN was a multicentre randomised controlled trial comparing hip arthroscopic surgery (HA) with personalised hip therapy (PHT, physiotherapist-led conservative care), for patients with hip pain attributed to femoroacetabular impingement (FAI) syndrome. Our aim was to describe the treatment and trial participation experiences of patients, to contextualise the trial results and offer further information to assist treatment decision-making in FAI. METHODS We conducted in-depth semi-structured telephone interviews with a purposive sample of trial participants from each of the trial arms. They were interviewed after they received treatment and completed their first year of trial participation. Thematic analysis and constant comparison analytical approaches were used to identify themes of patient treatment experiences during the trial. RESULTS Forty trial participants were interviewed in this qualitative study. Their baseline characteristics were similar to those in the main trial sample. On average, their hip-related quality of life (iHOT-33 scores) at 12 months follow-up were lower than average for all trial participants, indicating poorer hip-related quality of life as a consequence of theoretical sampling. Patient experiences occurred in five patient groups: those who felt their symptoms improved with hip arthroscopy, or with personal hip therapy, patients who felt their hip symptoms did not change with PHT but did not want HA, patients who decided to change from PHT to HA and a group who experienced serious complications after HA. Interviewees mostly described a trouble-free, enriching and altruistic trial participation experience, although most participants expected more clinical follow-up at the end of the trial. CONCLUSION Both HA and PHT were experienced as beneficial by participants in the trial. Treatment success appeared to depend partly on patients' prior own expectations as well as their outcomes, and future research is needed to explore this further. Findings from this study can be combined with the primary results to inform future FAI patients. TRIAL REGISTRATION Arthroscopic surgery for hip impingement versus best conventional care ( ISRCTN64081839 ). 28/02/2014.
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Affiliation(s)
- A X Realpe
- Population Health Sciences, University of Bristol, Canynge Hall 4.07, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - N E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - E J Dickenson
- University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - M Jepson
- Population Health Sciences, University of Bristol, Canynge Hall 4.07, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - D R Griffin
- University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - J L Donovan
- Population Health Sciences, University of Bristol, Canynge Hall 4.07, 39 Whatley Road, Bristol, BS8 2PS, UK
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40
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Abstract
INTRODUCTION AND AIMS COVID-19 has had a significant impact on orthopaedic surgery globally. This paper aims to evaluate the impact of COVID-19 on foot and ankle trauma in a major trauma centre. METHODS A retrospective observational study of prospectively collected data was performed. All foot and ankle trauma patients over a 33 week period (1st December 2019-16th July 2020) were analysed. All patients with trauma classified by the AO/OTA as occurring at locations 43 and 81-88 were included. RESULTS Over the 33 weeks analysed, there was a total of 1661 trauma cases performed; of these, only 230 (13.85%) were foot and ankle trauma cases. As percentage of cases during each period of lockdown, foot and ankle made up 15.20% (147 out of 967) pre-lockdown, 8.81% (17 out of 193) during lockdown and 13.17% (66 out of 501) post lockdown. This difference was statistically significant (p < .001). The most significant change in trauma management was the treatment of malleolar fractures. Further analysis showed that during the lockdown period 29 foot and ankle fractures were treated the same and 13 were treated differently, (i.e. 31% of fractures were treated conservatively, when the consultants preferred practice would have been surgical intervention). Of the 13 patients, 3 have had surgical management since lockdown has been eased. CONCLUSION It is evident that the trauma case activity within foot and ankle was significantly reduced during the COVID-19 period. The consequences of change in management were mitigated due to a reduction in case load.
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An L, Zhang J, Ma W, Zhu L, He X, Ying J, Zhuang Y, Zhuang Y, Yu T. Clinical comparison of single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures: A randomized controlled trial. J Orthop Surg (Hong Kong) 2021; 28:2309499020930305. [PMID: 32536316 DOI: 10.1177/2309499020930305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The purpose of this study was to clinically compare the single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures. METHODS In total, 93 patients were enrolled, and the mean follow-up was 15 months (range 12-19 months). The patients treated for open reduction and internal fixation were randomly classified into two groups based on the approach used: 45 patients were treated using the single-incision approach (group 1) and 48 patients were treated using the dual-incision approach (group 2). In these two groups, operation time, discharge time, postoperative complications, and ankle function evaluations (Olerud-Molander Ankle Score) were compared between the two groups. RESULTS There were no significant differences in the mean operation time (98.2 ± 18.5 vs. 103.6 ± 19.3), discharge time (11.1 ± 3.9 vs. 12.5 ± 5.7), overall surgical complication rates (9/45 vs. 15/48), or ankle function between the two groups (p > 0.05). However, the rate of soft tissue-related complications, such as skin slough, infection, nonunion, and delayed union, was significantly lower in group 1 (5/45) than in group 2 (14/48) (p < 0.05). CONCLUSION The two incision approaches were found to have similar clinical outcomes. However, with regard to soft tissue conservation, the single-incision approach was superior to the dual-incision and maybe a reliable alternative.
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Affiliation(s)
- Lin An
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Jingwei Zhang
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Weihu Ma
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Limei Zhu
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Xianfeng He
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Jichong Ying
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Yunqiang Zhuang
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Yunqiang Zhuang
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, Zhejiang, People's Republic of China
| | - Tianming Yu
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, Zhejiang, People's Republic of China
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Tutton E, Saletti-Cuesta L, Langstaff D, Wright J, Grant R, Willett K. Patient and informal carer experience of hip fracture: a qualitative study using interviews and observation in acute orthopaedic trauma. BMJ Open 2021; 11:e042040. [PMID: 33542042 PMCID: PMC7925874 DOI: 10.1136/bmjopen-2020-042040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The time taken for older people to recover from hip fracture can be extensive. The aim of this study was to gain an understanding of patient and informal carer experience of recovery in the early stage, while in acute care. DESIGN A phenomenological (lived experience) approach was used to guide the design of the study. Interviews and observation took place between March 2016 and December 2016 in acute care. SETTING Trauma wards in a National Health Service Foundation Trust in the South West of England. PARTICIPANTS A purposive sample of 25 patients were interviewed and observation taking 52 hours was undertaken with 13 patients and 12 staff. 11 patients had memory loss, 2 patients chose to take part in an interview and observation. The age range was 63-91 years (median 83), 10 were men. A purposive sample of 25 informal carers were also interviewed, the age range was 42-95 years (mean 64), 11 were men. RESULTS The results identified how participants moved forward together after injury by sharing the journey. This was conveyed through three themes: (1) sustaining relationships while experiencing strong emotions and actively helping, (2) becoming aware of uncertainty about the future and working through possible outcomes, (3) being changed, visibly looking different, not being able to walk, and enduring indignity and pain. CONCLUSION This study identified the experience of patients and informal carers as they shared the journey during a challenging life transition. Strategies that support well-being and enable successful negotiation of the emotional and practical challenges of acute care may help with longer term recovery. Research should focus on developing interventions that promote well-being during this transition to help provide the foundation for patients and carers to live fulfilled lives.
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Affiliation(s)
- Elizabeth Tutton
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Trauma and Major Trauma Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Lorena Saletti-Cuesta
- Culture and Society Research and Study Centre, National Scientific and Technical Research Council, Cordoba, Argentina
| | - Debbie Langstaff
- Trauma and Major Trauma Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Julie Wright
- Trauma and Major Trauma Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Richard Grant
- Patient and Public Involvement Partner, Kadoorie, Oxford Trauma and Emergency Care, University of Oxford, Oxford, UK
| | - Keith Willett
- Kadoorie, Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Lu P, Liao Z, Zeng Q, Chen H, Huang W, Liu Z, Chen Y, Zhong J, Huang G. Customized Three-Dimensional-Printed Orthopedic Close Contact Casts for the Treatment of Stable Ankle Fractures: Finite Element Analysis and a Pilot Study. ACS OMEGA 2021; 6:3418-3426. [PMID: 33553960 PMCID: PMC7860236 DOI: 10.1021/acsomega.0c06031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/14/2021] [Indexed: 06/12/2023]
Abstract
Ankle fracture is one of the most common traumatic fractures among the elderly population. The majority of ankle fractures are stable types with the typically conservative strategy of close contact casting treatment. The continuous use of unventilated standard cast immobilization severely affects patient's satisfaction and compliance and markedly increases the rates of various complications. Three-dimensional (3D) printing for casts has advantages of lightweight, ventilated, proper-fit, and esthetic improvements. In this work, this novel 3D-printed cast has been applied to individuals with stable ankle fractures, and its effectiveness can be successfully validated with finite element analysis and a pilot study. A 30% reduction of the volume was chosen as the optimal result in topology optimization. Both 3D-printed casts and conventional casts showed significant ankle function improvement after immobilization for 6 weeks (p = 0.000). The 3D-printed casts were superior to the traditional casts in Olerud-Molander Ankle Scores (OMAS), with the mean difference of 8.3 ± 8.57 OMAS points (95% CI -10.8 to 27.5; p = 0.354) for 6 weeks, implying that the 3D-printed casts possibly maintain the equal clinical efficacy as the traditional casts. The statistically significant difference between groups from the 3D-printed cast and the traditional one observed in C-QUEST 2.0 was 11.3 ± 1.5 points (95% CI 8.0-14.6; p = 0.000), indicating that the 3D-printed cast possesses outperforming satisfaction and compliance and has great potential in practical applications. There were no severe complications in the 3D-printed casts, but more moderate complications were observed in the traditional casts.
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Affiliation(s)
- Pengcheng Lu
- Department
of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
- Rehabilitation
Medical School, Southern Medical University, Guangzhou 510280, China
| | - Zhengwen Liao
- Department
of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
- Rehabilitation
Medical School, Southern Medical University, Guangzhou 510280, China
| | - Qing Zeng
- Department
of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
- Rehabilitation
Medical School, Southern Medical University, Guangzhou 510280, China
| | - Huan Chen
- Department
of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
- Rehabilitation
Medical School, Southern Medical University, Guangzhou 510280, China
| | - Weichun Huang
- School
of Chemistry and Chemical Engineering, Nantong
University, Nantong 226019, China
| | - Zhen Liu
- Department
of Rehabilitation Medicine, The First People’s
Hospital of Foshan, Foshan 528000, China
| | - Yanjun Chen
- Guangdong
Medical Innovation Platform for Translation of 3D Printing Application,
Department of Medical Radiology, The Third
Affiliated Hospital of Southern Medical University, Guangzhou 510515, China
| | - Jing Zhong
- Guangdong
Engineering Research Center for Translation of Medical 3D Printing
Application, Guangdong Provincial Key Laboratory of Medical Biomechanics,
School of Basic Medical Sciences, Southern
Medical University, Guangzhou 510515, China
| | - Guozhi Huang
- Department
of Rehabilitation Medicine, Zhujiang Hospital, Southern Medical University, Guangzhou 510280, China
- Rehabilitation
Medical School, Southern Medical University, Guangzhou 510280, China
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Walsh TP, Merlo GB, Rutter C, Abell B, Platt SR, Arnold JB. Cost-effectiveness of interventions for musculoskeletal foot and ankle conditions: a systematic review. Arthritis Care Res (Hoboken) 2020; 74:626-637. [PMID: 33202113 DOI: 10.1002/acr.24514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 10/06/2020] [Accepted: 11/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Musculoskeletal conditions of the foot and ankle are common, yet the cost-effectiveness of the variety of treatments available is not well defined. The aim of this systematic review was therefore to identify, appraise and synthesise the literature pertaining to the cost-effectiveness of interventions for musculoskeletal foot and ankle conditions. METHODS Electronic databases were searched for studies presenting economic evaluations of non-surgical and surgical treatments for acute or chronic musculoskeletal conditions of the foot and ankle. Data on cost, incremental cost-effectiveness and quality-adjusted life years for each intervention and comparison were extracted. Risk of bias was assessed using the Drummond checklist for economic studies (range 0-35). RESULTS Thirty-six studies were identified reporting non-surgical interventions (n=10), non-surgical versus surgical interventions (n=14) and surgical interventions (n=12). The most common conditions were osteoarthritis, ankle fracture and Achilles tendon rupture. The strongest economic evaluations were for interventions managing end-stage ankle osteoarthritis, ankle sprain, ankle fracture, calcaneal fracture, and Achilles tendon rupture. Total ankle replacement and ankle arthrodesis for end-stage ankle osteoarthritis, in particular, have been demonstrated through high-quality studies to be cost-effective compared to the non-surgical alternative. CONCLUSION Selected interventions for musculoskeletal foot and ankle conditions dominate comparators, whereas others require thoughtful consideration as they provide better clinical improvements, but at an increased cost. Researchers should consider measuring and reporting costs alongside clinical outcome to provide context when determining the appropriateness of interventions for other foot and ankle complaints to best inform future clinical practice guidelines.
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Affiliation(s)
- Tom P Walsh
- Queensland University of Technology (QUT), Faculty of Health, School of Clinical Sciences, Kelvin Grove, Queensland, 4059, Australia
| | - Greg B Merlo
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Herston, Queensland, 4006, Australia
| | - Cameron Rutter
- Queensland University of Technology (QUT), Faculty of Health, University Library, Kelvin Grove, 4059, Australia
| | - Bridget Abell
- Queensland University of Technology (QUT), Centre for Healthcare Transformation, Faculty of Health, Kelvin Grove, Queensland, 4059, Australia
| | - Simon R Platt
- Department of Orthopaedics, Gold Coast University Hospital, Southport, Queensland, 4215, Australia
| | - John B Arnold
- IMPACT in Health, Allied Health & Human Performance, University of South Australia, Adelaide, South Australia, 5000, Australia
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Griffin XL, Costa ML, Phelps E, Parsons N, Dritsaki M, Png ME, Achten J, Tutton E, Lerner R, McGibbon A, Baird J. Retrograde intramedullary nail fixation compared with fixed-angle plate fixation for fracture of the distal femur: the TrAFFix feasibility RCT. Health Technol Assess 2020; 23:1-132. [PMID: 31549959 DOI: 10.3310/hta23510] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Fractures of the distal femur are an increasingly common injury; the optimal management of these injuries remains controversial. The two interventions used in UK practice are intramedullary fixation, with a locked retrograde nail, and extramedullary fixation, with a fixed angle plate. OBJECTIVES This study assessed the feasibility of a definitive trial and included a process evaluation to understand the generalisability and likely success of a future trial. DESIGN A multicentre, parallel, two-arm, randomised controlled feasibility trial with an embedded process evaluation. Treatment with a plate or nail was allocated in a 1 : 1 ratio, stratified by centre and chronic cognitive impairment. Surgeons were not blinded, but participants were not told their allocation. SETTING Seven NHS hospitals. PARTICIPANTS Patients aged ≥ 18 years with a fracture of the distal femur who the attending surgeon believed would benefit from internal fixation were potentially eligible. Patients were excluded if they had a loose arthroplasty requiring revision or a femoral deformity or arthroplasty that precluded nail fixation. The sample was recruited between 29 September 2016 and 31 August 2017. Consent was obtained from the patient or appropriate consultee before enrolment. INTERVENTIONS Patients were randomised to receive fixation of their distal femur fracture with either a proximally and distally locked retrograde nail that spanned the diaphysis of the femur or an anatomical distal femoral locking plate with at least one locked screw distal to the fracture. Reduction and supplemental fixation were at the surgeon's discretion. OUTCOMES The primary outcome measures for this study were the recruitment rate and the completion rate of the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), at 6 weeks and 4 months. Additional measurements included baseline characteristics, measures of social support and self-efficacy, disability rating index, dementia quality-of-life measures and a radiographical assessment of any malunion. Participants' and staff views were obtained, at interview, for the process evaluation. RESULTS The process evaluation showed that surgeon-related factors, principally confidence with both technologies and a lack of individual equipoise, were key barriers to recruitment. A total of 23 participants were randomised and analysed (nail, n = 11; plate, n = 12). The recruitment rate was estimated as 0.42 [95% confidence interval (CI) 0.27 to 0.62] participants per centre per month, lower than the prespecified feasibility threshold of 1.0 participants per centre per month. Data completeness of the EQ-5D-5L was estimated at 65% (95% CI 43% to 83%). CONCLUSIONS This feasibility study has challenged many of the assumptions that underpinned the development of proposed definitive trial protocol. A modified protocol is proposed that would be feasible given the recruitment rate observed here, which is equal to that reported in the similar FixDT trial [Health Technology Assessment (HTA) 11/136/04: Costa ML, Achten J, Hennings S, Boota N, Griffin J, Petrou S, et al. Intramedullary nail fixation versus locking plate fixation for adults with a fracture of the distal tibia: the UK FixDT RCT. Health Technol Assess 2018;22(25)], which delivered to target and budget. FUTURE WORK A definitive trial with a modified design is recommended, including an internal pilot to confirm initial recruitment rate assumptions. REGISTRATION Current Controlled Trials ISRCTN92089567. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 51. See the NIHR Journals Library website for further project information. Funding was also supported by the NIHR Oxford Biomedical Research Centre.
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Affiliation(s)
- Xavier L Griffin
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Matthew L Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Emma Phelps
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK
| | - Nicholas Parsons
- Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - May Ee Png
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Juul Achten
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK
| | - Elizabeth Tutton
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK.,Warwick Research in Nursing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Robin Lerner
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK
| | | | - Janis Baird
- Medical Research Council Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, UK.,National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
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46
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van Gerven P, Krijnen P, Zuidema WP, El Moumni M, Rubinstein SM, van Tulder MW, Schipper IB, Termaat MF. Omitting Routine Radiography of Traumatic Ankle Fractures After Initial 2-Week Follow-up Does Not Affect Outcomes: The WARRIOR Trial: A Multicenter Randomized Controlled Trial. J Bone Joint Surg Am 2020; 102:1588-1599. [PMID: 32604381 DOI: 10.2106/jbjs.19.01381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The clinical consequences of routine follow-up radiographs for patients with ankle fracture are unclear, and their usefulness is disputed. The purpose of the present study was to determine if routine radiographs made at weeks 6 and 12 can be omitted without compromising clinical outcomes. METHODS This multicenter randomized controlled trial with a noninferiority design included 246 patients with an ankle fracture, 153 (62%) of whom received operative treatment. At 6 and 12 weeks of follow-up, patients in the routine-care group (n = 128) received routine radiographs whereas patients in the reduced-imaging group (n = 118) did not. The primary outcome was the Olerud-Molander Ankle Score (OMAS). Secondary outcomes were the American Academy of Orthopaedic Surgeons (AAOS) foot and ankle questionnaire, health-related quality of life (HRQoL) as measured with the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L) and Short Form-36 (SF-36), complications, pain, health perception, self-perceived recovery, the number of radiographs, and the indications for radiographs to be made. The outcomes were assessed at baseline and at 6, 12, 26, and 52 weeks of follow-up. Data were analyzed with use of mixed models. RESULTS Reduced imaging was noninferior compared with routine care in terms of OMAS scores (difference [β], -0.9; 95% confidence interval [CI], -6.2 to 4.4). AAOS scores, HRQoL, pain, health perception, and self-perceived recovery did not differ between groups. Patients in the reduced-imaging group received a median of 4 radiographs, whereas those in the routine-care group received a median of 5 radiographs (p < 0.05). The rates of complications were similar (27.1% [32 of 118] in the reduced-imaging group, compared with 22.7% [29 of 128] in the routine-care group, p = 0.42). The types of complications were also similar. CONCLUSIONS Implementation of a reduced-imaging protocol following an ankle fracture has no measurable negative effects on functional outcome, pain, and complication rates during the first year of follow-up. The number of follow-up radiographs can be reduced by implementing this protocol. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- P van Gerven
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - P Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - W P Zuidema
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - M El Moumni
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - S M Rubinstein
- Amsterdam Movement Science Research Institute, Department of Health Sciences, VU University, Amsterdam, the Netherlands
| | - M W van Tulder
- Amsterdam Movement Science Research Institute, Department of Health Sciences, VU University, Amsterdam, the Netherlands.,Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - I B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - M F Termaat
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Scott LJ, Jones T, Whitehouse MR, Robinson PW, Hollingworth W. Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England. BMC Health Serv Res 2020; 20:811. [PMID: 32867779 PMCID: PMC7457765 DOI: 10.1186/s12913-020-05682-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 08/23/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contact-casting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients. METHODS Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence. RESULTS Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved. CONCLUSIONS Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contact-casting, in line with recent evidence.
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Affiliation(s)
- Lauren J Scott
- NIHR ARC West, University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK.
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK.
| | - Tim Jones
- NIHR ARC West, University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
| | - Michael R Whitehouse
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Westbury-on-Trym, Bristol, BS10 5NB, UK
| | - Peter W Robinson
- Avon Orthopaedic Centre, Southmead Hospital, North Bristol NHS Trust, Westbury-on-Trym, Bristol, BS10 5NB, UK
| | - William Hollingworth
- NIHR ARC West, University Hospitals Bristol and Weston NHS Foundation Trust, 9th Floor Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS, UK
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Benedick A, Audet MA, Vallier HA. The effect of obesity on post-operative complications and functional outcomes after surgical treatment of torsional ankle fracture: A matched cohort study. Injury 2020; 51:1893-1898. [PMID: 32534816 DOI: 10.1016/j.injury.2020.05.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/21/2020] [Accepted: 05/02/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Obesity is a growing public health concern. While diabetes mellitus is associated with obesity and is a risk for infection and other complications, effects of obesity on outcomes remains less clear. The purpose was to determine effect of obesity on complications, secondary operations, and functional outcomes after surgical treatment of ankle fracture. METHODS 955 adult patients treated surgically for torsional ankle injury were reviewed. Obese patients (body mass index (BMI) ≥30), and patients without obesity were matched for age, sex, race, diabetes, and fracture pattern. Patient reported outcomes, measured by Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA), were obtained after 12 months. RESULTS 632 patients (316 obese [mean BMI 36.7] and 316 non-obese [mean BMI 25.5]) with mean age 44.6 years were analyzed. Each group was 52.5% female, and 6.6% had diabetes mellitus. 75.6% of fractures in each group were AO/OTA type 44B and 24.4% were 44C. Non-obese patients were more likely tobacco users (63.3% vs 40.2%, p<0.001). Obese patients trended toward more dislocations (41.8% vs 35.4%, p=0.10), with similar rate of open fracture. Obese patients trended toward more complications (28.5% vs 22.5%. p=0.08) and wound healing problems (4.7% vs 2.2%, p=0.08) with similar rates of secondary procedures. Total FFI scores were higher (worse) for obese patients (35.4 vs 28.5, p=0.03); subcategory scores for disability and activity limitation were worse (p=0.03 and p=0.04, respectively), and obesity was associated with worse SMFA bothersome (31.0 vs 23.6, p=0.02) and mobility scores (41.8 vs 32.5, p=0.008), with a trend towards worse SMFA dysfunction scores in obese patients (29.7 vs 24.7, p=0.06). CONCLUSIONS Obesity is associated with worse functional outcomes by FFI and SMFA surveys. Contributions of baseline limitations to these poor scores in obese patients remain unclear. Injury characteristics were similar between obese and non-obese patients, though obese patients may be more prone to dislocations. A trend was noted for obese patients to experience more complications and wound healing issues, although rates of secondary operations were no different. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alex Benedick
- Study performed at MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
| | - Megan A Audet
- Study performed at MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University
| | - Heather A Vallier
- Study performed at MetroHealth Medical Center, Cleveland, Ohio, affiliated with Case Western Reserve University.
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A mixed-methods systematic review of patients' experience of being invited to participate in surgical randomised controlled trials. Soc Sci Med 2020; 253:112961. [PMID: 32247942 DOI: 10.1016/j.socscimed.2020.112961] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 03/03/2020] [Accepted: 03/22/2020] [Indexed: 11/21/2022]
Abstract
RATIONALE Randomised controlled trials (RCTs) of surgical interventions are increasing. Such trials encounter challenges that are not present in RCTs of non-surgical interventions because of the nature of the intervention. Several studies have explored patients' experiences of surgical trials to improve recruitment or identify barriers and facilitators to research in this setting. Synthesizing these studies may reveal further insights or confirm whether saturation of relevant themes has been achieved. OBJECTIVE This review aimed to understand the experiences of adults who are invited to participate in surgical RCTs. METHOD MEDLINE, Web of Science, and CINAHL were searched to identify articles meeting the inclusion criteria. Assessment of quality was conducted with studies given an overall quality rating of good, fair, or poor. A segregated approach was used to synthesize the data. This method included a thematic synthesis of the qualitative data and a narrative review of the quantitative data. The findings of both syntheses were then integrated. RESULTS Thirty-four articles reporting 28 trials were included. This review found that the decision to participate in a surgical trial is influenced by multiple factors including patients' individual circumstances and attitudes, and the characteristics of the trial itself. The study identified three themes which encompass both qualitative and quantitative findings. These themes reveal it was important for patients to i) make sense of the trial and trial processes, ii) weigh up the risks and benefits of their different treatment options and participation, and iii) trust the trial and staff. CONCLUSIONS A patient-centred approach to trial recruitment may help staff build trusting relationships with patients and address their individual concerns about the trial and the risks and benefits of participation.
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Keene DJ, Willett K. Implications of the Ankle Injury Management (AIM) trial: close contact casting or surgery for older adults with an unstable ankle fracture? Bone Joint J 2019; 101-B:1472-1475. [PMID: 31787004 DOI: 10.1302/0301-620x.101b12.bjj-2019-0171.r2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Ankle Injury Management (AIM) trial was a pragmatic equivalence randomized controlled trial conducted at 24 hospitals in the United Kingdom that recruited 620 patients aged more than 60 years with an unstable ankle fracture. The trial compared the usual care pathway of early management with open reduction and internal fixation with initially attempting non-surgical management using close contact casting (CCC). CCC is a minimally padded cast applied by an orthopaedic surgeon after closed reduction in the operating theatre. The intervention groups had equivalent functional outcomes at six months and longer-term follow-up. However, potential barriers to using CCC as an initial form of treatment for these patients have been identified. In this report, the results of the AIM trial are summarized and the key issues are discussed in order to further the debate about the role of CCC. Evidence from the AIM trial supports surgeons considering conservative management by CCC as a treatment option for these patients. The longer-term follow-up emphasized that patients treated with CCC need careful monitoring in the weeks after its application to monitor maintenance of reduction. Cite this article: Bone Joint J 2019;101-B:1472-1475.
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Affiliation(s)
- David J Keene
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and Oxford NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Keith Willett
- Kadoorie Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and Oxford NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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