Elton R. Edwards

Intramedullary skeletal kinetic distractor in the treatment of leg length discrepancy--a review of 16 cases and analysis of complications.

Objective: The intramedullary skeletal kinetic distractor (ISKD; Orthofix) is a relatively new device available for limb lengthening. This fully implantable mechanical nail promises reduced morbidity over traditional methods where external fixation is used. We report on our experience using this device in treating 16 patients with leg length discrepancy. Design: Retrospective review of 16 consecutive patients treated with ISKD. Setting: Tertiary trauma hospital. Patients: Thirteen males and 3 females were treated with the ISKD between 2004 and 2009. There were 11 femora and 5 tibiae. The indication for lengthening was posttraumatic shortening in 15 patients and congenital hypoplasia in the remaining patient. Outcome Measures: Limb length gained, rate of lengthening, time to consolidation, complications, and factors that may be associated with complications. Results: All patients in the series successfully completed treatment and reached the desired limb length with radiographic evidence of consolidation. The average leg length increase was 35 mm (21–75 mm). No infection, malunion, or joint contracture was observed. A length of less than 100 mm of the thick portion of the nail in the distal fragment is associated with the likelihood of a “runaway nail” (distraction index > 1.5 mm/d). Six patients had poor regenerate requiring bone grafting. Likelihood of poor regenerate was associated with number of previous operations on the lengthened bone. Three patients had nails that were difficult to distract and required closed manipulation under anesthesia. Conclusions: The ISKD is an effective method for correcting leg length discrepancies. Complications are frequent but are manageable with standard techniques. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison of measures of comorbidity for predicting disability 12-months post-injury

BackgroundUnderstanding the factors that impact on disability is necessary to inform trauma care and enable adequate risk adjustment for benchmarking and monitoring. A key consideration is how to adjust for pre-existing conditions when assessing injury outcomes, and whether the inclusion of comorbidity is needed in addition to adjustment for age. This study compared different approaches to modelling the impact of comorbidity, collected as part of the routine hospital episode data, on disability outcomes following orthopaedic injury.Methods12-month Glasgow Outcome Scale – Extended (GOS-E) outcomes for 13,519 survivors to discharge were drawn from the Victorian Orthopaedic Trauma Outcomes Registry, a prospective cohort study of admitted orthopaedic injury patients. ICD-10-AM comorbidity codes were mapped to four comorbidity indices. Cases with a GOS-E score of 7–8 were considered “recovered”. A split dataset approach was used with cases randomly assigned to development or test datasets. Logistic regression models were fitted with “recovery” as the outcome and the performance of the models based on each comorbidity index (adjusted for injury and age) measured using calibration (Hosmer-Lemshow (H-L) statistics and calibration curves) and discrimination (Area under the Receiver Operating Characteristic (AUC)) statistics.ResultsAll comorbidity indices improved model fit over models with age and injuries sustained alone. None of the models demonstrated acceptable model calibration (H-L statistic p < 0.05 for all models). There was little difference between the discrimination of the indices for predicting recovery: Charlson Comorbidity Index (AUC 0.70, 95% CI: 0.68, 0.71); number of ICD-10 chapters represented (AUC 0.70, 95% CI: 0.69, 0.72); number of six frequent chronic conditions represented (AUC 0.70, 95% CI: 0.69, 0.71); and the Functional Comorbidity Index (AUC 0.69, 95% CI: 0.68, 0.71).ConclusionsThe presence of ICD-10 recorded comorbid conditions is an important predictor of long term functional outcome following orthopaedic injury and adjustment for comorbidity is indicated when assessing risk-adjusted functional outcomes over time or across jurisdictions.

Twelve-month outcomes of serious orthopaedic sport and active recreation-related injuries admitted to Level 1 trauma centers in Melbourne, Australia.

Objective:To describe and identify predictors of 12-month outcomes of serious orthopaedic injuries due to sport and active recreation. Design:Prospective cohort study with 12-month follow-up. Setting:Two Level 1 adult trauma centers in Victoria, Australia. Participants:A total of 366 adults admitted to two Level 1 trauma centers for an orthopaedic sport and active recreation injury between August 2003 and March 2006. Patients were captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), followed up at 12 months, and were free of moderate to severe disability prior to injury. Assessment of risk factors:Independent variables assessed for predictors of outcome were sporting group, age, sex, marital status, education level, Injury Severity Score, injury patterns, and head injury status. Main outcome measurements:The 12-item Short Form Health Survey and maximum pain scores. Results:At 12 months postinjury, 22.8% of patients reported moderate to severe physical disability, 12.1% reported moderate to severe mental health disability, and 11.1% reported moderate to severe pain. There were significant differences in physical outcomes between sporting groups, with motor and equestrian sports reporting the worst physical outcomes. Multivariate analysis indentified increasing age (P = 0.010) and patterns of injury (P = 0.040) as significant predictors of a poor physical outcome at 12 months. No significant independent predictors of outcome for mental health and maximum pain at 12 months were identified. Conclusion:Almost one-quarter of participants reported moderate to severe physical disability at 12 months postinjury. Increasing age and patterns of injury were found to be significant predictors of a poor physical outcome at 12 months.

Discharge destination following lower limb fracture: development of a prediction model to assist with decision making.

BACKGROUND Accurate prediction of the likelihood of discharge to inpatient rehabilitation following lower limb fracture made on admission to hospital may assist patient discharge planning and decrease the burden on the hospital system caused by delays in decision making. AIMS To develop a prognostic model for discharge to inpatient rehabilitation. METHOD Isolated lower extremity fracture cases (excluding fractured neck of femur), captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), were extracted for analysis. A training data set was created for model development and validation data set for evaluation. A multivariable logistic regression model was developed based on patient and injury characteristics. Models were assessed using measures of discrimination (C-statistic) and calibration (Hosmer-Lemeshow (H-L) statistic). RESULTS A total of 1429 patients met the inclusion criteria and were randomly split into training and test data sets. Increasing age, more proximal fracture type, compensation or private fund source for the admission, metropolitan location of residence, not working prior to injury and having a self-reported pre-injury disability were included in the final prediction model. The C-statistic for the model was 0.92 (95% confidence interval (CI) 0.88, 0.95) with an H-L statistic of χ(2)=11.62, p=0.17. For the test data set, the C-statistic was 0.86 (95% CI 0.83, 0.90) with an H-L statistic of χ(2)=37.98, p<0.001. CONCLUSION A model to predict discharge to inpatient rehabilitation following lower limb fracture was developed with excellent discrimination although the calibration was reduced in the test data set. This model requires prospective testing but could form an integral part of decision making in regards to discharge disposition to facilitate timely and accurate referral to rehabilitation and optimise resource allocation.

Preinjury status : Are orthopaedic trauma patients different than the general population?

Objective: To describe the preinjury health-related quality of life (HRQL) of orthopaedic trauma patients admitted to Level I trauma centers relative to the general population. Design: Prospective cohort study using retrospectively collected preinjury HRQL measures. Setting: Two Level I adult trauma centers in Melbourne, Australia. Participants: A total of 2388 admitted orthopaedic trauma patients aged ≥18 years were included, captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) between October 2003 and January 2006. Patients with a significant head injury (Abbreviated Injury Scale severity score >2), dementia, mental illness, mental disability, who were non-English speakers, or who were postoperatively confused were excluded. Main Outcome Measurements: The 12-item Short Form Health Survey (SF-12). Results: The preinjury SF-12 was obtained for 1839 patients [median (interquartile range) of 6 (3-12) days postinjury]. The VOTOR population reported mean physical SF-12 scores above population norms (50.9 vs. 48.9, P < 0.001). The differences were predominant in men and confined to patients aged 18 to 54 years. The mean mental SF-12 scores of the VOTOR population were also greater than population norms (54.5 vs. 52.4, P < 0.001) and this was most apparent for women. Conclusions: Establishing the preinjury HRQL of trauma patients is important for evaluating the quality of orthopaedic trauma patient outcomes. Reliance on population norms for this purpose may lead to an underestimation of the impact of injury in particular age and sex subgroups, but given the size of the differences seen, any underestimation would be small. Where individual preinjury data cannot be collected, population norms could be used as a reasonable estimate of preinjury patient status for assessing quality of recovery.

Association between perception of fault for the crash and function, return to work and health status 1 year after road traffic injury: a registry-based cohort study

Objectives To establish the association between the patients perception of fault for the crash and 12-month outcomes after non-fatal road traffic injury. Setting Two adult major trauma centres, one regional trauma centre and one metropolitan trauma centre in Victoria, Australia. Participants 2605 adult, orthopaedic trauma patients covered by the states no-fault third party insurer for road traffic injury, injured between September 2010 and February 2014. Outcome measures EQ-5D-3L, return to work and functional recovery (Glasgow Outcome Scale—Extended score of upper good recovery) at 12 months postinjury. Results After adjusting for key confounders, the adjusted relative risk (ARR) of a functional recovery (0.57, 95% CI 0.46 to 0.69) and return to work (0.92, 95% CI 0.86 to 0.99) were lower for the not at fault compared to the at fault group. The ARR of reporting problems on EQ-5D items was 1.20–1.35 times higher in the not at fault group. Conclusions Patients who were not at fault, or denied being at fault despite a police report of fault, experienced poorer outcomes than the at fault group. Attributing fault to others was associated with poorer outcomes. Interventions to improve coping, or to resolve negative feelings from the crash, could facilitate better outcomes in the future.

Rest easy? Is bed rest really necessary after surgical repair of an ankle fracture?

INTRODUCTION Bed rest with elevation of the affected limb is commonly prescribed postoperatively following ankle fracture fixation although there is no evidence that this is necessary. AIM The aim of this prospective, randomised study was to investigate the effects of early mobilisation following surgical fixation of an ankle fracture on wound healing and length of stay (LOS). METHOD A total of 104 patients underwent primary internal fixation of an ankle fracture at The Alfred hospital, Melbourne between July 2008 and January 2010. INTERVENTION The strategy included either early mobilisation group (first day post surgery) or control group (bed rest with elevation until day 2 post surgery). OUTCOME MEASURES Data collected included demographic, injury type and surgical procedure. Outcome data included inpatient LOS, wound condition at 10-14 days, opioid use and re-admission rate. RESULTS Groups were comparable at baseline. Wound breakdown rate was 2.9% (3 patients in the control group). Median LOS of the early mobilisation group was 55 h compared with 71 h in the control group (p<0.0001). Opioid use for the control group was an average of 90 mg morphine equivalent in the first 24 h post surgery compared with 67 mg morphine equivalent for the early mobilisation group (p=0.32). CONCLUSION This study indicates that early mobilisation following surgical fixation of an ankle fracture results in a shorter hospital stay without evidence of an increased risk of re-admission or wound complication.

Bicycling crash characteristics: an in-depth crash investigation study

The aim of this study was to describe the crash characteristics and patient outcomes of a sample of patients admitted to hospital following bicycle crashes. Injured cyclists were recruited from the two major trauma services for the state of Victoria, Australia. Enrolled cyclists completed a structured interview, and injury details and patient outcomes were extracted from the Victorian State Trauma Registry (VSTR) and the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). 186 cyclists consented to participate in the study. Crashes commonly occurred during daylight hours and in clear weather conditions. Two-thirds of crashes occurred on-road (69%) and were a combination of single cyclist-only events (56%) and multi-vehicle crashes (44%). Of the multi-vehicle crashes, a motor vehicle was the most common impact partner (72%) and distinct pre-crash directional interactions were observed between the cyclist and motor vehicle. Nearly a quarter of on-road crashes occurred when the cyclist was in a marked bicycle lane. Of the 31% of crashes that were not on-road, 28 (15%) occurred on bicycle paths and 29 (16%) occurred in other locations. Crashes on bicycle paths commonly occurred on shared bicycle and pedestrian paths (83%) and did not involve another person or vehicle. Other crash locations included mountain bike trails (39%), BMX parks (21%) and footpaths (18%). While differences in impact partners and crash characteristics were observed between crashes occurring on-road, on bicycle paths and in other locations, injury patterns and severity were similar. Most cyclists had returned to work at 6 months post-injury, however only a third of participants reported a complete functional recovery. Further research is required to develop targeted countermeasures to address the risk factors identified in this study.

Twelve-month mortality and functional outcomes in hip fracture patients under 65 years of age

INTRODUCTION There has been a recent call for improved functional outcome reporting in younger hip fracture patients. Younger hip fracture patients represent a different population with different functional goals to their older counterparts. Therefore, previous research on mortality and functional outcomes in hip fracture patients may not be generalisable to the younger population. The aims of this study were to report 12-month survival and functional outcomes in hip fracture patients aged <65 years and predictors of functional outcome. METHODS Hip fracture patients aged <65years (range 17-64) registered by the Victorian Orthopaedic Trauma Outcomes Registry over four years were included and their 12-month survival and functional outcomes (Extended Glasgow Outcome Scale) reported. Ordered multivariable logistic regression was used to identify predictors of higher function. RESULTS There were 507 patients enrolled in the study and of the 447 patients (88%) with 12-month outcomes, 24 (5%) had died. The majority of patients had no comorbidities or pre-injury disability and were injured via road trauma or low falls. 40% of patients sustained additional injuries to their hip fracture. 23% of patients had fully recovered at 12 months and 39% reported ongoing moderate disability. After adjusting for all key variables, odds of better function 12-months post-fracture were reduced for patients with co-morbidities, previous disability or additional injuries, those receiving compensation or injured via low falls. CONCLUSIONS While 12-month survival rates were satisfactory in hip fracture patients aged under 65 years, their functional outcomes were poor, with less than one quarter having fully recovered 12 months following injury. This study provides new information about which patients may have difficulty returning to their pre-injury level of function. These patients may require additional or more intensive post-discharge care in order to fulfil their functional goals and continue to contribute productively to society.

Twelve-month work–related outcomes following hip fracture in patients under 65 years of age

INTRODUCTION Recent research has highlighted the need for improved outcome reporting in younger hip fracture patients. For this population, return to work (RTW) is a particularly important measure against which to evaluate treatment outcomes. However, to date, only two small studies have reported RTW outcomes in young hip fracture patients and neither investigated factors predictive of RTW. The aims of this study were to report return to work (RTW) status and predictors of RTW 12 months after hip fracture in patients <65 years. METHODS Two hundred and ninety-one adults aged <65 years, admitted with hip fractures between July 2009 and June 2013 and registered by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) were included in this prospective cohort study. Twelve-month return to work status was collected through structured telephone interviews conducted by trained interviewers. Multivariate logistic regression was used to identify demographic and injury variables that were important predictors of 12-month work status. RESULTS Sixty-five per-cent of patients had returned to work 12 months after hip fracture (62% of whom had an isolated hip fracture and 38% of whom had additional injuries). Relative to patients aged 16-24 years, odds of RTW was reduced by 78%-89% for each 10-year increase in age (p=0.02). Relative to patients employed as managers/administrators/professionals, odds of RTW were 68% to 95% lower for all other workers (p<0.001). For those reporting a pre-injury disability, odds of RTW were 79% lower compared to those without disability (p=0.004) and 69% lower for patients with multiple injuries compared to isolated hip fracture patients (p=0.002). Finally, patients compensated by a work or transport insurer had a 67% lower odds of RTW relative to patients who were not compensated (p=0.02). CONCLUSIONS Approximately one third of patients <65years had not returned to work 12 months after hip fracture. Patients who are older, have multiple injuries or pre-existing disabilities or who work in more physical occupations may need more assistance to RTW following hip fracture. The compensation system should be examined to determine why compensated patients may be at risk of poor RTW outcomes.