Owen Douglas Williamson

Predictors of Moderate or Severe Pain 6 Months After Orthopaedic Injury: A Prospective Cohort Study

Objective: To determine predictors of moderate or severe pain 6 months after orthopaedic injury. Design: Prospective cohort study. Setting: Two adult level 1 trauma centers in Victoria, Australia. Participants: A total of 1290 adults admitted with orthopaedic injuries and registered by the Victorian Orthopaedic Trauma Outcomes Registry. Main Outcome Measures: Participant self-reported pain and health status using an 11-point numerical rating scale and the 12-item Short-Form health survey, respectively. Results: The prevalence of moderate or severe pain was 48% [95% confidence interval (CI), 45-51] at discharge and 30% (95% CI, 28-33) at 6 months postinjury. Failure to complete high school [adjusted odds ratio (AOR) 1.5 (95% CI, 1.1-1.9)], self-reported preinjury pain-related disability [AOR 1.8 (95% CI, 1.3-2.5)], eligibility for compensation [AOR 2.1 (95% CI, 1.6-2.8)], and moderate or severe pain at discharge from the acute hospital [AOR 2.4 (95% CI, 1.8-3.1)] were found to be independent predictors of moderate or severe pain at 6 months postinjury. Conclusions: Moderate or severe pain is commonly reported 6 months after orthopaedic trauma. Pain intensity at discharge and the effects of a “no-fault” compensation system are potentially modifiable factors that might be addressed through intervention studies to reduce the burden of persistent pain after orthopaedic trauma.

Nonoperative Management of Type II Odontoid Fractures in the Elderly

Study Design. Retrospective case series of elderly patients with Type II odontoid fractures, with prospective functional follow-up. Objective. We aimed to investigate the functional outcomes after nonoperative management of Type II odontoid fractures in elderly patients at a Level 1 trauma center. Summary of Background Data. Controversy exists regarding the most appropriate method of treatment of Type II odontoid fractures in the elderly population. The primary aim of management has generally been considered to be the achievement of osseous fusion. Methods. Patients ≥65 years of age presenting to a Level 1 trauma center with Type II odontoid fractures were identified retrospectively from a prospective neurosurgery database. Those initially treated operatively, or who died before follow-up were excluded. Long-term pain and functional outcomes were assessed. Results. Forty-two patients were followed up at a median of 24 months post injury. Ten patients (24%) were treated in cervical collars alone and 32 patients (76%) were managed in halothoracic braces. Radiographically demonstrated osseous fusion occurred in 50% of patients treated in collars and in 37.5% of patients managed in halothoracic bracing. However, fracture stability was achieved in 90% and 100% of cases respectively. In patients treated in collars, 1 patient had severe residual neck pain, severe disability, and poor functional outcome. There were no cases of severe pain or disability, or poor functional outcome in patients managed in halothoracic orthoses. There was no difference in outcome in those achieving osseous union compared with stable fibrous union. Conclusion. The nonoperative management of Type II odontoid fractures in elderly patients results in fracture stability, by either osseous union or fibrous union in almost all patients. Long-term clinical and functional outcomes seem to be more favorable when fractures have been treated with halothoracic bracing in preference to cervical collars. Stable fibrous union may be an adequate aim of management in elderly patients.

Incidence of serious injury and death during sport and recreation activities in Victoria, Australia

Background: Participation in sport and recreation is widely encouraged for general good health and the prevention of some non-communicable diseases. However, injury is a significant barrier to participation, and safety concerns are a factor in the decision to participate. An understanding of the sport/recreation activities associated with serious injury is useful for informing physical activity choices and for setting priorities for the targeting of injury prevention efforts. Objectives: To describe the epidemiology of serious injuries sustained in sport/recreation activities by adults in Victoria, Australia. Methods: The Victorian State Trauma Registry and the National Coroner’s Information Service were used to identify and describe sport/recreation related serious injuries, including deaths, occurring during the period July 2001 to June 2003. Age adjusted rates of serious injury and death were calculated using participation figures for each sport and general population data. Results: There were 150 cases of serious injury and 48 deaths. The rates of serious injury and death were 1.8 and 0.6 per 100 000 participants per year respectively. Motor, power boat, and equestrian sports had the highest rates of serious injury. Most deaths were due to drowning. Conclusion: Although the risk of serious injury through sport/recreation participation is low, motor, power boat, and equestrian sports should be priorities for further research into injury prevention. Most sport/recreation related deaths are due to drowning, highlighting this area for prevention efforts.

Functional measures at discharge: are they useful predictors of longer term outcomes for trauma registries?

Objective:Trauma registries are integral to trauma systems, but reliance on mortality as the primary outcome measure remains a limitation. Some registries have included measures of discharge function, usually the modified Functional Independence Measure (FIM) or the Glasgow Outcome Scale (GOS), with the potential benefit being the ability to identify patients at risk for poor outcome. This study investigates the ability of these measures to predict longer term outcomes. Methods:Two hundred forty-three blunt major trauma patients participated. Data were captured from the trauma registry and discharge function was assessed using the modified FIM, FIM, and GOS. At 6 months postinjury, the GOS, FIM, modified FIM, return to work/study, and other outcome measures were collected by telephone interview. Multivariate analyses were used to assess the performance of discharge functional measures as predictors of 6-month outcomes. Results:Two hundred thirty-six (97.1%) participants were followed at 6 months postinjury. Disability was prevalent at 6 months; 42% had not returned to work/study, and only 32% were categorized as a “good recovery” by the GOS. Neither the GOS nor modified FIM at discharge were independent predictors of 6-month outcomes, whereas the FIM score and the FIM motor score were independent predictors of functional recovery (adjusted odds ratios 0.97; 95% confidence intervals: 0.96–0.99) and return to work/study (adjusted odds ratios 1.03, 95% confidence intervals: 1.01–1.04), respectively. Conclusions:For trauma registries to compare outcomes between regions and improvements over time, it is important that survivors with poor long-term outcomes are identified. Present measurement of discharge outcomes for trauma patients is inadequate for this purpose.

OUTCOMES OF PATIENTS WITH ORTHOPAEDIC TRAUMA ADMITTED TO LEVEL 1 TRAUMA CENTRES

Background:  Although orthopaedic trauma results in significant disability and substantial financial cost, there is a paucity of large cohort studies that collectively describe the functional outcomes of a variety of these injuries. The current study aimed to investigate the outcomes of patients admitted with a range of orthopaedic injuries to adult Level 1 trauma centres.

Segmental malalignment with the Bryan Cervical Disc prosthesis-contributing factors

Part 1 of the current study found that use of the Bryan Cervical Disc prosthesis resulted in a median loss of 2 degrees in functional spinal unit (FSU) lordosis when compared with preoperative imaging (P<0.0001, range: 8-degree loss to 5-degree gain). The observed changes were generally small but varied among both the patients and the surgeons, suggesting that variables may exist which affect postoperative sagittal alignment. The aim of the current study was to identify which, if any, of a range of patient and surgical variables may contribute significantly to postoperative FSU malalignment. The change in FSU angulation between the preoperative and postoperative neutral, erect x-rays of 67 consecutive patients (88 disc levels) were correlated with 35 demographic and radiographic variables. Postoperative change in disc space height, angle of prosthesis insertion, and the amount of bone removed from the anterior aspect of the cephalad vertebra varied significantly among the 3 surgeons and correlated with change in FSU alignment. Intraoperative disc space distraction correlated with subsequent loss of disc space height. Multiple linear regression analysis confirmed that loss of disc space height and angle of prosthesis insertion contributed independently to a model with a coefficient of determination of 0.39 (P<0.0001). Attempts to identify factors contributing to change in alignment have not shown any single factor to be wholly responsible. Although the prescribed surgical technique is relatively standardized, it seems likely that a number of surgical variables, particularly those leading to loss of disc space height and affecting annular tension are important.

Mechanical or inflammatory low back pain: what are the potential signs and symptoms?

Non-specific low back pain (NSLBP) is commonly conceptualised and managed as being inflammatory and/or mechanical in nature. This study was designed to identify common symptoms or signs that may allow discrimination between inflammatory low back pain (ILBP) and mechanical low back pain (MLBP). Experienced health professionals from five professions were surveyed using a questionnaire listing 27 signs/symptoms. Of 129 surveyed, 105 responded (81%). Morning pain on waking demonstrated high levels of agreement as an indicator of ILBP. Pain when lifting demonstrated high levels of agreement as an indicator of MLBP. Constant pain, pain that wakes, and stiffness after resting were generally considered as moderate indicators of ILBP, while intermittent pain during the day, pain that develops later in the day, pain on standing for a while, with lifting, bending forward a little, on trunk flexion or extension, doing a sit up, when driving long distances, getting out of a chair, and pain on repetitive bending, running, coughing or sneezing were all generally considered as moderate indicators of MLBP. This study identified two groups of factors that were generally considered as indicators of ILBP or MLBP. However, none of these factors were thought to strongly discriminate between ILBP and MLBP.

Does the disabilities of the arm, shoulder and hand (DASH) scoring system only measure disability due to injuries to the upper limb?

Although the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was designed, and has been validated, as a measure of disability in patients with disorders of the upper limb, the influence of those of the lower limb on disability as measured by the DASH score has not been assessed. The aim of this study was to investigate whether it exclusively measures disability associated with injuries to the upper limb. The Short Musculoskeletal Functional Assessment, a general musculoskeletal assessment instrument, was also completed by participants. Disability was compared in 206 participants, 84 with an injury to the upper limb, 73 with injury to the lower limb and 49 controls. We found that the DASH score also measured disability in patients with injuries to the lower limb. Care must therefore be taken when attributing disability measured by the DASH score to injuries of the upper limb when problems are also present in the lower limb. Its inability to discriminate clearly between disability due to problems at these separate sites must be taken into account when using this instrument in clinical practice or research.

Biomodeling as an aid to spinal instrumentation

Study Design. Prospective trial. Objective. To develop and validate a new method of spinal stereotaxy. Summary of Background Data. Biomodeling has been found to be helpful for complex skeletal surgery. Frameless stereotaxy has been used for spinal surgery but has significant limitations. A novel stereotactic technique using biomodels has been developed. Methods. Twenty patients with complex spinal disorders requiring instrumentation were recruited. A three-dimensional CT scan of their spine was performed, and the data were transferred via a DICOM network to a computer workstation. ANATOMICS BIOBUILD software was used to generate the code required to manufacture exact acrylate biomodels of each spine using rapid prototyping. The biomodels were used to obtain informed consent from patients and to simulate surgery. Simulation was performed using a standard power drill to place trajectory pins into the spinal biomodel. Acrylate drill guides were manufactured using the biomodels and trajectory pins as templates. The biomodels and drill guides were sterilized and used intraoperatively to assist with surgical navigation and the placement of instrumentation. Results. The biomodels were found to be highly accurate and of great assistance in the planning and execution of the surgery. The ability to drill optimum screw trajectories into the biomodel and then accurately replicate the trajectory was judged especially helpful. Accurate screw placement was confirmed with postoperative CT scanning. The design of the first two templates was suboptimal as the contact surface area was too great and complex. Approximately 20 minutes was spent before surgery preparing each biomodel and template. Operating time was reduced, as less reliance on intraoperative radiograph was necessary. Patients stated that the biomodels improved informed consent. Conclusions. The authors have developed a novel method of spinal stereotaxy using exact plastic copies of the spine manufactured using biomodeling technology. Biomodel spinal stereotaxy is a simple and accurate technique that may have advantages over frameless stereotaxy.

Comparing the Responsiveness of Functional Outcome Assessment Measures for Trauma Registries

BACKGROUND Measuring long-term disability and functional outcomes after major trauma is not standardized across trauma registries. An ideal measure would be responsive to change but not have significant ceiling effects. The aim of this study was to compare the responsiveness of the Glasgow Outcome Scale (GOS), GOS-Extended (GOSE), Functional Independence Measure (FIM), and modified FIM in major trauma patients, with and without significant head injuries. METHODS Patients admitted to two adult Level I trauma centers in Victoria, Australia, who survived to discharge from hospital, were aged 15 years to 80 years with a blunt mechanism of injury, and had an estimated Injury Severity Score >15 on admission, were recruited for this prospective study. The instruments were administered at baseline (hospital discharge) and by telephone interview 6 months after injury. Measures of responsiveness, including effect sizes, were calculated. Bootstrapping techniques, and floor and ceiling effects, were used to compare the measures. RESULTS Two hundred forty-three patients participated, of which 234 patients (96%) completed the study. The GOSE and GOS were the most responsive instruments in this major trauma population with effect sizes of 5.3 and 4.4, respectively. The GOSE had the lowest ceiling effect (17%). CONCLUSIONS The GOSE was the instrument with greatest responsiveness and the lowest ceiling effect in a major trauma population with and without significant head injuries and is recommended for use by trauma registries for monitoring functional outcomes and benchmarking care. The results of this study do not support the use of the modified FIM for this purpose.