Aims

The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures.

Aims. Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery. Methods. The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trial examined adults with an open or closed tibial shaft fracture who were treated with either reamed or unreamed intramedullary nails. HRQoL was assessed at hospital discharge (for pre-injury level) and at 12 months post-fracture using the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction, SMFA Bother, 36-Item Short Form 36 (SF-36) Physical, and SF-36 Mental Component scores. We used multiple linear regression analysis to determine if baseline and surgical factors, as well as post-intervention procedures within one year of fracture, were associated with these HRQoL outcomes. Significance was set at p < 0.01. We hypothesize that, irrespective of the four measures used, prognosis is guided by both modifiable and non-modifiable factors and that patients do not return to their pre-injury level of function, nor HRQoL. Results. For patient and surgical factors, only pre-injury quality of life and isolated fracture showed a statistical effect on all four HRQoL outcomes, while high-energy injury mechanism, smoking, and race or ethnicity, demonstrated statistical significance for three of the four HRQoL outcomes. Patients who did not require reoperation in response to infection, the need for bone grafts, and/or the need for implant exchanges had statistically superior HRQoL outcomes than those who did require intervention within one year after initial tibial fracture nailing. Conclusion. We identified several baseline patient factors, surgical factors, and post-intervention procedures within one year after intramedullary nailing of a tibial shaft fracture that may influence a patient’s HRQoL. Cite this article: Bone Jt Open 2021;2(1):22–32

High energy pelvic injury poses a challenging setting for the treating surgeon. Often multiple injuries are associated, which makes the measurement of short- and long-term functional outcomes a difficult task. The purpose of this study was to determine the incidence of pelvic dysfunction and late impacts of high energy pelvic ring fractures on pelvic floor function in women, with respect to urinary, sexual and musculoskeletal function. This was compared to a similar cohort of women with lower limb fractures without pelvis involvement. The data in our study was prospectively gathered between 2010 and 2013 on 229 adult females who sustained injury between 1998 and 2012. Besides demographic and operative variables, the scores of three validated health assessment tools were tabulated: King's Health Questionnaire (KHQ), Female Sexual Function Index (FSFI) and the Short Musculoskeletal Functional Assessment (SMFA). A multivariate regression analysis was done to compare groups. The incidence of sexual dysfunction was 80.8% in the pelvis and 59.4% in the lower extremity group. A Wilcoxon rank sum test showed a significant difference in KHQ-score (p<0.01) with the pelvis group being worse. When adjusting for age, follow-up and Injury Severity Score this difference was not significant (p=0.28), as was for FSFI and SMFA score. The mean FSFI scores of both groups met the criteria for female sexual dysfunction (<26). Patients with a Tile C fracture have better FSFI scores (16.98) compared to Tile B fractures (10.12; p=0.02). Logistic regression predicting FSFI larger than 26.5 showed that older age and pelvic fractures have a higher likelihood having a form of sexual dysfunction. Sexual dysfunction after lower extremity trauma is found in patients regardless of pelvic ring involvement. Urinary function is more impaired after pelvic injuries, but more data is needed to confirm this. Older age and pelvic fracture are predictors for sexual dysfunction in women. This study is important as it could help counsel patients on the likelihood of sexual dysfunction, something that is probably under-reported and recognized during our patient follow up

Tibial shaft fractures require surgical stabilization preferably by intramedullary nailing. However, patients often report functional limitations even years after the injury. This study investigates the influence of the surgical approach (transpatellar vs. parapatellar) on gait performance and patient reported outcome six months after surgery. Twenty-two patients with tibial shaft fractures treated by intramedullary nailing through a transpatellar approach (TP: n=15, age 41±15, BMI 24±3) or a parapatellar approach (PP: n=7, age 34±15, BMI 23±2) and healthy, matched controls (n=22, age 39±13, BMI 24±2) were assessed by instrumented motion analysis six months after intramedullary nailing. Short musculoskeletal function assessment questionnaire (SMFA) as well as kinematic and kinetic gait data were collected during level walking. Comparisons among approach methods and control group were performed by analysis of variance and Mann-Whitney test. Six months after surgery, knee kinetics in both groups differed significantly compared to controls (p <.04). The approach method affected gait speed (TP: p = .002; PP: p = .08) and knee kinematics in the early stance phase (TP: p = .011; PP: p = .082), with the parapatellar approach showing a more favorable outcome. However, the difference between patient groups was not significant for any of the assessed gait parameters (p > .2). Also, no differences could be found in the bother index (BI) or function index (FI) of SMFA between surgical approach methods (BI: TP: Mdn = 7.2, PP: Mdn = 9.4; FI: TP: Mdn = 10.3, PP: Mdn = 9.2, p > .7). Our study demonstrates, that six months after surgery for tibial shaft fractures functional limitations remain. These limitations appear not to be different for either a trans- or a parapatellar approach for the insertion of the intramedullary nail. The findings of this study are limited by the relatively short follow up time period and small number of patients. Future studies should investigate the source of the functional limitation after intramedullary nailing of tibial shaft fractures

The purpose of this study was to evaluate functional outcome following supracondylar femur fractures using patient-based outcome measures. Patients having sustained supracondylar femur fractures between 1990 and 2004 were identified from the fracture databases of two level-one trauma centres. Three patient-based outcome measures, the Short Form-36 (SF-36) Version two, the Short Musculoskeletal Functional Scale (SMFA), and the Lower Extremity Functional Scale (LEFS) were used to evaluate functional outcome. Each patient’s medical record was also reviewed to obtain information regarding potential predictors of outcome, including age, gender, fracture type (AO classification), presence of comorbidities, smoking status, open vs. closed fracture, and occurrence of complications. Univariate and multivariate models were then used to identify significant predictors of outcome, as reflected in the SMFA bother and dysfunction scores. Sixty-one patients (thirty-five males and twenty-six females) with an average age (at time of injury) of 53 ± 18 years consented to participate. The average length of follow-up was 64 ± 34 months from the time of injury. Mean SF-36 V2 scores were lower than Canadian population norms indicating decreased function or greater pain, while mean SMFA scores were higher than published population norms indicating greater impairment and bother. The mean LEFS score was 40.78 ± 15.90 out of a maximum score of eighty. At the univariate level, the presence of complications was a significant predictor of both the SMFA bother (p=0.002) and dysfunction scores (p=0.015), while positive smoking status was a significant predictor of the bother score (p=0.002). Based on a multivariate linear regression model, the presence of complications (p=0.013) and positive smoking status (p=0.011) were both significant predictors of a higher SMFA bother score. In the multivariate model for SMFA dysfunction score, the presence of complications (p=0.014) and the presence of comorbidities (p=0.017) were significant predictors of a higher score. Comparing SF-36 and SMFA scores with published population norms, supracondylar femur fractures were associated with residual impact. Based on our analysis, smoking, the presence of medical comorbidities at the time of fracture, and the occurrence of complications following fracture repair were the main predictors of poorer patient outcomes following supracondylar femur fracture

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Limited long term data exists comparing operatively and non-operatively treated Achilles tendon ruptures. A previous randomised controlled trial comparing early outcomes showed a short term advantage for surgery, but there are no long term prospective randomised comparisons. Our aim was to determine whether surgery conferred long term benefits in terms of patient reported outcomes or re-rupture. 64 patients (80%) were followed up with postal questionnaires. Patients were asked to complete the Short Musculoskeletal Function Assessment (SMFA), Achilles Tendon Total Rupture Score (ATRS) and EQ-5D questionnaires, and to report re-ruptures. 32 patients were treated non-operatively and 32 operatively; 59 completed the SMFA and 64 the ATRS and EQ-5D assessments. There was no significant difference in SMFA score (median 1.09, IQR 4.89 in the cast group versus 2.17 and 7.07 in the operative group; p=0.347), ATRS (median 96, IQR 18 versus 93 and 15; p=0.509), EQ-5D Index (median 1.0, IQR 0.163 versus 1.0 and 0.257; p=0.327) and EQ-5D Visual Analogue Score (median score 85, IQR 15 versus 85 and 24; p=0.650). There were 2 re-ruptures in the operative group and 4 in the non-operative group (p=0.067). This is the first prospective, randomised, long term report comparing operative and non-operative management. At follow up between 13–17 years after injury, patients reported good function and health related quality of life. There was no significant difference in re-rupture rate between the treatment groups

Objective: The primary aim was to describe the epidemiology of the Holstein-Lewis humeral shaft fracture, its association with radial nerve palsy and the outcome regarding recovery from the radial nerve palsy and fracture healing. The secondary aim was to analyze the long-term functional outcome. Setting: Six major hospitals in Stockholm County. Design: Descriptive study. Retrospective assessment of radial nerve recovery and fracture healing. Prospective assessment of functional outcome. Patients: All 27 patients with a 12A1.3 humeral shaft fracture according to the OTA classification satisfying the criteria of a Holstein-Lewis fracture in a population of 358 consecutive patients with 361 traumatic humeral shaft fractures. Intervention: Nonoperative or operative treatment according to the decision of the attending orthopedic surgeon. Main Outcome Measurements: Recovery of the radial nerve, fracture healing and functional outcome according to the Short Musculoskeletal Function Assessment (SMFA). Results: The Holstein-Lewis humeral shaft fracture constituted 7.5% of all humeral shaft fractures and was associated with an increased risk of acute radial nerve palsy compared to other types of humeral shaft fractures, 22% versus 8% (p< 0.05). The fractures of six of the seven operatively treated patients healed after the primary surgical procedure while one fracture healed after revision surgery. The fractures of all patients treated nonoperatively healed without any further intervention. All six radial nerve palsies (two patients treated nonoperatively and four operatively) recovered. The functional outcome according to the SMFA was good with no differences between the nonoperatively and operatively treated patients: SMFA dysfunction index 7.6 and 9.7, respectively, and SMFA bother index 6.1 and 6.8, respectively. Conclusion: The Holstein-Lewis humeral shaft fracture was associated with a significantly increased risk of acute radial nerve palsy. The overall outcome regarding fracture healing, radial nerve recovery, and function is excellent regardless of the primary treatment modality, i.e. operative or nonoperative treatment. The indication for primary operative intervention in this fracture type appears to be relative

Thirty-eight patients with nonunion of the humeral shaft underwent a comprehensive assessment including completion of three patient-based functional outcome surveys as well as the determination of the Constant shoulder and Mayo elbow scores. Treatment consisted of compression plating with or without bone grafting. Smokers were found to have significantly longer time to union as compared to nonsmokers (25.1 weeks vs. 16.2 weeks, p< 0.001). Our results also demonstrated that increased time to union had a significant negative effect on the patient-reported functional outcome scores. To evaluate the functional outcome and identify prognostic factors that influence the healing time of surgically treated humeral shaft nonunions. Time to consolidation of operatively treated humeral shaft nonunions was significantly longer in smokers versus non-smokers. Time to union was negatively associated with the patient-reported functional outcome scores. The long-term functional outcome following surgical treatment of humeral shaft nonunions is dependent upon the time to consolidation. Smoking is a significant remediable risk factor for delayed union following surgical repair of humeral shaft nonunion. We identified thirty-eight patients (mean age fifty-five years) treated surgically for nonunion of the humeral shaft at a mean follow-up of sixty months. All patients underwent a comprehensive assessment including the completion of the SF-36, the DASH, the SMFA and the determination of the Constant shoulder and Mayo elbow scores. Seventeen (44.7%) patients were classified as ‘smokers’ and twenty-one (55.3%) were ‘non-smokers’. All nonunions united with a mean time of 16.2 weeks for non-smokers and 25.1 weeks for smokers (p< 0.001). Time to union was negatively associated with the Physical Function portion of the SF-36 (p=0.01), the DASH (p=0.01), and the Arm and Hand Function part of the SMFA (p=0.005). The only other factor that had a significant negative effect on the functional outcome scores was the presence of one or more comorbid factors (SF-36, p< 0.001; DASH, p< 0.001; SMFA, p< 0.001). Patient-oriented and surgeon based scores were found to correlate well (range r=0.545 to r=0.916, p< 0.001 for all combinations)

Purpose: To analyze the long-term functional outcome of vertical shear fractures to other forms of severe pelvic injuries: APC-III, LC-III, and complex acetabular fractures. Methods: We identified 31 VS fractures in 29 consecutive patients. A retrospective chart analysis was performed and analyzed in a control group comprising of 98 patients matched for age and sex: 34 APCIII, 32 LC-III and 32 complex acetabular fractures. Functional outcome was assessed in all patients using EuroQol EQ-5D, SF36, VAS, SMFA, Majeed score. Merle d Aubigne and Postel scores (Matta 1986) and radiologic degenerative hip scores (Matta 1994) were used to assess patients with acetabular fractures. Results: Mean age of patients was 43.5 yrs, median ISS-22. In VS group 35% returned to their previous jobs (49% in control group), 30% had changed jobs (30%) and 25% (14%) had retired from regular work. In acetabular group 10 patients had neurologic injury and 3 patients had total hip arthroplasties at 29,40,51months. The clinical outcome (Matta scores) of patients in the acetabular group was:5 excellent (3 THA), 4 good, 13 fair,10 poor. The radiologic Matta score for acetabular group was: 4 excellent, 8 good, 14 fair, 3 poor. Mean EQ-5D description scores were 0.43, 0.63, 0.69, 0.49 and mean valuation scores were 46.1, 62.3, 78, and 51.4 for the VS, LCIII, APIII, and acetabular groups respectively. SF 36 physical health scores were 44.4, 62.5, 78.3, 54,2 and mental health score of 26.2, 68, 76.5 and 56.3 for VS, LCIII, APIII, and acetabular groups. SMFA dysfunction index was 63.3, 44.6, 38.3, 54.1 and the bother index was 60.5, 49, 34.2 and 57.2. There was a significant difference in EQ-5D score, SMFA, SF36 scores indicating poor outcome in the VS group compared to AP-III, LCIII group. There was no significant functional difference between the VS and acetabular group. Conclusion: VS fractures represent the spectrum of high-energy pelvic disruption. Functional outcome is significantly better in patients with APC III, LC III fractures when compared to VS and complex acetabular fractures reflecting the severity of injury. Secondary osteoarthritis, neurologic injuries appear to contribute to the poor outcome of acetabular fractures. Sound reconstruction of pelvic ring is not always associated with good results probably due to extensive pelvic floor trauma as seen in this series of patients. Younger individuals seem to have a relatively better outcome when compared to the older age group

Purpose. Our hypothesis was that closed tibia fractures treated with intramedullary nails are impacted by surgeon and center volumes. Method. Data from 813 patients with closed tibia fractures were obtained from the SPRINT study. Using multiple regression, we examined the effect of center and surgeon volume (categorized as high, moderate, or low), and geographic differences by country (Canada, USA, and the Netherlands) on health-related quality-of-life and revision surgeries to gain union at one year. Our measures of quality-of-life were the Short-Form 36 Health Survey Questionnaire (SF-36 PCS) and the Short Musculoskeletal Function Assessment (SMFA). Results. Patients treated by moderate volume surgeons had a reduced risk of reoperation versus patients treated by low volume surgeons (odds ratio =0.54, 95% CI = 0.33 to 0.89, p=0.02). No effects of surgeon volume were seen for the other outcomes. Patients treated at moderate volume centers had poorer quality of life at one year than patients treated at low volume centers, based on the SMFA Bother score (difference = 7.33, 95% CI = 2.65 to 12.01). This effect was not seen with the other outcomes. Patients with isolated fractures have better quality-of-life at one year, based on all three measures, p<0.001. Older patients have poorer SMFA scores at one year than younger patients, p<0.001. There were no significant differences by country. Conclusion. The traditional volume versus outcome relationship for closed tibial fractures within intramedullary nailing does not hold. Further analyses in other areas of orthopaedic trauma surgery are advisable

Ankle arthroplasty with custom-made talar component is used to avoid talar subsidence, one of the most common causes of ankle prosthesis failure. We have used Agility ankle system with custom-made talar component to treat young patients with postraumatic arthritis, revision arthroplasty and takedown ankle arthrodesis. Ankle substitution was indicated in young patients who refused arthrodesis and understood that revision or additional surgery would be inevitable in the future. Twelve cases were revised with a minimum of nine months of follow-up, females, 2; males, 10; average age, 42 years. Primary replacements were performed in 9 patients, takedown fusion in 2 and revision arthroplasty in 1. Other additional procedures as subtalar fusion (8 cases), calcaneal osteotomies (6), medial column reconstruction (2), anterior compartment tendon lengthening (2 cases) and TAL or gastrocnemius lengthening (12 cases) and reoperation were also revised. Early complications included a fracture of the malleoli in 1 ankle and a dehiscence of the principal wound in 1 case. The mean postoperative ankle ROM was 32° (range 10°–40°) in comparison with preoperatively (0° –15°). The postoperative functional results were evaluated with the SMFA (Short Musculoskeletal Function Assessment) score system and a visual analog pain scale (VAS Questionnaire). The average preoperative SMFA and VAS scores for all patients was, 40,6 and 8,1 respectively. Postoperatively, these scores averaged 18,9 and 2,0 respectively. Those patients with conversion to ankle arthroplasty presented more stiffness after surgery and had required more rehabilitation time. Despite short-term follow-up, talar stems may provide an excellent alternative for the difficult problem of talar subsidence in young patients in total ankle arthroplasty, with good results and restoration of ankle function

Purpose. The objective of this study was to compare items from musculoskeletal outcome questionnaires with items generated by pre- and post-operative ankle arthrodesis and arthroplasty patients (patient-selected portion of the Patient-Specific Index (PASI-P)) to determine if existing questionnaires address patients' concerns. Materials/Methods. Patients (n=142) completed the PASI-P. Items from 6 standardised questionnaires (AAOS, patient-reported portion of AOFAS, FFI, LEFS, SMFA, WOMAC) and PASI-P were matched by 3 reviewers to corresponding categories in the International Classification of Functioning, Disability and Health (ICF). The ICF classification hierarchy codes broad first categories and increasingly detailed second, third, and fourth categories. The standardised questionnaires were then compared to the ‘gold standard’ of PASI-P. Results. 690 concepts were identified in the patients' responses, which corresponded to 45 ICF categories. Most PASI-P concepts fell into Activities and Participation (60.3%) and Body Functions and Body Structures (35.2%), including the second level categories ‘walking’ (21.6%), ‘pain’ (18.7%), and ‘recreation and leisure’ (17.4%). A total of 237 concepts was identified in the 6 questionnaires and linked to 39 second level ICF categories. Overall, SMFA addressed the most second level categories and had the closest proportion of Activities and Participation (68.9%) and Body Functions (23.0%) concepts compared to the patient-generated responses. The patient-reported portion of AOFAS addressed the fewest categories. LEFS only contained items from Activities and Participation. AAOS was the only questionnaire to address the issue of ‘swelling’, though it represented 5.6% of all patient-generated responses. The concepts of ‘swelling’, ‘recreation and leisure’, and ‘sports’ were seldom included in the questionnaires. Conclusion. No single questionnaire captured all concerns identified by patients, and the standardised questionnaires differed largely in content. Clinicians should recognise patient concerns relevant to the ankle currently not included in available questionnaires. This analysis will guide the development of a more comprehensive instrument for evaluating ankle outcomes

Purpose: To evaluate the functional outcome of operatively treated Lisfranc injuries. Method: Over a 7-year interval from 1998 to 2005, 184 skeletally mature patients were identified retrospectively with operatively treated Lisfranc injuries. 85 patients had prospectively measured SMFA functional outcomes and satisfaction surveys. The gender was 37 males and 48 females. Mean age was 39 years (range 17–93). Results: The mechanism was fall (31), MVA (24), crush (15), equestrian (5), or twisting (10). Patients were operatively treated with open reduction internal fixation (ORIF, 53) or primary arthrodesis (PA, 32). The SMFA reliability for this patient sample was 0.892. The function and bother outcomes were 19.4 and 15.8, respectively. The function (21.5 vs. 16.0, p=.11) and bother (17.5 vs. 13.0, p=.25) outcomes were not significantly different for ORIF vs. PA, respectively. In the ORIF group, HW removal (40 of 53) performed better than HW retention (13 of 53) with outcome bother but not function measures of (14.7 vs. 26.1, p< 0.05). Conclusion: If performed well, either ORIF or PA technique function well. Patients are more satisfied with the results and appearance of PA over ORIF. HW removal compared to HW retention positively affect bother not function measures. Secondary surgeries negatively affect both bother and function measures. Patients with pain, associated foot or polytrauma injuries function worse

Introduction: We sought to determine the 1 year patient based outcomes and return to activities for patients with tibia fractures in a randomized trial of reamed and unreamed nail insertion. Methods: 1226 patients with 830 closed and 392 open tibial shaft fractures were enrolled in a randomized trial comparing reamed with unreamed tibial nail insertion and completed one year follow-up. The average age was 39±16 and 74% were male. Patient based outcomes were determined using the validated SF-36 PCS, the SMFA, and a published return to activity questionnaire. Statistical analysis was performed as a stratified analysis comparing the groups with p < 0.05 designated as significant. Results: There was no difference in any outcome parameter for any time frame between the reamed and unreamed groups. The 1 year SF36 PCS (a 100 point scale with a mean of 50 in the general population, higher better) was 42.9±11 for the reamed group and 43.5±11 for unreamed group as compared with 52.5±9 for the reamed group and 53.1±9 for the unreamed group pre-injury. The 1 year SMFA (100 point scale, higher is worse) was 18±17 for the reamed group and 17.5±17 for the unreamed group as compared with 7.9±13 for the reamed group and 7.7±13 unreamed group pre-injury. Conclusion: In patients with tibial shaft fractures treated with intramedullary nails, patient based outcomes are not related to reamed or unreamed insertion. Patients do not return to their preinjury status based on validated outcomes assessments or return to activity by one year after injury

Purpose: The objective of this study is to compare items from patient-reported questionnaires measuring musculoskeletal outcomes with items generated by pre-and post-operative ankle arthrodesis and arthroplasty patients using the Patient-Specific Index (PSI-P). The International Classification of Functioning, Disability and Health (ICF) was used as an external reference. Method: A literature review identified six questionnaires that assess lower extremity outcomes (AAOS, patient-reported portion of AOFAS, FFI, LEFS, SMFA, WOMAC). Surgical patients (n=142) from an orthopaedic surgeon’s practice completed the patient-selected items from PSI-P. Items from questionnaires and PSI-P were coded by three reviewers and linked to the ICF. The ICF is divided into four components (Body Functions and Structures, Activities and Participation, Environmental Factors, and Personal Factors) which are then further divided into second level categories. A higher number of second level categories would indicate a questionnaire that captures a broader range of experiences. Results: Patient’s responses from PSI-P identified 690 meaningful concepts that were linked to 45 second level ICF categories. Most PSI-P responses fell into Activities and Participation (60.6%) and Body Functions and Body Structures (35.2%) including the second level categories Walking (19.1%), Pain (16.5%), and Recreation and Leisure (15.4%). There was no statistical difference between arthrodesis and arthroplasty patients nor between pre-operative versus postoperative patients in terms of the proportion of patient responses that fell into each ICF component. A total of 237 meaningful concepts were identified in the 6 questionnaires studied and linked to 38 second level ICF categories. Overall, SMFA addressed the most number of second level categories and had the closest proportion of Body Function (23.0%) and Activities and Participation (68.9%) concepts as compared to PSI-P. The patient-reported portion of AOFAS addressed the fewest categories. LEFS only contained items from Activities and Participation. AAOS was the only questionnaire to address the issue of ‘swelling’, though it represented 4.9% of all PSI-P responses. Conclusion: Questionnaires differ largely in their content and no single questionnaire captured all of the concerns identified by PSI-P. This analysis will guide us in the development of a new and more comprehensive instrument for evaluating ankle outcomes following fusion or replacement

Aim: We have reviewed the patients treated in our institution with vertical shear fractures of the pelvis and report on our treatment protocol and long term functional outcome. Methods: Between Jan 1993 and Jan 2002 patients with vertical shear fractures were identiþed. Data such as age, sex, aetiology, associated injuries, ISS, resuscitation requirements, transfusion requirements, ICU/HDU stay, treatment, urological injuries, systemic complications, neurological injury and mortality were recorded and analysed. Functional outcome assessment was performed using the following generic tools: Euro-qol 5D (EQ), SF36 v2 (Short form), SMFA, Majeed score and VAS. Results: Out of 380 pelvic ring injuries we identiþed 31 vertical shear fractures in 29 consecutive patients (4 female). The median ISS Score was 22. Motorcycle accidents were responsible for 27%. Injuries were identiþed in the chest (12 patients), abdomen (8 patients) and extremities (14 patients). Urethral injury was present in 9 patients. Ruptured viscus was identiþed in 3 cases. At presentation neurologic deþcit was present in 9 cases. Posterior ring was stabilised in 3(0–13) days. Systemic complications developed in 6 patients Ð ARDS in 4 patients and sepsis in 2 (6%). The mean follow up was 39 months. Functional outcome using the Majeed score revealed that 1/3 of the patients did fair. TheSF-36 v2 analysis, EQ 5-D revealed a moderate functional outcome. The SMFA and the visual analogue score also revealed similar outcomes. Conclusions: Prompt resuscitation and early temporarily stabilisation of the pelvic ring is essential. Sound reconstruction of the pelvic ring is not always associated with good results probably due to the extensive pelvic ßoor trauma as seen in this series of patients. Younger individuals seem to have a relatively better outcome when compared to the older age group

We have reviewed the patients with vertical shear fractures of the Pelvis and report on our treatment protocol and long-term functional outcome. Methods: Between January 1993 and January 2002, out of 581 pelvic ring injuries treated in our unit, we identified 31 vertical shear fractures in 29 (4.9%) patients (4 female). Data such as age, sex, aetiology, associated injuries, ISS, resuscitation and transfusion requirements were recorded. ICU/HDU stay, surgical stabilization, urological injuries, systemic complications, neurological injury and mortality were recorded and analysed. Functional outcome was assessed using the following generic tools: EuroQol EQ-5D, SF36v2, SMFA, Majeed score and VAS. Results: The mean age was 43.5 (16–71). The median ISS was 22 (12–32). Motorcycle accidents were responsible for 27%. Associated injuries included the chest (12 patients), abdomen (8 patients) and extremities (14 patients). Urethral injury was present in 9 and ruptured viscus was identified in 3 patients. Neurologic deficit was present in 9 cases. Posterior ring was stabilized in 3 (0 – 13) days. 6 patients developed systemic complications – ARDS in 4 (12%) patients, sepsis in 2 (6%). The mean follow up was 39 (12–101) months. Functional outcome using the Majeed score revealed that one-third of the patients were fair. SF-36 (physical and mental scores) and EQ 5-score revealed that one-third of the patients were fair. SF-36 (physical and mental scores) and EQ 5-score revealed that one-third of the patients were fair. SF-36 (physical and mental scores) and EQ 5- D revealed a moderate functional outcome. The SMFA and the visual analogue score also revealed similar outcomes. Conclusion: Prompt resuscitation and early temporarily stabilization of the pelvic ring is essential. Sound reconstruction of the pelvic ring is not always associated with good results, probably due to the extensive pelvic floor trauma seen in this series of patients. Younger individuals seem to have a relatively better outcome when compared to the older age group

Fifty-six patients, with a median fourteen years follow-up of isolated tibial shaft fracture treated with an IM nailing, underwent functional evaluation with SMFA and SF-36 questionnaires, as well as an injury specific questionnaire. Thirty-three also underwent clinical and radiological evaluation. Overall, SF-36 scores (PCS 49.9, MCS 52.0) were near normal. Five (15.2%) had physical findings of venous stasis, while a third reported symptoms A third had at least mild OA on radiographs (knee-seven, ankle-eleven). A third of patients had a loss in ankle dorsiflexion, and more than half reported knee pain that was limiting to at least one activity. We conducted a study to evaluate the long term functional outcomes and disabilities of patients with an isolated tibial shaft fracture treated with intramedullary nailing. We identified two hundred and fifty eligible patients from the VGH Orthopaedic Trauma database between 1987 and 1992. A total of fifty-six patients agreed to participate. All were evaluated with the SF-36 and SMFA functional questionnaires, as well as an injury specific questionnaire focusing on knee pain, and symptoms of venous insufficiency. A sub-group of thirty-three patients were evaluated radiographically and by physical examination. We had a median follow-up of fourteen years, with a range from twelve to seventeen years. The SF-36 scores (PCS 49.9, MCS 52.0) were comparable to population norms. Of the questionnaire group (n=56), fifteen denied knee pain with any activity, while twenty-nine had knee pain that was limiting to at least one type of activity. With respect to swelling, eighteen reported asymmetrical swelling affecting the injured limb. However, in the examination group, only five had objective evidence of venous stasis. Knee range of motion was essentially equivalent to the unaffected side, while thirteen patients had a restricted range of motion of the ankle. Radiographically, seven patients had at least mild OA of at least one knee compartment, while eleven had at least mild OA of the tibio-talar joint, despite near anatomic fracture healing. At a median fourteen years following tibial nailing of isolated tibial fractures, patients function very well, but objective and subjective evaluation shows not insignificant sequellae