Functional outcomes are important for patients with bone tumors undergoing lower extremity endoprosthetic reconstruction; however, there is limited empirical evidence evaluating function longitudinally. The objective of this study was to determine the changes in function over time in patients undergoing endoprosthetic reconstructions of the proximal femur, distal femur and proximal tibia.

We conducted a secondary analysis of functional outcome data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial. Patient function was assessed with the Musculoskeletal Tumor Society Score 93 (MSTS) and the Toronto Extremity Salvage Score (TESS), which were administered preoperatively and at 3, 6 and 12 months postoperatively. Both instruments are scored from 0-100, with higher scores indicated greater function. Mean functional scores were evaluated over time and we explored for differences among patients undergoing proximal femur reconstructions (PFR), distal femur reconstructions (DFR) and proximal tibia reconstructions (PTR). The patient-importance of statistically significant differences in function was evaluated utilizing the minimally important difference (MID) of 12 for the MSTS and 11 for the TESS. We explored for differences in change scores between each time interval with paired t-tests. Differences based on endoprosthetic reconstruction undertaken were evaluated by analysis of variance and post-hoc comparisons using the Tukey test.

A total of 573 patients were included. The overall mean MSTS and TESS scores were 77.1(SD±21) and 80.2(SD±20) respectively at 1-year post-surgery, demonstrating approximately a 20-point improvement from baseline for both instruments. When evaluating change scores over time by type of reconstruction, PFR patients experienced significant functional improvement during the 3-6 and 6-12 month follow-up intervals, DFR patients demonstrated significant improvements in function at each follow-up interval, and PTR patients reported a significant decrease in function from baseline to 3 months, and subsequent improvements during the 3-6 and 6-12 month intervals.

On average, patients undergoing endoprosthetic reconstruction of the lower extremity experience important improvements in function from baseline within the first year. Patterns of functional recovery varied significantly based on type of reconstruction performed. The results of this study will inform both clinicians and patients about the expected rehabilitation course and functional outcomes following endoprosthetic reconstruction of the lower extremity.

Functional outcomes are commonly reported in studies of musculoskeletal oncology patients undergoing limb salvage surgery; however, interpretation requires knowledge of the smallest amount of improvement that is important to patients – the minimally important difference (MID). We established the MIDs for the Musculoskeletal Tumor Society Rating Scale (MSTS) and Toronto Extremity Salvage Score (TESS) in patients with bone tumors undergoing lower limb salvage surgery.

This study was a secondary analysis of the recently completed PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) study. This data was used to calculate: (1) the anchor-based MIDs using an overall function scale and a receiver operating curve analysis, and (2) the distribution-based MIDs based on one-half of the standard deviation of the change scores from baseline to 12-month follow-up, for both the MSTS and TESS.

There were 591 patients available for analysis. The Pearson correlation coefficients for the association between changes in MSTS and TESS scores and changes in the external anchor scores were 0.71 and 0.57, indicating “high” and “moderate” correlation. Anchor-based MIDs were 12 points and 11 points for the MSTS and TESS, respectively. Distribution-based calculations yielded MIDs of 16-17 points for the MSTS and 14 points for the TESS.

The current study proposes MID scores for both the MSTS and TESS outcome measures based on 591 patients with bone tumors undergoing lower extremity endoprosthetic reconstruction. These thresholds will optimize interpretation of the magnitude of treatment effects, which will enable shared decision-making with patients in trading off desirable and undesirable outcomes of alternative management strategies. We recommend anchor-based MIDs as they are grounded in changes in functional status that are meaningful to patients.

Persistent post-surgical pain and associated disability are common after a traumatic fracture repair. Preliminary evidence suggests that patients' beliefs and perceptions may influence their prognosis. We sought to explore this association.

We used data from the Fluid Lavage of Open Wounds trial to determine, in 1560 open fracture patients undergoing surgical repair, the association between Somatic PreOccupation and Coping (captured by the SPOC questionnaire) and recovery at 1 year.

Of the 1218 open fracture patients with complete data available for analysis, 813 (66.7%) reported moderate to extreme pain at 1 yr. The addition of SPOC scores to an adjusted regression model to predict persistent pain improved the concordance statistic from 0.66 to 0.74, and found the greatest risk was associated with high SPOC scores [odds ratio: 5.63, 99% confidence interval (CI): 3.59–8.84, absolute risk increase 40.6%, 99% CI: 30.8%, 48.6%]. Thirty-eight per cent (484 of 1277) reported moderate to extreme pain interference at 1 yr. The addition of SPOC scores to an adjusted regression model to predict pain interference improved the concordance statistic from 0.66 to 0.75, and the greatest risk was associated with high SPOC scores (odds ratio: 6.06, 99% CI: 3.97–9.25, absolute risk increase: 18.3%, 95% CI: 11.7%, 26.7%). In our adjusted multivariable regression models, SPOC scores at 6 weeks post-surgery accounted for 10% of the variation in short form-12 physical component summary scores and 14% of short form-12 mental component summary scores at 1 yr.

Amongst patients undergoing surgical repair of open extremity fractures, high SPOC questionnaire scores at 6 weeks post-surgery were predictive of persistent pain, reduced quality of life, and pain interference at 1 yr.

Persistent post-surgical pain affects 10%-80% of individuals after common operations, and is more common among patients with psychological factors such as depression, anxiety, or catastrophising. We conducted a systematic review and meta-analysis of randomised, controlled trials to evaluate the efficacy of perioperative psychotherapy for persistent postsurgical pain and physical impairment.

We searched Medline, PsycINFO, CINAHL, and the Cochrane Central Registry of Controlled Trials to identify relevant RCTs, in any language, from inception of each database to September 1, 2016. Paired independent reviewers identified studies, extracted data, and assessed risk of bias. We pooled treatment effects of perioperative psychotherapy on similar outcomes across eligible trials, focusing on intention-to-treat analysis. We used random effects models to perform all meta-analyses. The Grading of Recommendations, Assessment, Development and Evaluation system was used to assess the quality of evidence.

Our search found 15 trials (2220 patients) that were eligible for review. For both persistent post-surgical pain and physical impairment, perioperative education was ineffective, while active psychotherapy suggested a benefit (test of interaction P=0.01 for both outcomes). Moderate quality evidence showed that active perioperative psychotherapy (cognitive-behaviour therapy, relaxation therapy, or both) significantly reduced persistent post-surgical pain [weighted mean difference (WMD) −1.06 cm on a 10 cm visual analogue scale for pain, 95% confidence interval (CI) −1.56 to −0.55 cm, risk difference (RD) for achieving no more than mild pain (3 cm or less) 14%, 95% CI 8–21%] and physical impairment [WMD −9.87% on the 0–100% Oswestry Disability Index, 95% CI −13.42 to −6.32%, RD for achieving no more than mild disability (20% or less) 21%, 95% CI 13–29%].

Perioperative cognitive behavioural therapy and relaxation therapy are effective for reducing persistent pain and physical impairment after surgery. High quality evidence shows no significant effects of perioperative education or psychological support on persistent post-surgical pain or physical impairment compared with usual care. Future studies should explore targeted psychotherapy for surgical patients at higher risk for poor outcome.

Electrical stimulators are commonly used to accelerate fracture healing, resolve nonunions or delayed unions, and to promote spinal fusion. The efficacy of electrical stimulator treatment, however, remains uncertain. We conducted a meta-analysis of randomised sham-controlled trials to establish the effectiveness of electrical stimulation for bone healing.

We searched MEDLINE, EMBASE, CINAHL and Cochrane Central to identify all randomised sham-controlled trials evaluating electrical stimulators in patients with acute fractures, non-union, delayed union, osteotomy healing or spinal fusion, published up to February 2015. Our outcomes were radiographic nonunion, patient-reported pain and self-reported function. Two reviewers independently assessed eligibility and risk of bias, performed data extraction, and rated overall confidence in the effect estimates according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Fifteen randomised trials met our inclusion criteria. Electrical stimulation reduced the relative risk of radiographic nonunion or persistent nonunion by 35% (95%CI 19% to 47%; 15 trials; 1247 patients; number needed to treat = 7; p < 0.01; moderate certainty). Electrical stimulation also showed a significant reduction in patient-reported pain (Mean Difference (MD) on the 100-millimeter visual analogue scale = −7.67; 95% CI −13.92 to −1.43; 4 trials; 195 patients; p = 0.02; moderate certainty). Limited functional outcome data showed no difference with electrical stimulation (MD −0.88; 95% CI −6.63 to 4.87; 2 trials; 316 patients; p = 0.76; low certainty).

Patients treated with electrical stimulation as an adjunct for bone healing have a reduced risk of radiographic nonunion or persistent nonunion and less pain; functional outcome data are limited and requires increased focus in future trials.

Purpose: We aimed to preliminarily validate a newly developed system, the radiographic union scale for tibial (RUST) fracture healing. We hypothesized that RUST would demonstrate better inter-rater reliability than assessment of the number of cortices bridged and correlate with functional outcomes at least as strongly as surgeon’s assessment of cortical bridging.

Method: Three blinded orthopaedic trauma surgeons independently assigned a RUST score and a number of cortices bridged by callus (zero to four) to each set of AP and lateral radiographs at each follow up period. RUST is scored from four (definitely not healed) to 12 (definitely healed) based on the presence or absence of callus and of a visible fracture line at the total of four cortices visible.

Results: For 549 sets of reviewed radiographs, inter-rater reliability for RUST scores were found to be substantially higher than for assessment of the number of cortices bridged (intra-class correlation coefficient=0.84; 95% CI, 0.80–0.87 versus kappa = 0.73; 95% CI, 0.64 – 0.81, respectively). Both methods of assessing radiographic healing were strongly correlated with weight-bearing status (r and ρ> 0.50), moderately correlated with patient-reported functional recovery and the SF-36 Physical Functioning component scores (r and ρ> 0.30), and minimally correlated with HUI Mark II scores, return to work, and the SF-36 Role Physical component and Physical Component Summary scores (r and ρ> 0.10). Neither assessment was correlated with patient-reported pain scores. All correlations were similar for RUST and the number of cortices bridged.

Conclusion: This study provides preliminary evidence that RUST can be used as a valid and reliable alternative assessment of tibial fracture healing.

Little is known about the psychological morbidity associated with orthopaedic trauma. Our study aimed to determine the extent of psychological symptoms and whether patient psychological symptoms were predictive of outcomes following orthopaedic trauma. Overall, trauma patients experienced higher intensity of psychological symptoms than population norms. Psychological symptoms, patient age, and ongoing litigation predicted functional outcomes. Patients may benefit from early interventions by social workers and psychologists to process their psychological states post injury.

Little is known about the psychological morbidity associated with orthopaedic trauma.

Our study aimed to determine the extent of psychological symptoms and whether patient psychological symptoms were predictive of outcomes following orthopaedic trauma.

All patients attending ten orthopaedic fracture clinics at three University-affiliated Hospitals were approached for study eligibility. All consenting patients would be requested to complete a baseline assessment form, a 90-item symptom checklist-90R (SCL-90R), and the Short-Form–36. The SCL-90R constitutes nine dimensions (Somatization, Obsessive-compulsive, Interpersonal sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation, Psychoticism) and three global indices (Global severity index, Positive symptom distress index, positive symptom total). We conducted regression analyses to determine predictors of quality of life among study patients.

Of two hundred and fifteen patients, 59% were male at a mean age of 44.5 years. Over half of patients had lower extremity fractures. Trauma patients experienced greater psychological symptoms than population norms. Overall, trauma patients experienced higher intensity of psychological symptoms than population norms. Patient functional outcomes were predicted by patient age, ongoing litigation, and Positive Symptom Distress. This model predicted 21% of the variance in patient function. Patient somatization was an important psychological symptom resulting in increasing intensity of symptoms. Smoking, alcohol, open fracture, surgeons’ perception of technical outcome, level of education, and time since injury were not predictive in this model.

Psychological symptoms, patient age, and ongoing litigation predicted functional outcomes. Patients may benefit from early interventions by social workers and psychologists to process their psychological states post injury.

Funding: This study was funded in part by research grants from AO North America and Regional Medical Associates, McMaster University. Dr. Bhandari was funded, in part, by a 2004 Detweiler Fellowship, Royal Colleges of Physicians and Surgeons of Canada. Dr. Busse is funded by a Canadian Institutes of Health Research Fellowship Award.

Introduction: Closed and open grade I (low energy) tibial shaft fractures are a common and costly event and optimal management for such injuries remains uncertain.

Methods: We explored costs associated with treatment of low energy tibial fractures with either casting, casting with therapeutic ultrasound, or intramedullary nailing (with and without reaming) by use of a decision tree.

Results: From a governmental perspective the mean associated costs were USD $3 365 (standard deviation [SD] ± 1 425) for operative management by reamed intramedullary nailing, $5 041 (SD ± 1 363) for operative management by non-reamed intramedullary nailing, $5 017 (SD±1 370) for casting, and $5 312 (SD±1 474) for casting with therapeutic ultrasound. From a societal perspective the mean associated costs were ($12 449; SD±4 894) for reamed intramedullary nailing, ($13 266; SD±3 692) for casting with therapeutic ultrasound, ($15 571; SD±4 293) for operative management by non-reamed intramedullary nailing, and ($17 343; SD±4 784) for casting alone.

Interpretation: Our analysis suggests that, from an economical standpoint, reamed intramedullary nailing is the treatment of choice for closed and open grade I tibial shaft fractures. There is preliminary evidence, from a societal perspective, that treatment of low energy tibial fractures with therapeutic ultrasound and casting may also be an economically-sound intervention.

Introduction: Little is known about the psychological morbidity associated with orthopaedic trauma.

Purpose: Our study aimed to determine the extent of psychological symptoms and whether patient psychological symptoms were predictive of outcomes following orthopaedic trauma.

Methods: All patients attending 10 orthopaedic fracture clinics at 3 University-affiliated Hospitals were approached for study eligibility. All consenting patients would be requested to complete a baseline assessment form, a 90-item symptom checklist-90R (SCL-90R), and the Short-Form–36. The SCL-90R constitutes 9 dimensions (Somatization, Obsessive-compulsive, Interpersonal sensitivity, Depression, Anxiety, Hostility, Phobic anxiety, Paranoid ideation, Psychoticism) and three global indices (Global severity index, Positive symptom distress index, positive symptom total). We conducted regression analyses to determine predictors of quality of life among study patients.

Results: Of 215 patients, 59% were male at a mean age of 44.5 years. Over half of patients had lower extremity fractures. Trauma patients experienced greater psychological symptoms than population norms. Overall, trauma patients experienced higher intensity of psychological symptoms than population norms. Patient functional outcomes were predicted by patient age, ongoing litigation, and Positive Symptom Distress. This model predicted 21% of the variance in patient function. Patient somatization was an important psychological symptom resulting in increasing intensity of symptoms. Smoking, alcohol, open fracture, surgeons’ perception of technical outcome, level of education, and time since injury were not predictive in this model.

Conclusions: Psychological symptoms, patient age, and ongoing litigation predicted functional outcomes. Patients may benefit from early interventions by social workers and psychologists to process their psychological states post injury.