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The Bone & Joint Journal
Vol. 103-B, Issue 6 | Pages 1055 - 1062
1 Jun 2021
Johal H Axelrod D Sprague S Petrisor B Jeray KJ Heels-Ansdell D Bzovsky S Bhandari M

Aims

Despite long-standing dogma, a clear relationship between the timing of surgical irrigation and debridement (I&D) and the development of subsequent deep infection has not been established in the literature. Traditionally, I&D of an open fracture has been recommended within six hours of injury based on animal studies from the 1970s, however the clinical basis for this remains unclear. Using data from a multicentre randomized controlled trial of 2,447 open fracture patients, the primary objective of this secondary analysis is to determine if a relationship exists between timing of wound I&D (within six hours of injury vs beyond six hours) and subsequent reoperation rate for infection or healing complications within one year for patients with open limb fractures requiring surgical treatment.

Methods

To adjust for the influence of patient and injury characteristics on the timing of I&D, a propensity score was developed from the dataset. Propensity-adjusted regression allowed for a matched cohort analysis within the study population to determine if early irrigation put patients independently at risk for reoperation, while controlling for confounding factors. Results were reported as odds ratios (ORs), 95% confidence intervals (CIs), and p-values. All analyses were conducted using STATA 14.


The Bone & Joint Journal
Vol. 100-B, Issue 9 | Pages 1227 - 1233
1 Sep 2018
Gitajn IL Titus AJ Tosteson AN Sprague S Jeray K Petrisor B Swiontkowski M Bhandari M Slobogean G

Aims

The aims of this study were to quantify health state utility values (HSUVs) after a tibial fracture, investigate the effect of complications, to determine the trajectory in HSUVs that result in these differences and to quantify the quality-adjusted life years (QALYs) experienced by patients.

Patients and Methods

This is an analysis of 2138 tibial fractures enrolled in the Fluid Lavage of Open Wounds (FLOW) and Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trials. Patients returned for follow-up at two and six weeks and three, six, nine and 12 months. Short-Form Six-Dimension (SF-6D) values were calculated and used to calculate QALYs.


The Bone & Joint Journal
Vol. 100-B, Issue 3 | Pages 361 - 369
1 Mar 2018
Sprague S Bhandari M Heetveld MJ Liew S Scott T Bzovsky S Heels-Ansdell D Zhou Q Swiontkowski M Schemitsch EH

Aims

The primary aim of this prognostic study was to identify baseline factors associated with physical health-related quality of life (HRQL) in patients after a femoral neck fracture. The secondary aims were to identify baseline factors associated with mental HRQL, hip function, and health utility.

Patients and Methods

Patients who were enrolled in the Fixation using Alternative Implants for the Treatment of Hip Fractures (FAITH) trial completed the 12-item Short Form Health Survey (SF-12), Western Ontario and McMaster Universities Arthritis Index, and EuroQol 5-Dimension at regular intervals for 24 months. We conducted multilevel mixed models to identify factors potentially associated with HRQL.


The Bone & Joint Journal
Vol. 100-B, Issue 1 | Pages 88 - 94
1 Jan 2018
Sprague S Petrisor B Jeray K McKay P Heels-Ansdell D Schemitsch E Liew S Guyatt G Walter SD Bhandari M

Aims

The Fluid Lavage in Open Fracture Wounds (FLOW) trial was a multicentre, blinded, randomized controlled trial that used a 2 × 3 factorial design to evaluate the effect of irrigation solution (soap versus normal saline) and irrigation pressure (very low versus low versus high) on health-related quality of life (HRQL) in patients with open fractures. In this study, we used this dataset to ascertain whether these factors affect whether HRQL returns to pre-injury levels at 12-months post-injury.

Patients and Methods

Participants completed the Short Form-12 (SF-12) and the EuroQol-5 Dimensions (EQ-5D) at baseline (pre-injury recall), at two and six weeks, and at three, six, nine and 12-months post-fracture. We calculated the Physical Component Score (PCS) and the Mental Component Score (MCS) of the SF-12 and the EQ-5D utility score, conducted an analysis using a multi-level generalized linear model, and compared differences between the baseline and 12-month scores.


The Bone & Joint Journal
Vol. 99-B, Issue 11 | Pages 1526 - 1532
1 Nov 2017
Tarride JE Hopkins RB Blackhouse G Burke N Bhandari M Johal H Guyatt GH Busse JW

Aims

This 501-patient, multi-centre, randomised controlled trial sought to establish the effect of low-intensity, pulsed, ultrasound (LIPUS) on tibial shaft fractures managed with intramedullary nailing. We conducted an economic evaluation as part of this trial.

Patients and Methods

Data for patients’ use of post-operative healthcare resources and time taken to return to work were collected and costed using publicly available sources. Health-related quality of life, assessed using the Health Utilities Index Mark-3 (HUI-3), was used to derive quality-adjusted life years (QALYs). Costs and QALYs were compared between LIPUS and control (a placebo device) from a payer and societal perspective using non-parametric bootstrapping. All costs are reported in 2015 Canadian dollars unless otherwise stated.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 2 | Pages 250 - 257
1 Feb 2010
Ferguson TA Patel R Bhandari M Matta JM

Using a prospective database of 1309 displaced acetabular fractures gathered between 1980 and 2007, we calculated the annual mean age and annual incidence of elderly patients > 60 years of age presenting with these injuries. We compared the clinical details and patterns of fracture between patients > 60 years of age (study group) with those < 60 years (control group). We performed a detailed evaluation of the radiographs of the older group to determine the incidence of radiological characteristics which have been previously described as being associated with a poor patient outcome.

In all, 235 patients were > 60 years of age and the remaining 1074 were < 60 years. The incidence of elderly patients with acetabular fractures increased by 2.4-fold between the first half of the study period and the second half (10% (62) vs 24% (174), p < 0.001). Fractures characterised by displacement of the anterior column were significantly more common in the elderly compared with the younger patients (64% (150) vs 43% (462), respectively, p < 0.001). Common radiological features of the fractures in the study group included a separate quadrilateral-plate component (50.8% (58)) and roof impaction (40% (46)) in the anterior fractures, and comminution (44% (30)) and marginal impaction (38% (26)) in posterior-wall fractures.

The proportion of elderly patients presenting with acetabular fractures increased during the 27-year period. The older patients had a different distribution of fracture pattern than the younger patients, and often had radiological features which have been shown in other studies to be predictive of a poor outcome.


The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 11 | Pages 1487 - 1494
1 Nov 2008
Zlowodzki M Brink O Switzer J Wingerter S Woodall J Petrisor BA Kregor PJ Bruinsma DR Bhandari M

We have studied the effect of shortening of the femoral neck and varus collapse on the functional capacity and quality of life of patients who had undergone fixation of an isolated intracapsular fracture of the hip with cancellous screws. After screening 660 patients at four university medical centres, 70 patients with a mean age of 71 years (20 to 90) met the inclusion criteria. Overall, 66% (46 of 70) of the fractures healed with > 5 mm of shortening and 39% (27 of 70) with > 5° of varus. Patients with severe shortening of the femoral neck had significantly lower short form-36 questionnaire (SF-36) physical functioning scores (no/mild (< 5 mm) vs severe shortening (> 10 mm); 74 vs 42 points, p < 0.001). A similar effect was noted with moderate shortening, suggesting a gradient effect (no/mild (< 5 mm) vs moderate shortening (5 to 10 mm); 74 vs 53 points, p = 0.011). Varus collapse correlated moderately with the occurrence of shortening (r = 0.66, p < 0.001). Shortening also resulted in a significantly lower EuroQol questionnaire (EQ5D) index scores (p = 0.05). In a regression analysis shortening of the femoral neck was the only significant variable predictive of a low SF-36 physical functioning score (p < 0.001).


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 12 | Pages 1618 - 1624
1 Dec 2006
Bhandari M Matta J Ferguson T Matthys G

We aimed to identify variables associated with clinical and radiological outcome following fractures of the acetabulum associated with posterior dislocation of the hip. Using a prospective database of 1076 such fractures, we identified 109 patients with this combined injury managed operatively within three weeks and followed up for two or more years. The patients had a mean age of 42 years (15 to 79), 78 (72%) were male, and 84 (77%) had been involved in motor vehicle accidents. Using multivariate analysis the quality of reduction of the fracture was identified as the only significant predictor of radiological grade, clinical function and the development of post-traumatic arthritis (p < 0.001). All patients lacking anatomical reduction developed arthritis whereas only 25.5% (24 patients) with an anatomical reduction did so (p = 0.05).

The quality of the reduction of the fracture is the most important variable in forecasting the outcome for patients with this injury. The interval to reduction of the dislocation of the hip may be less important than previously described.


The Journal of Bone & Joint Surgery British Volume
Vol. 84-B, Issue 1 | Pages 15 - 18
1 Jan 2002
Whelan DB Bhandari M McKee MD Guyatt GH Kreder HJ Stephen D Schemitsch EH

The reliability of the radiological assessment of the healing of tibial fractures remains undetermined. We examined the inter- and intraobserver agreement of the healing of such fractures among four orthopaedic trauma surgeons who, on two separate occasions eight weeks apart, independently assessed the radiographs of 30 patients with fractures of the tibial shaft which had been treated by intramedullary fixation. The radiographs were selected from a database to represent fractures at various stages of healing. For each radiograph, the surgeon scored the degree of union, quantified the number of cortices bridged by callus or with a visible fracture line, described the extent and quality of the callus, and provided an overall rating of healing.

The interobserver chance-corrected agreement using a quadratically weighted kappa (κ) statistic in which values of 0.61 to 0.80 represented substantial agreement were as follows: radiological union scale (κ = 0.60); number of cortices bridged by callus (κ = 0.75); number of cortices with a visible fracture line (κ = 0.70); the extent of the callus (κ = 0.57); and general impression of fracture healing (κ = 0.67). The intraobserver agreement of the overall impression of healing (κ = 0.89) and the number of cortices bridged by callus (κ = 0.82) or with a visible fracture line (κ = 0.83) was almost perfect.

There are no validated scales which allow surgeons to grade fracture healing radiologically. Among those examined, the number of cortices bridged by bone appears to be a reliable, and easily measured radiological variable to assess the healing of fractures after intramedullary fixation.


The Journal of Bone & Joint Surgery British Volume
Vol. 83-B, Issue 1 | Pages 62 - 68
1 Jan 2001
Bhandari M Guyatt GH Swiontkowski MF Schemitsch EH

We have systematically reviewed the effect of alternative methods of stabilisation of open tibial fractures on the rates of reoperation, and the secondary outcomes of nonunion, deep and superficial infection, failure of the implant and malunion by the analysis of 799 citations on the subject, identified from computerised databases. Although 68 proved to be potentially eligible, only eight met all criteria for inclusion. Three investigators independently graded the quality of each study and extracted the relevant data.

One study (n = 56 patients) suggested that the use of external fixators significantly decreased the requirement for reoperation when compared with fixation with plates. The use of unreamed nails, compared with external fixators (five studies, n = 396 patients), reduced the risk of reoperation, malunion and superficial infection.

Comparison of reamed with unreamed nails showed a reduced risk of reoperation (two studies, n = 132) with the reamed technique. An indirect comparison between reamed nails and external fixators also showed a reduced risk of reoperation (two studies) when using nails.

We have identified compelling evidence that unreamed nails reduced the incidence of reoperations, superficial infections and malunions, when compared with external fixators. The relative merits of reamed versus unreamed nails in the treatment of open tibial fractures remain uncertain.