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OBJECTIVE: To spotlight the challenges, gaps, and opportunities to improve workforce mental health and well-being in higher education institutions (HEIs). METHODS: We convened a full-day summit of subject matter experts from academia, business, government, and practice to share research and best practices on workplace mental health. RESULTS: Highlights from the summit are presented in this paper covering the importance of leadership and culture; the mental health costs associated with being a Black STEM scholar; the role of the environment; case studies of three university mental health and well-being programs; and the future of work. CONCLUSIONS: Establishing a culture of caring requires leadership commitment; strategic planning; accountability and shared responsibility; and measurement and evaluation. HEI leaders are called to lead by example; foster community partnerships; adopt a Total Worker Health framework; and regularly evaluate progress.
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BACKGROUND: The Short Musculoskeletal Function Assessment (SMFA) is a well validated, widely used patient-reported outcome (PRO) measure for orthopaedic patients. Despite its widespread use and acceptance, this measure does not have an agreed upon minimal clinically important difference (MCID). The purpose of the present study was to create distributional MCIDs with use of a large cohort of research participants with severe lower extremity fractures. METHODS: Three distributional approaches were used to calculate MCIDs for the Dysfunction and Bother Indices of the SMFA as well as all its domains: (1) half of the standard deviation (one-half SD), (2) twice the standard error of measurement (2SEM), and (3) minimal detectable change (MDC). In addition to evaluating by patient characteristics and the timing of assessment, we reviewed these calculations across several injury groups likely to affect functional outcomes. RESULTS: A total of 4,298 SMFA assessments were collected from 3,185 patients who had undergone surgical treatment of traumatic injuries of the lower extremity at 60 Level-I trauma centers across 7 multicenter, prospective clinical studies. Depending on the statistical approach used, the MCID associated with the overall sample ranged from 7.7 to 10.7 for the SMFA Dysfunction Index and from 11.0 to 16.8 for the SMFA Bother Index. For the Dysfunction Index, the variability across the scores was small (<5%) within the sex and age subgroups but was modest (12% to 18%) across subgroups related to assessment timing. CONCLUSIONS: A defensible MCID can be found between 7 and 11 points for the Dysfunction Index and between 11 and 17 points for the Bother Index. The precise choice of MCID may depend on the preferred statistical approach and the population under study. While differences exist between MCID values based on the calculation method, values were consistent across the categories of the various subgroups presented. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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BACKGROUND: The purpose of this study was to compare 18-month clinical and patient-reported outcomes between patients with severe lower-limb injuries treated with a transtibial amputation or a hind- or midfoot amputation. Despite the theoretical benefits of hind- and midfoot-level amputation, we hypothesized that patients with transtibial amputations would report better function and have fewer complications. METHODS: The study included patients 18 to 60 years of age who were treated with a transtibial amputation (n = 77) or a distal amputation (n = 17) and who were enrolled in the prospective, multicenter Outcomes Following Severe Distal Tibial, Ankle, and/or Foot Trauma (OUTLET) study. The primary outcome was the difference in Short Musculoskeletal Function Assessment (SMFA) scores, and secondary outcomes included pain, complications, amputation revision, and amputation healing. RESULTS: There were no significant differences between patients with distal versus transtibial amputation in any of the domains of the SMFA: dysfunction index [distal versus transtibial], 31.2 versus 22.3 (p = 0.13); daily activities, 37.3 versus 26.0 (p = 0.17); emotional status, 41.4 versus 29.3 (p = 0.07); mobility, 36.5 versus 27.8 (p = 0.20); and bother index, 34.4 versus 23.6 (p = 0.14). Rates of complications requiring revision were higher for distal amputations but not significantly so (23.5% versus 13.3%; p = 0.28). One distal and no transtibial amputees required revision to a higher level (p = 0.18). A higher proportion of patients with distal compared with transtibial amputation required local surgical revision (17.7% versus 13.3%; p = 0.69). There was no significant difference between the distal and transtibial groups in scores on the Brief Pain Index at 18 months post-injury. CONCLUSIONS: Surgical complication rates did not differ significantly between patients who underwent transtibial versus hind- or midfoot amputation for severe lower-extremity injury. The average SMFA scores were higher (worse), although not significantly different, for patients undergoing distal compared with transtibial amputation, and more patients with distal amputation had a complication requiring surgical revision. Of note, more patients with distal amputation required closure with an atypical flap, which likely contributed to less favorable outcomes. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Amputação Cirúrgica , Medidas de Resultados Relatados pelo Paciente , Tíbia , Humanos , Amputação Cirúrgica/métodos , Amputação Cirúrgica/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Adulto , Feminino , Estudos Prospectivos , Tíbia/cirurgia , Traumatismos do Pé/cirurgia , Traumatismos da Perna/cirurgia , Adulto Jovem , Adolescente , Resultado do TratamentoRESUMO
Policy Points Traditional approaches to addressing motor vehicle crashes are yielding diminishing returns. A comprehensive strategy known as the Safe Systems approach shows promise in both advancing safety and equity and reducing motor vehicle crashes. In addition, a range of emerging technologies, enabled by artificial intelligence, such as automated vehicles, impairment detection and telematics hold promise to advance road safety. Ultimately, the transportation system will need to evolve to provide the safe, efficient, and equitable movement of people and goods without reliance on private vehicle ownership, towards encouraging walking, bicycling and the use of public transportation.
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Acidentes de Trânsito , Inteligência Artificial , Humanos , Segurança , CiclismoRESUMO
Objective: Time to care is a determinant of trauma patient outcomes, and timely delivery of trauma care to severely injured patients is critical in reducing mortality. Numerous studies have analyzed access to care using prehospital intervals from a Carr et al. meta-analysis of studies from 1975 to 2005. Carr et al.'s research sought to determine national mean activation and on-scene intervals for trauma patients using contemporary emergency medical services (EMS) records. Since the Carr et al. meta-analysis was published, the National Highway Traffic Safety Administration (NHTSA) created and refined the National Emergency Medical Services Information System (NEMSIS) database. We sought to perform a modern analysis of prehospital intervals to establish current standards and temporal patterns.Methods: We utilized NEMSIS to analyze EMS data of trauma patients from 2016 to 2019. The dataset comprises more than 94 million EMS records, which we filtered to select for severe trauma and stratified by type of transport and rurality to calculate mean activation and on-scene intervals. Furthermore, we explored the impact of basic life support (BLS) and advanced life support (ALS) of ground units on activation and on-scene time intervals.Results: Mean activation and on-scene intervals for ground transport were statistically different when stratified by rurality. Urban, suburban, and rural ground activation intervals were 2.60 ± 3.94, 2.88 ± 3.89, and 3.33 ± 4.58 minutes, respectively. On-scene intervals were 15.50 ± 10.46, 17.56 ± 11.27, and 18.07 ± 16.13 minutes, respectively. Mean helicopter transport activation time was 13.75 ± 7.44 minutes and on-scene time was 19.42 ± 16.09 minutes. This analysis provides an empirically defined mean for activation and on-scene times for trauma patients based on transport type and rurality. Results from this analysis proved to be significantly longer than the previous analysis, except for helicopter transport on-scene time. Shorter mean intervals were seen in ALS compared to BLS for activation intervals, however ALS on-scene intervals were marginally longer than BLS.Conclusions: With the increasing sophistication of geospatial technologies employed to analyze access to care, these intervals are the most accurate and up-to-date and should be included in access to care models.
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Serviços Médicos de Emergência , Humanos , Bases de Dados Factuais , Sistemas de Informação , Estudos Retrospectivos , Fatores de TempoRESUMO
BACKGROUND: Severe lower extremity trauma among working-age adults is highly consequential for returning to work; however, the economic impact attributed to injury has not been fully quantified. The purpose of this study was to examine work and productivity loss during the year following lower extremity trauma and to calculate the economic losses associated with lost employment, lost work time (absenteeism), and productivity loss while at work (presenteeism). METHODS: This is an analysis of data collected prospectively across 3 multicenter studies of lower extremity trauma outcomes in the United States. Data were used to construct a Markov model that accumulated hours lost over time due to lost employment, absenteeism, and presenteeism among patients from 18 to 64 years old who were working prior to their injury. Average U.S. wages were used to calculate economic loss overall and by sociodemographic and injury subgroups. RESULTS: Of 857 patients working prior to injury, 47.2% had returned to work at 1 year. The average number of productive hours of work lost was 1,758.8/person, representing 84.6% of expected annual productive hours. Of the hours lost, 1,542.3 (87.7%) were due to working no hours or lost employment, 71.1 (4.0%) were due to missed hours after having returned, and 145.4 (8.3%) were due to decreased productivity while working. The 1-year economic loss due to injury totaled $64,427/patient (95% confidence interval [CI], $63,183 to $65,680). Of the 1,758.8 lost hours, approximately 88% were due to not being employed (working zero hours), 4% were due to absenteeism, and 8% were due to presenteeism. Total productivity loss was higher among older adults (≥40 years), men, those with a physically demanding job, and the most severe injuries (i.e., those leading to amputation as well as Gustilo type-IIIB tibial fractures and type-III pilon/ankle fractures). CONCLUSIONS: Patients with severe lower extremity trauma carry a substantial economic burden. The costs of lost productivity should be considered when evaluating outcomes.
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SUMMARY: Limited data are available on the longer-term physical and psychosocial consequences after major extremity trauma apart from literature on the consequences after major limb amputation. The existing literature suggests that although variations in outcome exist, a significant proportion of service members and civilians sustaining major limb trauma will have less than optimal outcomes or health and rehabilitation needs over their life course. The proposed pilot study will address this gap in current research by locating and consenting METRC participants with the period of 5-7 years postinjury, identifying potential participation barriers and appropriate use of incentives, and conducting the follow-up examination at several data collection sites. The resulting data will inform the primary objective of refining and developing specific hypotheses to determine the design, scope, and feasibility of the main long-term consequences of major extremity trauma. Three METRC enrollment centers will contact past participants to achieve the goal of completing an interview, select patient-reported outcomes, perform a medical record review, and conduct an in-person clinic visit that will consist of a physical examination, blood draw, and x-ray of the study injury area. If successful, it will be possible to design studies to further examine these effects and develop future therapeutic interventions.
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Amputação Cirúrgica , Extremidades , Humanos , Medidas de Resultados Relatados pelo Paciente , Projetos PilotoRESUMO
SUMMARY: In current clinical practice, weight-bearing is typically restricted for up to 12 weeks after definitive fixation of lower extremity periarticular fractures. However, muscle atrophy resulting from restricting weight-bearing has a deleterious effect on bone healing and overall limb function. Antigravity treadmill therapy may improve recovery by allowing patients to safely load the limb during therapy, thereby reducing the negative consequences of prolonged non-weight-bearing while avoiding complications associated with premature return to full weight-bearing. This article describes a multicenter randomized controlled trial comparing outcomes after a 10-week antigravity treadmill therapy program versus standard of care in adult patients with periarticular fractures of the knee and distal tibia. The primary hypothesis is that, compared with patients receiving standard of care, patients receiving antigravity treadmill therapy will report better function 6 months after definitive treatment.
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Padrão de Cuidado , Fraturas da Tíbia , Adulto , Teste de Esforço , Fixação Interna de Fraturas , Humanos , Suporte de CargaRESUMO
OBJECTIVES: To compare outcomes in patients with open tibia shaft fractures based on defect size. DESIGN: Retrospective review. SETTING: Eighteen trauma centers. POPULATION: The study included 132 patients with diaphyseal tibia bone defects >1 cm and ≥50% cortical loss treated with intramedullary nail. OUTCOMES: The primary outcome was number of secondary surgeries to promote healing (bone graft, revision fixation, or bone transport). Additional outcomes included occurrence of secondary surgeries (bone graft, infection, amputation, and flap failure) and proportion healed at one year. Results are compared by "radiographic apparent bone gap" of <2.5 or ≥2.5 cm. RESULTS: The estimated conditional probability of bone grafting within one year given graft-free at 90 days was 44% and 47% in the <2.5 cm and ≥2.5 cm groups, respectively. An estimated infection risk of 14% was observed in both groups [adjusted hazard ratio (HR) 0.98, 95% confidence interval (CI): 0.33-2.92], estimated amputation risk was 9% (<2.5 cm) and 4% (≥2.5 cm) (unadjusted HR 0.66, 95% CI: 0.13-3.29), and estimated flap failure risk (among those with flaps) was 10% and 13%, respectively (unadjusted HR 1.71, 95% CI: 0.24-12.25). There was no appreciable difference in the proportion healed at one year between defect sizes [adjusted HR: 1.07 (95% CI, 0.63-1.82)]. CONCLUSIONS: Larger size bone defects were not associated with higher number of secondary procedures to promote healing or a lower overall one-year healing rate. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fixação Intramedular de Fraturas , Fraturas Expostas , Fraturas da Tíbia , Pinos Ortopédicos , Fixação Intramedular de Fraturas/métodos , Consolidação da Fratura , Fraturas Expostas/cirurgia , Humanos , Estudos Retrospectivos , Tíbia , Fraturas da Tíbia/cirurgia , Resultado do TratamentoRESUMO
OBJECTIVE: To examine the effect of severe lower extremity trauma on meeting Physical Activity Guidelines for Americans (PAGA) 18 months after injury and perform an exploratory analysis to identify demographic, clinical, and psychosocial factors associated with meeting PAGA. DESIGN: Secondary analysis of observational cohort study. SETTING: A total of 34 United States trauma centers PARTICIPANTS: A total of 328 adults with severe distal tibia, ankle and mid- to hindfoot injuries treated with limb reconstruction (N=328). INTERVENTIONS: None. MAIN OUTCOME MEASURES: The Paffenbarger Physical Activity Questionnaire was used to assess physical activity levels 18 months after injury. Meeting PAGA was defined as combined moderate- and vigorous-intensity activity ≥150 minutes per week or vigorous-intensity activity ≥75 minutes per week. RESULTS: Fewer patients engaged in moderate- or vigorous-intensity activity after injury compared with before injury (moderate: 44% vs 66%, P<.001; vigorous: 18% vs 29%; P<.001). Patients spent 404±565 minutes per week in combined moderate- to vigorous-intensity activity before injury compared with 224±453 minutes postinjury (difference: 180min per week; 95% confidence interval [CI], 103-256). The adjusted odds of meeting PAGA were lower for patients with depression (adjusted odds ratio [AOR], 0.45; 95% CI, 0.28-0.73), women (AOR, 0.59; 95% CI, 0.35-1.00), and Black or Hispanic patients (AOR, 0.49; 95% CI, 0.28-0.85). Patients meeting PAGA prior to injury were more likely to meet PAGA after injury (odds ratio, 2.0; 95% CI, 1.20-3.31). CONCLUSIONS: Patients spend significantly less time in moderate- to vigorous-intensity physical activity after injury. Patients with depression are less likely to meet PAGA. Although the causal relationship is unclear, results highlight the importance of screening for depression.
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Tornozelo , Tíbia , Adulto , Exercício Físico , Feminino , Humanos , Razão de Chances , Centros de Traumatologia , Estados UnidosRESUMO
Social insects have high levels of cooperation and division of labor. In bumble bees this is partly size-based, with larger bees performing tasks outside the nest and smaller bees remaining inside, although bumble bees still display considerable behavioral plasticity. The level of specialization in tasks outside the colony, including foraging, guarding and drifting (entering a foreign colony), is currently unknown for bumble bees. This study aimed to assess division of labor between outside tasks and the degree of specialization in foraging, guarding, and switching colonies in commercially reared bumble bees placed in the field. Nine factory-bought Bombus terrestris colonies were placed on three farms in Sussex, UK, between June and August 2015. Forty workers from each colony were radio-tagged and a reader on the colony entrance recorded the date, time and bee ID as they passed. The length and frequency of foraging trips and guarding behavior were calculated, and drifting recorded. The mean (±SD) length of foraging trips was 45 ± 36 min, and the mean number of foraging trips per day was 7.75 ± 7.71. Low levels of specialization in guarding or foraging behavior were found; however, some bees appeared to guard more frequently than others, and twenty bees were categorized as guards. Five bees appeared to exhibit repeated "stealing" behavior, which may have been a specialist task. The division of labor between tasks was not size-based. It is concluded that commercial bumble bees are flexible in performing outside nest tasks and may have diverse foraging strategies including intra-specific nest robbing. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10905-021-09790-0.
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OBJECTIVES: Assess the burden and co-occurrence of pain, depression, and posttraumatic stress disorder (PTSD) among service members who sustained a major limb injury, and examine whether these conditions are associated with functional outcomes. DESIGN: A retrospective cohort study. SETTING: Four U.S. military treatment facilities: Walter Reed Army Medical Center, National Naval Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. PATIENTS/PARTICIPANTS: Four hundred twenty-nine United States service members who sustained a major limb injury while serving in Afghanistan or Iraq met eligibility criteria upon review of their medical records. INTERVENTION: Not applicable. MAIN OUTCOME MEASUREMENTS: Outcomes assessed were: function using the short musculoskeletal functional assessment; PTSD using the PTSD Checklist and diagnostic and statistical manual criteria; pain using the chronic pain grade scale. RESULTS: Military extremity trauma and amputation/limb salvage patients without pain, depression, or PTSD, were, on average, about one minimally clinically important difference (MCID) from age- and gender-adjusted population norms. In contrast, patients with low levels of pain and no depression or PTSD were, on average, one to 2 MCIDs from population norms. Military extremity trauma and amputation/limb salvage patients with either greater levels of pain, and who experience PTSD, depression, or both, were 4 to 6 MCIDs from population norms. Regression analyses adjusting for injury type (upper or lower limb, salvage or amputation, and unilateral or bilateral), age, time to interview, military rank, presence of a major upper limb injury, social support, presence of mild traumatic brain injury/concussion, and combat experiences showed that higher levels of pain, depression, and PTSD were associated with lower one-year functional outcomes. CONCLUSIONS: Major limb trauma sustained in the military results in significant long-term pain and PTSD. Overall, the results are consistent with the hypothesis that pain, depression, and PTSD are associated with disability in this population. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Militares , Transtornos de Estresse Pós-Traumáticos , Afeganistão , Amputação Cirúrgica , Depressão/epidemiologia , Depressão/etiologia , Humanos , Iraque , Guerra do Iraque 2003-2011 , Salvamento de Membro , Extremidade Inferior , Dor , Estudos Retrospectivos , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To evaluate the diagnostic performance of perfusion pressure (PP) thresholds for fasciotomy. DESIGN: Prospective observational study. SETTING: Seven Level-1 trauma centers. PATIENTS/PARTICIPANTS: One hundred fifty adults with severe leg injuries and ≥2 hours of continuous PP data who had been enrolled in a multicenter observational trial designed to develop a clinical prediction rule for acute compartment syndrome (ACS). MAIN OUTCOME MEASUREMENTS: For each patient, a given PP criterion was positive if it was below the specified threshold for at least 2 consecutive hours. The diagnostic performance of PP thresholds between 10 and 30 mm Hg was determined using 2 reference standards for comparison: (1) the likelihood of ACS as determined by an expert panel who reviewed each patient's data portfolio or (2) whether the patient underwent fasciotomy. RESULTS: Using the likelihood of ACS as the diagnostic standard (ACS considered present if median likelihood ≥70%, absent if <30%), a PP threshold of 30 mm Hg had diagnostic sensitivity 0.83, specificity 0.53, positive predictive value 0.07, and negative predictive value 0.99. Results were insensitive to more strict likelihood categorizations and were similar for other PP thresholds between 10- and 25-mm Hg. Using fasciotomy as the reference standard, the same PP threshold had diagnostic sensitivity 0.50, specificity 0.50, positive predictive value 0.04, negative predictive value 0.96. CONCLUSION: No value of PP from 10 to 30 mm Hg had acceptable diagnostic performance, regardless of which reference diagnostic standard was used. These data question current practice of diagnosing ACS based on PP and suggest the need for further research. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Síndromes Compartimentais , Adulto , Síndromes Compartimentais/diagnóstico , Síndromes Compartimentais/cirurgia , Fasciotomia , Humanos , Perfusão , Valor Preditivo dos Testes , Estudos ProspectivosRESUMO
BACKGROUND: Severe upper-extremity injuries account for almost one-half of all extremity trauma in recent conflicts in the Global War on Terror. Few long-term outcomes studies address severe combat-related upper-extremity injuries. This study's objective was to describe long-term functional outcomes of amputation compared with those of limb salvage in Global War on Terror veterans who sustained severe upper-extremity injuries. Limb salvage was hypothesized to result in better arm and hand function scores, overall functional status, and quality of life, with similar pain interference. METHODS: This retrospective cohort study utilized data from the Military Extremity Trauma Amputation/Limb Salvage (METALS) study for a subset of 155 individuals who sustained major upper-extremity injuries treated with amputation or limb salvage. Participants were interviewed by telephone 40 months after injury, assessing social support, personal habits, and patient-reported outcome instruments for function, activity, depression, pain, and posttraumatic stress. Outcomes were evaluated for participants with severe upper-extremity injuries and were compared with participants with concomitant severe, lower-extremity injury. The analysis of outcomes comparing limb salvage with amputation was restricted to the 137 participants with a unilateral upper-extremity injury because of the small number of patients with bilateral upper-extremity injuries (n = 18). RESULTS: Overall, participants with upper-extremity injuries reported moderate to high levels of physical and psychosocial disability. Short Musculoskeletal Function Assessment (SMFA) scores were high across domains; 19.4% screened positive for posttraumatic stress disorder (PTSD), and 12.3% were positive for depression. Nonetheless, 63.6% of participants were working, were on active duty, or were attending school, and 38.7% of participants were involved in vigorous recreational activities. No significant differences in outcomes were observed between patients who underwent limb salvage and those who underwent amputation. CONCLUSIONS: Severe, combat-related upper-extremity injuries result in diminished self-reported function and psychosocial health. Our results suggest that long-term outcomes are equivalent for those treated with amputation or limb salvage. Addressing or preventing PTSD, depression, chronic pain, and associated health habits may result in less disability burden in this population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Amputação Cirúrgica/métodos , Traumatismos do Braço/cirurgia , Salvamento de Membro/métodos , Militares/estatística & dados numéricos , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Adulto , Amputação Cirúrgica/psicologia , Traumatismos do Braço/diagnóstico , Traumatismos do Braço/reabilitação , Membros Artificiais , Estudos de Coortes , Avaliação da Deficiência , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Guerra do Iraque 2003-2011 , Salvamento de Membro/psicologia , Masculino , Militares/psicologia , Medidas de Resultados Relatados pelo Paciente , Implantação de Prótese/métodos , Estudos Retrospectivos , Medição de Risco , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
The detailed study of prehospital injury death is critical to advancing trauma and emergency care, as circumstance and causality have significant implications for the development of mitigation strategies. Though there is no true 'Golden Hour,' the time from injury to care is a critical element in the analysis matrix, particularly in patients with severe injury. Currently, there is no standard method for the assessment of time to definitive care after injury among prehospital deaths. This article describes a methodology to estimate total prehospital time and distance for trauma patients transported via ground emergency medical services and helicopter emergency medical services using a geographic information system. Data generated using this method, along with medical examiner and field investigation reports, will be used to estimate the potential survivability of prehospital trauma deaths occurring in five US states and the District of Columbia as part of the Multi-Institutional Multidisciplinary Injury Mortality Investigation in the Civilian Pre-Hospital Environment study. One goal of this work is to develop standard metrics for the assessment of total prehospital time and distance, which can be used in the future for more complex spatial analyses to gain a deeper understanding of trauma center access. Results will be used to identify high priority areas for research and development in injury prevention, trauma system performance improvement, and public health.
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OBJECTIVES: To evaluate inter-rater reliability of the modified Radiographic Union Score for Tibial (mRUST) fractures among patients with open, diaphyseal tibia fractures with a bone defect treated with intramedullary nails (IMNs), plates, or definitive external fixation (ex-fix). DESIGN: Retrospective cohort study. SETTING: Fifteen-level one civilian trauma centers; 2 military treatment facilities. PATIENTS/PARTICIPANTS: Patients ≥18 years old with open, diaphyseal tibia fractures with a bone defect ≥1 cm surgically treated between 2007 and 2012. INTERVENTION: Three of 6 orthopedic traumatologists reviewed and applied mRUST scoring criteria to radiographs from the last clinical visit within 13 months of injury. MAIN OUTCOME MEASUREMENTS: Inter-rater reliability was assessed using Krippendorff's alpha (KA) statistic; intraclass correlation coefficient (ICC) is presented for comparison with previous publications. RESULTS: Two hundred thirteen patients met inclusion criteria including 115 IMNs, 24 plates, 29 ex-fixes, and 45 cases that no longer had instrumentation at evaluation. All reviewers agreed on the pattern of scoreable cortices for 90.4% of IMNs, 88.9% of those without instrumentation, 44.8% of rings, and 20.8% of plates. Thirty-one (15%) cases, primarily plates and ex-fixes, did not contribute to KA and ICC estimates because <2 raters scored all cortices. The overall KA for the 85% that could be analyzed was 0.64 (ICC 0.71). For IMNs, plates, ex-fixes, and no instrumentation, KA (ICC) was 0.65 (0.75), 0.88 (0.90), 0.47 (0.62), and 0.48 (0.57), respectively. CONCLUSIONS: In tibia fractures with bone defects, the mRUST seems similarly reliable to previous work in patients treated with IMN but is less reliable in those with plates or ex-fixes, or after removal of instrumentation.
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Pinos Ortopédicos , Placas Ósseas , Fixação Intramedular de Fraturas/instrumentação , Fraturas Expostas/cirurgia , Fraturas da Tíbia/diagnóstico por imagem , Fraturas da Tíbia/cirurgia , Adolescente , Adulto , Idoso , Criança , Estudos de Coortes , Diáfises/diagnóstico por imagem , Diáfises/lesões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Radiografia , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
Importance: Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population. Objectives: To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes. Design, Setting, and Participants: A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018. Main Outcomes and Measures: At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months. Results: Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups. Conclusions and Relevance: This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.