Trajectory of Recovery following ORIF for Distal Radius Fractures.

Background Distal radius fractures are commonly seen among the elderly, though studies examining their long-term outcomes are limited. Purpose The aim of this study was to describe the 5-year trajectory of recovery of distal radius fractures treated with open reduction and internal fixation (ORIF). Methods Patients with distal radius fractures (AO/OTA 23.A-C) treated by ORIF were prospectively studied. Patient-Rated Wrist Evaluation (PRWE) score was measured at baseline (preinjury recall) and postoperatively at 6 months, 1 year, and 5 years. Clinically relevant change in PRWE score was assessed using the minimal clinically important difference (MCID). Results A total of 390 patients were included, of which 75% completed 5-year follow-up. Mean baseline PRWE score was 1.25 (standard deviation, SD: 2.9). At 6 months, mean PRWE score was at its highest up to 20.2 (SD: 18.4; p < 0.01). A significant improvement in mean PRWE score was observed at 1 year down to 15.2 (SD: 17.6; p < 0.01); 44% of patients were still one MCID outside of their baseline PRWE score at 1 year. Further significant improvement in mean PRWE score occurred at 5 years down to 9.4 (SD: 13.4; p < 0.01); 29% of patients remained one MCID outside of their baseline PRWE score at 5 years. Conclusion Recovery after ORIF for distal radius fractures showed significant worsening after surgery, followed by significant improvements up to 1 year and between years 1 and 5, albeit to a lesser extent. Statistically and clinically relevant wrist pain and disability persisted at 5 years. Future research should examine different treatment modalities and include a nonoperative treatment arm for comparison. Level of Evidence Prognostic level II.

Evaluation of the trajectory of recovery following surgically treated acetabular fractures.

Aims: Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years. Methods: Eligible patients at a level I trauma centre were recruited into a longitudinal registry of surgical acetabular fractures between June 2004 and August 2019. Patient-reported outcome measures (PROMs), including the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS), were recorded at baseline pre-injury recall and six months, one year, two years, and five years postoperatively. Comparative analyses were performed for elementary and associated fracture patterns. The proportion of patients achieving minimal clinically important difference (MCID) was determined. The rate of, and time to, conversion to total hip arthroplasty (THA) was also established. Results: We recruited 251 patients (253 fractures), with a 4:1 male to female ratio and mean age of 46.1 years (SD 16.4). Associated fracture patterns accounted for 56.5% of fractures (n = 143). Trajectory analysis showed all timepoints had significant disability versus baseline, including final follow-up (p < 0.001). Elementary fractures had higher SF-36 PCS at six months (p = 0.023) and one year (p = 0.007) compared to associated fractures, but not at two years (p = 0.135) or five years (p = 0.631). The MCID in SF-36 PCS was observed in 37.3% of patients (69/185) between six months and one year, 26.9% of patients (39/145) between one and two years, and 23.3% of patients (20/86) between two and five years, highlighting the long recovery potential of these injuries. A significant proportion of patients failed to attain the MCID after five years (38.1%; 40/105). Conversion to THA occurred in 13.1% of patients (11/110 elementary and 22/143 associated fractures). Approximately two-thirds of THAs (21/33 patients; 63.6%) were performed within two years of index surgery. Conclusion: Acetabular fractures significantly impact physical function. Recovery trajectory is often elongated beyond one year, with two-thirds of our patients displaying persistent clinically relevant long-term disability.

Assessing the Change in Operative Treatment Rates for Acute Midshaft Clavicle Fractures: Incorporation of Evidence-Based Surgery Results in Orthopaedic Practice.

In 2007, a randomized controlled trial (RCT) by the Canadian Orthopaedic Trauma Society (COTS) demonstrated better functional outcomes and a lower proportion of patients who developed malunion or nonunion following operative, compared with nonoperative, treatment of midshaft clavicle fractures. The primary aim of the present study was to compare the proportion of midshaft clavicle fractures treated operatively prior to and following the publication of the COTS RCT. An additional exploratory aim was to assess whether the proportion of midshaft clavicle fractures that were treated with surgery for malunion or nonunion decreased. Methods: This retrospective cohort analysis used population-level administrative health data on the residents of British Columbia, Canada. Cases were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes and procedure fee codes. Adult patients (≥18 years) with closed middle-third clavicle fractures between 1997 and 2018 were included. Multivariable logistic regression modeling compared the proportion of clavicle fractures treated operatively before and after January 1, 2007, controlling for patient factors. The Pearson chi-square test compared the proportion of fractures treated operatively for malunion or nonunion in the cohorts. Results: A total of 52,916 patients were included (mean age, 47.5 years; 65.6% male). More clavicle fractures were treated operatively from 2007 onward: 6.9% compared with 2.2% prior to 2007 (odds ratio [OR] = 3.35, 95% confidence interval [CI] = 3.03 to 3.70, p < 0.001). Male sex, moderate-to-high income, and younger age were associated with a greater proportion of operative fixation. The rate of surgery for clavicle malunion or nonunion also increased over this time period (to 4.1% from 3.4%, OR = 1.26, 95% CI = 1.15 to 1.38, p < 0.001). Conclusions: We found a significant change in surgeon practice regarding operative management of clavicle fractures following the publication of a Level-I RCT. With limited high-quality trials comparing operative and nonoperative management, it is important that clinicians, health-care institutions, and health-authority administrations determine what steps can be taken to increase responsiveness to new clinical studies and evidence-based guidelines. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

If at first you don't succeed, should you try again? The efficacy of repeated closed reductions of distal radius fractures.

INTRODUCTION: A repeated closed reduction ("re-reduction") of a displaced distal radius fracture is a common procedure performed to obtain satisfactory alignment and avoid surgery when the initial reduction is deemed unsatisfactory. However, the efficacy of re-reduction is unclear. Compared to a single closed reduction, does a re-reduction of a displaced distal radius fracture: (1) improve radiographic alignment at the time of fracture union and, (2) decrease the rate of operative intervention? MATERIALS AND METHODS: Retrospective cohort analysis of 99 adults aged 20-99 years with extra-articular or minimally displaced intra-articular, dorsally angulated, displaced distal radius fracture with or without an associated ulnar styloid fracture who underwent a re-reduction, compared against 99 adults matched for age and sex who were managed with a single reduction. Exclusion criteria were skeletal immaturity, fracture-dislocation and articular displacement greater than 2 mm. Outcome measures included radiographic alignment at fracture union and rate of surgical intervention. RESULTS: At 6-8 weeks follow-up, the single reduction group had greater radial height (p = 0.045, CI 0.04 to 3.57), and less ulnar variance (p < 0.001, CI - 3.08 to - 1.00) compared to the re-reduction group. Immediately following re-reduction, 49.5% of patients met radiographic non-operative criteria, but by 6-8 weeks follow-up, only 17.5% of patients continued to meet these criteria. Patients in the re-reduction group were treated with surgery 34.3% of the time, compared to 14.1% of the time for patients in the single reduction group (p = 0.001). In patients aged under 65 years, 49.0% of those who underwent a re-reduction were managed with surgery, compared to 21.0% of those who had a single reduction (p = 0.004). CONCLUSION: A re-reduction performed to improve radiographic alignment and avoid surgical management in this subset of distal radius fractures had minimal value. Alternative treatment options should be considered before attempting a re-reduction.

Responsiveness of the PROMIS physical function measure in orthopaedic trauma patients.

OBJECTIVES: To compare the responsiveness of the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) to the 36-Item Short Form Survey Physical Component Score (SF36-PCS) in orthopaedic trauma patients from pre-injury to one year recovery. DESIGN AND SETTING: Prospective cohort study at a Level 1 trauma centre. PARTICIPANTS: Patients over the age of 18 with orthopaedic trauma injuries to the pelvis, lower extremity or upper extremity between 2017 and 2018. MAIN OUTCOMES MEASUREMENTS: The PROMIS-PF and SF36-PCS assessments were conducted at baseline, 3 months, 6 months and 12 months. Responsiveness of each measure was assessed between time points by calculating the standardized response mean (SRM), the proportions of patients exceeding minimal clinically important difference (MCID), and the floor and ceiling effects. RESULTS: Sixty-eight patients with completed assessments at every timepoint were included: mean age 44.7 years, 39 were male and mean Injury Severity Score (ISS) was 7.4 (range: 4-16). Mean time of completion for the SF-36 at all the time points was 5.6 min vs 1.7 min for the PROMIS-PF (p<0.01). The SRM was comparable between measures at all the time points. Although a greater proportion of patients achieved MCID for SF36-PCS between all the time points, this only approached statistical significance between the 6- and 12-month assessments (47.1% vs 33.8%; p = 0.15). There was a significant ceiling effect demonstrated with the PROMIS-PF at baseline and 12-month assessments, with 34 (50.0%) patients and 7 (10.3%) patients achieving the maximum scores at each time point, respectively. DISCUSSION AND CONCLUSIONS: PROMIS-PF has a more favourable responder burden based on lower time to completion and comparable responsiveness to the SF-36 PCS. However, there are limitations in responsiveness with the PROMIS-PF in patients who are higher functioning as demonstrated by the ceiling effects in patients at baseline pre-injury and at 12 months post-injury timepoints.

Quantifying Urinary and Sexual Dysfunction After Pelvic Fracture.

OBJECTIVES: To quantify the severity of urinary and sexual dysfunction and to evaluate the relationship between urinary and sexual dysfunction, injury, and treatment factors in patients with pelvic fracture. DESIGN: Prospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred thirteen patients with surgically treated pelvic fracture (65.5% OTA/AO 61B fractures; 7 open fractures; 74 men). INTERVENTIONS: Surgical pelvic stabilization. MAIN OUTCOME MEASURES: The 36-Item Short Form Health Survey and International Consultation Incontinence Questionnaire responses were collected at baseline, 6 months, and 1, 2, and 5 years. Patients were scored on symptoms of voiding and incontinence, and filling (for women), to derive urinary function. Sexual function was scored as a single domain. Both genders reported urinary and sexual bothersome symptoms. Regression analysis was used to isolate the importance of predictive factors on urinary and sexual function, urinary and sexual bother, and their impact on quality of life. RESULTS: Patients with pelvic fracture have significant urinary and sexual dysfunction, which is sustained or worsens over time. Male urinary function was predicted by Injury Severity Score (P = 0.03) and 61C fracture (odds ratio: 3.23, P = 0.04). Female urinary function was predicted by urinary tract injury at admission (odds ratio: 7.57, P = 0.03). Neurologic injury and anterior fixation were identified as significant predictors for male sexual function and sexual bother, whereas urological injuries were important in predicting female urinary and sexual bother (P < 0.01). Sexual function (P = 0.02) and sexual bother (P < 0.001) were important predictors of overall mental well-being in men. CONCLUSIONS: Urinary and sexual dysfunction are prevalent and sustained in men and women and do not follow the prolonged slow recovery trajectory seen in physical function. Male urinary and sexual dysfunction was closely tied to neurologic injury, whereas female urinary and sexual dysfunction was predicted by the presence of a urinary tract injury. Urinary and sexual dysfunction were important to overall mental well-being in men. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Long-Term Trajectory of Recovery Following Pilon Fracture Fixation.

OBJECTIVES: To describe the trajectory of recovery following fixation of pilon fractures from baseline to 5-year follow-up. DESIGN: Prospective cohort study. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Patients with pilon fractures (OTA/AO 43.C) treated with open reduction and internal fixation. INTERVENTION: None. MAIN OUTCOMES MEASURES: Patient-reported outcome measures were measured at baseline, 6 months, 1 year, and 5 years using the Short-Form 36 Health Survey (SF-36) Physical Component Score and Mental Component Score, Short Musculoskeletal Functional Assessment, and the Foot and Ankle Outcome Score. RESULTS: One hundred two patients were enrolled: mean age was 42.6 years; 69% were males; 88% had an injury severity score of 9; 74 patients (73%) completed 1-year follow-up; 40 patients (39%) completed 5-year follow-up. Trajectory of recovery of physical function showed a significant decline between baseline and 6 months, with significant improvement between 6 months and 1 year and then ongoing but slower improvement between 1 year and 5 years. Sixty-four patients returned to baseline SF-36 Physical Component Score at 5 years. Pain was a persistent issue and remained significantly worse at 5 years when compared with baseline. Psychological well-being (SF-36 Mental Component Score) did not significantly change from baseline at 5 years. CONCLUSION: Functional recovery following open reduction and internal fixation for pilon fractures was characterized by an initial decrease in function from baseline, followed by an increase between 6 months and 1 year, and then slower but continued increases from 1 year to 5 years. Function did not return to baseline levels, pain was a persistent issue, and mental well-being showed no change from baseline at 5 years. This information may be useful when counselling patients. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparing the responsiveness of a generic and a musculoskeletal specific functional outcome measure in orthopaedic patients with operative fixation of pelvic ring, acetabulum, or tibia fractures: a comparison between single injury and multiply injured patients.

OBJECTIVES: This study compares the responsiveness, or the ability to detect clinical change in a disease, between the generic Short Form-36 (SF-36) and musculoskeletal specific Short Musculoskeletal Functional Assessment (SMFA) patient-reported outcome measures (PROMs) in the orthopaedic trauma population. Stratified analysis was performed to compare whether responsiveness differs between patients with single or multiple orthopaedic injuries. DESIGN: Prospective case series. SETTING: Level 1 Trauma Center. PATIENTS: A total of 659 patients with orthopaedic trauma injuries to the pelvis, acetabulum, or tibia were included for analysis. There were 485 patients with a single isolated injury and 174 patients with multiple orthopaedic injuries. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Responsiveness was calculated through the standard response mean (SRM), the proportion meeting a minimal clinically important difference, and floor and ceiling effects. RESULTS: Between baseline and 6 months the magnitude of the SRM for SF-36 was consistently greater than that of SMFA in patients with single (P < .01) and multiple injuries (P < .01). Between 6 and 12 months, there were no differences in SRM across all cohorts. The proportion of patients who achieved minimal clinically important difference was consistently higher when assessed with SF-36 compared with SMFA between baseline and 6 months (81.8% vs 68.1%, P < .0001) and between 6 and 12 months (63.3% vs 55.4%, P = .01).A ceiling effect was only observed at baseline for the SMFA with 16.6% of patients achieving the maximal level of functioning detectable. No floor effects were seen in either PROM. CONCLUSION: This study demonstrates that SF-36 has superior responsiveness versus SMFA in both polytrauma and isolated injury patients and supports the collection of SF-36 as the primary PROM in prospective orthopaedic trauma studies irrespective of whether the patient has an isolated injury or multiple injuries.

Which general functional outcome measure does a better job of capturing change in clinical status in pelvic and acetabular fracture patients? An analysis of responsiveness over the first year of recovery.

OBJECTIVE: To compare the responsiveness of the Short Form-36 (SF-36) physical component score (PCS) to the Short Musculoskeletal Function Assessment (SMFA) dysfunction index (DI) in pelvic and acetabular fracture patients over multiple time points in the first year of recovery. DESIGN: Prospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Four hundred seventy-three patients with surgically treated pelvic and acetabular fractures (Orthopaedic Trauma Association B or C-type pelvic ring disruption or acetabular fracture) were enrolled into the center's prospective orthopaedic trauma database between January 2005 and February 2015. Functional outcome data were collected at baseline, 6 months, and 12 months. MAIN OUTCOME MEASUREMENTS: Evaluation was performed using the SF-36 Survey and Short Musculoskeletal Function Assessment. Responsiveness was assessed by calculating the standard response mean (SRM), the minimal clinically important difference (MCID), and floor and ceiling effects. RESULTS: Three hundred five patients had complete data for both outcome scores. SF-36 PCS and SMFA DI scores showed strong correlation for all time intervals (r = -0.55 at baseline, r = -0.78 at 6 months, and r = -0.85 at 12 months). The SRM of the SF-36 PCS was greater in magnitude than the SRM of SMFA DI at all time points; this was statistically significant between baseline and 6 months (P < .001), but not between 6 and 12 months (P = .29). Similarly, the proportion of patients achieving MCID in SF-36 PCS was significantly greater than the proportion achieving MCID in SMFA DI between baseline and 6 months (84.6% vs 69.8%, P < .001), and between 6 and 12 months (48.5% vs 35.7%, P = .01). There were no ceiling or floor effects found for SF-36 PCS at any time intervals. However, 16.1% of patients achieved the highest level of functioning detectable by the SMFA DI at baseline, along with smaller ceiling effects at 6 months (1.3%) and 12 months (3.3%). CONCLUSIONS: SF-36 PCS is a more responsive measure of functional outcome than the SFMA DI over the first year of recovery in patients who sustain a pelvic ring disruption or acetabular fracture. This superiority was found in using the SRM, proportion of patients meeting MCID, and ceiling effects. Furthermore, the SF-36 PCS correlated with the more disease-specific SMFA DI. LEVEL OF EVIDENCE: Prognostic Level II.

Measuring Outcomes Over Time in Distal Radius Fractures: A Comparison of Generic, Upper Extremity-Specific and Wrist-Specific Outcome Measures.

Purpose: This study compared the responsiveness of a generic (Short Form-36 [SF-36]), an upper extremity-specific (Disabilities of the Arm, Shoulder, and Hand [DASH]) and a wrist-specific (Patient-Rated Wrist Evaluation [PRWE]) outcome score when evaluating distal radius fractures over time. Methods: We observed 235 patients who met the inclusion criteria of an isolated distal radius fracture treated surgically or nonsurgically and greater than age 50 years for 12 months in this prospective study. Standardized assessments were performed at baseline and at 6 and 12 months. Exclusion criteria included subjects with concomitant injuries in the ipsilateral limb and follow-up of less than 1 year. Responsiveness was evaluated through the standardized response mean and the proportion who met a minimal clinically important difference. Floor and ceiling effects were also calculated. Results: The standardized response mean was significantly greatest for the DASH between baseline and 6 months (P < .001), and the PRWE between both baseline and 6 months (P < .01) and 6 and 12 months (P < .01) compared with the SF-36. The proportion of patients who met a minimal clinically important difference between baseline and 6 months was greater in the PRWE, but it did not meet statistical significance (P = .12). The PRWE demonstrated a high ceiling effect at baseline (76.6%) but less so at 12 months (16.9%). The DASH demonstrated similar ceiling effects at baseline (62.9%) and 12 months (18.6%). The SF-36 had no ceiling effect. Conclusions: In the first 6 months, both the DASH and PRWE have greater responsiveness in assessing change over the SF-36 in distal radius fractures. From 6 to 12 months, the wrist-specific PRWE has greater responsiveness over both the DASH and SF-36. This supports the use of the anatomy- and injury-specific outcome measures over the generic outcome measure in detecting change over a patient's early recovery. However, as the time from injury increases, the absence of a ceiling effect from the generic outcome measure may become more useful. Clinical relevance: This study demonstrates the responsiveness of the DASH, PRWE, and SF36 in assessing distal radius fractures treated in patients greater than age 50 in the first year. In establishing the most responsive measure, respondent burden can be decreased in future research.

The Longitudinal Short-, Medium-, and Long-Term Functional Recovery After Unstable Pelvic Ring Injuries.

OBJECTIVES: Describe the trajectory of functional recovery for patients with surgically treated unstable pelvic ring injuries from baseline to 5 years. DESIGN: Prospective cohort study. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: One hundred eight adult patients with surgically treated pelvic fractures (72% OTA/AO 61 B1-B3 and 28% OTA/AO 61 C1-C3) were enrolled into the institutions orthopaedic trauma database between 2004 and 2015. The cohort was 78% men with a mean age of 44.9 years and injury severity score of 16.9. INTERVENTION: Surgical pelvic stabilization. MAIN OUTCOME MEASUREMENTS: Function was measured at baseline and prospectively at 6 months, 1, and 5 years postoperatively using the Short Form-36 Physical Component Score (SF-36 PCS). The trajectory was mapped, and the proportion of patients achieving a minimal clinically important difference (MCID) between time points was determined. RESULTS: The mean SF-36 PCS improved for the entire group between 6 and 12 months (P = 0.001) and between 1 and 5 years (P = 0.02), but did not return to baseline at 5 years (P < 0.0001). The proportion of patients achieving a MCID between 6 and 12 months and 1 and 5 years was 75% and 60%, respectively. The functional level was similar between type B and C groups at baseline (P = 0.5) and 6 months (P = 0.2); however, the type B cohort reported higher scores at 1 year (P = 0.01) and 5 years (P = 0.01). Neither group regained their baseline function (P < 0.0001). CONCLUSIONS: Functional recovery for patients with surgically treated pelvic fractures is characterized by an initial decline in function, followed by sharp improvement between 6 and 12 months, and continued steady improvement between 1 and 5 years. Type B injuries show better early recovery than type C and reach a higher level of function at the final follow-up. Despite the proportion of patients achieving MCID, patients do not regain the preinjury level of function. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Softer Tissue Issues in Orthopaedic Trauma.

There are number of significant issues outside of the bone and/or fracture that are important to consider in the treatment of orthopaedic trauma. Joint contractures, heterotopic bone formation, managing a traumatized soft-tissue envelope or substantial soft-tissue defects represent a few of these important issues. This article reviews these issues, including the best available evidence on how to manage them.

Predicting completion of follow-up in prospective orthopaedic trauma research.

OBJECTIVE: Orthopaedic trauma studies that collect long-term outcomes are expensive and maintaining high rates of follow-up can be challenging. Knowing what factors influence completion of follow-up could allow interventions to improve this. We aimed to assess which factors influence completion of follow-up in the 12 months following surgery in prospective orthopaedic trauma research. DESIGN: Prospective Cohort Study. SETTING: Level 1 Trauma Center, Vancouver, Canada. PARTICIPANTS: Eight hundred seventy patients recruited to 4 prospective studies investigating the outcomes of operatively treated lower extremity fractures. MAIN OUTCOME MEASUREMENTS: Completion of follow-up defined as completion of all outcome measures at all time points up to 12 months following injury. RESULTS: Univariate analysis and subsequent analysis by building a reductive multivariate regression model allowed for estimation of the influence of factors in completion of follow-up.Eight hundred seventy patients with complete data had previously been recruited and were included in the analysis. Seven hundred seven patients (81.2%) completed follow-up to 12 months. Factors associated with completion of follow up included higher physical component score of SF-36 at baseline, not being on social assistance at the time of injury, being married and having a higher level of educational attainment. CONCLUSIONS: Our study has demonstrated several important factors identifiable at baseline which are associated with a failure to complete follow-up. Although these factors are not modifiable themselves, we advocate that researchers designing studies should plan for additional follow-up resources and interventions for at risk patients. LEVEL OF EVIDENCE: Level IV.

Comparison of Generic, Musculoskeletal-Specific, and Foot and Ankle-Specific Outcome Measures Over Time in Tibial Plafond Fractures.

BACKGROUND: This study performed a psychometric analysis assessing and comparing the responsiveness of the relevant components of a generic (Short Form-36 [SF36]), a musculoskeletal-specific (Short Musculoskeletal Functional Assessment [SMFA]), and a foot and ankle-specific (Foot and Ankle Outcome Score [FAOS]) outcome score when evaluating surgically treated tibial plafond fractures over time. METHODS: Fifty-one patients were followed for 12 months after their tibial plafond fracture. Responsiveness, or the ability to detect clinical change in a disease, was evaluated through the standardized response mean (SRM), the proportion meeting a minimal clinically important difference (MCID), and floor and ceiling effects. RESULTS: The SRM of the SF36-Physical Component Summary (PCS) was significantly greater than the SMFA-dysfunction index (DI) (P < .01) and FAOS-Activities of Daily Living (ADL) (P = .01) between baseline and 6 months, whereas the SRMs of only SF36-PCS and FAOS-ADL differed (P = .01) between 6 and 12 months. The proportion of patients achieving an MCID for SF36-PCS was higher than FAOS-ADL (P = .03) between baseline and 6 months and higher than SMFA-DI (P = .04) between 6 and 12 months. The FAOS-ADL showed substantial ceiling effects at baseline (88.2%) but much less at 6 months (5.9%) and 12 months (9.8%). Smaller ceiling effects were observed for the SMFA-DI (11.8%) at baseline, whereas none were observed for the SF36-PCS. CONCLUSIONS: This study found that the SF36-PCS had greater responsiveness in assessing tibial plafond fractures compared to the SMFA-DI and FAOS-ADL, particularly in the first 6 months after surgery. In addition, limitations were revealed in the SMFA-DI and FAOS-ADL. This study illustrates the necessary diligence required for selection of outcome measures, as musculoskeletal and anatomy specific scores are not necessarily superior. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Trajectory of Short- and Long-Term Recovery of Tibial Shaft Fractures After Intramedullary Nail Fixation.

OBJECTIVE: To determine the trajectory of recovery after tibial shaft fracture treated with intramedullary nail over the first 5 years and to evaluate the magnitude of the changes in functional outcome at various time intervals. DESIGN: Prospective cohort study. SETTING: A Level 1 trauma center. PATIENTS/PARTICIPANTS: One hundred thirty-two patients with tibial shaft fracture (OTA 42-A, B, C) were enrolled into the Center's prospective orthopaedic trauma database between January 2005 and February 2010. Functional outcome data were collected at baseline, 6 months, 1 year, and 5 years. INTERVENTION: Enrolled patients were treated acutely with intramedullary nailing of their tibia. MAIN OUTCOME MEASUREMENTS: Evaluation was performed using the Short Form-36 and Short Musculoskeletal Function Assessment (SMFA). RESULTS: Mean SF-36 physical component scores improved between 6 and 12 months (P = 0.0008) and between 1 and 5 years (P = 0.0029). Similarly, mean SMFA dysfunction index scores improved between 6 and 12 months (P = 0.0254) and between 1 and 5 years (P = 0.0106). In both scores, the rate or slope of this improvement is flatter between 1 and 5 years than it is between 6 and 12 months. Furthermore, SF-36 and SMFA scores did not reach baseline at 5 years (SF-36 P < 0.0001, SMFA P = 0.0026). A significant proportion of patients were still achieving a minimal clinically important difference in function between 1 and 5 years (SF-36 = 54%, SMFA = 44%). CONCLUSIONS: The trajectory of functional recovery after tibial shaft fracture is characterized by an initial decline in function, followed by improvement between 6 and 12 months. There is still further improvement beyond 1 year, but this is of flatter trajectory. The 5-year results indicate that function does not improve to baseline by 5 years after injury. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Factors affecting orthopedic residency selection: a cross-sectional survey.

BACKGROUND: Annually, orthopedic residency programs rank and recruit the best possible candidates. Little evidence exists identifying factors that potential candidates use to select their career paths. Recent literature from nonsurgical programs suggests hospital, social and program-based factors influence program selection. We sought to determine what factors influence the choice of an orthopedic career and a candidate's choice of orthopedic residency program. METHODS: We surveyed medical student applicants to orthopedic programs and current Canadian orthopedic surgery residents (postgraduate year [PGY] 1-5). The confidential online survey focused on 3 broad categories of program selection: educational, program cohesion and noneducation factors. Questions were graded on a Likert Scale and tailed for mean scores. RESULTS: In total, 139 residents from 11 of 17 Canadian orthopedic programs (49% response rate) and 23 medical student applicants (88% response rate) completed our survey. Orthopedic electives and mandatory rotations were reported by 71% of participants as somewhat or very important to their career choice. Collegiality among residents (4.70 ± 0.6), program being the "right fit" (4.65 ± 0.53) and current resident satisfaction with their chosen program (4.63 ±0.66) were ranked with the highest mean scores on a 5-point Likert scale. CONCLUSION: There are several modifiable factors that residency programs may use to attract applicants, including early availability of clerkship rotations and a strong mentorship environment emphasizing both resident-resident and resident-staff cohesion. Desirable residency programs should develop early access to surgical and operative skills. These must be balanced with a continued emphasis on top-level orthopedic training.

CONTEXTE: Chaque année, les programmes de résidence en orthopédie évaluent et recrutent les meilleurs candidats possibles. On dispose de peu de renseignements au sujet des critères sur lesquels les candidats fondent leur choix de parcours professionnel. Selon la littérature récente issue de programmes non chirurgicaux, les critères de sélection des programmes ont à voir avec les hôpitaux, les programmes eux-mêmes et certains facteurs sociaux. Nous avons voulu savoir quels sont les facteurs qui influent sur le choix d'une carrière en orthopédie et le choix d'un programme de résidence en orthopédie par les candidats. MÉTHODES: Nous avons interrogé les étudiants en médecine candidats aux programmes d'orthopédie et les médecins résidents actuels en chirurgie orthopédique au Canada (année de résidence [R] de 1 à 5). Le questionnaire en ligne confidentiel portait sur 3 grandes catégories de critères de choix d'un programme : facteurs didactiques, facteurs liés à la cohésion des programmes et facteurs non didactiques. Les questions ont été classées sur une échelle de Likert et les scores moyens ont été estimés. RÉSULTATS: En tout, 139 candidats et médecins résidents actuels de 11 programmes d'orthopédie sur 17 au Canada ont répondu au questionnaire (taux de réponse 49 %). Soixante et onze pour cent des participants ont qualifié les stages électifs et obligatoires en orthopédie de relativement ou très importants pour leur choix de carrière. La collégialité entre les médecins résidents (4,70 ± 0,6), l'adéquation des programmes (4,65 ± 0,53) et la satisfaction actuelle des médecins résidents à l'endroit du programme choisi (4,63 ± 0,66) ont obtenu les scores moyens les plus élevés sur l'échelle de Likert en 5 points. CONCLUSION: Les programmes de résidence pourraient utiliser plusieurs facteurs modifiables pour attirer des candidats, y compris une offre de stage hâtive et un solide mentorat, mettant l'accent sur la cohésion résident-résident et résident-personnel. Les programmes de résidence attrayants devraient offrir un accès rapide aux compétences chirurgicales et opératoires. Et ces compétences devraient être en phase avec le maintien d'une formation orthopédique de haut niveau.

Is Early Definitive Fixation of Bicondylar Tibial Plateau Fractures Safe? An Observational Cohort Study.

OBJECTIVES: The optimal treatment protocol for bicondylar plateau fractures remains controversial. Contrary to popular practice which favors a staged protocol in many high-energy fracture patterns, we have used early single-stage open reduction and internal fixation (ORIF) to treat these injuries whenever possible. The purpose of this study was to determine the complication rate and the functional and radiographic outcomes of this strategy. DESIGN: Retrospective cohort study and prospective data collection. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: One hundred one patients with 102 OTA/AO type 41-C bicondylar tibial plateau fractures were treated with early definitive ORIF, defined as nonstaged surgery performed within 72 hours from injury. A subset of patients was part of a longitudinal study and reported functional outcomes at 1 year. INTERVENTION: Early definitive ORIF. MAIN OUTCOME MEASUREMENT: Primary outcome: reoperation rate, defined as any surgery within 12 months after the index operation; secondary outcomes: quality and stability of radiographic fracture reduction; and functional outcome [Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and short musculoskeletal functional assessment (SMFA)]. RESULTS: Nonstaged operative treatment of bicondylar plateau fractures was performed in 91.3% of the fractures during the study period. For those, early definitive ORIF (surgery within 72 hours from injury) was performed in 82.3% fractures. Mean time from injury to ORIF, for closed fractures, was 29.8 hours. Sixteen (15.7%) fractures, which were treated with early definitive ORIF, required an additional surgical procedure within 12 months. Complications included wound infection requiring surgical management, compartment syndrome requiring fasciotomies, nonunion, early fixation failure, and implant removal for discomfort. The reoperation rate was 12.7% if implant removal was excluded. At least 3 of the 4 radiographic criteria used to assess the adequacy of reduction were achieved in 95.1% of cases, and all 4 criteria were met in 59.8% of fractures. The Physical Component of the SF-36 at 12 months was 42.6, which is comparable to values reported in previous studies for operative treatment of bicondylar plateau fractures. CONCLUSIONS: In a model where surgery is performed without delay by experienced orthopaedic trauma surgeons, a large proportion of bicondylar tibial plateau fractures can be safely treated with early definitive ORIF. Early surgery was associated with satisfactory postoperative radiographic reductions. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Timing of Hip Fracture Surgery and 30-Day Outcomes.

The goal of this study was to determine the proportion of patients admitted with a hip fracture to participating American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) hospitals who were treated within the United Kingdom's National Institute for Health and Care Excellence (NICE) time-to-hip-fracture-surgery benchmark. The secondary goals were to identify factors associated with missing the benchmark and to determine whether the benchmark was associated with improved 30-day patient outcomes. Patients aged 60 years or older who underwent hip fracture surgery between 2005 and 2013 were identified from the ACS-NSQIP database. Of the 26,066 patients who met the enrollment criteria, 71.4% were treated within the NICE benchmark. Many variables, including sex, race, procedure type, and hip fracture diagnosis, were statistically significant predictors of missing the benchmark (P<.001). Meeting the NICE benchmark was not associated with reductions in major complications (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.83-1.05; P=.234); however, it was associated with reductions in 30-day mortality (OR, 0.88; 95% CI, 0.78-0.99; P=.028), minor complications (OR, 0.92; 95% CI, 0.84-0.995; P=.038), and postoperative length of stay (beta=-0.77; P<.001). Current practice at participating ACS-NSQIP hospitals is compatible with the NICE time-to-surgery benchmark. However, the findings highlight the importance of further prospective investigation to monitor the effect of early-treatment benchmarks on 30-day patient outcomes. [Orthopedics. 2016; 39(6):361-368.].

Role of Depression in Outcomes of Low-Energy Distal Radius Fractures in Patients Older Than 55 Years.

OBJECTIVES: This study examines depression and outcomes in patients older than 55 years with distal radius fracture. DESIGN: Prospective data collection included patient characteristics, treatment, general and limb symptoms and disability, and complications at baseline, 3 months, and 1 year. Bivariate analysis and multivariable linear regression were used to assess relationships between depression and outcome measures, specifically the Short Form-36 (SF-36), Disability of the Arm, Shoulder, and Hand (DASH) scores, and the Centre of Epidemiologic Studies Depression (CES-D) scale. SETTING: The study was conducted in a level-1 trauma center. PARTICIPANTS: All patients older than 55 years with isolated distal radius fracture were recruited (2007-2011). INTERVENTION: Patients were treated operatively or nonoperatively. MAIN OUTCOME MEASURES: The SF-36 and DASH scores measured general and upper extremity status. Depression was measured using CES-D scale. All complications were recorded. RESULTS: Of 228 patients, 25% were depressed at baseline, 32% at 3 months, and 26% after 1 year. Thirty-two patients (14%) had complications. There was no relationship between depression at baseline and complications; however, there was a statistically significant relationship at 3 months (P = 0.021). There was a statistically significant association between baseline depression and the worse 1-year SF-36. Patients with baseline depression had poorer 1-year DASH scores (20 ± 2.3) than nondepressed patients (11 ± 1.3) (P = 0.0031), and less improvement in DASH scores over the first year (P = 0.023). Multivariable linear regression demonstrated that baseline depression is the strongest predictor of poorer 1-year DASH scores (3.7, P = 0.0078) and change in DASH scores over the first year (2.9, P = 0.026). CONCLUSIONS: Baseline depression predicts worse function and disability outcomes 1 year from injury. Depression (CES-D ≥16) is the strongest predictor of worse 1-year DASH scores and SF-36 outcome measures, after controlling for other potential predictors. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.