The relationship between publication of high-quality evidence and changes in the volume and trend of subacromial decompression surgery for patients with subacromial pain syndrome in hospitals across Australia, Europe and the United States: a controlled interrupted time series analysis.

AIMS: To evaluate the extent to which publication of high-quality randomised controlled trials(RCTs) in 2018 was associated with a change in volume or trend of subacromial decompression(SAD) surgery in patients with subacromial pain syndrome(SAPS) treated in hospitals across various countries. METHODS: Routinely collected administrative data of the Global Health Data@work collaborative were used to identify SAPS patients who underwent SAD surgery in six hospitals from five countries (Australia, Belgium, Netherlands, United Kingdom, United States) between 01/2016 and 02/2020. Following a controlled interrupted time series design, segmented Poisson regression was used to compare trends in monthly SAD surgeries before(01/2016-01/2018) and after(02/2018-02/2020) publication of the RCTs. The control group consisted of musculoskeletal patients undergoing other procedures. RESULTS: A total of 3.046 SAD surgeries were performed among SAPS patients treated in five hospitals; one hospital did not perform any SAD surgeries. Overall, publication of trial results was associated with a significant reduction in the trend to use SAD surgery of 2% per month (Incidence rate ratio (IRR) 0.984[0.971-0.998]; P = 0.021), but with large variation between hospitals. No changes in the control group were observed. However, publication of trial results was also associated with a 2% monthly increased trend (IRR 1.019[1.004-1.034]; P = 0.014) towards other procedures performed in SAPS patients. CONCLUSION: Publication of RCT results was associated with a significantly decreased trend in SAD surgery for SAPS patients, although large variation between participating hospitals existed and a possible shift in coding practices cannot be ruled out. This highlights the complexities of implementing recommendations to change routine clinical practice even if based on high-quality evidence.

Orthopaedic injuries due to electric scooter trauma presenting to a level 1 trauma centre before and after introduction of a scooter-sharing scheme.

Background: Epidemiological data from various jurisdictions has shown that electric scooters are associated with significant trauma. The Victorian state government introduced a trial scooter sharing scheme on February 1, 2022 in inner city Melbourne. This is a descriptive study from the largest trauma centre in Victoria, geographically at the heart of the government sharing scheme, investigating the "scope of the problem" before and after introduction of the ride sharing scheme. Methods: Retrospective case series. Insitutional orthopaedic department database was searched from 1 Jan 2021 to 30 June 2022 to identify all admissions, requiring orthopaedic management, associated with e-scooter trauma. Data collected included, alcohol/drug involvement, hospital LOS, injury severity score, ICU admission, injuries sustained, surgical procedures, discharge destination, and death. Results: In the 12 months prior to, and five months since introduction of the ride share scheme, 43 patients sustaining e-scooter related injuries were identified. Eighteen patients (42%) presented in the five months since ride sharing was introduced and 25 patients in the preceding 12 months. 58% of patients were found to be intoxicated. Fourteen percent required an ICU admission. Forty-four percent of patients were polytrauma admissions. The median length of stay was two days, longest individual hospital stay was 69 days. There were 49 surgical procedures in 35 patients including neurosurgical, plastics and maxillofacial operations. The mean Injury Severity Score was 17.28. Conclusion: Electric scooters are associated with a significant trauma burden. This data may be combined with other clinical services and could be used to inform policy makers.

Functional outcomes following knee replacement in community-dwelling older adults.

BACKGROUND: Knee replacements are increasingly performed in older adults but uncertainty remains regarding their benefits in the context of age-related decline in physical function and other comorbidities. This study aimed to examine (1) the effect of knee replacement on functional outcomes in the context of age-related decline in physical function and (2) the factors associated with minimal important improvement in physical function after knee replacement in community-dwelling older adults aged ≥ 70 years. METHODS: This cohort study was performed within the ASPREE trial, with 889 participants undergoing knee replacement during the trial and 858 age- and sex-matched controls without knee or hip replacement identified from 16,703 Australian participants aged ≥ 70 years. Health-related quality of life was assessed annually using the SF-12, including its physical and mental component summary (PCS and MCS). Gait speed was measured biennially. Multiple linear regression and analysis of covariance were used to adjust for potential confounders. RESULTS: Participants with knee replacement had significantly lower pre- and post-replacement PCS scores and gait speed compared with age- and sex-matched controls. Participants with knee replacement had significant improvement in PCS score following knee replacement (mean change 3.6, 95% CI 2.9-4.3) while PCS score remaining unchanged in age- and sex-matched controls (-0.02, 95% CI -0.6 to 0.6) during follow-up period. The greatest improvements were observed for bodily pain and physical function. Following knee replacement, 53% of participants experienced minimal important improvement in PCS score (increased by ≥ 2.7), while 24% experienced worsened PCS score (reduced by > 2.7). Participants experiencing improved PCS score postoperatively had significantly lower PCS and higher MCS scores pre-surgery. CONCLUSIONS: Although community-based older adults experienced a significant improvement in PCS scores after knee replacement, their postoperative physical functional status remained significantly lower than age- and sex-matched controls. The degree of preoperative physical function impairment was a strong predictor of functional improvement, suggesting that this could be an important consideration when identifying older people most likely to benefit from knee replacement surgery.

Risk Stratification of Elderly Patients Undergoing Spinal Surgery Using the Modified Frailty Index.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: To validate the 11-item modified Frailty Index (mFI) as a perioperative risk stratification tool in elderly patients undergoing spine surgery. METHODS: All consecutive cases of spine surgery in patients aged 65 years or older between July 2016 and June 2018 at a state-wide trauma center were retrospectively reviewed. The primary outcome was post-operative major complication rate (Clavien-Dindo Classification ≥ III). Secondary outcome measures included the rate of all complications, 6-month mortality and surgical site infection. RESULTS: A total of 348 cases were identified. The major complication rate was significantly lower in patients with an mFI of 0 compared to ≥ 0.45 (18.3% versus 42.5%, P = .049). As the mFI increased from 0 to ≥ 0.45 there was a stepwise increase in risk of major complications (P < .001). Additionally, 6-month mortality rate was considerably lower when the mFI was 0 rather than ≥ 0.27 (4.2% versus 20.4%, P = .007). Multivariate analysis demonstrated an mFI ≥ 0.27 was significantly associated with an increased incidence of major complication (OR 2.80, 95% CI 1.46-5.35, P = .002), all complication (OR 2.93, 95% CI 1.70-15.11, P < .001), 6-month mortality (OR 7.39, 95% CI 2.55-21.43, P < .001) and surgical site infection (OR 4.43, 95% CI 1.71-11.51, P = .002). The American Society of Anesthesiologists' (ASA) index did not share a stepwise relationship with any outcome. CONCLUSION: The mFI is significantly associated in a gradated fashion with increased morbidity and mortality. Patients with an mFI ≥ 0.27 are at greater risk of major complications, all-complications, 6-monthy mortality, and surgical site infection.

Functional Outcomes Following Hip Replacement in Community-Dwelling Older Adults.

Uncertainty remains regarding the benefit of hip replacement in older adults in the context of age-related decline in physical function. This study aimed to examine the effect of hip replacement on functional outcomes and identify factors associated with clinically important improvement in physical function postoperatively in community-dwelling older adults. This cohort study was performed within the ASPREE trial, with 698 participants receiving hip replacement and 677 age- and sex-matched controls without knee or hip replacement during the trial drawn from 16,703 Australian participants aged ≥70 years. Health status (physical and mental component summary [PCS and MCS]) was assessed annually using the SF-12. Participants receiving hip replacement had significantly lower pre- and post-replacement PCS scores compared with controls (p < 0.0001). There was significant improvement in PCS score following hip replacement (mean change 4.9, 95%CI 4.0−5.7) but no change in controls (0.01, 95%CI −0.7−0.7). Following hip replacement, 46.7% of participants experienced clinically important improvement in PCS score, while 15.5% experienced worsened PCS score. Participants experiencing improved postoperative PCS score had significantly lower PCS and higher MCS scores preoperatively. The degree of preoperative physical function impairment was a significant indicator of older people most likely to benefit from hip replacement surgery.

Posterior Instrumented Spinal Surgery Outcomes in the Elderly: A Comparison of the 5-Item and 11-Item Modified Frailty Indices.

STUDY DESIGN: Retrospective Cohort. OBJECTIVES: To validate the most concise risk stratification system to date, the 5-item modified frailty index (mFI-5), and compare its effectiveness with the established 11-item modified frailty index (mFI-11) in the elderly population undergoing posterior instrumented spine surgery. METHODS: A single centre retrospective review of posterior instrumented spine surgeries in patients aged 65 years and older was conducted. The primary outcome was rate of post-operative major complications (Clavien-Dindo Classification ≥ 4). Secondary outcome measures included rate of all complications, 6-month mortality and surgical site infection. Multi-variate analysis was performed and adjusted receiver operating characteristic curves were generated and compared by DeLong's test. The indices were correlated with Spearman's rho. RESULTS: 272 cases were identified. The risk of major complications was independently associated with both the mFI-5 (OR 1.89, 95% CI 1.01-3.55, P = .047) and mFI-11 (OR 3.73, 95% CI 1.90-7.30, P = .000). Both the mFI-5 and mFI-11 were statistically significant predictors of risk of all complications (P = .007 and P = .003), surgical site infection (P = .011 and P = .003) and 6-month mortality (P = .031 and P = .000). Adjusted ROC curves determined statistically similar c-statistics for major complications (.68 vs .68, P = .64), all complications (.66 vs .64, P = .10), surgical site infection (.75 vs .75, P = .76) and 6-month mortality (.83 vs .81, P = .21). The 2 indices correlated very well with a Spearman's rho of .944. CONCLUSIONS: The mFI-5 and mFI-11 are equally effective predictors of postoperative morbidity and mortality in this population. The brevity of the mFI-5 is advantageous in facilitating its daily clinical use.

Outcomes of surgical site infections following spinal column trauma.

BACKGROUND: Surgical site infections (SSI) are an undesirable outcome of spinal surgery for both the patient and healthcare system. To date, few studies have investigated the impact of SSI on patient-reported and clinical outcomes. Sepsis and readmission are potential sequelae of SSI, with sepsis potentially being life threatening. This study aimed to assess the association between SSI and patient outcomes in a spinal trauma cohort. METHODS: Adult (16+ years) patients who underwent emergency spinal surgery due to trauma between January 2010 and December 2016 at a major trauma centre in Melbourne, Australia, were identified through the Victorian Orthopaedic Trauma Outcomes Registry. The presence of an SSI was abstracted from the electronic medical record and outcomes were compared between patients with and without an SSI. Clinical outcomes were obtained from the medical record, and patient-reported outcomes at 6 and 12 months were obtained from the Victorian Orthopaedic Trauma Outcomes Registry. Chi-squared tests were used to compare patient outcomes between groups. RESULTS: Of the 458 included patients, 26 (5.7%) developed an SSI. Patient-reported outcomes at 6 and 12 months were not different between the groups. An SSI was associated with sepsis (χ21 = 24.20, P < 0.01), readmission (χ21 = 215.34, P < 0.01), revision surgery (χ21 = 171.21, P < 0.01) and removal of implants (χ21 = 4.31, P = 0.04) within 12 months of discharge. CONCLUSION: These findings indicate that spine trauma SSIs are not associated with patient-reported outcomes and may not have lasting effects on patients. Larger studies are required to assess further follow-up and support our findings and possibly distinguish outcomes between superficial and deep SSI.

Risk factors for surgical site infections following spinal column trauma in an Australian trauma hospital.

BACKGROUND: There is limited, and often conflicting, data in the literature about the prevalence and risk factors for surgical site infections (SSI) in spine surgery patients, with the majority consisting of elective spine surgery cohorts. Furthermore, there is no reported Australian data regarding rates of SSI in a spinal trauma cohort. The aim of this study is to identify factors associated with SSI following spinal column trauma. METHODS: Adult (16+ years) patients that underwent surgery following emergency admission for spinal trauma between January 2010 and December 2016 at a major trauma centre in Melbourne, Australia, were identified through the Victorian Orthopaedic Trauma Outcomes Registry. The presence of an SSI was confirmed from the electronic medical record. Patient and clinical factors were analysed by SSI status. Generalized Estimating Equations were used to model predictors of SSI, with a P-value <0.05 deemed significant. RESULTS: Data for 458 patients and 520 surgical wounds were collected. Twenty-six (5.7%) patients developed an SSI. Staphylococcus aureus was the most common microorganism with methicillin-sensitive S. aureus found in 46% of SSI cases. A posterior surgical approach and same site reoperation were predictors of SSI with adjusted odds ratios (95% confidence intervals) of 4.26 (1.22-14.80, P = 0.02) and 4.99 (1.10-22.58, P = 0.04), respectively. CONCLUSIONS: A posterior surgical approach and same site reoperation increased the risk of SSI after spinal trauma. Further research into modifiable associations within these and other factors will help mitigate the risk of SSI and hence decrease the personal and financial costs of this potentially devastating complication.

The impact of an innovative pharmacist-led inpatient opioid de-escalation intervention in post-operative orthopedic patients.

OBJECTIVE: Many patients are discharged from hospital after surgery with excessive doses of opioid, and prescription opioid addiction has become a serious public health problem. Inpatient opioid de-escalation performed by clinical phar-macists may assist in reducing opioids before discharge. We aimed to evaluate whether clinical pharmacist-led opioid de-escalation for inpatients after orthopedic surgery led to significant reductions in opioid use at discharge, without resulting in greater pain intensity and side effects. DESIGN: This retrospective pre-/post-intervention study evaluated patients before and after implementation of a phar-macist-led opioid de-escalation service. SETTING: A major tertiary institution. PARTICIPANTS: Ninety eight participants underwent de-escalation, and 98 controls received standard care following ortho-pedic surgery. INTERVENTION: Pharmacist-led opioid de-escalation was initiated after discharge from the institution's Acute Pain Service. MAIN OUTCOME MEASURE: Primary outcome was total morphine oral equivalence (MOE) required in the 24-hours before discharge between the two groups. Secondary outcomes included pain intensity scores and opioid-related side effects. RESULTS: The post-intervention group used significantly less opioids in the 24 hours preceding discharge compared with the precohort (total MOE 30 vs 45 mg; p = 0.025).There were no differences in pain intensity at rest (p = 0.19) or with movement (p = 0.19). Cases experienced significantly less constipation (29 vs 49 percent; p = 0.004); no differences were observed for other side effects. DISCUSSION: We observed statistically similar pain intensity ratings, in the setting of significantly lowered opioid doses among the post-intervention group prior to discharge. CONCLUSION: Pharmacist-led inpatient opioid de-escalation is effective, does not increase pain intensity, and reduces constipation. Hospitals should explore the viability of extending pharmacist-led opioid de-escalation to other surgical patients and following hospital discharge, aiming for opioid cessation.

Perioperative antimicrobial decision making: Focused ethnography study in orthopedic and cardiothoracic surgeries in an Australian hospital.

OBJECTIVE: Antimicrobial use in the surgical setting is common and frequently inappropriate. Understanding the behavioral context of antimicrobial use is a critical step to developing stewardship programs. DESIGN: In this study, we employed qualitative methodologies to describe the phenomenon of antimicrobial use in 2 surgical units: orthopedic surgery and cardiothoracic surgery. SETTING: This study was conducted at a public, quaternary, university-affiliated hospital. PARTICIPANTS: Healthcare professionals from the 2 surgical unit teams participated in the study. METHODS: We used focused ethnographic and face-to-face semi-structured interviews to observe antimicrobial decision-making behaviors across the patient's journey from the preadmission clinic to the operating room to the postoperative ward. RESULTS: We identified 4 key themes influencing decision making in the surgical setting. Compartmentalized communication (theme 1) was observed with demarcated roles and defined pathways for communication (theme 2). Antimicrobial decisions in the operating room were driven by the most senior members of the team. These decisions, however, were delegated to more junior members of staff in the ward and clinic environment (theme 3). Throughout the patient's journey, communication with the patient about antimicrobial use was limited (theme 4). CONCLUSIONS: Approaches to decision making in surgery are highly structured. Although this structure appears to facilitate smooth flow of responsibility, more junior members of the staff may be disempowered. In addition, opportunities for shared decision making with patients were limited. Antimicrobial stewardship programs need to recognize the hierarchal structure as well as opportunities to engage the patient in shared decision making.

Correlation of Anterior Interbody Graft Choice With Patient-Reported Outcomes in Cervical Spine Trauma.

STUDY DESIGN: Ambispective observational cohort study. OBJECTIVES: Synthetic graft usage avoids morbidity associated with harvest and reduces operative time. This study aims to evaluate outcomes of anterior cervical stabilization surgery using a synthetic cage in comparison with iliac crest bone graft (ICBG) following cervical spine trauma. METHODS: An ambispective review was conducted on patients from the Alfred Trauma Registry. Consecutive patients treated at a level 1 trauma center, aged 18 years and older who were treated with standalone anterior cervical stabilization following spine trauma (2011-2016) were included in the study. Primary outcome measures were patient overall satisfaction, Neck Disability Index (NDI), neck pain 10-point visual analogue scale (VAS-neck) and arm pain 10-point visual analogue scale (VAS-arm). Secondary outcome measures were radiographic evidence of fusion and rate of revision surgery. All patients had follow-up for at least 1 year. RESULTS: Between 2011 and 2016, 114 traumatic disc levels in 104 patients were treated. ICBG was used in 32% and polyetheretherketone (PEEK) cage in 68% of the patients. Both groups had similar demographic metrics. There was no significant difference in primary outcome measures between the graft types: (1) patient satisfaction (P = .15), (2) NDI (P = .11), (3) VAS-neck (P = .13), and (4) VAS-arm (P = .20). Radiology based fusion assessment 6 months postsurgery did not show statistical significance (P = .10). The rates of revision surgery were similar. CONCLUSIONS: This study showed no significant difference in patient-reported outcome measures when comparing the usage of PEEK cage and ICBG in anterior stand alone cervical spine stabilization. Level 1 evidence studies are required to further investigate this finding.

Clinical clearance of the thoracic and lumbar spine: a pilot study.

BACKGROUND: In patients who are awake with normal mental and neurologic status, it has been suggested that the thoracolumbar (TL) spine may be cleared by clinical examination, irrespective of the mechanism of injury. The aim of this pilot study was to test the feasibility and accuracy of a clinical decision tool focused towards clearance of the TL spine during assessment of patients in the emergency department after trauma. METHODS: A prospective interventional study was conducted at two major trauma centres. The intervention of a clinical decision tool for assessment of the TL spine was applied prospectively to all patients with subsequent imaging results acting as the comparator. The primary outcome variable was fracture of the thoracic or lumbar vertebra(e). The clinical decision tool was assessed using sensitivity and specificity for detecting a TL fracture and reported with 95% confidence intervals (CIs). RESULTS: There were 188 cases included for analysis that all underwent imaging of the thoracic and/or lumbar vertebrae. There were 34 (18%) patients diagnosed with fractures of the thoracic and/or lumbar vertebrae. In this pilot study, sensitivity of the clinical decision tool was 100% (95% CI 87.3-100%) and specificity was 37.0% (95% CI 29.5-45.2%) for the detection of a thoracic or lumbar vertebral fracture. CONCLUSIONS: Feasibility of clinical clearance of the TL spine in two major trauma centres was demonstrated in a clinical study setting. Evaluation of this clinical decision tool in patients following blunt trauma, particularly in reducing imaging rates, is indicated using a larger prospective study.

Outcomes of total hip arthroplasty surgery in heart and lung transplant recipients.

BACKGROUND: Traditionally, arthroplasty in heart and lung transplant patients has been undertaken to manage transplant-related complications. More recently, arthroplasty is increasingly being performed for end-stage osteoarthritis. This study reviewed short-term outcomes and complications of total hip arthroplasty (THA) in heart and lung transplant recipients. METHODS: A retrospective cohort of heart and lung transplant recipients who underwent THA was identified using ICD-10 coding. Post-operative complications and hospital outcomes were collected using the patient medical record. RESULTS: Thirteen patients underwent 17 primary THA between 2008 and 2017, including five for osteoarthritis and 12 for femoral head avascular necrosis. Of the 13 patients, nine were bilateral sequential lung transplant recipients and four were orthotopic heart transplant recipients. The mean patient age was 61 years, with nine being male. Overall, five patients had one post-operative complication with eight having two or more complications. Surgical complications included three intraoperative fractures, three patients with superficial infection and one with deep infection requiring surgery. Seven patients had significant bleeding requiring blood transfusion. Prosthetic dislocations occurred in two patients, with one patient requiring revision surgery (developing a joint infection). Other complications included one pulmonary embolism, two episodes of pneumonia and six episodes of acute kidney injury, whilst three patients developed post-operative delirium. At 6-week follow-up, five patients had ongoing pain and seven had limitations with mobility. At 12-month follow-up, three patients reported ongoing pain. CONCLUSION: Complications following THA after transplant are common. The risks and benefits of THA should be carefully considered preoperatively in this cohort.

Using Patient-Reported Outcomes to Predict Revision Arthroplasty Following Femoral Neck Fracture: Enhancing the Value of Clinical Registries through Data Linkage.

The aim of this study was to determine the association between patient-reported outcome measures (PROMs) six months following femoral neck fracture after a low fall and future arthroplasty, and the factors associated with this. Six-month post-fracture PROMs were collected from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) for patients aged >55 years who were admitted for a femoral neck fracture after a low fall between March 2007 and June 2015. These cases were linked with those registered by Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) up to October 2016. Multivariable analysis was performed using a Cox proportional hazards model to determine factors associated with future arthroplasty, including six-month PROMs. Of the 7077 hip fracture patients registered by VOTOR during the study period, 2325 met the inclusion criteria. Internal fixation being used for the initial hip fracture surgery, being younger and having no pre-injury disability were all independently associated with future revision or conversion to arthroplasty. Out of all PROMs, reporting pain and discomfort six months post-fracture was associated with a 9.5-fold increase in the risk of future arthroplasty (95% CI: 3.81, 23.67). The value of clinical registries can be enhanced via data linkage, in this case by using PROMs to predict arthroplasty following femoral neck fracture.

Bone graft in posterior spine fusion for adolescent idiopathic scoliosis: a meta-analysis.

BACKGROUNDS: The aim of this study was to systematically analyse and perform a meta-analysis on the current available literature comparing the fusion rates and complications associated with use of autograft, allograft and bone substitutes to supplement posterior spinal fusion for adolescent idiopathic scoliosis (AIS). METHODS: The electronic databases including Embase, PubMed, Medline, Cinahl and Cochrane Library were searched to identify relevant studies. A total of 12 studies with 2389 patients were included for meta-analysis. The primary outcome was fusion rate, while the secondary outcomes included blood loss, operation time, infection rates and post-operative pain. RESULTS: The current meta-analysis found no difference in fusion rates between groups with an overall fusion rate of 100% (95% confidence interval (CI) 0.99-1.00; P < 0.05). Total estimated blood loss was significantly higher in the iliac crest bone graft (ICBG) group compared with control group (1018 versus 861 mL; P < 0.01). In addition, the mean operative time was significantly higher in the ICBG group (259 versus 237 min; P < 0.001). The ICBG group also had increased post-operative pain issues compared with the control group (26 versus 9%; P < 0.001). There was no significant difference in terms of post-operative wound infection between groups with an overall infection rate of 1% (95% CI 0.0-0.02; P = 0.06). CONCLUSION: ICBG confers no advantage over the other graft options in achieving fusion in AIS surgery. Furthermore, crest harvesting was associated with significant increases in blood loss, operative time and post-operative pain issues. Therefore, allograft and bone substitutes are attractive alternatives to autogenous grafting during posterior fusion in AIS.

Factors Associated With Revision Surgery After Internal Fixation of Hip Fractures.

BACKGROUND: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. METHODS: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. RESULTS: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (for every 5-point increase) (HR 1.19, 95% CI 1.02-1.39; P = 0.027), displaced fracture (HR 2.16, 95% CI 1.44-3.23; P < 0.001), unacceptable quality of implant placement (HR 2.70, 95% CI 1.59-4.55; P < 0.001), and smokers treated with cancellous screws versus smokers treated with a sliding hip screw (HR 2.94, 95% CI 1.35-6.25; P = 0.006). Additionally, for every 10-year decrease in age, participants experienced an average increased risk of 39% for hardware removal. CONCLUSIONS: Results of this study may inform future research by identifying high-risk patients who may be better treated with arthroplasty and may benefit from adjuncts to care (HR 1.39, 95% CI 1.05-1.85; P = 0.020). LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Factors Associated With Health-Related Quality of Life in Patients With Open Fractures.

OBJECTIVES: To analyze FLOW data to identify baseline patient, injury, fracture, and treatment factors associated with lower health-related quality of life (HRQoL) at 12-month postfracture. DESIGN: Prognostic study using data from a prospective randomized controlled trial. SETTING: Thirty-one clinical centers in the United States, Canada, Australia, and India. PATIENTS/PARTICIPANTS: One thousand four hundred twenty-seven patients with open fracture from the FLOW trial with complete 12-month Short Form-12 (SF-12) follow-up assessment and no missing data for selected baseline factors. INTERVENTION: Not applicable. MAIN OUTCOME MEASUREMENT: Physical Component Score (PCS) and the Mental Component Score (MCS) of the SF-12 at 12-month postfracture. RESULTS: One thousand four hundred twenty-seven patients were included in the SF-12 PCS and MCS linear regression models. Smoking, lower preinjury SF-12 PCS and MCS, and work-related injuries were significantly associated with lower SF-12 PCS and MCS at 12-month postfracture. A lower extremity fracture and a wound that was not closed at initial irrigation and debridement were significantly associated with lower 12-month SF-12 PCS but not MCS. Only the adjusted mean difference for lower extremity fractures approached the minimally important difference for the SF-12 PCS. CONCLUSIONS: We identified a number of statistically significant baseline factors associated with lower HRQoL; however, only the presence of a lower extremity fracture approached clinical significance. More research is needed to quantify the impact of these factors on patients and to determine whether changes to modifiable factors at baseline will lead to clinically significant improvements in HRQoL after open fractures. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of halo immobilization in the management of subaxial cervical facet fractures.

BACKGROUND: Spinal injury causes a significant burden on patients, families and health services. Cervical facet fractures are uncommon, and there is a paucity of functional and health-related quality-of-life data in patients who are managed non-operatively for this injury. METHODS: Victorian State Trauma Registry patients managed in a halothoracic brace for cervical facet injuries from August 2006 to June 2013 were included. Health status (12-item Short-Form health survey), function (Glasgow Outcome Scale-Extended), pain and return to work outcomes were assessed at 6, 12 and 24 months post-injury. Subgroup analysis was performed for age, sex, comorbidity, compensable status, Injury Severity Score (ISS) and education. RESULTS: Outcome data were available for 54 patients, with road trauma being the most common mechanism (69%), followed by a fall from height (18%). Overall, good 24-month function was achieved in 35% of patients, and 51% and 77% of patients reported good physical and mental health status, respectively. Ongoing moderate-severe neck pain was present in 19% of patients. Poorer function was associated with compensable status (P = 0.05), an ISS > 12 (P = 0.001) and a lower level of education (P = 0.04). Poorer physical health status was associated with age ≥50 (P = 0.05), pre-existing comorbidities, an ISS > 12 (P = 0.04) and a lower level of education (P = 0.03). CONCLUSION: Although many patients achieved good function and health status by 24 months, neck pain remains prevalent. A number of demographic factors were associated with a poorer outcome. This understanding helps to inform prognosis when managing this injury.