Prediction of recovery in trauma patients using Latent Markov models.

PURPOSE: Patients' expectations during recovery after a trauma can affect the recovery. The aim of the present study was to identify different physical recovery trajectories based on Latent Markov Models (LMMs) and predict these recovery states based on individual patient characteristics. METHODS: The data of a cohort of adult trauma patients until the age of 75 years with a length of hospital stay of 3 days and more were derived from the Brabant Injury Outcome Surveillance (BIOS) study. The EuroQol-5D 3-level version and the Health Utilities Index were used 1 week, and 1, 3, 6, 12, and 24 months after injury. Four prediction models, for mobility, pain, self-care, and daily activity, were developed using LMMs with ordinal latent states and patient characteristics as predictors for the latent states. RESULTS: In total, 1107 patients were included. Four models with three ordinal latent states were developed, with different covariates in each model. The prediction of the (ordinal) latent states in the LMMs yielded pseudo-R2 values between 40 and 53% and between 21 and 41% (depending of the type R2 used) and classification errors between 24 and 40%. Most patients seem to recover fast as only about a quarter of the patients remain with severe problems after 1 month. CONCLUSION: The use of LMMs to model the development of physical function post-injury is a promising way to obtain a prediction of the physical recovery. The step-by-step prediction fits well with the outpatient follow-up and it can be used to inform the patients more tailor-made to manage the expectations.

Longitudinal analysis of health status the first year after trauma in severely injured patients.

PURPOSE: While survival rates after a trauma are increasing a considerable part of the trauma population are still at risk for both short and long term disabilities. Little is known about prognostic factors over time after a severe trauma. The aim of the present prospective cohort study was to examine trauma and patient related prognostic factors for a lower health status over time after a severe trauma. METHODS: A multicentre prospective observational cohort study was conducted. Adult trauma patients with severe injuries (ISS ≥ 16) were included from August 2015 until November 2016 if admitted to one of the hospitals in Noord-Brabant (the Netherlands). Outcome measure was health status, measured by the EuroQol-5D (EQ-5D utility and EQ-Visual analogue scale) and the Health Utilities Index (HUI2 and HUI3) one week and one, three, six, and twelve months after injury. Patient and trauma characteristics were analysed as prognostic factors with linear mixed models. The effect of each prognostic factor over time was analysed by adding the interaction term between the prognostic factor and time point in a multivariable linear mixed model, adjusted for confounders. Additionally, the risk factors for problems in the EQ-5 dimensions of HS and cognition were analysed. RESULTS: In total 239 severely injured patients participated. Pre-injury health status, hospital length of stay, ISS and comorbidities were significant prognostic factors for a lower health status. A younger age and extremity injury were prognostic factors for a lower health status until one month after trauma and unemployment before trauma and comorbidities six until twelve months after trauma. In the EQ-5 dimensions 44.1% remained problems in mobility, 15.3% in self-care, 46.4% in activity, 53.3% in pain, 32.5% in anxiety and 35.7% in cognition. CONCLUSIONS: Lower pre-injury health status, longer hospital length of stay, higher ISS, and comorbidities were significant prognostic factors for a lower health status during one year after a severe injury. A younger age and an extremity injury were short-term prognostic factors and unemployment before trauma and comorbidities were long-term prognostic factors. Even after twelve months patients in our population reported more problems in all EQ-5D dimensions when compared to the Dutch reference population.

Weight-bearing or non-weight-bearing after surgical treatment of ankle fractures: a multicenter randomized controlled trial.

PURPOSE: The goal of this study was to assess if unprotected weight-bearing as tolerated is superior to protected weight-bearing and unprotected non-weight-bearing in terms of functional outcome and complications after surgical fixation of Lauge-Hansen supination external rotation stage 2-4 ankle fractures. METHODS: A multicentered randomized controlled trial was conducted in patients ranging from 18 to 65 years of age without severe comorbidities. Patients were randomized to unprotected non-weight-bearing, protected weight-bearing, and unprotected weight-bearing as tolerated. The primary endpoint of the study was the Olerud Molander Ankle Score (OMAS) 12 weeks after randomization. The secondary endpoints were health-related quality of life using the SF-36v2, time to return to work, time to return to sports, and the number of complications. RESULTS: The trial was terminated early as advised by the Data and Safety Monitoring Board after interim analysis. A total of 115 patients were randomized. The O'Brien-Fleming threshold for statistical significance for this interim analysis was 0.008 at 12 weeks. The OMAS was higher in the unprotected weight-bearing group after 6 weeks c(61.2 ± 19.0) compared to the protected weight-bearing (51.8 ± 20.4) and unprotected non-weight-bearing groups (45.8 ± 22.4) (p = 0.011). All other follow-up time points did not show significant differences between the groups. Unprotected weight-bearing showed a significant earlier return to work (p = 0.028) and earlier return to sports (p = 0.005). There were no differences in the quality of life scores or number of complications. CONCLUSIONS: Unprotected weight-bearing and mobilization as tolerated as postoperative care regimen improved short-term functional outcomes and led to earlier return to work and sports, yet did not result in an increase of complications.