Early prediction of tibial and femoral fracture healing: Are we reliable?

INTRODUCTION: To evaluate the ability of orthopaedic trauma subspecialists to predict early bony union in femoral and tibia shaft fractures. MATERIALS AND METHODS: Eight orthopaedic trauma subspecialists prospectively predicted the probability of bony union at 6 and 12 weeks post-operatively for an aggregate of 48 femoral and tibial shaft fractures treated at a Level 1 trauma centre. An additional orthopaedic trauma subspecialist was blinded to treating surgeon and adjudicated healing at 18 weeks. The Squared-Error Skill Score (SESS) determined the likelihood of accurate forecasting for bony union. RESULTS: Nine patients were lost follow-up, resulting in 39 fractures (81.25% retention) including 20 femoral and 19 tibial fractures. Fourteen fractures were open, 15 were not-yet united at final follow-up. SESS values were 0.25-0.77. The ability to predict union (sensitivity) was 1.000. The ability to predict nonunions (specificity) was 0.330-0.500. The probability of a correct predicted union was 0.727 and correct predicted nonunion at final follow-up was 1.000. AO/OTA type A fractures pattern predictions were highly accurate. As body mass index increased, predictions trended toward decreased accuracy (p=0.06). Tobacco use, age, gender, associated injuries, open fractures, and surgeons' years in clinical practice were not associated with accuracy of predictions. CONCLUSIONS: At 12-weeks post-operatively orthopaedic trauma subspecialists can confidently predict the union state in this patient population. This data is most useful in the nonunion patient, directing early intervention, thereby decreasing patient disability and discomfort.

Unloader knee braces for osteoarthritis: do patients actually wear them?

BACKGROUND: Unloader braces are a nonsurgical approach for predominantly unicompartmental knee arthritis. Although noninvasive, braces are expensive and it is unclear whether clinical factors, if any, will predict regular brace use. QUESTIONS/PURPOSES: We asked: (1) Do patients continue to use the unloader brace more than 1 year after it is prescribed? (2) Do any clinical or radiographic factors predict continued use of the unloader brace after the first year? (3) What are the most common subjective reasons that patients give for discontinuing the brace? METHODS: We administered 110 surveys to all patients who were fitted for unloader knee braces for predominantly unicompartmental osteoarthritis 12 to 40 months before administration of the survey. Standardized indications and fitting protocols were used. The following parameters were tested for association with ongoing brace use: alignment, arthritis severity, compartment involved, BMI, weight, age, gender, pain and function, number of refittings, and problems with the brace. The survey response rate was 81% (89 of 110). RESULTS: Of the 89 responders, 28% reported regular brace use (twice per week, an hour at a time, or more); at 2 years, 25% used the brace regularly. No clinical or radiographic factors considered were associated with ongoing brace use. Patients reported lack of symptomatic relief, brace discomfort, poor fit, and skin irritation as reasons for discontinuing the brace. CONCLUSIONS: Surgeons and patients need to balance the benefits and absence of complications of bracing against cost and the low likelihood of ongoing use 1 year or more after the prescription of the brace.

Comparison of trauma mortality between two hospitals in Turkey to one trauma center in the US.

OBJECTIVES: The development of comprehensive international trauma case registries could be used to perform outcomes analysis and comparisons between countries with the goal of improving trauma care worldwide. METHODS: A retrospective study (April 2004 to April 2005) of injured patients from a Pennsylvania state trauma center (PSTC) were case matched according to age, sex, and injury severity score with two Turkish hospitals. Patients' demographics (age, sex), prehospital information (mechanism of injury, mode of transportation), injury severity (injury severity score and Glasgow coma score), and outcomes (intensive care unit length of stay, hospital length of stay, mortality) were collected. STATISTICAL ANALYSIS: P value of less than 0.05, odds ratio (OR), chi2 test, two-sample t-test, mean+/-SD. RESULTS: Medical records from 506 Turkish trauma patients were abstracted and compared with 506 injured patients in the PSTC registry. Patients in Turkey presented more commonly with a Glasgow coma score of less than or equal to 8 (13.09 vs. 4.26%, P<0.01, OR 3.38) had increased mortality (8.30 vs. 0.79%, P<0.01, OR 11.36) and required mechanical ventilation more than 1 day more often (16.44 vs. 8.75%, P<0.01, OR 2.05). Motor vehicle crashes were the leading cause of injury in both groups. Assaults and falls were more frequent in the PSTC. Pedestrian injuries were more common and had higher mortality rates in Turkey (P<0.05). CONCLUSION: This study demonstrates significantly worse outcomes in trauma care and higher mortality rates in Turkey versus PSTC. Developing a trauma registry to monitor improvements in patient care and to target injury prevention strategies should be a high priority for the Turkish healthcare system.