Radiographic Assessment of Ankle Fracture Displacement: A Validation Study.

BACKGROUND: Ankle fracture displacement is an important outcome in clinical research examining the effectiveness of surgical and rehabilitation interventions. However, the assessment of displacement remains subjective without well-described or validated measurement methods. The aim of this study was to assess inter- and intrarater reliability of ankle fracture displacement radiographic measures and select measurement thresholds that differentiate displaced and acceptably reduced fractures. METHODS: Eight fellowship-trained orthopaedic surgeons evaluated a set of 26 postoperative ankle fracture radiographs on 2 occasions. Surgeons followed standardized instructions for making 5 measurements: coronal displacement (3) talar tilt (1), and sagittal displacement (1). Inter- and intraobserver interclass correlations were determined by random effects regression models. Logistic regression was used to determine the optimal sensitivity and specificity for the measurements with the highest correlation. RESULTS: Three of the 5 measures had excellent interobserver reliability (correlation coefficient > 0.75): (1) coronal plane distance between the lateral border of tibia and lateral border of talus, (2) coronal plane talar tilt, and (3) sagittal plane displacement. The threshold that best discriminated displaced from well-aligned fractures was 2 mm for coronal plane distance (sensitivity 82.1%, specificity 85.4%), 3 degrees for talar tilt (sensitivity 80.4%, specificity 82.2%), and 5 mm for sagittal plane distance (sensitivity 83.9%, specificity 84.9%). CONCLUSION: This study identified 3 reliable measures of ankle fracture displacement and determined optimal thresholds for discriminating between displaced and acceptably reduced fractures. These measurement criteria can be used for the design and conduct of clinical research studying the impact of surgical treatment and rehabilitation interventions.

Improving outcomes at Level I trauma centers: an early evaluation of the Trauma Survivors Network.

BACKGROUND: The Trauma Survivors Network (TSN), a program developed to help patients and families manage the psychosocial impact of their injuries, combines information access, self-management training, peer support, and online social networking. The purpose of this study was to evaluate the effectiveness of the TSN in improving patient reported outcomes among orthopedic trauma patients at a Level I trauma center. METHODS: We prospectively enrolled 251 patients with either severe lower-extremity injuries or polytrauma in two cohorts: one group (n = 125) before implementation of the TSN and one group (n = 126) after implementation. Participants were interviewed during their initial hospital stay and at 6 months. Outcomes evaluated at 6 months included depression, anxiety, self-efficacy, health status, and patient activation. RESULTS: Participation in the individual components of the TSN was low, ranging between 3% for the NextSteps self-management program and 27% for receipt of the Patient and Family Handbook. There were no statistically significant differences between treatment and control groups in self-efficacy, anxiety, health status, or activation. There were statistically significant differences in depression (24% of patients with probable depression in the TSN group vs. 40% in the control group, p = 0.02). However, the groups were not balanced with respect to sex, education, and baseline social support. After controlling for these differences, the TSN group still had 49% lower odds (95% confidence interval, 0% to 74%) of depression (p = 0.05). CONCLUSION: The TSN represents a potentially important step toward the development of comprehensive psychosocial support programs for trauma survivors. Despite improvements in one important outcome, a key finding of this evaluation is the low rate of use of program components. This finding highlights the need for greater understanding of use barriers and efforts to increase adoption. LEVEL OF EVIDENCE: Therapeutic study, level IV.