Abstract
BackgroundOpen lower limb fractures are serious injuries requiring combined ortho-plastic surgery and have significantly worse outcomes than similar closed fractures. There is little objective published data to determine which functional outcome measures best reflect progress or completeness of physical recovery.Our hypothesis was that objective measures combining strength, mobility and balance would better reflect recovery than isolated parameters (e.g. range of motion ROM) and would compare well to patients’ perceived recovery.MethodsAdult open lower limb fracture patients were reviewed 6 and 12 weeks, 6, 9 and 12 months post-injury. The mechanism, injury pattern, age, gender and treatment were recorded. Isolated parameter objective functional outcome measures (OFOMs) (ROM and MRC strength grade) were compared to combined OFOMs (timed up and go, comfortable gait speed and fast gait speed, Edgren Side Step Test (TUAG, CGS, FGS, ESST) and Single Leg balance. Patient reported outcomes were recorded (Global Perceived Effect (GPE) score and Disability Rating Index (DRI)). Statistical analysis used non-parametric tests (e.g. Spearman correlation) compared each with time since injury.ResultsSixty-eight patients (54 male) with a median age of 45(20–75) years. Of the 19 isolated OFOMs, only knee flexion and ankle plantar flexion ROM and strength improved with time (Spearman correlation p = 0.042, 0.008, 0.032, 0.036 respectively). TUAG, ESST, CGS, FGS and GPE scores showed significant improvement (Spearman correlation p < 0.001). Patients’ estimation of recovery paralleled these measures (Spearman correlation p < 0.001) with all but 2 patients achieving the minimum clinical important difference in DRI by 12 months compared to baseline. However, the GPE score had a higher proportion of improving responses than DRI at each time-point.DiscussionFunctional recovery is a key determinant in patients returning to work, providing for themselves and their family or resuming independent living for older patients. This study has demonstrated time-related improvements in combined OFOMs measuring mobility, strength, agility and balance paralleling patients’ perception of recovery in the 12 months after open lower limb fractures. Over the same time-frame, the simple GPE score compared favourably with the DRI. Such parameters could become part of a defined core outcomes set. Focussing rehabilitation towards these combined OFOMs may help hasten recovery.Trial registrationSouth West Wales REC 06/WMW02/10).
Highlights
Open lower limb fractures are serious injuries requiring combined ortho-plastic surgery and have significantly worse outcomes than similar closed fractures
Of the 19 isolated objective functional outcome measures (OFOMs), only knee flexion and ankle plantar flexion Range of motion (ROM) and strength improved with time (Spearman correlation p = 0.042, 0.008, 0.032, 0.036 respectively)
Patients’ estimation of recovery paralleled these measures (Spearman correlation p < 0.001) with all but 2 patients achieving the minimum clinical important difference in Disability Rating Index (DRI) by 12 months compared to baseline
Summary
Open lower limb fractures are serious injuries requiring combined ortho-plastic surgery and have significantly worse outcomes than similar closed fractures. Even when the limb is preserved and wound and bone healing are complete, a wide range of clinical outcomes are seen, ranging from pain free mobility and a return to manual work, to ongoing pain, troublesome disfiguring scarring and problems with mobility This distinguishes recovery from open lower limb fractures from their closed counterparts. In our recent systematic review, we have shown that published outcome measures after either open and closed tibial fractures are inconsistently reported and seldom include direct measures of the patients’ locomotor ability [5] For these reasons the need for a defined core outcome set for open lower limb fractures has been recognised [5]. This would enable the meaningful comparison of surgical strategies within and between future studies
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