Short Musculoskeletal Function Assessment Dysfunction Research Articles

Minimal Clinically Important Difference (MCID) for the Short Musculoskeletal Function Assessment (SMFA) in Severe Lower Extremity Trauma: Pooled Data from 7 Multicenter, Prospective Clinical Trials.

The Short Musculoskeletal Function Assessment (SMFA) is a well validated, widely used patient-reported outcome (PRO) measure for orthopaedic patients. Despite its widespread use and acceptance, this measure does not have an agreed upon minimal clinically important difference (MCID). The purpose of the present study was to create distributional MCIDs with use of a large cohort of research participants with severe lower extremity fractures. Three distributional approaches were used to calculate MCIDs for the Dysfunction and Bother Indices of the SMFA as well as all its domains: (1) half of the standard deviation (one-half SD), (2) twice the standard error of measurement (2SEM), and (3) minimal detectable change (MDC). In addition to evaluating by patient characteristics and the timing of assessment, we reviewed these calculations across several injury groups likely to affect functional outcomes. A total of 4,298 SMFA assessments were collected from 3,185 patients who had undergone surgical treatment of traumatic injuries of the lower extremity at 60 Level-I trauma centers across 7 multicenter, prospective clinical studies. Depending on the statistical approach used, the MCID associated with the overall sample ranged from 7.7 to 10.7 for the SMFA Dysfunction Index and from 11.0 to 16.8 for the SMFA Bother Index. For the Dysfunction Index, the variability across the scores was small (<5%) within the sex and age subgroups but was modest (12% to 18%) across subgroups related to assessment timing. A defensible MCID can be found between 7 and 11 points for the Dysfunction Index and between 11 and 17 points for the Bother Index. The precise choice of MCID may depend on the preferred statistical approach and the population under study. While differences exist between MCID values based on the calculation method, values were consistent across the categories of the various subgroups presented. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Validity of the short musculoskeletal function assessment questionnaire in patients with a spine fracture

PurposeThe aim of this study was to validate the use of the Short Musculoskeletal Function Assessment (SMFA) questionnaire in patients with a spine fracture.MethodsCross-sectional cohort of individuals that had sustained a spine fracture (C1-L5) one year earlier. Patients were asked to fill out SMFA, Oswestry Disability Index (ODI), EQ-5D-3L and EQ-VAS. Spearman’s rank correlation coefficient (rho) was used to assess convergent validity for each patient-reported outcome measure (PROM). Bland–Altman plots were used to assess PROM agreement.Results82 patients completed all questionnaires. The correlations between SMFA Dysfunction and Bother indices and ODI were 0.89 and 0.86, with EQ-5D-3L index 0.89 and 0.80, and with EQ-VAS 0.80 and 0.73, respectively. The correlation for separate categories of the SMFA dysfunction index (daily activities, emotional status, arm and hand function, mobility) ranged between 0.71–0.87 for ODI, 0.72–0.84 for EQ-5D-3L index, and 0.67–0.77 for EQ-VAS. A selection of the ten items of SMFA that had the highest correlations with ODI resulted in a correlation of 0.91. The agreements between SMFA indices and ODI in Bland–Altman plots were good with small differential biases and minimal proportional biases, but worse for SMFA and EQ-5D-3L index and EQ-VAS.ConclusionThe SMFA indices are highly correlated with ODI in patients with a spine fracture. The Dysfunction index and Bother index, or selected SMFA items, may be used to assess outcome in patients with spine fractures as an alternative to ODI.

Unilateral Sacral Fractures Demonstrate Slow Recovery of Patient-Reported Outcomes Irrespective of Treatment.

To report functional outcomes of unilateral sacral fractures treated both operatively and nonoperatively. Prospective, multicenter, observational study. Sixteen Level 1 trauma centers. Skeletally mature patients with unilateral zone 1 or 2 sacral fractures categorized as displaced nonoperative (DN), displaced operative (DO), nondisplaced nonoperative (NN), and nondisplaced operative (NO). Pelvic displacement was documented on injury plain radiographs. Short Musculoskeletal Function Assessment (SMFA) scores were obtained at baseline and at 3, 6, 12, and 24 months after injury. Displacement was defined as greater than 5 mm in any plane at the time of injury. Two hundred eighty-six patients with unilateral sacral fractures were initially enrolled, with a mean age of 40 years and mean injury severity score of 16. One hundred twenty-three patients completed the 2-year follow-up as follows: 29 DN, 30 DO, 47 NN, and 17 NO with 56% loss to follow-up at 2 years. Highest dysfunction was seen at 3 months for all groups with mean SMFA dysfunction scores: 25 DN, 28 DO, 27 NN, and 31 NO. The mean SMFA scores at 2 years for all groups were 13 DN, 12 DO, 17 NN, and 17 NO. All groups (operative/nonoperative and displaced/nondisplaced) reported worst function 3 months after injury, and all but (DN) continued to recover for 2 years after injury, with peak recovery for DN seen at 1 year. No functional benefit was seen with operative intervention for either displaced or nondisplaced injuries at any time point. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Tobacco smoking is associated with more pain and worse functional outcomes after torsional ankle fracture

Objective:The purpose of this study was to assess the impact of current and remote tobacco smoking on clinical and functional outcomes after torsional ankle fracture.Methods:Nine hundred thirty-five patients treated surgically for torsional ankle fracture over 9 years were reviewed. Tobacco smoking status at the time of injury was defined as current (48.3%), former (11.7%), and nonsmoker (40.0%). Complications, unplanned secondary procedures, pain medication use, and functional outcome scores, as measured by Foot Function Index and Short Musculoskeletal Function Assessment (SMFA) surveys.Results:Mean age was 44.8 years, with 50.3% male. More than 6 months following injury current smokers were more likely than former smokers and nonsmokers to report ankle pain (67.8% vs 45.8% vs 47.5%) and to use prescription pain medicines (23.0% vs 10.4% vs 6.3%), all P < .05. Multiple logistic regression found current tobacco use to be an independent predictor for prescription pain medication use, and worse scores for the Foot Function Index, SMFA Dysfunction, and SMFA Bothersome scores, all P < .05. Complications occurred in 15.5% of all patients, and 10.7% underwent unplanned secondary operations. Tobacco smoking was not associated with more complications or secondary procedures.Conclusion:Current smokers are more likely to use prescription pain medications several months after injury and have worse patient-reported functional outcome scores after surgical treatment of torsional ankle fractures than former smokers and nonsmokers.

Functional Outcomes Following Operative Management of Ankle Fractures: Intermediate Length Follow-Up

Category:Ankle; Ankle Arthritis; TraumaIntroduction/Purpose:Ankle fractures are among the most commonly surgically treated orthopaedic injuries, with debate regarding their long-term outcomes and the clinical benefit of contemporary fixation strategies. The purpose of this study was to retrospectively evaluate the functional outcomes of patients following surgical management of ankle fractures, and to determine what, if any, limitations and effects their injury has on their daily lives. The authors of this study hypothesized that despite patients having some degree of measurable impairments, these did not cause meaningful disruption in their everyday lives.Methods:We retrospectively reviewed a total of 259 patients who underwent surgical management of their ankle fractures between 2004 and 2012. Two separate patient reported outcome measures, the Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA) were obtained at a minimum of 5 years following time of surgery. Multivariate linear regression analysis was performed to compare FFI and SMFA against several patient and injury specific variables.Results:A total of 259 patients with ankle fractures were included in the study population. 7 of the demographic and injury- related variables were found to have a statistically significant relationship to both the FFI and SMFA scores. The multivariate linear regression analysis using these 7 variables in addition to both sub-group components of the SMFA to predict the total FFI score yielded an output adjusted-r2 = 0.78. The SMFA dysfunction sub-category was found to correlate with FFI (standardized beta 0.85, p<0.001), but the SMFA bothersome sub-category did not (p=0.866). Ankle pain limiting function and Medicaid insurance status were also predictive of higher FFI scores.Conclusion:Despite patients, at times, experiencing persistent issues with pain and mild activity limitations following surgical management of ankle fractures, these did not lead to measured burdens in daily activities. At a moderate-length follow-up, patients overall do well from a functional standpoint after sustaining ankle fractures treated surgically.

Determinants of functional outcome following ankle fracture.

Objectives:To assess the patient and injury characteristics that impact functional outcomes after ankle fracture.Design:Retrospective study.Setting:Urban level I trauma center.Patients/Participants:One thousand patients underwent fixation of ankle fracture (AO/OTA 44) between 2006 and 2015. Four hundred sixteen completed functional outcome surveys by telephone or mail at a mean of 5.9 years after injury.Intervention:Open reduction internal fixation.Main outcome measure:Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA).Results:Mean age was 46.7 years, with 46.2% male. Higher (worse) FFI scores were seen in tobacco users (38.9 vs 30.1), recreational drug users (45.9 vs 32.7), and the morbidly obese (52.0 vs 30.6), all P < .005. Higher (worse) SMFA dysfunction and bothersome scores were also seen in these groups, and in females and alcohol users. Multiple regression analysis identified female gender, obesity, tobacco and alcohol use, complications, secondary procedures, and multiple additional injuries as independent predictors of higher scores (all P < .04). Fracture patterns, open fracture, and development of arthritis had no impact on FFI or SMFA scores.Conclusion:Patient characteristics, not under surgeon-control, such as female sex, obesity, and substance use, appear to contribute to patient-reported functional outcome scores more than injury characteristics.Level of Evidence:Level 3, prognostic

Persistent Pain, Physical Dysfunction, and Decreased Quality of Life After Combat Extremity Vascular Trauma

Combat-related extremity vascular injuries (EVI) have long-lasting impact on Iraq/Afghanistan veterans. The purpose of this study is to describe long-term functional outcomes in veterans with EVI using survey measures and identify modifiable factors that may be improved to reduce chronic pain and injury-related dysfunction. Veterans with upper and lower EVI undergoing an initial limb salvage attempt were identified using the Department of Defense Trauma Registry and validated with chart abstraction. Surveys measured pain; Short Musculoskeletal Function Assessment (SMFA) for self-reported bother and dysfunction; and Veterans RAND 12-Item Health Survey (VR-12) physical and mental component scores (PCS; MCS) for quality of life, depression, post-traumatic stress disorder, and the potentially modifiable factors of reintegration into civilian life, resilient coping, resilience, and family functioning. Eighty-one patients responded with an average time since injury of 129months (SD: 31; range 67-180months). Mechanism of injury included 64% explosions and 31% gunshot wounds; 16% of the respondents were diagnosed with moderate/severe/penetrating traumatic brain injury. Limb salvage rates were 100% and 77% for upper and lower extremities, respectively (P=0.004). Respondents screened positive for probable depression (55%) and post-traumatic stress disorder (51%). Compared with population norms, SMFA bother and dysfunction indices were higher (worse), MCS was lower (worse), and PCS was similar. The multivariable models adjusted for age, marital status and pain. The higher SMFA is part of the results of the multivariable models. MCS decreased with difficulty reintegrating into civilian life and was positively correlated with increased resilience and resilient coping. SMFA scores were greater for patients with high pain intensity and increased 6-11 points per point increase in difficulty with civilian-life reintegration. SMFA dysfunction was associated with better family functioning. EVI results in significant long-term disability with lasting deficits in physical function, frequent depressive symptoms, and below average self-reported quality of life. Strengthening modifiable factors including resiliency and resilient coping, and providing ongoing assistance to improve reintegration into civilian life, may ameliorate the functional disabilities and chronic pain experienced by veterans with EVI.

Improvement in Functional Outcomes After Elective Symptomatic Orthopaedic Implant Removal.

Introduction:The relative indications for removing symptomatic implants after osseous healing are not fully agreed on. The purpose of this study was to (1) determine whether patients showed improvement in functional outcomes after the removal of symptomatic orthopaedic implants, (2) compare the outcomes between upper and lower extremity implant removal, and (3) determine the rate of implant removal complications.Methods:A prospective study was conducted between 2013 and 2016. Patients completed a Short Musculoskeletal Function Assessment outcome questionnaire before implant removal and at the 6-month follow-up. Demographic data were stratified and compared between upper and lower extremity groups and between preimplant removal and 6-month postremoval.Results:Of the 119 patients included in the study, 85 (71.4%) were lower extremity and 34 (28.6%) were upper extremity. Significant improvement after implant removal was seen in the dysfunction index (P ≤ 0.001), bother index (P ≤ 0.001), and daily activities domain (P ≤ 0.001). Depression or anxiety (P = 0.016) were statistically significant predictors for an improved Short Musculoskeletal Function Assessment dysfunction index score at 6 months. The complication rate was 10.1% (n=12) for the cohort.Discussion:Implant removal in both the upper and lower extremity presented notable improvement in dysfunction. Complications that require surgical intervention are extremely rare.

A Randomized Controlled Trial Comparing Traditional Plaster Cast Rehabilitation With Functional Walking Boot Rehabilitation for Acute Achilles Tendon Ruptures

Background: There has been a shift toward functional nonoperative rehabilitation in the treatment of Achilles tendon rupture (ATR) despite a shortage of studies directly comparing nonoperative functional rehabilitation with traditional nonoperative immobilization. Purpose: To compare patient-reported outcome measures and functional outcomes for nonoperatively treated ATR with traditional cast immobilization or functional rehabilitation in a walking boot. Study Design: Randomized controlled clinical trial; Level of evidence, 2. Methods: In a single-center nonblinded study, 140 patients were randomized to compare treatment for acute ATR in (1) an immobilizing cast in reducing degrees of equinus over a 10-week period with 8 weeks of nonweightbearing mobilization or (2) a walking boot for 8 weeks with reducing equinus and immediate full weightbearing. Exclusion criteria were delayed presentation >2 weeks after injury, tendon reruptures, and latex allergy. Analysis was undertaken on an intention-to-treat basis. Results: A total of 69 patients (median age, 41 years [interquartile range, 33-50.5 years]) were randomized to walking boot treatment and 71 patients (41 [32-49]) to cast treatment. At 6 months, patients treated in a walking boot reported better Short Musculoskeletal Function Assessment (SMFA) dysfunction index (6.62 [2.21-12.50] vs 10.66 [4.96-13.42]; P = .050), SMFA bother index (7.29 [2.08-14.58] vs 10.42 [5.73-19.27]; P = .04), Achilles Tendon Total Rupture Score (71.5 [53.50-84.25] vs 54.0 [37-76]; P = .01), and Foot and Ankle Questionnaire core score (91 [81.89-97.55] vs 85 [78.25-92.09]; P = .04). At 1 year, there was no difference in SMFA dysfunction index (2.21 [0.74-5.88] vs 2.94 [1.47-6.62]; P = .25), SMFA bother index (2.08 [0-9.38] vs 5.21 [0.52-11.98]; P = .25), Achilles Tendon Total Rupture Score (92 [72.50-96] vs 87.5 [66.0-94.75]; P = .21), or Foot and Ankle Questionnaire core score (97.75 [89.46-99.00] vs 95.50 [90.88-97.50]; P = .18). Rerupture occurred in 5 and 11 patients (P = .075) and venous thromboembolism in 2 and 3 patients (P = .67) in the boot and cast groups, respectively. Fifteen patients in the boot group but none in the cast group had skin problems (P < .001). Patients treated in a boot returned to driving at a median 12 weeks (vs 13 weeks for cast; P = .045), but there was no difference in time to return to work (P = .48). Conclusion: Functional rehabilitation with early weightbearing is a safe alternative to traditional immobilizing treatment for ATR, giving better early functional outcomes, albeit with a higher incidence of transient minor skin complications. Registration: NCT02598843 (ClinicalTrials.gov identifier).

Timeline for maximal subjective outcome improvement following total ankle arthroplasty

BackgroundMaximal medical improvement (MMI) establishes the timepoint when patients no longer experience clinically significant improvements following surgery. The purpose of this investigation is to establish when patients achieve MMI following total ankle arthroplasty (TAA) through the use of patient reported outcome measures (PROMs). MethodsA systematic review to identify studies on TAA which reported consecutive PROMs for two years postoperatively was performed. Pooled analysis was done at 6 months, 12 months, and 24 months. Clinically significant improvement was defined as improvement between time intervals exceeding the minimal clinically important difference. ResultsTwelve studies and 1514 patients met inclusion criteria. Clinically significant improvement was seen up to 6 months postoperatively in both the American Orthopaedic Foot and Ankle Society Ankle Hindfoot Score and Visual Analog Scale scoring systems. The Short Musculoskeletal Function Assessment Dysfunction and Bother subsections showed maximal clinically significant improvement by 1 year postoperatively. ConclusionFollowing TAA, MMI is seen by one year postoperatively. Physicians may allocate the majority of resources within the first year when most of the improvement is perceived. This data may help inform preoperative counseling as it establishes a timeline for MMI. Level of evidenceIV.

The effect of obesity on post-operative complications and functional outcomes after surgical treatment of torsional ankle fracture: A matched cohort study

BackgroundObesity is a growing public health concern. While diabetes mellitus is associated with obesity and is a risk for infection and other complications, effects of obesity on outcomes remains less clear. The purpose was to determine effect of obesity on complications, secondary operations, and functional outcomes after surgical treatment of ankle fracture. Methods955 adult patients treated surgically for torsional ankle injury were reviewed. Obese patients (body mass index (BMI) ≥30), and patients without obesity were matched for age, sex, race, diabetes, and fracture pattern. Patient reported outcomes, measured by Foot Function Index (FFI) and Short Musculoskeletal Function Assessment (SMFA), were obtained after 12 months. Results632 patients (316 obese [mean BMI 36.7] and 316 non-obese [mean BMI 25.5]) with mean age 44.6 years were analyzed. Each group was 52.5% female, and 6.6% had diabetes mellitus. 75.6% of fractures in each group were AO/OTA type 44B and 24.4% were 44C. Non-obese patients were more likely tobacco users (63.3% vs 40.2%, p<0.001). Obese patients trended toward more dislocations (41.8% vs 35.4%, p=0.10), with similar rate of open fracture. Obese patients trended toward more complications (28.5% vs 22.5%. p=0.08) and wound healing problems (4.7% vs 2.2%, p=0.08) with similar rates of secondary procedures. Total FFI scores were higher (worse) for obese patients (35.4 vs 28.5, p=0.03); subcategory scores for disability and activity limitation were worse (p=0.03 and p=0.04, respectively), and obesity was associated with worse SMFA bothersome (31.0 vs 23.6, p=0.02) and mobility scores (41.8 vs 32.5, p=0.008), with a trend towards worse SMFA dysfunction scores in obese patients (29.7 vs 24.7, p=0.06). ConclusionsObesity is associated with worse functional outcomes by FFI and SMFA surveys. Contributions of baseline limitations to these poor scores in obese patients remain unclear. Injury characteristics were similar between obese and non-obese patients, though obese patients may be more prone to dislocations. A trend was noted for obese patients to experience more complications and wound healing issues, although rates of secondary operations were no different. Level of EvidenceIII

Chronic Pain Self-Management Support With Pain Science Education and Exercise (COMMENCE) for People With Chronic Pain and Multiple Comorbidities: A Randomized Controlled Trial

ObjectiveTo investigate the effectiveness of chronic pain self-management support with pain science education and exercise (COMMENCE) on improving function, pain interference, work status, pain intensity, fatigue, psychological factors associated with pain, health care visits, satisfaction, and perceived change compared with usual care. DesignParallel group randomized controlled trial with 1- and 12-week follow-ups. SettingCommunity health center. ParticipantsAdults (N=102) with chronic noncancer pain referred for self-management support. Eighty of 102 participants completed 12-week follow-up assessments. No participants withdrew with adverse events. InterventionsParticipants were randomized to COMMENCE or usual care. Main Outcome MeasuresPrimary: Function measured using the Short Musculoskeletal Function Assessment–Dysfunction Index. Secondary: Short Musculoskeletal Function Assessment–Bother Index, Patient Reported Outcomes Measurement Information System pain interference, work status, numeric pain, and fatigue rating scales, Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Pain Self-Efficacy Scale, Neurophysiology of Pain Questionnaire, number of health care visits, satisfaction, and global rating of change. ResultsCOMMENCE resulted in greater improvements in function (mean difference [MD] at 12-wk follow-up=−8.0; 95% CI, −14.7 to −1.3), bother with functional difficulties (MD, −12.0; 95% CI, −20.8 to −3.2), pain intensity (MD, −1.0; 95% CI, −2.1 to −0.1), catastrophizing (MD , −8.2; 95% CI, −14.5 to −2.0), self-efficacy (MD, 7.0; 95% CI, 0.8-13.2), knowledge (MD, 2.8; 95% CI, 1.6-3.9), satisfaction (MD, 1.2; 95% CI, 0.7-1.8), and perceived change (MD, 1.4; 95% CI, 0.8-2.1). There were no significant between-group differences in pain interference, work, fatigue, depressive symptoms, or health care visits. ConclusionCOMMENCE is more effective than usual care at improving function, pain, catastrophic thinking, self-efficacy, pain knowledge, satisfaction, and perceived change but not pain interference, work status, fatigue, depressive symptoms, or health care visits.

Surgical effectiveness of ankle "Logsplitter" injury plus avulsion fractures without tibiofibular joint screwing

Objective To explore the surgical efficacy of trans-syndesmotic ankle fracture dislocation (the Logsplitter injury) plus the Tillaux-Chaput fracture/the Wagstaffe-Lefort fracture and the Volkmann fracture without tibiofibular joint screwing. Methods Between January 2015 and December 2018, 16 adult patients with the Logsplitter injury plus avulsion fractures were treated by open reduction and internal fixation at Department of Orthopaedics, The Sixth Affiliated Hospital, Xinjiang Medical University. They were 11 males and 5 females with an average age of 36.4 years (range, from 27 to 56 years). There were 2 open fractures (one type Ⅱ and one type ⅢA by the Anderson-Gustilo classification) and 14 closed ones; all fractures were type 44-C by the AO/OTA classification; according to the Lauge-Hansen classification, there were 9 cases of pronation-abduction rotation, 3 cases of pronation-external rotation and 4 cases of supination-external rotation. The fibular fractures were treated through a single lateral approach followed by plate fixation. The Volkmann fractures were fixed with screws and the Tillaux-Chaput fractures/the Wagstaffe-Lefort fractures with screws or Kirschner wires. The ankle functions were assessed postoperatively using the ankle-hindfoot rating system of the American Orthopaedic Foot and Ankle Society (AOFAS), and the dysfunction index and bother index of Short Musculoskeletal Function Assessment (SMFA). Results All the patients were followed up for 8 to 27 months (average, 21.3 months). X-ray films showed complete fracture healing in all cases after 12 to 18 weeks postoperatively (mean, 14.8 weeks). At the last follow up, 13 patients walked normally and 2 with mild discomfort. Their AOFAS scores averaged 96.3 (range, from 86 to 100), giving 12 excellent, 3 good and one poor cases; their SMFA dysfunction index was 15.9 (range, from 8 to 17)and SMFA bother index 6.5 (range, from 3 to 9)at the last follow-up. Conclusions In the treatment of trans-syndesmotic ankle fracture dislocation - the Logsplitter injury, open reduction and internal fixation of the Tillaux-Chaput fracture/the Wagstaffe-Lefort fracture and the Volkmann fracture to reconstruct the lower tibiofibular horizontal stable ring , without tibiofibular joint screwing, can obtain satisfactory clinical results. Key words: Ankle joint; Fractures; Fracture fixation, internal; Logsplitter injury; Distal tibiofibular syndesmosis

Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma

ImportanceNumerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient’s recovery. Little is known about how to identify clinically actionable subgroups within this population.ObjectivesTo examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes.Design, Setting, and ParticipantsA prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018.Main Outcomes and MeasuresAt 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months.ResultsAmong the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups.Conclusions and RelevanceThis study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.

Functional Outcomes of Syndesmotic Injuries Based on Objective Reduction Accuracy at a Minimum 1-Year Follow-Up.

To evaluate whether objective syndesmosis reduction predicts functional outcomes and pain scores in patients with operatively treated syndesmotic injuries at a minimum 1-year follow-up. Prospective Cohort. Urban Level I Trauma Center. Sixty-nine patients with operatively treated syndesmotic injuries were initially identified and consented for inclusion in the study. Nine patients were excluded perioperatively. Twelve patients were lost to follow-up. Forty-eight patients with operatively treated unilateral syndesmotic injuries were available and participated at the final follow-up. Trans-syndesmotic stabilization with either 1 or 2 quadricortical position screws. Postoperatively, bilateral ankle computed tomography scans were obtained to objectively assess syndesmosis reduction accuracy. Olerud-Molander Ankle Score, Short Musculoskeletal Function Assessment Dysfunction Index and Bother Index, and Numeric Pain Rating Scales at a minimum 1-year postoperative follow-up. At 1-year follow-up, there was no significant difference in functional outcomes between reduced and malreduced groups at the 1.5-, 2-, and 3-mm thresholds for linear measurements. Similarly, there was no functional difference between the reduced and malreduced groups for rotational malreductions at a 10 or 15 degrees threshold. Patients with state-sponsored insurance (Medicaid) had significantly worse functional scores and pain scores when compared with the groups with private insurance, Medicare, or no insurance. At 1-year follow-up, functional outcomes were not related to objective measures of syndesmosis reduction. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Trajectory of Short- and Long-Term Recovery of Tibial Shaft Fractures After Intramedullary Nail Fixation.

To determine the trajectory of recovery after tibial shaft fracture treated with intramedullary nail over the first 5 years and to evaluate the magnitude of the changes in functional outcome at various time intervals. Prospective cohort study. A Level 1 trauma center. One hundred thirty-two patients with tibial shaft fracture (OTA 42-A, B, C) were enrolled into the Center's prospective orthopaedic trauma database between January 2005 and February 2010. Functional outcome data were collected at baseline, 6 months, 1 year, and 5 years. Enrolled patients were treated acutely with intramedullary nailing of their tibia. Evaluation was performed using the Short Form-36 and Short Musculoskeletal Function Assessment (SMFA). Mean SF-36 physical component scores improved between 6 and 12 months (P = 0.0008) and between 1 and 5 years (P = 0.0029). Similarly, mean SMFA dysfunction index scores improved between 6 and 12 months (P = 0.0254) and between 1 and 5 years (P = 0.0106). In both scores, the rate or slope of this improvement is flatter between 1 and 5 years than it is between 6 and 12 months. Furthermore, SF-36 and SMFA scores did not reach baseline at 5 years (SF-36 P < 0.0001, SMFA P = 0.0026). A significant proportion of patients were still achieving a minimal clinically important difference in function between 1 and 5 years (SF-36 = 54%, SMFA = 44%). The trajectory of functional recovery after tibial shaft fracture is characterized by an initial decline in function, followed by improvement between 6 and 12 months. There is still further improvement beyond 1 year, but this is of flatter trajectory. The 5-year results indicate that function does not improve to baseline by 5 years after injury. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does Hardware Removal Improve Function Following Ankle Open Reduction and Internal Fixation?

Category: Ankle, Trauma Introduction/Purpose: Orthopaedic hardware removal (HWR) is one of the most common orthopaedic procedures performed, with rates reported between 5% and 16%. Despite the high rates of HWR, there is still no consensus or guideline for removal after osseous healing without infection. Outcome studies for HWR are scarce, particularly in the lower extremity. The purpose of this study is to evaluate the effect of removal of symptomatic ankle hardware using the Short Musculoskeletal Function Assessment (SMFA) dysfunction index as the primary outcome. We hypothesize that HWR after ankle fracture will result in improved functional outcomes. Methods: Utilizing a prospectively collected ankle fracture registry, all patients that underwent HWR between 2013 and 2016 were retrospectively reviewed. Inclusion criteria were skeletal maturity, closed intra-articular ankle fracture, symptomatic ankle hardware and completion of the SMFA questionnaire prior to and 5-months after hardware removal. Exclusion criteria were development of a nonunion, infection or complex regional pain syndrome from initial surgery. The primary outcome was change in SMFA score from baseline. Paired t-test was used to compare baseline and follow-up SMFA scores. A multiple linear regression model evaluated the effects of age, sex, body mass index (BMI), smoking status, number of comorbidities, and Lauge-Hansen fracture classification on outcomes. Results: The study included 43 patients (31 females, 12 males), mean age 49.9 (range, 19 to 83). Mean time from initial surgery to HWR was 37±46 months (range, 2.2 to 209). Follow-up SMFA questionnaires were completed 5.7±0.5 months (range, 5.1 to 7.4) after HWR. The fractures were classified as 23 (53%) supination-external rotation, 6 (14%) pronation-external rotation, 2 (4.7%) pronation-abduction and 1 (2.3%) supination-adduction. Eleven fractures (26%) were classified as pilons. The SMFA dysfunction index improved significantly from baseline to follow-up (3.71±7.4, p=0.002). Significant improvement was seen in the secondary outcomes of SMFA bother index (4.40±8.9, p=0.003) and SMFA daily activities domain (4.12±9.1, p=0.006). Regression analysis revealed a significant improvement in the bother index correlating with female gender (p=0.01) and decreasing number of comorbidities (p=0.03). Conclusion: Our study demonstrates that patients with ankle fractures have a significant improvement in function following the removal of symptomatic ankle hardware. Patients also showed a significant improvement in the bother index and daily activities domain of the SMFA. Further investigation into the specific indications for HWR and the impact of injury and fracture pattern on outcomes is warranted.

Reaming Does Not Affect Functional Outcomes After Open and Closed Tibial Shaft Fractures: The Results of a Randomized Controlled Trial.

We sought to determine the effect of reaming on 1-year 36-item short-form general health survey (SF-36) and short musculoskeletal function assessment (SMFA) scores from the Study to Prospectively Evaluate Reamed Intramedullary Nails in patients with Tibial Fractures. Prospective randomized controlled trial.1319 patients were randomized to reamed or unreamed nails. Fractures were categorized as open or closed. Twenty-nine academic and community health centers across the US, Canada, and the Netherlands. One thousand three hundred and nineteen skeletally mature patients with closed and open diaphyseal tibia fractures. Reamed versus unreamed tibial nails. SF-36 and the SMFA. Outcomes were obtained during the initial hospitalization to reflect preinjury status, and again at the 2-week, 3-month, 6-month, and 1-year follow-up. Repeated measures analyses were performed with P < 0.05 considered significant. There were no differences between the reamed and unreamed groups at 12 months for either the SF-36 physical component score [42.9 vs. 43.4, P = 0.54, 95% Confidence Interval for the difference (CI) -2.1 to 1.1] or the SMFA dysfunction index (18.0 vs. 17.6, P = 0.79. 95% CI, -2.2 to 2.9). At one year, functional outcomes were significantly below baseline for the SF-36 physical componentf score, SMFA dysfunction index, and SMFA bothersome index (P < 0.001). Time and fracture type were significantly associated with functional outcome. Reaming does not affect functional outcomes after intramedullary nailing for tibial shaft fractures. Patients with open fractures have worse functional outcomes than those with a closed injury. Patients do not reach their baseline function by 1 year after surgery. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Validation of the Short Musculoskeletal Function Assessment in patients with battlefield-related extremity vascular injuries

Vascular extremity injuries can be a significant burden on a patient's long-term quality of life. Currently, no limb-specific surveys have been used to quantify the relation between injury pattern and the resultant physical or psychological impact. The objective of this study was to validate the use of the Short Musculoskeletal Function Assessment (SMFA) in the setting of extremity vascular injury. The Joint Theater Trauma Registry was queried and filtered for U.S. troops with an extremity vascular injury isolated to a single limb. Injury and management data were obtained, and the SMFA was administered after patient contact and consent. Validity was analyzed by characterization of SMFA score distribution, correlation with 36-Item Short Form Health Survey (SF-36) scores, and assessment of its discriminative capability to external measures of injury severity (ie, Injury Severity Score [ISS], Mangled Extremity Severity Score [MESS], and Medicare Part A disability qualification). At mean follow-up of 5 years, 164 patients (median age, 25 years; interquartile range, 22-31 years) completed both surveys. The overall SMFA Dysfunction Index was 24.8 ± 15.2 (range, 0-78; skewness, 0.60; floor/ceiling effect, 0%-1.2%; and nonresponse, 0%), and the overall Bother Index was 29.4 ± 20.2 (range, 0-96; skewness, 0.58; floor/ceiling effect, 0%-4.3%; and nonresponse, 0.6%). SF-36 physical component summary scores correlated inversely with the Dysfunction Index (r = -0.64; P < .01), whereas mental component summary scores correlated inversely with the Bother Index (r = -0.59; P < .01). No difference was found in reported scores between those considered severely injured (ISS > 15) and those not severely injured (ISS ≤ 15). However, those with mangled extremities (MESS ≥ 7) reported higher Dysfunction and Bother indices than those with lower scores (P < .05). In addition, patients considered disabled (per Medicare Part A qualifications) reported higher Dysfunction and Bother indices compared with those not considered disabled (P < .05). Use of the SMFA is validated in those with extremity vascular injuries, and it should be considered an adjunctive tool in evaluating long-term patient outcomes.

Acetabular Fractures in the Elderly Treated With a Primary Burch–Schneider Reinforcement Ring, Autologous Bone Graft, and a Total Hip Arthroplasty

To investigate the clinical and radiologic outcomes in elderly patients suffering from an acetabular fracture operated with an acute primary acetabular reinforcement ring, autologous bone graft, and a total hip arthroplasty (THA). Prospective cohort study. Tertiary care university hospital. Fifteen elderly patients (7 women) with a mean age of 76 years and a displaced acetabular fracture after a low-energy trauma were included. The fractures involved the anterior column, but no patients with associated both column fractures were included. All the patients were able to walk independently before the fracture occurred. Primary operation with a Burch-Schneider reinforcement ring, autologous bone graft, and a THA. The patients were reviewed at 4, 12, 24, and 48 months after the fracture occurred. The outcome assessments included complications, reoperations, activity of daily living function, functional scores (Harris hip score and short musculoskeletal function assessment), health-related quality of life [EuroQol (EQ-5D) index score], and radiologic evaluation. There were no prosthetic dislocations, periprosthetic fractures, deep infections, or other adverse events. There were no radiologic signs of loosening of the reinforcement ring or the prosthesis components at any of the follow up sessions, and the autologous bone graft was well incorporated in all the patients at the final follow-up. At 48 months, the mean Harris hip score was 88, the mean short musculoskeletal function assessment dysfunction score was 30, the bother score was 25, and the mean EQ-5D index score was 0.65. All the patients were able to walk independently at the final follow-up. Treatment of displaced anterior column, anterior column posterior hemitransverse and transverse acetabular fractures in elderly patients using a primary reinforcement ring, autologous bone graft, and a THA seems to be a safe option with good functional and radiologic outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.