Victorian Orthopaedic Trauma Outcomes Registry Research Articles

Primary and Periprosthetic Distal Femur Fractures in Older Adults: No Difference in 12-Month Mortality and Patient-Reported Outcomes.

To compare fracture incidence, mortality, and patient-reported health outcomes at 6 and 12 months postinjury between primary and periprosthetic distal femur fractures in older adults. A registry-based cohort study was conducted including all adults 70 years of age or older registered by the Victorian Orthopaedic Trauma Outcomes Registry who experienced a primary or periprosthetic distal femur fracture between 2007 and 2017. Outcomes included mortality and health status (Three-Level European Quality of Life-Five Dimensions Scale [EQ-5D-3L]) collected at 6 and 12 months postinjury. All distal femur fractures were confirmed by radiological review. Multivariable logistic regression was conducted to report associations between fracture type and mortality and health status. A final cohort of 292 participants was identified. Overall mortality for the cohort was 29.8%, and no significant differences were found in mortality rate or EQ-5D-3L outcomes between fracture types (ie, primary vs. periprosthetic). A large proportion of participants reported problems across all EQ-5D-3L domains at 6 and 12 months postinjury, with slightly worse outcomes in the primary fracture group. This study reports high mortality and poor 12-month outcomes in an older adult cohort with both periprosthetic and primary distal femur fractures. Given these poor outcomes, fracture prevention and a greater focus on long-term rehabilitation is needed in this cohort. In addition, the involvement of an ortho-geriatrician should be considered as a routine component of care. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

FUNCTIONAL OUTCOMES FOLLOWING HIGH- AND LOW-ENERGY LISFRANC INJURIES: A LARGE REGISTRY-BASED STUDY

Lisfranc injuries account for 0.2% of all fractures and have been linked to poorer functional outcomes, in particular resulting in post-traumatic arthritis, midfoot collapse and chronic pain. This study assesses the longitudinal functional outcomes in patients with low and high energy Lisfranc injuries treated both operatively and non-operatively.Patients above 16 years with Lisfranc injuries from January 2008 and December 2017 were identified through the Victorian Orthopaedic Trauma Outcomes (VOTOR) registry. Follow-up performed at 6, 12 and 24 months through telephone interviews with response rate of 86.1%, 84.2% and 76.2% respectively. Longitudinal functional outcome data using Global Outcome Assessment, EQ-5D-5L, numerical pain scale, Short-Form 12, the WHO Disability Assessment Schedule and return to work status were collected. Univariate analysis was performed and variables showing a significant difference between groups (p < 0.25) were analysed with multivariable mixed effects regression model.745 patients included in this retrospective cohort study. At 24 months, both the operative and non-operative groups demonstrated similar functional outcomes trending towards an improvement. Mixed effect regression models for the EQ items for mobility (OR 1.80, CI 0.91 – 3.57), self-care (OR 1.95, 95% CI 1.09-3.49), usual activities (OR 1.10, 95% CI 0.99-1.03), pain (OR 1.07, 95% CI 0.61-1.89), anxiety (OR 1.29, 95% CI 0.72-2.34) and pain scale (OR 1.07, 95% CI 0.51 – 2.22) and return to work (OR 1.28, 95% CI 0.56-2.91) between groups were very similar and not statistically significantly different.We concluded that there was no statistically significant difference between operative and non-operative patients with low and high energy Lisfranc injuries. Current clinical practices in Lisfranc injury management are appropriate and not inadvertently causing any further harm to patients. Future research comparing fracture patterns, fixation types and corresponding functional outcomes can help determine gold standard Lisfranc injury management.

A registry-based observational cohort study examining patterns of pain and mental health symptoms and their impact on work or other activities after injury.

This registry-based observational cohort study included all people ≥ 16 years old hospitalized for unintentional injuries from 2007 to 2014 who were included in the Victorian State Trauma Registry or Victorian Orthopaedic Trauma Outcomes Registry, survived to 12-months postinjury and did not have severe brain injury or spinal cord injury (N = 31,073). Symptoms and related impacts were measured with pain Numerical Rating Scale, EuroQol Five Dimensions Three Level questionnaire (EQ-5D-3L), and 12-item Short Form Health Survey (SF-12) pain and mental health items at 6-, 12-, and 24-months postinjury. Symptom patterns over time, and their predictors, were examined using Latent Class and Transition Analyses and multinomial logistic regression. Four classes were identified: (1) Low pain and mental health problems (49-54%); (2) mental health problems only (11-12%); (3) pain problems only (18-23%); and (4) pain and mental health problems (16-17%). Most people stayed within the same class over time, or transitioned to fewer problems. People who transitioned to lower problems had higher socioeconomic status (e.g., higher education level, higher neighborhood-level advantage, and employment), better preinjury health (e.g., no disability or substance use condition) and noncompensable injuries. Reduced pain and mental health symptoms and related impairments were primarily associated with nonmodifiable biological, social, or economic characteristics. People with persistent symptoms were often already living with social disadvantage preinjury, and may have benefited from risk screening and proactive interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Pain and mental health symptom patterns and treatment trajectories following road trauma: a registry-based cohort study

Purpose This study aimed to characterise recovery from pain and mental health symptoms, and identify whether treatment use facilitates recovery. Methods Victorian State Trauma Registry and Victorian Orthopaedic Trauma Outcomes Registry participants without neurotrauma who had transport injury claims with the Transport Accident Commission from 2007 to 2014 were included (n = 5908). Latent transition analysis of pain Numeric Rating Scale, SF-12, and EQ-5D-3L pain and mental health items from 6 to 12 months, and 12 to 24 months post-injury were used to identify symptom transitions. Results Four transition groups were identified: transition to low problems by 12-months; transition to low problems at 24-months; stable low problems; and no transition from problems. Group-based trajectory modelling of pain and mental health treatments found three treatment trajectories: low/no treatment, a moderate treatment that declined to low treatment 3–12 months post-injury, and increasing treatment over time. Predictors of pain and mental health recovery transitions, identified using multinomial logistic regression, were primarily found to be non-modifiable socioeconomic and health-related characteristics (e.g., higher education, working pre-injury, and not having comorbidities), and low treatment trajectories. Conclusions Targeted and collaborative rehabilitation should be considered for people at risk of persistent pain or mental health symptoms to optimise their recovery, particularly patients with socioeconomic disadvantage. IMPLICATIONS FOR REHABILITATION Two-thirds of people experience pain and/or mental health within the first 24-months after hospitalization for road trauma, of whom only 6–7% recover by 12-months, and a further 6% recover by 24-months post-injury. There were three main trajectories of administrative records of treatments received in the first two years after injury: 76 and 83% had low treatment, 18 and 12% had moderate then declining treatment levels, and 6 and 5% had stable high treatment for pain or mental health, respectively. People who recovered from pain or mental health symptoms generally had lower treatment and higher socioeconomic position, highlighting that coordinated rehabilitation care should be prioritized for people living with socioeconomic disadvantage.

Predicting fracture outcomes from clinical registry data using artificial intelligence supplemented models for evidence-informed treatment (PRAISE) study protocol.

Distal radius (wrist) fractures are the second most common fracture admitted to hospital. The anatomical pattern of these types of injuries is diverse, with variation in clinical management, guidelines for management remain inconclusive, and the uptake of findings from clinical trials into routine practice limited. Robust predictive modelling, which considers both the characteristics of the fracture and patient, provides the best opportunity to reduce variation in care and improve patient outcomes. This type of data is housed in unstructured data sources with no particular format or schema. The "Predicting fracture outcomes from clinical Registry data using Artificial Intelligence (AI) Supplemented models for Evidence-informed treatment (PRAISE)" study aims to use AI methods on unstructured data to describe the fracture characteristics and test if using this information improves identification of key fracture characteristics and prediction of patient-reported outcome measures and clinical outcomes following wrist fractures compared to prediction models based on standard registry data. Adult (16+ years) patients presenting to the emergency department, treated in a short stay unit, or admitted to hospital for >24h for management of a wrist fracture in four Victorian hospitals will be included in this study. The study will use routine registry data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), and electronic medical record (EMR) information (e.g. X-rays, surgical reports, radiology reports, images). A multimodal deep learning fracture reasoning system (DLFRS) will be developed that reasons on EMR information. Machine learning prediction models will test the performance with/without output from the DLFRS. The PRAISE study will establish the use of AI techniques to provide enhanced information about fracture characteristics in people with wrist fractures. Prediction models using AI derived characteristics are expected to provide better prediction of clinical and patient-reported outcomes following distal radius fracture.

Outcomes of severe lower limb injury with Mangled Extremity Severity Score ≥ 7

Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J2021;103-B(4):769-774.

Risk factors for surgical site infections following spinal column trauma in an Australian trauma hospital

There is limited, and often conflicting, data in the literature about the prevalence and risk factors for surgical site infections (SSI) in spine surgery patients, with the majority consisting of elective spine surgery cohorts. Furthermore, there is no reported Australian data regarding rates of SSI in a spinal trauma cohort. The aim of this study is to identify factors associated with SSI following spinal column trauma. Adult (16+ years) patients that underwent surgery following emergency admission for spinal trauma between January 2010 and December 2016 at a major trauma centre in Melbourne, Australia, were identified through the Victorian Orthopaedic Trauma Outcomes Registry. The presence of an SSI was confirmed from the electronic medical record. Patient and clinical factors were analysed by SSI status. Generalized Estimating Equations were used to model predictors of SSI, with a P-value <0.05 deemed significant. Data for 458 patients and 520 surgical wounds were collected. Twenty-six (5.7%) patients developed an SSI. Staphylococcus aureus was the most common microorganism with methicillin-sensitive S. aureus found in 46% of SSI cases. A posterior surgical approach and same site reoperation were predictors of SSI with adjusted odds ratios (95% confidence intervals) of 4.26 (1.22-14.80, P = 0.02) and 4.99 (1.10-22.58, P = 0.04), respectively. A posterior surgical approach and same site reoperation increased the risk of SSI after spinal trauma. Further research into modifiable associations within these and other factors will help mitigate the risk of SSI and hence decrease the personal and financial costs of this potentially devastating complication.

Outcomes of surgical site infections following spinal column trauma.

Surgical site infections (SSI) are an undesirable outcome of spinal surgery for both the patient and healthcare system. To date, few studies have investigated the impact of SSI on patient-reported and clinical outcomes. Sepsis and readmission are potential sequelae of SSI, with sepsis potentially being life threatening. This study aimed to assess the association between SSI and patient outcomes in a spinal trauma cohort. Adult (16+ years) patients who underwent emergency spinal surgery due to trauma between January 2010 and December 2016 at a major trauma centre in Melbourne, Australia, were identified through the Victorian Orthopaedic Trauma Outcomes Registry. The presence of an SSI was abstracted from the electronic medical record and outcomes were compared between patients with and without an SSI. Clinical outcomes were obtained from the medical record, and patient-reported outcomes at 6 and 12 months were obtained from the Victorian Orthopaedic Trauma Outcomes Registry. Chi-squared tests were used to compare patient outcomes between groups. Of the 458 included patients, 26 (5.7%) developed an SSI. Patient-reported outcomes at 6 and 12 months were not different between the groups. An SSI was associated with sepsis (χ21 = 24.20, P < 0.01), readmission (χ21 = 215.34, P < 0.01), revision surgery (χ21 = 171.21, P < 0.01) and removal of implants (χ21 = 4.31, P = 0.04) within 12 months of discharge. These findings indicate that spine trauma SSIs are not associated with patient-reported outcomes and may not have lasting effects on patients. Larger studies are required to assess further follow-up and support our findings and possibly distinguish outcomes between superficial and deep SSI.

Outcomes following operatively managed acetabular fractures in patients aged 60 years and older.

Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA). We conducted a retrospective, registry-based study of 80 patients aged 60 years and older with acetabular fractures treated surgically at The Alfred and Royal Melbourne Hospital. We reviewed charts and radiological investigations and performed patient interviews/examinations and functional outcome scoring. Data were provided by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Survival analysis was used to describe conversion to THA in the group of patients who initially underwent open reduction and internal fixation (ORIF). Multivariate regression analyses were performed to identify factors associated with conversion to THA. Seven patients (8.8%) had died at a median follow-up of 18 months (interquartile range (IQR) 12 to 25), of whom four were in the acute THA group. Eight patients (10%) underwent acute THA. Of the patients who underwent ORIF, 17/72 (23.6%) required conversion to THA at a median of 10.5 months (IQR 4.0 to 32.0) . After controlling for other factors, transport-related cases had an 88% lower rate of conversion to THA (hazard ratio (HR) 0.12, 95% confidence interval (CI) 0.02 to 0.91). Mean standardized Physical Component Summary Score (PCS-12) of the 12-Item Short Form Health Survey (SF-12) was comparable with the general population (age-/sex-matched) by 12 to 24 months. Over half of patients working prior to injury (14/26) returned to work by six months and two-thirds of patients (19/27) by 12 months. Patients over 60 years of age managed operatively for displaced acetabular fractures had a relatively high mortality rate and a high conversion rate to THA in the ORIF group but, overall, patients who survived had mean PCS-12 scores that improved over two years and were comparable with controls. Cite this article: Bone Joint J 2020;102-B(12):1735-1742.

Discharge destination and patient-reported outcomes after inpatient treatment for isolated lower limb fractures.

To examine the association between discharge destination (home or inpatient rehabilitation) for adult patients treated in hospital for isolated lower limb fractures and patient-reported outcomes. Review of prospectively collected Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) data. Adults (18-64 years old) treated for isolated lower limb fractures at four Melbourne trauma hospitals that contribute data to the VOTOR, 1 March 2007 - 31 March 2016. Return to work and functional recovery (assessed with the extended Glasgow Outcomes Scale, GOS-E); propensity score analysis of association between discharge destination and outcome. Of 7961 eligible patients, 1432 (18%) were discharged to inpatient rehabilitation, and 6775 (85%) were followed up 12 months after their injuries. After propensity score adjustment, the odds of better functional recovery were 56% lower for patients discharged to inpatient rehabilitation than for those discharged directly home (odds ratio, 0.44; 95% CI, 0.37-0.51); for the 5057 people working before their accident, the odds of return to work were reduced by 66% (odds ratio, 0.34; 95% CI, 0.26-0.46). Propensity score analysis improved matching of the discharge destination groups, but imbalances in funding source remained for both outcome analyses, and for also for site and cause of injury in the GOS-E analysis (standardised differences, 10-16%). Discharge to inpatient rehabilitation after treatment for isolated lower limb fractures was associated with poorer outcomes than discharge home. Factors that remained unbalanced after propensity score analysis could be assessed in controlled trials.

Twelve month mortality rates and independent living in people aged 65 years or older after isolated hip fracture: A prospective registry-based study

Introduction: This study investigated which patient and injury characteristics are associated with 12-month mortality rates and living independently after isolated hip fracture.Methods: Older adults aged ≥65 years were included if they had an isolated hip fracture, were admitted to hospital between July 2009 and June 2016, inclusive, and were registered to the Victorian Orthopaedic Trauma Outcomes Registry. Mortality up to 12 months (365 days) post-injury, and functional outcomes (Glasgow Outcome Scale-Extended; GOS-E) at 12 months post-injury were examined. Multivariable Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs), and multivariable logistic regression was used to identify predictors of living independently compared with severe disability or death on the GOS-E.Results: 4,912 patients were included, of whom 28% died, 46% had moderate-severe disability, and 26% were living independently 12 months post-injury. Mortality rates were lower in women (aHR=0.56, 95%CI: 0.50, 0.63), and in people injured in a high fall vs low fall (aHR=0.47, 95%CI: 0.31, 0.72). Mortality rates were higher in people in the older age groups (75–84 years: aHR=1.53, 95%CI: 1.21, 1.93; 95+ years: aHR=3.58, 95%CI: 2.68, 4.77), living in areas with the highest level of socioeconomic disadvantage (aHR=1.25, 95%CI: 1.01, 1.55), with a Charlson Comorbidity Index weighting of one (aHR=1.60, 95%CI: 1.36, 1.88) or more than one (aHR=2.21, 95%CI: 1.94, 2.53), whose injury occurred in a residential institution versus at home (aHR=2.63, 95%CI: 1.97, 3.52), that resulted in intensive care unit admission (aHR=1.68, 95%CI: 1.21, 2.32), and in people who did not have surgery versus people who had internal fixation (aHR=1.65, 95%CI: 1.33, 2.04). Independent living was inversely associated with most of the same characteristics; however, people also had lower odds of living independently if they were from metropolitan residential areas versus rural areas (aOR=0.77, 95%CI: 0.62, 0.96), or had mild to moderate (aOR=0.33, 95%CI: 0.27, 0.39) or marked to severe (aOR=0.13, 95%CI: 0.09, 0.20) preinjury disability vs no preinjury disability.Conclusions: Characteristics that are associated with social disadvantage, frailty, poor health and reduced independence before injury were associated with increased rates of death and reduced odds of living independently 12 months after isolated hip fracture.

The road to recovery for vulnerable road users hospitalised for orthopaedic injury following an on-road crash

BackgroundPedestrians, cyclists and motorcyclists are vulnerable to serious injury due to limited external protective devices. Understanding the level of recovery, and differences between these road user groups, is an important step towards improved understanding of the burden of road trauma, and prioritisation of prevention efforts. This study aimed to characterise and describe patient-reported outcomes of vulnerable road users at 6 and 12 months following orthopaedic trauma. MethodsA registry-based cohort study was conducted using data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and included pedestrians, cyclists and motorcyclists who were hospitalised for an orthopaedic injury following an on-road collision that occurred between January 2009 and December 2016. Outcomes were measured using the 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3 L), Glasgow Outcome Scale – Extended (GOS-E) and return to work questions. Outcomes were collected at 6 and 12 months post-injury. Multivariable generalized estimating equations (GEE), adjusted for confounders, were used to compare outcomes between the road user groups over time. Results6186 orthopaedic trauma patients met the inclusion criteria during the 8-year period. Most patients were motorcyclists (42.8%) followed by cyclists (32.6%) and pedestrians (24.6%). Problems were most prevalent on the usual activities item of the EQ-5D-3 L at 6-months post-injury, and the pain/discomfort item of the EQ-5D-3 L at 12 months. The adjusted odds of reporting problems on all EQ-5D-3 L items were lower for cyclists when compared to pedestrians. Moreover, an average cyclist had a greater odds of a good recovery on the GOS-E, (AOR 2.75, 95% CI 2.33, 3.25) and a greater odds of returning to work (AOR = 3.13, 95% CI 2.46, 3.99) compared to an average pedestrian. ConclusionPedestrians and motorcyclists involved in on-road collisions experienced poorer patient-reported outcomes at 6 and 12 months post-injury when compared to cyclists. A focus on both primary injury prevention strategies, and investment in ongoing support and treatment to maximise recovery, is necessary to reduce the burden of road trauma for vulnerable road users.

Agreement between medical record and administrative coding of common comorbidities in orthopaedic trauma patients

ObjectiveTo i) quantify the agreement between comorbidities documented within medical records and an orthopaedic trauma dataset; and ii) compare agreement between these sources before and after the introduction of new comorbidity coding rules in Australian hospitals. Study design and settingA random sample of adult (≥ 16 years) orthopaedic trauma patients (n = 400) were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Diagnoses of obesity, arthritis, diabetes and cardiac conditions documented within patients’ medical records were compared to ICD-10-AM comorbidity codes (provided by hospitals) for the same admission. Agreement was calculated (Cohen’s kappa) before and after the introduction of new coding rules. ResultsAll comorbidities had the same or higher prevalence in medical record data compared to coded data. Kappa values ranged from <0.001 (poor agreement) for coronary artery disease to 0.94 (excellent agreement) for type 2 diabetes. There was improvement in agreement between sources for most conditions following the introduction of new coding rules. ConclusionThere has been improvement in the coding of certain comorbidities since the introduction of new coding rules, suggesting that, since 2015, administrative data has improved capacity to capture patients’ comorbidity profiles. Consideration must be taken when using the ICD-10-AM data due to its limitations.

Using Patient-Reported Outcomes to Predict Revision Arthroplasty Following Femoral Neck Fracture: Enhancing the Value of Clinical Registries through Data Linkage.

The aim of this study was to determine the association between patient-reported outcome measures (PROMs) six months following femoral neck fracture after a low fall and future arthroplasty, and the factors associated with this. Six-month post-fracture PROMs were collected from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) for patients aged >55 years who were admitted for a femoral neck fracture after a low fall between March 2007 and June 2015. These cases were linked with those registered by Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) up to October 2016. Multivariable analysis was performed using a Cox proportional hazards model to determine factors associated with future arthroplasty, including six-month PROMs. Of the 7077 hip fracture patients registered by VOTOR during the study period, 2325 met the inclusion criteria. Internal fixation being used for the initial hip fracture surgery, being younger and having no pre-injury disability were all independently associated with future revision or conversion to arthroplasty. Out of all PROMs, reporting pain and discomfort six months post-fracture was associated with a 9.5-fold increase in the risk of future arthroplasty (95% CI: 3.81, 23.67). The value of clinical registries can be enhanced via data linkage, in this case by using PROMs to predict arthroplasty following femoral neck fracture.

Incidence, Costs and Predictors of Non-Union, Delayed Union and Mal-Union Following Long Bone Fracture.

Fracture healing complications are common and result in significant healthcare burden. The aim of this study was to determine the rate, costs and predictors of two-year readmission for surgical management of healing complications (delayed, mal, non-union) following fracture of the humerus, tibia or femur. Humeral, tibial and femoral (excluding proximal) fractures registered by the Victorian Orthopaedic Trauma Outcomes Registry over five years (n = 3962) were linked with population-level hospital admissions data to identify two-year readmissions for delayed, mal or non-union. Study outcomes included hospital length-of-stay (LOS) and inpatient costs. Multivariable logistic regression was used to determine demographic and injury-related factors associated with admission for fracture healing complications. Of the 3886 patients linked, 8.1% were readmitted for healing complications within two years post-fracture, with non-union the most common complication and higher rates for femoral and tibial shaft fractures. Admissions for fracture healing complications incurred total costs of $4.9 million AUD, with a median LOS of two days. After adjusting for confounders, patients had higher odds of developing complications if they were older, receiving compensation or had tibial or femoral shaft fractures. Patients who are older, with tibial and femoral shaft fractures should be targeted for future research aimed at preventing complications.

Outcomes of midfoot and hindfoot fractures in multitrauma patients

IntroductionMultitrauma patients suffering hindfoot fractures, including calcaneal and talar fractures, often result in poor outcomes. However, less is known about the outcomes following midfoot fracture in the mutitrauma population. This study aims to describe the epidemiology of midfoot fractures in multitrauma patients and to compare the outcomes of midfoot and hindfoot fractures in this population. MethodsData about multitrauma patients (Injury Severity Score >12) sustaining a unilateral midfoot or hindfoot fracture were obtained from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) and from retrospective review of medical records at a major trauma centre. Further outcome data were obtained via a survey using the American Academy of Orthopedic Surgeons Foot and Ankle Score (AAOS FAS) and the 12-item Short Form Health Survey (SF-12). Results122 multitrauma patients were included; 81 with hindfoot fractures and 41 with midfoot fractures. The median ISS (IQR) was 22 (17–29) and 27 (17–24) for the hindfoot and midfoot groups, respectively (p = 0.23). Hindfoot and midfoot fractures were commonly associated with intracranial injuries (80.3%), spine injuries (60.7%), ipsilateral lower extremity injuries (24.6%) and pelvic injuries (16.4%). The mean (SD) time to follow up was 4.5 (±2.7) years. There were no differences in mean SF-12 physical (37.97 vs 35.22, p = 0.33) or mental (46.90 vs 46.67, p = 0.94) component summary scores between the groups. There were no differences in mean AAOS FAS standard scores (69.3 vs 69.1, p = 0.97) or shoe comfort scores (median 40 vs 40 p = 0.18) between the groups. ConclusionFunctional outcomes in multitrauma patients with midfoot or hindfoot fractures were comparable. These findings suggest that midfoot fractures should be treated with the same degree of due diligence as hindfoot fractures in the multitrauma patient.

Validating injury burden estimates using population birth cohorts and longitudinal cohort studies of injury outcomes: the VIBES-Junior study protocol

IntroductionTraumatic injury is a leading contributor to the global disease burden in children and adolescents, but methods used to estimate burden do not account for differences in patterns of injury...

Financial and recovery worry one year after traumatic injury: A prognostic, registry-based cohort study

BackgroundLevels of stress post-injury, especially after compensable injury, are known to be associated with worse long-term recovery. It is therefore important to identify how, and in whom, worry and stress manifest post-injury. This study aimed to identify demographic, injury, and compensation factors associated with worry about financial and recovery outcomes 12 months after traumatic injury. MethodsParticipants (n = 433) were recruited from the Victorian Orthopaedic Trauma Outcomes Registry and Victorian State Trauma Registry after admission to a major trauma hospital in Melbourne, Australia. Participants completed questionnaires about pain, compensation experience and psychological wellbeing as part of a registry-based observational study. ResultsLinear regressions showed that demographic and injury factors accounted for 11% and 13% of variance in financial and recovery worry, respectively. Specifically, lower education, discharge to inpatient rehabilitation, attributing fault to another and having a compensation claim predicted financial worry. Worry about recovery was only predicted by longer hospital stay and attributing fault to another. In all participants, financial and recovery worry were associated with worse pain (severity, interference, catastrophizing, kinesiophobia, self-efficacy), physical (disability, functioning) and psychological (anxiety, depression, PTSD, perceived injustice) outcomes 12 months post-injury. In participants who had transport (n = 135) or work (n = 22) injury compensation claims, both financial and recovery worry were associated with sustaining permanent impairments, and reporting negative compensation system experience 12 months post-injury. Financial worry 12 months post-injury was associated with not returning to work by 3–6 months post-injury, whereas recovery worry was associated with attributing fault to another, and higher healthcare use at 6–12 months post-injury. ConclusionsThese findings highlight the important contribution of factors other than injury severity, to worry about finances and recovery post-injury. Having a compensation claim, failure to return to work and experiencing pain and psychological symptoms also contribute to elevated worry. As these factors explained less than half of the variance in worry, however, other factors not measured in this study must play a role. As worry may increase the risk of developing secondary mental health conditions, timely access to financial, rehabilitation and psychological supports should be provided to people who are not coping after injury.

Epidemiology and outcomes of traumatic knee dislocations: Isolated vs multi-trauma injuries

Background and purposeTraumatic dislocation of the knee (TKD) is a rare injury, accounting for approximately 0.02% of orthopaedic injuries. They are a challenging entity for orthopaedic surgeons to manage, and can have devastating consequences.The aim of this study was to describe the epidemiology of traumatic knee dislocations (TKD'S) and contrast the incidence of neurovascular injury between isolated and multi-trauma dislocations as well as key patient reported outcomes achieved between these groups. Material and methodsPatients who had a traumatic disruption of the tibiofemoral articulation between March 1 2007 and February 31, 2015 were identified from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Data was cross-checked with medical records and radiological reports to confirm true multi-ligamentous dislocation. VOTOR collects information pertaining to orthopaedic injuries, treatment, complications and outcomes from four adult hospitals in Victoria, Australia, including the major trauma centers. Patient-reported outcomes are collected by VOTOR at 12 months post-injury including the EQ-5D-3L (EQ-5D) and Glasgow Extended Outcome Scores (GOS-E) and return to work status. Patient reported functional and quality of life outcomes at 12 months after injury were analysed. ResultsA cohort of 88 patients were identified that fit the inclusion criteria for the study, and at 12 months post-injury there was data available for 80 patients (90.9%). There were 38 (42.9%) patients who experienced an isolated traumatic knee dislocation and 52 (57.1%) who experienced a traumatic knee dislocation in association with another injury. Of the 88 patients identified as eligible for the study, two had bilateral knee dislocations, hence there were 90 multi-ligamentous knee injuries. Those who were injured at a higher velocity were more likely to have additional injuries. Dislocations that occurred at a lower velocity were shown to have better overall outcomes, as did dislocations that occurred in isolation. ConclusionsTraumatic knee dislocations that occur in isolation typically result in better outcomes than those that occur with associated injuries. TKD's are a rare but severe injury that requires further research in order for functional outcomes to be optimized.

Associations between compensable injury, perceived fault and pain and disability 1 year after injury: a registry-based Australian cohort study

ObjectivesCompensable injury increases the likelihood of having persistent pain after injury. Three-quarters of patients report chronic pain after traumatic injury, which is disabling for about one-third of patients. It is...