Victorian Orthopaedic Trauma Outcomes Registry Research Articles

EXPLORING PATIENT PERCEPTIONS OF BARRIERS AND FACILITATORS TO RECOVERY FOLLOWING TRAUMA

BackgroundThe consequences of injury are many, resulting in diverse patient outcomes and recovery experiences. While disability is prevalent post-injury, ‘why’ and ‘how’ patient and system factors interact to impact on...

Patient outcomes following traumatic fracture of the femoral shaft. Does surgical approach influence outcomes?

Background and AimLower limb fractures are often associated with poorer patient outcomes. The aim was to describe the 12-month outcomes of bony union, complication rates, health related quality of life...

The impact of sport and active recreation injuries on physical activity levels at 12 months post‐injury

The aim of this study was to evaluate the impact of serious sport and active recreation injury on 12-month physical activity levels. Adults admitted to hospital with sport and active recreation-related injuries, and captured by the Victorian Orthopaedic Trauma Outcomes Registry were recruited to the study. Changes between preinjury and 12 month post-injury physical activity was assessed using the short International Physical Activity Questionnaire (IPAQ). Independent demographic, injury, and hospital variables were assessed for associations with changes in physical activity levels, using multivariate linear regression. A total of 324 patients were recruited, of which 98% were followed up at 12 months. Mean short IPAQ scores decreased from 7650 METS (95% CI: 7180, 8120) preinjury to 3880 METS; (95% CI: 3530, 4250) post-injury, independent of functional recovery. Education level and occupation group were the only variables independently associated with changes in physical activity levels post-injury. These results highlighted that sport and active recreation injuries lead to significant reductions in physical activity levels. Hence, the prevention of sport and active recreation injuries is important when considering promotion of activity at a population level.

Return to pre-injury health status and function 12 months after hospitalisation for sport and active recreation related orthopaedic injury

BackgroundHospitalised sport and active recreation injuries can have serious long-term consequences. Despite this, few studies have examined the long-term outcomes of these injuries. The purpose of this study was to...

Inception of an Australian Spine Trauma Registry: the Minimum Dataset

Background The establishment of a spine trauma registry collecting both spine column and spinal cord data should improve the evidential basis for clinical decisions. This is a report on the pilot of a spine trauma registry including development of a minimum dataset. Methods A minimum dataset consisting of 56 data items was created using the modified Delphi technique. A pilot study was performed on 104 consecutive spine trauma patients recruited by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Data analysis and collection methodology were reviewed to determine its feasibility. Results Minimum dataset collection aided by a dataset dictionary was uncomplicated (average of 5 minutes per patient). Data analysis revealed three significant findings: (1) a peak in the 40 to 60 years age group; (2) premorbid functional independence in the majority of patients; and (3) significant proportion being on antiplatelet or anticoagulation medications. Of the 141 traumatic spine fractures, the thoracolumbar segment was the most frequent site of injury. Most were neurologically intact (89%). Our study group had satisfactory 6-month patient-reported outcomes. Conclusion The minimum dataset had high completion rates, was practical and feasible to collect. This pilot study is the basis for the development of a spine trauma registry at the Level 1 trauma center.

Level of agreement between patient and proxy responses to the EQ-5D health questionnaire 12 months after injury

Health-related quality of life represents a patient's experiences and expectations and should be collected from the patient. In trauma, collection of information from the patient can be challenging, particularly for subgroups where cognitive impairment is prevalent, increasing reliance on proxy reporting. This study assessed the agreement between patient and proxy reporting of health-related quality of life 12 months after injury. The Victorian State Trauma Registry and Victorian Orthopaedic Trauma Outcomes Registry collect EQ-5D data at 12 months after injury. Cases where data were collected from the patient and proxy were extracted. Agreement between patient and proxy responses was compared using kappa (K) coefficients for the individual EQ-5D items, and Bland-Altman plots and Wilcoxon signed-rank tests for the EQ-5D summary score and visual analog scale (VAS). Agreement between patient and proxy respondents was substantial for the mobility (K = 0.61) and personal care items (K = 0.67) and moderate for the usual activities (K = 0.50), pain/discomfort (K = 0.42), and anxiety/depression items (K = 0.47). The mean difference between proxy and patient-reported scores for the VAS (0.74, 95% confidence interval: -2.73, 4.21) and the EQ-5D summary score (-0.02, 95% confidence interval: -0.07, 0.03) was small, but the limits of agreement were wide (-34.22 to 35.71 for VAS and -0.55 to 0.51 for summary score), suggesting no systematic bias. Although proxy and patient responses for the EQ-5D VAS may differ, the differences show random variability rather than systematic bias. Group comparisons using proxy responses are unlikely to be biased, but proxy responses should be used with caution when assessing individual patient recovery.

Discharge destination following lower limb fracture: Development of a prediction model to assist with decision making

BackgroundAccurate prediction of the likelihood of discharge to inpatient rehabilitation following lower limb fracture made on admission to hospital may assist patient discharge planning and decrease the burden on the hospital system caused by delays in decision making. AimsTo develop a prognostic model for discharge to inpatient rehabilitation. MethodIsolated lower extremity fracture cases (excluding fractured neck of femur), captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), were extracted for analysis. A training data set was created for model development and validation data set for evaluation. A multivariable logistic regression model was developed based on patient and injury characteristics. Models were assessed using measures of discrimination (C-statistic) and calibration (Hosmer–Lemeshow (H–L) statistic). ResultsA total of 1429 patients met the inclusion criteria and were randomly split into training and test data sets. Increasing age, more proximal fracture type, compensation or private fund source for the admission, metropolitan location of residence, not working prior to injury and having a self-reported pre-injury disability were included in the final prediction model. The C-statistic for the model was 0.92 (95% confidence interval (CI) 0.88, 0.95) with an H–L statistic of χ2=11.62, p=0.17. For the test data set, the C-statistic was 0.86 (95% CI 0.83, 0.90) with an H–L statistic of χ2=37.98, p<0.001. ConclusionA model to predict discharge to inpatient rehabilitation following lower limb fracture was developed with excellent discrimination although the calibration was reduced in the test data set. This model requires prospective testing but could form an integral part of decision making in regards to discharge disposition to facilitate timely and accurate referral to rehabilitation and optimise resource allocation.

Modelling Long Term Disability following Injury: Comparison of Three Approaches for Handling Multiple Injuries

BackgroundInjury is a leading cause of the global burden of disease (GBD). Estimates of non-fatal injury burden have been limited by a paucity of empirical outcomes data. This study aimed to (i) establish the 12-month disability associated with each GBD 2010 injury health state, and (ii) compare approaches to modelling the impact of multiple injury health states on disability as measured by the Glasgow Outcome Scale – Extended (GOS-E).Methods12-month functional outcomes for 11,337 survivors to hospital discharge were drawn from the Victorian State Trauma Registry and the Victorian Orthopaedic Trauma Outcomes Registry. ICD-10 diagnosis codes were mapped to the GBD 2010 injury health states. Cases with a GOS-E score >6 were defined as “recovered.” A split dataset approach was used. Cases were randomly assigned to development or test datasets. Probability of recovery for each health state was calculated using the development dataset. Three logistic regression models were evaluated: a) additive, multivariable; b) “worst injury;” and c) multiplicative. Models were adjusted for age and comorbidity and investigated for discrimination and calibration.FindingsA single injury health state was recorded for 46% of cases (1–16 health states per case). The additive (C-statistic 0.70, 95% CI: 0.69, 0.71) and “worst injury” (C-statistic 0.70; 95% CI: 0.68, 0.71) models demonstrated higher discrimination than the multiplicative (C-statistic 0.68; 95% CI: 0.67, 0.70) model. The additive and “worst injury” models demonstrated acceptable calibration.ConclusionsThe majority of patients survived with persisting disability at 12-months, highlighting the importance of improving estimates of non-fatal injury burden. Additive and “worst” injury models performed similarly. GBD 2010 injury states were moderately predictive of recovery 1-year post-injury. Further evaluation using additional measures of health status and functioning and comparison with the GBD 2010 disability weights will be needed to optimise injury states for future GBD studies.

The impact of serious sport and active recreation injuries on physical activity levels

BackgroundSport and active recreation are important avenues for health enhancing physical activity. These health benefits can however be negated by injury. The impact of sport and active recreation injury on...

Twelve-month health related quality of life and functional outcomes of hospitalised orthopaedic sport and active recreation injuries

BackgroundSerious sport and active recreation injuries are common with the potential for grave long-term consequences. Despite this few studies have examined the long-term outcomes of these injuries.ObjectiveTo establish if patients...

Factors that predict poor outcomes in patients with traumatic vertebral body fractures

Study design Prospective cohort study. Objective To identify factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit. Summary of background data There is a paucity of information on factors that predict poor patient-reported outcomes in patients with traumatic vertebral body fracture(s) of the thoracic and/or lumbar spine without neurological deficit. Methods Patients were identified from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). VOTOR includes all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria, Australia. Patient-reported outcomes and data on possible predictive factors, including demographic details, injury-related and treatment-based factors, were obtained from the VOTOR database. Patient-reported outcomes were measured at 12 months post-injury using the 12-Item Short-Form Health Survey (SF-12), a Numerical Rating Scale (NRS) for pain, global outcome questions and data was collected on return to work or study. For the identification of predictive factors, univariate analyses of outcome vs. each predictor were carried out first, followed by logistic multiple regression. Results 344 patients were eligible for the study and data were obtained for 264 (76.7%) patients at 12 months follow-up. Patients reported ongoing pain at 12 months post-injury (moderate–severe: 33.5%), disability (70.1%) and inability to return to work or study (23.3%). A number of demographic, injury-related and treatment-based factors were identified as being predictive of poor patient-reported outcomes. Patients who had associated radius fracture(s) were more likely to have moderate to severe disability (odds ratio (OR) = 3.85, 95% confidence interval = 1.30–11.39), a poorer physical health status (OR = 3.73, 1.37–10.12) and moderate to severe pain (OR = 3.23, 1.22–8.56) at 12 months post-injury than patients without radius fracture. Patients who did not receive compensation for work-related or road traffic-related injuries were less likely to report moderate to severe pain (OR = 0.45, 0.23–0.90) or have a poorer mental health status (OR = 0.17, 0.04–0.70) at 12 months post-injury than those who received compensation. Conclusions The prognostic factors identified in this study may assist clinicians in the identification of patients requiring more intensive follow-up or additional rehabilitation to ultimately improve patient care.

Twelve-Month Outcomes of Serious Orthopaedic Sport and Active Recreation-Related Injuries Admitted to Level 1 Trauma Centers in Melbourne, Australia

To describe and identify predictors of 12-month outcomes of serious orthopaedic injuries due to sport and active recreation. Prospective cohort study with 12-month follow-up. Two Level 1 adult trauma centers in Victoria, Australia. A total of 366 adults admitted to two Level 1 trauma centers for an orthopaedic sport and active recreation injury between August 2003 and March 2006. Patients were captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), followed up at 12 months, and were free of moderate to severe disability prior to injury. Independent variables assessed for predictors of outcome were sporting group, age, sex, marital status, education level, Injury Severity Score, injury patterns, and head injury status. The 12-item Short Form Health Survey and maximum pain scores. At 12 months postinjury, 22.8% of patients reported moderate to severe physical disability, 12.1% reported moderate to severe mental health disability, and 11.1% reported moderate to severe pain. There were significant differences in physical outcomes between sporting groups, with motor and equestrian sports reporting the worst physical outcomes. Multivariate analysis indentified increasing age (P = 0.010) and patterns of injury (P = 0.040) as significant predictors of a poor physical outcome at 12 months. No significant independent predictors of outcome for mental health and maximum pain at 12 months were identified. Almost one-quarter of participants reported moderate to severe physical disability at 12 months postinjury. Increasing age and patterns of injury were found to be significant predictors of a poor physical outcome at 12 months.

Outcomes of isolated tibial shaft fractures treated at level 1 trauma centres

Although most tibial shaft fractures are expected to heal within 24 weeks, the long-term effects of these injuries on patients in terms of self-reported health status, disability, and pain are largely unknown. To investigate the clinical and patient-reported outcomes of patients with isolated tibial shaft fractures treated at the two level 1 adult trauma centres in Victoria, Australia. Sixty patients with isolated tibial shaft fractures treated at the Royal Melbourne Hospital and the Alfred Hospital between August 2003 and August 2004 were identified via the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Patient-reported outcomes were prospectively measured 1 year post-injury using the 12-Item Short-Form Health Survey (SF-12) (also administered at baseline); the Work subscale of the Sickness Impact Profile; and a Numerical Rating Scale for pain. A priori defined clinical outcomes were also determined by retrospectively reviewing hospital medical records and X-rays. Full weight-bearing status was achieved after a median inter quartile range (IQR) time of 14.0 (12.5-20.0) weeks, and the median (IQR) time to radiological union was 35.8 (23.3-51.6) weeks. Sixty percent of patients completed the SF-12 at both baseline and 12 months post-injury. Although there were no clear changes in mental health scores (median change=+1.0; IQR=-3.5 to 4.0; p=0.52), physical health scores were significantly reduced (median change=-3.0; IQR=-19.5 to 0.3; p=0.003). Additionally, 47% of patients reported work-related disability and 40% experienced persistent pain 1 year post-injury. These results indicate that long-term physical disability remains a problem for many patients following tibial shaft fracture, and they should be considered when providing prognostic information to patients. Further research is required to identify the specific health problems experienced as well as the factors contributing to disability in order to inform post-fracture rehabilitation planning.

Preinjury Status: Are Orthopaedic Trauma Patients Different Than the General Population?

To describe the preinjury health-related quality of life (HRQL) of orthopaedic trauma patients admitted to Level I trauma centers relative to the general population. Prospective cohort study using retrospectively collected preinjury HRQL measures. Two Level I adult trauma centers in Melbourne, Australia. A total of 2388 admitted orthopaedic trauma patients aged > or = 18 years were included, captured by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) between October 2003 and January 2006. Patients with a significant head injury (Abbreviated Injury Scale severity score >2), dementia, mental illness, mental disability, who were non-English speakers, or who were postoperatively confused were excluded. The 12-item Short Form Health Survey (SF-12). The preinjury SF-12 was obtained for 1839 patients [median (interquartile range) of 6 (3-12) days postinjury]. The VOTOR population reported mean physical SF-12 scores above population norms (50.9 vs. 48.9, P < 0.001). The differences were predominant in men and confined to patients aged 18 to 54 years. The mean mental SF-12 scores of the VOTOR population were also greater than population norms (54.5 vs. 52.4, P < 0.001) and this was most apparent for women. Establishing the preinjury HRQL of trauma patients is important for evaluating the quality of orthopaedic trauma patient outcomes. Reliance on population norms for this purpose may lead to an underestimation of the impact of injury in particular age and sex subgroups, but given the size of the differences seen, any underestimation would be small. Where individual preinjury data cannot be collected, population norms could be used as a reasonable estimate of preinjury patient status for assessing quality of recovery.

OUTCOMES OF PATIENTS WITH ORTHOPAEDIC TRAUMA ADMITTED TO LEVEL 1 TRAUMA CENTRES

Although orthopaedic trauma results in significant disability and substantial financial cost, there is a paucity of large cohort studies that collectively describe the functional outcomes of a variety of these injuries. The current study aimed to investigate the outcomes of patients admitted with a range of orthopaedic injuries to adult Level 1 trauma centres. Patients were recruited from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), which included all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria (Australia). Patients were categorised into three groups; isolated orthopaedic injuries, multiple orthopaedic injuries and orthopaedic and other injuries. Demographic and injury data were collected from the medical record and hospital/trauma databases, and functional outcome instruments were given at 6 months post-injury. Of the 1303 patients recruited for VOTOR over a 12-month period, 1181 patients were eligible for the study and a response rate of 75.6% was obtained at 6 months post-injury. Patients reported ongoing pain (moderate-severe: 37.2%), disability (79.5%) and inability to return to work (35.2%). Poorer outcomes were evident in patients with orthopaedic and other injuries than those with single or multiple orthopaedic injuries alone. A large percentage of patients have ongoing pain and disability and a reduced capacity to return to work 6 months after orthopaedic trauma. Further research into the long-term outcomes of patients with orthopaedic injuries is required to identify patient subgroups and specific injuries and procedures that result in high morbidity.

Characterisation of orthopaedic trauma admitted to adult Level 1 Trauma Centres

Despite the vast number of traumatic injuries that are orthopaedic in nature, comprehensive epidemiological data that characterise orthopaedic trauma are limited. The aim of this study was to investigate the nature of orthopaedic trauma admitted to adult Level 1 Trauma Centres. Data were obtained from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), which includes all patients with orthopaedic trauma admitted to the two adult Level 1 Trauma Centres in Victoria (Australia). Information was collected from the medical record and hospital databases on patients' demographics and injury event, diagnoses and management. Data were analysed on 784 patients recruited between August 2003 and March 2004. Patients were mainly young (<65 years) (70.7%), male (59.1%) and injured in a transport collision (51.3%). Fractures of the femur (23.7%) and spine (23.5%) were the most common injuries and were predominately managed with operative (87.6%) and conservative (78.8%) methods, respectively. Differences in most parameters were evident between younger (<65 years) and older (> or =65 years) patients. This study presents epidemiological data on patients with orthopaedic trauma who were admitted to adult Level 1 Trauma Centres. This information is critical for the future monitoring and evaluation of the outcomes of orthopaedic trauma.