The primary objectives of this study were to: 1) identify risk factors for subsequent surgery following initial treatment of proximal humerus fractures, stratified by initial treatment type; 2) generate risk prediction tools to predict subsequent shoulder surgery following initial treatment; and 3) internally validate the discriminative ability of each tool.

We identified patients ≥ 50 years with a diagnosis of proximal humerus fracture from 2004 to 2015 using linkable health datasets in Ontario, Canada. We used procedural and fee codes within 30 days of the index fracture to classify patients into treatment groups: 1) surgical fixation; 2) shoulder replacement; and 3) conservative. We used intervention and diagnosis codes to identify all instances of complication-related subsequent shoulder surgery following initial treatment within two years post fracture. We developed logistic regression models for randomly selected two thirds of each treatment group to evaluate the association of patient, fracture, surgical, and hospital variables on the odds of subsequent shoulder surgery following initial treatment. We used regression coefficients to compute points associated with each of the variables within each category, and calculated the risk associated with each point total using the regression equation. We used the final third of each cohort to evaluate the discriminative ability of the developed risk tools (via the continuous point total and a dichotomous point cut-off value for “higher” vs. “lower” risk determined by Receiver Operating Curves) using c-statistics.

We identified 20,897 patients with proximal humerus fractures that fit our inclusion criteria for analysis, 2,414 treated with fixation, 1,065 treated with replacement, and 17,418 treated conservatively. The proportions of patients who underwent subsequent shoulder surgery within two years were 13.8%, 5.1%, and 1.3%, for fixation, replacement, and conservative groups, respectively. Predictors of reoperation following fixation included the use of a bone graft, and fixation with a nail or wire vs. a plate. The only significant predictor of reoperation following replacement was poor bone quality. The only predictor of subsequent shoulder surgery following conservative treatment was more comorbidities while patients aged 70+, and those discharged home following initial presentation (vs. admitted or transferred to another facility) had lower odds of subsequent shoulder surgery. The risk tools developed were able to discriminate between patients who did or did not undergo subsequent shoulder surgery in the derivation cohorts with c-statistics of 0.75–0.88 (continuous point total), and 0.82–0.88 (dichotomous cut-off), and 0.53–0.78 (continuous point total) and 0.51–0.79 (dichotomous cut-off) in the validation cohorts.

Our results present potential factors associated with subsequent shoulder surgery following initial treatment of proximal humerus fractures, stratified by treatment type. Our developed risk tools showed good to strong discriminative ability in both the derivation and validation cohorts for patients treated with fixation, and conservatively. This indicates that the tools may be useful for clinicians and researchers. Future research is required to develop risk tools that incorporate clinical variables such as functional demands.

Researchers and clinicians measuring outcomes following total ankle replacement (TAR) are challenged by the wide range of outcome measures used in the literature without consensus as to which are valid, reliable, and responsive in this population. This review identifies region- or joint-specific outcome measures used for evaluating TAR outcomes and synthesises evidence for their measurement properties.

A standard search strategy was conducted of electronic databases MEDLINE, EMBASE and CINAHL (to June 2015) to identify foot/ankle measures in use. A best evidence synthesis approach was taken to critically appraise measurement properties [COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)] of identified measures. The review was restricted to English publications and excluded cross-cultural adaptations. Measurement properties collected from each article were coded for validity, reliability, responsiveness, or interpretability. Clinimetric evidence exists for identified measures tested in non-TAR populations, but were not the focus of this review.

The search identified 14 studies to include in the best evidence synthesis with 32 articles providing clinimetric evidence for eight of the measures (one CBO, seven PRO), however only five measures were tested in a TAR population (Foot Function Index, Ankle Osteoarthritis Scale, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale [AOFAS], Foot and Ankle Outcome Score, Self-Reported Foot and Ankle Score). Five studies provided clinimetric evidence in a TAR population and their methodological quality was assessed: (1) Validity—two good quality studies examining different measures provide moderate evidence supporting construct validity (FFI, AOS, AOFAS self-reported items; SEFAS); (2) Reliability—two good quality studies examining different measures provide moderate evidence supporting internal consistency and test-retest reliability (FFI, AOS, AOFAS self-reported items; FAOS, SEFAS); (3) Responsiveness—three poor quality studies, thus unknown evidence for responsiveness; (4) Interpretability—two studies provide interpretability values (AOS, FFI, AOFAS self-reported items; AOS).

This review offers a basis for choosing the most appropriate instrument for evaluating TAR outcomes. Numerous outcome measures were identified with evidence supporting their use in populations with various foot/ankle conditions, but none have strong evidence supporting use in a TAR population. Measures must have adequate clinimetric properties in all patient groups in which they are applied. Evidence supporting or critiquing an instrument should not be based on studies with poor quality methodology, as identified by this review. Further testing in a TAR population would benefit identified measures with emphasis on adequate sample sizes, testing a priori hypotheses, and evaluating their content validity for a TAR population.

Introduction

There has been a paradigm shift in orthopaedic research, it is now recognized that the extent to which interventions really make a difference to a patient's overall life is indicated by measuring one's general health status. The primary aim of this study was to report how the methodology of current evidence in hip fracture research can improve if studies included patients with cognitive impairment.

Introduction

Lack of standardization of outcome measurement has hampered an evidence-based approach to clinical practice and research. We report on the progress on establishing a minimal set of core domains for outcome measurement in distal radius fracture.

Purpose: The objective of this study is to compare items from patient-reported questionnaires measuring musculoskeletal outcomes with items generated by pre-and post-operative ankle arthrodesis and arthroplasty patients using the Patient-Specific Index (PSI-P). The International Classification of Functioning, Disability and Health (ICF) was used as an external reference.

Method: A literature review identified six questionnaires that assess lower extremity outcomes (AAOS, patient-reported portion of AOFAS, FFI, LEFS, SMFA, WOMAC). Surgical patients (n=142) from an orthopaedic surgeon’s practice completed the patient-selected items from PSI-P. Items from questionnaires and PSI-P were coded by three reviewers and linked to the ICF. The ICF is divided into four components (Body Functions and Structures, Activities and Participation, Environmental Factors, and Personal Factors) which are then further divided into second level categories. A higher number of second level categories would indicate a questionnaire that captures a broader range of experiences.

Results: Patient’s responses from PSI-P identified 690 meaningful concepts that were linked to 45 second level ICF categories. Most PSI-P responses fell into Activities and Participation (60.6%) and Body Functions and Body Structures (35.2%) including the second level categories Walking (19.1%), Pain (16.5%), and Recreation and Leisure (15.4%). There was no statistical difference between arthrodesis and arthroplasty patients nor between pre-operative versus postoperative patients in terms of the proportion of patient responses that fell into each ICF component. A total of 237 meaningful concepts were identified in the 6 questionnaires studied and linked to 38 second level ICF categories. Overall, SMFA addressed the most number of second level categories and had the closest proportion of Body Function (23.0%) and Activities and Participation (68.9%) concepts as compared to PSI-P. The patient-reported portion of AOFAS addressed the fewest categories. LEFS only contained items from Activities and Participation. AAOS was the only questionnaire to address the issue of ‘swelling’, though it represented 4.9% of all PSI-P responses.

Conclusion: Questionnaires differ largely in their content and no single questionnaire captured all of the concerns identified by PSI-P. This analysis will guide us in the development of a new and more comprehensive instrument for evaluating ankle outcomes following fusion or replacement.

Background: Hip fracture trials have employed a wide range of patient-reported outcomes (PRO) suggesting a lack of consensus among clinicians on what are considered the most relevant outcomes. Variability in functional outcome reporting in hip fracture management creates challenges in the comparison of results across trials. The purpose of this study was to conduct a systematic review of the functional outcomes fielded in randomized controlled trials in post-operative hip fracture treatment for the aged. We hypothesized that over time there had been an increase in patient-reported outcomes along with aggregate scoring systems of hip function.

Methods: An electronic database search was conducted using key terms combining: ‘hip fracture’ with ‘RCT’ with ‘age 65 years and over’. s and titles were screened in duplicate and independently. All of the articles that met eligibility criteria were reviewed using the 21-point Detsky Quality Assessment Scale.

Results: In 2451 citations, 86 studies were included and also met accepted standards of inter-observer reliability (kappa, 0.92; 95% confidence interval, 0.87 to 0.98). The mean score (and standard error) for the quality of the randomized trials was: 75.8% ± 1.76% (95% confidence interval, 72.3%–79.3%) and 27 (32.6%) of the trials scored < 75%. Medical trials had a higher mean quality score than did surgical trials (83.7% compared with 72.7 %, p = 0.025). 59 trials (30 Surgical, 11 medical and 18 rehabilitation trials) scored > 75% in quality. Out of 86 trials, 8 (13.6%) used EQ-5D for utility and 6 (10.1%) used the SF-36 health status measures. At most, 12 trials used the same composite score: 12 (13.9%) ADL Katz Index, 9 (10.4%) trials used the HHS and 8 (9.3%) trials used Parker’s mobility score.

Conclusion: Although in the past decade more studies have made use of outcome instruments that capture both impairment and functional status in one aggregate score, there is a lack of standardized assessment.

Background: The literature on hip fractures is increasingly reporting patient-reported outcomes along with aggregate scoring systems. However, this rapid growth in the number and types of patient-based outcomes can be confusing. The purpose of this paper is to conduct a systematic review of the functional outcome instruments fielded in high quality randomized clinical trials evaluating postoperative hip fracture management and rehabilitation in the aged.

Methods: An electronic database search was conducted using a variety of key terms combining: ‘hip fracture’ with ‘RCT’ with ‘age 65 years and over’. Abstracts and titles were screened in duplicate and independently. Studies were eligible based on the following criteria: hip fracture, randomized controlled trial, mean age of 65 years, and in the English language. Studies were excluded based on the following criteria: inclusion of fractures other than hip, minimum age of patient enrolment < 50 years old and prevention or fracture risk reduction as primary outcome of study. All of the articles that met eligibility criteria were reviewed using the Detsky Quality Assessment Scale.

Results: In 2451 citations, 86 studies were included and also met accepted standards of inter-observer reliability (kappa, 0.92; 95% confidence interval, 0.87 to 0.98). Discordance was resolved by consensus. The mean score (and standard error) for the quality of the randomized trials was: 75.8% ± 1.76% (95% confidence interval, 72.3%–79.3%) and 27 (32.6%) of the trials scored < 75%. Medical trials had a higher mean quality score than did surgical trials (83.7% compared with 72.7 %, p = 0.025). Data was abstracted from the 59 trials (30 Surgical, 11 medical and 18 rehabilitation trials) scoring > 75% in quality. Surgical trials had 16.7% more measures of disability than measures of impairment. Furthermore, 70% of the surgical trials used composite scores when compared to either medical or rehabilitation trials. Eight trials (13.6%) used EQ-5D for utility and 6 (10.1%) used the SF-36 health status measures. At most, 10 trials used the same composite score: 10 (16,9%) ADL Katz Index, 9 (15.2%) trials used the Harris hip score and 5 (8.5%) trials used Parker’s mobility score.

Discussion/Conclusion: Although there is a trend towards studies assessing functional recovery as a primary outcome in the aged with hip fractures, none of the measures were used consistently. A lack of standardized assessment in these groups of patients will overestimate treatment effects.

Health utilities indicate the value of a given health state. They are essential components of decision analyses, and economic evaluations. In the area of total shoulder arthroplasty (TSA) we were unable to find literature estimating changes in utilities or the effect of method of obtaining utilities. The purpose of this pilot study was to describe the trajectory of utility scores before and after TSA using three approaches: the EQ-5D and the Health Utilities Index (HUI2 and HUI3) self-report format.

Twenty-four patients undergoing TSA at two teaching hospitals (Boston and Toronto) were assessed twice preoperatively, as well as at four and twelve weeks follow-up by self report mailed survey. At each survey all three utility estimates were obtained. Demographic and functional status was also gathered. The EQ-5D is a five item questionnaire which scores into a profile to which utility weights obtained from the developers were applied. The HUI self-report is a fifteen item scale obtaining a score on eight domains. A multiplicative formula is used to assign utility weights to these responses. Descriptive analysis of the sample, baseline characteristics and change in utility were completed. Intra-class correlation coefficients were used to calculate test-retest reliability between the two preoperative visits. Standardised response means (SRM) (mean change/SD of change) and relative efficiency (RE=ratio of SRM2) were calculated. Individual trajectories of change were graphed and examined for trends.

Twenty-four patients participated with average age of sixty-seven years, 58% were female and experienced large improvements in disability and pain (mean change DASH = 18.9/100, SPADI Pain = 30.3/100). Utility scores had low to moderate correlations with each other (0.26–0.68). Mean baseline scores were low (EQ5D=0.44, HUI2=0.68, HUI3 = 0.50). The average change in utility is shown in the following table along with effect size estimations and test-retest reliability.

Patients experience clinically important and statistically significant changes in their utility values even in the early stages of recovery after TSA (three months). The HUI3 and EQ-5D were most responsive to changes experienced in this sample.

The purpose of this study was to evaluate functional outcome following supracondylar femur fractures using patient-based outcome measures.

Patients having sustained supracondylar femur fractures between 1990 and 2004 were identified from the fracture databases of two level-one trauma centres. Three patient-based outcome measures, the Short Form-36 (SF-36) Version two, the Short Musculoskeletal Functional Scale (SMFA), and the Lower Extremity Functional Scale (LEFS) were used to evaluate functional outcome. Each patient’s medical record was also reviewed to obtain information regarding potential predictors of outcome, including age, gender, fracture type (AO classification), presence of comorbidities, smoking status, open vs. closed fracture, and occurrence of complications. Univariate and multivariate models were then used to identify significant predictors of outcome, as reflected in the SMFA bother and dysfunction scores.

Sixty-one patients (thirty-five males and twenty-six females) with an average age (at time of injury) of 53 ± 18 years consented to participate. The average length of follow-up was 64 ± 34 months from the time of injury. Mean SF-36 V2 scores were lower than Canadian population norms indicating decreased function or greater pain, while mean SMFA scores were higher than published population norms indicating greater impairment and bother. The mean LEFS score was 40.78 ± 15.90 out of a maximum score of eighty. At the univariate level, the presence of complications was a significant predictor of both the SMFA bother (p=0.002) and dysfunction scores (p=0.015), while positive smoking status was a significant predictor of the bother score (p=0.002). Based on a multivariate linear regression model, the presence of complications (p=0.013) and positive smoking status (p=0.011) were both significant predictors of a higher SMFA bother score. In the multivariate model for SMFA dysfunction score, the presence of complications (p=0.014) and the presence of comorbidities (p=0.017) were significant predictors of a higher score.

Comparing SF-36 and SMFA scores with published population norms, supracondylar femur fractures were associated with residual impact. Based on our analysis, smoking, the presence of medical comorbidities at the time of fracture, and the occurrence of complications following fracture repair were the main predictors of poorer patient outcomes following supracondylar femur fracture.

Clinicians ask patients “How are you now?” to ascertain treatment outcomes and to set a plan for subsequent care. However, sometimes patient views do not agree with those of the clinicians. This study compared patient and clinician views of outcome one to two years after an operatively managed extremity fracture and described any discordance. There were significant differences between groups, especially in areas such as pain and disruption of their personal and work lives. A discordance was observed between patient and physician views of recovery after fracture, likely associated with disruptions to personal life, unaccounted for in a clinician’s view of outcome.

Clinicians ask patients “How are you now?” to ascertain treatment outcomes and to set a plan for subsequent care. However, sometimes patient views differ from those of clinicians’.

The purpose of this study is to compare patient and clinician views of outcome one to two years after an extremity fracture and to describe any discordance.

Cross-sectional survey of patients one to two years after an operatively managed upper or lower extremity fracture. Patients were recruited from two tertiary care centres and completed a mailback questionnaire that included measures of health (DASH, SMFA), self-rated recovery, burden of illness (Illness Intrusiveness, Loss of self), symptoms, and work status. These were linked with clinical records of radiologic and clinical recovery.

Two hundred and fifty-five patients returned usable questionnaires. Mean age was forty-two years and 42% were female. Sixty-seven patients said that they were completely better (CB), one hundred and thirty-four almost better (AB) and fifty-four not completely better (NCB). Significant differences were found between groups. In four variables, NCB was distinct from AB/CB, while in all other variables, such as pain, disability and disruption of their personal and work lives, all three groups were unique (Duncan’s post hoc). However, of the patients who said they were not better, the radiologist and clinician reports stated that thirty (68%) and twenty-eight (64%) were healed, respectively.

A discordance was observed between patient and physician views of recovery after fracture. It appeared associated with disruptions to personal life that may not be accounted for in a clinician’s view of outcome.

Funding: Canadian Institutes of Health Research (CIHR)

The purpose of this study was to investigate patient-based functional outcome and objectively measure strength following plate fixation of fractures of both bones of the forearm. Twenty-five subjects were clinically and radiographically reviewed. Strength of elbow flexion, extension, supination, pronation, wrist flex-ion, extension and grip were significantly reduced in the injured arm. (p< 0.01, range 62%–84% of normal). Mean (+/− SE) DASH score was 19.5 +/− 4.0 and eighty-eight percent (22/25) scored good to excellent on the Gartland-Werley scale (mean 4.04 +/− 0.91). No statistical difference in mean maximal radial bow (MRB) or location of MRB between injured and non-injured arm was found.

The purpose of this study was to investigate functional outcome and objectively measure strength following plate fixation of fractures of both bones of the forearm (BBOF).

Anatomic reduction was associated with good to excellent functional outcome. However strength of the elbow, forearm, wrist and grip were significantly reduced in the injured arm.

Despite good to excellent functional outcome following this injury, significant reduction in strength of the upper extremity should be expected, and thus is an area for potential improvement in post-operative care.

Twenty-five subjects (M/F 19/6, mean age 47.6 (range 20–71)) treated with plate fixation for fractures of BBOF were clinically and radiographically reviewed. Mean duration of follow-up was 5.7 years (range 2–13.4 y). Post-operative protocol included short-term immobilization followed by active-assisted ROM and strengthening starting between four and six weeks. Isometric muscle strength was objectively measured with the Baltimore Therapeutic Equipment work simulator (model WS-20). Strength of elbow flexion (72% of non-injured arm, p< 0.0001), elbow extension (84%, p=0.0004), forearm supination (75%, p=0.005), forearm pronation (69%, p< 0.0001), wrist flexion (81%, p=0.009), wrist extension (62%, p< 0.0001) and grip (70%, p< 0.0001) were all significantly reduced in the injured arm. Mean (+/− SE) DASH and Gartland-Werley scores were 19.5 +/− 4.0 (range 0–61) and 4.04 +/− 0.91 (range 0–15) respectively. Eighty-eight percent (22/25) scored good to excellent on the Gartland-Werley scale. No statistical difference in mean maximal radial bow (MRB) between injured and non-injured arm was found (mean +/− SE, 1.42 +/− 0.07 vs 1.58 +/− 0.05 respectively) or in location of MRB (61% vs 59%).

Purpose: To evaluate the impact of the Osteoporosis Exemplary Care Program (OECP) on orthopaedic surgeons’ practice patterns at St. Michael’s Hospital.

Methods: A chart audit was performed to collect data on two groups of 54 patients identified with fragility fractures. The intervention group consisted of patients treated during the first four months of the OECP, while the control (pre-intervention) group consisted of age, sex, and fracture-type matched patients treated prior to implementation of the OECP. Characteristics of the intervention and control groups were compared using chi-square tests. Multivariable logistic regression analysis was then performed to identify significant correlates of OP care.

Results: Preliminary results from 54 matched pairs (108 patients in total) indicate that the OECP group was more likely to have OP risk or OP diagnosis documented (unadjusted OR 2.49; 95% CI 1.05–5.87), as well as to be referred for further investigation of OP (unadjusted OR 3.08; 95% CI 1.37–6.91) or to receive treatment or follow-up related to OP (unadjusted OR 9.01; 95% CI 3.77–21.54). As one surgeon was known to have been providing a high level of OP care prior to implementation of the OECP, the analysis was repeated after removing his patients. In addition, the analysis was repeated after removing patients who were already being treated for OP at the time of their fragility fracture. In both cases, larger increases in the likelihood of OP documentation and care were observed. Through multivariable analysis, age and fracture type (i.e. wrist vs. hip) were found to be significant correlates of having received OP care for patients with fragility fractures treated prior to implementation of the OECP. Following implementation of the OECP, there were no significant correlates of receiving OP care.

Conclusions: Preliminary results indicate that the OECP had a significant impact on orthopedic surgeons’ practice patterns. Following implementation of the OECP all patients were equally likely to receive appropriate referral, treatment, and follow-up whereas, prior to implementation of the program, age and fracture type affected the likelihood that a patient would receive such care.

Funding : Commerical funding

Funding Parties : The Osteoporosis Exemplary Care Program is funded by an unrestricted program grant provided by Merck Frosst Canada and Co. Dr. Beaton is supported by a New Investigators Award, from the Canadian Institute of Health Research.

Introduction The purpose of this study was to identify issues of importance to Juvenile Idiopathic Arthritis (JIA) patients before and after total hip arthroplasty (THA) and to determine if these issues are included in widely utilized, standardized outcome measures for THA (Western-Ontario and McMaster Universities Arthritis Index – WOMAC; Patient Specific Index – PASI).

Methods JIA patients who underwent THA between 1986 and 1999 in our institution participated in the study (n=31). An independent observer was asked to gather data forms including patient demographics, a postoperative WOMAC questionnaire, postoperative patient-generated items from the PASI, a retrospectively completed preoperative PASI form, and changes in items from pre-operative to postoperative PASI. Descriptive analysis was completed on demographic information and clinical outcomes as well as for the WOMAC and PASI scores. Spearmans rank correlation coefficients were calculated to describe the association between WOMAC and PASI scores

Results Issues deemed important by JIA patients included four symptom areas (pain, joint motion, strength, discomfort) and five activity areas (light household, leisure, clothing, sports, sex); some indicated they had no symptoms or difficulties. Issues relevant to patients shifted from predominantly symptoms before surgery, to recreational and social activities at follow-up. Comparison of postoperative WOMAC questionnaires with preoperative and postoperative PASI questionnaires revealed fundamental differences between items found in the standardized WOMAC and items deemed important by the patient. The WOMAC included less than 10% of the unweighted content deemed important by these patients at follow-up.The shift in the PASI towards more physically demanding activities after surgery indicates that patients improved, which is not reflected in the WOMAC. Correlations between postoperative WOMAC and PASI scores for pain sub-scales were low to moderate (Spearman‘s coefficient rs=0.53) and 63% of JRA patients had higher PASI than WOMAC normalized scores.

Conclusion The self-generated, self-reported portion of the PASI questionnaire provided a different perspective on the impact of THA in JIA patients. The WOMAC did not include content deemed to be important by JRA patients and did not correlate well with the patient specific instrument.

Introduction and Aims: In this study, we identify issues of importance to adult Juvenile Rheumatoid Arthritis (JRA) patients before and after total hip arthroplasty (THA) and determine if these issues are included in widely utilised, standardised outcome measures for THA (Western-Ontario and McMaster Universities Arthritis Index – WOMAC; Patient Specific Index – PASI).

Method: Adult JRA patients who underwent THA between 1986 and 1999 at our institution participated in the study (n=31). An independent observer gathered data, including patient demographics, a post-operative WOMAC questionnaire, post-operative patient-generated items from the PASI, a retrospectively completed pre-operative PASI form, and changes in items from pre-operative to post-operative PASI. Descriptive analysis was completed on demographic information and clinical outcomes, as well as for the WOMAC and PASI scores. Spearman’s rank correlation coefficients were calculated to describe the association between WOMAC and PASI scores.

Results: Issues deemed important by JRA patients included four symptom areas (pain, joint motion, strength, discomfort) and five activity areas (light household, leisure, clothing, sports, sex); some patients indicated they had no symptoms or difficulties. Before surgery, issues identified as relevant by patients were predominantly symptoms, whereas at follow-up, patients primarily identified recreational and social activities as the issues relevant to them.

Comparison of post-operative WOMAC questionnaires with pre-operative and post-operative PASI questionnaires revealed fundamental differences between items found in the standardised WOMAC and items deemed important by the patient. The WOMAC included less than 10% of the unweighted content deemed important by these patients at follow-up. The shift in the PASI towards more physically demanding activities after surgery indicates that patients improved, which is not reflected in the WOMAC. Correlations between post-operative WOMAC and PASI scores for pain subscales were low to moderate (Spearman rank correlation coefficient: rs = 0.53) and 63% of JRA patients had higher PASI than WOMAC normalised scores.

Conclusion: The self-generated, self-reported portion of the PASI provided a different perspective on the impact of THA in adult JRA patients and more information on issues important to these patients. The WOMAC did not include content deemed to be important by JRA patients and did not correlate well with the PASI.

Introduction and Aims: The combination of ipsilateral intertrochanteric and femoral shaft fractures is an uncommon pattern associated with high-energy trauma. This retrospective study used self-report measures to evaluate functional outcome of patients sustaining this fracture pattern and compared two common treatment methods.

Method: Three patient-based outcome measures, the Short Form-36 (SF-36), Short Musculoskeletal Functional Assessment (SMFA), and Lower Extremity Functional Scale (LEFS) were used to evaluate the functional outcome of twenty-one patients (13 male, mean 46.7 +/− 16.5 years) treated with a reconstruction nail (n=11) or with a sliding hip screw and retrograde nail (n=10).

Results: Mechanisms of injury included motor vehicle accidents (66.7%) and falls from height (14.3%). SF-36 physical and mental component scores were less than Canadian norms, with mean values of 35.9 (p=0.0001) and 43.7 (p=0.02), respectively. There was a trend towards better functional outcome in the group treated with the sliding hip screw with retrograde nail despite this group sustaining more severe injuries as measured by ISS (p=0.004), number of days in hospital (p=0.027), and number of days in ICU (p=0.009).

Conclusion: Functional outcome following treatment of ipsilateral intertrochanteric and femoral shaft fractures was reduced compared to Canadian norms. Despite having sustained more severe injuries, the sliding hip screw with retrograde nail group showed a trend towards better outcome as compared to the group treated with the reconstruction nail.

Introduction and Aims: Patient-based functional outcome and strength following plate fixation of diaphyseal fractures of the radius and ulna is unknown. Therefore, the purpose of this study was to investigate patient-based functional outcome and objectively measured strength following plate fixation of fractures of both bones of the forearm (BBOF).

Method: Twenty-five subjects (M/F 19/6, mean age 47.6 (range 20–71) treated with plate fixation for fractures of BBOF were clinically and radiographically reviewed. Mean duration of follow-up was 5.7 years (range 2–13.4 years). Post-operative protocol included short-term immobilisation followed by active-assisted ROM and strengthening starting between four and six weeks. All subjects were assessed in person at follow-up with a detailed examination of strength of their injured and non-injured arms. Isometric muscle strength was objectively measured with the Baltimore Therapeutic Equipment work simulator (model WS-20). Standardised anteroposterior and lateral radiographs were made of both forearms.

Results: Strength of elbow flexion (72% of non-injured arm, p< 0.0001), elbow extension (84%, p=0.0004), forearm supination (75%, p=0.005), forearm pronation (69%, p< 0.0001), wrist flexion (81%, p=0.009), wrist extension (62%, p< 0.0001) and grip (70%, p< 0.0001) were all significantly reduced in the injured arm. Mean (+/− SE) DASH and Gartland-Werley scores were 19.5 +/− 4.0 (range 0–61) and 4.04 +/− 0.91 (range 0–15) respectively. Eighty-eight percent (22/25) scored good to excellent on the Gartland-Werley scale. No statistical difference in mean maximal radial bow (MRB) between injured and non-injured arm was found (mean +/− SE, 1.42 +/− 0.07 vs 1.58 +/− 0.05 respectively) or in location of MRB (61% vs 59%).

Conclusion: Restoration of anatomic alignment with stable internal fixation following BBOF fracture results in good to excellent functional outcome. Despite this, significant reduction in strength of the elbow, forearm, wrist and grip should be expected following this injury, and is an area for potential improvement in post-operative care.