Orthopedic injury, classification of the patient and the fracture

Abstract

In this thesis clinical studies and literature research were presented to assist physicians in the decision-making process for treatment of orthopaedic trauma patients Part 1 - Classification of the patient Pain and disability are often associated with physical factors such as stiffness and movement patterns, and behavioral or psychological factors (e.g. fear, beliefs, stress, depression, physical inactivity). As a result, (conservative) interventions can be broadly categorized into physical, psychological or combined interventions. Pain and disability are often misinterpreted by patients but also by physicians. Since psychological factors are often undervalued, although they are important or even the most important predictors of symptom intensity and disability. Physical interventions usually aim to improve physical capacity. Behavioral and psychologically informed interventions aim to improve behaviors, cognitions or mood (e.g. relaxation and cognitive behavioral therapy). Combined interventions aim to improve physical and psychological factors, contributing to patients’ pain and helping them understand the pathophysiology of the pain. The studies presented in this thesis can assist physicians in the decision-making process for treatment of orthopedic injuries. The focus thereby lies on the classification of both disease and patient characteristics. In other words, we should both treat the physical and the psychological aspects of the patients’ disease. In chapter 2 a prognostic cohort was presented to measure factors correlated with the patient’s expectations and if their expectations were met after the appointment with the physician. Higher pre-visit expectations were associated with more depressive symptoms, lower pain self-efficacy, higher pain intensity, and lower social economic status. Patients in the low and moderate met expectations categories had significantly more symptoms of depression, and more disability compared to those in the high-met expectations category. Cognitive flexibility and psychological distress influence a patient’s expectations and decision-making process. Cognitive flexibility is better known as a patient’s mental ability to switch thinking between different concepts, adaptation and resilience. In chapter 3 we showed that cognitive flexibility had no correlation with patient disability or pain. However, there was a correlation between self-efficacy and symptoms of depression and disability. This suggests that physicians should focus more on improving a patients coping strategies rather than encouraging one’s open mindedness. Prior research has described that psychosocial factors such as symptoms of depression and low pain self-efficacy correlate with pain intensity and magnitude of limitations in patients with some musculoskeletal disorders. In chapter 4 we presented a prognostic cohort exploring the correlation between pain self-efficacy, depression and disability in patients with an ankle sprain. This study showed that these psychosocial and coping factors explain more about the variation in symptoms and limitations after ankle sprain than the degree of pathophysiology such as pain, swelling and grade of the sprain. Chapter 5 described the validation of an abbreviated 2-item questionnaire of the pain self-efficacy questionnaire. Reduction of the number of questions of the original PSEQ for screening purposes for patient self-efficacy will result in more efficient screening and less burden for the patient and physician, making this a more applicable tool in daily clinical practice. Part 2 - Classification of the injury Ankle injuries are the most frequent encountered injuries in the emergency department of the lower extremity. Besides a fracture, a broad variety of ankle ligaments can be affected. Therefore, proper assessment of an injury is of the utmost importance to choose the appropriate treatment, and for prognostic purposes. In the second part of this thesis we emphasized on the classification and epidemiology of ankle injuries and explored its possible consequences for treatment and prognosis. Ideally a system for classification of injuries is easy to use in daily clinical practice. The best classification system for describing ankle fractures is the Lauge Hansen classification. However, the reproducibility of the Lauge Hansen classification is mediocre with poor intra- and inter-observer variability. In chapter 6 we introduced a new, more reliable more descriptive classification system for ankle fractures. This new descriptive classification system showed better intra- and interobserver variation in novice, semi expert and even in expert observers. To improve clinical handoffs and reduce the limitations of current classification systems this descriptive system is a useful alternative and can be further developed and implemented. In chapter 7 a retrospective cohort was described comparing ankle fractures in mono and polytrauma patients. This study showed that polytrauma patients suffer a different type of ankle fracture. Mono trauma patients predominantly had supination external rotation or pronation external rotation whereas supination adduction or pronation abduction injuries were mostly observed in polytrauma patients. This implicates that mono and polytrauma patients experience different fracture patterns, which could be directly linked to the differences in energy transfer. To further assess differences between patients, a large retrospective series of patients with surgical fixation of an ankle fracture was described in chapter 8. We described epidemiology and other factors such as fracture classification associated with general and implant related complications. Complications are determined by patient-, trauma- and treatment factors, not by the postoperative care regimen. Most frequent encountered complications were wound infections (10.2%) and implant failure (4.4%). Postoperative wound related complications were multifactorial and depended on a combination of trauma-, patient- and treatment related factors. In contrast, implant related complications occurred due to the interaction between the type of fracture (classified according to the Lauge Hansen classification) and subsequent surgical treatment, perhaps making this a more important quality parameter. In the systematic review and meta-analysis presented in chapter 9 of this thesis the effectiveness and safety of currently used post-operative care regimens after surgically fixed ankle fractures was presented. This meta-analysis showed that 1) active exercises and 2) early weight bearing expedite return to work and resumption of daily activities compared to immobilization and late weight bearing. There was also preliminary evidence that immediate unprotected weight bearing as tolerated was a safe post-operative care regimen resulting in quicker recovery and return to work. This systematic review and meta-analysis resulted in the study design presented in chapter 10. In this chapter we present the rationale and design of a multicenter prospective randomized controlled trial comparing 1) protected weight bearing, 2) unprotected non-weight bearing and 3) immediate unprotected weight bearing as tolerated. Inclusion is based on both patient and fracture characteristics, synergizing the work in the previous chapters, in an attempt to tailor treatment.