Pilot study assessing functional outcome of tibial pilon fractures using the VSTORM method

Summary

Introduction

The importance of long-term function and quality of life after trauma is well recognised, but gathering data is difficult. The Victoria State Trauma Registry (VSTORM) collects patient-reported outcome data after major trauma using telephone interview, following prospective enrolment. Key components of the VSTORM interview include use of the Glasgow Outcome Scale-Extended (GOS-E), collection of pre-injury demographics, use of 12-Item Short Form Health Survey (SF-12) and EQ-5D instruments as well as a pain numerical rating scale. The aim of this pilot study was to determine whether this methodology would capture clinically relevant data for a population sustaining a severe fracture associated with a wide range of potential outcomes.

Methods

Following ethical approval, patients with surgically managed tibial pilon fractures sustained between March 2002 and January 2010 were identified from the logbook of the senior author (IP) and contacted by post. After obtaining consent, a structured telephone interview was performed using the VSTORM questionnaire.

Results

Twenty-six of 45 patients consented to interview and 23/26 patients were contactable (13 male, 10 female, mean age 44 years). There were 17 Arbeitsgemeinschaft für Osteosynthesefragen (AO) Type C fractures, six Type B and seven Grade III open injuries. The mean visual analogue scale (VAS) score for health pre-injury was 88.9 (range 50–100, median 92) versus 71.5 (range 35–100, median 75) post-injury. Seven of 18 patients in full-time employment prior to injury did not return to work. Only one patient returned to previous employment. Nine of 23 patients reported moderate – to-extreme pain interfering with work; 16/23 patients had problems with mobility; 9/23 reported problems climbing stairs; and 14/23 of patients could not resume regular social/leisure activities.

Conclusions

Prospective enrolment at the time of injury may improve follow-up. In those who participated, a credible range of outcomes were reported, comparable to recently published studies. This method appears efficient and acceptable to patients, and hence warrants larger-scale prospective evaluation.

Introduction

Tibial pilon fractures are uncommon injuries accounting for approximately 5% of surgically treated lower-leg fractures and only 1% of all lower-limb injuries.1, 2 Their cause is often violent and associated injuries are common. Careful patient assessment and surgical planning are paramount to avoid early surgical complications. Strategies for fixation using internal fixation, external fixation or a combination of the two methods have been devised to restore anatomic alignment, joint congruency and preserve soft-tissue attachment. The preservation of soft tissues is crucial to reducing the high risk of infective and healing complications associated with these injuries.³ Most surgeons advocate a staged management plan consisting of limited open reduction internal fixation (ORIF) of the articular surface, external skeletal fixation of the tibia ± ORIF of the fibula as the initial procedure if the soft-tissue envelope is in any doubt with definitive treatment delayed until 7–10 days later. There is however little consensus in the literature and these injuries remain challenging to manage. The available literature is difficult to interpret due to a number of factors including varying surgeons’ experiences, multiple classification systems, varied fracture configuration and soft-tissue components, high complication rates and numerous different treatment methods.

Little is known about the long-term consequences of tibial pilon fractures in the young adult population. Few studies have examined the extent to which impairment following these injuries translates into long-term functional limitations and disability, including the inability to resume major role activities such as work and keeping house.⁴ Collection of long-term outcomes data is necessary in order to establish the impact of injury and evaluate treatment approaches. Functional outcome studies using well-validated assessment tools are uncommon, hampered by barriers such as institutional ethics approval, cost, instrument selection and administration.5, 6, 7 The Victorian State Trauma Registry (VSTORM) however is an example of an instrument being developed to implement a routine, population-based follow-up of adult trauma patients.⁷ VSTORM is an Australian government initiative implemented in July 2001 to monitor and evaluate the Victorian State Trauma System.⁸ It collects data about all major trauma patients and is composed of a brief telephone interview that captures broad patient outcome information such as function, health-related quality of life, pain and work disability. The information is collected from either the patient or their next of kin with all questions and answers recorded on a VSTORM outcomes data collection form.⁷ Key components of the VSTORM interview include:

• The use of the Glasgow Outcome Scale – Extended (GOS-E) which has the ability to detect changing global function in both head–injured- and non-head-injured trauma patients and includes important domains such as self-care, mobility in the community, return to work, relationships, social activities and leisure activities.7, 9

• Collection of pre-injury demographics such as patients’ level of education, occupation and their employment status prior to injury; work-related disability is also recorded including whether the patient has returned to work, and if so, whether it is to the same employer and role within the organisation.

• Collection of patients’ residential and living status including the need for any additional support services.

• A comparison of global disability in the week prior to injury compared with the week prior to interview using a five-point Likert scale (none, mild, moderate, marked and severe disability).

• The use of the 12-Item Short Form Health Survey (SF-12), widely used in the literature and quick to perform over the phone, as a measure of health status. The SF-12 comprises 12 questions that include: two questions concerning physical functioning; two questions on role limitations because of physical health problems; one question on bodily pain; one question on general health perceptions; one question on vitality (energy/fatigue); one question on social functioning; two questions on role limitations because of emotional problems; and two questions on general mental health (psychological distress and psychological well-being).

• Use of the EQ-5D instrument enabling comparison with existing cohort and burden of injury studies. It is a standardised instrument used as a measure of health outcome and is applicable to a wide variety of health conditions and treatments providing simple, descriptive profiles and a single index value for health status.¹⁰

• A pain numerical rating scale ranging from zero (no pain at all) to 10 (worst possible pain).

In order to assess the feasibility of VSTORM as an instrument for collecting functional outcome data for tibial pilon fracture, we performed a pilot study using VSTORM methodology on patients with pilon injuries treated surgically by a trauma surgeon at Morriston Hospital, Swansea.