Abstract
Background
Nearly 20% of Americans consider themselves disabled. A common cause of disability is unexpected orthopaedic trauma. The purpose of this current study, assessing common lower extremity trauma, is the following: to assess the prevalence of self-reported feelings of disability following these injuries, to determine if self-reported feelings of disability impact functional outcomes, and to understand patient characteristics associated with self-reported feelings of disability.
Methods
The functional statuses of patients with tibial plateau fractures and ankle fractures were prospectively assessed. Patient reported feelings of disability (acquired from validated functional outcome surveys), which were compared with overall patient-reported functional outcome and emotional status at each follow-up visit. Additionally, patient demographics were analyzed, to assess associations with feelings of disability.
Results
A total of 710 patients were included in our analysis. At short-term follow-up (3 months), a strong positive correlation existed between self-reported feelings of disability and worse functional outcomes (rs = 0.744, P < 0.001). At long-term follow-up (12-months), a strong positive correlation existed between self-reported feelings of disability and worse functional outcomes (rs = 0.741, P < 0.001). Self-reported feelings of disability were associated with increased age at both short-term (P = 0.015) and long-term (P = 0.003) follow-ups. At short-term follow-up, 41% of males and 59% of females self-reported feelings of disability (P < 0.001) No significant differences existed between genders at long-term follow-up (P = 0.252). Self-reported feelings of disability declined at each follow-up visit, from 48.1% at short-term follow-up to 22.1% at long-term follow-up.
Conclusion
Self-reported feelings of disability, following lower extremity trauma, had strong positive correlations with worse outcomes. Orthopaedic trauma surgeons should be aware of the percentage of patients who feel disabled following lower extremity fractures, and know that this is associated with sub-optimal outcomes.
Level of Evidence
III.
Keywords: Orthopedic trauma, Feelings of disability, Orthopedic outcomes, Orthopedic disability
Introduction
Nearly one in every five Americans report having a disability, which contributes to difficulty performing activities of daily living or hinders their livelihood [1]. Resultant disabilities may additionally beget emotional and cognitive impairment [2, 3]. Individuals with disabilities represent the largest minority group in the United States. Patients with disabilities account for “hotspots” in health care, as they visit clinics and hospitals more than others. Hence, every physician will provide care to patients with disabilities during their career [2]. Unfortunately, patients with disabilities have been demonstrated to experience numerous disparities in healthcare, predominantly in the fields of preventative medicine [2]. The literature has demonstrated that these disparities are often the result of decreased accessibility to healthcare, financial barriers, and sub-optimal health literacy [2].
Orthopaedic injuries are a common reason for hospitalization following trauma, and they are a frequent cause of disability [4]. Nearly half of all Americans will sustain a fracture by the time they are sixty-five years of age [5]. These musculoskeletal ailments are associated with tremendous financial and social costs [6, 7]. Almost half of patients with fractures of the lower extremity were found to have residual disability at one-year follow-up [8]. Furthermore, a quarter of patients who sustain lower extremity injuries, are not able to return to work at one-year post-injury [9].
Although these studies provide awareness to the prevalence of disability following lower extremity fractures, there is a paucity of large prospective studies that assess how feelings of disability impact functional outcomes following orthopaedic trauma. The purpose of this current study, assessing common lower extremity trauma (tibial plateau and ankle fractures), is three-fold. (1) To assess the prevalence of self-reported feelings of disability following these injuries, (2) To determine if self-reported feelings of disability impact functional outcomes, following these injuries, (3) To understand if patient demographics are associated with self-reported feelings of disability, following these injuries.
Materials and Methods
An analysis was performed from two prospectively collected Institutional Review Board (IRB) approved databases of lower extremity fractures of the tibial plateau and ankle. Informed consent was obtained to include patients, and track their outcomes, in these databases. Outcomes in patients with acute tibial plateau fractures and acute ankle fractures were assessed using the validated Short Musculoskeletal Function Assessment (SMFA) survey. Questionnaires were collected by trained researchers at 3-month, 6-month, and long-term (12-month or greater) follow-up.
All questionnaires were obtained from interviewing consecutive patients seen at one of two outpatient settings at our academic center. Consecutive patients were prospectively followed, over a 6-year period, from October 2000 to January 2007 for acute ankle fractures. Consecutive patients were prospectively followed, over an 11-year period, from March 2006 to March 2016 for acute tibial plateau fractures. These time periods of prospective data collection were for two different IRB approved databases. Patients were excluded from inclusion in these prospective databases if they were under the age of 18. Patients were excluded from data analysis if they did not answer the question to assess feelings of disability at the given time-point.
Feelings of disability were evaluated utilizing the SMFA survey question of “How often do you feel disabled?”, in which patients chose one of five options “1 = None of the time, 2 = A little of the time, 3 = Some of the time, 4 = Most of the time, 5 = All the time.” Patients who responded to this question with one of the following answers, “3 = Some of the time, 4 = Most of the time, 5 = All the time,” were considered to have feelings of disability. This classifications of self-reported feelings of disability were calculated as a dichotomous variable, to allow for reporting the prevalence, and longitudinal changes, of patients who experienced moderate to severe feelings of disability following their injury. All other analyses considered the full range of responses to the questions assessing feelings of disability, 1–5, as ordinal values.
Statistical analysis was performed using a Spearman’s rho test to assess correlations between self-reported feelings of disability and overall function. Functional outcomes were assessed utilizing patient’s total SMFA score and SMFA sub-categories (function, bothersome nature of injury, daily activities, emotional status and mobility). Statistical significance was considered when P < 0.05.
Results
A total of 710 patients were included in our analysis. 435 patients sustained ankle fractures and 275 patients sustained tibial plateau fractures.
At short-term follow-up (3-months), a strong positive correlation existed between self-reported feelings of disability and worse functional outcomes (rs = 0.744, P < 0.001). At 3-month follow-up, strong positive correlations existed between self-reported feelings of disability and worse scores in the following SMFA categories: Function (rs = 0.718, P < 0.001), bothersome nature of the injury (rs = 0.703, P < 0.001), daily activities (rs = 0.670, P < 0.001), and emotional status (rs = 0.714, P < 0.001). A weak positive correlation existed between self-reported feelings of disability and decreased mobility (rs = 0.196, P < 0.001). This is demonstrated in Table 1.
Table 1.
Positive correlations between self-reported feelings of disability and worse functional outcomes at short-term (3 months) follow-up
| SMFA Category | Spearman’s rho | P value |
|---|---|---|
| Total | 0.744 | < 0.001 |
| Function | 0.718 | < 0.001 |
| Bothersome nature of injury | 0.703 | < 0.001 |
| Daily activities | 0.670 | < 0.001 |
| Emotional status | 0.714 | < 0.001 |
| Mobility | 0.196 | < 0.001 |
At long-term follow-up (12 months), a strong positive correlation existed between self-reported feelings of disability and worse functional outcomes (rs = 0.741, P < 0.001). At long-term follow-up, strong positive correlations existed between self-reported feelings of disability and worse scores in the following SMFA categories: Function (rs = 0.723, P < 0.001), bothersome nature of the injury (rs = 0.723, P < 0.001), daily activities (rs = 0.732, P < 0.001), emotional status (rs = 0.731, P < 0.001) and mobility (rs = 0.692, P < 0.001). This is demonstrated in Table 2.
Table 2.
Positive correlations between self-reported feelings of disability and worse functional outcomes at long-term (12 months) follow-up
| SMFA category | Spearman’s rho | P value |
|---|---|---|
| Total | 0.741 | < 0.001 |
| Function | 0.723 | < 0.001 |
| Bothersome nature of injury | 0.723 | < 0.001 |
| Daily activities | 0.732 | < 0.001 |
| Emotional status | 0.731 | < 0.001 |
| Mobility | 0.692 | < 0.001 |
Self-reported feelings of disability were associated with increased age at both short-term (P = 0.015) and long-term (P = 0.003) follow-up [Table 3]. At short-term follow-up, 41% of males and 59% of females self-reported feelings of disability (P < 0.001). At long-term follow-up, 21% of males and 26% of females self-reported feelings of disability (P = 0.252).
Table 3.
Differences in mean age between patients exist, between those who have self-reported feelings of disability following lower extremity trauma, and those who did not
| Short term follow-up | Self-reported feelings of disability | No self-reported feelings of disability |
|---|---|---|
| 43.8 years old | 47.2 years old |
| Long-term follow-up | Self-reported feelings of disability | No self-reported feelings of disability |
|---|---|---|
| 45.5 years old | 50.4 years old |
Self-reported feelings of disability declined at each follow-up visit (Fig. 1).
Fig. 1.
Self-reported feelings of disability, following lower extremity trauma, decreased at each additional follow-up visit
Discussion
In this study, self-reported feelings of disability were strongly correlated with worse functional outcomes following lower extremity orthopaedic trauma. Previous studies have demonstrated that psychosocial factors, such as catastrophic thinking, anxiety, or mental illness, may explain much of the inter-patient variability of disability that exists following orthopaedic pathologies [10–12]. Yet, to our knowledge, this is the first study to correlate the degree of patient-perceived disability with prospective functional outcomes following lower extremity orthopaedic trauma.
Recent reports have validated a need for the adaptation of evidence-based bio-psychosocial models of care in orthopedics, to more comprehensively treat patients, while concurrently reducing the wide variability of inter-patient disability [13]. Formulating a better understanding of both the causes and effects of patient-reported feelings of disability is an important undertaking that will further facilitate this adaptation.
A recent study from Lindenhovius reported the relationship between patient-reported disability measures and objective physical impairment following elbow trauma. However, much of the total patient-reported disability remains unexplained and poorly related to objective impairment or injury severity [14]. These findings are similar to a study from Doornberg et al. which reported that only 17% of the variation in measured disability following elbow trauma was a result of objective impairment [15].
Related studies have demonstrated that psychosocial factors are important long-term predictors of disability following orthopaedic pathology [10, 11, 16]. In particular, a patient’s perception of pain, pain interference, or mental illness has been described as strong predictors of measured disability [15, 17]. This is in agreement with the results of our study, which demonstrate worse emotional status among patients who report feelings of disability. A recent review from Hadjistavropolus et al. discusses this further, specifically describing the influence of health related anxiety on both disability and the development of chronic pain [18]. Vranceanu et al. better defined this relationship in their report on patients with upper extremity pain, in which a cognitive-behavioral model of health related anxiety was utilized, to assess the relationship between increased health concerns and perceived disability. Their study reports a strong, positive relationship between health concerns and perceived disability. The study likewise demonstrates that this perceived disability was also correlated with somatic symptoms and idiopathic, well-defined pain [13].
The concept that patient perceptions are associated with patient outcomes in orthopedics is expanded upon by the correlation between self-reported feelings of disability and decreased functional outcomes, as demonstrated in our present study. Our results may also suggest using patient perceptions of disability as risk factors for poor outcomes. This has been described in other areas of medicine. De Heer et al. demonstrated that poor perceptions of health are risk factors for depression and worsened outcomes in patients who suffer from Fibromyalgia [19]. Additionally, our study corroborates the necessity of bio-psychosocial models of care in orthopaedic surgery, and further suggests the interrelatedness of psychological, social, and biological factors regarding outcomes in orthopedics, particularly lower extremity trauma.
This study is limited by the inherent weaknesses of our outcome measure, the Short Musculoskeletal Function Assessment. In such an assessment, it is difficult to gain a completely objective measure of functional status, as the information is self-reported. Therefore, the presence of anxiety or negativity may have contributed to a portion of the relationship between feelings of disability and worse outcomes. However, we feel the SMFA is a well-defined and tested measure, and these weaknesses should not deter the importance and clinical impact of this study.
Conclusion
Self-reported feelings of disability, following lower extremity trauma, had strong positive correlations with worse outcomes, at both short-term and long-term follow-up. However, the patients who felt disabled at the 3-month time point had worse emotional status. Patients who felt disabled were of older age. At long-term follow-up, self-reported feelings of disability significantly decreased. Orthopaedic trauma surgeons should be aware of the percentage of patients who feel disabled following lower extremity fractures, and know that this is associated with sub-optimal outcomes.
Funding
The authors have not received grant support. Research funding was received from OREF. The authors do not have any proprietary interests in the materials described in the article.
Declarations
Conflict of interest
David Kugelman declares he has no conflict of interest. Jack Haglin declares he has no conflict of interest. Ariana Lott declares she has no conflict of interest. Sanjit Konda declares he has no conflict of interest. Kenneth Egol declares he has no conflict of interest.
Ethical standards
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.
Informed consent
Informed consent was obtained from all patients for being included in the study.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
David N. Kugelman, Email: David.kugelman@nyumc.org
Jack M. Haglin, Email: Haglin.jack@mayo.edu
Ariana Lott, Email: Ariana.lott@nyumc.org.
Sanjit R. Konda, Email: Sanjit.konda@nyumc.org
Kenneth A. Egol, Email: Kenneth.egol@nyumc.org
References
- 1.Brault, MW. (2012). Americans with disabilities: 2010, current population reports, P70–131, U.S. Washington, DC: Census Bureau. http://www.census.gov/prod/2012pubs/p70-131.pdf
- 2.Reis Judy, Panko., Mary Lou, Breslin., Lisa, I. Iezzoni., & Kristi, L. Kirschner. (2014). (It takes more than ramps to solve the crisis of healthcare for people with disabilities. Rehabilitation Institute of Chicago.
- 3.Iezzoni LI. Going beyond disease to address disability. New England Journal of Medicine. 2006;355(10):976. doi: 10.1056/NEJMp068093. [DOI] [PubMed] [Google Scholar]
- 4.Nota SP, Bot AG, Ring D, Kloen P. Disability and depression after orthopaedic trauma. Injury. 2015;46(2):207–212. doi: 10.1016/j.injury.2014.06.012. [DOI] [PubMed] [Google Scholar]
- 5.Brinker MR, O'Connor DP. The incidence of fractures and dislocations referred for orthopaedic services in a capitated population. JBJS. 2004;86(2):290–297. doi: 10.2106/00004623-200402000-00011. [DOI] [PubMed] [Google Scholar]
- 6.Lerner RK, Esterhai JL, Polomono RC, Cheatle MC, Heppenstall RB, Brighton CT. Psychosocial, functional, and quality of life assessment of patients with posttraumatic fracture nonunion, chronic refractory osteomyelitis, and lower extremity amputation. Archives of Physical Medicine and Rehabilitation. 1991;72(2):122–126. [PubMed] [Google Scholar]
- 7.Wasterlain AS, Melamed E, Bello R, Karia R, Capo JT, Adams J, et al. The effect of price on surgeons’ choice of implants: a randomized controlled survey. The Journal of Hand Surgery. 2017;42(8):593–601. doi: 10.1016/j.jhsa.2017.05.005. [DOI] [PubMed] [Google Scholar]
- 8.Butcher JL, MacKenzie EJ, Cushing B, Jurkovich G, Morris J, Burgess A, et al. Long-term outcomes after lower extremity trauma. Journal of Trauma and Acute Care Surgery. 1996;41(1):4–9. doi: 10.1097/00005373-199607000-00002. [DOI] [PubMed] [Google Scholar]
- 9.Sluys KP, Shults J, Richmond TS. Health related quality of life and return to work after minor extremity injuries: a longitudinal study comparing upper versus lower extremity injuries. Injury. 2016;47(4):824–831. doi: 10.1016/j.injury.2016.02.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Vranceanu AM, Barsky A, Ring D. Psychosocial aspects of disabling musculoskeletal pain. JBJS. 2009;91(8):2014–2018. doi: 10.2106/JBJS.H.01512. [DOI] [PubMed] [Google Scholar]
- 11.Ring D, Kadzielski J, Malhotra L, Lee SGP, Jupiter JB. Psychological factors associated with idiopathic arm pain. JBJS. 2005;87(2):374–380. doi: 10.2106/00004623-200502000-00021. [DOI] [PubMed] [Google Scholar]
- 12.Niekel MC, Lindenhovius AL, Watson JB, Vranceanu AM, Ring D. Correlation of DASH and QuickDASH with measures of psychological distress. The Journal of Hand Surgery. 2009;34(8):1499–1505. doi: 10.1016/j.jhsa.2009.05.016. [DOI] [PubMed] [Google Scholar]
- 13.Vranceanu AM, Safren SA, Cowan J, Ring DC. Health concerns and somatic symptoms explain perceived disability and idiopathic hand and arm pain in an orthopedics surgical practice: A path-analysis model. Psychosomatics. 2010;51(4):330–337. doi: 10.1016/S0033-3182(10)70704-0. [DOI] [PubMed] [Google Scholar]
- 14.Lindenhovius AL, Buijze GA, Kloen P, Ring DC. Correspondence between perceived disability and objective physical impairment after elbow trauma. JBJS. 2008;90(10):2090–2097. doi: 10.2106/JBJS.G.00793. [DOI] [PubMed] [Google Scholar]
- 15.Doornberg JN, Ring D, Fabian LM, Malhotra L, Zurakowski D, Jupiter JB. Pain dominates measurements of elbow function and health status. JBJS. 2005;87(8):1725–1731. doi: 10.2106/JBJS.D.02745. [DOI] [PubMed] [Google Scholar]
- 16.Vranceanu AM, Jupiter JB, Mudgal CS, Ring D. Predictors of pain intensity and disability after minor hand surgery. The Journal of Hand Surgery. 2010;35(6):956–960. doi: 10.1016/j.jhsa.2010.02.001. [DOI] [PubMed] [Google Scholar]
- 17.Ring D, Kadzielski J, Fabian L, Zurakowski D, Malhotra LR, Jupiter JB. Self-reported upper extremity health status correlates with depression. JBJS. 2006;88(9):1983–1988. doi: 10.2106/JBJS.E.00932. [DOI] [PubMed] [Google Scholar]
- 18.Hadjistavropoulos HD, Hadjistavropoulos T. The relevance of health anxiety to chronic pain: research findings and recommendations for assessment and treatment. Current Pain and Headache Reports. 2003;7(2):98–104. doi: 10.1007/s11916-003-0019-z. [DOI] [PubMed] [Google Scholar]
- 19.de Heer EW, Vriezekolk JE, van der Feltz-Cornelis CM. Poor illness perceptions are a risk factor for depressive and anxious symptomatology in fibromyalgia syndrome: a longitudinal cohort study. Frontiers in Psychiatry. 2017;8:217. doi: 10.3389/fpsyt.2017.00217. [DOI] [PMC free article] [PubMed] [Google Scholar]