The Effect of Social Deprivation on Fracture-Healing and Patient-Reported Outcomes Following Intramedullary Nailing of Tibial Shaft Fractures.

BACKGROUND: Social deprivation is a state marked by limited access to resources due to poverty, discrimination, or other marginalizing factors. We investigated the links between social deprivation and orthopaedic trauma, including patient-reported outcomes, radiographic healing, and complication rates following intramedullary nailing of tibial shaft fractures. METHODS: We retrospectively reviewed 229 patients who underwent intramedullary nailing of tibial shaft fractures at our Level-I trauma center. The Area Deprivation Index (ADI), a validated proxy for social deprivation, was used to group patients into the most deprived tercile (MDT), the intermediate deprived tercile (IDT), and the least deprived tercile (LDT) for outcome comparison. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used to measure the domains of Physical Function (PF), Pain Interference (PI), Anxiety, and Depression, and radiographic healing was assessed with the Radiographic Union Scale in Tibial fractures (RUST) system. RESULTS: On univariate analyses, patients from the MDT reported worse PF, PI, Anxiety, and Depression scores than those from the LDT within the first year of postoperative follow-up. On multivariable regression analysis, PROMIS score outcomes were influenced by age, race, and smoking status, but not by social deprivation tercile. Furthermore, residing in the MDT was associated with a 31% increase in time to radiographic union compared with the LDT (ß = 0.27; p = 0.01). CONCLUSIONS: Following intramedullary nailing of tibial shaft fractures, social deprivation is associated with slower fracture-healing and potentially influences short-term PROMIS scores. These results warrant further investigation in additional patient populations with orthopaedic trauma and highlight the importance of developing interventions to reduce inequities faced by patients from low-resource settings. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

In-Hospital Morbidity and Mortality With Delays in Femoral Shaft Fracture Fixation.

OBJECTIVES: To investigate trends in the timing of femur fracture fixation in trauma centers in the United States, identify predictors for delayed treatment, and analyze the association of timing of fixation with in-hospital morbidity and mortality using data from the National Trauma Data Bank. METHODS: Patients with femoral shaft fractures treated from 2007 to 2015 were identified from the National Trauma Data Bank and grouped by timing of femur fixation: <24, 24-48 hours, and >48 hours after hospital presentation. The primary outcome measure was in-hospital postoperative mortality rate. Secondary outcomes included complication rates, hospital length of stay (LOS), days spent in the intensive care unit LOS (ICU LOS), and days on a ventilator. RESULTS: Among the 108,825 unilateral femoral shaft fractures identified, 74.2% was fixed within 24 hours, 16.5% between 24 and 48 hours, and 9.4% >48 hours. The mortality rate was 1.6% overall for the group. When fixation was delayed >48 hours, patients were at risk of significantly higher mortality rate [odds ratio (OR) 3.60; 95% confidence interval (CI), 3.13-4.14], longer LOS (OR 2.14; CI 2.06-2.22), longer intensive care unit LOS (OR 3.92; CI 3.66-4.20), more days on a ventilator (OR 5.38; CI 4.89-5.91), and more postoperative complications (OR 2.05; CI 1.94-2.17; P < 0.0001). CONCLUSIONS: Our study confirms that delayed fixation of femoral shaft fractures is associated with increased patient morbidity and mortality. Patients who underwent fixation >48 hours after presentation were at the greatest risk of increased morbidity and mortality. Although some patients require optimization/resuscitation before fracture fixation, efforts should be made to expedite operative fixation. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.