Assessment of quality of life in patients with tibia fractures

Abstracts

OBJETIVO: Avaliar o impacto da fratura na qualidade de vida dos pacientes. MÉTODO: Os pacientes foram submetidos a um protocolo de dados clínicos e epidemiológicos, a uma avaliação específica para fraturas da tíbia, o método de Johner e Wruhs, cujo dados foram analisados por um questionário genérico para avaliação da qualidade de vida, o SF-36, o qual foi aplicado pelos autores, com um mínimo de seis meses de pós-operatório. Estes instrumentos foram também estratificados com relação ao retorno ou não dos pacientes a todas as atividades que realizavam antes do acidente. RESULTADOS: Observou-se uma diminuição dos valores de avaliação do questionário SF-36 demonstrada estatisticamente (p<0,05) tanto pelo teste U de Mann-Whitney, entre os itens do SF-36 e retorno ou não às atividades prévias, como com relação ao resultado do SF36 estratificado para a avaliação clínica (Johner e Wruhs), por meio do teste de Kruskal-Wallis. CONCLUSÃO: De acordo com os critérios estabelecidos, e com base nos resultados obtidos, a fratura da tíbia, mesmo com uma boa evolução clínica, promoveu uma piora na qualidade de vida dos pacientes analisados.

Fraturas da tíbia; Fixação intramedular de fraturas; Qualidade de vida

ORIGINAL ARTICLE

Assessment of quality of life in patients with tibial fractures

Oswaldo Roberto Nascimento; Fábio Serra Cemin; Maurício de Morais; Rui dos Santos Barroco; Edison Noboru Fujiki; Carlo Milani

ABC Medical School

Correspondences to

ABSTRACT

OBJECTIVE: To evaluate the impact of tibial fractures on patient's quality of life.

METHOD: All patients were evaluated by means of a protocol of clinical and epidemiological data. The Johner and Wruhs method was employed to evaluate tibial fractures and the results were compared to those of the SF-36 Health Survey, which was applied by the authors from the sixth month postoperatively. Those methods were applied considering the return of the patients or not to all the activities they used to perform before the accident.

RESULTS: We found a statistical significance (p<0.05) showed by Mann-Whitney's U-test between the component of SF-36, and return or not to previous activities. Regarding the results of SF-36 and clinical evaluation (Johner and Wruhs), on the Kruskal-Wallis' test, we also found significant correlation.

CONCLUSION: According to the established criteria and based on the results, tibial fractures, even with favorable clinical outcomes, result in a diminished quality of life.

Keywords: Tibial fractures. Fracture fixation. Intramedullary. Quality of life.

INTRODUCTION

Tibia accounts for the long bone with the highest prevalence of fractures^1-3, showing the highest number of treatment alternatives.^4-6 As a result of the development of osteosynthesis techniques, making surgical procedures easier and reducing its associated risks, respecting the binomial biology-mechanics and modern increasingly trend to reintegrate patients into society, promoting a swift return to their activities, the bloody approach has occupied a top position in the ranking of orthopaedic doctors' preference.^7,8

Locked intramedullary nails, in the recent years, have been shown to be of great usefulness, being currently the most disseminated fixation method for tibial shaft fractures.^9-11

The concept of quality of life had been traditionally delegated to poets and philosophers; however, there is an increasing interest today from doctors and researchers to transform it into a quantitative measurement that could be used in clinical assays and economic models.^12-14 Quality of life is regarded as a very complex term, of difficult definition. According to the World Health Organization, quality of life is "an individual's perception of his/ her position in life, in the context, in the cultural and values system in which he/ she lives and concerning his/ her objectives, expectations, standards and concerns".¹⁵ From an orthopaedic point of view, the end result of treatment concerning union, presence or absence of complications, angle and rotational displacements, shortenings, functional recovery and quality of gait have always been assessed. However, what would be a patient's personal assessment concerning his/ her treatment and results? Has the "Quality of Life", even with a good physical recovery, been impacted? The objective of this study is to demonstrate whether a change of quality of life occurred or not for the patients studied here.

MATERIAL AND METHODS

Our series was constituted of 30 patients, who, after being informed about the development of the study and having signed a Free and Informed Consent Term, were submitted to clinical examination, X-ray studies, application of the Evaluation Protocol and of the SF-36 Questionnaire, applied by the authors as interviews, at the outpatient facilities of the hospitals where surgeries were performed: Hospital IFOR in São Bernardo do Campo, Hospital e Maternidade Dr. Cristóvam da Gama in Santo André, Hospital São Leopoldo in São Paulo, and Hospital Estadual Mário Covas in Santo André. As an inclusion criterion for our study, patients diagnosed with tibial fracture and submitted to surgical treatment with locked intramedullary nail and spinal cord canal milling and access port through patellar ligament and not submitted to dynamization and not using anchor screw ("poller") (surgical method) between January, 1999 and April , 2005, with a minimum follow-up time of six months postoperatively were included. Multiple-trauma and multiple-fractured patients, those with cranial-encephalic trauma (CET) requiring hospitalization at Intensive Care Units (ICU), patients with grade II and II open fractures according to the classification by Gustilo, Gruninger and Davis¹⁶, as well as those who evolved to pseudoarthrosis and serious infections were excluded from the study. The selection was made by assessing the medical files obtained at the Medical Files Service (SAME) of each hospital and excluding patients according to the criteria listed above. For the selected Group, the age of the 30 patients at the time of surgery ranged from 14 to 56 years (mean: 36.1; median: 36.5; standard deviation 12.449). Concerning gender, 20 (66.6%) were males and 10 (33.3%) females. Concerning the affected side, there were 19 (63.3%) left tibiae and 11 (36.6%) right tibiae. Concerning bone exposure, there were 21 (70%) closed and 9 (30%) Gustilo, Gruninger e Davis'¹⁶ grade I open fractures. Twenty-seven (90%) patients showed associated fibular fracture and in only 3 (10%) patients, fibula was shown to be intact. An assessment protocol was prepared for patients where epidemiological, clinical and X-ray-related aspects were reviewed, and all patients were submitted to clinical and X-ray tests, according to the method by Johner and Wrus.¹⁷ For quality of life assessment, the MOS 36-item Short-Form Health Survey (SF-36) questionnaire by Ware and Sherbourne¹⁸, translated and validated into Portuguese by Ciconelli was used.¹⁹ SF-36 is a generic multi-dimensional tool comprising 36 items divided into eight domains, which can be grouped as two broad components: physical and mental.²⁰ For the analysis of results, a score is assigned to each question, which, subsequently, is transformed into a 0-100 scale, where zero corresponds to the worst health status and 100 corresponds to the best health status, with each component being assessed separately.¹⁹ For the statistical evaluation, a descriptive analysis was made for all variables of the study. Qualitative analyses were presented as absolute and relative values (percentages) and the quantitative analyses as core and dispersion trend values. Two stratifications were made for analysis. The group was divided into patients returning to their previous activities and patients not returning to their previous activities, and a further division concerning the result of the assessment by the method by Johner and Wruhs.¹⁷ In order to check for the association between qualitative variables and groups, the Chi-Squared test and the Fisher's exact test were applied, adopting a significance level of 5%. In order to compare groups, return to previous activities or not, concerning the domains of the SF-36¹⁸, the non-parametric Mann--Whitney's U-test was employed, because variables didn't present a normal distribution (Kolmogorov-Smirnov's test) and homocedastity (Levene's Test). When the group was stratified by Johner and Wruhs¹⁷ assessment, the Kruskal-Wallis' test was used to compare the three assessments, followed by the multiple-comparison test Honest Significant Differences (HSD-tukey).^21,22

RESULTS

On Chart 1, we present the scores assigned to patients after calculating the results of the Quality of Life-related questionnaire for the eight SF-36 domains.¹⁸

On Table 1, the distribution of number and percentage of the results of the evaluation by Johner and Wruhs17 method is shown for overall and stratified groups concerning the return status to previous activities, with the result of the Chi-squared test.

On Table 2, a descriptive analysis of the values obtained for SF-36 domains¹⁸ is shown for the overall and stratified group concerning the return to previous activities or not and the result of the Mann-Whitney's U-test.

On Table 3, a descriptive analysis of the values obtained for SF36 domains¹⁸ stratified for the results achieved by means of the assessment by the method by Johner and Wruhs¹⁷ is presented. The "poor" evaluation (IV) was not considered for having only one patient included (nr. 10) [statistical limitation].

DISCUSSION

In our study, we assessed patients with tibial fractures submitted to surgical treatment with locked intramedullary nail, which is currently regarded as the "gold standard" for treating most tibial fractures.^11,23,24

By reviewing the results of the assessment by the method by Johner and Wruhs¹⁷, stratified for return to previous activities or not, we found an association between the groups described on Table 1 and the results, since all patients with excellent results returned to their previous activities, all patients with results scored as fair and poor did not return to their previous activities, and, among the 12 (100%) who scored good from a clinical point of view, 8 (66.6%) did not return to previous activities (extreme activities) and 4 (33.3%) did (p<0.001). Also by the method described by Johner and Wruhs¹⁷, by comparing results, we found excellent outcomes in 11 patients (36.6%), good in 12 (40%), fair in 6 (20%) and poor in 1 (3.3%).

In the last decade, one of the greatest developments in the field of health has been the recognition of the importance of patient's opinion concerning his/ her disease, as well as the quality monitoring of employed therapeutic measures.²⁵ Therefore, the best way to judge them is not the frequency in which a medical service is provided to a patient, but how close the achieved results are to critical goals of extending life, relieve pain, restore function and prevent disabilities.^26-28

In the quality of life evaluation, two approaches were used: one to assess SF-36 domains¹⁸ stratified to evaluate patients by the method of Johner and Wruhs¹⁷ (Table 1), being excellent (Group I), Good (Group II), Fair (Group III), excluding Poor evaluation (Group IV) for counting on only one patient. By means of the Mann-Whitney's U-test, we could find a significant difference between both studied groups concerning their scores (Table 2). Considering these data, we can see a significant association between the scores of each assessed question and the groups, because it shows us that the patients who returned to their previous activities achieved significantly higher scores than those who didn't return to previous activities. In our literature search, we didn't find any authors discussing the matter. On the second approach, we compared a generic tool - the SF-36¹⁸ - to a specific tool, the method by Johner and Wruhs¹⁷ (Table 3), and we found a significant association by the non-parametric Kruskal-Wallis' test for Physical component domains (Functional Ability, Physical Aspects, Pain, and Overall Health Status) where a proportionality exists between clinical assessment and SF-36 scores.¹⁸ (Table 3) Concerning Mental component domains (Vitality, Social Aspects, Emotional Aspects, and Mental Health), by the same test, we found a significant difference for items Vitality, Social Aspects and Mental Health; however, there was no statistical difference for Emotional Aspects [(p=0.15) (Table 3)], which, in our opinion, does not invalidate the fact that the tibial fracture has also caused an impact on the mental component. Emotional Aspects have been defined as being assessed by measuring the emotional challenges restricting labor activities, social life and daily life activities. Thus, this item could be impaired by answers, for addressing, as other items of the Mental Component, subjective questions that could present variable answers according to the personality and momentum of each patient. Although the patients included in our study, being assessed by the method of Johner and Wruhs¹⁷ have shown good results from a clinical (orthopaedic) perspective and following our inclusion and exclusion criteria, when we evaluated the answers to the SF-36¹⁸ questionnaire, we found that tibial fractures treated with locked intramedullary nail has yielded a "worsening of the quality of life" of patients. Because the assessed group was homogenous for gender and age, and all fractures showed union, better results could be expected when the quality of life of these patients was measured. Could other factors have influenced these results? According to Filan²⁹, the "Labor withdrawal and Benefit" system (corresponding to our Caixa-INSS) would contribute to a delayed return to labor activities, and could save millions of dollars if it had an incentive program to encourage a swift return to work, obviously without damages to a good treatment outcome. We don't have enough data in our study to allow comments on this subject.

CONCLUSION

Tibial fractures, even with good clinical evolution after treatment, according to the criteria established hereon, causes a worsening of the quality of life of these patients.

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Publication Dates

• Publication in this collection
  11 Sept 2009
• Date of issue
  2009

History

• Accepted
  10 Jan 2009
• Received
  30 Jan 2008