Longitudinal study of recovery following diaphyseal fracture of the tibia or femur
Watson, Hilary Joy
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The lack of scientific research into the treatment of fractures, in general, was noted by orthopaedic surgeons some ten years ago and is of particular importance in the study of lower limb fracture because it is acknowledged as one of the most opinionated and contentious fields of orthopaedic practice. Therefore, in 1984, a study of this patient population was initiated at the instigation of members of the Department of Orthopaedic Surgery within the University of Edinburgh. Following a review of the literature, it became apparent that there was no standard way of monitoring or measuring outcome following fracture. Many of the commonly used clinical instruments, such as time to union, complication rates and the incidence of malunion, were based upon subjective judgements that had not been adequately tested in terms of their properties of measurement, while the descriptive data in scientific literature on this subject was found to be contradictory. Thus, in response to these findings, a longitudinal study was planned with three objectives in view. Firstly, the intention was to standardise, test and select instruments that could be used to measure different clinical and rehabilitative aspects of recovery following lower limb injury. Secondly, the patient population was to be described in greater detail than had been attempted hitherto in order to provide sound empirically derived data to assist with the design and planning of future clinical trials. Finally, post hoc analyses were to be conducted in order to determine the prognostic potential of various factors thought to influence recovery upon different types of outcome. The fieldwork for this longitudinal study took place between June 1985 and May 1987 and during this time a series of 112 patients, admitted to the Royal Infirmary of Edinburgh, were recruited to the study. Subjects were followed-up over a nine month period with each subject being interviewed on three specific occassions. Five computer compatible coding schedules were used to collect the data which comprised clinical, socio-economic psychological and functional variables. As a result of this study, a methodology has been specified and research instruments have been designed and tested for the future evaluation of fracture treatments. Three measures have been identified which were sufficiently sensitive, valid and reliable to measure outcome following lower limb fracture. Furthermore, suggestions have been made as to the possible research design and type of statistical analyses which might be employed in the context of an experimental study. Four main recommendations have been made for the development of clinical research in this area of interest, namely: (1) that immediate attention be given to improving and testing clinical and radiological measures of union; (2) that a large scale survey of the natural healing process should be undertaken; (3) that a clinical trial be conducted to evaluate the benefit of conservative versus operative procedures for stabilising tibial shaft fractures; and (4) that serious consideration be given to developing the appropriate resources and expertise necessary to conduct clinical orthopaedic research based on the methods of the social and behavioural sciences as well as those of the basic biological sciences.