THE USE OF INDICATORS OF AN INCREASE IN THE PATIENT'S QUALITY OF LIFE IN THE COURSE OF TREATMENT TO PREDICT THE RESULTS OF SURGICAL TREATMENT OF FRACTURES OF THE FEMURS Yamshchikov O.N., Emelyanov S.A.
Derzhavin Tambov State University, Institute of Medicine, Tambov, Russia
The results of treatment of patients with hip fractures are far from ideal ones, and the issues of postsurgical management of patients and estimation of treatment course have not been studied properly, considering the wide variety of conservative and surgical techniques for femur fractures, and quite high level of rehabilitation methods for surgical patients. So, Ryabchikov I.V. et al. (2013) indicate that the problem of studying of balance and motor habits in trauma and orthopedic patients with persistent disorders or functional limitations is actual for many subject areas [1]. According to Sayapov R.S. (2007) and Belinov N.V. (2017), the recovery of physical capability in working age persons with femur fractures is an important task, and the presence of a metal construct in young patients of working age presents the contraindication for return to professional activity in some cases [2, 3]. Moreover, according to Nedrigaylanov O.N. (1955), Miroshnichenko V.F. and Shimbaretsky A.N. (1985), the appropriate restoring treatment is realized at the background of already formed joint contractures after osteosynthesis of the hip and the leg in almost all patients [4-6]. Ryabchikov I.V. (2013) offered using the digital hardware and software complex for diagnosis and treatment of disorders in balance and motor habits [1]. Currently, Harris score, Iowa method, HSS, Hip Score and UCLA score are used. These techniques estimate the quantitative intensity of pain, walking, muscular strength and movements, and functional social adaptation, resulting in integral estimation of treatment efficiency in numeral value.
However these techniques have some disadvantages since they do not consider the time factor. For example, if two patients have similar numerical results of treatment, and duration of achievement of these results differs significantly, then it is not correctly to say about similar results of treatment. Therefore, according to our opinion, both a degree and rate of recovery are to be considered when estimating results of treatment.
Objective – to assess the relationship between the increase in the patient’s quality of life after femur osteosynthesis and the likelihood of a good treatment outcome.
MATERIALS AND METHODS
Life quality was estimated in 360 patients with femur fractures within 3-6 months after surgery. Then the increase in life quality (%) was estimated with SF-36. The time interval of 3-6 months after surgery was selected as the most informative one since the patients show activation, and the load to the operated extremity increases in this period. The age of the patients varied from 18 to 88. The study included the patients with femur fractures. The surgical treatment was conducted within two weeks after trauma. All patients received the complex examination and treatment in compliance with the standards for arrangement of medical care for patients with femur fractures. The exclusion criteria were accident with a fracture more than two weeks before surgery, presence of severe concurrent pathology (cardiovascular diseases, traumatic shock at admission, infected wounds in the fracture site etc.) impeding the realization of surgical treatment or resulting in more than two weeks of delay; an old fracture of the femoral bone at the stage of union or formation of the false joint; significant deformations of the lower extremities due to inborn of acquired diseases; soft tissue defects; extremity amputation at the level of union or formation of the false joint; presence of an abnormal fracture at the background of an oncologic disease; significant deformations of the lower extremities due to inborn or acquired diseases; soft tissue defects; extremity amputation below the level of a fracture; mental diseases impeding the appropriate follow-up in the period of restorative treatment and to adherence of medical recommendations; presence of neurological diseases, which significantly influence on static and dynamic function of the lower extremities; impossibility of follow-up during restorative treatment.
We used SF-36 for realization of the integral approach, which characterizes the rate of recovery of various functions of the hip after trauma. The life quality was estimated according to 8 items of SF-36: physical functioning (PF), role functioning determined by physical condition (RF), pain intensity (PI), general health (GH), life activity (LA), social function (SF), mental health (MH), role functioning determined by emotional state (RE).
After calculation of life quality increase, all patients were distributed into 3 subgroups for each item of the questionnaire. Therefore, the total amount of subgroups was 24. Moreover, one and the same patient could be in subgroups with different increase in life quality according to different scores. The first subgroup for each score included the patients with less than 50 % of increase in life quality according to SF-36 in within 3-6 months after surgery. The second subgroup included the patients with 50-75 % of increase. The third subgroup included the patients with more than 75 % of increase (the table 1).
Table
Number of patients in study groups
|
SF-36 scale |
Increasing values of quality of life (%) |
Number of patients (n) |
Number of patients with good treatment results in one year (n) |
|
|
LA |
≤ 50 % |
129 |
75 |
|
|
50-75 % |
136 |
91 |
||
|
≥ 75 % |
133 |
107 |
||
|
PF |
≤ 50 % |
104 |
47 |
|
|
50-75 % |
180 |
128 |
||
|
≥ 75 % |
76 |
62 |
||
|
RF |
≤ 50 % |
127 |
79 |
|
|
50-75 % |
167 |
121 |
||
|
≥ 75 % |
66 |
49 |
||
|
PI |
≤ 50 % |
137 |
92 |
|
|
50-75 % |
153 |
117 |
||
|
≥ 75 % |
70 |
55 |
||
|
GH |
≤ 50 % |
115 |
64 |
|
|
50-75 % |
126 |
99 |
||
|
≥ 75 % |
119 |
91 |
||
|
SF |
≤ 50 % |
101 |
70 |
|
|
50-75 % |
149 |
102 |
||
|
≥ 75 % |
110 |
83 |
||
|
MH |
≤ 50 % |
101 |
69 |
|
|
50-75 % |
132 |
92 |
||
|
≥ 75 % |
127 |
100 |
||
|
RE |
≤ 50 % |
109 |
74 |
|
|
50-75 % |
155 |
106 |
||
|
≥ 75 % |
96 |
72 |
||
|
Total |
360 |
253 |
||
Note: PF – physical functioning, RF – role functioning determined by physical condition, PI – pain intensity, GH – general health, LA – life activity, SF – social functioning, MH – mental health, RE – role functioning determined by emotional condition.
Then the incidence of good results of treatment in each group was estimated. One year after surgery, the treatment result was good if the fracture united, the working capability restored, social activity returned (at the level before trauma), pain disappeared, the deficiency of movements in the joints of injured and healthy extremities did not exceed the statistical error, and the posttraumatic hypotrophy of soft tissues was not more than 10 % of normal values.
All patients or their legal representatives gave their informed consent according to the requirements of the Federal Law No.152-FZ, 27 June 2006 (edited on 22 February 2017) “About Personal Data”, and Helsinki Declare – Ethical Principles for Medical Research with Human Subjects 1964 (revision 2013), and the Rules for Clinical Practice in the Russian Federation confirmed by the Order of Health Ministry of RF, 19 June 2003, No.266. The findings have been anonymised.
The statistical analysis was conducted by means of SPSS Statistics 21. The homogeneity of the populations was tested. The normal pattern of distribution was determined. The mean errors in the values in all samples, and t-value of reliability of two relative values were calculated. The critical level of significance (p) was 0.05 for testing the statistical hypotheses.
RESULTS
The figure shows the incidence of good results of treatment one year after surgery in dependence on the increase in life quality according to different items of SF-36 within 3-6 months after surgery.
Figure
Incidence of good results of treatment 1 year after surgery in dependence on increase in life quality indicators.
Note: PF – physical functioning, RF – role functioning determined by physical condition, PI – pain intensity, GH – general health, LA – life activity, SF – social functioning, MH – mental health, RE – role functioning determined by emotional condition.
As the presented data shows, the highest incidence of good results of treatment one year after surgery was found in the subgroup with life quality increase more than 75 % according to scores of physical functioning and life activity. In the subgroup with life quality increase < 50 % according to physical functioning score, good results of treatment were observed in 45.2 ± 4.9 % of cases, i.e. 25.1 % lower than the mean value for general population (t = 4.6, p = 0.000005). At the same time, the subgroup with life quality increase > 75 %, the higher (by 11.28 %) incidence of good results of treatment was observed in 81.6 ± 4.4 % in comparison with the mean value of 70.3 ± 2.4 % (t = 2.25, p = 0.024658). According to the life activity score, the subgroup with < 50 % of life quality increase showed the good results of treatment in 58.2 ± 4.3 % of cases, i.e. 12 % lower than the mean value (t = 2.46, p = 0.014353). The subgroup with life quality increase above 75 %, the incidence of good results of treatment increased by 10.1 % (t = 2.25, p = 0.025070). According to general health condition, the statistically significant differences in the incidence of good results of treatment were observed in only 50 %; it was 55.7 ± 4.6 %, i.e. 14.9 % lower than the mean value (t = 2.81, p = 0.005098). Therefore, the factors with the highest probability of achievement of good results of treatment one year after surgery are intensity of dynamics according to physical functioning and life activity scores of SF-36. It means that these scores are the most informative ones according estimation of good results one year later.
DISCUSSION
Currently, there are not any individual objective and clear predictive criteria estimating the time course of the recovery period in patients with femur fractures. Development of these criteria can help to predict the treatment results in the late period and to target to terms of working disability. Also it allows realizing the correction of treatment, changing the rehabilitation program and determining the indications for recurrent surgery. According to our opinion, the identified differences in distribution of incidence of good results of treatment in the subgroups with use of SF-36 are natural, and they reflect the main moments in the period of rehabilitation. Consideration of all scores of the questionnaire would allow making a more precise prognosis. However the consideration of 8 parameters is much more labor-intensive process, with difficulties due to possible absence of significant differences in values of separate scores in each patient.
CONCLUSION
The use of the offered approach to estimation of the treatment process on the basis of estimation of time course of recovery of life quality according to physical functioning and vital activity scores of SF-36 favors the development of more rational plan of recovery treatment, and also allows estimating the capabilities for recovery of working and social activity.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article