D. T. Meijer, B. D. J. G. Deynoot, S. A. Stufkens, G. M. M. J. Kerkhoffs, J. N. Doornberg, Department of Orthopaedic Surgery, Academic Medical Center, Amsterdam, The Netherlands D. T. Meijer, Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands I. N. Sierevelt, Slotervaart Center of Orthopedic Research and Education, Department of Orthopaedic Surgery, Medical Centre Slotervaart, Amsterdam, The Netherlands J. C. Goslings, Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands G. M. M. J. Kerkhoffs, Academic Center for Evidence-based Sports Medicine, Amsterdam Collaboration for Health and Safety in Sports, IOC Research Center, Amsterdam, The Netherlands J. N. Doornberg, Flinders University, Adelaide, Australia.
Clin Orthop Relat Res. 2019 Apr;477(4):863-869. doi: 10.1097/CORR.0000000000000623.
Psychosocial factors, such as depression and catastrophic thinking, might account for more disability after various orthopaedic trauma pathologies than range of motion and other impairments. However, little is known about the influence of psychosocial aspects of illness on long-term symptoms and limitations of patients with rotational-type ankle fractures, including a posterior malleolar fragment. Knowledge of the psychosocial factors associated with long-term outcome after operative treatment of trimalleolar ankle fractures might improve recovery.
QUESTIONS/PURPOSES: (1) Which factors related to patient demographics, physical exam, diagnosis, or psychological well-being (in particular, depression), if any, are associated with better or worse scores on validated lower-extremity outcomes instruments after surgical treatment for rotational ankle fractures (including a posterior malleolar fragment) at long-term followup?
Between 1974 and 2002, 423 patients underwent open reduction internal fixation for rotational ankle fractures with posterior malleolar fragments according to the basic principles of the AO (Arbeitsgemeinshaft für Osteosynthesfragen). Minimum followup for inclusion here was 10 years (range, 12.5-39.4 years). When posterior malleolar fragments involved more than 25% of the articular surface as assessed on plain lateral radiographs, the fracture was generally fixed with AP or posterior-anterior (PA) screws. Of those treated surgically during the period in question, 319 were lost to followup, had too much missing data to include, or declined to participate in this study (or could not because of reasons of mental illness) (68%), leaving 104 (32%) for analysis in this retrospective study. Independent observers not involved in patient care measured disability using the patient-based Foot and Ankle Ability Measure questionnaire and using the subscale Activities in Daily Living (ADL) and pain score of the Foot and Ankle Outcome Score. General physical and mental health status was evaluated using the SF-36. Depressive symptoms were measured with the Center for Epidemiologic Studies-Depression scale score (range, 0-60 points). A score above 16 indicated a depressive disorder. Misinterpretation or overinterpretation of nociception was measured with the Pain Catastrophizing Scale score. Scores above 13.9 were considered abnormal. Statistical analyses included uni- and multivariate regression analysis. In general, patients in this series reported good to excellent outcomes; the mean ± SD scores were 91 ± 15 for Foot and Ankle Ability Measure, 93 ± 16 for Foot and Ankle Outcome Score (ADL), 91 ± 15 for Foot and Ankle Outcome Score (pain), 49 ± 9 for SF-36 mental component score, and 52 ± 9 for SF-36 physical component score.
Implant removal (β = -8.199, p < 0.01) was associated with worse Foot and Ankle Ability Measure scores. Better flexion/extension arc (β = 0.445, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (β = -0.527, p < 0.01) were associated with better Foot and Ankle Ability Measure scores. Osteoarthritis (β = -4.823, p < 0.01) was associated with worse Foot and Ankle Outcome Score (pain) scores. Better flexion/extension arc (β = 0.454, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (β = -0.596, p < 0.01) were associated with better Foot and Ankle Outcome Score (pain) scores. Better flexion/extension arc (β = -0.431, p < 0.01) and lower Center for Epidemiologic Studies-Depression scores (β = -0.557, p < 0.01) were associated with better Foot and Ankle Outcome Score (ADL) scores. Finally, we found that a better inversion/eversion arc (β = 0.122, p = 0.024) was associated with better SF-36 physical component score and that a lower Center for Epidemiologic Studies-Depression score (β = -0.567, p < 0.01) was associated with better SF-36 mental component score.
Psychological aspects of recovery from musculoskeletal injury merit greater attention, perhaps even over objective, unmodifiable predictors. A mean of 24 years after surgical treatment of ankle fractures with a posterior malleolar fragment, patient-reported outcome measures have little to do with pathophysiology; they mostly reflect impairment and depression symptoms. Further research is needed to determine whether early indentification and treatment of at-risk patients based on psychosocial factors can improve long-term outcomes.
Level III, therapeutic study.
心理社会因素，如抑郁和灾难性思维，可能比运动范围和其他损伤对各种骨科创伤病理后的残疾程度影响更大。然而，对于旋转型踝关节骨折患者（包括后踝骨碎片），术后长期症状和功能受限与疾病的心理社会方面的关系知之甚少。了解与三踝骨折手术后长期结果相关的心理社会因素可能会改善康复。
问题/目的：（1）在长期随访中，与患者人口统计学、体格检查、诊断或心理健康（特别是抑郁）相关的哪些因素，如果有的话，与手术治疗旋转型踝关节骨折（包括后踝骨碎片）后使用经过验证的下肢结局测量工具的更好或更差评分相关？
1974 年至 2002 年间，根据 AO（骨科学研究协会）的基本原则，423 例患者接受切开复位内固定治疗伴后踝骨碎片的旋转型踝关节骨折。本研究的纳入标准为至少随访 10 年（范围，12.5-39.4 年）。当后踝骨碎片在标准侧位 X 线片上评估时涉及关节面的 25%以上时，通常使用 AP 或后前（PA）螺钉固定骨折。在研究期间接受手术治疗的 319 例患者中，319 例失访，或因数据缺失过多而无法纳入，或拒绝参与本研究（或因精神疾病原因无法参与）（占 68%），因此仅 104 例（占 32%）可用于回顾性研究。不参与患者护理的独立观察者使用基于患者的足踝能力测量问卷以及日常生活活动（ADL）和足踝结局评分的疼痛评分来衡量残疾程度。使用 SF-36 评估一般身体和心理健康状况。使用中心流行病学研究抑郁量表评分（范围，0-60 分）评估抑郁症状。评分高于 16 分表示存在抑郁障碍。使用疼痛灾难化量表评分测量对疼痛的误解或过度解释。评分高于 13.9 分被认为异常。统计分析包括单变量和多变量回归分析。一般来说，本系列患者报告了良好到极好的结果；足踝能力测量的平均±SD 评分为 91±15，足踝结局评分（ADL）为 93±16，足踝结局评分（疼痛）为 91±15，SF-36 心理成分评分为 49±9，SF-36 生理成分评分为 52±9。
植入物去除（β=-8.199，p<0.01）与足踝能力测量评分较差相关。更好的屈伸弧（β=0.445，p<0.01）和更低的中心流行病学研究抑郁量表评分（β=-0.527，p<0.01）与更好的足踝能力测量评分相关。骨关节炎（β=-4.823，p<0.01）与足踝结局评分（疼痛）较差相关。更好的屈伸弧（β=0.454，p<0.01）和更低的中心流行病学研究抑郁量表评分（β=-0.596，p<0.01）与足踝结局评分（疼痛）更好相关。更好的屈伸弧（β=-0.431，p<0.01）和更低的中心流行病学研究抑郁量表评分（β=-0.557，p<0.01）与足踝结局评分（ADL）更好相关。最后，我们发现更好的内翻/外翻弧（β=0.122，p=0.024）与 SF-36 生理成分评分更好相关，而更低的中心流行病学研究抑郁量表评分（β=-0.567，p<0.01）与 SF-36 心理成分评分更好相关。
肌肉骨骼损伤康复过程中的心理社会方面值得更多关注，甚至可能超过客观的、不可改变的预测因素。在接受后踝骨碎片的踝关节骨折手术治疗 24 年后，患者报告的结局测量结果与病理生理学关系不大；它们主要反映了损伤和抑郁症状。需要进一步研究，以确定是否可以根据心理社会因素早期识别和治疗高危患者，从而改善长期结果。
III 级，治疗性研究。
