Adverse Mental Health Outcomes After Modern External Ring Fixation Versus Internal Fixation for Severe Open Tibia Fractures: A Secondary Analysis of the FIXIT Study.

OBJECTIVES

To report the prevalence of adverse mental health outcomes 1 year after severe open tibial shaft fractures and their association with treatment and complication risk factors.

DESIGN

Randomized controlled trial.

SETTING

Multicenter.

PATIENT SELECTION CRITERIA: Eligible patients were 18-64 years of age with severe open tibial shaft fractures (AO/OTA 41-43) treated with modern external ring fixation or internal fixation. All Gustilo-Anderson type IIIB fractures were included and some type IIIA meeting specific severity criteria.

OUTCOME MEASURES AND COMPARISONS: Outcome measures included Patient Health Questionnaire scores for depression symptoms, posttraumatic stress disorder (PTSD) Checklist for DSM-IV (PCL-S), and the Brief Pain Inventory. Primary comparisons assessed depression, PTSD, and pain between treatment groups (modern external ring fixation vs. internal fixation).

RESULTS

A total of 254 patients were treated with external ring fixation (n = 121) or internal fixation (n = 133). The mean age was 39 years (SD = 13) and 16% were female. At 12 months after injury, 34% of patients had Patient Health Questionnaire-9 scores consistent with moderate to severe depression. Risk factors for depression were female sex (RR: 1.70 [1.01-2.86]), high school educational attainment or less (RR: 1.93 [1.27-3.04]), and any baseline mental health condition (RR: 1.91 [1.22-2.99]), all P < 0.05. At 12 months, 45% of patients met criteria for PTSD. Any baseline mental health condition was a risk factor for developing PTSD (RR: 2.07 [1.50-2.88]), P < 0.001. Protective factors against the development of depression and PTSD included higher self-efficacy at 6 weeks after injury and any major limb complication (eg, infection) within 12 months, both P < 0.01. Moderate to severe daily pain interference was reported by 49% of participants at 12 months and was associated with high school-level education attainment or less (RR: 1.41 [1.03-1.94]) and was mitigated by self-efficacy at 6 weeks postinjury (RR: 0.53 [0.38-0.74]), both P < 0.05. Fixation modality (external ring fixation vs. internal fixation) was not associated with depression (RR: 0.82 [0.83-1.27], P = 0.37), PTSD (RR: 1.06 [0.77-1.48], P = 0.71), pain intensity (RR: 0.98 [0.63-1.51], P = 0.92), or pain interference (0.96 [0.70-1.33], P = 0.83).

CONCLUSIONS

Mental health sequelae and moderate to severe pain were common 1 year after sustaining a severe open tibial shaft fracture. Adverse mental health outcomes and pain were not influenced by fixation modality (external ring fixation vs. internal fixation).

LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.