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.

Methods

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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.