BACKGROUND/RATIONALE:
Osteoporotic-related fractures are a serious problem for patients with Spinal Cord Injury (SCI). However, best management for acute care of these fractures including whether surgical vs. nonsurgical treatment should be done and the factors that influence this decision is not known. This point is well appreciated by providers, who have identified to SCI QUERI that research to establish best practices for treatment of fractures in patients with a SCI should be a priority area. Surgical treatment for lower extremity fractures is done more frequently than previously reported, with approximately 10-37% of these fractures now managed surgically. The review of the literature conducted for this study suggests that surgical management for lower extremity osteoporotic fractures in SCI may be associated with fewer complications than nonsurgical management. However, the factors that influence the choice of surgical vs. nonsurgical fracture treatments and outcomes following these therapies have not been described. In this study we will utilize administrative databases, semi-structured questionnaires and case scenarios, and convene an outstanding advisory panel to review this information and existing literature to start the process of understanding best management for osteoporotic fractures in SCI. We will include both patients and providers (orthopedic surgeons and physical medicine and rehabilitation [PM&R] physicians) in the surveys. This study is of direct, immediate potential clinical benefit to the expanding population of patients with SCI. It will provide invaluable information for providers to better be able to care for these patients when they sustain an osteoporotic fracture.

OBJECTIVE(S):
Specific Aim 1: To develop a consensus-based decision support guide for managing fractures in SCI.

Specific Aim 2: To understand factors that lead to adverse outcomes following lower extremity fracture treatment.

Specific Aim 3: To examine patient and provider perceptions and decision-making processes concerning optimal treatment of lower extremity fractures.

METHODS:
This project will include a systemic review of the existing literature, structured chart abstractions of patients with adverse events, semi-structured interviews with patients and providers and hypothetical fracture case surveys for providers. Information will be presented to an expert advisory panel for review, synthesis and creation of a decision support tool.

FINDINGS/RESULTS:
No findings at this time; we are collecting data from the administrative data files, chart reviews, provider surveys and from patient and provider interviews.
Literature review from our DOD study on osteoporosis suggests that surgical management of fractures may result in fewer adverse events than medical management.

IMPACT:
Understanding of optimal management of acute fractures in SCI can substantially and positively impact quality of life and potentially reduce post fracture morbidity and mortality in patients with SCI. Results are pending. Impact will be a best practices guide for providers to facilitate informed decision making.

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External Links for this Project

NIH Reporter

Grant Number: I01HX002090-01A2
Link: https://reporter.nih.gov/project-details/9293507

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PUBLICATIONS:

Journal Articles

1. Elam R, Doan J, Weaver F, Ray C, Miskevics S, Gonzalez B, Obremskey W, Carbone L. "Pathological" fractures in spinal cord injuries and disorders: Insight into International classification of diseases, ninth revision coding. The journal of spinal cord medicine. 2023 Mar 1; 46(2):317-325. [view]
2. Carbone LD, Ahn J, Adler RA, Cervinka T, Craven C, Geerts W, Hsu JR, Huang D, Karunakar MA, Kiratli BJ, Krause PC, Morse LR, Mirick Mueller GE, Nana A, Rogers E, Rivera JC, Spitler C, Weaver FM, Obremskey W. Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury: 2022 Delphi Consensus Recommendations. JB & JS open access. 2022 Dec 8; 7(4). [view]
3. Morse LR, Biering-Soerensen F, Carbone LD, Cervinka T, Cirnigliaro CM, Johnston TE, Liu N, Troy KL, Weaver FM, Shuhart C, Craven BC. Bone Mineral Density Testing in Spinal Cord Injury: 2019 ISCD Official Position. Journal of clinical densitometry : the official journal of the International Society for Clinical Densitometry. 2019 Oct 1; 22(4):554-566. [view]
4. Etingen B, Carbone LD, Guihan M, Ray C, Aslam H, Elam R, Weaver FM. Lower extremity fracture prevention and management in persons with spinal cord injuries and disorders: The patient perspective. The journal of spinal cord medicine. 2022 Nov 1; 45(6):946-956. [view]
5. Le B, Gonzalez B, Weaver F, Sinnott B, Ray C, Chu E, Premji S, Raiford M, Mayur O, Carbone L. Malunions following lower extremity fractures in veterans with a spinal cord injury/disorder. The journal of spinal cord medicine. 2023 Mar 28; 1-7. [view]
6. Guihan M, Roddick K, Cervinka T, Ray C, Sutton C, Carbone L, Weaver FM. Physical and occupational therapist rehabilitation of lower extremity fractures in veterans with spinal cord injuries and disorders. The journal of spinal cord medicine. 2022 Jan 1; 45(1):33-41. [view]
7. Elam RE, Ray CE, Miskevics S, Weaver FM, Gonzalez B, Obremskey W, Carbone LD. Predictors of lower extremity fracture-related amputation in persons with traumatic spinal cord injury: a case-control study. Spinal Cord. 2023 Apr 1; 61(4):260-268. [view]
8. Zleik N, Weaver F, Harmon RL, Le B, Radhakrishnan R, Jirau-Rosaly WD, Craven BC, Raiford M, Hill JN, Etingen B, Guihan M, Heggeness MH, Ray C, Carbone L. Prevention and management of osteoporosis and osteoporotic fractures in persons with a spinal cord injury or disorder: A systematic scoping review. The journal of spinal cord medicine. 2019 Nov 1; 42(6):735-759. [view]
9. Sinnott B, Ray C, Weaver F, Gonzalez B, Chu E, Premji S, Raiford M, Elam R, Miskevics S, Parada S, Carbone L. Risk Factors and Consequences of Lower Extremity Fracture Nonunions in Veterans With Spinal Cord Injury. JBMR plus. 2022 Mar 1; 6(3):e10595. [view]
10. Weaver FM, Etingen B, Guihan M, Ray C, Priebe M, Burns S, Carbone L. Spinal cord injury providers' perspectives on managing sublesional osteoporosis. The journal of spinal cord medicine. 2020 Jul 1; 43(4):428-434. [view]
11. Huang D, Weaver F, Obremskey WT, Ahn J, Peterson K, Anderson J, Veazie S, Carbone LD. Treatment of Lower Extremity Fractures in Chronic Spinal Cord Injury: A Systematic Review of the Literature. PM & R : the journal of injury, function, and rehabilitation. 2021 May 1; 13(5):510-527. [view]

DRA: Health Systems, Brain and Spinal Cord Injuries and Disorders
DRE: Treatment - Observational, TRL - Applied/Translational
Keywords: Best Practices, Guideline Development and Implementation, Risk Factors, Spinal Cord Injury
MeSH Terms: none