Abstract
Background:
The Life Space Assessment (LSA) is a validated outcomes measure that aims to assess the level of mobility and physical functioning within one’s own environment following a medical event. We sought to study the recovery of geriatric ankle fracture patients utilizing the LSA. We hypothesized that the LSA would provide improved assessment of these patients and help identify key differences in operative and nonoperatively treated patients.
Methods:
Prospective observational study of geriatric patients age 65 years and older with an ankle fracture with 1-year follow-up. Operative versus nonoperative intervention was determined by the attending physician on a patient-specific basis. The LSA, Short Form–36 (SF-36), and visual analog pain scale (VAPS) were administered at predetermined intervals postinjury and scores were analyzed for significance.
Results:
20 patients were enrolled in this study. 11 underwent surgery whereas 9 were treated nonoperatively. Regardless of treatment, the preinjury LSA score was 86.7. This significantly dropped to 20.6 at 6 weeks and recovered to 73.6 at 12 months. In the operative cohort, the LSA scores preinjury were 91.4 and improved to 87.6 after 1 year. The nonoperative group recorded 80.9 preinjury and only improved to 59.5 at 1 year (P = 0.007). There was no statistically significant difference when comparing the results of the SF-36 and VAPS to the LSA.
Conclusion:
The LSA was effective in assessing recovery in geriatric ankle fracture patients. A severe deficit in mobility was seen for the first 6 months of recovery regardless of treatment. Operative patients ultimately returned to their baseline LSA at 1 year while nonoperative patients did not. Outcomes from the VAS and SF-36 mirrored the LSA but were not found to be statistically significant.
Level of Evidence:
Level II.
Introduction
Ankle fractures are the third most common type of fracture seen in the elderly patient population, second only to hip and distal radius fractures.1,2,4,6 –8,14 It is estimated that annually 1 of every 3 elderly patients experience a fall, and 20% of these falls result in serious injury such as a fracture.1,2,4,6 –8,14 Recent work has shown that operative intervention of geriatric ankle fractures yields less morbidity and mortality as compared to conservative treatment, suggesting that the improved early mobility after an operative intervention may play a protective role. 3 However, current outcome measures such as the Short Form-36 (SF-36) and visual analog pain scale (VAPS) do not specifically assess mobility, and it has been our experience that they tend to demonstrate a floor and ceiling effect that makes their use limited in this particular patient population.
In this study, we utilized the Life Space Assessment (LSA) to evaluate a cohort of geriatric ankle fracture patients. The LSA is a validated medical assessment that focuses specifically on how a patient functions within his or her environment (ie, “life space”) following a medical event. The survey assesses where and how often patients travel within their environment and any assistance needed to accomplish that task during the 4 weeks leading up to the assessment. Mobility, in terms of life-space, can be visualized as a pattern of areas defined by distance extending from the location where a person sleeps (Figure 1). The LSA permits the assessment of mobility across a wide spectrum of environments and limitations. This can range from mobility dependent on the assistance of another person limited to the room where he or she sleeps, to daily independent travel out of the person’s town. 12 The LSA contains 5 subscores that are summed to obtain the composite score. Each subscore is obtained by multiplying the corresponding life space level by its frequency and independence. Scores range from 0 to 120, with higher scores indicating greater mobility (Figure 2). 12 Previous authors have effectively used this measure to demonstrate a correlation between or change in the life space of elderly patients following general nonoperative and operative hospitalizations, gynecological surgery, and mental illness such as depression.5,13,15 This assessment, however, has never been applied to the field of orthopedics. Although many functional and physical performance assessments determine what patients are able to do, the LSA reveals what patients actually do and whether assistance is needed. 12
Conceptual model showing life-space levels as a series of concentric areas radiating from the room where a person sleeps with average survey scores and standard deviations for each level. 9
Example of scoring of the Life-Space Assessment. The subject traveled to all levels (levels 1–4) except for out of town (level 5); traveled daily to levels 1 and 2, and traveled 1 to 3 times each week to levels 3 and 4; uses a cane at all times and requires assistance with driving. 9
It is well understood throughout the orthopedic literature that maintaining mobility following an injury or surgery leads to improved functional outcomes and reduces risk of medical complications. 4 This is especially true in the elderly population. This patient group tends to have more medical comorbidities and lower baseline physical function compared to younger patients. Therefore, it is important for clinicians to understand just how profound of an impact a relatively common injury such as an ankle fracture can have in this geriatric population. Thus, in an attempt to eliminate the floor and ceiling effect of other commonly used physical functioning assessments such as the SF-36 and VAPS, we chose to study the mobility of this cohort throughout recovery using the LSA.
The purpose of this study was to serve as a pilot study to assess the LSA’s effectiveness in measuring postinjury mobility in geriatric patients with ankle fractures in order to better understand the impact that this injury can have on this particular population. Secondarily, we attempted to identify any key differences between patients treated nonoperatively and with open reduction and internal fixation in an effort to assess recovery based on treatment modality. We postulated that the LSA would provide a more accurate representation of mobility in geriatric ankle fracture patients as compared to the SF-36 and VAPS and demonstrate that this injury is severely limiting in this population. Additionally, we hypothesized that operatively managed ankle fractures would demonstrate improved mobility throughout recovery compared to nonoperative fractures.
Material and Methods
We conducted an institutional review board–approved prospective observational study including patients aged 65 years and older with any type of ankle fracture. Patients of a single surgeon who met the inclusion criteria were invited to participate in the study when they presented for their initial visit after injury. The decision between operative and nonoperative treatment was based on fracture pattern and patient factors. Isolated lateral malleolar fractures without radiographic evidence of talar instability were managed nonoperatively with immediate weightbearing as tolerated in a boot. Bimalleolar, bimalleolar-equivalent, and trimalleolar fractures were managed operatively unless the patient’s medical/functional status biased the risk-benefit analysis toward nonoperative treatment. The LSA was administered at the initial visit as a measure of preinjury status and also at 6 weeks, 3 months, 6 months, and 12 months post injury/surgery. The SF-36 and VAPS surveys were administered at 6 and 12 months solely as a standard of care in this practice. Survey scores for all 3 were tallied, and standard means were determined for each time point. Statistical analyses as outlined below were performed to determine significance.
We identified 26 patients who met inclusion criteria, and 20 were enrolled in the study over a 2.5-year period. Five participants were male and 15 were female (P = 1.0). Eleven patients underwent surgery whereas 9 were treated nonoperatively. The average age of the entire cohort was 74.8 years. The average age of the nonoperative group was 74.2 and the operative group was 75.4 years (P = .70). The average number of medical comorbidities for the entire group was 2.9 (SD = 2.0). The nonoperative group averaged 3.5 (SD = 2.2) medical problems whereas the operative group averaged 2.3 (SD = 1.7) (P = .18). Six patients had stable isolated lateral malleolar fractures and all were managed nonoperatively. We identified 10 bimalleolar or bimalleolar-equivalent fractures and 7 were managed operatively. We identified 4 trimalleolar fractures and all were managed operatively. The difference in fracture morphology was found to be statistically significant (P = .0012) (Table 1).
Descriptive Statistics.
Abbreviation: ORIF, open reduction internal fixation.
Statistical Analysis
The descriptive statistics for gender, age, and medical comorbidities were tested using a t test. Fracture morphology was tested using a Fisher exact test. Unadjusted means and standard deviations of all surveys collected at each time point were calculated. Additionally, because of the small sample sizes, medians and interquartile ranges (IQRs) were calculated for each survey and time point. The results of the Life Space survey were examined by treatment and time period using a repeated measures linear means model. Using these models, adjusted means and 95% confidence intervals were calculated for each time period. In addition to the previous analysis, the results of the Life Space survey were compared to the results of the VAPS and SF-36 Mental and Physical scores. All surveys were examined across treatment and the 6- and 12-month time periods using a repeated measures linear means model for the 6- and 12-month time periods. All analyses were completed using Statistical Analysis Software (SAS) v9.4 (Cary, NC) at an alpha level of 0.05. A power analysis for this study was unable to be performed as this was a pilot study looking at survey outcomes that have not been applied to this patient population. The data from this study will be used to determine power for subsequent studies.
Results
The unadjusted descriptive statistics for each survey were calculated over time (Table 2). The LSA score for the cohort was 86.7 preinjury. This declined to 20.7 at 6 weeks post injury and gradually rose to 73.6 at 12 months. The operative LSA group scored 91.4 preinjury and 19.2 at 6 weeks, which improved to 87.6 after 1 year. The nonoperative LSA group recorded 80.88 preinjury, 22.3 for 6 weeks, and only improved to 59.5 at 1 year. For the VAS survey, operative patients reported pain of 2.2 and 1.4 at 6 and 12 months respectively. Nonoperative VAS patients recorded pain of 2.3 and 2.4 at 6 and 12 months respectively. For SF-36 physical score, operative patients recorded 57.6 and 70.9 at 6 and 12 months, while nonoperative patients scored 53.2 and 60.1. SF-36 mental scores for the operative group were 60.6 and 77.8 at 6 and 12 months, while nonoperative patients recorded 76.9 and 86.50.
Unadjusted Descriptive Statistics for Surveys Over Time.
Abbreviations: LSA, Life Space Assessment; ORIF, open reduction internal fixation; SF-36, Short Form–36; VAS, visual analog scale.
The adjusted descriptive statistics solely for the LSA in a comparison of operative and nonoperative treatment using a 95% confidence level were calculated (Table 3). This was performed in an effort to dampen the effect of outliers in a smaller sample size. The results of this table are graphically plotted in Figure 3. The adjusted LSA means for the nonoperative group were 78.7 preinjury, 22.3 at 6 weeks, and rose to 67.6 at 12 months. The operative group recorded LSA means of 91.4 preinjury, 19.1 at 6 weeks, and improved to 86.7 at 12 months. A statistical comparison of LSA outcomes-based treatment yielded a P value of <.01.
Adjusted Descriptive Statistics for LSA Total Over Time.
Abbreviations: CI, confidence interval; LSA, Life Space Assessment; ORIF, open reduction internal fixation.
Adjusted means of LSA total scores by time and treatment, P value = .0070.
Finally, adjusted descriptive statistics for all surveys at 6 months and 12 months using a 95% confidence interval were calculated (Table 3) The P values for the results of the LSA, VAPS, and SF-36 Mental and Physical components were found to be 0.14, 0.84, 0.90, and 0.74 respectively. None of the results were found to be statistically significant as there was no single P value <.05.
Discussion
Ankle fractures represent a very common medical problem facing the geriatric population, and the incidence is on the rise. 9 Limited mobility, multiple medical comorbidities, poor bone quality, and frequent falls all contribute to the high incidence of ankle fractures in this unique patient population. Despite the common nature of geriatric ankle fractures, the true impact of this injury on mobility is underreported and underappreciated. This study aimed to highlight the effectiveness of the LSA in quantifying the mobility of geriatric ankle fracture patients throughout recovery.
Regardless of treatment regimen, patients saw a rapid decline in life space scores following injury, and this persisted through the 6-week assessment. The average preinjury LSA score of the group regardless of treatment was 86.7, which is generally consistent with Level 5 life space functioning with little to no limitations. However, following injury, the group as a whole averaged 20.7 at 6 weeks, which is consistent with Level 1 or 2 life space. These patients demonstrated severe limitations, needing maximum assistance, and rarely left the home. In fact, many patients seldom left their room on a regular basis and only left the house to make their clinic appointment. At 1 year, the group averaged a life space score of 73.6, which was a deficit of 13.1 points from the preinjury state. This loss can be equated to a constriction of independent movement by one life space zone, such as from within one’s town to within one’s neighborhood.
The LSA has been used to evaluate geriatric patients following medical and operative hospital admissions as well as following elective urogynecological and nonelective gynecological oncology procedures. The investigators found a 23-point decline in life space score following nonelective gynecological oncology surgery 15 ; however, this returned to baseline at 6 months and was maintained out to 1 year. Additionally, the LSA has been retrospectively evaluated after hospitalization for general medical and operative admissions. 5 Patients who were hospitalized for various major surgeries were found to have a life space score decline of 23 points; however, this returned to baseline at 1 year. Comparatively, we found an average life space score decreased by 66 points following injury or surgery at the 6-week mark. Unlike patients in these 2 studies, geriatric ankle fracture patients treated operatively were still significantly limited at 6 months but ultimately recovered to near baseline by 1 year. This highlights the significant level of impairment seen throughout recovery with this injury.
When assessing recovery based on treatment regimen using the LSA, we found that operative patients nearly returned to their baseline score, whereas nonoperative patients continued to have lower mobility at 12 months In looking at the adjusted means for the LSA in Table 3, the life space score deficit between preinjury and 12 months in the nonoperative group was 11.1 whereas in the operative group it was only 4.7. This outcome difference equates to an approximate loss of 1 life space level in the nonoperative group at 12 months compared to the operative group. Regardless of treatment, patients appeared to be significantly limited in mobility for the first 3 months; however, operative patients’ recovery ultimately surpassed that of nonoperative patients at 12 months, and this was statistically significant. In concordance with prior studies looking at generalized outcomes of operative ankle fractures in elderly patients, this study demonstrated satisfactory subjective outcomes at 12 months. 3 It is important to point out that there was no statistical difference in terms of patient gender, age, and number of medical comorbidities. Thus, this appears to be a matched cohort albeit a small, underpowered sample size.
The results of the VAPS mirrored those of the LSA but there was no statistical difference between the results of the surveys at 6 and 12 months. Operative patients reported pain of 2.2 and 1.4 at 6 and 12 months, respectively, whereas nonoperative patients recorded pain of 2.3 and 2.4, indicating mild improvement of pain in the surgically managed patients compared to no improvement in pain in nonoperatively managed patients This resembles the results of the LSA in that operative patients improved more so than nonoperative patients by the 12-month mark. As patients in the nonoperative group demonstrated higher residual pain after 12 months, in addition to lower LSA scores, there may be an association between the higher residual pain and decreased mobility in this patient group. However, is important to note that we did not collect preinjury VAS scores as this wasn’t the standard of care in this clinic. Therefore, it is difficult to determine the significance of these pain levels as well as their clinical significance.
The SF-36 physical and mental scores both improved between 6 and 12 months overall and in both treatment groups. The operative patients recorded scores of 57.6 and 70.9 at 6 and 12 months, whereas nonoperative patients scored 53.2 and 60.1 on the SF-36 physical (P = .74). SF-36 mental scores for the operative group were 60.6 and 77.8 at 6 and 12 months, whereas nonoperative patients recorded 76.9 and 86.50 (P = .90). The SF-36 physical survey was satisfactory in being able to capture the improvement in function throughout recovery. Additionally, it demonstrated the improved functioning with operative patients over nonoperative patients, as seen with the LSA, but none of the comparisons were statistically significant. Therefore, we were unable to conclude that the LSA was superior to the SF-36 physical survey in assessing physical functioning following an ankle fracture in the geriatric population. However, keep in mind that the SF-36 score is a comprehensive measure of overall physical functioning. The LSA, on the other hand, not only demonstrates true mobility but also ties in how frequent and the degree of assistance required. It documents what patients actually do, not what they can do.
Although there was a trend toward improved scores in the LSA, VAPS, and SF-36 physical scores at 6 and 12 months in operatively managed patients, there was no statistical significance when comparing adjusted means of each survey at 6 and 12 months (Table 4). The P value was .1405 for the LSA, which was lower than the other 3 surveys. One could generalize that the results of the LSA seen with this study are less likely to occur by random chance given a lower P value, albeit this is still not statistically significant.
Adjusted Descriptive Statistics for All Surveys at 6 and 12 Months.
Abbreviations: LSA, Life Space Assessment; ORIF, open reduction internal fixation; SF-36, Short Form–36; VAS, visual analog scale.
The improved results of operatively managed geriatric ankle fractures highlighted in this study are consistent with most of what is seen in the current literature. For example, prior Medicare database studies determined the 1-year mortality among those who underwent operative treatment of their geriatric ankle fractures to be 6.7% and 9.1% at 1 year whereas nonoperative fractures showed a mortality of 9.2% and 21.5%.3,10,11 Based on this study, one can deduce that the LSA has effectively demonstrated improved mobility at the 12-month time point in this patient population that undergoes surgery. Thus, an extrapolation can be made that the improved mobility seen in the operative group may be directly related to a lower mortality rate.
This study has several limitations. It is limited by its small number of participants (n = 20) and thus is substantially underpowered. Additionally, although the LSA is a great modality for assessing functional recovery following an injury such as an ankle fracture, the scores can be affected by multiple variables (ie, preinjury functional status, recent changes in medical health, comorbidities, etc). Although our small sample size did not yield a statistical difference in descriptive statistics and number of medical comorbidities, a higher preinjury LSA score in our operative group was noted that may be attributable to the specific medical comorbidities and overall medical/physical health of this cohort. There was a statistical difference in terms of the types of fractures that were treated nonoperatively and operatively, as one would expect, based on the stability of the injury and specific patient situation. The decision for surgery was made by the attending physician on a patient-specific basis, and this can inherently introduce selection bias into the study. Some of the typically operative fractures were managed nonoperatively because of the overall health/function of the patient, and thus this could be reflected in the poorer results of the nonoperative group. Lastly, a high level of patient attrition was seen throughout the course of data collection over 1 year, especially in the LSA group at 6 and 12 months.
Conclusion
In conclusion, this pilot study was designed to assess how effective the LSA would be in quantifying the mobility deficits seen following geriatric ankle fractures. The LSA was able to highlight this deficit. When comparing outcomes based on intervention, we found a statistically significant improvement in mobility in the operative patients. We also assessed the LSA alongside the SF-36 and VAPS and we did not find a statistical difference; however, this result should be viewed with caution as this study was not adequately powered. On the other hand, these data will serve to aid in the determination of power in future investigations. The LSA may ultimately prove to be a better measure of functional status in the elderly because it documents a patient’s true mobility and participation in society over time and space. This allows us to appreciate not only what patients can do, but what they are actually doing. 11
Footnotes
This article was originally published as: Ahearn B, Mueller C, Boden S, Mignemi D, Tenenbaum S, Bariteau J. Assessment of recovery from geriatric ankle fracture using the life space mobility assessment (LSA): a pilot study. Foot Ankle Orthop. 2018 Oct 29;3(4):2473011418795160. doi:10.1177/2473011418795160.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
