The present study investigated the radiological and functional outcomes of intentional fallers after osteosynthesis for their pelvic and acetabular fractures and compared their clinical outcomes to those who fell accidentally. The results revealed that all patients who fell intentionally had pre-existing mental disorders. Additionally, intentional fallers presented with female sex predominance, higher ISS, NISS, AIS-chest, AIS-abdomen, and longer hospital stay. However, the result of early loss of fixation and functional outcomes at the 6- and 12-month follow-up did not significantly differ between the intentional and accidental fallers.
Falls, regardless of the etiologies, cause great impact to the socio-economic development. Accidental fallers are usually at the working age; hence, they have financial contributions to their families and society . Functional disability following a fall injury may impact their work productivity. On the other hand, intentional fallers, also called suicide jumpers, are a popular public health concern affecting low to advanced societies [8–16]. In Taiwan, suicide is the second leading cause of death among young people aged 15–24 years, the third among those aged 25–44 years, and the 12th in the general population . Regardless of the reason of fall, all survivors in our case series fell from a height of > 6 m and hit architectural ledges or fell onto hard-impact sites. Thus, they obtained higher ISS and NISS when compared to those patients in previous reports [2, 8].
According to the literature, the suicidal risk is 10 times higher in patients with psychiatric disorder than those without such disorders; at least one psychiatric disorder was reported between 60% and 98% of individuals who committed or attempted suicide [18–20]. The most common mental disorder found in people who committed suicide is depressive disorder (35–80%), followed by schizophrenia (10%) and dementia or delirium (5%), which was in line with the result of our study . Prevention of suicidal attempts is also a key point to reduce the morbidity and mortality from suicide. In our series, all intentional fallers were reported to have pre-existing mental disorders. A routine psychiatric consultation was performed for each faller with an existing mental disorder in our series, and medication treatment and mental health consultation were conducted to prevent fall accidents from occurring again. Fortunately, more than half of the intentional fallers complied well to the medical orders; thus, there were no recidivisms during our follow-up period.
In general, post-osteosynthesis patients should strictly follow the medical advice and rehabilitation protocols in the early postoperative stage to prevent fixation failure, especially for those with unstable pelvic and acetabular fractures. The patients with mental disorders were thought to have a poorer compliance to medical orders [2, 22, 23]. Under this concept, we expected that intentional fallers with pelvic and acetabular fractures would have a higher incidence of fixation failure than accidental fallers. Although 25% of the incidental fallers experienced fixation failure at the early stage, no significant difference was found between the I and A groups (P = 015). This finding might indicate that a secure fixation against the fractures was made for all of the patients, which allowed them to start with gait training as soon as possible. For the accidental fallers, they were too eager to return to their activities of daily living as well as return to work so that they could earn and would not be laid out from their jobs. Therefore, we noticed a 13% loss of reduction and fixation in accidental fallers during our follow-up.
Several factors were associated with functional outcomes following orthopedic surgeries, such as the characteristic of fractures, quality of reduction and fixation, complications, rehabilitation protocol, patients’ compliance, and so on [23–28]. During the study period, the principles, implants, surgical techniques, and physical therapies for treating pelvic and acetabular fractures were similar for all patients. Therefore, the influence of surgeons’ and therapists’ factors could be minimized. Our data revealed that the severity of injury and length of hospital were statistically higher and longer in the I group than in the A group. However, at the 6-month and 12-month evaluations, there was no difference in the functional outcomes between the two groups. During the interviews of all patients, we found that most of the intentional fallers were satisfied and thankful of the outcomes, whereas the accidental fallers had more complaints with their present situation and their functional disability.
Although we made efforts to prevent any biases from occurring, there were still some limitations in the current study. First, relatively small populations were enrolled into this study. Although we tried to contact the cohort for outcome evaluation, only 73.5% of the patients completed radiological and functional outcomes. Nevertheless, two of the important findings of our study were that the functional outcomes of the intentional fallers were not inferior to those of the accidental fallers if the fractures were managed appropriately and that there was no recidivism during the follow-up period. Second, we classified the patients by etiologies of injuries according to their self-report history. The true numbers of intentional fallers with mental disorders might be under-reported, thereby affecting the results of the analysis. Lastly, the concept of functional evaluations of pelvic and acetabular fractures may be different. We found that 22.4% (11/49) of the cohort were diagnosed with commitment pelvic and acetabular fractures. Therefore, we used two evaluation scales (Merle d'Aubigné hip score and Majeed hip score) to evaluate their functional performance during activities of daily living. In the future, a large sample size should be enrolled, and these patients should undergo routine psychiatric examination to determine their mental condition. In addition, different evaluation tools, such the Short Form-36 and other hip functional scores, should be applied to comprehensively evaluate the patients.
In conclusion, intentional fallers with pelvic and acetabular fractures might not have worse clinical presentations compared to accidental fallers. Under a well-designed surgical protocol and individualized physical and mental rehabilitation program, the radiological and functional outcomes of the intentional fallers could be comparable to those of the accidental fallers.