ORIGINAL ARTICLE
Loss of Follow-up in Orthopaedic Trauma: Who Is Getting
Lost to Follow-up?
Boris A. Zelle, MD,* Frank A. Buttacavoli, MD,* Jeffrey B. Shroff, BS,* and
Jacob B. Stirton, MD
Objectives: Noncompliance with postoperative follow-up visits
remains a common problem in orthopaedic trauma. The aim of this
study was to identify risk factors for loss of follow-up after
orthopaedic trauma.
Design: Retrospective review.
Setting: Urban level 1 academic trauma center.
Patients: A total of 307 (226 men/81 women) patients undergoing
surgical treatment of their orthopaedic injuries were included in this
study. The average age was 40.4 6 17 years.
Intervention: All patients were treated surgically for their
orthopaedic injuries and were instructed to follow-up in the
orthopaedic trauma clinic after hospital discharge.
Main Outcome Measurements: Noncompliance with follow-up
appointment at 6 months after injury.
Results: Over a 6-month postoperative period, a total of 215
patients were noncompliant with at least one of their follow-up
appointments between hospital discharge and the 6-month follow-
up. A logistic regression showed male gender, uninsured or
government insurance, and smoker to be statistically signicant risk
factors for noncompliance with the 6-month follow-up (P , 0.05).
Noncompliance with any follow-up appointment was signicantly
increased in patients with illicit drug abuse (P = 0.02) as per logistic
regression analysis.
Conclusions: Loss of follow-up is a common problem in
orthopaedic trauma. Our study suggests different risk factors
for noncompliance, including male gender, smoker, lack of
commercial health insurance, and illicit drug abuse. Health care
providers may consider establishing protocols for facilitating
follow-up appointments to patients who are at risk for
noncompliance.
Key Words: compliance, follow-up, trauma
Accepted for publication March 30, 2015.
From the *Division of Orthopaedic Traumatology, Department of Orthopaedic
Surgery, University of Texas Health Science Center at San Antonio, San
Antonio, TX; and Department of Orthopaedic Surgery, University of
Toledo, Toledo, OH.
The authors report no conict of interest.
Reprints: Boris A. Zelle, MD, Division of Orthopaedic Traumatology,
Department of Orthopaedic Surgery, University of Texas Health Science
Center at San Antonio, 7703 Floyd Curl Drive, MC 7774, San Antonio,
TX 78229 (e-mail: zelle@uthscsa.edu).
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Level of Evidence: Prognostic Level II. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2015;29:510515)
INTRODUCTION
Noncompliance with follow-up appointments is a fre-
quently encountered problem in orthopaedic trauma. Loss of
follow-up poses signicant challenges to the practicing
orthopaedic trauma surgeon and to investigators conducting
clinical studies in the eld of orthopaedic trauma. From the
clinical perspective, patients who miss their outpatient follow-
up appointment are at risk for delayed recognition of
complications, such as wound problems, surgical site infec-
tions, fracture nonunions, and malunions. Moreover, neces-
sary adjustments of the postoperative treatment protocol, such
as modication of the weight-bearing status, initiation of
range of motion exercises, and referral to physical therapy,
may be missed or implemented in a delayed fashion. From the
scientic standpoint, loss of follow-up will signicantly bias
orthopaedic trauma outcome studies and several investigators
have pointed out the challenges of minimizing loss of follow-
up in clinical investigations.1,2 Recent investigations have
demonstrated that any loss of follow-up can potentially bias
the study results emphasizing the importance of this prob-
lem.3 For these reasons, detailed knowledge on the risk fac-
tors for loss of follow-up after orthopaedic trauma may
provide important information both for the practicing sur-
geons and clinical investigators.
Although loss of follow-up in orthopaedic trauma is
a widespread problem, reports in the literature regarding this
issue are sparse.4,5 As of today, the risk factors for loss of
follow-up after orthopaedic trauma remain poorly dened.
Investigations performed in general surgery trauma popula-
tions have suggested various demographic and clinical varia-
bles as potential risk factors for loss of follow-up after
trauma.6,7 However, data from the general surgery literature
can certainly not be extrapolated to the orthopaedic trauma
population. Therefore, the goal of this study is to identify
demographic and clinical variables that are associated with
the risk of loss of follow-up in the orthopaedic trauma
population.
PATIENTS AND METHODS
Patients enrolled in this study were identied from the
case log of 1 orthopaedic trauma surgeon (B.A.Z.) over
J Orthop Trauma  Volume 29, Number 11, November 2015
 J Orthop Trauma  Volume 29, Number 11, November 2015
a 10-month period from September 2011 to July 2012. All
patients included in this study were admitted and treated at
a university-based level 1 trauma center. Patients included in
this review included multiple injured patients with associated
orthopaedic injuries and patients with isolated acute ortho-
paedic injuries. All patients received treatment for acute
orthopaedic injuries; no elective patients were included in this
study. Only patients who underwent surgical treatment of
their orthopaedic injuries in the operating room and under
anesthesia were included. Patients who underwent nonoper-
ative treatment of orthopaedic injuries were not included in
this study. Patients who only underwent minor orthopaedic
procedures at the bedside or in the emergency department
were also excluded from this study. Patients who deceased
during their hospital stay or after discharge were not included
in the statistical analysis.
All patients undergoing surgical treatment of their
orthopaedic injuries during this period were discharged from
our level 1 trauma center with appropriate follow-up instruc-
tions for the orthopaedic trauma clinic. During daily patient
rounds, the patients were educated by the surgical team that
follow-up as an outpatient was needed. The rst outpatient
follow-up appointment was arranged by the social worker
before hospital discharge. On discharge, all patients received
a discharge folder with their discharge instructions. The
follow-up instructions included the name of their physicians,
dates and times of follow-up appointments, address and
directions to the trauma clinic, and the clinic phone number.
All discharge instructions were handed and explained to the
patients by their oor nurses. As per protocol, patients who
missed their follow-up appointment were contacted by phone
to reschedule their follow-up appointment. Patients who
missed 3 subsequent follow-up appointments or who did
not return 3 subsequent phone calls were sent a letter with the
appropriate contact information and the request to reschedule
their follow-up appointment. Routine follow-up appointments
were scheduled at 2 weeks, 6 weeks, 12 weeks, and 6 months
after surgery. Patients who required closer monitoring, such
as additional wound checks, were scheduled for additional
follow-up appointments. Moreover, in patients undergoing
surgical fracture xation, it is also our routine practice to
obtain follow-up appointments at 1 year and 2 years after
surgery.
All patient data used in this analysis were extracted
from the electronic medical records. The following variables
were extracted from the patient charts as potential predictors
for loss of follow-up: age, gender, marital status, primary
language, workmens compensation status, employment sta-
tus, insurance status, documented home address, living ar-
rangements (living alone vs. living with another person),
diagnosis of mental illness, tobacco use, illicit drug abuse,
alcohol use, mechanism of injury, isolated versus multiple
injuries, discharge disposition, discharging service (orthopae-
dic service vs. other), and distance of residence from hospital.
Distance of the patients residence from the hospital was
determined using Google maps (https://maps.google.com/).
In addition, the compliance with scheduled follow-up ap-
pointments was extracted from the electronic medical records.
For the purpose of this study, we recorded all patients who
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Loss of Follow-up in Orthopaedic Trauma
did not comply with their scheduled follow-up appointment at
2 weeks, 6 weeks, 12 weeks, and 6 months. Each event of
noncompliance was recorded for these specic time points.
The main outcome measure for the purpose of this study was
noncompliance with the 6-month follow-up appointment.
Noncompliance with any follow-up appointment was used
as a secondary outcome measure. Institutional review board
approval (protocol 12-02-3434) was obtained for this study
on August 7, 2012.
Statistical Analysis
All statistical analysis was performed using R for
Windows version 2.15.3 (R Foundation). Noncompliance
with the 6-month follow-up visit was used as the main
outcome measure. Noncompliance with any follow-up
appointment was used as a secondary outcome measure. In
a rst step, a univariate analysis was performed to identify
any differences of demographic and clinical variables
between patients who were compliant with their 6-month
follow-up appointment and noncompliant patients. Continu-
ous variables were compared using the MannWhitney U test.
Categorical variables were compared using the x2 or the
Fisher exact test. The clinical and demographic variables that
were signicant at the level P , 0.05 entered a logistic
regression model. Regarding the secondary outcome measure,
noncompliance with any follow-up visit, we similarly per-
formed a univariate analysis rst followed by a logistic
regression analysis.
RESULTS
The data of 309 patients, who were at least 6 months
out from their last orthopaedic procedure, were recorded. Two
patients deceased during this period and were not included in
this analysis. The average age of the remaining 307 patients
was 40.4 6 17 years. There were 226 male and 81 female
patients. The most pertinent demographic data are shown in
Table 1. There were a total of 41 missing data points within
our database after the completed chart review. Within the 307
patients, a total of 381 orthopaedic conditions required surgi-
cal treatment. These included 321 fractures, 32 acute soft-
tissue injuries, and 28 musculoskeletal infections. Among
the 321 surgically treated fractures, there were a total of 73
open fractures (22.7%). The anatomic locations of the 321
surgically treated fractures are listed in Table 2, according
to the OTA/AO classication system.8
Over a 6-month postoperative period, a total of 215
patients were noncompliant with at least one of their follow-
up appointments at 2 weeks, 6 weeks, 12 weeks, or 6 months.
The actual numbers (n) of noncompliant patients were 82, 87,
112, and 182 for 2 weeks, 6 weeks, 12 weeks, and 6 months
of follow-up appointments, respectively.
Regarding our main outcome measure, noncompliance
with the 6-month follow-up appointment, a univariate anal-
ysis was performed (Table 3). In the univariate analysis, the
following variables showed a statistically signicant differ-
ence at the level P , 0.05: young age (P = 0.02), male gender
(P = 0.02), lack of commercial insurance (P = 0.02), smoker
(P = 0.01), illicit drug use (P = 0.01), and isolated orthopaedic
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 Zelle et al J Orthop Trauma  Volume 29, Number 11, November 2015

TABLE 1. Characteristics of Patient Population TABLE 2. Anatomic Fracture Locations of Surgically Treated
Missing Data Fractures
N = 307 Points OTA/AO Anatomic Location8 N (%)
Age, y 40.4 6 17 0 12humeral shaft 4 (1.25)
Gender, n (%) 0 13distal humerus 5 (1.56)
Male 226 (73.6) 14scapula 1 (0.31)
Female 81 (26.4) 15clavicle 5 (1.56)
Marital status, n (%) 1 21olecranon 8 (2.49)
Single 176 (57.5) 22forearm 18 (5.61)
Married 92 (30.1) 23distal radius 23 (7.17)
Divorced 38 (12.4) 31proximal femur 33 (10.28)
Have a current home address, n (%) 275 (89.9) 1 32femoral shaft 24 (7.48)
Living alone, n (%) 47 (15.6) 5 33distal femur 2 (0.62)
Distance from hospital 101 6 64 miles 1 34patella 9 (2.80)
Primary language, n (%) 1 41tibial plateau 21 (6.54)
English 276 (90.2) 42tibial shaft 25 (7.79)
Spanish 25 (8.2) 43pilon 19 (5.92)
English and Spanish 4 (1.3) 44malleolar ankle 66 (20.56)
Other 1 (0.33) 61pelvic ring 10 (3.12)
Employment at the time of 7 62acetabulum 16 (4.98)
injury, n (%) 7hand 3 (0.93)
Unemployed 121 (40.3) 8foot 29 (9.03)
Employed 121 (40.3)
Disabled 14 (4.7)
Student 31 (10.3) discharge disposition (P = 1), and discharge by the orthopaedic
Others 13 (4.3) service (P = 1).
Insurance status, n (%) 0 A logistic regression model was created, with the
Uninsured 103 (33.6) variables age, gender, insurance status, smoker, illicit drug
Commercial 95 (30.9) abuse, and multiple injuries. The results of the logistic regres-
Government 109 (35.5) sion are shown in Table 4. According to the logistic regres-
Workmans compensation, n (%) 5 (1.6) 3 sion analysis, the variables male gender, uninsured or
Injury mechanism, n (%) 3 government insurance, and smoker were found to be statisti-
Motor vehicle/motorcycle 117 (38.5) cally signicant (P , 0.05) predictors for noncompliance
Fall 81 (26.6) with the 6-month follow-up visit. Patients with isolated ortho-
Gunshot wound 9 (3) paedic injuries trended to have a higher rate of noncompliance
Infection 29 (9.5) with their 6-month follow-up visit (P = 0.09), but this was not
Other 68 (22.4) statistically signicant. The variables age and illicit drug
Multiple injuries, n (%) 93 (30.5) 2 abuse were not statistically signicant in the logistic regres-
Associated mental illness, n (%) 22 (7.3) 4 sion (P . 0.05). The area under the curve for the logistic
Smoker, n (%) 115 (38) 4 regression model was 0.67.
Regular use of alcohol, n (%) 155 (51.2) 4 Regarding our secondary outcome measure, noncom-
Illicit drug abuse, n (%) 60 (19.9) 5 pliance with any follow-up appointment, we similarly per-
Discharged by orthopaedic service, 128 (41.7) 0 formed a univariate analysis. This univariate analysis
n (%)
suggested the following variables to be signicantly different
Discharge disposition, n (%) 0
(P , 0.05) among compliant and noncompliant patients:
Home 270 (87.95)
insurance status, lack of permanent address, smoker, and
Rehab or nursing facility 37 (12.05)
illicit drug abuse. The logistic regression showed an area
under the curve of 0.64 and established illicit drug abuse as
a signicant risk factor for noncompliance with any follow-up
injuries (P = 0.02). These variables were included in the appointment (P = 0.02).
logistic regression model. The remaining variables were not
found to be statistically signicant and were not considered
for the logistic regression model, including marital status DISCUSSION
(P = 0.18), primary language (P = 0.75), workmens com- Loss of follow-up is commonly observed in an
pensation (P = 1), employment status (P = 0.17), docu- orthopaedic trauma practice. Patients noncompliance with
mented home address (P = 0.23), distance from hospital scheduled clinic visits may be associated with potentially
(P = 0.73), living alone (P = 0.30), mental illness (P = 0.27), devastating clinical consequences. Thus, postoperative com-
alcohol use (P = 0.65), mechanism of injury (P = 0.10), plications, such as surgical site infections, fracture nonunions,

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 J Orthop Trauma  Volume 29, Number 11, November 2015 Loss of Follow-up in Orthopaedic Trauma

TABLE 3. Univariate Comparison of Compliant Versus TABLE 3. (Continued ) Univariate Comparison of Compliant
Noncompliant Patients Regarding 6 Months of Follow-up Versus Noncompliant Patients Regarding 6 Months of
Appointment Follow-up Appointment
N Noncompliant Compliant P N Noncompliant Compliant P
Age, y 38.8 6 17.7 43.1 6 16.6 0.02 Regular use of alcohol 0.65
Gender 0.02 Yes 155 95/155 60/155
Male 226 143/226 83/226 No 148 86/148 62/148
Female 81 39/81 42/81 Illicit drug abuse 0.01
Marital status 0.18 Yes 60 45/60 15/60
Single 176 112/176 64/176 No 242 134/242 108/242
Married 92 48/92 44/92 Discharged by 1
Divorced 38 22/38 16/38 orthopaedic service
Have a current home 0.23 Yes 128 76/128 52/128
address No 179 106/179 73/179
Yes 275 159/275 116/275 Discharge disposition 1
No 31 22/31 9/31 Home 37 22/37 15/37
Living alone 0.30 Rehab or nursing 270 160/270 110/260
Yes 47 24/47 23/47 facility
No 255 154/255 101/255 Bold indicates statistically signicant values (P , 0.05).
Distance from hospital 99.9 6 63.8 102.8 6 63.4 0.73
Primary language 0.75
English 276 162/276 114/276
Spanish 25 17/25 8/25
and malunions, may be treated in a delayed fashion. Moreover,
English and Spanish 4 2/4 2/4
necessary adjustments to the postoperative treatment protocol,
Other 1 1/1 0/1
such as adjustment of weight-bearing status, initiation of range
Employment at the time 0.17
of motion exercises, referral to physical therapy, or necessary
of injury hardware removal, may not be implemented in an appropriate
Unemployed 121 78/121 43/121 and timely fashion. From the scientic standpoint, loss of
Employed 121 63/121 58/121 follow-up may signicantly bias clinical outcome studies and
Disabled 14 11/14 3/14 it has been shown that even relatively small rates of loss of
Student 31 20/31 11/31 follow-up may signicantly change the study results.3
Others 13 8/13 5/13 Although noncompliance of orthopaedic trauma patients with
Insurance status 0.02 their follow-up visits is a widespread problem in orthopaedic
Uninsured 103 66/103 37/103 trauma, the issue has gained relatively little attention in the
Commercial 95 45/95 50/95 orthopaedic literature. Our study provides important informa-
Government 109 71/109 38/109 tion on the demographics of orthopaedic trauma patients who
Workmans 1 are at risk for noncompliance with their follow-up visits. Using
compensation a logistic regression, we identied male gender, smoker, and
Yes 5 3/5 2/5 lack of commercial health insurance as risk factors for non-
No 299 179/299 120/299 compliance with the 6-month visit. Moreover, patients with
Injury mechanism 0.10 isolated orthopaedic injuries trended toward a higher risk of
Motor vehicle/ 117 59/117 58/117 noncompliance. In addition, illicit drug abuse was identied in
motorcycle a logistic regression as a signicant risk factor for noncompli-
Fall 81 51/81 30/81 ance with any follow-up appointment, which was our second-
Gunshot wound 9 7/9 2/9 ary outcome measure. Identifying these risk factors may
Infection 29 21/29 8/29 facilitate the implementation of protocols and resource
Other 68 42/68 26/69
Multiple injuries 0.02
Yes 93 46/93 47/93
TABLE 4. Logistic Regression Analysis for Noncompliance
No 212 134/212 78/212 With 6 Months of Follow-up
Associated mental 0.27
illness Odds Ratio (95%
Condence Interval) P
Yes 22 16/22 6/22
No 281 164/281 117/281 Age 1.01 (0.991.03) 0.24
Smoker 0.01 Male gender 2.65 (1.057.01) 0.04
Yes 115 80/115 35/115 Lack of commercial health insurance 3.02 (1.168.26) 0.03
No 188 99/188 89/188 Smoker 2.38 (1.125.22) 0.03
Illicit drug abuse 1.58 (0.574.87) 0.4
Isolated orthopaedic injuries 1.99 (0.914.39) 0.09

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 Zelle et al
allocation for improving the compliance of orthopaedic trauma
patients with their postoperative follow-up appointment.
Limitations of our investigation include the single
surgeon and the single institution experience, which carries
the potential risk of selection bias. We believe that the
patients included in this study are representative of a pure
orthopaedic trauma practice at an urban level 1 trauma center.
However, we cannot exclude that geographic factors and local
differences may have impacted our investigation. Moreover,
our investigation was performed through a retrospective chart
review. Data documented in hospital charts are typically
recorded by different health care providers, and the quality of
these data certainly does not measure up to the quality of data
from prospective clinical investigations. This is evidenced by
a total of 41 missing data points arising from incomplete
documentations within the hospital charts. Moreover, inter-
esting patient demographics, such as race/ethnicity, level of
education, and household income, were not captured appro-
priately in our electronic medical records, and the inclusion of
these variables potentially could have strengthened the results
of this study. Further prospective investigations may provide
results that are less biased from the quality of the data
sources. In addition, our investigation focused on noncom-
pliance within the rst 6 months after surgery. The 6-month
follow-up visit was arbitrarily chosen as the main outcome
measure based on the assumption that, clinically, this is
considered a crucial time point for determining fracture union
versus nonunion, decision making for further surgical inter-
ventions, and also possible discharge of patients from clinic.
Therefore, we cannot make any assumptions about non-
compliance with 1-year and 2-year follow-up visits, which
seem to have a high relevance for research investigations. We
would also like to emphasize that our investigation is focused
on clinical data and not on research data. We assume that the
risk factors for noncompliance with postoperative follow-up
visits may be similar to the risk factors for noncompliance
with research visits. However, this must be proven in further
investigations using research databases. We also acknowl-
edge that our study does not provide any information why
patients were noncompliant with their postoperative follow-
up. Thus, we assume that the missed follow-up appointments
were due to patient factors. However, we cannot exclude that
scheduling errors may have occurred in some of these
patients. Finally, our study was underpowered regarding
some demographic variables. For instance, the percentage
of patients with mental illness, as a likely risk factor for
noncompliance, was too small to allow any conclusions for
these patients.
Noncompliance with scheduled follow-up clinic visits
has been well studied in other elds of medicine including the
emergency medicine literature913 and the general surgery
trauma literature.6,7 Data from the general surgery trauma
literature have suggested multiple demographic variables as
potential risk factors, such as age, minority, low income, low
educational level, insurance status, and distance from hospi-
tal.6,7 However, these results can certainly not be extrapolated
to the orthopaedic trauma population. As of now, the ortho-
paedic trauma literature on risk factors for loss of follow-up
remains limited. In 2002, Murnaghan and Buckley4 reported
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J Orthop Trauma  Volume 29, Number 11, November 2015
on 236 patients with calcaneus fractures who were enrolled in
a prospective randomized clinical trial, whereby 38 patients
were lost to follow-up. The authors recorded young age,
aboriginal descent, and lower educational level as risk factors
for loss of follow-up. Anecdotally, the authors also found
a relatively high percentage of alcohol abuse, psychiatric
admission, and incarcerations in these patients. The authors
concluded that lower income, lower educational level, psy-
chiatric problems, and substance abuse may interfere with the
patients ability to follow up as part of a study. However, their
investigation was based on noncompliance with study visits,
whereas our investigation focused on noncompliance with
regular postoperative clinic visits. ten Berg and Ring5 re-
ported on 335 patients with isolated metacarpal fractures
and found that unmarried, unemployed, and underinsured pa-
tients were at higher risk for noncompliance with scheduled
clinic visits. These authors summarized that social depriva-
tion can be suggested as a main risk factor for noncompli-
ance with scheduled clinic visits after treatment of metacarpal
fractures. In contrast to these studies, our investigation
focused on scheduled clinic visits in the orthopaedic trauma
population. Similarly to other patient populations, we identi-
ed a number of social variables as risk factors for noncom-
pliance with the postoperative follow-up appointments.
Similar to the observations by ten Berg and Ring,5 social
variables suggesting a potentially lower socio-economic sta-
tus, such as smoker, illicit drug abuse, and lack of commercial
health insurance, seem to be associated with the risk of
noncompliance.
In contrast to the previously published literature,
distance from the hospital did not correlate with our patients
missing their 6-month follow-up appointment or any other
follow-up appointment. Previous reports from the emergency
medicine and the general surgery trauma literature have found
distance and travel costs to be a risk factor for noncompliance
with follow-up visits.6,9 Despite the relatively large geo-
graphic area that our trauma center serves (average distance
from hospital, approximately 100 miles), we did not nd any
correlation between distance from the hospital and noncom-
pliance in our patient population.
CONCLUSIONS
Loss of follow-up is a common problem in orthopaedic
trauma. Noncompliance with follow-up visits complicates
patient management and biases clinical investigations. Data in
the orthopaedic trauma literature on risk factors for non-
compliance with follow-up visits remain limited. Our study
suggests different risk factors for noncompliance, including
male gender, smoker, lack of commercial health insurance,
and illicit drug abuse. Health care providers may consider
establishing protocols for facilitating follow-up appointments
to patients who are at risk for noncompliance. Similarly,
researchers conducting clinical trials in orthopaedic trauma
may consider providing additional resources to these patients
to minimize the risk of bias from loss of follow-up.
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 J Orthop Trauma  Volume 29, Number 11, November 2015
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