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Ponkilainen V, Laurema A, Mattila VM, Karjalainen T. Regional variation in low-value musculoskeletal surgery: a nationwide study from the Finnish Care Register. Acta Orthop 2024; 95:553-561. [PMID: 39301978 DOI: 10.2340/17453674.2024.41930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND AND PURPOSE Healthcare systems globally are grappling with resource constraints and rising costs. Concerns have been raised about "low-value" care, which consumes healthcare resources without benefiting patients. We aimed to examine regional differences in common low-value musculoskeletal surgeries in Finland and explore explanatory factors behind the variation. METHODS Using data from the Finnish Care Register for Health Care, surgeries conducted from 2006-2007 compared with 2020-2021 were analyzed across 20 hospital districts. Selected surgeries (acromioplasty, rotator cuff repair, partial meniscectomy, wrist arthroscopy, ankle arthroscopy, and distal radius fracture fixation) were categorized based on NOMESCO procedure codes, and incidence rates in older populations were calculated based on population size derived from Statistics Finland. RESULTS We found substantial regional disparities in low-value surgeries. The incidence rates were higher in hospitals with high historical incidence rates and smaller population sizes, suggesting that the uptake of evidence is slower in small non-academic hospitals. CONCLUSION The incidence of low-value surgery is declining but regional differences remain large. It is unlikely that regional variation in disease incidence explains such large variation in low-value surgery. Instead, local treatment culture seems to be the driving force behind low-value surgery, and the practices seem to be more entrenched in small hospitals.
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Affiliation(s)
- Ville Ponkilainen
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Finland.
| | - Anniina Laurema
- Department of Surgery, Mikkeli Central Hospital, Mikkeli, Finland
| | - Ville M Mattila
- Department of Orthopaedics and Traumatology, Tampere University Hospital; COXA Hospital for Joint Replacement, Tampere; Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Teemu Karjalainen
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
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Johnston G, Stewart SA, Sims LA. Serial Range of Motion and Grip Strength Measurements, Patient-Reported Outcomes, and Radiographic Thresholds Associated With Less Satisfactory Outcomes After Low-Energy Distal Radius Fracture in Women Aged 50 Years and Older. J Hand Surg Am 2024; 49:827-845. [PMID: 39007798 DOI: 10.1016/j.jhsa.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 01/06/2024] [Accepted: 01/24/2024] [Indexed: 07/16/2024]
Abstract
PURPOSE To document the change of clinical (wrist motion and grip strength) measurements and Patient-Rated Wrist Evaluation (PRWE) scores at 9 weeks and 3, 6, and 12 months after distal radius fracture (DRF) in women 50 years and older with exclusively isolated, displaced, and low-energy DRFs treated by either closed and/or open reduction and to relate these outcomes to their radiographic results. METHODS In this retrospective single-institution cohort study, patients' post-DRF clinical measurements and PRWE scores were prospectively collected from December 2007 through September 2018 and stratified according to their final radiographic values of volar/dorsal tilt, ulnar variance, and radial inclination. RESULTS Of the 1,319 women identified, 1,126 (85%) were treated nonsurgically, and 193 (15%) were treated operatively. At 12 months, patients averaged restoration (ratio of injured and uninjured sides' values) of 96% pronation, 95% extension, 91% supination, 81% flexion, and 80% (77% nondominant, 85% dominant) grip strength. The mean PRWE score was 39.5 at week 9 and 14.4 at 12 months with 54% of patients scoring <10 and 13% scoring zero. The mean volar/dorsal tilt, ulnar variance, and radial inclination values in those treated nonsurgically were 1.4° dorsal, +3.9 mm, and 18.0°, respectively. Analogous values in patients treated surgically were 6° volar, +2.6 mm, and 22°, respectively. Volar tilt ≥25°, dorsal tilt >10°, ulnar variance >+7.5 mm, and radial inclination ≤13° were thresholds beyond which motion and grip strength were reduced and/or PRWE scores increased. In general, older patients experienced more residual deformity and were less likely to have undergone surgery. CONCLUSIONS Generally, outcomes were satisfactory for patients with radiographic results within identified thresholds for acceptable fracture reduction. Outcomes were significantly less favorable for patients with radiographic results beyond these thresholds; for these patients, early surgical intervention should be considered. Low-energy DRFs should prompt bone density investigation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic 2b.
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Affiliation(s)
- Geoffrey Johnston
- Division of Orthopaedics, Department of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; RebalanceMD, Victoria, British Columbia, Canada; Department Orthopaedic Surgery, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Samuel A Stewart
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Laura A Sims
- Department of Surgery, University of Saskatchewan, Saskatoon Orthopedic and Sports Medicine Centre, Saskatoon, Saskatchewan, Canada
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Mehta SP, Karagiannopoulos C, Pepin ME, Ballantyne BT, Michlovitz S, MacDermid JC, Grewal R, Martin RL. Distal Radius Fracture Rehabilitation. J Orthop Sports Phys Ther 2024; 54:CPG1-CPG78. [PMID: 39213418 DOI: 10.2519/jospt.2024.0301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Distal radius fracture (DRF) is arguably the most common upper extremity fracture resulting from a fall accident. These clinical practice guidelines (CPG) were developed to guide all aspects of the management of DRF by physical therapists and other rehabilitation practitioners, such as certified hand therapists. This CPG employed a systematic review methodology to locate, appraise, and synthesize contemporary evidence while developing practice recommendations for determining the prognosis of outcomes, examination, and interventions while managing individuals with DRF. The quality of the primary studies found in the literature search was appraised using standardized tools. The strength of the available evidence for a particular practice domain (e.g., prognosis or intervention) was graded as strong, moderate, weak, or conflicting, where such gradings guided the level of obligation for each practice recommendation. Lastly, the CPG also provided the gaps in the evidence pool for the rehabilitation of DRF that future research efforts can address. J Orthop Sports Phys Ther 2024;54(9):CPG1-CPG78. doi:10.2519/jospt.2024.0301.
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Hao W, Zhang C, He J, Pei R, Huo H, Liu H. Effect of ultrasound-guided nerve blocks on anesthesia and pulmonary function in patients undergoing distal radius fracture surgery. Medicine (Baltimore) 2024; 103:e39436. [PMID: 39213208 PMCID: PMC11365669 DOI: 10.1097/md.0000000000039436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Revised: 07/18/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024] Open
Abstract
This study aimed to assess the impact of ultrasound (US)-guided nerve blocks (NBs) on anesthesia and their protective effect on pulmonary function (PF) in patients undergoing distal radius fracture (DRF) surgery. A total of 122 patients undergoing DRF surgery between April 2020 and June 2023 were included. According to the type of peripheral NB technique, these patients were randomized into a control group (CG; n = 60) receiving brachial plexus block (BPB) using blinded techniques, and an observation group (OG; n = 62) receiving US-guided supraclavicular BPB. Anesthetic effects, BPB-related indexes, adverse events, PF parameters (forced expiratory volume in 1 second, forced vital capacity, peak expiratory flow), and serum biochemical indexes (interleukin [IL]-6/10) were compared. The OG showed a relatively higher proportion of good anesthetic effects, shorter onset and completion times of block, and longer block duration compared to the CG, with a lower AE rate. Despite reductions in PF parameters and IL-10 levels after intervention, the OG maintained higher values than the CG. IL-6 levels increased significantly in the OG but remained lower than in the CG. In conclusion, US-guided NBs demonstrated significant anesthetic efficacy and apparently reduced anesthesia adverse events while also exerting a protective effect on PF in DRF surgery patients.
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Affiliation(s)
- Weihong Hao
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunmin Zhang
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiandong He
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruomeng Pei
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haiyan Huo
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huihui Liu
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Model Z, Guenthner G, Zhang D, Bauer A. Variation in Treatment of Young Adult Distal Radius Fractures by Pediatric and Adult Orthopaedic Surgeons. J Am Acad Orthop Surg 2024:00124635-990000000-01073. [PMID: 39186612 DOI: 10.5435/jaaos-d-24-00085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 07/05/2024] [Indexed: 08/28/2024] Open
Abstract
INTRODUCTION There remains a lack of consensus on the optimal treatment of isolated distal radius fractures in young adults. The primary aim of this study was to identify differences in treatment of isolated distal radius fractures in patients aged 17 to 21 years treated by adult versus pediatric orthopaedic surgeons. The secondary aim was to identify whether there is a variation in utilization of open reduction and internal fixation (ORIF) versus closed reduction and percutaneous pinning when treated surgically by adult versus pediatric orthopaedic surgeons. METHODS Patients aged 17 to 21 years with isolated distal radius fractures who were treated by adult or pediatric orthopaedic surgeons at 1 of 3 hospitals were identified through retrospective chart review. 72 patients in the pediatric surgeon cohort and 64 patients in the adult surgeon cohort were included. Demographic details were recorded, and radiographs from the initial clinic visit and final follow-up were obtained. Bivariate analysis was used to evaluate for primary and secondary aims. RESULTS 40 of 136 patients were treated surgically. Bivariate analysis showed that factors associated with surgical treatment were treatment by an adult orthopaedic surgeon, higher body mass index, radiographic severity, AO classification, intraarticular involvement, distal radial-ulnar joint involvement, and meeting AAOS clinical practice guideline surgical criteria. Factors associated with ORIF compared with closed reduction and percutaneous pinning included treatment by an adult orthopaedic surgeon, older age, higher body mass index, and greater articular step-off. DISCUSSION In comparable cohorts of young adult patients with distal radius fractures with similar fracture characteristics, there was notable variation in treatment between adult and pediatric orthopaedic surgeons. Surgical treatment was used more by adult surgeons, and when treated surgically, ORIF was used more by adult surgeons. Variation among surgeons illustrates the persistent lack of consensus on the optimal treatment in this population and highlights the need for additional research on this topic to guide management. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Zina Model
- From the Mass General Brigham, Harvard Combined Orthopaedic Residency Program, Boston, MA (Model), Tufts Orthopedic Residency Program, Boston, MA (Guenthner), Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA (Zhang), Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA (Bauer)
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Davidson A, Feldman G, Mosheiff R, Suna A, Joskowicz L, Weil YA. Computer-Generated Radiographic Measurements of Distal Radius Fractures: Does It Help With Decision Making? J Hand Surg Am 2024; 49:796.e1-796.e7. [PMID: 36336570 DOI: 10.1016/j.jhsa.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 08/30/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Operative management of distal radius fractures (DRFs) has become increasingly common. Age, activity levels, and comorbid conditions are major factors influencing the treatment decision, although operative indications are still controversial. Radiographic parameters (RPs), such as radial inclination, dorsal tilt, and articular step-off, can provide objective support for effective decision making. However, manual measurement of RPs may be imprecise and subject to inconsistency. To address this problem, we developed custom software of an algorithm to automatically detect and compute 6 common RPs associated with DRF in anteroposterior and lateral radiographs. The aim in this study was to assess the effect of this software on radiographic interobserver variability among orthopedic surgeons. Our hypothesis was that precise and consistent measurement of RPs will improve radiographic interpretation variability among surgeons and, consequently, may aid in clinical decision making. METHODS Thirty-five radiograph series of DRFs were presented to 9 fellowship-trained hand and orthopedic trauma surgeons. Each case was presented with basic clinical information, together with plain anteroposterior and lateral radiographs. One of the 2 possible treatment options was selected: casting or open reduction with a locking plate. The survey was repeated 3 weeks later, this time with computer-generated RP measurements. Data were analyzed for interobserver and intraobserver variability for both surveys, and the interclass coefficient, kappa value, was calculated. RESULTS The interobserver reliability (interclass coefficient value) improved from poor to moderate, 0.35 to 0.50, with the provided RP. The average intraobserver interclass coefficient was 0.68. When participants were assessed separately according to their subspecialties (trauma and hand), improved interobserver variability was found as well. CONCLUSIONS Providing computed RPs to orthopedic surgeons may improve the consistency of the radiographic judgment and influence their clinical decision for the treatment of DRFs. CLINICAL RELEVANCE Orthopedic surgeons' consistency in the radiographic judgment of DRFs slightly improved by providing automatically calculated radiographic measurements to them.
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Affiliation(s)
- Amit Davidson
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem, Israel; Orthopedic Department, Shaare Zedek Medical Center, Jerusalem, Israel.
| | - Guy Feldman
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem, Israel; Orthopedic Department, Emek Medical Center, Afula, Israel
| | - Rami Mosheiff
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Avigail Suna
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Leo Joskowicz
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yoram A Weil
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem, Israel
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Yu X, Zhang X, Li N, Yu Y, Yang X. Percutaneous treatment of type C distal radius fractures using dual-external fixator. J Orthop Sci 2024:S0949-2658(24)00144-1. [PMID: 39054230 DOI: 10.1016/j.jos.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/28/2024] [Accepted: 07/07/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND This study aimed to introduce a potential alternative percutaneous treatment for AO types C1, C2, and C3 distal radius fractures using dual-external fixator (a no-bridging cemented-pin frame and a conventional wrist-bridging external fixator). MATERIALS AND METHODS From January 2018 to January 2021, 52 patients (52 distal radius fractures) were treated with dual-external fixator. For comparison, 61 patients (61 distal radius fractures) were treated with a plate and screw system. Wrist function was assessed using the Mayo Wrist Score. Patient satisfaction was assessed using the Short Assessment of Patient Satisfaction. A P < 0.05 was considered statistically significant. RESULTS Fracture healing was achieved in all patients. At the final follow-up of 29 months (range, 24-34 months) vs 36 months (range, 26-39 months) (P > 0.05), the patients treated with dual-external fixator and a plate and screw system achieved mean ulnar deviations of 31° vs 29° (P < 0.05), mean Mayo Wrist Scores of 91.12 ± 5.98 vs 88.12 ± 7.54 (P < 0.05), and mean patient satisfaction scores of 23.42 ± 2.47 vs 23.04 ± 2.32 (P > 0.05). CONCLUSIONS AO types C1, C2, and C3 distal radius fractures can be treated successfully using dual-external fixator. The technique is a potential alternative in addition to the conventional treatments. LEVEL OF EVIDENCE Level IIa.
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Affiliation(s)
- Xiaofei Yu
- Department of Hand Surgery, Third Hospital of Heibei Medical University, Shijiazhuang, Hebei, 050051, China.
| | - Xu Zhang
- Department of Hand Surgery, Third Hospital of Heibei Medical University, Shijiazhuang, Hebei, 050051, China.
| | - Nan Li
- Department of Neuromuscular Diseases, Third Hospital of Heibei Medical University, Shijiazhuang, Hebei, 050051, China.
| | - Yadong Yu
- Department of Hand Surgery, Third Hospital of Heibei Medical University, Shijiazhuang, Hebei, 050051, China.
| | - Xiaoliang Yang
- Department of Hand Surgery, Third Hospital of Heibei Medical University, Shijiazhuang, Hebei, 050051, China.
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Yang W, Zeng H, Jin Y. Robotic pancreaticoduodenectomy in patients with overweight or obesity: a meta-analysis protocol. BMJ Open 2024; 14:e080605. [PMID: 39019640 DOI: 10.1136/bmjopen-2023-080605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/19/2024] Open
Abstract
INTRODUCTION The prevalence of overweight or obesity among patients undergoing pancreaticoduodenectomy is on the rise. The utilisation of robotic assistance has the potential to enhance the feasibility of performing minimally invasive pancreaticoduodenectomy in this particular group of patients who are at a higher risk. The objective of this meta-analysis is to assess the safety and effectiveness of robotic pancreaticoduodenectomy in individuals with overweight or obesity. METHODS AND ANALYSIS This investigation will systematically search for randomised controlled trials (RCTs) and non-randomised comparative studies that compare robotic pancreaticoduodenectomy with open or laparoscopic pancreaticoduodenectomy in patients with overweight or obesity, using PubMed, Embase and the Cochrane Library databases. The methodological quality of studies will be evaluated using the Cochrane risk of bias tool for RCTs and the Newcastle-Ottawa Scale for observational studies. RevMan software (V.5.4.1) will be used for statistical analysis. The OR and weighted mean differences will be calculated separately for dichotomous and continuous data. The selection of a fixed-effects or random-effects model will depend on the level of heterogeneity observed among the included studies. ETHICS AND DISSEMINATION This study will be conducted based on data in the published literature from publicly available databases. Therefore, ethics approval is not applicable. The results will be disseminated in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023462321.
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Affiliation(s)
- Wenxiao Yang
- Business School, University of Shanghai for Science & Technology, Shanghai, China
| | - Hai Zeng
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yueling Jin
- Shanghai Science and Technology Museum, Shanghai, China
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Ahmed O, Balakrishnan P, Perumal R, Agraharam D, Velmurugesan PS, Jayaramaraju D, Rajasekaran S. A prospective randomized control trial comparing outcomes of casting, pinning, and plating for distal end of radius fractures (AO type A2, A3, C1, or C2) in the elderly population. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2473-2482. [PMID: 38642122 DOI: 10.1007/s00590-024-03949-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/03/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE With this prospective randomized control trial (RCT), we aim to provide the outcome analyses of the three most used treatment modalities for distal end of radius (DER) fracture management in the elderly. METHODS A prospective randomized control trial was performed. Fifty-two patients with DER fractures (AO A2, A3, C1, or C2) were randomized to the casting (n = 17), percutaneous pinning (n = 18), and the volar plating group (n = 17). Radiological measurements measured were radial inclination (RI), radial height (RH), volar tilt (VT), and ulnar variance (UV). The outcome was measured based on range-of-motion, grip strength, Patient-Related-Wrist-Evaluation (PRWE) score, and the Quick-Disabilities-of-the-Arm-Shoulder-Hand (QDASH) score. RESULTS Immediate post-operative and 1-year-follow-up X-rays showed a significant difference measurement between the groups (p < 0.05). Pairwise comparisons of the casting and pinning groups (p < 0.05) and the casting and plating groups (p < 0.05) revealed significant differences at the 1-year follow-up, but not the pinning and plating groups (p > 0.05). The analysis found significant differences in clinical outcomes after 1 month of follow-up, with the plating group outperforming the other two (p > 0.05). However, after a year of follow-up, all groups had comparable outcomes; however, the plating group showed improved palmar flexion (p < 0.001), radial deviation (p < 0.001), and a lower PRWE score (p < 0.05), indicating better wrist function. Complications were more in casting group. CONCLUSION The study found a radiologically significant difference between groups throughout the follow-up, but it did not affect functional results. Clinical outcomes were similar across the groups, with plating showing better palmar flexion and radial deviation. Grip strength was also better in the plating group, but statistically insignificant. The study suggests plating should be chosen over other treatments for high-demand patients.
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Affiliation(s)
- Owais Ahmed
- Department of Orthopaedics and Trauma, Ganga Medical Center and Hospital Pvt LTD., 313, Mettupalayam Road, Coimbatore, 641043, India
| | - Pradeep Balakrishnan
- Department of Orthopaedics and Trauma, Ganga Medical Center and Hospital Pvt LTD., 313, Mettupalayam Road, Coimbatore, 641043, India
| | - Ramesh Perumal
- Department of Orthopaedics and Trauma, Ganga Medical Center and Hospital Pvt LTD., 313, Mettupalayam Road, Coimbatore, 641043, India.
| | - Devendra Agraharam
- Department of Orthopaedics and Trauma, Ganga Medical Center and Hospital Pvt LTD., 313, Mettupalayam Road, Coimbatore, 641043, India
| | | | - Dheenadhayalan Jayaramaraju
- Department of Orthopaedics and Trauma, Ganga Medical Center and Hospital Pvt LTD., 313, Mettupalayam Road, Coimbatore, 641043, India
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Akgülle AH, Uysal D, Bekiroğlu GN. Factors influencing study outcomes in recent literature on distal radial fracture treatment. J Hand Surg Eur Vol 2024; 49:859-864. [PMID: 38031965 DOI: 10.1177/17531934231214662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
The main tools used by an orthopaedic surgeon for managing distal radial fracture treatment are recent literature and treatment guidelines. The aim of the present study was to find which factors within the study design influence study outcomes the most. Trials in three major databases (PubMed, Scopus, Embase) comparing surgical and non-surgical treatment options for adolescent and adult distal radial fractures with their original data, between 2013 and 2021, were included. The selected 47 studies were classified according to their outcomes. The relationship between study characteristics and outcomes was statistically analysed. It was more likely to find no difference in outcomes between volar locking plate and less invasive treatments when the sample size was above 100, follow-up was more than 1 year and functional assessments were used. A small sample size and short follow-up time affect study outcomes in favour of a volar locking plate. Readers should focus on the design criteria and read the full text of the studies before making any conclusions. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Ahmet Hamdi Akgülle
- Dilara Uysal, MS. Medical Student, Marmara University School of Medicine, GSM: +90 (533) 2323007, E mail:
- Gülnaz Nural Bekiroğlu; Prof, Marmara University School of Medicine, Department of Biostatistics, Istanbul, Turkey. Assessed the results. E mail: , +9053234474 84
| | - Dilara Uysal
- Dilara Uysal, MS. Medical Student, Marmara University School of Medicine, GSM: +90 (533) 2323007, E mail:
- Gülnaz Nural Bekiroğlu; Prof, Marmara University School of Medicine, Department of Biostatistics, Istanbul, Turkey. Assessed the results. E mail: , +9053234474 84
| | - Gülnaz Nural Bekiroğlu
- Dilara Uysal, MS. Medical Student, Marmara University School of Medicine, GSM: +90 (533) 2323007, E mail:
- Gülnaz Nural Bekiroğlu; Prof, Marmara University School of Medicine, Department of Biostatistics, Istanbul, Turkey. Assessed the results. E mail: , +9053234474 84
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Mahmoud Y, Chung J, Pirzada W, Ilyas AM. Understanding Changing Demographic and Treatment Trends of Distal Radius Fractures: A TriNetX Database Contemporary Analysis of 32,912 Patients. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:477-483. [PMID: 39166207 PMCID: PMC11331155 DOI: 10.1016/j.jhsg.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024] Open
Abstract
Purpose Distal radius fractures (DRF) are among the most commonly encountered fractures. The population of the United States is rapidly growing, aging, and diversifying. This study was undertaken to better understand current incidences and treatment trends across all ages, gender, and races to inform resource allocation and to potentially address treatment inequities. Methods The TriNetX US Collaborative Network was queried for all patients diagnosed with DRFs from 2017 to 2022. Cohorts were defined by inclusion and exclusion of Current Procedural Terminology procedure codes and categorized into operative and nonsurgical groups. Statistical analysis was performed to determine differences in management among demographic groups across the 6-year time period. Results Incidence rates of operative intervention for DRF increased from 19.6% in 2017 to 23.6% in 2022. Incidence rates of operative intervention increased from 21.7% to 25.2% for females and from 15.3% to 19.7% for males. A bimodal distribution was observed in females with more fractures occurring in the pediatric and geriatric ages, but this distribution was not observed in males. All demographic groups had an overall higher incidence of nonsurgical intervention. Patients aged 40-64 years were more likely to undergo operative intervention than patients 18-39 years. Females were more likely to undergo operative intervention than males. White patients were more likely to undergo operative intervention than Black patients and Asian patients. Conclusions The incidence of DRFs continues to climb, as does their rate of operative management. The classic bimodal distribution was observed in females, but not males. However, differences in management of DRFs were also observed across different demographic groups with ongoing racial disparities. Future consideration should be taken into optimizing treatment disparities relative to demographic status. Type of Study/Level of Evidence Prognosis IV.
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Affiliation(s)
- Yusuf Mahmoud
- Department of Orthopedics, Hackensack Meridian School of Medicine, NJ
| | - Juliet Chung
- Department of Orthopedics, Penn State College of Medicine, Hershey, PA
| | - Wali Pirzada
- Drexel University College of Medicine, Philadelphia, PA
| | - Asif M. Ilyas
- Drexel University College of Medicine, Philadelphia, PA
- Rothman Orthopaedic Institute, Philadelphia, PA
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Emmert AS, Swenson AK, Matar RN, Ross PR, Stern PJ. Characterization of Major Complications of Bridge Plating of Distal Radius Fractures at a Level I Trauma Center. Hand (N Y) 2024:15589447241257964. [PMID: 38869067 DOI: 10.1177/15589447241257964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
BACKGROUND Comminuted, markedly displaced distal radius fractures can cause instability requiring advanced stabilization with dorsal bridge plating. However, published complication rates of bridge plating widely vary. We hypothesize that complications of bridge plating of distal radius fractures are more prevalent than published rates. METHODS A retrospective review was performed on all patients at an academic level I trauma center treated with a bridge plate for a distal radius fracture from 2014 to 2022. RESULTS Sixty-five wrists were included in the final analysis: average age 53 years, male 51%, average plate retention 4 months, and average follow-up 6 months. Carpal tunnel release (CTR) was performed at time of primary procedure in 7 (10%) cases. Radial height, radial inclination, dorsal tilt, and ulnar variance were all significantly improved (P < .001). Grip strength, flexion, extension, and supination were significantly limited (P < .03). Twenty-one patients (32%) developed 35 major complications requiring unplanned reoperation, including mechanical hardware-related complication (15%), deep infection (11%), nonunion/delayed union (9%), adhesions (6%), median neuropathy (6%), symptomatic arthritis (5%), and tendon rupture (2%). Plate breakage occurred in 3 patients (5%) and was always localized over the central drill holes of the bridge plate. CONCLUSIONS Major complications for bridge plating of distal radius fractures were higher at our institution than previously published. Plate breakage should prompt reconsideration of plate design to avoid drill holes over the wrist joint. Signs and symptoms of carpal tunnel syndrome should be carefully assessed at initial presentation, and consideration for concomitant CTR should be strongly considered.
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Affiliation(s)
| | - Alan K Swenson
- Orthopedic Physicians Alaska, OrthoAlaska, Anchorage, USA
| | | | | | - Peter J Stern
- University of Cincinnati College of Medicine, OH, USA
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Derksen BM, Jawahier PA, Wijers O, Knops SP, de Vries MR, van Hooff CCD, Verhofstad MHJ, Schep NWL. Refraining from closed reduction of displaced distal radius fractures in the emergency department-in short: the RECORDED trial. Trials 2024; 25:303. [PMID: 38711069 PMCID: PMC11075287 DOI: 10.1186/s13063-024-08118-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/16/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND With roughly 45,000 adult patients each year, distal radius fractures are one of the most common fractures in the emergency department. Approximately 60% of all these fractures are displaced and require surgery. The current guidelines advise to perform closed reduction of these fractures awaiting surgery, as it may lead to post-reduction pain relief and release tension of the surrounding neurovascular structures. Recent studies have shown that successful reduction does not warrant conservative treatment, while patients find it painful or even traumatizing. The aim of this study is to determine whether closed reduction can be safely abandoned in these patients. METHODS In this multicenter randomized clinical trial, we will randomize between closed reduction followed by plaster casting and only plaster casting. Patients aged 18 to 75 years, presenting at the emergency department with a displaced distal radial fracture and requiring surgery according to the attending surgeon, are eligible for inclusion. Primary outcome is pain assessed with daily VAS scores from the visit to the emergency department until surgery. Secondary outcomes are function assessed by PRWHE, length of stay at the emergency department, length of surgery, return to work, patient satisfaction, and complications. A total of 134 patients will be included in this study with follow-up of 1 year. DISCUSSION If our study shows that patients who did not receive closed reduction experience no significant drawbacks, we might be able to reorganize the initial care for distal radial fractures in the emergency department. If surgery is warranted, the patient can be sent home with a plaster cast to await the call for admission, decreasing the time spend in the emergency room drastically. TRIAL REGISTRATION This trial was registered on January 27, 2023.
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Affiliation(s)
- B M Derksen
- Department of Trauma Surgery, Maasstad Hospital, Rotterdam, the Netherlands.
| | - P A Jawahier
- Department of Trauma Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - O Wijers
- Department of Trauma Surgery, Franciscus Gasthuis and Vlietland, Rotterdam, the Netherlands
| | - S P Knops
- Department of Trauma Surgery, Ikazia Hospital, Rotterdam, the Netherlands
| | - M R de Vries
- Department of Trauma Surgery, IJsselland Hospital Rotterdam, Capelle Aan Den IJssel, the Netherlands
| | | | - M H J Verhofstad
- Department of Trauma Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - N W L Schep
- Department of Trauma Surgery, Maasstad Hospital, Rotterdam, the Netherlands
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Wellborn PK, Jeffs AD, Allen AD, Zaidi ZS, Koutlas NT, Draeger RW, Patterson JMM, Chen AT. Outcomes Following Surgical Fixation of Distal Radius Fractures in Patients With Chronic Kidney Disease. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:395-398. [PMID: 38817745 PMCID: PMC11133898 DOI: 10.1016/j.jhsg.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 06/01/2024] Open
Abstract
Purpose Moderate-to-severe chronic kidney disease (CKD, stages III-IV) and end-stage renal disease (ESRD or CKD stage V) are known to be independent risk factors for fragility fracture. Altered bone and mineral metabolism contributes to greater complications and mortality rates in the setting of fractures, although most existing literature is limited to hip fractures. We hypothesized that patients with moderate-to-severe CKD or ESRD would have greater complication rates after surgical treatment of distal radius fractures compared with those without CKD. Methods We retrospectively identified all patients at a level 1 trauma center between 2008 and 2018 who had a diagnosis of stage III-IV CKD or ESRD at the time of operative fixation of a distal radius fracture. We recorded demographic data, comorbidities, and surgical complications. Data for readmissions within 90 days and 1-year mortality were collected. A 2:1 sex-matched control group without CKD who underwent distal radius fixation was selected for comparison, with age-adjusted analysis. Results A total of 32 patients with CKD (78.1% CKD stage III/IV, 21.9% ESRD) and 62 without CKD were identified. The mean age was 67 ± 12 years in the CKD group and 55 ± 15 years in the control group. The CKD group had a higher Charlson Comorbidity Index (5.7 vs 2.0). Surgical complication rate in the CKD group was 12.5% (12.0% CKD III/IV; 14.3% ESRD). Neither early nor late surgical complication rates were statistically different from those in patients without CKD. Reoperation rate as well as 30- and 90-day readmission rates were similar between groups. Overall, 1-year mortality was greater in the CKD group (9.4% vs 0%). Conclusions Surgical complications and readmission rates are similar in patients with and without CKD after distal radius fracture fixation. However, 1-year mortality rate is significantly higher after distal radius fixation in patients with moderate-to-severe CKD or ESRD. Type of study/level of evidence Prognostic IIIa.
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Affiliation(s)
| | - Alexander D. Jeffs
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Andrew D. Allen
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | - Zohair S. Zaidi
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | | | - Reid W. Draeger
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
| | | | - Andrew T. Chen
- Department of Orthopaedics, University of North Carolina, Chapel Hill, NC
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15
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Chung J, Mahmoud Y, Ilyas AM. Incidence and Treatment of Carpal Tunnel Syndrome Following Distal Radius Fractures: A TriNetX Analysis of 39,603 Patients. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:308-312. [PMID: 38817743 PMCID: PMC11133837 DOI: 10.1016/j.jhsg.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Abstract
Purpose Distal radius fractures (DRFs) are among the most common fractures and occur among all age groups. Carpal tunnel syndrome (CTS) is a known sequela of DRFs, but its incidence is poorly understood. This study was undertaken to determine the incidence of CTS following a DRF, with the hypothesis being that CTS occurs more commonly after nonsurgical treatment of a DRF. Methods The TriNetX US Collaborative Network was queried for all patients diagnosed with DRFs from January 2016 to December 2022. Cohorts were defined by inclusion and exclusion of the procedure Current Procedural Terminology codes into surgical and nonsurgical groups and subsequent ICD-10 diagnosis codes of CTS. Statistical analysis was performed to determine differences in management across the study period. Results A total of 39,603 patients met inclusion with a diagnosis of a DRF. The incidence of CTS within one year of a DRF was 5.3%. Among all DRF cases, 10,279 (26%) patients underwent surgical treatment, whereas 29,324 (74%) patients underwent nonsurgical treatment. The incidence of CTS in the surgical group was 1194 (12%), whereas the incidence of CTS in the nonsurgical group was 915 (3%). Patients undergoing surgical treatment for a DRF had a 9% risk of developing CTS, whereas patients undergoing nonsurgical treatment had a 5% risk. Among all the patients having been diagnosed with CTS, 63% of those with an operatively treated DRF underwent surgical release, whereas 23% of those with a nonoperatively treated DRF underwent surgical release for CTS. Conclusions Patients having undergone surgical treatment for DRF had a four times higher rate of developing CTS, compared with those having undergone nonsurgical treatment. Among patients who underwent surgical treatment of a DRF with the subsequent development of CTS, there was a nearly three times higher rate of surgical release of CTS. Type of study/level of evidence Prognostic III.
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Affiliation(s)
| | | | - Asif M. Ilyas
- Drexel University College of Medicine, Philadelphia, PA
- Rothman Orthopaedic Institute, Philadelphia, PA
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16
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Dhanjani SA, Gomez G, Rogers D, LaPorte D. Are There Racial and Ethnic Disparities in Management and Outcomes of Surgically Treated Distal Radius Fractures? Hand (N Y) 2024; 19:471-480. [PMID: 36196925 PMCID: PMC11067843 DOI: 10.1177/15589447221124248] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Racial/ethnic disparities have been demonstrated across multiple orthopedic sub-specialties. There is a paucity of literature examining disparities in distal radius fracture (DRF) management. METHODS Using the National Surgical Quality Improvement Program database, we analyzed 15 559 non-Hispanic (NH) White, NH Black, NH Asian, and Hispanic adults who underwent open reduction and internal fixation for DRF from 2013 to 2019. We evaluated time from hospital admission to surgery and length of stay using Poisson regression. Deep venous thrombosis, pulmonary embolism (PE), and wound complications were reported using descriptive statistics. Thirty-day reoperation and readmission were analyzed using binary logistic regression. RESULTS Wait time to surgery was longer for Hispanic patients than NH White patients (incidence rate ratio [IRR]: 2.54, P < .001); this narrowed over time (IRR: 0.944, P = .047). Length of stay was longer for NH Black (IRR: 1.78, P < .001) and Hispanic patients (IRR: 1.83, P < .001), but shorter for NH Asian (IRR: 0.715, P = .019) than NH White patients; this temporally narrowed for NH Black patients (IRR: 0.908, P = .001). Deep venous thrombosis, PE, and wound complications occurred at a rate less than 0.30% across all groups. Hispanic patients were less likely to undergo reoperation than NH White patients (odds ratio [OR]: 0.254, P = .003). While there was no difference in readmission between groups in the aggregated study period, NH Black patients experienced a temporal increase in readmissions relative to NH White patients (OR: 1.40, P = .038). CONCLUSIONS Racial and ethnic disparities exist in DRF management. Further investigation on causes for and solutions to combat these disparities in DRF care may help improve the inequities observed.
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Affiliation(s)
| | - Gabriela Gomez
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Davis Rogers
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dawn LaPorte
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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17
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Emet A, Veizi E, Karaman Y, Akgun E, Tolunay T, Firat A. Volar fixed plating of distal radius fractures: optimizing plate position for enhanced clinical outcomes. BMC Musculoskelet Disord 2024; 25:320. [PMID: 38654260 PMCID: PMC11036783 DOI: 10.1186/s12891-024-07415-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/04/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND The precise influence of plate position on clinical outcomes in the context of volar fixed-angle plating for distal radius fractures is not fully understood. This article aims to investigate the influence of plate position on clinical results, and functional outcomes in patients treated with volar fixed plating for distal radius fractures. METHODS A total of 58 patients with 64 distal radius fractures were included in the study. Patient demographics, fracture characteristics, surgical details, and radiographic data were collected. Post-operative AP and Lat views of all patients taken on the first day after surgery were evaluated. Volar Tilt, Radial Inclination and Radial Height measurements were used as reduction criteria. In the follow-up, the patients were called for their last control, flexion and extension angles of the wrist and Mayo Wrist Scores, the distance of the plate to the joint line and the angle between the plate and the radial shaft were measured and recorded. RESULTS A total of 64 distal radius fractures, with a mean age of 46.9 years, and the mean follow-up period 24.9 months were included in this study. There was a significant relationship between the Radial Inclination and Plate-Shaft Angle variables and the Mayo Wrist Score at a 99% confidence interval. Additionally, a relationship was observed between the Radial Height variable and the Mayo Score at a 90% confidence interval. A significant positive association was observed between radial inclination and achieving a Good-to-Excellent Mayo score (OR = 1.28, 95% CI [1.08-1.51], p = 0.004). Plate distance to joint line demonstrated a marginally significant positive association with a Good-to-Excellent Mayo score (OR = 1.31, 95% CI [0.97-1.77], p = 0.077). Univariate analysis revealed a significant negative association between plate-shaft angle and achieving a Good-to-Excellent Mayo score (OR = 0.71, 95% CI [0.52-0.99], p = 0.045). This negative association remained statistically significant in the multivariate analysis (p = 0.016). CONCLUSION Radial inclination, plate distance to joint line, and angle between plate and radius shaft were identified as significant factors associated with improved Mayo Wrist Scores.
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Affiliation(s)
- Abdulsamet Emet
- Department of Orthopedics and Traumatology, Etlik City Hospital, Turan Gunes Blv. Koz Apt. 41/22 Cankaya, Ankara, Turkey.
| | - Enejd Veizi
- Ankara City Hospital, Department of Orthopedics and Traumatology, Yıldırım Beyazıt University, Ankara, Turkey
| | - Yavuz Karaman
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey
| | - Erkan Akgun
- Department of Orthopedics and Traumatology, Etlik City Hospital, Turan Gunes Blv. Koz Apt. 41/22 Cankaya, Ankara, Turkey
| | - Tolga Tolunay
- Department of Orthopedics and Traumatology, Gazi University, Ankara, Turkey
| | - Ahmet Firat
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey
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Beyer F, Oppermann J, Prasse T, Müller LP, Eysel P, Bredow J. How Preoperative Closed Reduction and Time to Surgery Impact Postoperative Palmar Inclination in Distal Radius Fractures. J Clin Med 2024; 13:2316. [PMID: 38673588 PMCID: PMC11051345 DOI: 10.3390/jcm13082316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Background: The anatomical reconstruction of the wrist is the aim when treating distal radius fractures. Current literature on the importance of preoperative reduction in fractures that are treated operatively is limited. Methods: This study investigated the effect of the preoperative closed reduction of distal radius fractures on the day of trauma and the time to surgery on postoperative palmar inclination. A total of eighty patients (48 females and 32 males, mean age 55.6 years) were studied retrospectively. All patients were treated with an open reduction and internal fixation. The palmar inclination angle was measured using X-rays by two investigators, and the interobservers and pre- and post-reduction parameters were compared. Results: When the surgical management of closed distal radius fractures is required, neither initial repositioning nor a delay of up to 14 days to the surgical treatment influences postoperative palmar inclination. Conclusions: The significance of preoperative reduction of distal radius fractures without neurovascular or extensive soft tissue damage is limited and is not leading to improved outcomes. When surgery is about to be performed, surgeons should carefully consider if reduction is really vital preoperatively. Level of evidence: III.
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Affiliation(s)
- Frank Beyer
- Department of Orthopedics and Trauma Surgery, Krankenhaus Porz am Rhein, Urbacher Weg 19, 51149 Cologne, Germany;
| | - Johannes Oppermann
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (J.O.); (T.P.); (L.P.M.); (P.E.)
| | - Tobias Prasse
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (J.O.); (T.P.); (L.P.M.); (P.E.)
| | - Lars Peter Müller
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (J.O.); (T.P.); (L.P.M.); (P.E.)
| | - Peer Eysel
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany; (J.O.); (T.P.); (L.P.M.); (P.E.)
| | - Jan Bredow
- Department of Orthopedics and Trauma Surgery, Krankenhaus Porz am Rhein, Urbacher Weg 19, 51149 Cologne, Germany;
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Dworkin M, Harrison WJ, Chidothi P, Mbowuwa F, Martin C, Agarwal-Harding K, Chokotho L. Epidemiology and Treatment of Distal Radius Fractures at Four Public Hospitals in Malawi. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202404000-00003. [PMID: 38530958 DOI: 10.5435/jaaosglobal-d-23-00282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/06/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Little is known about the burden or management of distal radius fractures (DRFs) in low- and middle-income countries. The purpose of this study was to describe the care of DRFs in Malawi. METHODS We retrospectively reviewed a registry of all patients with fractures who presented to the orthopaedic departments at four public hospitals in Malawi. RESULTS Totally, 1,440 patients (14.5%) were with a DRF. Average age was 40, and 888 (62.0%) were male. Surgery was done for 122 patients (9.5%). Patients presenting to Queen Elizabeth Hospital, patients presenting after a fall, and patients initially evaluated by an orthopaedic registrar or orthopaedic clinical officer had lower odds of receiving surgical treatment. Meanwhile, open injuries had the greatest odds of receiving surgery. CONCLUSION The most common musculoskeletal injury among patients in the Malawi Fracture Registry was fractures of the distal radius. These most affected young adult male patients may benefit from surgery; however, the majority were managed nonsurgically. Lack of access to surgical fixation and conservative follow-up may have long-term functional consequences in a predominantly agrarian society. Outcomes-based research is needed to help guide management decisions and standardize patient care and referral protocols.
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Affiliation(s)
- Myles Dworkin
- From the Department of Orthopaedic Surgery, The Warren Alpert School of Medicine at Brown University, Ontario, RI (Dr. Dworkin), Harvard Global Orthopaedics Collaborative, Boston, MA (Dr. Dworkin). AO Alliance, Davos, Switzerland (Mr. Harrison, Mr. Chidothi, Mr. Mbowuwa, and Dr. Martin); Countess of Chester Hospital NHS Foundation Trust, London (Mr. Harrison and Mr. Chidothi); Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding); Department Harvard Medical School, Program in Global Surgery and Social Change, Global Health and Social Medicine, Boston, MA (Dr. Agarwal-Harding), Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi (Ms. Chokotho)
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20
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Ax M, Palola V, Ponkilainen V, Launonen AP, Mattila VM. Duration of sick leave after operated and non-operated distal radial fracture: a Finnish cohort study of 19,995 patients. J Hand Surg Eur Vol 2024; 49:316-321. [PMID: 37624727 PMCID: PMC10882944 DOI: 10.1177/17531934231194673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
The purpose of this study was to investigate whether operative treatment for distal radial fracture reduces the length of sick leave and the costs of treatment. We identified 19,995 patients from a registry who received a state sick leave allowance between 2010 and 2019 owing to distal radial fractures. We compared these patients to a registry of operations and identified 4346 operated patients. Operated patients had a mean sick leave of 75 days, whereas non-operated patients had a sick leave of 63 days. In the operated group, the cost of sick leave was €7505 (UK£6419; US$8070), which was 34% higher than in the non-operated group. Over the analysed period, the duration of sick leave decreased. Although several studies have shown better early functional outcomes after operation, this does not seem to shorten sick leave.Level of evidence: III.
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Affiliation(s)
- Maarit Ax
- Faculty of Medicine and Health Sciences, University of Tampere, Tampere, Finland
| | - Vili Palola
- Faculty of Medicine and Health Sciences, University of Tampere, Tampere, Finland
| | - Ville Ponkilainen
- Faculty of Medicine and Health Sciences, University of Tampere, Tampere, Finland
- Department of Surgery, Central Finland Central Hospital Nova, Jyväskylä, Finland
| | - Antti P Launonen
- Faculty of Medicine and Health Sciences, University of Tampere, Tampere, Finland
- Department of Orthopedics and Traumatology, Tampere University Hospital, Elämänaukio, Tampere, Finland
| | - Ville M Mattila
- Faculty of Medicine and Health Sciences, University of Tampere, Tampere, Finland
- Department of Orthopedics and Traumatology, Tampere University Hospital, Elämänaukio, Tampere, Finland
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21
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Nordback PH, Ragupathi T, Cheah A. A proposed paradigm shift in the management of distal radius fractures. J Orthop 2024; 49:117-122. [PMID: 38152426 PMCID: PMC10749825 DOI: 10.1016/j.jor.2023.11.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/25/2023] [Indexed: 12/29/2023] Open
Abstract
Background and objective Distal radius fractures represent a remarkable orthopaedic entity. Most distal radius fractures can be treated conservatively with closed reduction and immobilisation with satisfactory results, while open reduction and internal fixation is reserved for displaced fractures. Our objective was to propose a paradigm shift in the management of distal radius fractures. Methods A literature search of management of distal radius fractures was conducted. PubMed and Cochrane databases were used for the search. English articles with open access or institutional subscription availability were included. Key content and finding Current literature supports operative management for younger active patients with defined radiographic inclusion parameters, but among the elderly there is little evidence of benefit. Most orthopaedic literature defines "elderly" as patients above 65 years of age. Non-surgical treatment for fractures of the distal radius tends to yield satisfactory functional results, and these favourable outcomes do not necessarily align with normal radiological parameters. For the minority of patients that have symptomatic malunion, corrective osteotomy is a good option to improve the function provided the symptoms can be clearly attributed to the malalignment. Conclusion The vast majority of distal radius fractures can be managed conservatively. Further studies are recommended to explore the feasibility of advocating for universal conservative treatment for patients with less functional demands while still having the option of staged surgery in the form of corrective osteotomy where there is symptomatic malunion amenable to anatomical correction. Future research should also aim to identify patients who would benefit most from surgical intervention by considering the type of functional recovery needed, rather than relying predominantly on the patient's chronological age as the determining factor in the decision-making process.
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Affiliation(s)
- Panu H. Nordback
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
- Musculoskeletal and Plastic Surgery, Department of Hand Surgery, University of Helsinki and Helsinki University Hospital, Finland
| | - Tharun Ragupathi
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Andre.E.J. Cheah
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
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22
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Veiga RB, Hobi R, Marot RP, Schuroff GZ, Sobania RL, Kuhn IK, Faccioni ALC. Comparison of Sociodemographic and Radiographic Features in Distal Radio Fracture Treatment: Hand Surgeons versus Non-specialists. Rev Bras Ortop 2024; 59:e46-e53. [PMID: 38524724 PMCID: PMC10957272 DOI: 10.1055/s-0043-1776017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/27/2023] [Indexed: 03/26/2024] Open
Abstract
Objective: This study evaluated sociodemographic and radiographic features of patients with distal radial fractures treated at a trauma hospital in southern Brazil, comparing those treated by hand surgery specialists (group 1) and non-specialists (group 2). Methods: This study consists of a retrospective cohort of 200 patients treated in 2020. After reviewing medical records and radiographs, the following parameters were analyzed: age, gender, trauma mechanism, laterality, associated comorbidities and fractures, fracture classification (AO), radial height, radial inclination, and volar inclination. Comparison of the two groups used the Student t-test, chi-square test, or Fisher exact test. Results: Most subjects were women (54%), sustained low-energy traumas (58%), and were left-handed (53%). Group 1 had a lower mean age (50.2 years); most of their subjects sustained high-energy trauma (54%) and had type C fractures (73%); type A fractures prevailed in group 2 (72%). Radiographs showed a significant difference regarding the mean radial inclination (21.5° in group 1 and 16.5° in group 2 [ p < 0.001] in women, and 21.3° in group 1 and 17° in group 2 [ p < 0.001] in men) and volar inclination (10.1° and 12.8° in groups 1 and 2, respectively [ p < 0.001]). In addition, the absolute number of cases with reestablished anatomical parameters per the three evaluated variables was also significantly different; all parameters were better in group 1. Conclusion: Hand surgeons treated the most severe fractures and had the best radiographic outcomes.
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Affiliation(s)
- Rafael Bulyk Veiga
- Departamento de Ortopedia e Traumatologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Renê Hobi
- Departamento de Ortopedia e Traumatologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Ricardo Pereira Marot
- Departamento de Ortopedia e Traumatologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Gustavo Zeni Schuroff
- Departamento de Ortopedia e Traumatologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Roberto Luiz Sobania
- Departamento de Ortopedia e Traumatologia, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Ivan Killing Kuhn
- Departamento de Ortopedia e Traumatologia, Hospital do Trabalhador, Universidade Federal do Paraná, Curitiba, PR, Brasil
| | - Ana Lucia Campos Faccioni
- Departamento de Ortopedia e Traumatologia, Hospital do Trabalhador, Universidade Federal do Paraná, Curitiba, PR, Brasil
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Zhao H, Chen J, Zhang H, Xing J, Liu M, Wang W. Factors Associated with Re-Displacement after Nonsurgical Treatment of Distal Radius Fractures in Adults: A Retrospective Study. Orthop Surg 2024; 16:234-244. [PMID: 38041507 PMCID: PMC10782234 DOI: 10.1111/os.13950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 12/03/2023] Open
Abstract
OBJECTIVE Closed reduction combined with external fixation is a frequently utilized approach for treating distal radial fractures in adults. Nonetheless, the potential for re-displacement following external fixation remains. Analyzing the factors influencing re-displacement after nonsurgical treatment of distal radial fractures in adults is vital for preventing re-displacement and making prognostic assessments. METHODS A retrospective analysis was performed on 884 patients who underwent nonsurgical treatment for distal radius fractures in the reduction room of the Orthopedics and Traumatology Department of Integrated Traditional Chinese and Western Medicine at Tianjin Hospital, Tianjin, China, between July 2019 and December 2022. Patients were categorized into two groups, namely displaced and nondisplaced, based on radiographic outcomes. Factors affecting fracture re-displacement were examined, including sex, age, side, AO/OTA type, external fixation, and radiographic outcomes at pre-reduction and immediate reduction. Logistic regression analysis was employed to identify the risk factors for fracture re-displacement, and ROC curves were constructed. RESULTS Among the 884 patients, 563 (63.69%) experienced re-displacement after fracture reduction. There were no statistically significant differences (p > 0.05) between the two groups in terms of gender, external fixation method, and palmar tilt angle at pre-reduction and immediate reduction, while significant differences (p < 0.05) were observed in age, side, AO/OTA type, and radial inclination, radial length, and radiographic outcomes of ulnar variance at pre-reduction and immediate reduction. Multifactorial logistic regression analysis revealed that age (odds ratio [OR] = 1.027, p < 0.001), AO/OTA type (OR = 2.327, p = 0.005), ulnar variance at pre-reduction (OR = 1.142, p = 0.048), and ulnar variance at immediate reduction (OR = 1.685, p < 0.001) were significant factors (p < 0.05) associated with re-displacement following nonoperative treatment of adult distal radius fractures. For patients aged ≥60 years, the amount of missing radiographic outcomes was positively correlated with age. The receiver operating characteristic curve demonstrated that age ≥65.5 years, ulnar variance >3.26 mm at pre-reduction, and ulnar variance >2.055 mm at immediate reduction were high-risk factors for fracture re-displacement. CONCLUSIONS Nonsurgical treatment of distal radius fractures exhibits a higher rate of re-displacement. Age, AO/OTA type, pre-reduction, and immediate reduction ulnar variance are key factors predicting fracture re-displacement.
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Affiliation(s)
- Hong‐zhou Zhao
- Reduction Room of Orthopedics and Traumatology Department of Integrated Traditional Chinese and Western MedicineTianjin HospitalTianjinChina
| | - Jian‐ge Chen
- Orthopedics DepartmentFirst Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and MoxibustionTianjinChina
| | - Hai‐ning Zhang
- Tuina DepartmentFirst Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and MoxibustionTianjinChina
| | - Jia‐hui Xing
- Reduction Room of Orthopedics and Traumatology Department of Integrated Traditional Chinese and Western MedicineTianjin HospitalTianjinChina
| | - Ming‐jun Liu
- Reduction Room of Orthopedics and Traumatology Department of Integrated Traditional Chinese and Western MedicineTianjin HospitalTianjinChina
| | - Wei‐min Wang
- Orthopedics DepartmentFirst Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and MoxibustionTianjinChina
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van Veelen NM, Babst R, Link BC, van de Wall BJM, Beeres FJP. [Distal radius fracture-tactic and approach]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:352-369. [PMID: 37395767 DOI: 10.1007/s00064-023-00818-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/21/2022] [Accepted: 12/25/2022] [Indexed: 07/04/2023]
Abstract
OBJECTIVE The aim of surgical treatment is fracture healing with restored alignment, rotation, and joint surface. Stable fixation allows for functional postoperative aftercare. INDICATIONS Displaced intra- and extra-articular fractures which either could not be adequately reduced or in which a secondary displacement is to expected due to instability criteria. The following factors are considered instability criteria: age > 60 years, female, initial dorsal displacement > 20°, dorsal comminution, radial shortening > 5 mm, palmar displacement. CONTRAINDICATIONS The only absolute contraindication is if the patient is deemed unfit for surgery due to concerns regarding anesthesia. Old age is a relative contraindication, as it is currently debated whether older patients benefit from the operation. SURGICAL TECHNIQUE The surgical technique is guided by the fracture pattern. Palmar plating is most commonly performed. If the joint surface needs to be visualized, a dorsal approach (in combination with another approach or alone) or arthroscopically assisted fixation should be chosen. POSTOPERATIVE MANAGEMENT In general, a functional postoperative regime can be carried out after plate fixation with mobilization without weightbearing. Short-term splinting can provide pain relief. Concomitant ligamentous injuries and fixations, which are not stable enough for functional aftercare (such as k‑wires) require a longer period of immobilization. RESULTS Provided the fracture is reduced correctly, osteosynthesis improves functional outcome. The complication rate ranges between 9 and 15% with the most common complication being tendon irritation/rupture and plate removal. Whether surgical treatment holds the same benefits for patients > 65 years as for younger patients is currently under debate.
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Affiliation(s)
- Nicole M van Veelen
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Schweiz.
| | - Reto Babst
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Schweiz
- Fakultät für Gesundheitswissenschaften und Medizin, Universität Luzern, Frohburgstrasse 3, 6002, Luzern, Schweiz
| | - Björn-Christian Link
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Schweiz
| | - Bryan J M van de Wall
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Schweiz
| | - Frank J P Beeres
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstrasse, 6000, Luzern, Schweiz
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25
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Gill SS, Namireddy SR. Surgical vs Non-surgical interventions for distal radius fractures: a quantitative analysis of Patient-Rated Wrist Evaluation measures. Acta Orthop Belg 2023; 89:701-708. [PMID: 38205764 DOI: 10.52628/89.4.12408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Trials to assess differences in PRWE (Patient Related Wrist Evaluation) over time, for both surgical and non-surgical interventions post DRFs (distal radius fractures) are rare. The DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire has been shown to be improved by a greater margin in the medium term for surgical interventions, than non surgical interventions. However, a study found that PRWE can be considered superior to the DASH questionnaire for DRFs, due to greater specificity to wrist pain and function. Conflicting data makes it difficult to determine surgical vs non-surgical superiority for DRF's over time with PRWE as a recovery metric. PubMed and Cochrane were searched for randomised controlled trials up to 31.8.23, reporting PRWE over 3, and 12 months. Data was extracted by 2 researchers. The differences in PRWE over time post surgical and non-surgical interventions was assessed using unpaired T testing. 1226 records were screened. 4 studies enrolling 817 participants met the eligibility criteria and were analysed. Significantly lower PRWE in surgical intervention has been identified at the 3 month mark (p<0.001). There was greater significant change in non-surgical intervention between months 3 and 12 (p<0.001). Change in PRWE over time may be a good indicator of functional outcomes in DRFs post surgical or non-surgical interventions. This could inform future clinical trial design and surgical decision-making. Further work is required to design even more user-friendly and digital patient- reported outcomes specifically for DRFs.
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Dong W, Lisitano LSJ, Marchand LS, Reider LM, Haller JM. Weight-bearing Guidelines for Common Geriatric Upper and Lower Extremity Fractures. Curr Osteoporos Rep 2023; 21:698-709. [PMID: 37973761 DOI: 10.1007/s11914-023-00834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review paper is to summarize current weight-bearing guidelines for common geriatric fractures, around weight-bearing joints, of the upper and lower extremities. RECENT FINDINGS There is an increasing amount of literature investigating the safety and efficacy of early weight-bearing in geriatric fractures, particularly of the lower extremity. Many recent studies, although limited, suggest that early weight-bearing may be safe for geriatric distal femur and ankle fractures. Given the limited data pertaining to early weight-bearing in geriatric fractures, it is difficult to establish concrete weight-bearing guidelines in this population. However, in the literature available, early weight-bearing appears to be safe and effective across most injuries. The degree and time to weight-bearing vary significantly based on fracture type and treatment method. Future studies investigating postoperative weight-bearing protocols should focus on the growing geriatric population and identify methods to address specific barriers to early weight-bearing in these patients such as cognitive impairment, dependence on caregivers, and variations in post-acute disposition.
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Affiliation(s)
- Willie Dong
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Leonard S J Lisitano
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA
| | - Lisa M Reider
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
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He LD, Duggan JL, Lans J, Harper CM, Rozental TD. Trends in Orthopedic Management of Distal Radius Fractures Among Medicare Beneficiaries From 2019 to 2020: A Claims Analysis. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:717-721. [PMID: 38106940 PMCID: PMC10721538 DOI: 10.1016/j.jhsg.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 06/13/2023] [Indexed: 12/19/2023] Open
Abstract
Purpose Radius and ulna fractures are among the most common fractures. These fractures are managed through operative or nonsurgical treatment, with varying implications in terms of cost and functional outcome. There are few studies that robustly characterize the management of distal radius fractures (DRFs) in the United States during the COVID-19 pandemic. Furthermore, this has not been studied among the Medicare patient population, who are particularly vulnerable to fragility fractures and COVID-19. The purpose of this study is to analyze the services provided to Medicare beneficiaries both before and during the COVID-19 pandemic to determine how procedure volume was affected in this patient population. Methods We retrospectively analyzed services using the physician or supplier procedure summary data from the Centers for Medicare and Medicaid Services. All services provided by physicians between January 1, 2019, and December 31, 2020, were included. The data were stratified by US census region using insurance carrier number and pricing locality codes. We also compared data between states that maintained governors affiliated with the Democratic or Republican parties for the duration of the study. Results There was an overall decrease in claims regarding DRFs management from 2019 to 2020. There was a dramatic decline in procedure volume (-6.3% vs -12.9%). Of all distal radius related claims there was a relative increase in the proportion of operatively managed DRFs in 2020, from 50.2% to 52.0%. The Midwest saw the greatest decline in operatively managed DRFs, whereas the West experienced the smallest per-capita decline across all procedures. After separating the data by party affiliation, it was also found that operative and nonsurgical procedure volumes fell more sharply in states with Democratic governors. Conclusions This study shows a decrease in DRF procedural volume among Medicare beneficiaries. This data suggests that the operative and nonsurgical management of DRFs may have been affected by pandemic factors such as quarantine guidelines and supply chain or resource limitations. This may assist surgeons and health care systems in predicting how similar crises may affect operative volume. Type of study/level of evidence Therapeutic IV.
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Affiliation(s)
| | | | - Jonathan Lans
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Carl M. Harper
- Division of Hand and Upper Extremity Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tamara D. Rozental
- Division of Hand and Upper Extremity Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Harper CM, Model Z, Xiong G, Hegermiller K, Rozental TD. Do Surgeons Accurately Predict Level of Activity in Patients With Distal Radius Fractures? J Hand Surg Am 2023; 48:1083-1090. [PMID: 37632514 DOI: 10.1016/j.jhsa.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/25/2023] [Accepted: 07/12/2023] [Indexed: 08/28/2023]
Abstract
PURPOSE One factor influencing the management of distal radius fractures is the functional status of the patient. The purpose of this study was to assess the agreement between patient and surgeon assessments of patient activity level in patients sustaining a distal radius fracture. METHODS Ninety-seven patients were included, with a mean age of 58.5 years (range, 18-92 years). Patients completed the International Physical Activity Questionnaire, a validated survey that provides a score of low, moderate, or high activity levels. Treating surgeons provided an independent assessment using the same scale. Agreement between patient and surgeon assessments was evaluated using a weighted kappa-statistic, with a secondary analysis using logistic regression models to assess odds of surgical treatment. RESULTS Interrater agreement between surgeons and patients demonstrated only "fair" agreement, with a kappa-statistic of 0.33. Predictive models showed that surgeons accurately identified 73% of "high activity" patients but failed to correctly identify more than 41% of patients rated as "moderate activity" or "low activity." There was a correlation between surgical intervention and increasing physical activity status as assessed by the surgeon; however, the magnitude of this effect was unclear (odds ratio, 2.14; 95% confidence interval, 1.07-4.30). This relationship was no longer significant after adjusting for age, Charlson comorbidity index, and fracture class. There was no association between surgical intervention and physical activity status when using the status provided by the patient. CONCLUSIONS Surgeon assessment of patient activity level does not have strong agreement with patients' independent assessment. Surgeons are most accurate at identifying "high activity level" patients but lack the ability to identify "moderate activity level" or "low activity level" patients. CLINICAL RELEVANCE Recognition of surgeon assessment of patient activity level as flawed can stimulate improved dialog between patients and physicians, ultimately improving the shared decision-making process.
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Affiliation(s)
- Carl M Harper
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Zina Model
- Harvard Combined Orthopaedic Residency Program, Boston, MA
| | - Grace Xiong
- Harvard Combined Orthopaedic Residency Program, Boston, MA
| | - Katherine Hegermiller
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Tamara D Rozental
- Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Joo PY, Halperin SJ, Dhodapkar MM, Adeclat GJ, Elaydi A, Wilhelm C, Grauer JN. Racial Disparities in Surgical Versus Nonsurgical Management of Distal Radius Fractures in a Medicare Population. Hand (N Y) 2023:15589447231198267. [PMID: 37737570 DOI: 10.1177/15589447231198267] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND As racial/ethnic disparities in management of distal radius fractures (DRFs) have not been well elucidated in the literature, this study sought to evaluate the correlation of race/ethnicity on surgical versus nonsurgical management of DRFs in a Medicare population. METHODS The PearlDiver Standard Analytical Files Medicare claims database was used to identify patients ≥65 years old with isolated DRF. Patients with polytrauma or surgery performed for upper extremity neoplasm were excluded. Surgical versus nonsurgical management was compared based on demographics, comorbidity (Elixhauser Comorbidity Index, ECI), race/ethnicity, and whether the fracture was open or closed. Univariate and multivariable analyses were used to assess for independent predictors. RESULTS Of 54 564 isolated DRFs identified, surgery was performed for 20 663 (37.9%). On multivariable analysis, patients were independently less likely to receive surgical management if they were: older (relative to 65- to 69-year-olds, incrementally decreasing by age bracket up to >85 years where odds ratio [OR] was 0.27, P < .001), higher ECI (per 2 increase OR: 0.96, P < .001), and closed fractures (OR: 0.35, P < .001). For race/ethnicity: black (OR: 0.64, P < .001), Hispanic (OR: 0.71, P < .001), and Asian (OR: 0.60, P < .001) patients were less likely to undergo surgery. CONCLUSIONS While age, comorbidities, and fracture type are known to affect surgical decision-making for DRF, race/ethnicity has not previously been reported, and its independent prediction of nonsurgical management for several groups points to a disparity in surgical decision-making/access to care. This highlights the need for increased attention to initiatives that seek to provide equitable care to all patients. LEVEL OF EVIDENCE Level III-Retrospective review of national database.
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Affiliation(s)
| | | | | | | | - Ali Elaydi
- Yale School of Medicine, New Haven, CT, USA
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30
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Zha Q, Xu Z, Cai X, Zhang G, Shen X. Wearable rehabilitation wristband for distal radius fractures. Front Neurosci 2023; 17:1238176. [PMID: 37781255 PMCID: PMC10536142 DOI: 10.3389/fnins.2023.1238176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/07/2023] [Indexed: 10/03/2023] Open
Abstract
Background Distal radius fractures are a common type of fracture. For patients treated with closed reduction with splinting, a period of rehabilitation is still required after the removal of the splint. However, there is a general lack of attention and low compliance to rehabilitation training during this period, so it is necessary to build a rehabilitation training monitoring system to improve the efficiency of patients' rehabilitation. Methods A wearable rehabilitation training wristband was proposed, which could be used in the patient's daily rehabilitation training scenario and could recognize four common wrist rehabilitation actions in real-time by using three thin film pressure sensors to detect the pressure change curve at three points on the wrist. An algorithmic framework for classifying rehabilitation training actions was proposed. In our framework, an action pre-detection strategy was designed to exclude false detections caused by switching initial gestures during rehabilitation training and wait for the arrival of the complete signal. To classify the action signals into four categories, firstly an autoencoder was used to downscale the original signal. Six SVMs were then used for evaluation and voting, and the final action with the highest number of votes would be used as the prediction result. Results Experimental results showed that the proposed algorithmic framework achieved an average recognition accuracy of 89.62%, an average recognition recall of 88.93%, and an f1 score of 89.27% on the four rehabilitation training actions. Conclusion The developed device has the advantages of being small size and easy to wear, which can quickly and accurately identify and classify four common rehabilitation training actions. It can easily be combined with peripheral devices and technologies (e.g., cell phones, computers, Internet) to build different rehabilitation training scenarios, making it worthwhile to use and promote in clinical settings.
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Affiliation(s)
- Qing Zha
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Science, Suzhou, China
| | - Zeou Xu
- School of Biomedical Engineering (Suzhou), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
- Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Science, Suzhou, China
| | - Xuefeng Cai
- Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Guodong Zhang
- Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Xiaofeng Shen
- Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
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Neder AT, da Costa AC, de Barros RSM, Nakachima LR, de Souza SCA, Rodrigues MP, de Oliveira RK, da Gama SAM. The woman's hand. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023S108. [PMID: 37556627 PMCID: PMC10411716 DOI: 10.1590/1806-9282.2023s108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/24/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Antonio Tufi Neder
- Orizonti Instituto and Mater Dei Hospital, Hand Surgery Division – Belo Horizonte (MG), Brazil
| | - Antonio Carlos da Costa
- Santa Casa de Misericórdia de São Paulo, Department of Orthopedics and Traumatology, Hand Surgery and Microsurgery Division – São Paulo (SP), Brazil
| | | | - Luís Renato Nakachima
- Universidade Federal de São Paulo, Hand Surgery Group, Escola Paulista de Medicina – São Paulo (SP), Brazil
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Schmidt V, Gordon M, Tägil M, Sayed-Noor A, Mukka S, Wadsten M. Association Between Radiographic and Clinical Outcomes Following Distal Radial Fractures: A Prospective Cohort Study with 1-Year Follow-up in 366 Patients. J Bone Joint Surg Am 2023; 105:1156-1167. [PMID: 37172109 PMCID: PMC10377255 DOI: 10.2106/jbjs.22.01096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Several studies of distal radial fractures have investigated final displacement and its association with clinical outcomes. There is still no consensus on the importance of radiographic outcomes, and published studies have not used the same criteria for acceptable alignment. Previous reports have involved the use of linear or dichotomized analyses. METHODS The present study included 438 patients who were managed with either reduction and cast immobilization or surgery for the treatment of distal radial fractures. Radiographic outcomes were determined on the basis of radiographs that were made 3 months after the injury. Clinical outcome was determined on the basis of the QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) score, range of motion, and grip strength at 1 year after the injury. Nonlinear relations were analyzed with cubic splines. RESULTS Three hundred and sixty-six patients (84%) had both radiographic and clinical follow-up. Seventy patients were lost to follow-up. The mean age was 57 years (range, 18 to 75 years), and 79% of the patients were female. Dorsal tilt was the radiographic parameter that was most strongly associated with the QuickDASH score, grip strength, and range of motion. We found nonlinear relations. Clinical outcomes were found to worsen with increasing dorsal tilt, with the cutoff value being approximately 5°. CONCLUSIONS We found that clinical outcomes following distal radial fractures have a nonlinear relationship with dorsal tilt, with worse outcomes being associated with increasing dorsal tilt. The decline in clinical outcome starts at 5°, but there is unlikely to be a noticeable difference in capability as measured with the QuickDASH until 20° of dorsal tilt (based on the minimum clinically important difference) in a population up to 75 years old. LEVEL OF EVIDENCE Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Viktor Schmidt
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Max Gordon
- Department of Clinical Sciences, Danderyd Hospital (KIDS), Karolinska Institutet, Stockholm, Sweden
| | - Magnus Tägil
- Orthopaedic Unit, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
| | - Arkan Sayed-Noor
- Department of Clinical Sciences, College of Medicine, University of Sharjah, United Arab Emirates
| | - Sebastian Mukka
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Mats Wadsten
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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Scollan JP, Emara AK, Chughtai M, Jin Y, Styron JF. Validation of a Novel Smartphone-Based Electronic Data Capture System Following Surgical Fixation of Distal Radial Fractures. Hand (N Y) 2023; 18:751-757. [PMID: 34991356 PMCID: PMC10336805 DOI: 10.1177/15589447211057301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Large prospective institutional data provide the opportunity to conduct level II and III studies using robust methodologies and adequately powered sample-sizes, while circumventing limitations of retrospective databases. We aimed to validate a prospective data collection tool, the Orthopaedic Minimal Data Set Episode of Care (OME), implemented at a tertiary North American health care system for distal radial fracture (DRF) open reduction and internal fixation (ORIF). METHODS The first 100 DRF ORIFs performed after OME inception (February 2015) were selected for this validation study. A blinded review of the operative notes and charts was performed, and extracted data of 75 perioperative DRF ORIF procedure variables were compared with OME collected data for agreement. Outcomes included completion rates and agreement measures in OME versus electronic medical record (EMR)-based control datasets. Data counts were evaluated using raw percentages and McNemar tests. Cohen (κ) and concordance correlation coefficient analyzed categorical and numerical variable agreement, respectively. RESULTS Overall, OME demonstrated superior completion and agreement parameters versus EMR-based retrospective review. Nine data points (12.0%) demonstrated significantly higher completion rates within the OME dataset (P < .05, each), and 88% (66/75) of captured variables demonstrated similar completion rates. Up to 80.0% (60/75) of variables either demonstrated an agreement proportion of ≥0.90 or were solely reported in the OME. Of 33 variables eligible for agreement analyses, 36.4% (12/33) demonstrated almost perfect agreement (κ > 0.80), and 63.6% (21/33) exhibited almost perfect or substantial agreement (κ > 0.60). CONCLUSIONS The OME is a valid and accurate prospective data collection tool for DRF ORIF that is reliably able to match or supersede traditional retrospective chart review. Future investigations could use this tool for large-scale analyses investigating peri/intraoperative DRF ORIF variables.
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Jayaram M, Wood SM, Kane RL, Yang LY, Chung KC. Association of Open Reduction and Internal Fixation With Volar Locking Plate for Distal Radius Fractures With Patient-Reported Outcomes in Older Adults: A Network Meta-analysis. JAMA Netw Open 2023; 6:e2318715. [PMID: 37326988 PMCID: PMC10276304 DOI: 10.1001/jamanetworkopen.2023.18715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Importance Randomized clinical trials (RCTs) and meta-analyses have reported inconsistent conclusions regarding optimal distal radius fracture (DRF) treatment in older adults and are limited due to the inclusion of cohort studies with small sample sizes. A network meta-analysis (NMA) addresses these limitations by only synthesizing direct and indirect evidence from RCTs and may clarify optimal DRF treatment in older adults. Objective To examine DRF treatment results in optimal short-term and intermediate-term patient-reported outcomes. Data Sources Searches of MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials were conducted for RCTs that investigated DRF treatment outcomes in older adults between January 1, 2000, and January 1, 2022. Study Selection Randomized clinical trials including patients with a mean age of 50 years or older that compared the following DRF treatments were eligible for inclusion: casting, open reduction and internal fixation with volar lock plating (ORIF), external fixation, percutaneous pinning, and nail fixation. Data Extraction and Synthesis Two reviewers independently completed all data extraction. An NMA aggregated all direct and indirect evidence among DRF treatments. Treatments were ranked by surface under the cumulative ranking curve score. Data are reported as standard mean differences (SMDs) and 95% CIs. Main Outcomes and Measures The primary outcome was short-term (≤3 months) and intermediate-term (>3 months to 1 year) Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores. Secondary outcomes included Patient-Rated Wrist Evaluation (PRWE) scores and 1-year complication rates. Results In this NMA, 23 RCTs consisting of 3054 participants (2495 women [81.7%]) with a mean (SD) age of 66 (7.8) years were included. At 3 months, DASH scores were significantly lower for nail fixation (SMD, -18.28; 95% CI, -29.93 to -6.63) and ORIF (SMD, -9.28; 95% CI, -13.90 to -4.66) compared with casting. The PRWE scores were also significantly lower for ORIF (SMD, -9.55; 95% CI, -15.31 to -3.79) at 3 months. In the intermediate term, ORIF was associated with lowered DASH (SMD, -3.35; 95% CI, -5.90 to -0.80) and PRWE (SMD, -2.90; 95% CI, -4.86 to -0.94) scores. One-year complication rates were comparable among all treatments. Conclusions and Relevance The findings of this NMA suggest that ORIF may be associated with clinically significant improvements in short-term recovery compared with casting for multiple patient-reported outcomes measures with no increase in 1-year complication rates. Shared decision-making with patients may be useful to identify patient preferences regarding recovery to determine optimal treatment.
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Affiliation(s)
- Mayank Jayaram
- Medical Student, University of Michigan Medical School, Ann Arbor
| | - Shannon M. Wood
- Master’s Student, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Robert L. Kane
- Division of Plastic Surgery, Department of Surgery, The Medical University of South Carolina, Charleston
| | - Lan-Yan Yang
- Biostatistics Unit, Clinical Trial Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Kevin C. Chung
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor
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Tankersley MP, Zhuang T, Julian K, Fernandez A, Kamal RN, Shapiro LM. Disparities in Treatment of Closed Distal Radius Fractures in Patients Aged 18-64 Years and ≥65 Years by Insurance Type. J Hand Surg Am 2023; 48:566-574. [PMID: 37029034 PMCID: PMC10278954 DOI: 10.1016/j.jhsa.2023.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/03/2023] [Accepted: 03/03/2023] [Indexed: 04/09/2023]
Abstract
PURPOSE Type of and time to definitive treatment for distal radius fractures can influence the outcomes. The impact of social determinants of health (eg, insurance type) on distal radius fracture care remains unknown despite having health equity implications. Thus, we evaluate the association between insurance type and rate of surgery, the time to surgery, and the complication rate for distal radius fractures. METHODS We conducted a retrospective cohort study using the PearlDiver Database. We identified adults with closed distal radius fractures. Patients were divided into subgroups by age (18-64 years, 65+ years) and further stratified on the basis of the insurance type (Medicare Advantage, Medicaid-managed care, and commercial). The primary outcome was the rate of surgical fixation. Secondary outcomes included the time to surgery and 12-month complication rates. Logistic regression modeling was used to calculate the odds ratios for each outcome, adjusting for age, sex, geographic region, and comorbidities. RESULTS In patients aged ≥65 years, a lower proportion of Medicaid patients underwent surgery within 21 days of diagnosis compared with Medicare or commercially insured patients (12.1% vs 15.9% or 17.5%, respectively). Complication rates did not differ between Medicaid and other insurance types. In patients aged <65 years, fewer Medicaid patients underwent surgery compared with commercially insured patients (16.2% vs 21.1%). However, in this younger group, Medicaid patients had higher adjusted odds of malunion/nonunion (adjusted odds ratio [aOR] = 1.39 [95% CI, 1.31-1.47]) and subsequent repair (aOR = 1.38 [95% CI, 1.25-1.53]). DISCUSSION Although older Medicaid patients experienced lower surgical rates, this may not lead to differential clinical outcomes. However, Medicaid patients aged <65 years experienced lower surgical rates that correlated with the increased rates of malunion or nonunion. CLINICAL RELEVANCE In younger patients with a closed distal radius fracture and Medicaid insurance, system and patient-directed efforts should be considered to address delayed time to surgery and a higher odds for malunion/nonunion.
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Affiliation(s)
- Morgan P Tankersley
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Kaitlyn Julian
- Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA
| | - Alicia Fernandez
- Department of Medicine, University of California at San Francisco, San Francisco, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA.
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Shen O, Chen CT, Jupiter JB, Chen NC, Liu WC. Functional outcomes and complications after treatment of distal radius fracture in patients sixty years and over: A systematic review and network meta-analysis. Injury 2023:S0020-1383(23)00396-0. [PMID: 37188586 DOI: 10.1016/j.injury.2023.04.054] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/17/2023]
Abstract
AIM This network meta-analysis aims to compare functional outcomes and complications between conservative treatment and surgery for distal radius fractures in patients aged 60 years and over. METHODS We searched the PubMed, EMBASE, and Web of Science databases for randomized controlled trials (RCTs) assessing the effect of conservative treatment and surgery for distal radius fractures in patients aged 60 years and over. Primary outcomes included grip strength and overall complications. Secondary outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH) scores, Patient-Rated Wrist Evaluation (PRWE) scores, wrist range of motion and forearm rotation, and radiographic assessment. All continuous outcomes were assessed using standardized mean differences (SMDs) with 95% confidence intervals (CIs), and binary outcomes were assessed using odds ratio (OR) with 95% CIs. The surface under the cumulative ranking curve (SUCRA) was used to determine a hierarchy of treatments. Cluster analysis was performed for grouping treatments based on the SUCRA values of primary outcomes. RESULTS Fourteen RCTs were included to compare conservative treatment, volar lockedplate (VLP), K-wires fixation, and external-fixation. VLP outperformed conservative treatment for 1-year and minimum 2-year grip strength (SMD; 0.28 [0.07 to 0.48] and 0.27 [0.02 to 0.53], respectively). VLP yielded the optimal grip strength at 1-year and minimum 2-year follow-up (SUCRA; 89.8% and 86.7%, respectively). In a subgroup analysis of patients aged 60 to 80 years old, VLP outperformed conservative treatment in DASH and PRWE scores (SMD, 0.33 [0.10, 0.56] and 0.23 [0.01, 0.45], respectively). In addition, VLP had the fewest complications (SUCRA = 84.3%). Cluster analysis suggested that VLP and K-wire fixation were more effective treatment groups. CONCLUSION Evidence to date demonstrates that VLP provides measurable benefits in grip strength and fewer complications to those 60 years of age and over, and that benefit is not reflected in current practice guidelines. There is a subgroup of patients where K-wire fixation outcomes are similar to those of VLP; defining this subgroup may yield substantial societal benefits.
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Affiliation(s)
- Oscar Shen
- Hand and Arm Center, Department of Orthopedics, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | - Chih-Ting Chen
- Department of Clinical Education, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Jesse B Jupiter
- Hand and Arm Center, Department of Orthopedics, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | - Neal C Chen
- Hand and Arm Center, Department of Orthopedics, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
| | - Wen-Chih Liu
- Hand and Arm Center, Department of Orthopedics, Massachusetts General Hospital, Harvard Medical School, Boston, USA; Department of Orthopedics, Kaohsiung Medical University Hospital, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Lawson A, Naylor J, Mittal R, Kale M, Xuan W, Harris IA. Does Radiographic Alignment Correlate With Patient-Reported Functional Outcomes and Posttreatment Complications in Older Patients Treated for Wrist Fractures? J Hand Surg Am 2023:S0363-5023(23)00115-6. [PMID: 37115143 DOI: 10.1016/j.jhsa.2023.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 02/05/2023] [Accepted: 02/15/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE Surgical treatment of distal radius fractures provides better fracture alignment than closed reduction; however, surgical treatment does not lead to better patient-reported function at 12 months. The aims of this study were to report the radiographic outcomes from the Combined Randomized and Observational Study of Surgery for Fractures In the distal Radius in the Elderly trial, investigate the association between radiographic outcomes and patient-reported function, and explore whether this association was affected by posttreatment complications and direction of malalignment. METHODS This study used the outcomes of the Combined Randomized and Observational Study of Surgery for Fractures In the distal Radius in the Elderly trial, which is a combined randomized and observational trial that compared volar-locking plate fixation with closed reduction and cast immobilization, to treat distal radius fractures in patients aged ≥60 years. Four radiographic outcomes (dorsal angulation, radial inclination, ulnar variance, and articular step) were reported at the following three time frames: (1) baseline, (2) after treatment, and (3) ≥6 weeks by treatment group. Secondary analysis was correlation of 12-month patient-reported function scores with 6-week radiographic measures for each of four radiographic parameters, and a subgroup analysis was conducted to investigate if this was affected by posttreatment complications. Tertiary analysis investigated if direction of malalignment affected the secondary analysis. RESULTS We recruited 300 participants (166 randomized and 134 observational); 113 had volar-locking plate fixation, and 187 had closed reduction. There were no between-group differences for each of the four pretreatment radiographic parameters, but there were between-treatment group differences for all four radiographic parameters apart from articular step. We found no association between patient-reported function at 12 months and each of the four radiographic parameters at 6 weeks. This lack of association was unaffected by posttreatment complications and the direction of malalignment. CONCLUSIONS For patients with wrist fractures aged ≥60 years, final radiographic alignment did not correlate with patient-reported function at 12 months. These findings were not affected by treatment type, and there was no association between radiographic alignment and posttreatment complications. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Andrew Lawson
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia; South Western Sydney Clinical School, UNSW Sydney, Sydney, Australia.
| | - Justine Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia; South Western Sydney Clinical School, UNSW Sydney, Sydney, Australia
| | - Rajat Mittal
- South Western Sydney Clinical School, UNSW Sydney, Sydney, Australia
| | - Michael Kale
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
| | - Wei Xuan
- Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia; South Western Sydney Clinical School, UNSW Sydney, Sydney, Australia
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Von Matthey F, Rammensee J, Müller M, Biberthaler P, Abel H. Can elderly patients regain their preoperative functional level after distal radius fracture type A? Results from a fracture register study using PROM. Front Surg 2023; 10:877252. [PMID: 37091269 PMCID: PMC10113482 DOI: 10.3389/fsurg.2023.877252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 03/08/2023] [Indexed: 04/09/2023] Open
Abstract
IntroductionAlthough distal radius fractures (DRFs) are the most common fractures of the human body, there are still ongoing debates concerning the treatment for type A fractures, especially in elderly patients. In spite of good clinical outcomes, it remains unclear whether elderly patients, especially, could regain the preoperative functional level of the wrist. Therefore, we have quantified wrist function within a retrospective study design using patient-reported outcome measures (PROM) and we have analyzed the influence of age between control and patient collective and young vs. old, respectively.Patients and methodsThe retrospective study included all patients with a surgically treated DRF type A and a control group of healthy patients, age and gender matched. The function of the wrist was examined by using a self-assessment questionnaire called the Munich Wrist Questionnaire (MWQ) according to the patient-related outcome measurements PROM.ResultsWe could enroll 110 patients and controls, and the average follow-up was 66 months. Subgroup matching induced similar age group distribution: in both groups, 7 individuals <30 years, 67 between 31 and 64 years, 29 between 65 and 79 years, and 7 individuals >80 years, were enrolled, respectively. In the fracture group, women were significantly older than men (59 ± 15 vs. 47 ± 17 (M ± SD). There was no significant difference between the control and the patient groups (96 ± 6 vs. 95 ± 7). The function was significantly different between controls and patients <30 years (100 ± 1 vs. 98 ± 2). In the control group, there was a functional difference in the age group <30 compared with 65–79 and >80 and in the age group 30–64 compared with 65–79 and >80. In the control group, the function was found to be significantly decreasing with advancing age, whereas in the patient group, this influence was absent. A correlation analysis showed a worse function with increasing age in the control group and therefore a negative correlation. In the fracture group, a similar result could not be obtained.DiscussionAge has a relevant influence on wrist function. Although the wrist function decreases significantly with aging, in the patient group, this influence is absent, and the functional results after surgery are excellent. Even elderly patients can regain their preoperative functional level.
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Falk SSI, Maksimow A, Mittlmeier T, Gradl G. Does access through the pronator quadratus influence pronation strength in palmar plate fixation of distal radius fractures in elderly patients? Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04847-5. [PMID: 36973374 PMCID: PMC10374697 DOI: 10.1007/s00402-023-04847-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/12/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Palmar plate fixation of the distal radius fracture involves dissecting the pronator quadratus (PQ). This is regardless of whether the approach is radial or ulnar to the flexor carpi radialis (FCR) tendon. It is not yet clear whether and to what extent this dissection leads to a functional loss of pronation or pronation strength. The aim of this study was to investigate the functional recovery of pronation and pronation strength after dissection of the PQ without suturing. MATERIALS AND METHODS From October 2010 to November 2011, patients aged over 65 with fracture were prospectively enrolled in this study. Fracture stabilisation was performed via the FCR approach without suturing the PQ. Follow-up examinations took place 8 weeks and 12 months postoperatively, and pronation and supination strength were analysed by means of an especially developed measuring device. RESULTS 212 patients were initially screened and 107 were enrolled. The range of motion compared to the healthy opposite side was Ext/Flex 75/66% 8 weeks postoperatively. Pronation was 97% with a pronation strength of 59%. After 1 year, the scores improved to Ext/Flex 83/80%. Pronation recovered to 99% and pronation strength to 78%. CONCLUSION The present study can show a recovery of pronation as well as pronation strength in a large patient population. At the same time, the pronation strength is still significantly lower 1 year after the operation than on the opposing healthy side. As the pronation strength recovers as the grip strength and is at all times on a par with the supination strength, we believe that we can continue to refrain from re-fixating the pronator quadratus.
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Affiliation(s)
- Steffi S I Falk
- Clinic of Trauma, Hand and Reconstructive Surgery, University of Rostock, Schillingallee 35, 18055, Rostock, Germany.
| | - Anna Maksimow
- Clinic of Trauma, Hand and Reconstructive Surgery, University of Rostock, Schillingallee 35, 18055, Rostock, Germany
| | - Thomas Mittlmeier
- Clinic of Trauma, Hand and Reconstructive Surgery, University of Rostock, Schillingallee 35, 18055, Rostock, Germany
| | - Georg Gradl
- Clinic of Trauma, Orthopaedic, Hand and Reconstructive Surgery, Munich Municipal Hospital Group, Clinic Harlaching, Sanatoriumsplatz 2, 81545, Munich, Germany
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Prospective Evaluation of Two Cohorts of Non-Operatively Treated Patients with Displaced vs. Minimally and Non-Displaced Distal Radius Fractures. J Clin Med 2023; 12:jcm12052076. [PMID: 36902861 PMCID: PMC10004318 DOI: 10.3390/jcm12052076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/01/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Distal radius fractures (DRFs) in the elderly are common. Recently, the efficacy of operative treatment of displaced DRFs in patients above 65 years of age has been questioned and it has been suggested that non-operative treatment should be the gold standard. However, the complications and functional outcome of displaced vs. minimally and non-displaced DRFs in the elderly has not been evaluated yet. The aim of the present study was to compare non-operatively treated displaced DRFs vs. minimally and non-displaced DRFs in terms of complications, PROMs, grip strength and range of motion (ROM) after 2 weeks, 5 weeks, 6 months and 12 months. METHODS We used a prospective cohort study that compared patients with displaced DRFs (n = 50), i.e., >10 degrees of dorsal angulation after two reduction attempts, with patients with minimally or non-displaced DRFs after reduction. Both cohorts received the same treatment of 5 weeks of dorsal plaster casting. Complications and functional outcomes (quick disabilities of the arm, shoulder and hand (QuickDASH), patient-rated wrist/hand evaluation (PRWHE), grip strength and EQ-5D scores) were assessed after 5 weeks, 6 months and 12 months post-injury. The protocol of the VOLCON RCT and present observational study has been published (PMC6599306; clinicaltrials.gov: NCT03716661). RESULTS One year after 5 weeks of dorsal below-elbow casting of low-energy DRFs in patients ≥ 65 years old, we found a complication rate of 6.3% (3/48) in minimally or non-displaced DRFs and 16.6% (7/42) in displaced DRFs (p = 0.18). However, no statistically significant difference was observed in functional outcomes in terms of QuickDASH, pain, ROM, grip strength or EQ-5D scores. DISCUSSION In patients above 65 years of age, non-operative treatment, i.e., closed reduction and dorsal casting for 5 weeks, yielded similar complication rates and functional outcomes after 1 year regardless of whether the initial fracture was non-displaced/minimally displaced or still displaced after closed reduction. While the initial closed reduction should still be attempted in order to restore the anatomy, failure to achieve the stipulated radiological criteria may not be as important as we thought in terms of complications and functional outcome.
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Is the Postoperative Outcome after Intraarticular Distal Radius Fracture Influenced by Age and Gender? A PROM Study. J Clin Med 2023; 12:jcm12031202. [PMID: 36769848 PMCID: PMC9918132 DOI: 10.3390/jcm12031202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/26/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Although the most common fracture of the human body, so far, only few data concerning gender-specific outcomes after distal radius fracture exist. Typically, elderly women suffer from DRF due to a low-energy fall because of osteoporosis. The aim of this study was to analyze the outcome after a surgically treated intraarticular DRF with the help of patient-reported outcome measurement (PROM) and with special regard to gender and age impact. PATIENTS AND METHODS It is a retrospective case-control study in which all patients with an intraarticular DRF were enrolled. The control group was composed of healthy volunteers. Munich Wrist Questionnaire (MWQ) was used as Patient Related Outcome Measurement (PROM) for analyzing the outcome. Moreover, age, gender, handedness, fracture classification and follow-up interval were detected. The functional outcome of the fracture group was compared to a healthy control group. Analyses of gender, age and handedness-specific results compared to the healthy control groups were performed as well. RESULTS 197 patients with distal radius fracture could be enrolled in the study (134 were female and 63 were male). Women (mean age 62 years) were significantly older than men (mean age 50 years). The control group comprised 110 healthy subjects, 71 females (mean age 56 years) and 39 males (mean age 53 years). The whole fracture group had significantly lower MWQ scores compared to the control group (p < 0.001). The male fracture group (90.6 ± 12.4) and the female fracture group (90.8 ± 11.4) had a significantly worse outcome compared to the corresponding control group (p < 0.001 male and p = 0.034 female). Although significantly younger, the male patients had a similar outcome compared to the female patients. DISCUSSION Even elderly patients can reach the preoperative level after operative treatment of an intraarticular distal radius fracture. Although significantly younger than the female patients, men have significantly worse functional outcomes compared to their control and cannot perform better than the significantly older female patients. Gender might influence the outcome as well; however, age seems to have a greater impact on the outcome than gender.
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Rigney B, Casey C, McDonald C, Pomeroy E, Cleary MS. Distal radius fracture fixation using WALANT versus general and regional anesthesia: A systematic review and meta-analysis. Surgeon 2023; 21:e13-e22. [PMID: 35216922 DOI: 10.1016/j.surge.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 01/04/2022] [Accepted: 01/26/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND WALANT (wide-awake local anaesthetic no tourniquet) has become a popular technique in upper limb surgery including distal radius fracture fixation. The purpose of this systematic review and meta-analysis is to assess the effectiveness of the WALANT technique in distal radius fracture fixation, and to compare it to both general and regional anaesthesia. METHODS Pubmed, Embase, and Scopus databases were searched on 26/06/21 according to the PRISMA guidelines with the following search terms: radius, WALANT, "local anesthetic", wide-awake surgery. All studies comparing WALANT with other forms of anaesthesia for distal radius fracture fixation were included. RESULTS 110 articles were identified, six studies (410 patients) were included, 164 of these patients were in the WALANT group. Two patients (1.2%) in the WALANT group and seven (6.5%) in the regional anaesthesia group required conversion to general anaesthesia. There was no statistically significant difference in post-operative complications, intra-operative VAS pain scores, operative times, functional or radiological outcomes. A statistically significant 8.6 mls increase in pooled mean blood loss in the WALANT group was noted (p = 0.02) although the clinical significance of this is doubtful. CONCLUSION The WALANT technique for distal radius fracture fixation is non-inferior to regional and general anaesthesia. It is a safe and effective technique that surgeons may consider utilising, especially for patients not suitable for general anaesthetic or in centres in which there is a lack of access to specialist anaesthetic equipment and care.
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Affiliation(s)
- Brian Rigney
- Trauma and Orthopaedic Department, University Hospital Waterford, Dunmore Road, Waterford, Ireland; Discipline of Surgery, National University of Ireland Galway, Galway, Ireland.
| | - Conor Casey
- Trauma and Orthopaedic Department, University Hospital Waterford, Dunmore Road, Waterford, Ireland
| | - Ciaran McDonald
- Trauma and Orthopaedic Department, University Hospital Waterford, Dunmore Road, Waterford, Ireland
| | - Eoghan Pomeroy
- Trauma and Orthopaedic Department, University Hospital Waterford, Dunmore Road, Waterford, Ireland
| | - May S Cleary
- Trauma and Orthopaedic Department, University Hospital Waterford, Dunmore Road, Waterford, Ireland; Department of Surgery, College of Medicine & Health, University College Cork, Cork, Ireland
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Linnanmäki L, Hevonkorpi T, Repo J, Karjalainen T. Anterior locking plate versus non-operative treatment in different age groups with distal radial fractures: a systematic review and meta-analysis. J Hand Surg Eur Vol 2023; 48:532-543. [PMID: 36624925 DOI: 10.1177/17531934221143636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This meta-analysis compared anterior locking plate and non-operative treatment for distal radial fractures and assessed if the age of the patients is associated with the treatment effect. We searched the MEDLINE, Embase and CENTRAL databases and included 12 studies with 1366 patients. Compared with non-operative care, anterior locking plate treatment does not seem to provide clinically important benefits in mean DASH score, mean pain or their mean quality of life at 12 to 24 months if the patients' ages are not considered (moderate to low certainty evidence). However, the younger the patients, the larger the benefit for surgery. Meta-regression with the DASH score suggested that while people over 70 likely experience no clinically relevant benefit from surgery, the mean effects cannot be generalized to people under 60. The evidence regarding the risk of adverse events is too uncertain to make firm conclusions.
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Affiliation(s)
| | | | - Jussi Repo
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
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Asmara AAGY, Karna MB, Meregawa PF, Deslivia MF. Outcomes of the Management of Distal Radius Fractures in the Last 5 Years: A Meta-analysis of Randomized Controlled Trials. Rev Bras Ortop 2022; 57:899-910. [PMID: 36540735 PMCID: PMC9757966 DOI: 10.1055/s-0042-1754379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 06/14/2022] [Indexed: 12/23/2022] Open
Abstract
Objective Over the last decades, volar locking plates (VLPs) have been the mainstay treatment for distal radius fractures (DRFs). With the growing body of evidence, we systematically reviewed studies on recent VLP modifications. Methods A systematic search was performed in the PubMed/MEDLINE database for studies published in English in the past five years. The inclusion criteria were randomized controlled trials (RCTs) on the operative treatment of DRFs. We excluded ongoing trials and studies not directly addressing DRF. The primary outcomes assessed were subjective (such as the scores on the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire, the Patient-rated Wrist Evaluation [PRWE], the European Quality of Life-5 Dimensions [EQ-5D], the 36-item Short Form Health Survey [SF-36], and the Visual Analog Scale [VAS]) and objective clinical outcomes (the complication rate). Results We identified 29 articles published from 2016 to 2020 with high quality of evidence, except for one, which had evidence of moderate quality. In total, 3,079 DRFs were analyzed in the present study. All studies except one had a greater proportion of female participants, and only in 1 study the mean age of the sample was < 40 years old. There were no significant differences between the VLP and external fixation (EF) in terms of the scores on the DASH ( p = 0.18) and PRWE ( p = 0.77). The VLP alone without pronator quadratus (PQ) repair yielded significantly better outcomes. Conclusion In unstable fractures, the VLP and EF yielded comparable long-term results. There is no clear benefit of adding PQ repair to current the VLP surgical technique. Level of Evidence Level I.
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Affiliation(s)
- Anak Agung Gede Yuda Asmara
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Udayana University, Sanglah General Hospital, Bali, Indonésia,Endereço para correspondência Anak Agung Gede Yuda Asmara Orthopedics and Traumatology Department, Faculty of Medicine, Udayana University, Sanglah General HospitalJl, Kesehatan no.1, BaliIndonesia
| | - Made Bramantya Karna
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Udayana University, Sanglah General Hospital, Bali, Indonésia
| | - Putu Feryawan Meregawa
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Udayana University, Sanglah General Hospital, Bali, Indonésia
| | - Maria Florencia Deslivia
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Udayana University, Sanglah General Hospital, Bali, Indonésia
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Munaretto N, Tagliero A, Patel R, Rhee PC. Distal Radius Fracture Treatment Outcomes in Patients With Ipsilateral Hemiplegia or Hemiparesis. Hand (N Y) 2022; 17:19S-24S. [PMID: 33789515 PMCID: PMC9793617 DOI: 10.1177/1558944721999733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Little information exists to guide decision-making with regard to distal radius fractures in the setting of ipsilateral hemiparesis or hemiplegia. METHODS Patients who sustained a distal radius fracture in the setting of ipsilateral hemiparesis or hemiplegia secondary to brain injury were evaluated. Investigated variables included perioperative pain, preinjury House functional classification score, length of immobilization, radiographic outcome measurements, and time to union. RESULTS There were 15 patients with distal radius fractures with a mean age of 65.9 years. The mean clinical and radiographic follow-up was 2.8 and 2.9 years, respectively. Wrists were placed into the nonoperative group (NOG, n = 10) and operative group (OG, n = 5). Pain significantly decreased at final follow-up for both groups. Baseline House functional classification scores averaged 1.3 and 1.6 for the NOG and OG, respectively, and were maintained at final follow-up. Length of immobilization for the NOG was 46 days and OG was 37 days, P = .15. Radiographic outcomes at final follow-up in the NOG and OG, respectively, were a mean radial height of 9.3 versus. 11.6 mm, radial inclination of 18.3° versus 22.3°, 4.2° dorsal tilt versus 5.3° volar tilt, and tear drop angle of 45.6° versus 44.5°. There were no significant differences in these measurements. Time to radiographic union averaged 58 days for the NOG and 67 days for the OG, P = .42. There were no revision surgeries. CONCLUSIONS Based on this small case series, patients with distal radius fracture and ipsilateral hemiparesis or hemiplegia may have similar clinical, functional, and radiographic outcomes, regardless of nonoperative or operative treatment.
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Howell M, Lawson A, Naylor J, Howard K, Harris IA. Surgical plating versus closed reduction for fractures in the distal radius in older patients: a cost-effectiveness analysis from the hospital perspective. ANZ J Surg 2022; 92:3311-3318. [PMID: 36333993 PMCID: PMC10947348 DOI: 10.1111/ans.18134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Given the cost differential between surgical and non-surgical management of distal radius fractures, we aimed to evaluate the cost-effectiveness of surgical compared with non-surgical treatment of distal radius fractures in a cohort of older patients. METHODS This evaluation was conducted alongside the combined randomized and observational study of surgery for fractures of the distal radius in the elderly (CROSSFIRE) trial (ACTRN 12616000969460) which compared surgical (open reduction and internal fixation using volar-locking plate (VLP) fixation) and non-surgical (closed fracture reduction and cast immobilization (CR)) treatment for displaced distal radius fractures in patients ≥60 years. Cost-effectiveness was assessed from the perspective of the public hospital funder. Hospital records from a sub-sample of participants were used to estimate costs. Outcomes were patient-reported wrist pain and function questionnaire (PRWE) scores and quality adjusted life years (QALYs) calculated using the EuroQoL five-dimension five-level tool (EQ-5D-5L). RESULTS From 166 participants (81 surgical, 85 non-surgical), costs were obtained for 56 (29 surgical, 27 non-surgical). The mean costs for VLP fixation were Australian dollars (AUD) 6668 (95% CI $4857 to $8479) compared to AUD 3343 (95% CI $1304 to $5381) for CR. The incremental cost-effectiveness ratios (ICER) to achieve a 1-point improvement in the PRWE were AUD 375, AUD 1736 and AUD 1126 at 3, 12 and 24 months for VLP compared with CR. At 12 months, the cost effectiveness was dominated by CR (lower cost and better QoL) whereas at 24 months, the incremental cost per QALY gained by VLP was AUD 1 946 127. CONCLUSION In the treatment of distal radius fractures in patients ≥60 years, VLP fixation was not cost-effective compared with CR from the perspective of hospital funders.
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Affiliation(s)
- Martin Howell
- School of Public Health, Faculty of Medicine and HealthUniversity of SydneySydneyAustralia
| | - Andrew Lawson
- Whitlam Orthopaedic Research CentreIngham Institute for Applied Medical ResearchSydneyAustralia
- South Western Sydney Clinical SchoolUNSWSydney
| | - Justine Naylor
- Whitlam Orthopaedic Research CentreIngham Institute for Applied Medical ResearchSydneyAustralia
- South Western Sydney Clinical SchoolUNSWSydney
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine and HealthUniversity of SydneySydneyAustralia
| | - Ian A. Harris
- Whitlam Orthopaedic Research CentreIngham Institute for Applied Medical ResearchSydneyAustralia
- South Western Sydney Clinical SchoolUNSWSydney
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Neumeister MW. New Research on Distal Radius Fractures. Hand (N Y) 2022; 17:5S. [PMID: 36527205 PMCID: PMC9793623 DOI: 10.1177/15589447221144408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Thorninger R, Wæver D, Tjørnild M, Lind M, Rölfing JD. VOLCON: a randomized controlled trial investigating complications and functional outcome of volar plating vs casting of unstable distal radius fractures in patients older than 65 years. J Orthop Traumatol 2022; 23:54. [PMID: 36443579 PMCID: PMC9705678 DOI: 10.1186/s10195-022-00673-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/29/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Primary aim: to compare complications of operative vs non-operative treatment of unstable distal radius fractures (DRF) fulfilling national clinical guidelines for operative treatment. Secondary aim: to compare the functional outcomes. MATERIALS AND METHODS A single-centre randomized controlled trial of unstable DRF. 50 patients: volar locking plate, 2 weeks casting + 3 weeks orthosis. 50 patients: 5 weeks casting. PRIMARY OUTCOME complications assessed after 2 and 5 weeks and 6 and 12 months. SECONDARY OUTCOMES Quick-DASH, PRWHE, range of motion, grip strength, EQ-5D-3L. RESULTS 148 patients were screened from November 2019 to March 2021. 48 patients did not want to participate or were unable to participate in the follow-up. 100 patients were randomized and 85 patients were available for full analysis due to there being 4 deaths, 6 withdrawals, 1 wrong inclusion, 1 emigration, 1 refracture, 1 patient with compartment syndrome, and 1 who was advised to undergo surgery after being randomized to non-operative treatment. Median age was 74 years (range 65-92), 81 women/19 men, 42 right/58 left side, 87 retired, 11 smokers, 86 ASA class 1 or 2. Complication rates did not statistical significantly vary between the operative and non-operative group: 20.9% (9/43) vs 16.6% (7/42), p = 0.78 (Fisher's exact test). Complications were driven by sensory disturbances. Four reoperations were performed: two in the non-operative group: carpal tunnel syndrome; two in the operative group: one carpal tunnel syndrome, one protruding screw causing extensor tendon irritation. Mean difference in Quick-DASH varied from 2.3 (95% CI - 3 to 8) pre-injury to 4.2 (- 4 to 12) at 12 months. Quick-DASH and PRWHE were neither statistically nor clinically-relevant different between groups. CONCLUSIONS Complication rates after operative and non-operative treatment of DRF were similar. Volar plating did not improve the functional outcome after 5 weeks, 6 months, and 12 months. These findings are in line with recent RCTs and mandate a revision of guidelines towards more conservative treatment. TAKE HOME MESSAGES (1) consider non-operative treatment in elderly patients sustaining unstable DRFs; (2) choosing operative treatment in patients older than 65 years should not be the gold standard; (3) however, non-operative treatment still carries a risk for complications. LEVEL OF EVIDENCE II. Trial registration Clinicaltrials.gov NCT03716661, registered 23rd Oct 2018; Published protocol PMC6599306.
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Affiliation(s)
- Rikke Thorninger
- Department of Orthopaedics, Regional Hospital Randers, Skovlyvej 15, 8930, Randers, Denmark. .,Department of Clinical Medicine, HEALTH, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus, Denmark.
| | - Daniel Wæver
- Department of Orthopaedics, Regional Hospital Randers, Skovlyvej 15, 8930, Randers, Denmark
| | - Michael Tjørnild
- Department of Orthopaedics, Regional Hospital Randers, Skovlyvej 15, 8930, Randers, Denmark
| | - Martin Lind
- Department of Clinical Medicine, HEALTH, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus, Denmark.,Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark
| | - Jan Duedal Rölfing
- Department of Clinical Medicine, HEALTH, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus, Denmark. .,Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark.
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Kazzam ME, Clowes R, Wilson C, Walker L. Reducing Exposure to X-Ray in Patients With Conservatively Managed Distal Radius Fractures: A Closed-Loop Pilot Audit. Cureus 2022; 14:e31929. [DOI: 10.7759/cureus.31929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 11/28/2022] Open
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Llopis E, Cerezal L, Auban R, Aguilella L, Piñal FD. Postoperative Imaging of the Wrist and Hand. Magn Reson Imaging Clin N Am 2022; 30:645-671. [DOI: 10.1016/j.mric.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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