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Ballet S, Guerzider-Regas I, Aouzal Z, Pozet A, Quemener-Tanguy A, Koehly A, Obert L, Loisel F. Distal radius fractures after 75 years of age: are six-month functional and radiological outcomes better with plate fixation than with conservative treatment? Orthop Traumatol Surg Res 2024:103959. [PMID: 39059547 DOI: 10.1016/j.otsr.2024.103959] [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: 08/23/2023] [Revised: 01/13/2024] [Accepted: 01/25/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Surgery and non-operative treatment produce similar 1-year functional outcomes in patients older than 65 years. Data are lacking for patients older than 75 years. The main objective of this study was to compare surgical vs. non-operative treatment regarding short-term outcomes in patients older than 75 years. In addition to an overall analysis, sub-group analyses were done in patients with displacement and severe displacement (>20 ° posterior tilt). HYPOTHESIS Surgery provides better clinical and radiological outcomes than does non-operative treatment. PATIENTS AND METHODS Patients older than 75 years at the time of a distal radius fracture were included prospectively over a 2-year period. A follow-up duration of at least 6 months was required. Treatment choices were based on displacement, Charlson's Co-morbidity Index, and patient autonomy. Surgery consisted in open fixation using an anterior locking plate and non-operative treatment in a short arm cast without reduction. The main assessment was based on clinical criteria: range of motion, strength, visual analogue scale (VAS) scores, the short version of the Disabilities of the Arm, Shoulder, and Hand tool (QuickDASH), the Patient Rated Wrist Evaluation (PRWE), and the 36-Item Short Form Health Survey (SF-36). The secondary assessment criteria were the radiological outcomes and the complications. RESULTS 74 patients were included, among whom 24 were treated surgically and 50 non-operatively. At 1.5 months, surgery was associated with significantly better results for flexion, ulnar inclination, and supination, with range increases of at least 7 ° vs. non-operative treatment, and with greater dorsal angle and ulnar variance values (p < 0.05 for all comparisons). At 6 months, pronation and the radio-ulnar index were better with surgery (p < 0.05 for both comparisons). In the patients with displacement or severe displacement, surgery was associated with 10° gains vs. conservative treatment for flexion, ulnar inclination, and supination at 1.5 months (p < 0.05 for all comparisons). DISCUSSION In patients older than 75 years, surgery for distal radius fracture was associated with significantly better clinical and radiological outcomes within 6 months. Surgery is recommended for displaced and severely displaced distal radius fractures to expedite the recovery of joint motion ranges. Beyond 6 months, the outcomes are similar. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Safire Ballet
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, CHU Besançon, SINERGIES, Nanomédecine, Imagerie, Thérapeutique-EA 4662, Université de Bourgogne Franche-Comté, Sciences Médicales et Pharmaceutiques, 19 Rue Ambroise Paré, 25030 Besançon, France.
| | - Inès Guerzider-Regas
- Service de Chirurgie Orthopédique et Traumatologique, Centre Hospitalier Edmond Garcin, Hôpital Public Aubagne, 179 avenue des sœurs Gastine, 13677 Aubagne, France
| | - Zouhair Aouzal
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, CHU Besançon, SINERGIES, Nanomédecine, Imagerie, Thérapeutique-EA 4662, Université de Bourgogne Franche-Comté, Sciences Médicales et Pharmaceutiques, 19 Rue Ambroise Paré, 25030 Besançon, France
| | - Astrid Pozet
- Délégation de la Recherche Clinique et de l'Innovation (DRCI), CHU de Besançon, 3 Boulevard Alexandre Fleming, 25030 Besançon, France
| | - Alexandre Quemener-Tanguy
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, CHU Besançon, SINERGIES, Nanomédecine, Imagerie, Thérapeutique-EA 4662, Université de Bourgogne Franche-Comté, Sciences Médicales et Pharmaceutiques, 19 Rue Ambroise Paré, 25030 Besançon, France
| | - Axel Koehly
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, CHU Besançon, SINERGIES, Nanomédecine, Imagerie, Thérapeutique-EA 4662, Université de Bourgogne Franche-Comté, Sciences Médicales et Pharmaceutiques, 19 Rue Ambroise Paré, 25030 Besançon, France
| | - Laurent Obert
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, CHU Besançon, SINERGIES, Nanomédecine, Imagerie, Thérapeutique-EA 4662, Université de Bourgogne Franche-Comté, Sciences Médicales et Pharmaceutiques, 19 Rue Ambroise Paré, 25030 Besançon, France
| | - François Loisel
- Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main, Université de Franche-Comté, CHU Besançon, SINERGIES, Nanomédecine, Imagerie, Thérapeutique-EA 4662, Université de Bourgogne Franche-Comté, Sciences Médicales et Pharmaceutiques, 19 Rue Ambroise Paré, 25030 Besançon, France
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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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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:S0363-5023(24)00028-5. [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] [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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Knee CJ, Campbell RJ, Graham DJ, Handford C, Symes M, Sivakumar BS. Examining the role of ChatGPT in the management of distal radius fractures: insights into its accuracy and consistency. ANZ J Surg 2024. [PMID: 38967407 DOI: 10.1111/ans.19143] [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: 02/11/2024] [Revised: 03/19/2024] [Accepted: 06/15/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND The optimal management of distal radius fractures remains a challenge for orthopaedic surgeons. The emergence of Artificial Intelligence (AI) and Large Language Models (LLMs), especially ChatGPT, affords significant potential in improving healthcare and research. This study aims to assess the accuracy and consistency of ChatGPT's knowledge in managing distal radius fractures, with a focus on its capability to provide information for patients and assist in the decision-making processes of orthopaedic clinicians. METHODS We presented ChatGPT with seven questions on distal radius fracture management over two sessions, resulting in 14 responses. These questions covered a range of topics, including patient inquiries and orthopaedic clinical decision-making. We requested references for each response and involved two orthopaedic registrars and two senior orthopaedic surgeons to evaluate response accuracy and consistency. RESULTS All 14 responses contained a mix of both correct and incorrect information. Among the 47 cited references, 13% were accurate, 28% appeared to be fabricated, 57% were incorrect, and 2% were correct but deemed inappropriate. Consistency was observed in 71% of the responses. CONCLUSION ChatGPT demonstrates significant limitations in accuracy and consistency when providing information on distal radius fractures. In its current format, it offers limited utility for patient education and clinical decision-making.
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Affiliation(s)
- Christopha J Knee
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Ryan J Campbell
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - David J Graham
- Australian Research Collaboration on Hands [ARCH], Mudgeeraba, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Southport, Queensland, Australia
- School of Medicine, University of Queensland, Herston, Queensland, Australia
- Department of Musculoskeletal Services, Gold Coast University Hospital, Southport, Queensland, Australia
- Department of Orthopaedic Surgery, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Cameron Handford
- Department of Orthopaedic Surgery, St George Hospital, Kogarah, New South Wales, Australia
| | - Michael Symes
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Department of Orthopaedic Surgery, St George Hospital, Kogarah, New South Wales, Australia
| | - Brahman S Sivakumar
- Australian Research Collaboration on Hands [ARCH], Mudgeeraba, Queensland, Australia
- Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia
- Department of Orthopaedic Surgery, Hornsby Ku-ring-gai Hospital, Hornsby, New South Wales, Australia
- Department of Orthopaedic Surgery, Nepean Hospital, Kingswood, New South Wales, Australia
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5
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Graesser EA, Tian AC, Dardas AZ, Calfee RP, Wall LB. Development of a Patient Decision Aid for Distal Radius Fractures in Patients aged ≥65 years. J Hand Surg Am 2024:S0363-5023(24)00203-X. [PMID: 38934995 DOI: 10.1016/j.jhsa.2024.04.011] [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: 11/27/2023] [Revised: 03/11/2024] [Accepted: 04/03/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE The ideal management of distal radius fractures (DRFs) in patients aged 65 years and older is debated. Acknowledging the evidence that both nonsurgical and surgical treatment yield similar outcomes one year after injury, a patient decision aid (PDA) could facilitate patient engagement in treatment decision-making. The purpose of this study was to develop a PDA to guide patients in the treatment of DRFs in patients ≥65 years of age. METHODS The DRF PDA was developed using an established decision sciences framework. The PDA included an overview of DRFs, treatment options (casting vs surgery), risk/benefits, and a values clarification section. During the development phase, hand surgeons and patients reviewed the PDA; then, semistructured interviews were performed with participants to elicit feedback. RESULTS Eleven patients and 11 hand surgeons participated in the study. All patients found the PDA useful and almost all stated it would make the treatment decision easier. Most patients believed that there was enough information in the PDA, but one desired more information about surgical risks. Almost all surgeons stated the PDA would be easy for patients to use and understand, and approximately half believed that it would help patients make a more informed decision. Most surgeons expressed that the PDA would complement their usual approach to counseling patients, but some noted it would involve changes to their workflow. Most participants believed the information presented was unbiased, but one patient thought it was biased toward surgery, whereas a few surgeons believed that it was biased toward nonsurgical treatment. CONCLUSIONS All patients expressed that the PDA was informative, comprehensive, and easy to understand and would be helpful if they were deciding about DRF treatment. Surgeons believed that patients would find the PDA easy to use and understand, but some had concerns about incorporating it into their clinic workflow. CLINICAL RELEVANCE A decision aid for the treatment of DRFs in patients aged ≥65 years can be used to engage patients in the shared decision-making process.
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Affiliation(s)
- Elizabeth A Graesser
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Andrea C Tian
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Agnes Z Dardas
- Department of Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ryan P Calfee
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO
| | - Lindley B Wall
- Department of Orthopaedic Surgery, Washington University School of Medicine, Saint Louis, MO.
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Guasconi M, Zilli Riboni D, Civardi A, Bolzoni M, Granata C, Beretta M, Genovese A, Mozzarelli F, Quattrini F, Maniscalco P. The use of adhesive elastic tape for hand oedema control in patients with a wrist fracture treated in a cast: A pilot study. Int J Orthop Trauma Nurs 2024; 53:101059. [PMID: 38261469 DOI: 10.1016/j.ijotn.2023.101059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 10/03/2023] [Accepted: 10/17/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND The adhesive elastic tape use is indicated for controlling oedema, although currently there is not the definitive evidence regarding its effectiveness. Wrist fractures are a frequent occurrence, often leading to oedema development in patients treated with forearm casts. This pilot study aims to investigate the effects of elastic tape in controlling hand oedema among patients with forearm casts for wrist fractures and the feasibility of a future randomized controlled trial. METHODS The study was conducted on adult patients with unilateral conservatively treated wrist fracture. The tape was applied to the intervention group after cast application, while the control group received the standard treatment. The circumference difference between baseline and the 7-day follow-up of both the 1st finger and the remaining 4 fingers merged together was evaluated. Ethical approval for the study has been obtained. RESULTS 23 participants were enrolled. The intervention group showed a higher reduction in finger circumferences compared to the control group (median difference T1-T0 No tape vs Tape: 0 cm vs -0.2 cm for the 1st finger and 0.5 cm vs -0.5 cm for the remaining 4 fingers), although the changes were not statistically significant. CONCLUSION Although the number of enrolled patients was limited due to Covid-19 pandemic, the study results suggest a potential reduction in oedema after the use of adhesive elastic tape, justifying the needed of a future full-scale study. Given its low cost and ease of use, we believe that tape can be considered in clinical practice. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04683887.
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Affiliation(s)
- Massimo Guasconi
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Azienda USL of Piacenza, Piacenza, Italy.
| | | | | | | | | | - Maurizio Beretta
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Azienda USL of Piacenza, Piacenza, Italy
| | - Anna Genovese
- University of Parma, Department of Medicine and Surgery, Parma, Italy
| | - Fabio Mozzarelli
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Azienda USL of Piacenza, Piacenza, Italy
| | - Fabrizio Quattrini
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Azienda USL of Piacenza, Piacenza, Italy
| | - Pietro Maniscalco
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Azienda USL of Piacenza, Piacenza, Italy
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Roberts T, Sambhariya V, Ly C, Ho A, Pientka WF. The Effect of Age and Sex on Early Postoperative Outcomes after Surgical Treatment of Distal Radius Fractures. J Hand Surg Asian Pac Vol 2024; 29:125-133. [PMID: 38494162 DOI: 10.1142/s2424835524500140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Background: We aim to evaluate the impact of advanced age and sex on postoperative complications and radiographic outcomes after open reduction with internal fixation of distal radius fractures (DRF). Methods: We conducted a retrospective chart review, including all patients who underwent open reduction with internal fixation of a DRF between 2012 and 2018 at a single level 1 trauma centre. We recorded patient age, sex, fracture classification (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA]), time from injury to surgical date, surgical duration, diabetes status, tobacco use, illicit drug use, history of osteoporosis, use of adjuvants, fixation type, postoperative radiographic restoration of normal parameters and early complications including loss of reduction within 30 days postoperatively. Advanced age was defined as age greater than 60 years. Results: A total of 521 patients underwent operative treatment - 264 males and 257 females. Males were twice as likely (23.5% vs. 10.1%; p < 0.0001) to sustain a type C3 fracture and be treated with a wrist spanning plate (5.3% vs. 0; p < 0.0001). A larger percentage of elderly patients undergoing operative treatment of DRF were female (20.2% vs. 5.7%; p < 0.0001) and females were more likely to carry a pre-injury diagnosis of osteoporosis (9.3% vs. 0%; p < 0.0001). And 100% of the elderly patients received were treated with a volar plate. The overall early loss of reduction was 7.5%. The overall complication rate was 8.2%. No differences in early postoperative complications were identified between sexes or age groups. Neither female sex nor advanced age was found to have increased risk of postoperative complications or early loss of reduction. Similar postoperative radiographic parameter measurements were obtained across groups as well. Conclusions: Our results support the idea that operative treatment of unstable DRF in elderly patients and women is a reasonable treatment option without significant increases in early postoperative complications. Level of Evidence: Level III (Therapeutic III).
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Affiliation(s)
- Tyler Roberts
- Department of Orthopaedic Surgery, JPS Health Network, Fort Worth, TX, USA
| | - Varun Sambhariya
- Department of Orthopaedic Surgery, JPS Health Network, Fort Worth, TX, USA
| | - Colin Ly
- University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Alison Ho
- University of North Texas Health Science Center, Fort Worth, TX, USA
| | - William F Pientka
- Department of Orthopaedic Surgery, JPS Health Network, Fort Worth, TX, USA
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Aryee JNA, Frias GC, Haddad DK, Guerrero KD, Chen V, Ling F, Kirschenbaum D, Monica JT, Katt BM. Understanding Variations in the Management of Displaced Distal Radius Fractures With Satisfactory Reduction. Hand (N Y) 2024:15589447241233709. [PMID: 38456481 DOI: 10.1177/15589447241233709] [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: 03/09/2024]
Abstract
BACKGROUND The American Academy of Orthopaedic Surgeons has set forth Clinical Practice Guidelines (CPGs) to help guide management of closed, displaced distal radius fractures (DRFs). There still exists variation in practice regarding operative vs nonoperative decision-making. This study aims to identify which factors influence the decision to treat DRFs not indicated for surgery by the CPGs after initial closed reduction. METHODS Fifteen sets of DRFs and clinical vignettes were distributed via email to over 75 orthopedic residency programs, Orthopaedic Trauma Association, and New York Society for Surgery of the Hand membership. A Qualtrics survey collected respondent demographics, choice of treatment, and rationale. RESULTS Responses were received from 106 surgeons and resident trainees. The odds of selecting operative management for fractures with 5 or more radiographic instability signs versus 3 or 4 was 3.11 (P < .05). Age over 65, higher patient activity level, and dominant-hand injury were associated with greater odds of operative management (3.4, 30.28, and 2.54, respectively). In addition, surgeons with more years in practice and high-volume surgeons had greater odds of selecting operative management (2.43 and 2.11, respectively). CONCLUSIONS Assessment of instability at the time of injury, patient age and activity level, as well as surgeon volume and time in practice independently affect the decision to manage well-reduced DRF with surgical or nonsurgical treatment. The source of heterogeneity in the treatment of these fractures is borne at least in part from a lack of formal direction on the importance of prereduction instability from the CPGs.
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Affiliation(s)
- Jomar N A Aryee
- Department of Orthopedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Giulia C Frias
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Daniel K Haddad
- Department of Orthopedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Kevin D Guerrero
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Vivian Chen
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Fan Ling
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - David Kirschenbaum
- Department of Orthopedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - James T Monica
- Department of Orthopedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Brian M Katt
- Department of Orthopedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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Sellbrant I, Nellgård B, Karlsson J, Albert J, Jakobsson JG. Anaesthesia practice, quality indices including all-cause 30-day mortality associate to wrist fracture repositioning and surgery in Sweden: A perioperative register-based study 2018-2021. Acta Anaesthesiol Scand 2024; 68:402-409. [PMID: 37952557 DOI: 10.1111/aas.14358] [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: 05/24/2023] [Revised: 10/03/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Wrist fracture is one of most common fractures frequently requiring surgical anaesthesia. There is limited information related to the anaesthetic practice and quality including 30-day mortality associated with wrist fracture in Sweden in recent years. AIM The aim of the present register-based study was to investigate the anaesthesia techniques used and quality indices including 30-day mortality associated with wrist fracture surgery in Sweden during the period 2018-2021. MATERIALS AND METHODS All fracture repositions, and surgical interventions related to wrist fracture requiring anaesthesia in patients aged >18 years registered in the Swedish Perioperative Register (SPOR) between 2018 and 2021 were included in the analysis. Information on age, ASA class, anaesthesia technique, severe operative events, most reported side-effects during recovery room stay and all-cause 30-day mortality was collected. RESULTS The data set included 25,147 procedures split into 14,796 females and 10,252 males (missing information n = 99) with a mean age of 52.9 ± 18.7 years and a significant age difference between females and males, 60.3 ± 15.4 and 42.2 ± 17.7 years, respectively. Mean age and ASA class increased during the study period (2018-2021), from 52.8 ± 18.6 to 54.0 ± 18.4 and ASA class 3-5 from 8.1% to 9.4% (p < .001 and p < .041, respectively). General anaesthesia (GA), GA combined with regional anaesthesia (RA), RA with or without sedation and sedation only was used in 41%, 13%, 40% and 6% of procedures, respectively, with minor changes over the study period. Pain at arrival in the recovery room (RR), (3.4%), severe pain during RR stay (2.1%), hypothermia (1.4%), postoperative nausea and vomiting (PONV) (1.2%) and urinary retention (0.5%) were the most reported side-effects during the RR stay. (RA) was associated with significantly lower occurrence of pain and PONV, and shorter RR stay, compared with GA (p < .001). The all-cause 30-day mortality was low (19 of 25,147 (0.08%)) with no differences over the period studied or anaesthetic technique. CONCLUSION General anaesthesia or general anaesthesia combined with regional anaesthesia are the most used anaesthetic techniques for wrist fracture procedures in Sweden. Recovery room pain, PONV, hypothermia and urinary retention is reported in overall low frequencies, with no change over the period studied, but in lower frequencies for regional anaesthesia. All-cause 30-day mortality was low; 0.08% with no change over time or between anaesthetic techniques. Thus, the present quality review based on SPOR data supports high quality of perioperative anaesthesia care.
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Affiliation(s)
- Iren Sellbrant
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Bengt Nellgård
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jon Karlsson
- Department of Orthopaedics, Sahlgrenska University Hospital and Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Johanna Albert
- Department of Anaesthesia and Intensive Care, Department for Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Jan G Jakobsson
- Department of Anaesthesia and Intensive Care, Department for Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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10
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Chaudhry YP, Morway GR, Papadelis EA, Doerr NA, Graf KW, Mashru RP, Dolch HJ. Comparison of Short-Arm Immobilization and Long-Arm Immobilization in Conservatively Managed Distal Radius Fractures: A Meta-Analysis and Systematic Review. Cureus 2024; 16:e55813. [PMID: 38590464 PMCID: PMC10999297 DOI: 10.7759/cureus.55813] [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] [Accepted: 03/07/2024] [Indexed: 04/10/2024] Open
Abstract
Distal radius fractures are often treated conservatively with immobilization. Immobilizing above the elbow limits forearm rotation, though recent literature has suggested the effects on radiographic or functional outcomes may be negligible. This systematic review and meta-analysis aimed to analyze the radiographic and functional outcome scores of distal radius fractures managed with short-arm (SA) immobilization and long-arm (LA) immobilization. An electronic systematic search was performed of the PubMed and EMBASE databases from inception to October 5, 2022. All randomized controlled trials (RCTs) involving patients with acute distal radius fractures undergoing nonoperative treatment (involving application/maintenance of immobilization) comparing above-elbow versus below-elbow constructs were included. The outcomes of interest were changes in radiographic parameters (loss of volar tilt [VT], radial height [RH], and radial inclination [RI]), loss of reduction, requirement for surgery, and patient-reported functional outcomes (Disabilities of the Arm, Shoulder, or Hand [DASH] or Quick DASH survey). The Cochrane Risk of Bias Tool 2.0 was used for study quality assessment. The effect size of the interventions was assessed using random effect models to calculate mean differences (MDs) for continuous variables and odds ratios (ORs) for categorical variables. Standardized mean difference (SMD) was calculated for patient-reported functional outcome scores. Nine studies involving 983 cases were included, including 497 SA and 486 LA. No statistically significant differences were observed with regards to VT (P = 0.83), RH (P = 0.81), RI (P = 0.35), loss of reduction (P = 0.33), requirement for surgery (P = 0.33), or patient-reported functional outcomes (P = 0.10). There was no difference in radiographic outcomes, need for surgery, or functional scores among patients treated with SA and LA immobilization. Utilizing SA immobilization is a safe option for conservative management of distal radius fractures and the benefits of mitigating complications associated with LA immobilization may supersede the theoretical limited forearm rotational stability observed with SA immobilization. Further study is required to determine the optimal method of SA immobilization.
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Affiliation(s)
- Yash P Chaudhry
- Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, USA
| | - Genoveffa R Morway
- Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, USA
| | | | - Nikki A Doerr
- Orthopedic Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, USA
| | - Kenneth W Graf
- Orthopedics and Traumatology, Cooper University Hospital, Camden, USA
| | - Rakesh P Mashru
- Orthopedics and Traumatology, Cooper University Hospital, Camden, USA
| | - Henry J Dolch
- Orthopedics and Traumatology, Cooper University Hospital, Camden, USA
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11
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van Veelen NM, van de Wall BJM, Hoepelman RJ, IJpma FFA, Link BC, Babst R, Groenwold RHH, van der Velde D, Diwersi N, van Heijl M, Houwert RM, Beeres FJP. Let's Agree to Disagree on Operative Versus Nonoperative Treatment for Distal Radius Fractures in Older People: Protocol for a Prospective International Multicenter Cohort Study. JMIR Res Protoc 2024; 13:e52917. [PMID: 38349719 PMCID: PMC10900084 DOI: 10.2196/52917] [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: 09/27/2023] [Revised: 12/11/2023] [Accepted: 12/11/2023] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Distal radius fractures are the most frequently encountered fractures in Western societies, typically affecting patients aged 50 years and older. Although this is a common injury, the best treatment for these fractures in older patients is still under debate. OBJECTIVE This prospective study aims to compare the outcome of operatively and nonoperatively treated distal radius fractures in the older population. Only patients with distal radius fractures for which equipoise regarding the optimal treatment exists will be included. METHODS This prospective international multicenter observational cohort study will be designed as a natural experiment. Natural experiments are observational studies in which treatment allocation is determined by factors outside the control of the investigators but also (largely) independent of patient characteristics. Patients aged 65 years and older with an acute distal radius fracture will be considered for inclusion. Treatment allocation (operative vs nonoperative) will be based on the local preferences of the treating hospital either in Switzerland or the Netherlands. Hence, the process governing treatment allocation resembles that of randomization. Patients will be identified after treatment has been initiated. Based on the radiographs and baseline information of the patient, an expert panel of 6 certified trauma surgeons from 2 regions will provide their treatment recommendation. Only patients for whom the experts disagree on treatment recommendations will ultimately be included in the study (ie, for whom there is a clinical equipoise). For these patients, both operative and nonoperative treatment of distal radius fractures are viable, and treatment choice is predominantly determined by personal or local preference. The primary outcome will be the Patient-Rated Wrist Evaluation score at 12 weeks. Secondary outcomes will include the Physical Activity Score for the Elderly, the EQ questionnaire, pain, the living situation, range of motion, complications, and radiological outcomes. By including outcomes such as living situation and the Physical Activity Score for the Elderly, which are not relevant for younger cohorts, valuable information to tailor treatment to the needs of the older population can be gained. According to the sample size collection, which was based on the minimal important clinical difference of the Patient-Rated Wrist Evaluation, 92 patients will have to be included, with at least 46 patients in each treatment group. RESULTS Enrollment began in July 2023 and is expected to continue until summer 2024. The final follow-up will be 2 years after the last patient is included. CONCLUSIONS Although many trials on this topic have previously been published, there remains an ongoing debate regarding the optimal treatment for distal radius fractures in older patients. This observational study, which will use a fairly new methodological study design, will provide further information on treatment outcomes for older patients with distal radius fractures for which to date equipoise exists regarding the optimal treatment. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/52917.
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Affiliation(s)
- Nicole Maria van Veelen
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Bryan J M van de Wall
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Ruben J Hoepelman
- Department of Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, Netherlands
| | - Frank F A IJpma
- Department of Trauma Surgery, Universitair Medisch Centrum Groningen, Groningen, Netherlands
| | - Björn-Christian Link
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
| | - Reto Babst
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Universitair Medisch Centrum Leiden, Leiden, Netherlands
| | | | - Nadine Diwersi
- Department of General and Trauma Surgery, Kantonsspital Obwalden, Sarnen, Switzerland
| | - Mark van Heijl
- Department of Surgery, Diakonessenhuis Utrecht, Utrecht, Netherlands
| | - R Marijn Houwert
- Department of Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, Netherlands
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
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12
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Ma H, Ruan B, Li J, Zhang J, Wu C, Tian H, Zhao Y, Feng D, Yan W, Xi X. Topology-Optimized Splints vs Casts for Distal Radius Fractures: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2354359. [PMID: 38306099 PMCID: PMC10837751 DOI: 10.1001/jamanetworkopen.2023.54359] [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: 09/11/2023] [Accepted: 12/11/2023] [Indexed: 02/03/2024] Open
Abstract
Importance To date, there is currently no evidence-based medical support for the efficacy of topology-optimized splints in treating distal radius fractures. Objective To assess the clinical efficacy and complication rates of topology-optimized splints in the treatment of distal radius fractures after closed manual reduction. Design, Setting, and Participants This 12-week, multicenter, open-label, analyst-blinded randomized clinical trial (comprising a 6-week intervention followed by a 6-week observational phase) was carried out from December 3, 2021, to March 10, 2023, among 110 participants with distal radius fractures. Statistical analysis was performed on an intention-to-treat basis between June 3 and 30, 2023. Intervention Participants were randomly assigned to 2 groups: the intervention group received topology-optimized splint immobilization and the control group received cast immobilization after closed manual reduction for 6weeks. After this period, immobilization was removed, and wrist rehabilitation activities commenced. Main Outcomes and Measures The primary outcome was the Gartland-Werley (G-W) wrist score at 6 weeks (where higher scores indicate more severe wrist dysfunction). Secondary outcomes encompassed radiographic parameters, visual analog scale scores, swelling degree grade, complication rates, and 3 dimensions of G-W wrist scores. Results A total of 110 patients (mean [SD] age, 64.1 [12.7] years; 89 women [81%]) enrolled in the clinical trial, and complete outcome measurements were obtained for 101 patients (92%). Median G-W scores at 6 weeks were 15 (IQR, 13-18) for the splint group and 17 (IQR, 13-18) for the cast group (mean difference, -2.0 [95% CI, -3.4 to -0.6]; P = .03), indicating a statistically significant advantage for the splint group. At 12 weeks, no clinically significant differences in G-W scores between the 2 groups were observed. Complication rates, including shoulder-elbow pain and dysfunction and skin irritation, were less common in the splint group (shoulder-elbow pain and dysfunction: risk ratio, 0.28 [95% CI, 0.08-0.93]; P = .03; skin irritation: risk ratio, 0.30 [95% CI, 0.10-0.89]; P = .02). Conclusions and Relevance Findings of this randomized clinical trial suggest that patients with distal radius fractures that were managed with topology-optimized splints had better wrist functional outcomes and fewer complications at 6 weeks compared with those who received casting, with no difference at week 12. Therefore, topology-optimized splints with improved performance have the potential to be an advisable approach in the management of distal radius fractures. Trial Registration Chinese Clinical Trial Registry: ChiCTR2000036480.
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Affiliation(s)
- Honghong Ma
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Beite Ruan
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Li
- Clinical Research Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiahui Zhang
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Changgui Wu
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hao Tian
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yichen Zhao
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Debing Feng
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Yan
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaobing Xi
- Department of Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Shanghai Institute of Traumatology and Orthopaedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Graduate School, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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13
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Townsley SH, Pulos N, Shin AY. Complications of operatively treated distal radial fractures. J Hand Surg Eur Vol 2024; 49:215-225. [PMID: 38315130 DOI: 10.1177/17531934231192836] [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: 02/07/2024]
Abstract
Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications.Level of evidence: V.
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Affiliation(s)
- Sarah H Townsley
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Nicholas Pulos
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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14
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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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15
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Hustedt JW, Chartrand N, Merrell D, Reichenbach R, Pinkston E, Stecher C. The Moderating Effect of Age on Patient-Reported Benefits From Operative Management of Intra-Articular Distal Radius Fractures: A Meta-Regression Analysis. J Hand Surg Am 2023; 48:1193-1199. [PMID: 37831017 DOI: 10.1016/j.jhsa.2023.09.001] [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: 04/04/2023] [Revised: 08/28/2023] [Accepted: 09/13/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE The optimal treatment of intra-articular distal radius fractures in older adults (>65 years) remains uncertain despite numerous randomized trials. The purpose of this study was to examine the moderating effect of age on patient-reported benefits of volar locked plating versus cast immobilization for intra-articular distal radius fractures. METHODS A meta-analysis of randomized controlled trials was conducted to compare volar locked plating and cast immobilization of intra-articular distal radius fractures. Meta-regression analyses were used to examine the moderating effect of age on improvements in patient-reported outcome measures from operative treatment of distal radius factures. Modeling results were then used to estimate improvements in Disability of the Arm, Shoulder, and Hand (DASH) scores from surgery that are associated with ages ranging from 65 to 90 years. RESULTS Twelve randomized controlled trials including 1,806 patients were included. Age was a significant moderator of patient-reported benefits after operative treatment, with decreasing DASH score benefits from surgery associated with older ages. Model predictions show that a majority of patients aged <70 years will experience a clinically meaningful improvement in DASH scores from surgery. Patients aged 70-80 years have decreasing DASH benefits with age, but many may still experience a clinically meaningful improvement from surgery. Patients aged >80 years are unlikely to experience a clinically meaningful improvement in DASH scores with surgical management. CONCLUSIONS Older ages are associated with decreased benefits from surgical management with volar locked plating as compared to cast immobilization. Patients aged >80 years are unlikely to experience a clinically significant improvement with surgery. Surgeons and policymakers may use these data to counsel patients, health systems, and professional organizations on the risks and benefits of operative treatment in older adults. TYPE OF STUDY/LEVEL OF EVIDENCE Prognosis 1, Meta-Analysis of Randomized Controlled Trials.
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Affiliation(s)
- Joshua W Hustedt
- Department of Orthopedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, AZ.
| | - Nicholas Chartrand
- Department of Orthopedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, AZ
| | - Dallin Merrell
- Department of Orthopedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, AZ
| | - Rachel Reichenbach
- Department of Orthopedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, AZ
| | - Eric Pinkston
- Department of Orthopedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, AZ
| | - Chad Stecher
- College of Health Solutions, Arizona State University, Phoenix, AZ
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16
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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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17
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Gill S, Page RS. Doing our bit to save the planet: Identifying and abandoning low value surgery. ANZ J Surg 2023; 93:2565-2566. [PMID: 37326246 DOI: 10.1111/ans.18569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Stephen Gill
- Barwon Centre for Orthopaedic Research and Education (B-CORE), St John of God Hospital Geelong, Barwon Health and Deakin University, Geelong, Victoria, Australia
| | - Richard S Page
- Barwon Centre for Orthopaedic Research and Education (B-CORE), St John of God Hospital Geelong, Barwon Health and Deakin University, Geelong, Victoria, Australia
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18
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Manzar S, El Koussaify J, Garcia VC, Ozdag Y, Akoon A, Dwyer CL, Klena JC, Grandizio LC. Statistical Literacy in Hand and Upper-Extremity Patients. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:793-798. [PMID: 38106924 PMCID: PMC10721529 DOI: 10.1016/j.jhsg.2023.07.009] [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: 07/04/2023] [Accepted: 07/15/2023] [Indexed: 12/19/2023] Open
Abstract
Purpose Statistical literacy is the ability of a patient to apply basic statistical concepts to their health care. Understanding statistics is a critical component of shared decision making. The purpose of this investigation was to define levels of statistical literacy in an upper-extremity (UE) patient population. We aimed to determine if patient demographics would be associated with statistical literacy. Methods An electronic survey was administered to a consecutive series of UE patients at a single institution. We recorded baseline demographics, Single Assessment Numeric Evaluation scores, the Berlin Numeracy Test (BNT), and General Health Numeracy Test. We also included a surgical risk question, which asked: "Approximately 3% of patients who get carpal tunnel surgery develop an infection. If 100 patients get this surgery, how many would you expect to develop an infection?" A covariate-controlled adjusted odds ratio reflecting the association between each statistical literacy outcome measure and patient characteristics was reported. Results A total 254 surveys were administered, 148 of which were completed and included. Fifty percent of respondents had a high-school education or less. For the BNT, 78% scored in the bottom quartile, and 52% incorrectly answered all questions. For the General Health Numeracy Test, 34% answered 0 or 1/6 questions correctly. For the surgical risk question, 24% of respondents answered incorrectly. Respondents who had a college or graduate degree had 2.62 times greater odds (95% confidence interval, 1.09-6.32) of achieving a BNT score in a higher quartile than patients who did not have a college or graduate degree. Conclusions Overall levels of statistical literacy are low for UE patients. Clinical relevance When engaging in management discussions and shared decision making, UE surgeons should assume low levels of statistical literacy. Consideration of alternative formats, such as frequencies, video-based materials, and pictographs, may be warranted when discussing outcomes and risks of surgical procedures.
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Affiliation(s)
- Shahid Manzar
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Jad El Koussaify
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Victoria C. Garcia
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Yagiz Ozdag
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Anil Akoon
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - C. Liam Dwyer
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Joel C. Klena
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Louis C. Grandizio
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
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19
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Tai TH, Chu PJ, Lu KY, Wu JJ, Wong CC. Current Management and Volar Locking Plate Fixation with Bone Cement Augmentation for Elderly Distal Radius Fractures-An Updated Narrative Review. J Clin Med 2023; 12:6801. [PMID: 37959267 PMCID: PMC10648218 DOI: 10.3390/jcm12216801] [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: 09/09/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Distal radius fractures (DRFs) are the most common among all kinds of fractures with an increase in incidence due to the rapidly expanded size of the elderly population in the past decades. Both non-surgical and surgical treatments can be applied for this common injury. Nowadays, more and more elderly patients with DRFs undergo surgical treatments to restore pre-injury activity levels faster. However, optimal treatment for geriatric DRFs is still debated, and careful evaluation and selection of patients are warranted considering clinical and functional outcomes, and complications following surgical treatments. Furthermore, osteoporosis is a predominant factor in elderly DRFs mostly deriving from a low-energy trauma, so many treatment modalities are developed to enhance better bone healing. Among various options for bone augmentation, bone cement is one of the most widely used measures. Bone cement such as calcium phosphate theoretically improves fracture stability and healing, but whether the elderly patients with DRFs can significantly benefit from surgical fixation with bone cement augmentation (BCA) remains controversial. Hence, in the present review, the latest literature regarding current concepts of management and evidence about volar locking plate fixation (VLPF) with BCA for elderly DRFs was searched in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science; out of >1000 articles, full texts of 48 and 6 articles were then examined and analyzed separately for management and VLPF with BCA for elderly DRFs. We aim to provide the readers with updates concerning the above issues.
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Affiliation(s)
- Ting-Han Tai
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan (P.-J.C.)
| | - Po-Jui Chu
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan (P.-J.C.)
- Department of Primary Care Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan
| | - Kuan-Yu Lu
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan (P.-J.C.)
| | - Jeffrey J. Wu
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan (P.-J.C.)
| | - Chin-Chean Wong
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan (P.-J.C.)
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei 110301, Taiwan
- International PhD Program for Cell Therapy and Regenerative Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan
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Willigenburg NW, Poolman RW. The difference between statistical significance and clinical relevance. The case of minimal important change, non-inferiority trials, and smallest worthwhile effect. Injury 2023; 54 Suppl 5:110764. [PMID: 37923502 DOI: 10.1016/j.injury.2023.04.051] [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: 02/23/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 11/07/2023]
Abstract
Clinical relevance and statistical significance are different concepts, linked via the sample size calculation. Threshold values for detecting a minimal important change over time are frequently (mis)interpreted as a threshold for the clinical relevance of a difference between groups. The magnitude of a difference between groups that is considered clinically relevant directly impacts the sample size calculation, and thereby the statistical significance in clinical study outcomes. Especially in non-inferiority trials the threshold for clinical relevance, i.e. the predefined margin for non-inferiority, is a crucial choice. A truly inferior treatment will be accepted as non-inferior when this margin is chosen too large. The magnitude of a clinically relevant difference between groups should be carefully considered, by determining the smallest effect for each specific study that is considered worthwhile. This means taking into account the (dis)advantages of both study interventions in terms of benefits, harms, costs, and potential side effects. This article clarifies common sources of confusion, illustrates the implications for clinical research with an example and provides specific suggestions to improve the design and interpretation of clinical research.
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Affiliation(s)
- Nienke W Willigenburg
- Joint Research, Department of Orthopaedic Surgery, OLVG Hospital, Amsterdam, the Netherlands
| | - Rudolf W Poolman
- Joint Research, Department of Orthopaedic Surgery, OLVG Hospital, Amsterdam, the Netherlands; Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.
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Zhang H, Liu M, Duan SY, Liang HR, Xu RD, Cai ZC. Surgical options for distal radius fractures of type C in elderly patients over 65 years old: a comparison of external fixation with Kirschner wires and volar locking plate. J Orthop Surg Res 2023; 18:669. [PMID: 37689739 PMCID: PMC10493013 DOI: 10.1186/s13018-023-04162-0] [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: 05/05/2023] [Accepted: 09/04/2023] [Indexed: 09/11/2023] Open
Abstract
BACKGROUND ue to the lack of consensus on the optimal surgical treatment for distal radius fractures (DRF) in elderly patients over 65 years old, the purpose of this study was to compare the efficacy of external fixation (EF) with Kirschner wires and volar locking plate (VLP) in the treatment of DRF through a retrospective cohort study. We hypothesized that there would be no significant difference in overall complications and functional recovery between the two methods. METHODS We retrospectively analyzed 62 patients over 65 years old who underwent surgical treatment for C-type DRF between 2019 and 2022. Based on the different treatment methods, they were divided into the EF group and the VLP group. General data, inpatient data, and postoperative complications during follow-up were recorded. The X-ray images before surgery, after surgery, and at the last follow-up were analyzed, and the results of wrist motion range, Gartland-Werley wrist joint score, and DASH score were evaluated 6 months after surgery for both groups. RESULT Thirty patients underwent closed reduction and external fixation combined with Kirschner wire fixation, while 32 underwent open reduction and VLP fixation. The EF group had significantly shorter operation time, intraoperative blood loss, injury-to-surgery time, and hospital stay compared to the VLP group (all p < 0.001). At the last follow-up, the radiographic parameters (ulnar variance and radial inclination) and wrist joint function (wrist dorsiflexion and forearm supination) were better in the VLP group than in the EF group (p = 0.04, p = 0.01, p = 0.001, p = 0.02, respectively). However, there was no significant difference in overall Gartland-Werley wrist joint score, DASH score, and incidence of postoperative complications between the two groups (p = 0.31, p = 0.25, p = 0.47, respectively). CONCLUSION For patients aged 65 and above with distal radius fractures (DRF) of type C, VLP and external fixation with Kirschner wires yield comparable functional outcome and complications rate at the short term. However, VLP allowed restoration of better radiological parameters.
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Affiliation(s)
- He Zhang
- Department of Orthopedics Surgery, Central Hospital Affiliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Man Liu
- School of Basic Medical Sciences, Shenyang Medical College, 146 Huanghe North Street, Shenyang, 110034, Liaoning, China
| | - Si-Yu Duan
- Department of Orthopedics Surgery, Central Hospital Affiliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Hai-Rui Liang
- Department of Orthopedics Surgery, Central Hospital Affiliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Rong-Da Xu
- Department of Orthopedics Surgery, Central Hospital Affiliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China
| | - Zhen-Cun Cai
- Department of Orthopedics Surgery, Central Hospital Affiliated to Shenyang Medical College, 5 Nanqi West Road, Shenyang, 110075, Liaoning, China.
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Nwosu C, Rodriguez K, Zeng S, Klifto KM, Klifto CS, Ruch DS. Complications Following Volar Locking Plate Fixation of Distal Radius Fractures in Adults: A Systematic Review of Randomized Control Trials. J Hand Surg Am 2023; 48:861-874. [PMID: 37552141 DOI: 10.1016/j.jhsa.2023.04.022] [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: 10/07/2022] [Revised: 04/13/2023] [Accepted: 04/26/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE The purpose of this study was to assess the incidence of postoperative complications following volar locking plate (VLP) fixation of distal radius fractures (DRFs). METHODS A search using keywords and subject headings to represent the concepts of volar plating and radius fractures was generated. Databases such as MEDLINE (Ovid), Embase (Elsevier), Scopus (Elsevier), and SPORTDiscus (EBSCO) were searched from inception to November 24, 2021, for randomized controlled trials that reported complications following DRF treated with VLP. Inclusion criteria were studies with adult patients (aged ≥18 years) randomized to VLP fixation without other concomitant surgical interventions, with a minimum follow-up of 3 months. Study sample characteristics and post-surgical complications were extracted. The Cochrane Risk of Bias tool was used to evaluate quality of evidence. RESULTS Of the 4,059 articles identified using the search strategy, 1,778 titles/abstracts and 856 full-text articles were screened for inclusion, of which 35 articles were included for data extraction. Overall, 1,419 patients with a DRF were randomized to VLP fixation. The mean age was 60.3 years. The overall complication rate was 30.8% following VLP fixation, with 12.4% being major complications. The most common complications were median nerve-related (7.1%) and hardware removal (6.8%), secondary to other complications. Tenosynovitis was the most common tendon-related complication (3.4%). Other complications included complex regional pain syndrome (2.4%), malunion (1.3%), superficial wound infections (1.9%), and tendon rupture (1.3%). CONCLUSIONS A meta-analysis of high-quality studies that discuss the complications after VLP fixation for DRF showed an overall complication rate of 30.8%. VLP may be related to more hardware-related complications than those previously reported. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Chinemerem Nwosu
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | | | - Steven Zeng
- Duke University School of Medicine, Durham, NC
| | - Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO
| | - Christopher S Klifto
- Division of Hand Surgery, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
| | - David S Ruch
- Division of Hand Surgery, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC
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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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24
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Wang CW, Chung WT, Baxter NB, Chung KC. Are Observational Studies on Distal Radius Fracture Treatment Robust? An E-value Approach to Analysis. Clin Orthop Relat Res 2023; 481:1174-1192. [PMID: 36728049 PMCID: PMC10194513 DOI: 10.1097/corr.0000000000002528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/22/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Reported complication frequencies after distal radius fracture (DRF) treatment vary widely in the literature and are based mostly on observational evidence. Whether that evidence is sufficiently robust to use in practice is controversial. The E-value is an innovative sensitivity analysis that quantitates the robustness of observational evidence against unmeasured confounders, whereby a greater E-value usually implies more robust evidence and vice versa; with DRF complications, this approach can help guide readers to a more confident interpretation of the available evidence. QUESTIONS/PURPOSES In this study, we sought (1) to compare the complication frequencies among different DRF treatment modalities, and (2) to evaluate the robustness of these observational studies using the E-value as an index for unmeasured confounding. METHODS We searched PubMed, Embase, and SCOPUS for observational studies on the management of DRFs that were published from January 2001 to July 2021 with the last database search performed on July 31, 2021. All articles that compared different DRF treatment modalities with reported complication frequencies were included to accurately capture the quality of the observational studies in research about DRF. Risk ratios (RRs) of the overall complication and major complication risks were calculated for each subgroup comparison: volar plating versus dorsal plating, casting, external fixation, and percutaneous K-wire fixation. The RRs and their corresponding lower limits of the 95% confidence intervals (CIs) were used to derive the E-values. E-values can have a minimum possible value of 1, which signifies that the treatment-outcome association is not strong and can readily be overturned by unmeasured confounders. By contrast, a large E-value means that the observed treatment-outcome association is robust against unmeasured confounders. We averaged RRs and E-values for the effect estimates and lower limits of CIs across studies in each treatment comparison group. We identified 36 comparative observational studies that met the inclusion criteria. Seven studies compared volar with dorsal plating techniques. Volar plating was also compared with casting (eight studies), external fixation (15 studies), and percutaneous K-wire fixation (six studies). RESULTS Total and major complication risks did not differ among different DRF treatments. The mean RRs for total and major complications were 1.2 (95% CI 0.4 to 3.9; p = 0.74) and 1.8 (95% CI 0.4 to 11.4; p = 0.52) for the volar versus dorsal plating group; 1.2 (95% CI 0.3 to 11.2; p = 0.87) and 1.5 (95% CI 0.3 to 14.9; p = 0.74) for the volar plating versus casting group; 0.6 (95% CI 0.2 to 2.2; p = 0.33) and 0.8 (95% CI 0.2 to 6.7; p = 0.86) for the volar plating versus external fixation group; and 0.6 (95% CI 0.2 to 2.6; p = 0.47) and 0.7 (95% CI 0.2 to 4.0; p = 0.67) for the volar plating versus K-wire fixation group. The mean E-values for total and major complication frequencies for the between-group comparison ranged from 3.1 to 5.8; these were relatively large in the context of a known complication risk factor, such as high-energy impact (RR 3.2), suggesting a reasonable level of robustness against unmeasured confounding. However, the E-values for lower limits of CIs remained close to 1, which indicates the observed complication frequencies in these studies were likely to have been influenced by unmeasured confounders. CONCLUSION Complication frequencies did not differ among different DRF treatment modalities, but the observed complication frequencies from most comparative observational studies were less robust against potential unmeasured confounders. The E-value method, or another type of sensitivity analysis, should be implemented in observational hand surgery research at the individual-study level to facilitate assessment of robustness against potential unmeasured confounders. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Chien-Wei Wang
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - William T. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Natalie B. Baxter
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kevin C. Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
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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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Hassellund SS, Oftebro I, Williksen JH, Søreide E, Madsen JE, Frihagen F. Closed reduction of dorsally displaced distal radius fractures in the elderly provided improved final radiographic results. J Orthop Surg Res 2023; 18:247. [PMID: 36967433 PMCID: PMC10041711 DOI: 10.1186/s13018-023-03733-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 03/18/2023] [Indexed: 03/28/2023] Open
Abstract
BACKGROUND Recent guidelines recommend non-operative treatment as primary treatment in elderly patients with displaced distal radius fractures. Most of these fractures are closely reduced. We aimed to evaluate the radiological results of closed reduction and casting of dorsally displaced distal radius fractures in patients 65 years or older. METHODS A total of 290 patients treated during the years 2015, 2018 and 2019 in an urban outpatient fracture clinic with complete follow-up at least 5 weeks post-reduction were available for analysis. Closed fracture reduction was performed by manual traction under hematoma block. A circular plaster of Paris cast was used. Radiographs pre- and post-reduction and at final follow-up were analyzed. RESULTS Mean age was 77 years (SD 8) and 258 (89%) were women. Dorsal tilt improved from mean 111° (range 83-139) to 89° (71-116) post-reduction and fell back to mean 98° (range 64-131) at final follow-up. Ulnar variance was 2 mm ((-1)-12) pre-reduction, 0 mm ((-3)-5) post-reduction and ended at mean 2 mm (0-8). Radial inclination went from 17° ((-6)-30) to 23° (SD 7-33), and then back to 18° (0-32) at final follow-up. 41 (14%) patients had worse alignment at final follow-up compared to pre-reduction. 48 (17%) obtained a position similar to the starting point, while 201 (69%) improved. Fractures with the volar cortex aligned after reduction retained 0.4 mm (95% Confidence Interval (CI) 0.1 to 0.7; p = 0,022) more radius length during immobilization. In a regression analysis, less ulnar variance in initial radiographs (OR 1.8 (95% CI 1.4 to 2.3) per mm, p < 0.001) and lower age (OR 1.06 (95% CI 1.02 to 1.09) per year, p < 0.003) protected against loss of reduction. CONCLUSION Subsequent loss of reduction after initial closed reduction was seen in most distal radius fractures. Reduction improved overall alignment in 2/3 of the patients at final follow-up. An aligned volar cortex seemed to protect partially against loss of radial length.
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Affiliation(s)
- Sondre Stafsnes Hassellund
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Ingrid Oftebro
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | | | - Endre Søreide
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Jan Erik Madsen
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Frede Frihagen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway
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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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Gutiérrez-Espinoza H, Araya-Quintanilla F, Cuyul-Vásquez I, Gutiérrez-Monclus R, Reina-Gutiérrez S, Cavero-Redondo I, de Arenas-Arroyo SN. Effectiveness and Safety of Different Treatment Modalities for Patients Older Than 60 Years with Distal Radius Fracture: A Network Meta-Analysis of Clinical Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3697. [PMID: 36834390 PMCID: PMC9965012 DOI: 10.3390/ijerph20043697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 06/18/2023]
Abstract
The aim of this study was to compare the clinical effectiveness and complications of different treatment modalities for elderly patients with distal radius fracture (DRF). METHODS We performed a network meta-analysis (NMA) of randomized clinical trials (RCTs). Eight databases were searched. The eligibility criteria for selecting studies were RCTs that compared different treatment modalities (surgical or nonoperative) in patients older than 60 years with displaced or unstable intra-articular and/or extra-articular DRFs. RESULTS Twenty-three RCTs met the eligibility criteria (2020 patients). For indirect comparisons, the main findings of the NMA were in volar locking plate (VLP) versus cast immobilization, with the mean differences for the patient-rated wrist evaluation (PRWE) questionnaire at -4.45 points (p < 0.05) and grip strength at 6.11% (p < 0.05). Additionally, VLP showed a lower risk ratio (RR) of minor complications than dorsal plate fixation (RR: 0.02) and bridging external fixation (RR: 0.25). Conversely, VLP and dorsal plate fixation showed higher rates of major complications. CONCLUSIONS Compared with other treatment modalities, VLP showed statistically significant differences for some functional outcomes; however, most differences were not clinically relevant. For complications, although most differences were not statistically significant, VLP was the treatment modality that reported the lowest rate of minor and overall complications but also showed one of the highest rates of major complications in these patients. PROSPERO Registration: CRD42022315562.
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Affiliation(s)
| | - Felipe Araya-Quintanilla
- Escuela de Kinesiología, Facultad de Odontología y Ciencias de la Rehabilitación, Universidad San Sebastián, Santiago 7510157, Chile
| | - Iván Cuyul-Vásquez
- Faculty of Health, Therapeutic Process Department, Temuco Catholic University, Temuco 4780000, Chile
| | | | - Sara Reina-Gutiérrez
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
| | - Iván Cavero-Redondo
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca 7500912, Chile
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Jayaram M, Wu H, Yoon AP, Kane RL, Wang L, Chung KC. Comparison of Distal Radius Fracture Outcomes in Older Adults Stratified by Chronologic vs Physiologic Age Managed With Casting vs Surgery. JAMA Netw Open 2023; 6:e2255786. [PMID: 36780156 PMCID: PMC9926326 DOI: 10.1001/jamanetworkopen.2022.55786] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
IMPORTANCE Casting is recommended for adults older than 65 years with distal radius fractures (DRFs) because similar long-term outcomes are achieved regardless of treatment. However, physiologically younger adults could benefit from operative DRF management despite advanced chronologic age. OBJECTIVE To examine how chronologic age compares with measures of physiologic age in DRF treatment recovery. DESIGN, SETTING, AND PARTICIPANTS This retrospective secondary analysis of the Wrist and Radius Injury Surgical Trial (WRIST) was performed from May 1 to August 31, 2022. WRIST was a 24-center randomized clinical trial that enrolled participants older than 60 years with unstable DRFs from April 1, 2012, to December 31, 2016. INTERVENTIONS Participants selected casting or surgery. Patients who selected surgery were randomly assigned to volar lock plating, percutaneous pinning, or external fixation. Participants were stratified by chronologic age, number of comorbidities, and activity status. MAIN OUTCOMES AND MEASURES The primary outcome was Michigan Hand Outcomes Questionnaire (MHQ) score assessed at 6 weeks, 3 months, 6 months, and 1 year. Partial correlation (PC) analysis adjusted for confounding. RESULTS The final cohort consisted of 293 participants (mean [SD] age, 71.1 [8.89] years; 255 [87%] female; 247 [85%] White), with 109 receiving casting and 184 receiving surgery. Increased chronologic age was associated with increased MHQ scores in the surgery group at all time points but decreased MHQ scores in the casting group at 12 months (mean [SD] score, -0.46 [0.21]; P = .03). High activity was associated with improved MHQ scores in the surgical cohort at 6 weeks (mean [SD] score, 12.21 [5.18]; PC = 0.27; P = .02) and 12 months (mean [SD] score, 13.25 [5.77]; PC = 0.17; P = .02). Comorbidities were associated with decreased MHQ scores at all time points in the casting group. Clinically significant differences in MHQ scores were associated with low physical activity, 4 or more comorbidities, or increased age by 15 years. CONCLUSIONS AND RELEVANCE In this retrospective secondary analysis of WRIST, chronologic age was not associated with functional demand. These findings suggest that physicians should counsel active older adults with few comorbidities on earlier return to daily activities after surgery compared with casting. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01589692.
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Affiliation(s)
- Mayank Jayaram
- Department of Surgery, University of Michigan Medical School, Ann Arbor
| | - Hao Wu
- University of Michigan School of Public Health, Ann Arbor
| | - Alfred P. Yoon
- Section of Plastic Surgery, Department of Surgery, University of Michigan Hospital, Ann Arbor
| | - Robert L. Kane
- Section of Plastic Surgery, Department of Surgery, The Medical University of South Carolina, Charleston
| | - Lu Wang
- University of Michigan School of Public Health, Ann Arbor
| | - Kevin C. Chung
- Department of Surgery, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor
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31
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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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Yang Q, Cai G, Liu J, Wang X, Zhu D. Efficacy of cast immobilization versus surgical treatment for distal radius fractures in adults: a systematic review and meta-analysis. Osteoporos Int 2022; 34:659-669. [PMID: 36538053 PMCID: PMC10050022 DOI: 10.1007/s00198-022-06649-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
UNLABELLED This articl e includes high-quality randomized controlled trials in recent years and updates the past meta-analysis. It has been proved that cast immobilization can achieve similar functional results, reduce economic burden in the long-term compared with surgery, and provide a basis for doctors to make treatment choices. PURPOSE The efficacy of conservative and surgical treatment of distal radius fractures (DRFs) in adults is still controversial. Recently, some high-quality randomized controlled trials (RCTs) evaluated the efficacy of both treatments. We hypothesized that treatment of DRFs with closed reduction and cast immobilization would achieve functional outcomes similar to surgery. METHODS This study is a systematic review and summary of RCTs comparing conservative and surgical management of DRFs from 2005 to March 2022. Patients were evaluated for functional and imaging outcomes and complications. RESULTS A total of 11 studies [1-11] included 1775 cases of DRFs. At 1-year follow-up, the cast group had lower mean differences (MDs) in DASH scores than the surgery group by - 2.55 (95% CI = - 5.02 to - 0.09, P = 0.04); with an MD of 1.63 (95% CI = 1.08-2.45, P = 0.02), while the surgery group had a lesser complication rate than the cast group. CONCLUSIONS At 1-year follow-up, the lower DASH scores of the cast group showed advantages of this treatment, but the complication rate was higher than that of the surgery group. There was no massive distinction in other scoring methods.
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Affiliation(s)
- Qifan Yang
- Department of Orthopedics, the First Hospital of Jilin University, Changchun, Street Xinmin 71, China
| | - Guoyong Cai
- Department of Orthopedics, the Eleventh Hospital of Shanxi Medical University, Xinjian South Road, Yingze District, China
| | - Jing Liu
- The First Clinical Medical College of Bin Zhou Medical College, Street Huanghe 661, Yantai, China
| | - Xinyu Wang
- Department of Orthopedics, the First Hospital of Jilin University, Changchun, Street Xinmin 71, China
| | - Dong Zhu
- Department of Orthopedics, the First Hospital of Jilin University, Changchun, Street Xinmin 71, China.
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ÇAĞLAR C, NAZLIGÜL AS, AKBULUT B, AKKAYA M. Clinical and functional analysis of closed reduction-plastering and volar locking plate methods in distal radius fractures in patients over 60 years of age. EGE TIP DERGISI 2022. [DOI: 10.19161/etd.1208986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Aim: Many different methods have been described in the treatment of distal radius fractures (DRF) in the elderly population, and which one is the better method is a matter of debate among orthopedic surgeons. The aim of this study was to compare the results of closed reduction and plastering (CRP) and volar locking plate (VLP), which are used in the treatment of DRF in the elderly population.
Materials and Methods: Between January 2019 and December 2020, 36 patients with DRF aged > 60 years were evaluated retrospectively. There were 19 patients in the CRP group and 17 patients in the VLP group. Wrist flexion, extension, pronation, supination, ulnar deviation, and radial deviation degrees and grip strength were measured in the first year of their treatment. The patients were evaluated functionally by patient-rated wrist evaluation (PRWE), modified Green and O'Brien score (MGOS), and resting and stress visual analogue scale (VAS).
Results: In both groups, similar ROM values were obtained and no significant difference was observed. While the PRWE score was 17.5 ± 5.5 in the CRP group and 12.5 ± 4.8 in the VLP group, the MGOS score was 83.0 ± 7.4 in the CRP group and 86.8 ± 12.6 in the VLP group, and the scores were not significantly different (p = 0.802, p = 0.315). While there was almost no pain in both groups at rest, more pain was felt in the VKP group under stress. While grip strength was 20.9 ± 6.4 kg in the CRP group, it was 22.2 ± 6.8 kg in the VLP group, and there was no significant difference compared to the contralateral wrist.
Conclusion: There is no clinical and functional difference between CRP and VLP in the one-year period after DRF treatment in the patient population aged > 60 years. Treatment should be planned according to the functional capacity of the patient.
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Affiliation(s)
- Ceyhun ÇAĞLAR
- Ankara City Hospital, Department of Orthopedics and Traumatology, Ankara, Türkiye
| | - Ali Said NAZLIGÜL
- Ankara Yıldırım Beyazıt University, Department of Orthopedics and Traumatology, Ankara, Türkiye
| | - Batuhan AKBULUT
- Ankara City Hospital, Department of Orthopedics and Traumatology, Ankara, Türkiye
| | - Mustafa AKKAYA
- Ankara Yıldırım Beyazıt University, Department of Orthopedics and Traumatology, Ankara, Türkiye
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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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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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36
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Oldrini LM, Feltri P, Albanese J, Lucchina S, Filardo G, Candrian C. Volar locking plate vs cast immobilization for distal radius fractures: a systematic review and meta-analysis. EFORT Open Rev 2022; 7:644-652. [PMID: 36125012 PMCID: PMC9624483 DOI: 10.1530/eor-22-0022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction Materials and methods Results Conclusions
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Affiliation(s)
| | - Pietro Feltri
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
| | - Jacopo Albanese
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
| | - Stefano Lucchina
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland.,Surgical Department - Hand Surgery Unit EOC, Locarno's Regional Hospital, Locarno, Switzerland.,Locarno Hand Center, Locarno, Switzerland
| | - Giuseppe Filardo
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Christian Candrian
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland.,Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Gutiérrez-Espinoza H, Araya-Quintanilla F, Olguín-Huerta C, Gutiérrez-Monclus R, Valenzuela-Fuenzalida J, Román-Veas J, Campos-Jara C. Effectiveness of surgical versus conservative treatment of distal radius fractures in elderly patients: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2022; 108:103323. [PMID: 35589085 DOI: 10.1016/j.otsr.2022.103323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/25/2021] [Accepted: 12/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The aim of this study was to determine whether surgical treatment is more effective than conservative treatment in terms of functional outcomes in elderly patients with distal radius fractures (DRFs). METHODS An electronic search of the Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases was performed, from inception until July 2021. The eligibility criteria for selecting studies were randomized clinical trials that compared surgical versus conservative treatment in subjects older than 60 years with DRFs. Two authors independently performed the search, data extraction, and assessed risk of bias (RoB) using the Cochrane RoB tool. RESULTS Twelve trials met the eligibility criteria, and nine studies were included in the quantitative synthesis. For volar plate versus cast immobilization at 1-year follow-up, the mean difference (MD) for PRWE was -5.36 points (p=0.02), for DASH was -4.03 points (p=0.02), for grip strength was 8.32% (p=0.0004), for wrist flexion was 4.35 degrees (p=0.10), for wrist extension was -1.52 degrees (p=0.008), for pronation was 2.7 degrees (p=0.009), for supination was 4.88 degrees (p=0.002), and for EQ-VAS was 2.73 points (p=0.0007), with differences in favor of volar plate. For K-wire versus cast immobilization at 12 months, there were no statistically significant differences in wrist range of motion (p>0.05). CONCLUSIONS There was low to high evidence according to GRADE ratings, with a statistically significant difference in functional outcomes in favor of volar plate versus conservative treatment at 1-year follow-up. However, these differences are not minimally clinically important, suggesting that both types of management are equally effective in patients older than 60 years with DRFs. LEVEL OF EVIDENCE I; Therapeutic (Systematic review and meta-analysis of randomized clinical trials).
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Affiliation(s)
- Héctor Gutiérrez-Espinoza
- Exercise and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Fernández Concha Street 700, Santiago, Chile.
| | - Felipe Araya-Quintanilla
- Rehabilitation in Health Research Center (CIRES), University of the Americas, Manuel Montt Avenue 948, Santiago, Chile
| | - Cristian Olguín-Huerta
- Rehabilitation in Health Research Center (CIRES), University of the Americas, Manuel Montt Avenue 948, Santiago, Chile
| | | | - Juan Valenzuela-Fuenzalida
- Departamento de Ciencias Químicas y Biológicas, Facultad de Ciencias de la Salud, Universidad Bernardo O'Higgins, Santiago, Chile
| | | | - Christian Campos-Jara
- Exercise and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Fernández Concha Street 700, Santiago, Chile
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Cooper AM, Wood TR, Scholten II DJ, Carroll EA. Nonsurgical Management of Distal Radius Fractures in the Elderly: Approaches, Risks and Limitations. Orthop Res Rev 2022; 14:287-292. [PMID: 35996621 PMCID: PMC9391939 DOI: 10.2147/orr.s348656] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 08/02/2022] [Indexed: 11/23/2022] Open
Abstract
The elderly have conventionally been defined as individuals over the age of 65 and are projected to represent about 21% of the United States (US) population by the year 2030. Distal radius fractures (DRF) in particular are one of the most common fractures among elderly patients and their incidence continues to rise in part due to increased activity levels among the elderly, increased life expectancy, rising rates of obesity, changes to dietary habits, and the prevalence of osteoporosis. Although various treatment options exist for these injuries, nonsurgical treatment of distal radius fractures remains a mainstay among elderly patients with mounting evidence of its non-inferiority to surgical fixation in the literature. Here, we summarize the overall approach to nonsurgical treatment of distal radius fractures in the elderly population while examining its supporting data and highlighting potential risks and limitations to it.
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Affiliation(s)
- Alexus M Cooper
- Department of Orthopaedic Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Taylor R Wood
- Department of Orthopaedic Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Donald J Scholten II
- Department of Orthopaedic Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Eben A Carroll
- Department of Orthopaedic Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
- Correspondence: Eben A Carroll, Department of Orthopaedic Surgery, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA, Email
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Adie S, Griffin XL, Harris IA, Gorelik A, Chang WJ. Surgical (percutaneous pinning or plate fixation) versus non-surgical interventions for distal radius fractures in adults: an individual participant data review. Hippokratia 2022. [DOI: 10.1002/14651858.cd014933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Sam Adie
- School of Clinical Medicine; UNSW Medicine & Health; UNSW Sydney Australia
| | | | - Ian A Harris
- School of Clinical Medicine; UNSW Medicine & Health; UNSW Sydney Australia
| | - Alexandra Gorelik
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Malvern Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | - Wei-Ju Chang
- Centre for Pain IMPACT; Neuroscience Research Australia; Randwick Australia
- School of Health Sciences, College of Health, Medicine and Wellbeing; The University of Newcastle; Callaghan Australia
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40
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Südow H, Severin S, Wilcke M, Saving J, Sköldenberg O, Navarro CM. Non-operative treatment or volar locking plate fixation for dorsally displaced distal radius fractures in patients over 70 years - a three year follow-up of a randomized controlled trial. BMC Musculoskelet Disord 2022; 23:447. [PMID: 35549696 PMCID: PMC9097389 DOI: 10.1186/s12891-022-05394-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/03/2022] [Indexed: 02/02/2023] Open
Abstract
Background Surgical treatment of displaced distal radius fractures (DRF) in older patients has increased, despite lacking evidence of its superiority over non-operative treatment. How treatment choice affects these patients after the initial 12-month period remains unknown. This study presents a clinical and radiographic follow up at an average of 3 years after treatment in the context of a randomized clinical trial comparing outcomes in patients aged ≥70 years, with a dorsally displaced distal radius fracture treated either surgically with volar locking plate or non-operatively. Methods Between 2009 and 2017, 140 patients aged ≥70 years with dorsally displaced DRF were randomized to surgery with volar locking plate (VLP) or non-operative treatment. At an average of 3 years after inclusion the participants were invited to an additional follow-up. The primary outcome was Patient Rated Wrist Evaluation (PRWE). Secondary outcomes included additional Patient Reported Outcome Measures (PROM), grip strength, range of motion, complications and radiological results. Results Sixty six patients were available for a 3 year follow-up, 33 in the non-operatively treated group and 33 in the VLP-group. The mean age at injury was 77 years. At 3 years the median PRWE was better (0 points) in the VLP-group than in the non-operative treatment group (9 points) p-value: 0.027. No statistically significant difference was found in Disabilities of the Arm, Hand, and Shoulder (DASH), EuroQol 5 Dimensions (EQ-5D) or grip strength. Total arc of range of motion was larger in the operatively treated group. No significant difference in osteoarthritis was found. Both groups had regained grip strength. The complication rate was similar. Outcomes improved from the 1 year to the 3 year follow-up. Conclusions Surgery with volar locking plate gave less long-term disability compared to non-operative treatment for severely displaced distal radius fractures in patients aged ≥70 years. Our findings were statistically significant but in the lower range of clinical importance. Trial registration The study was registered at : NCT02154620 03/06/2014 and NCT01268397 30/12/2010. Ethical approval was obtained from Ethical Committee in Stockholm, Sweden (2009/37–31/3, 2013/105–31/2, 2014/1041–32, 2017/611–32).
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Affiliation(s)
- Hanna Südow
- Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, SE-118 83, Stockholm, Sweden. .,Department of Orthopedics, Södersjukhuset Hospital, Stockholm, Sweden.
| | - Sara Severin
- Karolinska Institute, Department of Clinical Science, Danderyd Hospital, Stockholm, Sweden.,Department of Orthopedics, Danderyd University Hospital Corp, Stockholm, Sweden
| | - Maria Wilcke
- Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, SE-118 83, Stockholm, Sweden.,Department of Hand Surgery, Södersjukhuset Hospital, Stockholm, Sweden
| | - Jenny Saving
- Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, SE-118 83, Stockholm, Sweden.,Capio Artro Clinic, Stockholm, Sweden
| | - Olof Sköldenberg
- Karolinska Institute, Department of Clinical Science, Danderyd Hospital, Stockholm, Sweden.,Department of Orthopedics, Danderyd University Hospital Corp, Stockholm, Sweden
| | - Cecilia Mellstrand Navarro
- Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, SE-118 83, Stockholm, Sweden.,Department of Hand Surgery, Södersjukhuset Hospital, Stockholm, Sweden
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41
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Lawson A, Naylor J, Buchbinder R, Ivers R, Balogh ZJ, Smith P, Xuan W, Howard K, Vafa A, Perriman D, Mittal R, Yates P, Rieger B, Smith G, Adie S, Elkinson I, Kim W, Sungaran J, Latendresse K, Wong J, Viswanathan S, Landale K, Drobetz H, Tran P, Page R, Beattie S, Mulford J, Incoll I, Kale M, Schick B, Li T, Higgs A, Oppy A, Harris IA. Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Secondary Analysis of a Randomized Clinical Trial. JAMA Surg 2022; 157:563-571. [PMID: 35476128 PMCID: PMC9047748 DOI: 10.1001/jamasurg.2022.0809] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Distal radius fractures are common and are managed with or without surgery. Current evidence indicates surgical treatment is not superior to nonsurgical treatment at 12 months. Objective Does surgical treatment for displaced distal radius fractures in patients 60 years or older provide better patient-reported wrist pain and function outcomes than nonsurgical treatment at 24 months? Design, Setting, and Participants In this secondary analysis of a combined multicenter randomized clinical trial (RCT) and a parallel observational study, 300 patients were screened from 19 centers in Australia and New Zealand. Of these, 166 participants were randomized to surgical or nonsurgical treatment. Participants who declined randomization (n = 134) were included in the parallel observational group with the same treatment options and follow-up. Participants were followed up at 3, 12, and 24 months by a blinded assessor. The 24-month outcomes are reported herein. Data were collected from December 1, 2016, to December 31, 2020, and analyzed from February 4 to October 21, 2021. Interventions Surgical treatment consisting of open reduction and internal fixation using a volar-locking plate (VLP group) and nonsurgical treatment consisting of closed reduction and cast immobilization (CR group). Main Outcomes and Measures The primary outcome was patient-reported function using the Patient-Rated Wrist Evaluation (PRWE) questionnaire. Secondary outcomes included health-related quality of life, wrist pain, patient-reported treatment success, patient-rated bother with appearance, and posttreatment complications. Results Among the 166 randomized and 134 observational participants (300 participants; mean [SD] age, 71.2 [7.5] years; 269 women [89.7%]), 151 (91.0%) randomized and 118 (88.1%) observational participants were followed up at 24 months. In the RCT, no clinically important difference occurred in mean PRWE scores at 24 months (13.6 [95% CI, 9.1-18.1] points for VLP fixation vs 15.8 [95% CI, 11.3-20.2] points for CR; mean difference, 2.1 [95% CI, -4.2 to 8.5]; P = .50). There were no between-group differences in all other outcomes except for patient-reported treatment success, which favored VLP fixation (33 of 74 [44.6%] in the CR group vs 54 of 72 [75.0%] in the VLP fixation group reported very successful treatment; P = .002). Rates of posttreatment complications were generally low and similar between treatment groups, including deep infection (1 of 76 [1.3%] in the CR group vs 0 of 75 in the VLP fixation group) and complex regional pain syndrome (2 of 76 [2.6%] in the CR group vs 1 of 75 [1.3%] in the VLP fixation group). The 24-month trial outcomes were consistent with 12-month outcomes and with outcomes from the observational group. Conclusions and Relevance Consistent with previous reports, these findings suggest that VLP fixation may not be superior to CR for displaced distal radius fractures for patient-rated wrist function in persons 60 years or older during a 2-year period. Significantly higher patient-reported treatment success at 2 years in the VLP group may be attributable to other treatment outcomes not captured in this study. Trial Registration ANZCTR.org Identifier: ACTRN12616000969460.
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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, University of New South Wales, Sydney, Australia
| | - Justine Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia
| | - Rebecca Ivers
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Zsolt J Balogh
- Department of Orthopedics, John Hunter Hospital, Newcastle, Australia.,Department of Orthopedics, University of Newcastle, Newcastle, Australia
| | - Paul Smith
- Department of Orthopedics, Canberra Hospital, Canberra, Australia
| | - Wei Xuan
- Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Arezoo Vafa
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Diana Perriman
- Department of Orthopedics, Canberra Hospital, Canberra, Australia
| | - Rajat Mittal
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Piers Yates
- Department of Orthopedics, Fiona Stanley Hospital, Perth, Australia
| | - Bertram Rieger
- Department of Orthopedics, Fiona Stanley Hospital, Perth, Australia
| | - Geoff Smith
- Department of Orthopedics, St George and Sutherland Hospitals, Sydney, Australia
| | - Sam Adie
- Department of Orthopedics, St George and Sutherland Hospitals, Sydney, Australia.,St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia
| | - Ilia Elkinson
- Department of Orthopedics, Wellington Hospital, Wellington, New Zealand
| | - Woosung Kim
- Department of Orthopedics, Wellington Hospital, Wellington, New Zealand
| | - Jai Sungaran
- Department of Orthopedics, Concord Hospital, Sydney, Australia
| | - Kim Latendresse
- Department of Orthopedics, Nambour Hospital and Sunshine Coast University Hospital, Nambour, Australia
| | - James Wong
- Department of Orthopedics, Westmead Hospital, Sydney, Australia
| | | | - Keith Landale
- Department of Orthopedics, Campbelltown Hospital, Sydney, Australia
| | - Herwig Drobetz
- Department of Orthopedics, Mackay Base Hospital, Mackay, Australia
| | - Phong Tran
- Department of Orthopedics, Western Health, Melbourne, Australia
| | - Richard Page
- Department of Orthopedics, University Hospital Geelong, Barwon Health, Geelong, Australia.,Barwon Centre for Orthopaedic Research and Education, School of Medicine, Deakin University, Geelong, Australia
| | - Sally Beattie
- Barwon Centre for Orthopaedic Research and Education, School of Medicine, Deakin University, Geelong, Australia
| | | | - Ian Incoll
- Gosford and Wyong Hospitals, Gosford, Australia
| | | | | | - Trent Li
- Prince of Wales Hospital, Sydney, Australia
| | | | - Andrew Oppy
- Royal Melbourne Hospital, Melbourne, Australia
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.,Liverpool Hospital, Sydney, Australia
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Chung KC. Physiologic vs Chronologic Age for Distal Radius Fracture Treatment. JAMA Surg 2022; 157:571-572. [PMID: 35476056 DOI: 10.1001/jamasurg.2022.0810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor
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43
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C3 geriatric distal humeral fracture - ORIF or replace with an endoprosthesis. Injury 2022; 53:218-220. [PMID: 34980463 DOI: 10.1016/j.injury.2021.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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[Clinical studies in trauma surgery and orthopedics: read, interpret and implement]. Unfallchirurg 2021; 124:1007-1017. [PMID: 34761281 PMCID: PMC8579904 DOI: 10.1007/s00113-021-01101-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 12/01/2022]
Abstract
Für eine informierte, partizipative ärztliche Entscheidungsfindung müssen Sie neben Ihrem Erfahrungswissen aktuelle wissenschaftliche Daten berücksichtigen. Die digitale Informationsflut macht es im klinischen Alltag allerdings schwer, immer auf dem Stand des Wissens zu bleiben. Der Beitrag bietet einige Hilfen an, wie mit diesem Problem umgegangen werden kann. Ein grundlegendes Verständnis über Vor- und Nachwahrscheinlichkeiten sowie systematische Fehler (Bias) erleichtert die Abwägung zwischen Nutzen und Risiko z. B. einer (chirurgischen) Intervention im Vergleich zu einer nichtoperativen Therapie. Randomisierte Studien („randomized controlled trials“, RCT, mit allen modernen Modifikationen) liefern unverzerrte Ergebnisse, führen in Orthopädie und Unfallchirurgie evtl. zu einer stark selektierten, nichtrepräsentativen Stichprobe, und ihre Resultate müssen durch weitere, unabhängige RCT bestätigt oder widerlegt werden. Große beobachtende Datenmengen (z. B. aus Registern) können quasiexperimentell modelliert werden und RCT in der Gesundheitstechnologiebewertung flankieren.
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Dipnall JF, Page R, Du L, Costa M, Lyons RA, Cameron P, de Steiger R, Hau R, Bucknill A, Oppy A, Edwards E, Varma D, Jung MC, Gabbe BJ. Predicting fracture outcomes from clinical registry data using artificial intelligence supplemented models for evidence-informed treatment (PRAISE) study protocol. PLoS One 2021; 16:e0257361. [PMID: 34555069 PMCID: PMC8460020 DOI: 10.1371/journal.pone.0257361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/27/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Distal radius (wrist) fractures are the second most common fracture admitted to hospital. The anatomical pattern of these types of injuries is diverse, with variation in clinical management, guidelines for management remain inconclusive, and the uptake of findings from clinical trials into routine practice limited. Robust predictive modelling, which considers both the characteristics of the fracture and patient, provides the best opportunity to reduce variation in care and improve patient outcomes. This type of data is housed in unstructured data sources with no particular format or schema. The "Predicting fracture outcomes from clinical Registry data using Artificial Intelligence (AI) Supplemented models for Evidence-informed treatment (PRAISE)" study aims to use AI methods on unstructured data to describe the fracture characteristics and test if using this information improves identification of key fracture characteristics and prediction of patient-reported outcome measures and clinical outcomes following wrist fractures compared to prediction models based on standard registry data. METHODS AND DESIGN Adult (16+ years) patients presenting to the emergency department, treated in a short stay unit, or admitted to hospital for >24h for management of a wrist fracture in four Victorian hospitals will be included in this study. The study will use routine registry data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), and electronic medical record (EMR) information (e.g. X-rays, surgical reports, radiology reports, images). A multimodal deep learning fracture reasoning system (DLFRS) will be developed that reasons on EMR information. Machine learning prediction models will test the performance with/without output from the DLFRS. DISCUSSION The PRAISE study will establish the use of AI techniques to provide enhanced information about fracture characteristics in people with wrist fractures. Prediction models using AI derived characteristics are expected to provide better prediction of clinical and patient-reported outcomes following distal radius fracture.
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Affiliation(s)
- Joanna F. Dipnall
- Clinical Registries, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Richard Page
- School of Medicine, Deakin University, St. John of God Hospital, University Hospital Geelong, Geelong, Victoria, Australia
| | - Lan Du
- Department of Data Science & AI, Faculty of Information Technology, Monash University, Clayton, Victoria, Australia
| | - Matthew Costa
- Oxford Trauma and Emergency Care, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Ronan A. Lyons
- Clinical Registries, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Data Research UK, Swansea University, Swansea, United Kingdom
- National Centre for Population Health and Wellbeing Research, Swansea University, Swansea, United Kingdom
| | - Peter Cameron
- Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Alfred Hospital, Prahran, Victoria, Australia
| | - Richard de Steiger
- Department of Surgery, University of Melbourne, Epworth HealthCare, Epworth, Richmond, Victoria, Australia
| | - Raphael Hau
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Andrew Bucknill
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew Oppy
- Department of Orthopaedic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne, Victoria, Australia
- Epworth Healthcare, Melbourne, Victoria, Australia
| | - Elton Edwards
- Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Alfred Hospital, Prahran, Victoria, Australia
| | - Dinesh Varma
- Department of Surgery, Monash University, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
- Department of Radiology, Alfred Hospital, Melbourne, Australia
| | - Myong Chol Jung
- Clinical Registries, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Data Science & AI, Faculty of Information Technology, Monash University, Clayton, Victoria, Australia
| | - Belinda J. Gabbe
- Clinical Registries, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Centre for Population Health and Wellbeing Research, Swansea University, Swansea, United Kingdom
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46
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Spotlight in Plastic Surgery: July 2021. Plast Reconstr Surg 2021; 148:268-271. [PMID: 34086618 DOI: 10.1097/prs.0000000000008128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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47
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Objective Outcome Measures Continue to Improve from 6 to 12 Months after Conservatively Treated Distal Radius Fractures in the Elderly-A Prospective Evaluation of 50 Patients. J Clin Med 2021; 10:jcm10091831. [PMID: 33922371 PMCID: PMC8122793 DOI: 10.3390/jcm10091831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 12/20/2022] Open
Abstract
Distal radius fractures (DRF) in the elderly population above 65 years represent 18% of all fractures and are thereby the second most frequent fracture in the elderly. Fracture dislocation and comminution are often used to determine whether non-operative or operative treatment is indicated. The purpose of this prospective case series of minimally displaced DRF treated with a dorsal cast was to assess the complication rate and patient-reported outcome measures. This single-centre, single-blinded, prospective case series followed 50 conservatively treated DRF patients for one year. Primary outcomes were complications and Quick Disability of Arm Shoulder and Hand (qDASH) score. Secondary outcomes were range of motion (ROM), grip strength and pain, and Patient-Rated Wrist/Hand Evaluation (PRWHE). Results showed only minor complications with a return to prior ROM, qDASH, and pain after 12 months and improvement in outcomes after 6-12 months. In conclusion, the majority of DRF patients who were treated non-operatively with five-week dorsal casting recover fully after minimally displaced DRF. This standard approach is thus considered safe, and the present results provide a reference for other studies.
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48
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Deune EG. A Prospective Randomized Study With No Clinically Important Differences in Closed vs Open Treatment for Distal Radius Fracture in Elderly Individuals. JAMA Surg 2021; 156:237-238. [PMID: 33439222 DOI: 10.1001/jamasurg.2020.5673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- E Gene Deune
- Division of Plastic Surgery/Hand Surgery, University of North Carolina, Chapel Hill
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