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Franovic S, Pietroski AD, Druskovich K, Page B, Burdick GB, Fathima B, McIntosh MJ, King EA, Muh SJ. A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 5:169-177. [PMID: 36974282 PMCID: PMC10039314 DOI: 10.1016/j.jhsg.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 11/28/2022] [Indexed: 12/29/2022] Open
Abstract
Purpose To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns. Methods We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis. Results Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness. Conclusions The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation. Type of study/level of evidence Economic/decision analysis II.
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Affiliation(s)
- Sreten Franovic
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | | | | | - Brendan Page
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Gabriel B. Burdick
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Bushra Fathima
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | | | - Elizabeth A. King
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Stephanie J. Muh
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
- Corresponding author: Stephanie J. Muh, MD, Division of Hand and Upper Extremity, Department of Orthopaedic Surgery, Henry Ford Health System, West Bloomfield, MI 48202.
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Hammer OL, Clementsen S, Hast J, Šaltytė Benth J, Madsen JE, Randsborg PH. Volar Locking Plates Versus Augmented External Fixation of Intra-Articular Distal Radial Fractures: Functional Results from a Randomized Controlled Trial. J Bone Joint Surg Am 2019; 101:311-321. [PMID: 30801370 DOI: 10.2106/jbjs.18.00014] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of the study was to compare the functional outcomes following fixation with a volar locking plate (VLP) with those outcomes after augmented external fixation (EF) of displaced, intra-articular distal radial fractures in patients 18 to 70 years of age. METHODS Following inclusion, randomization, and surgery, clinical examination and outcome assessments were conducted at 6 weeks, 12 weeks, 6 months, 1 year, and 2 years. The primary outcome was the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and secondary outcomes included wrist range of motion, grip strength, and pain assessed with a visual analog scale (VAS). RESULTS Over a span of 3 years, 166 patients were included in the study. The mean age was 55.0 years (standard deviation [SD] = 11.5 years), with the ages distributed evenly in each treatment group by block randomization (84 patients in the VLP group and 82 in the EF group). The patients in the VLP group had a significantly better mean QuickDASH score, range of motion, and grip strength at 6 weeks, 12 weeks, 6 months, and 1 year. There were no significant differences between the groups at 2 years. On the basis of the minimal clinically important difference, the difference in the QuickDASH score was clinically relevant only at 6 weeks and arguably at 3 months (9.2 and 8.5 points, respectively). Therefore, the statistically significant improvement in the functional outcome of VLP compared with that of EF cannot be safely said to have clinical relevance beyond 12 weeks. The overall complication rate was comparable between the 2 groups. The rate of follow-up at 2 years was 97.0%. CONCLUSIONS VLP fixation resulted in faster recovery of function compared with EF, but no functional advantage was demonstrated at 2 years. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ola-Lars Hammer
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway.,University of Oslo, Oslo, Norway
| | - Ståle Clementsen
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway.,University of Oslo, Oslo, Norway
| | - Joakim Hast
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway
| | - Jūratė Šaltytė Benth
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Oslo, Norway.,Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
| | - Jan Erik Madsen
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Per-Henrik Randsborg
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway
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Rectenwald JP, Bentley KA, Murray PM, Saha S. Strain as a Function of Time in Extrinsic Wrist Ligaments Tensioned Through External Fixation. Hand (N Y) 2018; 13:60-64. [PMID: 28720046 PMCID: PMC5755868 DOI: 10.1177/1558944717692091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The objective of this study is to determine the time-dependent dissipation of extrinsic wrist ligament tension following the application external fixation with axial distraction of the wrist in a cadaveric model. METHODS Six paired fresh-frozen cadaveric specimens underwent mechanical testing simulating external fixation with 1 arm of each pair osteotomized to simulate a distal radius fracture. The change in tension was then recorded over 24 hours. RESULTS The rate of stress relaxation decreased with time. The average loss in tension in the control arms and osteotomized arms was 55% and 59%, respectively, over a 24-hour period. There was no statistically significant difference in the stress relaxation behavior between the 2 groups. CONCLUSION This study further supports the recommendation that comminuted distal radius fractures treated with an external fixator should have Kirschner wire augmentation or other additional means of fixation to help maintain fracture length and alignment. The results of this study call in to question the efficacy of ligamentotaxis alone through external fixation as the sole means of maintaining reduction of displaced, unstable distal radius fractures.
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Affiliation(s)
| | | | - Peter M. Murray
- Mayo Clinic, Jacksonville, FL, USA,Peter M. Murray, Professor and Chair, Department of Orthopedic Surgery and Consultant in Orthopedic Surgery and Neurosurgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Horst TA, Jupiter JB. Stabilisation of distal radius fractures: Lessons learned and future directions. Injury 2016; 47:313-9. [PMID: 26553426 DOI: 10.1016/j.injury.2015.09.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/29/2015] [Indexed: 02/02/2023]
Abstract
Our understanding of the diagnosis and management of distal radius fractures has been a long developed over centuries. There has been a shift in treatment of these very common injuries from closed reduction and casting to internal fixation. The answer to the best method of treatment has yet to be found. Today, we have a multitude of treatment options available with varying degrees of evidence to support their use. This review helps to illustrate the lessons we have learned and future directions for treatment.
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Affiliation(s)
- Taylor A Horst
- Division of Hand Surgery, Massachusetts General Hospital, Boston, MA, United States
| | - Jesse B Jupiter
- Division of Hand Surgery, Massachusetts General Hospital, Boston, MA, United States.
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Raju P, Kini SG. Loss of correction in unstable comminuted distal radius fractures with external fixation and bone grafting--a long term followup study. J Orthop Surg Res 2011; 6:23. [PMID: 21600030 PMCID: PMC3118123 DOI: 10.1186/1749-799x-6-23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2010] [Accepted: 05/21/2011] [Indexed: 11/10/2022] Open
Abstract
Over the years, management of complex distal radius fractures by closed means has often failed leading to late collapse. We have chosen the principle of ligamentotaxis using external fixation and bone grafting in this study to prevent late complications. Eighty one patients with complex distal radius fractures belonging to Type IV A, IV B, IV C of Universal classification were treated with an AO external fixator between 1995 and 2001. Mean age group was 38. 47 years with longest follow up of 7 years. Bone grafting was done primarily in 20 patients and early grafting (within 3 weeks) in 5 patients. Statistically significant differences were observed between the two groups(with or without bone grafting) with respect to postoperative values of (radial length, radial tilt and volar tilt). Results were assessed based on Sarmientos criteria. 56 patients had excellent results, 9 had good results and 16 had poor results. Late collapse with decreased radial length was observed in 18 patients who did not undergo bone grafting. Mean grip strength was 63 percent. Osteoarthritic changes were noted in 20 patients. We conclude that accurate anatomic reduction is necessary for achieving good to excellent functional and cosmetic results. Bone grafting is the mainstay of treatment in comminuted distal radius fractures along with fracture stabilisation.
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Affiliation(s)
- PuttaKempa Raju
- Victoria Hospital, Bangalore Medical College and Research Institute, Bangalore, India
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Aktekin CN, Altay M, Gursoy Z, Aktekin LA, Ozturk AM, Tabak AY. Comparison between external fixation and cast treatment in the management of distal radius fractures in patients aged 65 years and older. J Hand Surg Am 2010; 35:736-42. [PMID: 20381979 DOI: 10.1016/j.jhsa.2010.01.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 01/21/2010] [Accepted: 01/26/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this study was to compare the functional and radiographic outcomes of dorsally displaced distal radius fractures treated by closed reduction plaster cast fixation (CRPCF) and external fixation (EF) in patients 65 years and older. METHODS This retrospective and nonrandomized study comprised 46 consecutive patients older than 65 years who had distal radial fractures. Patients were divided into 2 groups according to treatment: a CRPCF group and an EF group. All the fractures were dorsally displaced and AO/ASIF type A or C, without articular stepoff or gap. Cases were evaluated based on the criteria of Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, wrist range of motion, and radiologic results. RESULTS The mean follow-up period was 25.1 months. Union was achieved in all cases. Although it was not a statistically significant difference, posttreatment complications were more common in the CRPCF group (10 patients) than in the EF group (7 patients). In the CRPCF group, most complications were discomfort from the cast, whereas in the EF group, most were pin site infections. The average wrist extension and ulnar deviation (clinically) and palmar tilt and radial height (radiologically) were statistically better in the EF group at the final follow-up. The mean DASH scores were 20.3 in the CRPCF group and 21.9 in the EF group. There was no statistically significant difference in the DASH scores; in wrist flexion, radial deviation, pronation, supination, grip strength, or pinch strength (clinically); or in ulnar variance or radial inclination (radiologically). There was no correlation between the DASH scores and palmar tilt and ulnar variance. CONCLUSIONS We concluded that both CRPCF and EF are useful methods for distal radius fractures in elderly patients. The results showed significant differences in wrist extension and ulnar deviation.
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Xu GGQ, Chan SP, Puhaindran ME, Chew WYC. Prospective Randomised Study of Intra-Articular Fractures of the Distal Radius: Comparison Between External Fixation and Plate Fixation. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n7p600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Introduction: Intra-articular fractures of the distal radius represent high energy, complex, unstable injuries and the optimal method of treatment remains controversial.
Materials and Methods: The aim of the paper is to compare the outcomes of external fixation (EF) with open reduction internal fixation (ORIF) with plates and screw fixation in the treatment of intra-articular fractures of the distal radius. Thirty-five patients were enlisted from December 2003 to September 2005 after a failure of initial conservative treatment. The patients were randomised into EF or ORIF groups. The patients were followed-up at 1 week, 3, 6, 12 and 24 months. Clinical and radiological outcomes were measured. They were scored using the Green and O’Brien or the Gartland and Wertley score.
Results: Of the 35 patients, 5 defaulted the 6-month follow-up and were excluded. We found that the clinical and radiological outcomes for the 2 groups were not significantly different. Complication rates were also similar.
Conclusion: There is no significant difference in the outcome of intra-articular distal radius fractures treated with either EF or ORIF.
Introduction: Intra-articular fractures of the distal radius represent high energy, complex, unstable injuries and the optimal method of treatment remains controversial.
Materials and Methods: The aim of the paper is to compare the outcomes of external fixation (EF) with open reduction internal fixation (ORIF) with plates and screw fixation in the treatment of intra-articular fractures of the distal radius. Thirty-five patients were enlisted from December 2003 to September 2005 after a failure of initial conservative treatment. The patients were randomised into EF or ORIF groups. The patients were followed-up at 1 week, 3, 6, 12 and 24 months. Clinical and radiological outcomes were measured. They were scored using the Green and O’Brien or the Gartland and Wertley score.
Results: Of the 35 patients, 5 defaulted the 6-month follow-up and were excluded. We found that the clinical and radiological outcomes for the 2 groups were not significantly different. Complication rates were also similar.
Conclusion: There is no significant difference in the outcome of intra-articular distal radius fractures treated with either EF or ORIF.
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Slutsky DJ. External fixation of distal radius fractures. J Hand Surg Am 2007; 32:1624-37. [PMID: 18070654 DOI: 10.1016/j.jhsa.2007.09.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 09/12/2007] [Indexed: 02/02/2023]
Abstract
External fixation has been used for the treatment of distal radius fractures for more than 50 years. Although the fixator configurations have undergone considerable modification over time, the type of fixator itself is not as important as the underlying principles that provide the foundation for external fixation. Although volar plate fixation is currently in vogue, the indications for external fixation remain largely unchanged. Newer fixator designs have also expanded the traditional usage to include nonbridging applications that allow early wrist motion. The following discussion focuses on the myriad uses for external fixation as well as the shortcomings and potential pitfalls.
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Chang HC, Poh SY, Seah SC, Chua DTC, Cha BK, Low CO. Fragment-specific fracture fixation and double-column plating of unstable distal radial fractures using AO mini-fragment implants and Kirschner wires. Injury 2007; 38:1259-67. [PMID: 17631882 DOI: 10.1016/j.injury.2007.03.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Revised: 03/06/2007] [Accepted: 03/09/2007] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the efficacy of AO mini-fragment implants and 1.25-mm Kirschner wires using fragment-specific fracture fixation and double-column plating for displaced or unstable distal radial fractures. DESIGN prospective and consecutive. SETTING level II trauma hospital. PARTICIPANTS 28 people with 30 fractures and an average follow-up of 21.1 (range 12-41) months, treated with fragment-specific fracture fixation. OUTCOME MEASUREMENTS anatomical assessment using anteroposterior and lateral radiographs, graded according to Sarmiento's modification of Lidstrom's scoring system. CLINICAL OUTCOME ASSESSMENT: DASH and Modified Gartland and Werley scores. RESULTS There were 24 excellent and 6 good radiological results. Final mean grip strength was 83% of uninjured side, and mean wrist range of motion was 61 degrees dorsiflexion, 54 degrees palmar flexion, 85 degrees supination and 83 degrees pronation. Gartland and Werley's demerit point system revealed 13 (43%) excellent, 12 (40%) good, 5 (17%) fair and no poor results. The mean DASH score was 18, with a standard deviation of +/-18. CONCLUSION This fixation method is a reliable and low-cost alternative with good clinical and anatomical results, particularly useful in open reduction and internal fixation of comminuted intra-articular distal radial fractures.
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Affiliation(s)
- H C Chang
- Department of Orthopaedic Surgery, Changi General Hospital, Singapore 529889, Singapore.
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the anatomy and the biomechanical properties of the wrist. 2. Understand the standard examination process for wrist injuries. 3. Accurately diagnose common wrist conditions. 4. Establish a management plan for wrist problems. BACKGROUND Although common, wrist injuries and conditions are difficult to treat if the physician is unfamiliar with their management. METHODS Wrist anatomy and kinematics are discussed. Physical and radiographic examinations that are mandatory for diagnosing wrist conditions are presented. Common wrist injuries are reviewed. RESULTS Understanding the anatomy and kinematics of the wrist is important in diagnosing and treating wrist conditions and in predicting outcomes after treatment. Physical examination of the wrist requires an understanding of the surface anatomy and a number of specific maneuvers. Physicians should also be familiar with other diagnostic tests, which include radiography, arthrography, computed tomography, magnetic resonance imaging, and arthroscopy. CONCLUSIONS Physicians who treat wrist injuries should be able to establish an adequate management plan for common wrist injuries and conditions and be able to predict outcomes based on these treatment plans.
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Affiliation(s)
- Kenji Kawamura
- Ann Arbor, Mich. From the Section of Plastic Surgery, Department of Surgery, University of Michigan Health System
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Jeudy J, Pernin J, Cronier P, Talha A, Massin P. Ostéosynthèse par plaque antérieure verrouillée des fractures complexes de l’extrémité distale du radius. ACTA ACUST UNITED AC 2007; 93:435-43. [PMID: 17878834 DOI: 10.1016/s0035-1040(07)90325-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE OF THE STUDY Maintaining radial length, likely to be the main challenge in the treatment of complex distal radius fractures, is necessary for complete grip-strength and pro-supination range recovery. In spite of frequent secondary displacements, bridging external-fixation has remained the reference method, either isolated or in association with additional percutaneous pins or volar plating. Also, there seems to be a relation between algodystrophy and the duration of traction applied on the radio-carpal joint. Fixed-angle volar plating offers the advantage of maintaining the reduction until fracture healing, without bridging the joint. MATERIAL AND METHODS In a prospective study, forty-three consecutive fractures of the distal radius with a positivated ulnar variance were treated with open reduction and fixed-angle volar plating. Results were assessed with special attention to the radial length and angulation obtained and maintained throughout treatment, based on repeated measurements of the ulnar variance and radial angulation in the first six months postoperatively. RESULTS The correction of the ulnar variance was maintained until complete recovery, independently of initial metaphyseal comminution, and of the amount of radial length gained at reduction. Only 3 patients lost more than 1 mm of radial length after reduction. The posterior tilt of the distal radial epiphysis was incompletely reduced in 13 cases, whereas reduction was partially lost in 6 elderly osteoporotic female patients. There was 8 articular malunions, all of them less than 2 mm. Secondary displacements were found to be related to a deficient locking technique. Eight patients developed an algodystropy. The risk factors for algodystrophy were articular malunion, associated posterior pining, and associated lesions of the ipsilateral upper limb. CONCLUSION Provided that the locking technique was correct, this type of fixation appeared efficient in maintaining the radial length in complex fractures of the distal radius. The main challenge remains the reduction of displaced articular fractures. Based on these results, it is not possible to conclude that this method is superior to external fixation.
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Affiliation(s)
- J Jeudy
- Département de Chirurgie Osseuse, CHU d'Angers, 4, rue Larrey, 49100 Angers Cedex.
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