An economic analysis of outcomes and complications of treating distal radius fractures in the elderly

Analysis of factors influencing hospitalization cost of patients with distal radius fractures: an empirical study based on public traditional Chinese medicine hospitals in two cities, China

BACKGROUND

Distal radius fractures (DRFs) have become a public health problem for all countries, bringing a heavier economic burden of disease globally, with China's disease economic burden being even more acute due to the trend of an aging population. This study aimed to explore the influencing factors of hospitalization cost of patients with DRFs in traditional Chinese medicine (TCMa) hospitals to provide a scientific basis for controlling hospitalization cost.

METHODS

With 1306 cases of DRFs patients hospitalized in 15 public TCMa hospitals in two cities of Gansu Province in China from January 2017 to 2022 as the study object, the influencing factors of hospitalization cost were studied in depth gradually through univariate analysis, multiple linear regression, and path model.

RESULTS

Hospitalization cost of patients with DRFs is mainly affected by the length of stay, surgery and operation, hospital levels, payment methods of medical insurance, use of TCMa preparations, complications and comorbidities, and clinical pathways. The length of stay is the most critical factor influencing the hospitalization cost, and the longer the length of stay, the higher the hospitalization cost.

CONCLUSIONS

TCMa hospitals should actively take advantage of TCMb diagnostic modalities and therapeutic methods to ensure the efficacy of treatment and effectively reduce the length of stay at the same time, to lower hospitalization cost. It is also necessary to further deepen the reform of the medical insurance payment methods and strengthen the construction of the hierarchical diagnosis and treatment system, to make the patients receive reasonable reimbursement for medical expenses, thus effectively alleviating the economic burden of the disease in the patients with DRFs.

Impact of an Outpatient Fracture Liaison Service on Osteoporosis Evaluation Among Patients With Upper Extremity Fragility Fracture

BACKGROUND

The purpose of this study was to assess the impact of implementation of an outpatient fracture liaison service (FLS) on completion rates of dual-energy x-ray absorptiometry (DXA) and screening labs including 25-OH vitamin D and parathyroid hormone (PTH) in patients with upper extremity (UE) fragility fractures.

METHODS

At our institution, 367 patients were treated in 2014-2015 for UE fragility fractures of the distal radius and proximal humerus before implementation of our outpatient FLS and 395 patients in 2017-2018 after implementation. Retrospective chart review was conducted to identify completed DXA scans within 2 years of fracture treatment and completed 25-OH vitamin D and PTH labs within 1 year of fracture treatment.

RESULTS

There were no statistical differences in the demographics of patients treated for distal radial and proximal humeral fragility fractures during the 2014-2015 and 2017-2018 time periods. Implementation of the FLS resulted in a 9.9% increase (P value = .021) in completed DXA scans within 2 years of fracture treatment. Completed 25-OH vitamin D and PTH labs saw a significant increase of 17.1% and 23.8%, respectively (P values < .001).

CONCLUSIONS

Implementation of an outpatient FLS can help to improve osteoporosis evaluation with completed DXA scans and 25-OH vitamin D and PTH labs.

The ageless approach: Nonoperative mastery competes head-on with surgery for elderly distal radius fractures

The aim of the current study is to compare the clinical outcomes of cast immobilization (CI) versus surgical treatment after 1 year for distal radius fractures (DRFs) in the elderly population. The cohort included patients aged 70-89 who suffered an acute, closed, and displaced DRF and who were treated conservatively or surgically at our clinic between August 2018 and January 2022. Those who had pathological fractures, open fractures, concomitant ulna fractures (except ulna styloid fractures), were not between the ages of 70 and 89, or refused to participate were excluded from the study. The study gathered data on patient demographics, initial radiological measurements, clinical measurements after 1 year, treatment models employed, and rates of complications. Of the total number of patients (276), CI was used on 77.2% (213), whereas the other 25 had volar-locked plates (VLP), 25 received external fixators with percutaneous pinning (EFPP), and 13 had isolated percutaneous pinning (IPP). 19 of 276 individuals had complications, with Complex Regional Pain Syndrome and Carpal Tunnel Syndrome being the most often documented. EFPP resulted in significantly higher Disability of the Arm, Shoulder, and Hand (DASH) score values than VLP and IPP at the 1st postoperative year (p < 0.05). No statistically significant difference was found between the DASH score and ROM values at the 1st postoperative year for patients who received CI versus those who underwent surgery (p > 0.05). In the first postoperative year, CI still retains its validity and performs similarly to surgery for DRFs in older individuals. VLPP and IPP methods outperformed EFPP surgeries.

Regional versus General Anesthesia in Postoperative Pain Management after Distal Radius Fracture Surgery: Meta-Analysis of Randomized Controlled Trials

Distal radius fractures are the most prevalent upper extremity fractures, posing a significant public health concern. Recent studies comparing regional and general anesthesia for postoperative pain management after these fractures have yielded conflicting results. This meta-analysis aimed to compare the effectiveness of regional and general anesthesia concerning postoperative pain management and opioid consumption following distal radius fracture surgery. A comprehensive search was conducted in PubMed, Cochrane Library, and EMBASE databases to identify relevant randomized controlled trials. Four randomized trials involving 248 participants were included in the analysis. A pooled analysis revealed that regional anesthesia led to significantly reduced postoperative pain scores at 2 h compared to general anesthesia (SMD -2.03; 95% CI -2.88--1.17). However, no significant differences in pain scores were observed between the two anesthesia types after 12 h post-surgery. Regional anesthesia was associated with lower total opioid consumption (SMD -0.76; 95% CI -1.25--0.26) and fewer occurrences of nausea and vomiting compared to the general anesthesia. Nonetheless, opioid consumption on the first day post-discharge was significantly higher in the regional anesthesia group (SMD 0.83; 95% CI 0.47-1.20). The analgesic superiority of regional anesthesia is confined to the early postoperative hours with overall lower opioid use but a notable increase in opioid consumption on the first day post-discharge, potentially attributable to rebound pain.

Current and future utility of ultrasound imaging in upper extremity musculoskeletal rehabilitation: A scoping review

STUDY DESIGN

This study was a scoping review.

BACKGROUND

Continued advances in musculoskeletal sonography technology and access have increased the feasibility of point-of-care use to support day-to-day clinical care and decision-making. Sonography can help improve therapeutic outcomes in upper extremity (UE) rehabilitation by enabling clinicians to visualize underlying structures during treatment.

PURPOSE OF THE STUDY

This study aimed to (1) evaluate the growth, range, extent, and composition of sonography literature supporting UE rehabilitation; (2) identify trends, gaps, and opportunities with regard to anatomic areas and diagnoses examined and ultrasound techniques used; and (3) evaluate potential research and practice utility.

METHODS

Searches were completed in PubMed, CINAHL, SPORTDiscus, PsycINFO, and BIOSIS. We included data-driven articles using ultrasound imaging for upper extremity structures in rehabilitation-related conditions. Articles directly applicable to UE rehabilitation were labeled direct articles, while those requiring translation were labeled indirect articles. Articles were further categorized by ultrasound imaging purpose. Article content between the two groups was descriptively compared, and direct articles underwent an evaluation of evidence levels and narrative synthesis to explore potential clinical utility.

RESULTS

Average publication rates for the final included articles (n = 337) steadily increased. Indirect articles (n = 288) used sonography to explore condition etiology, assess measurement properties, inform medical procedure choice, and grade condition severity. Direct articles (n = 49) used sonography to assess outcomes, inform clinical reasoning, and aid intervention delivery. Acute UE conditions and emerging sonography technology were rarely examined, while tendon, muscle, and soft tissue conditions and grayscale imaging were common. Rheumatic and peripheral nerve conditions and Doppler imaging were more prevalent in indirect than direct articles. Among reported sonography service providers, there was a high proportion of nonradiologist clinicians.

CONCLUSION

Sonography literature for UE rehabilitation demonstrates potential utility in evaluating outcomes, informing clinical reasoning, and assisting intervention delivery. A large peripheral knowledge base provides opportunities for clinical applications; however, further research is needed to determine clinical efficacy and impact for specific applications.

Future Fracture Risk in Upper Extremity Fracture and Non-Fracture Patients

BACKGROUND

Upper extremity (UE) fragility fractures are common and strong predictors of subsequent fractures. To investigate the relative importance of an UE fragility fracture in determining future fracture risk, we conducted a cross-sectional study to compare future fracture risk between patients presenting for osteoporosis evaluation after an UE fragility fracture and a similarly aged cohort of patients without an UE fracture.

METHODS

In all, 129 UE fracture patients seen in our bone health clinic (BHC) and 114 non-fracture UE fracture patients seen in an UE clinic completed clinic intake surveys assessing for fracture risk factors. Prefracture fracture risk (PFFR) and fracture risk assessment tool (FRAX) scores estimated the future fracture risks at the timepoint before and after the UE fragility fracture event, respectively. The primary study outcome was the 10-year risk of future fracture.

RESULTS

The 10-year probability of major osteoporotic and hip fractures were significantly higher among the BHC group when estimated with FRAX. When estimated with PFFR score, there was no difference in the 10-year probability of hip fracture between the groups. Prevalence of secondary osteoporosis and glucocorticoid use was higher in the BHC group, and prevalence of rheumatoid arthritis was higher in the UE clinic group.

CONCLUSIONS

This study underscores the importance of an UE fragility fracture in determining the risk of future fracture. A fragility fracture of the UE should be considered a sentinel event and physicians who evaluate these patients should recognize them as a high-risk group for future hip fracture.

Analysis of Postoperative Distal Radius Fracture Outcomes in the Setting of Osteopenia and Osteoporosis for Patients with Comorbid Conditions

Purpose

Distal radius fractures (DRFs) are among the most common orthopedic injuries, especially in the elderly. A wide variety of approaches have been advocated as successful treatment modalities; yet, there remains variability in practice patterns of DRF in patients with osteoporosis and osteopenia. Using large data set analysis, we sought to determine the risk profile of operative fixation of DRF in patients with low bone mineral density.

Methods

A commercially available health care database, PearlDiver, was queried for all patients who underwent open reduction internal fixation of DRFs between 2010 and 2020. The study population was divided into groups based on the presence or absence of osteopenia or osteoporosis and was further classified by patients who were receiving bisphosphonate therapy. Complication rates were calculated, including rates of malunion, surgical site infection, osteomyelitis, hardware failure, and hardware removal. Five-year future fragility fractures were defined in hip, vertebrae, humerus, and wrist fractures. Chi-square analysis and logistic regression were performed to determine an association between these comorbidities and various postoperative complications.

Results

A total of 152,926 patients underwent open reduction internal fixation of a DRF during the study period. Chi-square analysis of major complications at 3 months showed a statistically significant increase in malunion in patients with osteopenia (P = .05) and patients with osteoporosis (P = .05) who underwent open reduction internal fixation. Logistic regression analysis at 12 months after surgery demonstrated that osteopenia was associated with an increased risk of hardware failure (P < .0001), hardware removal (P < .0001), surgical site infection (P < .0001), and malunion (P = .004). Osteoporosis was associated with a significantly increased risk of hardware failure (P = .01), surgical site infection (P < .0001), and malunion (P < .0001).

Conclusions

We demonstrated, using large data set analysis, that DRF patients with osteopenia and osteoporosis are predicted to be at increased risk of multiple postoperative complications, and thus, bone density should be strongly considered in treatment planning for these patients.

Type of study/level of evidence

Prognostic III.

Using MaxDiff Analysis to Elicit Patients' Treatment Preferences for Distal Radius Fractures in Patients Aged 60 Years and Older

PURPOSE

The objective of our study was to determine how the attributes of surgical and nonsurgical distal radius fracture (DRF) treatments affect patient treatment preferences.

METHODS

Two hundred fifty patients aged 60 years and older were contacted from a single-hand surgeon's practice, and 172 chose to participate. We built a series of best-worst scaling experiments for the MaxDiff analysis to determine the relative importance of treatment attributes. Hierarchical Bayes analysis was used to generate individual-level item scores (ISs) for each attribute that together have a total sum of 100.

RESULTS

One hundred general hand clinic patients without a history of a DRF and 43 patients with a history of a DRF completed the survey. For the general hand clinic patients, the most important attributes to avoid when choosing a DRF treatment (in descending order) were the longer time to full recovery (IS, 24.9; 95% confidence interval [CI]: 23.4-26.3), longer time spent in a cast (IS, 22.8; 95% CI, 21.5-24.2), and higher complication rates (IS, 18.4; 95% CI, 16.9-19.8). Meanwhile, for patients with a history of a DRF, the most important attributes to avoid (in descending order) were a longer time to full recovery (IS, 25.6; 95% CI, 23.3-27.9), longer time spent in a cast (IS, 22.8; 95% CI, 19.9-25.7), and abnormal alignment of the radius on x-ray (IS, 18.3; 95% CI, 15.4-21.3). For both the groups, the least concerning attributes based on the IS were appearance-scar, appearance-bump, and the need for anesthesia.

CONCLUSIONS

Eliciting patient preferences is a vital component of shared decision-making and advancing patient-centered care. As conceptualized in this MaxDiff analysis, when choosing a DRF treatment, patients mostly want to avoid a longer time to full recovery and a longer time in a cast, whereas patients have the least concern about appearance and need for anesthesia.

CLINICAL RELEVANCE

Eliciting patient preferences is a vital component of shared decision-making. Our results may provide guidance to surgeons in discussions on the relative benefits of surgical and nonsurgical DRF treatments, by quantifying the most and least important factors to patients.

The Association of Low Skeletal Muscle Mass with Complex Distal Radius Fracture

Objectives: Sarcopenia is a skeletal muscle loss disease with adverse outcomes, including falls, mortality, and cardiovascular disease (CVD) in older patients. Distal radius fractures (DRF), common in older people, are strongly related to falls. We aimed to investigate the correlation between DRF and low skeletal muscle mass, which strongly correlated to sarcopenia. Methods: We performed a retrospective review of data from patients diagnosed with or without DRF in our institute between 2015 and 2020. Finally, after propensity score matching, data from 115 patients with and 115 patients without DRF were used for analyses. Multivariate logistic regression analysis was performed for sex, body mass index (BMI), the presence of low skeletal muscle mass, bone quality measured by dual-energy X-ray absorptiometry (DXA), and comorbidities (diabetes mellitus, CVD). Results: We found that female sex (odds ratio = 3.435, p = 0.015), CVD (odds ratio = 5.431, p < 0.001) and low skeletal muscle mass (odds ratio = 8.062, p = 0.001) were significant predictors for DRF. BMI and osteoporosis were not statistically significantly related to DRF. Conclusions: Women with low skeletal muscle mass and CVD may be more responsible for DRF than osteoporosis.

Role of Pronator Quadratus Repair in Volar Locking Plate Treatment of Distal Radius Fractures

Distal radius fractures are the most common type of upper extremity fractures, and their incidence is increasing. There has been a rise in the surgical treatment of distal radius fractures, primarily with volar locking plate fixation. Although this procedure is commonly done among orthopaedic surgeons, the role of pronator quadratus repair after fixation remains controversial. The pronator quadratus serves as a secondary forearm pronator and a dynamic stabilizer of the distal radioulnar joint. Aside from a functional role, repair of the pronator quadratus has been proposed to serve as a biologic barrier between the volar locking plate and the flexor tendons to minimize tendon irritation. In this narrative review, we discuss the current treatment trends, the surgical approach for volar locking plate treatment of distal radius fractures, and the anatomy and function of the pronator quadratus. We discuss the case for and against the repair of the pronator quadratus, both for function and prevention of flexor tendon irritation and rupture. The preponderance of high-level evidence demonstrates no benefit to pronator quadratus repair for pain relief or function. The current evidence does not conclusively support or refute pronator quadratus repair as a biologic barrier from the flexor tendons.

Radiographic Outcomes and Complications of Delayed Fixation of Distal Radius Fractures

BACKGROUND

Surgeons are sometimes presented with patients with distal radius fractures who present in a delayed fashion or lose reduction after several weeks of attempted closed management. There are limited studies on delayed surgical treatment of distal radius fractures to assist providers in decision-making.

METHODS

We conducted a matched cohort study to compare radiographic outcomes and complications for patients with a distal radius fracture treated with delayed (3-5 weeks) or early (0-2 weeks) surgical fixation. Patients ages 18+ who underwent open reduction and internal fixation of distal radius fractures by a volar approach at 2 Level I trauma centers between 2003 and 2015 were eligible. We measured radiographic outcomes and reviewed medical records to determine operative approach and complications.

RESULTS

There were 25 cases and 50 controls matched for age (18-87), sex, and AO fracture type. The delayed group had surgery at a mean of 24.8 days from injury and the early group at 5.6 days. There was no statistically significant difference between the delayed and early cohorts in radiographic parameters on injury x-rays, in improvement in radiographic parameters on first postoperative x-rays, or in maintenance of radiographic parameters at union.

CONCLUSION

We did not find significant differences in radiographic outcomes or complication rates between patients with delayed versus early surgical treatment for distal radius fracture. Providers treating patients with late presentation or late displacement have the option of surgical fixation beyond the first few weeks after injury.

LEVEL OF EVIDENCE

III (Retrospective matched cohort study).

Can the Workplace Limitations Questionnaire Capture Short-term Productivity Losses in Acute Distal Radius Fractures Treated With Operative Fixation Versus Cast Immobilization in the Working Population?

Background: Distal radius fractures (DRFs) contribute substantially to overall morbidity in the elderly population. We believe that accurately capturing total productivity losses is vital to understanding the true economic impact of these injuries in working patients. Methods: We conducted a prospective nonrandomized cohort study and enrolled working patients with DRF treated with either casting or operative fixation. We administered the Workplace Limitations Questionnaire (WLQ, Tufts Medical Center) at the first visit following injury and at 2 weeks, 6 weeks, and 3 months after definitive treatment. The WLQ measures the degree to which employed individuals are experiencing limitations on-the-job due to their health problems and estimates health-related productivity loss. We also calculated the monetary value of work time lost at market value in US dollars. The treatment groups were analyzed for statistical similarity using Student t tests. Results: A total of 30 patients met our study's inclusion criteria. The WLQ index score trended downward in both groups across all time points and was lower in the operative cohort compared with the nonoperative cohort at 6 weeks (1.4% vs 12.9% productivity loss, P = .17). The monetary value of work time lost trended downward across all time points and was lower in the operative cohort compared with the nonoperative cohort ($200.21 vs $2846.90, P = .12). Conclusions: In this pilot study, we successfully applied the WLQ to working patients treated for DRF. The WLQ is effective in capturing short-term productivity losses following DRF and may suggest a decreased at-work burden among patients treated with operative fixation compared with casting.

Practical Application of the 2020 Distal Radius Fracture AAOS/ASSH Clinical Practice Guideline: A Clinical Case

The Clinical Practice Guideline Management of Distal Radius Fractures released by the American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand is a summary of the available evidence designed to guide surgeons and other qualified physicians in the management of distal radius fractures. According to this guideline, age of 65 is used as a proxy for functional activity and can serve as a threshold under which patients are likely to benefit from surgical fixation and over which patients are less likely to benefit from surgical fixation when compared with nonsurgical treatment. Supervised therapy and arthroscopic assistance should be used sparingly and on a case-by-case basis. Routine radiographs should also be used on a case-by-case basis. As strong evidence suggests no difference observed in clinical or radiographic outcomes by fixation technique used after 3 months, fixation technique should be driven by fracture pattern. These guidelines serve to guide physicians in the care of patients with distal radius fractures.

American Academy of Orthopaedic Surgeons/American Society for Surgery of the Hand Clinical Practice Guideline Summary Management of Distal Radius Fractures

The Management of Distal Radius Fractures Evidence-Based Clinical Practice Guideline is based on a systematic review of published studies for the treatment of distal radius fractures in adults older than 18 years. The scope of this guideline is limited to the treatment of acute distal radius fractures and does not address distal radius malunion. This guideline contains seven recommendations to assist orthopaedic surgeons and all qualified physicians managing patients with acute distal radius fractures based on the best current available evidence. It serves as an information resource for professional healthcare practitioners and developers of practice guidelines and recommendations. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development.

Distal Radius Fracture Clinical Practice Guidelines-Updates and Clinical Implications

The American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand released updated Clinical Practice Guidelines in 2020 on the evaluation and treatment of acute distal radius fractures. Following a rigorous methodology designed and implemented through the AAOS, 7 guidelines based upon the best available evidence were released to assist surgeons and physicians managing distal radius fractures. These guidelines can serve as a reference for surgeons when managing patients with distal radius fractures. We review the evidence behind each guideline and highlight the practical implications of each guideline on care.

Cost-Effectiveness of Treatments after Closed Extraarticular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial

BACKGROUND

This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures.

METHODS

This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio.

RESULTS

Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year.

CONCLUSIONS

Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.

Outcome Measurement for Distal Radius Fractures

Distal radius fractures (DRFs) are among the most common upper extremity injuries. Multiple medical conditions now are evaluated by standardized outcome sets that enable comparability. Recent international working groups have provided consensus statements for outcomes measurement after DRFs. These statements emphasized the growing importance of patient-reported outcome measures as well as traditional measures, including pain assessment, radiographic alignment, performance, and assessment of complications. A standardized instrument and timeline for measuring outcomes following DRFs offers clinicians, researchers, and health care economists a powerful tool. This article reviews the current evidence and provides recommendations for a DRF standardized outcome set.

What Is the Evidence in Treating Distal Radius Fractures in the Geriatric Population?

Distal radius fractures are common in the elderly population, second only to hip fractures in frequency. Historically, these injuries were treated almost exclusively without surgery, but an increase in operative management has occurred with development of volar locked plating in the early 2000s. Functional outcomes are similar between conservative and surgical treatment, but most studies assume low functional demands in older patients. Many elderly individuals today are active and independent. Decision-making in this higher-demand population is difficult. This article provides current evidence to facilitate informed, individualized decision-making when treating distal radius fractures in geriatric patients.

How to Treat Distal Radius Fractures: Right Patient, Right Care, Right Time, and Right Cost

Operative intervention for distal radius fractures is typically reserved for patients with displaced fractures that may result in bothersome compromises in function, although patient-specific factors (age, activity level, and preference) are considered. Operative intervention is associated with earlier improvement in function but exposes the patient to the risk of anesthesia and surgery. Although surgery is associated with an initial increase in cost of care, the benefits of earlier return to activity may offset these increases. Efforts to contain cost through implant selection, use of ambulatory surgical centers, and judicious referrals for postoperative therapy can aid surgeons in delivering high-value care.

The Wrist and Radius Injury Surgical Trial: 12-Month Outcomes from a Multicenter International Randomized Clinical Trial

BACKGROUND

Optimal treatment for distal radius fractures in older adults remains uncertain. No randomized trials comparing the most frequently used treatments in this population have been conducted. Surgical treatment rates vary widely, and the sustained benefits of surgery are uncertain.

METHODS

The Wrist and Radius Injury Surgical Trial, a randomized, multicenter trial, enrolled 304 adults aged 60 years and older with isolated, unstable distal radius fractures at 24 institutions. Patients who wanted surgery (n = 187) were randomized to internal fixation, external fixation, or percutaneous pinning; patients who preferred conservative management (n = 117) received casting. The primary outcome was the 12-month Michigan Hand Outcomes Questionnaire (MHQ) summary score.

RESULTS

At 12 months, there were no differences by treatment in primary outcome. Twelve-month MHQ summary scores differed between internal fixation and external fixation by 3 points (97.5 percent CI, 6.0 to 11.5) and between internal fixation and pinning by -0.14 (97.5 percent CI, -9.2 to 8.9). However, at 6 weeks, the mean MHQ summary score for internal fixation was greater than for external fixation by 19 (p < 0.001), pinning by 11 (p < 0.001), and casting by 7 (p = 0.03). Internal fixation participants demonstrated significantly better radiologic alignment throughout the follow-up period. Malunion was experienced by 48 percent of casting participants.

CONCLUSIONS

Recovery was fastest for internal fixation and slowest for external fixation according to most measures, but by 12 months there were no meaningful differences in outcomes. Casting participants experienced satisfactory results despite loss of radiologic alignment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Stable rates of operative treatment of distal radius fractures in Ontario, Canada: a population-based retrospective cohort study (2004–2013)

Background

Rates of surgical management of distal radius fractures are increasing internationally despite the higher cost and limited outcome evidence to support this shift. This study examines the epidemiology of distal radius fractures and asks if the same shift has occurred in Ontario, Canada (population 13.9 million).

Methods

This population-based, retrospective cohort study examined distal radius fractures in people aged 18 years and older over a 10-year period (2004–2013). The incidence analyses were based on the first occurrence of a fracture within a 2-year time period. The number of fractures, age-adjusted incidence rates and frequency of fracture treatment type by year were assessed. We used a Poisson regression with robust standard errors to determine if there was a statistically significant change in the frequency of fracture treatment type over time.

Results

There were 25 355 distal radius fractures among Ontarians 18 years of age and older in 2013. Between 2004 and 2013, the age-adjusted incidence rate for people 35 years of age and older was stable, between 2.32 and 2.70 per 1000 population. Rates of cast immobilization remained stable between 82% and 84%. Of those patients treated surgically, the rate of open reduction and internal fixation rose from 7% in 2004 to 13% in 2013 at the expense of other types of surgical management.

Conclusion

In Ontario, rates of cast immobilization are stable and there has been a movement toward open reduction and internal fixation among patients treated surgically.

Volar Plate Fixation in Adults with a Displaced Extra-Articular Distal Radial Fracture Is Cost-Effective

BACKGROUND

To our knowledge, a health economic evaluation of volar plate fixation compared with plaster immobilization in patients with a displaced extra-articular distal radial fracture has not been previously conducted.

METHODS

A cost-effectiveness analysis of a multicenter randomized controlled trial was performed. Ninety patients were randomly assigned to volar plate fixation or plaster immobilization. The use of resources per patient was documented prospectively for up to 12 months after randomization and included direct medical, direct non-medical, and indirect non-medical costs due to the distal radial fracture and the received treatment.

RESULTS

The mean quality-adjusted life-years (QALYs) at 12 months were higher in patients treated with volar plate fixation (mean QALY difference, 0.16 [bias-corrected and accelerated 95% confidence interval (CI), 0.07 to 0.27]). (The 95% CIs throughout are bias-corrected and accelerated.) In addition, the mean total costs per patient were lower in patients treated with volar plate fixation (mean difference, -$299 [95% CI, -$1,880 to $1,024]). The difference in costs per QALY was -$1,838 (95% CI, -$12,604 to $9,787), in favor of volar plate fixation. In a subgroup analysis of patients who had paid employment, the difference in costs per QALY favored volar plate fixation by -$7,459 (95% CI, -$23,919 to $3,233).

CONCLUSIONS

In adults with a displaced extra-articular distal radial fracture, volar plate fixation is a cost-effective intervention, especially in patients who had paid employment. Besides its better functional results, volar plate fixation is less expensive and provides a better quality of life than plaster immobilization.

LEVEL OF EVIDENCE

Economic Level I. See Instructions for Authors for a complete description of levels of evidence.

Outcomes and Complications in the Management of Distal Radial Fractures in the Elderly

BACKGROUND

The purpose of the present study was to identify trends in management and to compare the outcomes and complications following nonoperative and operative management (including external fixation, closed reduction and percutaneous pinning, and open reduction and internal fixation) for distal radial fractures in patients ≥65 years of age.

METHODS

We performed a retrospective analysis, with use of the OptumLabs Data Warehouse database, of patients ≥65 years of age who had been managed for a distal radial fracture between 2009 and 2014 (as indicated by diagnosis codes according to the International Classification of Diseases, Ninth Revision, Clinical Modification). Ninety-day and 1-year complication rates per 1,000 fractures were analyzed overall and by treatment modality.

RESULTS

Thirteen thousand, seven hundred and thirteen distal radial fractures were analyzed. The overall 90-day complication rate was 36.5 per 1,000 fractures, and the 1-year upper-extremity-specific complication rate was 236.2 and 307.5 per 1,000 fractures for nonoperative and operative management, respectively. Overall, post-injury stiffness was the most common 1-year upper-extremity-specific complication (incidence, 11.5%). There was no significant difference between operative and nonoperative management in terms of 90-day complication rates. However, operative management had a higher 1-year complication rate than nonoperative management (307.5 versus 236.2 per 1,000 fractures). Overall, the 5 most common upper-extremity-specific complications following operative treatment of distal radial fracture were stiffness (16.0%), chronic regional pain syndrome (9.9%), median neuropathy (8.0%), implant-related complications (3.8%), and tendon-related complications (2.8%). Stiffness was significantly more frequent following operative management (16.0% versus 9.8%; p < 0.01).

CONCLUSIONS

Operative management of a distal radial fracture should be carefully considered when discussing treatment options with patients ≥65 years of age.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Impact of Obesity and Smoking on Outcomes After Volar Plate Fixation of Distal Radius Fractures

PURPOSE

Distal radius fractures are common fractures of the upper extremity. Whereas surgical outcomes have been extensively investigated, the impact of risk factors such as body mass index (BMI) and smoking on patient outcomes has not been explored. We hypothesized that obesity and smoking would have a negative impact on the functional and radiographic outcomes of surgically treated patients with distal radius fractures.

METHODS

We performed a retrospective analysis of patients surgically treated for a distal radius fracture between 2006 and 2017 at 2 level 1 trauma centers. Patients were divided into obese (BMI ≥ 30) and nonobese (BMI < 30) groups according to the World Health Organization BMI Classification. Patients were also divided into current, former, and never smokers based on reported cigarette use. Primary outcomes included patient-reported outcome measures (Quick Disabilities of the Arm, Shoulder, and Hand [QuickDASH]), range of motion (ROM) arc (flexion-extension, pronation-supination), radiographic union (Radiographic Union Scoring System [RUSS] score), and change in radiographic alignment (radial height, radial inclination, volar tilt) between first and last follow-up. Multivariable models corrected for age, sex, comorbidities, fracture complexity, osteoporosis, and time to surgery.

RESULTS

Two hundred patients were identified, 39 with BMI of 30 or greater and 161 with BMI less than 30. Obese patients had more comorbidities but similar fracture types. At 3-month and 1-year follow-up, both groups achieved acceptable QuickDASH scores, close to those of the general population (21 vs 18, 14 vs 2, respectively). The 2 groups were similar in regard to motion, RUSS score, and alignment. There were 148 never smokers, 32 former smokers, and 20 current smokers. At 3 months, smokers demonstrated higher QuickDASH scores (42 vs 21-24) and a lower percentage of radiographically healed fractures (40% vs 69%-82%). At final follow-up, smokers reported small differences in patient-reported outcomes (QuickDASH 18 vs 9-13) whereas ROM, fracture healing, and complication rates were similar.

CONCLUSIONS

Both obese and nonobese patients can achieve excellent outcomes following surgical treatment of distal radius fracture with similar self-reported outcomes, motion, RUSS score, and alignment. Despite slower healing in the early postoperative period, smokers had similar QuickDASH scores, ROM, and union rates to past smokers and never smokers at final follow-up, with a similar complication profile.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The Complexity of Conducting a Multicenter Clinical Trial: Taking It to the Next Level Stipulated by the Federal Agencies

Randomized controlled trials are becoming increasingly difficult to organize and conduct efficiently. This, in turn, hinders the ability to derive the highest level of evidence. Often, investigators forget or remain unaware of essential practices that will help them fulfill their study goals. This article emphasizes the common issues that a study team experiences during the planning and conducting of randomized controlled trials. The authors sought to share remedies to overcome these issues with the experience garnered in conducting several multicenter clinical trials and observational studies. In addition, the authors list resources from sponsors such as the National Institutes of Health and the U.S. Food and Drug Administration that study teams can apply to undertake studies effectively.

Trends in the management of fractures of the distal radius in Ireland

Aims

The aim of this study was to examine trends in the management of fractures of the distal radius in Ireland over a ten-year period, and to determine if there were any changes in response to the English Distal Radius Acute Fracture Fixation Trial (DRAFFT).

Patients and Methods

Data was grouped into annual intervals from 2008 to 2017. All adult inpatient episodes that involved emergency surgery for fractures of the distal radius were included

Results

In 2008 Kirschner-wire (K-wire) fixation accounted for 59% of operations for fractures of the distal radius, and plate fixation for 21%. In 2017, the rate of K-wire fixation had fallen to 30%, and the proportion of patients who underwent plate fixation had risen to 62%.

Conclusion

There is an increasing trend towards open reduction and internal fixation for fractures of the distal radius in Ireland. This has been accompanied by a decrease in popularity for K-wire fixation. DRAFFT did not appear to influence trends in the management of fractures of the distal radius in Ireland. Cite this article: Bone Joint J 2019;101-B:1550–1556

A retrospective analysis of the number of therapy visits after distal radius fractures using a new provider-scored clinical severity scale

STUDY DESIGN

Retrospective study.

INTRODUCTION

Fractures of the distal radius are common as is a postfracture referral to occupational therapy (OT). This article examines factors that cause greater morbidity and a greater number of OT visits.

PURPOSE OF THE STUDY

This study aims to analyze which of 5 common sequelae of the distal radius fracture is most significant for increasing the number of therapy visits.

METHODS

Three-hundred Sixty charts were reviewed, and 89 were selected. Multiple regression was used to determine which of our 5 independent variables had the greatest predictive power for the total number of therapy visits.

RESULTS

The regression model demonstrated significance at P ≤ .01. Total active motion (TAM) of the digits (P ≤ .01) and TAM of the forearm (P ≤ .01) were the only complications that demonstrated statistical significance and a positive relationship with the number of therapy visits. In addition to this, TAM of the forearm and digits showed a strong correlation with the number of therapy visits. TAM of the wrist, pain, and edema had a weak correlation. Patients with high total group score on the clinical severity scale also had a moderate correlation.

DISCUSSION

The results of the study illustrate the importance of digital contractures on a patient's morbidity, function, and their need for OT visits.

CONCLUSION

The information from this study is important for the clinician as it identifies patients at risk for increased morbidity and identifies the complications that the clinician may want to stress early in the rehabilitation of that patient.

LEVEL OF EVIDENCE

3.

Adhering to Radiographic Clinical Practice Guidelines for Distal Radial Fracture Management Is Associated with Improved Outcomes and Lower Costs

BACKGROUND

The American Academy of Orthopaedic Surgeons Clinical Practice Guideline on the Treatment of Distal Radius Fractures has not been evaluated in clinical practice. We hypothesized that adhering to the distal radial fracture radiographic clinical practice guideline (CPG) improves outcomes and reduces costs.

METHODS

We reviewed 266 patients with distal radial fractures treated at 1 institution. Based on CPG radiographic parameters (Recommendation 3), care was rated as "appropriate" or "inappropriate." QuickDASH (an abbreviated version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) scores were collected. The direct costs of distal radial fracture care were determined. Descriptive statistics and nonparametric tests were used to evaluate demographic characteristics and outcomes across groups. QuickDASH scores, grouped by postoperative time interval, were analyzed using linear mixed effect models to predict outcome trends.

RESULTS

In this study, 145 patients in the operative treatment group and 121 patients in the nonoperative treatment group were included. Of the 145 patients in the operative treatment group, 6 underwent an inappropriate surgical procedure, limiting any analyses of that group. Of the 121 patients in the nonoperative treatment group, 68 were treated inappropriately. For the patients in the nonoperative treatment group, appropriate care provided a significant outcome benefit by 1 year; the median QuickDASH score was 10.1 points for the appropriate treatment group and 19.5 points for the inappropriate treatment group (p = 0.05). The total direct costs for inappropriate nonoperative treatment were, on average, 60% higher than appropriate nonoperative treatment. In predictive models, patients with appropriate care in the operative treatment group and the nonoperative treatment group had better outcomes than patients with inappropriate nonoperative treatment at all time points after 29 days.

CONCLUSIONS

When nonoperative distal radial fracture management was aligned with radiographic CPG criteria, patients in our cohort had improved patient-reported outcomes with lower costs.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Depression affects the recovery trajectories of patients with distal radius fractures: A latent growth curve analysis

BACKGROUND

Distal radius fractures (DRFs) are common and can lead to substantial pain and disability. Most people recover in six months, but some experience persistent pain and disability for one year or longer after injury. Therefore, it is important to understand the factors that can help predict poor recovery.

OBJECTIVE

To identify recovery trajectories in DRF patients and to determine the factors that can help predict poor recovery.

METHODS

Recovery was assessed in 318 patients using the Patient-Rated Wrist Evaluation scale at baseline, three, six, and 12 months. Demographic information was collected in addition to the Self-Administered Comorbidity Questionnaire, from which data regarding depression were extracted. Latent growth curve analysis (LGCA) was used to identify the recovery trajectories. Comparisons of proportion between the emergent classes were then conducted using chi-square and Kruskal-Wallis tests.

RESULTS

The LGCA revealed three distinct trajectories (rapid-recovery: (69%), slow-recovery: (23%), and non-recovery: (8%) as the best fit to the data. The proportion of people with depression was significantly greater in the non-recovery class (24%) compared to the slow (16%, p = 0.04) and rapid-recovery (8%, p = 0.03) classes. Additionally, the proportion of females were significantly lower in the non-recovery (64%, p = 0.03) compared to the slow (85%, p = 0.03) and the rapid-recovery classes (81%, p = 0.048).

CONCLUSION

Recovery from DRF was best described using three different trajectories. Greater self-reported depression and a lower proportion of females in the non-recovery class were distinguishing factors between the classes. Patients who appear to be in slow-recovery or non-recovery classes may be followed more closely.

Impact of Design on Force between Flexor Tendons and Distal Radius Volar Plates

Background  Flexor tendon injury is a rare but serious complication of distal radius volar plating. Purpose  This study aims to determine whether the design of distal radius volar plates impacts the amount of force exerted on the flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) tendons when the plates are placed proximal and distal to the watershed line. Methods  Three commercially available plates were applied to 10 fresh, matched-pair upper extremity specimens. Cyclical loading was applied to the tendons, and the force generated between tendon and plate was measured. Linear mixed effect models were used to evaluate differences in maximum and mean forces by plate position, plate design, and the interaction between position and design. Results  Forces on the tendons differed significantly by position but not plate design. For the FPL tendon, the average maximum force with a plate in Soong's grade 2 was 4.50 (95% confidence interval [CI]: 2.8-7.3) times higher than when the plate was in a Soong's grade 0 placement, and 4.63 (95% CI: 2.82-7.61) times higher for the FDP tendon. While not statistically significant, lower observed force values with thinner plates when plates were placed distal to the watershed line suggest that that plate thickness could also be a critical plate characteristic for distally placed plates. Conclusion  Despite differences in plate design, the main determinant of plate prominence and therefore flexor tendon injury potential is placement in relation to the watershed line. Clinical Relevance  This study may help to guide surgeon implant selection and volar plate design.

Use of Decision Analysis and Economic Evaluation in Upper Extremity Surgery: A Systematic Review

BACKGROUND

Decision analysis allows clinicians to apply evidence-based medicine to guide objective decisions in uncertain scenarios. There is no comprehensive review summarizing the various decision analysis tools used. The authors aimed to appraise and review the decision analytic models used in hand surgery.

METHODS

A search of English articles on the PubMed, Ovid, and Embase databases was performed. All articles, regardless of date of publishing, were considered. Two reviewers, based on strict inclusion criteria, independently assessed each article.

RESULTS

The search resulted in 5525 abstracts, which yielded 30 studies that met inclusion criteria. Included studies were grouped according to medical indications, with scaphoid fractures (n = 6) and carpal tunnel syndrome (n = 5) being the most commonly reported. Included articles used decision analysis (n = 15) and/or economic analyses (n = 23) to discuss diagnostic strategies or compare treatments. The three most common outcomes reported were utility (n = 12), cost per quality-adjusted life-year (n = 16), and quality-adjusted life-years (n = 16). The decision analysis models compared diagnostic strategies, management options, and novel treatments.

CONCLUSIONS

Decision analysis is increasingly popular in hand surgery. It is useful for comparing surgical strategies through evaluation of quality-of-life outcomes and costing data. The most common model was a simple decision tree. The quality of decision analysis models can be improved with the addition of sensitivity analysis. Surgeons should be familiar with the principles of decision analysis, so that complex decisions can be evaluated using rigorous probabilistic models that combine risks and benefits of multiple strategies.

A protocol for a single-center, single-blinded randomized-controlled trial investigating volar plating versus conservative treatment of unstable distal radius fractures in patients older than 65 years

BACKGROUND

Distal radius fractures (DRF) are very common in elderly patients, who present at the Emergency Department. Surgical treatment with open reduction and internal fixation using volar locking plates is widely prevalent despite the lack of evidence proving its superiority to conservative treatment with closed reduction and plaster immobilization. The purpose of this study is to investigate whether conservative treatment is superior to volar plating in terms of number of complications and results in a comparable or superior functional outcome in patients ≥65 years.

METHODS

In this single-center, single-blinded randomized-controlled trial, patients ≥65 years with distal radius fractures will be invited to participate. A total of 50 patients per treatment arm is required to provide 80% statistical power at a 5% alpha level assuming a difference of 20% in complication rate between operatively and conservatively treated patients. Primary outcome measures will be complication rate, Quick DASH score (Quick Disabilities of the Arm, Shoulder and Hand), PRWE (Patient rated Wrist evaluation), and range of motion of the wrist. Secondary outcome measures will be grip strength, pinch gauge, pain, use of pain medication EQ5D score (European Quality of life - 5 dimensions), standardized radiographs. One year of follow-up is planned with data collection at the day of injury, after 2 weeks, after 5 weeks, after 6 months, and after 12 months. An intention-totreat and per-protocol analysis will be performed.

DISCUSSION

This prospective trial helps to clarify the best treatment strategy for displaced DRF patients ≥65 years.

TRIAL REGISTRATION

This trial is approved by the Danish Scientific Ethical Committee (ID: 1-10-72-420-17) and registered at Clinicaltrials.gov (Trial registration number NCT03716661 ).

Treatment of radius or ulna fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and current practice

Background

The objective of the present study was to evaluate effectiveness, complications and cost-effectiveness of any surgical or non-surgical treatment for radius or ulna fractures in elderly patients. Secondary objectives were to analyze present treatment traditions of distal radius fractures (DRF) in Sweden and to calculate resource usage for its treatment.

Methods and findings

The assessment contains a systematic review of clinical and health economic studies comparing treatment options for radius or ulna fractures. The results regarding the effectiveness of the treatments are summarized in meta-analyses. In addition, the assessment contains a cost analysis for different treatment options commonly used for DRF care, and an analysis of registry data on the incidence and treatment of DRF. In total 31 randomized controlled trials were included in meta-analyses. When comparing functional outcome for plate fixation versus non-surgical treatment for DRF, there were no clinically important differences at one-year follow-up (mean difference [MD], -3.29, 95% CI, -7.03; 0.44). Similar results were found when comparing plating and percutaneous methods with respect to functional outcome (standardized mean difference [SMD], -0.07, 95% CI, -0.21; 0.07) and grip strength (MD, -3.47, 95% CI, -11.21; 4.28). There were no differences for minor complications, (risk difference [RD], -0.01, 95% CI, -0.07; 0.05) whereas major complications were less common for the percutaneous group, (RD, 0.02, 95% CI, 0.02; 0.03). Given the low number of studies, the evidence above was rated as moderate certainty. The cost for plate fixation versus plaster cast was estimated to 1698 compared to 137 US dollars. For DRF, plate fixation increased in Sweden between 2005 and 2013, and was the most common surgical method in 2013.

Conclusions

Surgical treatment of moderately displaced distal radius fractures in elderly patients offers no clear benefit compared to non-surgical treatment. Plating procedures have become more common during the second millennium and involve higher costs and higher risk of major complications than percutaneous options.

Considerations in the Treatment of Osteoporotic Distal Radius Fractures in Elderly Patients

PURPOSE OF REVIEW

With the incidence of distal radius fractures increasing in the elderly population, we sought to summarize the current orthopedic and medical management of these fractures in the elderly osteoporotic population.

RECENT FINDINGS

The number of osteoporotic patients undergoing surgical fixation for distal radius fractures has increased in recent years. This is likely due to the improved outcomes seen with volar locking plates, as well as an increase in the number of fellowship-trained hand surgeons. Despite this potential improvement in acute fracture management, a majority of these patients are underdiagnosed and undertreated for their underlying osteoporosis or endocrinopathies. The implementation of fracture liaison services and the ability of the treating orthopedist to recognize this gap in patient care result in a higher number of patients initiating appropriate treatment. It is vital that when discussing acute fracture management, a thorough discussion is had with patients regarding functional outcome and the benefits of both surgical and non-operative management. As these fractures become more prevalent and a greater percentage undergo surgical intervention, the economic burden of distal radius fractures will continue to rise. It is imperative that the treating surgeon view these fractures as sentinel events that are predictive of future hip and vertebral fractures. While relatively new, the use of fracture liaison services to help aide in proper screening and treatment of osteoporotic patients is of great value. Non-pharmacologic therapy such as physical therapy, smoking and alcohol cessation programs, and dietary modifications are crucial in treating patients with osteoporosis. While bisphosphonates remain the first-line treatment in patients with osteoporosis, novel therapies show promise for future use.

Older Patient Preferences for Internal Fixation after a Distal Radius Fracture: A Qualitative Study from the Wrist and Radius Injury Surgical Trial

BACKGROUND

Distal radius fracture treatments provide similar functional outcomes. It has been hypothesized that the use of internal fixation is increasing because of physician preferences. The multisite randomized Wrist and Radius Injury Surgical Trial provides a unique opportunity to examine patient preferences in the absence of surgeon influence. The authors' objective was to investigate patient preference for internal fixation even after being informed of the equipoise among treatments.

METHODS

The authors performed 30 semistructured interviews with older individuals, all older than 60 years, approached at their institution for the Wrist and Radius Injury Surgical Trial. The authors' sample included three groups: those with a preference for internal fixation (n = 11), those with preference for nonsurgical treatment (n = 6), and those without a preference who consented to surgical randomization (n = 13). We used grounded theory for data collection and analysis.

RESULTS

All participants indicated their chief concern was regaining full function. Patients based their preferences for internal fixation on multiple values, including obstacles to recovery, autonomy, aesthetics, and pain relief. Some patients who did not select internal fixation reflected on their experiences, questioning whether they would have had a potentially different outcome with internal fixation treatment.

CONCLUSIONS

Without evidence for a superior treatment, patients focus on factors that pertain to recovery rather than outcomes, with most preferring the volar locking plating system. To best align with patient values, physicians should focus their discussion with patients on aspects of the recovery period rather than functional outcomes. Evidence from the Wrist and Radius Injury Surgical Trial will provide high-level information about patient-reported, functional, and radiographic outcomes.

Distal Radius Fractures: Evaluation of Closed Reduction and Percutaneous Kirschner Wire Pinning

Objective Closed reduction and percutaneous pinning (CRPP) is losing popularity as a treatment modality for distal radius fractures. However, in select cases, CRPP may have advantages relative to open reduction and internal reduction. We aimed to retrospectively assess the outcomes after CRPP for the treatment of distal radius fractures. Study Design This is a retrospective cohort study. Methods We used billing records to identify all skeletally mature patients with a distal radius fracture who were treated with CRPP by a single surgeon at a level I trauma center in an urban city in the United States. We assessed the medical charts and recorded demographics, trauma and treatment characteristics, radiographic characteristics, and outcomes. Results All patients had a good or excellent range of motion regarding forearm rotation, and almost 80% had good or excellent range of motion regarding flexion or extension of their wrist. One patient had a concern for pin tract infection, and one had subcutaneous migration of a pin, which were both treated by pin removal. Conclusion CRPP is a good option in patients with few and sizeable fracture fragments in patients with a distal radius fracture, and it should be considered as an effective tool to restore radiographic parameters and functional outcomes.

Cost-utility studies in upper limb orthopaedic surgery: a systematic review of published literature

AIMS

The aim of this study was to assess the quality and scope of the current cost-effectiveness analysis (CEA) literature in the field of hand and upper limb orthopaedic surgery.

MATERIALS AND METHODS

We conducted a systematic review of MEDLINE and the CEA Registry to identify CEAs that were conducted on or after 1 January 1997, that studied a procedure pertaining to the field of hand and upper extremity surgery, that were clinical studies, and that reported outcomes in terms of quality-adjusted life-years. We identified a total of 33 studies that met our inclusion criteria. The quality of these studies was assessed using the Quality of Health Economic Analysis (QHES) scale.

RESULTS

The mean total QHES score was 82 (high-quality). Over time, a greater proportion of these studies have demonstrated poorer QHES quality (scores < 75). Lower-scoring studies demonstrated several deficits, including failures in identifying reference perspectives, incorporating comparators and sensitivity analyses, discounting costs and utilities, and disclosing funding.

CONCLUSION

It will be important to monitor the ongoing quality of CEA studies in orthopaedics and ensure standards of reporting and comparability in accordance with Second Panel recommendations. Cite this article: Bone Joint J 2018;100-B:1416-23.

Distal Radius Fractures in the Elderly: Use of the Volar Bearing Plate

BACKGROUND

Distal radius fractures represent some of the most common injuries to the upper extremity, yet current evidence demonstrates great variability in the management of this injury. Elderly patients, in particular, stand to benefit from the early mobilization provided by operative fixation with a volar bearing plate.

METHODS

We conducted a retrospective chart review on all patients 65 years or older who underwent unilateral open reduction internal fixation of distal radius fractures using a volar bearing plate at a single institution between January 2014 and January 2016. We excluded patients with bilateral injuries, multiple fractures, and major injuries to the same extremity.

RESULTS

Fifty-five patients met criteria for this study. By AO classification, we repaired 17 type A, 24 type B, and 14 type C fractures. At final radiographic measurements, average radial height compared with ulna measured -0.31 mm, average radial inclination measured 20.45 degrees, and average volar tilt measured 7.11 degrees. On discharge, 36 patients had wrist range-of-motion data consistent with a functional wrist. Four patients had limitations in the flexion/extension plane, 8 with radial-ulnar deviation, and 7 had limitations in both planes.

CONCLUSIONS

Distal radius fractures in the elderly may successfully be treated with a volar bearing plate. Useful strategies include supraperiosteal dissection of the radius from the pronator quadratus, use of a longer plate for stronger proximal fixation in osteoporotic bone, and regional block. This methodology allows for a safe procedure facilitating the early return of hand and wrist function.

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Surgical Management of Distal Radius Fractures

PURPOSE

Compared with cast treatment, surgery may expose patients with distal radius fractures to undue risk. Surgical intervention in this cohort may offer less benefit than previously thought and appropriate patient selection is imperative. The modified Frailty Index (mFI) predicts complications after other orthopedic surgeries. We hypothesized that this index would predict, and might ultimately prevent, complications in patients older than 50 years with distal radius fractures.

METHODS

We retrospectively reviewed the American College of Surgeons-National Surgery Quality Improvement Program (ACS-NSQIP) database, including patients older than 50 years who underwent open reduction and internal fixation of a distal radius fracture. A 5-item mFI score was then calculated for each patient. Postoperative complications, readmission and reoperation rates, as well as length of stay (LOS) were recorded. Bivariate and multivariable statistical analysis was then performed.

RESULTS

We identified 6,494 patients (mean age, 65 years). Compared with patients with mFI of 0, patients with mFI of 2 or greater were nearly 2.5 times as likely to incur a postoperative complication (1.7% vs 7.4%). Specifically, the rates of Clavien-Dindo IV, wound, cardiac, and renal complications were increased significantly in patients with mFI of 2 or greater. In addition, as mFI increased from 0 to 2 or greater, 30-day reoperation rate increased from 0.8% to 2.4%, 30-day readmission from 0.8% to 4.6%, and LOS from 0.5 days to 1.44 days. Frailty was associated with increased complications as well as rates of readmission and reoperation even when controlling for demographic data, LOS, and operative time. Age alone was not significantly associated with postoperative complications, readmission, reoperation, or LOS.

CONCLUSIONS

A state of frailty is highly predictive of postoperative complications, readmission, reoperation, and increased LOS following open reduction and internal fixation of distal radius fractures. Our data suggest that a simple frailty evaluation can help inform surgical decision making in patients older than 50 years with distal radius fractures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Cost of Surgical Treatment for Distal Radius Fractures and the Implications of Episode-Based Bundled Payments

PURPOSE

To examine the cost of care of surgical treatment for a distal radius fracture (DRF) and develop episodes that may be used to develop future bundled payment programs.

METHODS

Using 2009 to 2015 claims data from the Truven MarketScan Databases, we examined the cost of care for surgical treatment of DRFs among adult patients in the United States. We excluded patients with concurrent fractures, patients who required complex care, and patients in assisted living facilities. We extracted data on cost and type of services provided to eligible patients, tracking patients from 3 days prior to operation to 90 days after operation. From these data, we developed 4 episode-of-care scenarios to develop an estimated bundled payment. We computed the variation in cost between surgery types, time periods, and type of service provided.

RESULTS

Our final sample included 23,453 DRF operations, of which 15% were performed on patients 65 years of age or older. The majority (88%) underwent open fixation, the option associated with the highest cost. The average cost of care for a DRF patient ranged from $6,577 to $8,181 depending on the definition of an episode-of-care. Regardless of definition, the variation in cost was high. The cost of surgery itself composed 61% to 91% of the total cost of an episode. Of claims not directly related to the surgery, anesthesia and drugs, imaging, and therapy costs composed the next greatest proportions of the total cost of care.

CONCLUSIONS

Many DRF surgical episodes incur substantially higher costs than the average. To maximize cost reduction, bundled payments for DRFs are best designed with a clinically narrow definition that is limited to services related to the fracture and long enough to capture relevant postoperative therapy and imaging costs.

CLINICAL RELEVANCE

This study provides insight on spending to lay the foundation for shifting reimbursement strategies.

Comparison of Direct Perioperative Costs in Treatment of Unstable Distal Radial Fractures: Open Reduction and Internal Fixation Versus Closed Reduction and Percutaneous Pinning

BACKGROUND

As the United States transitions to value-based insurance, bundled payments, and capitated models, it is paramount to understand health-care costs and resource utilization. The financial implications of open reduction and internal fixation (ORIF) with a volar locking plate for management of unstable distal radial fractures have not been established. We aimed to elucidate cost differences between ORIF and closed reduction and percutaneous pinning (CRPP). Our hypothesis was that ORIF has greater direct perioperative costs than CRPP but that the costs equilibrate over time.

METHODS

We reviewed financial data for 40 patients prospectively enrolled and randomized to undergo CRPP or ORIF for treatment of a closed, displaced, unstable distal radial fracture. Clinical and functional outcomes, hospital-associated direct perioperative costs, postoperative care and therapy costs, and costs for additional procedures were compared. Cost data were stratified into perioperative, 90-day, and 1-year periods, and were reported utilizing cost ratios (CRs) relative to the CRPP cohort. Statistical analysis was performed with chi-square and independent-samples t tests with an alpha level of <0.05.

RESULTS

Seventeen patients underwent CRPP and 23 underwent ORIF with a volar plate. Patients who underwent ORIF incurred greater 90-day (CR = 2.03/1.0, p < 0.001) and 1-year (CR = 1.60/1.0, p < 0.001) direct costs than those who underwent CRPP. The differential was greatest in the immediate perioperative period and gradually decreased over time. Operating room fees (CR = 1.7/1.0, p < 0.001), operating room implants, anesthesia (CR = 1.8/1.0, p < 0.001), and total perioperative costs (CR = 2.7/1.0, p < 0.001) were significantly greater in the ORIF cohort. Rehabilitation and cast technician costs were comparable (CR = 0.9/1.0 [ORIF/CRPP], p = 0.69). At 1 year, the CR for all costs of decreased to 1.6/1.0 (ORIF/CRPP, p < 0.001). Compared with the CRPP cohort, the ORIF cohort demonstrated significantly better functional outcomes at 6, 9, and 12 weeks and similar outcomes at 1 year.

CONCLUSIONS

ORIF for a displaced, unstable distal radial fracture incurred greater direct costs than CRPP. Although implant costs for ORIF provided the greatest cost differential, additional procedures and higher clinic costs in the CRPP cohort narrowed the 90-day and 1-year cost gaps.

LEVEL OF EVIDENCE

Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Nordic Innovative Trial to Evaluate OsteoPorotic Fractures (NITEP-group): non-operative treatment versus surgery with volar locking plate in the treatment of distal radius fracture in patients aged 65 and over - a study protocol for a prospective, randomized controlled trial

BACKGROUND

In the literature, there are numerous studies that compare different surgical procedures in the treatment of distal radius fractures (DRF). It is, however, unknown whether operative treatment and better restoration of anatomy with volar locking plate yields a better functional outcome in the elderly population when compared with non-operative treatment.

METHODS AND DESIGN

This study is a prospective, randomized, controlled, multi-center trial. The purpose will be to compare the non-operative and operative treatment of initially or early malaligned distal radius fractures in patients aged 65 and older. The primary outcome in this study will be the patient rated wrist evaluation (PRWE) score measured after 1 and 2 years.

DISCUSSION

We expect that initial operative treatment of a DRF with volar locking plate will not yield superior results when compared with non-operative treatment with cast immobilization in terms of functional outcome, pain, disability, quality of life, grip strength, and number of complications.

TRIAL REGISTRATION

This trial is registered on clinicaltrials.gov , identifier NCT02879656 , registration date 08/17/2016.

Cost-utility analysis in orthopaedic trauma; what pays? A systematic review

BACKGROUND

As healthcare systems come under ever-increasing pressure to provide more care with fewer resources, emphasis is being placed on value-based systems that maximise quality and minimize cost. The aim of this study was to determine which interventions in fracture care have been demonstrated to be cost effective.

METHODS

A systemic review of cost-utility studies on the management of fractures from 1976 to 2015 was carried out using a search of the Cost-Effectiveness Analysis Registry, National Health Service Economic Evaluation Database (NHS EED) and MEDLINE.

RESULTS

20 studies were included with 15 (75%) studies assessing interventions in lower limb trauma and 8 (25%) studies assessing interventions in upper limb trauma. 50% of studies used a decision tree model and 50% used collected data alongside a randomised clinical trial. Interventions which were shown to be cost effective in lower limb trauma were total hip replacement in displaced femoral neck fractures, the SHS in stable (A1 and A2) fractures and IM nailing for unstable (A3) fractures, salvage treatment for grade IIIB and IIIC open tibial fractures and operative treatment of ankle and calcaneal fractures. For systems-based strategies, there is evidence demonstrating cost effectiveness to treating hip fractures in high volume centres and to having resources in place to facilitate fractures being treated within 48 h of injury. In upper limb trauma there was evidence showing operative treatment of displaced proximal humerus fractures to be neither clinically nor cost effective. There was evidence supporting the operative treatment of non-displaced scaphoid fractures. Overall the quality of the studies was poor with only 50% (10) of studies able to make a treatment recommendation. Reasons for this included poor quality primary source data and poor reporting methodological practices.

CONCLUSION

Certain aspects of fracture management have been shown to be cost effective. However, there is a paucity of evidence in this area and further research is required so that value-based interventions are chosen by healthcare providers engaged in orthopaedic trauma care.

Conservative treatment of distal fractures after the age of 65: a review of literature

The goal of this study was to evaluate the role of conservative treatment of distal radius fractures in the elderly since 2000. Our series included 22 articles, of which 3 reviews, 2 meta-analyses, 6 descriptive series of conservative treatment, 10 series comparing surgical and conservative treatments and 1 series comparing different types of conservative treatments. The reduction was performed by closed reduction in 7 cases and by traction in 3 cases. A short-arm cast was used in 8 cases and a long-arm cast in 4 cases for an average length of 6 weeks. The indications of conservative treatment were varied: AO type A fractures in 2 cases, type C fractures in 1 case, types A and C in 8 cases and types A, B and C in 3 cases. No article reported any significant difference between surgical and conservative treatments in terms of DASH or PRWE, whereas strength was sometimes improved when surgical treatment was used. Radiological results were always better after surgical treatment. The rate of complications varied greatly, greater, equally or lower compared to conservative treatment depending on the series. All in all, there is no consensus to assert that a conservative treatment is more justified than a surgical treatment to treat distal radius fractures after the age of 65. Most authors consider that the long-term clinical outcome is identical and that the radiological result is better after surgical treatment. The fact that the fixation of a distal radius fracture by a volar locking plate after 65 years speeds up the recovery remains to be proven.

The Cost-Effectiveness of Surgical Fixation of Distal Radial Fractures: A Computer Model-Based Evaluation of Three Operative Modalities

BACKGROUND

There is no consensus on the optimal fixation method for patients who require a surgical procedure for distal radial fractures. We used cost-effectiveness analyses to determine which of 3 modalities offers the best value: closed reduction and percutaneous pinning, open reduction and internal fixation, or external fixation.

METHODS

We developed a Markov model that projected short-term and long-term health benefits and costs in patients undergoing a surgical procedure for a distal radial fracture. Simulations began at the patient age of 50 years and were run over the patient's lifetime. The analysis was conducted from health-care payer and societal perspectives. We estimated transition probabilities and quality-of-life values from the literature and determined costs from Medicare reimbursement schedules in 2016 U.S. dollars. Suboptimal postoperative outcomes were determined by rates of reduction loss (4% for closed reduction and percutaneous pinning, 1% for open reduction and internal fixation, and 11% for external fixation) and rates of orthopaedic complications. Procedural costs were $7,638 for closed reduction and percutaneous pinning, $10,170 for open reduction and internal fixation, and $9,886 for external fixation. Outputs were total costs and quality-adjusted life-years (QALYs), discounted at 3% per year. We considered willingness-to-pay thresholds of $50,000 and $100,000. We conducted deterministic and probabilistic sensitivity analyses to evaluate the impact of data uncertainty.

RESULTS

From the health-care payer perspective, closed reduction and percutaneous pinning dominated (i.e., produced greater QALYs at lower costs than) open reduction and internal fixation and dominated external fixation. From the societal perspective, the incremental cost-effectiveness ratio for closed reduction and percutaneous pinning compared with open reduction and internal fixation was $21,058 per QALY and external fixation was dominated. In probabilistic sensitivity analysis, open reduction and internal fixation was cost-effective roughly 50% of the time compared with roughly 45% for closed reduction and percutaneous pinning.

CONCLUSIONS

When considering data uncertainty, there is only a 5% to 10% difference in the frequency of probability combinations that find open reduction and internal fixation to be more cost-effective. The current degree of uncertainty in the data produces difficulty in distinguishing either strategy as being more cost-effective overall and thus it may be left to surgeon and patient shared decision-making.

LEVEL OF EVIDENCE

Economic Level III. See Instructions for Authors for a complete description of levels of evidence.

Volar Plate Fixation in Patients Older Than 70 Years with AO Type C Distal Radial Fractures: Clinical and Radiologic Outcomes

Introduction  Treatment of unstable distal radial fractures (DRFs) in elderly patients is controversial, and considering the increasing life expectancy, their appropriate treatment is of growing importance. Our aim was to analyze the clinical and radiologic outcomes in the elderly patients with AO type C DRF treated with volar locking plate (VLP). Materials and Methods  Between 2007 and 2011, 572 DRFs were operated on in our hospital with open reduction and internal fixation with VLP. Of these, only 64 patients (66 DRFs) met the selection criteria (AO type C DRF, age > 70 years, minimum 12-month follow-up). Mean follow-up was 28 months. Outcome assessment included range of motion, grip strength, VAS pain, Mayo Clinic Score, and DASH score. Analysis of pre- and postoperative radiographs was performed. Complications were recorded. Statistical analysis was performed comparing the results with the contralateral side. Results  Mean postoperative range of motion of the injured wrist compared with the control contralateral side was 86% for flexion ( p  < 0.001), 92% for extension ( p  < 0.001). The average DASH was 12. Mayo Clinic Wrist Score showed 43 excellent results, 15 good, 4 satisfactory, and 4 poor. Articular step-offs were reduced in 34 of 38 wrists. Five (7%) patients required plate removal. Conclusion  The treatment of articular DRF (AO type C) with VLP in the elderly patients achieved greater than 90% of the wrist range of motion and grip strength with no residual pain in greater than 90% of the patients. Level of Evidence  Therapeutic IV, case series.

Epidemiology and time trends of distal forearm fractures in adults - a study of 11.2 million person-years in Sweden

Background

A distal forearm fracture is a very common injury causing both suffering and substantial health care costs. The incidence of this fracture type seemed to increase worldwide until the middle 1980’s, but thereafter most reports have shown stable or decreasing rates. As few large studies have been presented lately we aimed to describe recent epidemiology and time trends of distal forearm fractures in adults. We paid special attention to fractures in working ages as they present challenges in terms of treatment and costs for sick-leave, and have not previously been thoroughly investigated.

Methods

By use of population data from Statistics Sweden and official in- and out-patient register data of men and women (≥17 years) in Sweden (Skåne region), we ascertained distal forearm fractures and estimated age- and sex-specific rates and time-trends from year 1999 to 2010 (11.2 million person-years (py)).

Results

The total incidence rate was 278 per 100,000 py (31,233 fractures) with 23% higher annual numbers 2010 compared with 1999. An increase in the annual age standardized incidence was found in men, +0.7% per annum (95% confidence interval (CI) 0.1, 1.4), and women, +0.9% (95% CI 0.5, 1.3), driven mainly by an increasing incidence in working ages (17–64 years). Also, expected demographic changes including a 25% population increase may result in 38% more fractures until 2050, compared to 2017.

Conclusions

The incidence of distal forearm fractures in adults in southern Sweden is increasing, mainly driven by an increase in working ages. In combination with expected demographic changes these findings may present substantial challenges for the future.

Supervised physical therapy vs home exercise program for patients with distal radius fracture: A single-blind randomized clinical study

STUDY DESIGN

Randomized clinical study.

INTRODUCTION

Supervised physical therapy (PT) and home exercise programs (HEPs) are frequently used in the rehabilitation of patients with distal radius fracture (DRF). However, there is no consensus as to whether unsupervised HEP provides comparable benefits to those achieved by supervised PT.

PURPOSE OF THE STUDY

To compare the improvements in pain and functional status between a supervised PT program and unsupervised HEP in DRF patients older than 60 years.

METHODS

A total of 74 patients were randomized into 2 groups. One group received 12 sessions of supervised PT (n = 37), and the other group followed an exercise program at home (n = 37). Three evaluations were performed, before the initiation of treatment, at 6-week, and 6-month follow-up. The study conducted a statistical power analysis to detect an intergroup difference score of 15 points on the Patient-Rated Wrist Evaluation (PRWE). The t-test or Mann-Whitney test was used, and it was set with a significance level of .05.

RESULTS

The supervised PT group showed clinically significant differences in the total PRWE score at 6 weeks (17.67 points, P = .000) in the PRWE function score (15.2 points, P = .000) and in the PRWE pain score (5.6 points, P = .039). There was also a significant difference in the total PRWE score at 6-month follow-up (17.05 points, P = .000) in the PRWE function score (14.5 points, P = .000) and in the PRWE pain score (2.5 points, P = .35).

CONCLUSIONS

A supervised PT program is more effective for improving function in the short- and medium-term when compared with HEP in patients older than 60 years with DRF extraarticular without immediate complications.

LEVEL OF EVIDENCE

1b.