Predicting radiographic changes at the first visit following operative repair of distal radius fractures

Efficacy of post-operative X-rays after operatively treated ankle fractures: What is their role?

OBJECTIVE

The utility of routine post-operative imaging in clinically asymptomatic patients is unclear. We sought to determine how frequently X-rays following operatively treated ankle fractures result in a change in management.

DESIGN

Retrospective cohort study conducted with hospital electronic health record SETTING: Single level 1 trauma center in major urban city.

PATIENTS/PARTICIPANTS

193 patients with operatively treated ankle fractures at our institution between January 2020 and December 2021.

MAIN OUTCOME MEASURES

Patient radiographs were categorized as surveillance X-rays and clinically indicated X-rays. Changes in management were defined as alteration in follow-up, deviation from standard post-operative protocols, or revision surgery. A logistic regression was performed looking at factors predicting whether an X-ray changes management. A cost analysis was also performed looking at the financial implications of asymptomatic surveillance of ankle fractures.

RESULTS

438 post-operative X-rays were found and included in analysis. Of these, 391 were considered surveillance X-rays and 47 clinically indicated. 23 X-rays were determined to have resulted in changes in management (18 clinically indicated, 5 taken in asymptomatic patients). The number of management changing X-rays was significantly higher in the clinically indicated group (p < 0.0001). The only factor associated with whether an X-ray changed management was whether the patient was symptomatic at the visit (p < 0.0001). Asymptomatic surveillance X-rays cost our institution 21,825.62 USD per year.

CONCLUSIONS

Radiographs in clinically asymptomatic patients with operatively managed ankle fractures have a low likelihood of changing management. Such imaging represents costs to the healthcare system, increased time for patients during clinic visits, and radiation exposure. The use of screening radiographic studies remains commonplace because the risk of delayed diagnosis is great, and the goal of any surgeon should be the swift identification of complications in order to minimize patient morbidity. Future surveillance protocols should consider the findings of this and other studies on the use of screening radiographs and strike a careful balance between minimizing unnecessary imaging, maximizing early complication detection, and ensuring a personalized approach towards patient-level factors to optimize care and efficiency for both patient and health system.

LEVEL OF EVIDENCE

Level III.

Efficacy of Postoperative Radiographs After Intramedullary Nailing of the Tibia and Femur: When Are They Useful?

INTRODUCTION

Postoperative radiographs are used to monitor fractures of the tibia and femur after intramedullary fixation. This study sought to examine how frequently these radiographs change management.

METHODS

This was a single-center chart review of patients over a 4-year period at a level I trauma center. Radiographs were defined as either performed for routine surveillance or performed with some clinical correlate on history and examination. Participants received intramedullary nailing for diaphyseal fractures of the femur or tibia. Patients required at least one postoperative radiograph. All patients were subject to our institution's follow-up protocol: visits at 2, 6, 12, and 24 weeks. Radiographs that changed management were those that led to alterations in follow-up, directed counseling, or contributed to the decision to proceed with revision surgery.

RESULTS

A total of 374 patients were found. Two hundred seventy-seven received at least one post-op radiograph. The median follow-up was 23 weeks. Six hundred seventeen total radiographs were reviewed. Nine radiographs contributed to a change in management (9/617 = 1.5%). No surveillance radiograph taken before 14 weeks resulted in changes in management.

DISCUSSION

Our results suggest that radiographs taken in the first 3 months post-op in asymptomatic patients treated with lower extremity intramedullary rods do not result in changes to clinical management.

Potential Benefits of Limited Clinical and Radiographic Follow-up After Surgical Treatment of Ankle Fractures

Ankle fractures are one of the most prevalent musculoskeletal injuries, with a significant number requiring surgical treatment. Postoperative complications requiring additional interventions frequently occur during the early postoperative period. We hypothesize that there is a limited need for routine clinical and radiographic follow-up once the fracture is deemed healed.

Potential Economic Benefits of Limited Clinical and Radiographic Follow-up After Plate Fixation of Midshaft Clavicle Fractures

INTRODUCTION

The role of routine clinical and radiographic follow-up after clavicle fractures are healed was evaluated.

METHODS

A retrospective study performed in two level-1 trauma centers included 246 adults with healed clavicle fractures treated surgically between 2000 and 2013 and at least 24-month follow-up. Based on radiographs, changes in fracture alignment or implant position from union to final follow-up were documented. The average reimbursement for a follow-up clinical visit and a clavicle radiograph was estimated.

RESULTS

Mean time to union and mean time of follow-up were of 4.8 and 31.4 months, respectively. No changes in implant position or fracture alignment occurred after the fracture had healed. The amount reimbursed to our institution for two clinical visits and two clavicle radiographs was approximately $300 to $540.

CONCLUSION

Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. Limiting routine follow-up is safe and could be cost-effective for the healthcare system.

LEVEL OF EVIDENCE

Level-III retrospective cohort study.

Use of Postoperative Radiographs following Operative Fixation of Distal Radius Fractures

BACKGROUND

Recent studies show that routine postoperative films after open reduction and internal fixation for distal radius fractures rarely alter clinical management. This population study evaluates the use of postoperative radiographs after distal radius fracture fixation.

METHODS

The authors studied insurance claims from the Truven MarketScan databases to identify patients aged 18 years and older who underwent open reduction and internal fixation for a distal radius fracture between 2009 and 2011. Two years of postoperative data were collected to determine the number and timing of postoperative radiographs and related clinical events, including complications and reoperation. The authors also compared outcomes between cohorts who did and did not undergo radiography on the day of surgery.

RESULTS

The authors identified 20,041 patients who met study criteria. On average, 3.8 ± 2.1 radiographs per patient were obtained during the 2-year follow-up, with 3.0 ± 1.4 being obtained within the first 3 months; 59, 81, and 91 percent of patients did not undergo further imaging after 3, 6, and 12 months postoperatively, respectively. Radiographs were obtained on the day of surgery in 47 percent of patients (n = 9372), and more were obtained overall for these patients in the postoperative period (4.4 versus 3.2). Early reoperation rates (within 14 days) following distal radius fractures between patients who did and did not undergo same-day radiography were 5 percent versus 3 percent.

CONCLUSIONS

On average, four radiographs per patient were obtained following open reduction and internal fixation for a closed distal radius fracture. Nearly 50 percent of individuals underwent radiography on the day of surgery, despite low reoperation rates in the early postoperative period. An evidence-based approach to postoperative radiography has the potential to reduce distal radius fracture-related health care use.

The role of CT scan in postoperative evaluation of distal radius fractures: Retrospective analysis in regard to complications and revision rates

BACKGROUND

Intraarticular fractures of the distal radius present a challenging problem for surgeons. While preoperative CT scans are considered helpful to understand the type of fracture and to choose an adequate approach, the role of postoperative CT scans is not yet clearly defined. The aim of this study was to analyze indications for postoperative CT scans and to evaluate its potential therapeutic consequence in regard to detection of complications and its influence on revision rates in intraarticular fractures. These findings were used to establish an algorithm to help identifying patients that benefit from a postoperative CT scan.

PATIENTS AND METHODS

Ninety-two patients with intraarticular fractures were included. AO type C fractures were seen in about 90% of patients, with type C3 being present in 55% of the patients. According to Frykman's classification type 7 and 8 fractures were found in 93%. Data was analyzed in regard to radiographic results, complications and indication for a postoperative CT scan.

RESULTS

Six patients underwent revision surgery. When analyzing data in regard to correlation of radiographs and CT Scans a statistically significant correlation was found.

CONCLUSIONS

A high correlation between both imaging techniques can be shown. In inconclusive radiographs, CT scans are recommended to rule out intraarticular screw placement or step offs. Due to the number of patients and the retrospective design, further studies are needed.

Current Trends in the Management of Distal Radius Fractures

This article discusses recent reports on distal radius fractures. The keyword "distal radius fracture" was used to query the PubMed database of the US National Library of Medicine. From the resulting list, articles published in the Journal of Hand Surgery (American Volume), the Journal of Hand Surgery (European Volume), and the Journal of Orthopaedic Trauma from April 2014 through December 2015 were reviewed. Related commentaries were also evaluated. Case series of fewer than 5 patients were excluded. The 65 studies and commentaries identified are categorized and summarized. [Orthopedics. 2017; 40(3):145-152.].

Utility of Postoperative Imaging in Radial Shaft Fractures

BACKGROUND

Postoperatively, radial shaft fractures are often followed clinically with serial radiographs to assess for fracture healing. Currently, there is no standard of care regarding postoperative imaging for these injuries. The purpose of this study is to determine whether imaging influences management decisions.

METHODS

Patients who presented to a level I trauma center between 2009 and 2014 with an operatively treated radial shaft fracture were retrospectively screened for inclusion in our study. Patients with ipsilateral ulna or radius fractures, or with inadequate imaging or inadequate follow-up, were excluded. Four blinded, board-certified, orthopedic surgeons reviewed the postoperative films twice for each patient and stated whether the imaging would influence management decisions. Images were separated into 3 groups based on time from surgery: 0 to 4 weeks, 4 to 8 weeks, and greater than 8 weeks. The number of times imaging influenced these hypothetical management decisions was recorded. Interobserver and intraobserver agreements were calculated using Fleiss's and Cohen's kappa coefficients, respectively.

RESULTS

One hundred eighteen patients underwent operative fixation for an isolated radial shaft fracture, of whom 38 met inclusion criteria. Imaging from 0 to 4 weeks, 4 to 8 weeks, and greater than 8 weeks postoperatively resulted in a change of management in 0%, 32%, and 16% of patients, respectively. After 4 weeks, changes were primarily for immobilization and activity-level modification. Intraobserver and interobserver agreement kappa coefficients were 0.761 and 0.563, respectively.

CONCLUSIONS

Films obtained within 4 weeks of surgery for radial shaft fractures are unlikely to change postoperative management and may not be warranted during routine postoperative follow-up.