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

Impact of body mass index on fracture severity, clinical, radiological and functional outcome in distal radius fractures: a retrospective observational study after surgical treatment

INTRODUCTION

Distal radius fracture (DRF) is one of the three most common fractures of the human body with increasing incidences in all groups of age. Known causes of increasing incidence, such as ageing of the population or increased obesity, have been described and discussed. So far, literature reports ambivalent effects of body mass index (BMI) on bone physiology. It is worthwhile to examine the influence of BMI on the outcome of fractures more detailed. This study aims to investigate the influence of an abnormal BMI on fracture severity and treatment, as well as clinical, radiological, and functional outcome to improve clinical decision making.

MATERIALS AND METHODS

A retrospective observational study was conducted on data obtained from patients, who underwent open reduction and internal fixation (ORIF) of a DRF at a local Level 1 Trauma Center between May 2018 and October 2021. Follow-up examinations were performed approximately 1 year after surgical fracture treatment, during which various questionnaires and functional measurements (CMS, DASH, NRS, ROM) were applied. In addition, postoperative complications were recorded and radiological examinations of the affected hand were performed. After excluding incomplete data sets and applying set exclusion criteria, the complete data of 105 patients were analyzed.

RESULTS

74 patients were female and 31 male with significant difference in mean BMI [p = 0.002; female: 23.8 (SD ± 3.3), men: 26.2 (SD ± 3.9)]. Patients with higher BMI had significantly more severe fractures (p = 0.042). However, there was no significant difference in surgery time for fracture management. At follow-up, patients with lower BMI showed a smaller difference in hand strength between the fractured and the other hand (p = 0.017). The BMI had no significant effect on the clinical and radiological outcome.

CONCLUSION

Despite the ambivalent effects of BMI on the skeletal system, our findings indicate that a higher BMI is associated with more severe DRF. Thereby BMI does not correlate with surgery time for fracture treatment. Furthermore, no evidence of an influence on the clinical and radiological outcome could be detected.

Principles and Evaluation of Bony Unions

Nonunion is a common and costly problem. Unfortunately, there is no widely agreed upon and standardized definition for nonunion. The evaluation of bony union should start with a thorough history and physical examination. The clinician should consider patient-dependent as well as patient-independent characteristics that may influence the rate of healing and evaluate the patient for physical examination findings suggestive of bony union and infection. Radiographs and clinical examination can help confirm a diagnosis of union. When the diagnosis is in doubt, however, advanced imaging modalities as well as laboratory studies can help a surgeon determine when further intervention is necessary.

Does Construct Type Matter? A Retrospective Review Comparing Outcomes of Distal Radius Fractures Treated with Standard Volar Plating versus Fragment-Specific Fixation

Background  Treatment of intra-articular distal radius fractures (DRFs) rests on anatomic internal fixation. Fragment-specific fixation (FSF) is applied when fracture pattern is too complex for standard volar plating (SVP), oftentimes with potential increased risk of complications. We hypothesized that patients undergoing FSF would achieve less wrist range of motion (ROM) with higher risk of complications compared with SVP. Methods  We conducted a retrospective review of 159 consecutive patients undergoing DRF fixation from 2017 to 2020. Patients < 18 years old, < 8 weeks' follow-up, open fractures, ipsilateral trauma, and fractures requiring dorsal spanning plate were excluded. Patient demographics, specific construct type, AO fracture classification, ROM, and complications were assessed. ROM was calculated using average flexion, extension, supination, and pronation. t -Tests were used to determine differences in ROM among construct types. Results  Ninety-two patients met all inclusion criteria: 59 underwent SVP and 33 underwent FSF. Average wrist ROM for patients undergoing SVP was 57 degrees/50 degrees flexion-extension and 87 degrees/88 degrees supination-pronation; average ROM for patients undergoing FSF was 55 degrees/49 degrees flexion-extension and 88 degrees/89 degrees supination-pronation. No significant differences were identified when comparing final wrist flexion ( p  = 0.08), extension ( p  = 0.33), supination ( p  = 0.35), or pronation ( p  = 0.21). Overall reoperation rate was 5% and higher for FSF (12%) versus SVP (2%). Highest reoperation rate was observed in the double volar hook cohort (80%; N  = 4). Conclusion  Construct type does not appear to affect final ROM if stable internal fixation is achieved. SVP and FSF had similar complication rates; however, double volar hook constructs resulted in increased reoperations likely from fixation failure and plate prominence. Level of Evidence  Level IV, retrospective review.

Cannabis Abuse Is Associated With Greater Medical Complications, Emergency Department Visits, and Readmissions Following Open Reduction and Internal Fixation for Distal Radius Fractures

BACKGROUND

Despite increased legalization, little is known about the influence of cannabis use disorder (CUD) following open reduction and internal fixation (ORIF) for distal radius fractures (DRFs). The aims were to determine whether CUD patients undergoing ORIF for DRF have increased: (1) medical complications; and (2) health care utilization (emergency department [ED] visits and readmission rates).

METHODS

Patients were identified from an insurance database from 2010 to 2020 using Current Procedural Terminology codes: 25607, 25608, and 25609. Patients with a history of CUD were 1:5 ratio matched to controls by age, sex, tobacco use, alcohol abuse, opioid dependence, and comorbidities. This yielded 13,405 patients with (n = 2,297) and without (n = 11,108) CUD. Outcomes were to compare 90-day medical complications, ED visits, and readmissions. Multivariable logistic regression models computed the odds ratios of CUD on dependent variables. P values less than .005 were significant.

RESULTS

The incidence of CUD among patients aged 20 to 69 years undergoing ORIF increased from 4.0% to 8.0% from 2010 to 2020 (P < .001). Cannabis use disorder patients incurred significantly higher rates and odds of developing 90-day medical complications (15.24% vs 5.76%), including pneumoniae (3.66% vs 1.67%), cerebrovascular accidents (1.04% vs 0.32%), pulmonary emboli (0.57% vs 0.16%), respiratory failures (1.00% vs 0.48%), and surgical site infections (1.70% vs 1.04%; all P < .004). Emergency department visits (2.53% vs 1.14%) and readmission rates (5.79% vs 4.29%) within 90 days were higher among cannabis abusers.

CONCLUSIONS

With a greater number of states legalizing cannabis, hand surgeons should be cognizant of the association with increased 90-day complications and health care utilization parameters.

Strategies for Perioperative Optimization in Upper Extremity Fracture Care

Perioperative optimization in upper extremity fracture care must balance the need for timely treatment with the benefits of medical optimization. Care pathways directed at optimizing glycemic control, chronic anticoagulation, smoking history, nutrition, and frailty can reduce surgical risk in upper extremity fracture care. The development of multidisciplinary approaches that tie risk modification with risk stratification is needed.

Impact of tobacco usage on readmission and complication rates following shoulder replacement surgery: A study of 164,527 patients

Background

Tobacco carcinogens have adverse effects on bone health and are associated with inferior outcomes following orthopedic procedures. The purpose of this study was to assess the impact tobacco use has on readmission and complication rates following shoulder arthroplasty.

Methods

The 2016-2018 National Readmissions Database was queried to identify patients who underwent anatomical, reverse, and hemi-shoulder arthroplasty. ICD-10 codes Z72.0 ×  (tobacco use disorder) and F17.2 ×  (nicotine dependence) were used to define "tobacco-users." Demographic, 30-/90-day readmission, surgical complication, and medical complication data were collected. Inferential statistics were used to analyze complications for both the cohort as a whole and for each procedure separately (i.e. anatomical, reverse, and hemiarthroplasty).

Results

164,527 patients were identified (92% nontobacco users). Tobacco users necessitated replacement seven years sooner than nonusers (p < 0.01) and were more likely to be male (52% vs. 43%; p < 0.01). Univariate analysis showed that tobacco users had higher rates of readmission, revisions, shoulder complications, and medical complications overall. In the multivariate analysis for the entire cohort, readmission, revision, and complication rates did not differ based on tobacco usage; however, smokers who underwent reverse shoulder arthroplasty in particular were found to have higher 90-day readmission, dislocation, and prosthetic complication rates compared to nonsmokers.

Conclusion

Comparatively, tobacco users required surgical correction earlier in life and had higher rates of readmission, revision, and complications in the short term following their shoulder replacement. However, when controlling for tobacco usage as an independent predictor of adverse outcomes, these aforementioned findings were lost for the cohort as a whole. Overall, these findings indicate that shoulder replacement in general is a viable treatment option regardless of patient tobacco usage at short-term follow-up, but this conclusion may vary depending on the replacement type used.

The Effect of Obesity on Distal Radius Fractures: An Analysis from the NSQIP Database

The rate and severity of obesity has risen over the past 40 years, and class III (formerly morbid) obesity presents additional sequelae. The effect of obesity on the incidence and recovery of hand and wrist fractures remains unclear. We sought to quantify the relationship between class III obesity and postoperative distal radius fracture (DRF) complications.

Methods

We performed a retrospective analysis of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database for surgical DRF patients more than 50 years old from 2015 to 2020. We then stratified patients into class III obese (BMI > 40) and compared the rates of postoperative complications to a control group with BMI less than 40.

Results

We included 10,022 patients (570 class III obese vs. 9,452 not class III obese). Patients with class III obesity had significantly increased odds of experiencing any complication (OR 1.906, p<0.001), adverse discharge (OR 2.618, p<0.001), delayed hospital stay of longer than three days (OR 1.91, p<0.001), and longer than seven days (OR 2.943, p<0.001) than controls. They also had increased odds of unplanned reoperation (OR 2.138, p = 0.026) and readmission (OR 2.814, p < 0.001) than non-class III obese patients. Class III obese patients had a significantly longer average operation time (79.5 min vs. 72.2 min, p < 0.001). They also spent more time in the hospital postoperatively (0.86 days vs. 0.57 days, p = 0.001).

Conclusion

Class III obese patients undergoing DRF repair are more likely to experience postoperative complications than non-class III obese patients.

Predictors of Management of Distal Radius Fractures in Patients Aged >65 Years

BACKGROUND

Treatment of distal radius fractures (DRFs) in patients aged >65 years is controversial. The purpose of this study was to identify what patient and fracture characteristics may influence the decision to pursue surgical versus nonsurgical treatment in patients aged >65 years sustaining a DRF.

METHODS

We queried our institutional DRF database for patients aged >65 years who presented to a single academic, tertiary center hand clinic over a 5-year period. In all, 164 patients treated operatively were identified, and 162 patients treated nonoperatively during the same time period were selected for comparison (total N = 326). Demographic variables and fracture-specific variables were recorded. Patient and fracture characteristics between the groups were compared to determine which variables were associated with each treatment modality (operative or nonoperative).

RESULTS

The average age in our cohort was 72 (SD: 11) years, and 274 patients (67%) were women. The average Charlson Comorbidity Index (CCI) was 4.1 (SD: 2.1). The CCI is a validated tool that predicts 1-year mortality based on patient age and a list of 22 weighted comorbidities. Factors associated with operative treatment in our population were largely related to the severity of the injury and included increasing dorsal tilt (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.05-1.12; P < .001) and AO Classification type C fractures (OR, 5.42; 95% CI, 2.35-11.61; P < .001). Increasing CCI was the only factor independently associated with nonoperative management (OR, 0.84; 95% CI, 0.72-0.997; P = .046).

CONCLUSION

Fracture severity is a strong driver in the decision to pursue operative management in patients aged >65 years, whereas increasing CCI predicts nonoperative treatment.

Risk Factors for Complications following Volar Locking Plate (VLP) Fixation of Unstable Distal Radius Fracture (DRF)

Objective

To evaluate the incidence and risk factors for complications following volar locking plate (VLP) fixation of unstable distal radius fracture (DRF).

Methods

This retrospective study identified patients who underwent VLP fixation of unstable DRF between 2017 and 2020 with a minimum 12-month follow-up assessments. By reviewing electronic medical records and follow-up notes, patients were categorized complication or noncomplication group. Differences in variables were detected by using univariate analyses, and independent factors were identified using multivariate logistic regression analysis.

Results

During this study period, 423 patients were included, and 63 (rate, 14.9%) complications in 58 patients were documented. Wound infection (17, 4.0%) was most common, followed in decreasing frequency by carpal tunnel syndrome (13, 3.1%), tendon rupture/irritation (10, 2.4%), complex regional pain syndrome (8, 1.9%), and plate/screw-related complications (5, 1.7%). In the univariate analyses, 18 variables were found to be significantly different (p < 0.05). Logistic regression analysis identified 5 independent factors, including being male (OR, 3.5; p = 0.014), type C fracture (vs. type A, OR: 2.7, and p = 0.035), general anesthesia (vs. regional, OR: 2.4, and p = 0.045), bone grafting (OR, 6.3; p < 0.001), and surgery performed by less experienced surgeons (OR, 3.1; p = 0.003). The goodness-of-fit of the final model was acceptable.

Conclusions

These factors will help surgeons individualize and stratify the risk of complications and help patients for risk counselling; especially, an informed clinical decision targeting those modifiable factors (anesthesia mode, bone grafting, and surgeon experience) can be considered, when indicated.

The technique of "autologous bone grafting through channels" combined with double-plate fixation is effective treatment of femoral nonunion

PURPOSE

The aims of this retrospective study were to evaluate the effective treatment of femoral nonunion using the technique of "autologous bone grafting through channels" combined with double-plate fixation.

METHODS

In this study, 186 patients with nonunion fracture of femur who underwent surgery using the technique of "autologous bone grafting through channels" combined with double-plate fixation in Hong Hui Hospital from May 2010 to July 2020 were enrolled. Totally, 122 males and 64 females with mean age of 44 years were evaluated. These patients were evaluated for the full clinical and radiological union time, duration of follow-up, levels of post-operative limb shortening, and range of motion of adjacent joints, and incidence of serious complications.

RESULTS

The mean follow-up time was 22 ± 6.2 months (range 12-44 months). Mean union time from surgery using our technique to full clinical and radiological union was 7.6 ± 1.2 months (range 4-9 months). All patients have achieved the union after one operation or two operations using the technique. The one-operation union rate is 98.4%. Post-operative severe complications were seen in seven patients which included deep vein thrombosis; the surgical site infection and the fracture nonunion. The range of motion in the adjacent joint of 17.7% (33/186) in all patients have an effect to the limb function. Six patients have the limb shortening more than 10 mm after surgery.

CONCLUSION

The technique of "autologous bone grafting through channels" combined with double-plate fixation is showed to be safe, effective, and easy to master and operate surgical option for treating the femoral nonunion.

A novel bone graft technique combined with plating for aseptic recalcitrant long bone nonunion

Background

To evaluate the outcomes and efficacy of a new technique of autogenous iliac crest bone grafting combined with locking compression plate (LCP) vertical fixation for aseptic recalcitrant long bone nonunion.

Methods

From July 2010 to September 2020, 36 aseptic recalcitrant long bone nonunions were treated with a bone-forming channel technique and internal LCP fixation. All the patients had received one or more failed treatments. The injury mechanism, nonunion type and duration, and prior treatments were recorded pre-operation. The routine treatment process included nonunion area exposure, previous implant removal, sclerotic bone debridement, LCP fixation, bone-forming channel creation, and iliac bone grafting, and a second LCP fixation when required. At follow-up, X-ray images were obtained to assess bone healing and implant failure. Visual analog scale (VAS), fracture site stability, limb function, activity, muscle strength, limb length, and complications were recorded.

Results

A total of 34 patients (24 males and 10 females) were finally enrolled, with a mean age of 49.8 ± 12.3 years. At a mean follow-up of 35.6 ± 22.0 months, 32 patients displayed bone union, with a healing rate of 94.1% and mean union time of 6.8 ± 2.4 months. The VAS score was 0.7 ± 1 at the final follow-up. The functional results showed that 19 patients were excellent, 11 patients were good, 2 patients were poor, and 2 patients did not heal.

Conclusion

Bone-forming channel technique combined with LCP vertical fixation is an excellent option to treat recalcitrant long bone nonunion.

Level of evidence

Therapeutic Level IV.

Prolonged Operative Time Associated with Increased Healthcare Utilization after Open Reduction and Internal Fixation of Intra-Articular and Extra-Articular Distal Radial Fractures: An Analysis of 17,482 Cases

Background  The current literature does not contain a quantitative description of the associations between operative time and adverse outcomes after open reduction and internal fixation (ORIF) of distal radial fractures (DRF). Questions/Purpose  We aimed to quantify associations between DRF ORIF operative time and 1) 30-day postoperative health care utilization and 2) the incidence of local wound complications. Methods  The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for DRF ORIF cases (January 2012-December 2018). A total of 17,482 cases were identified. Primary outcomes included health care utilization (length of stay [LOS], discharge dispositions, 30-day readmissions, and reoperations) per operative-time category. Secondary outcome was incidence of wound complications per operative-time category. Multivariate regression was conducted to determine operative-time categories associated with increased risk while adjusting for demographics, comorbidities, and fracture type. Spline regression models were constructed to visualize associations. Results  The 121 to 140-minute category was associated with significantly higher risk of a LOS > 2 days (odds ration [OR]: 1.64; 95% confidence interval [CI]:1.1-2.45; p  = 0.014) and nonhome discharge (OR: 1.72; 95% CI:1.09-2.72; p  = 0.02) versus 41 to 60-minute category. The ≥ 180-minute category exhibited highest odds of LOS > 2 days (OR: 2.08; 95%CI: 1.33-3.26; p  = 0.001), nonhome discharge disposition (OR: 1.87; 95% CI: 1.05-3.33; p  = 0.035), and 30-day reoperation occurrence (OR: 3.52; 95% CI: 1.59-7.79; p  = 0.002). There was no association between operative time and 30-day readmission ( p  > 0.05 each). Higher odds of any-wound complication was first detected at 81 to 100-minute category (OR: 3.02; 95% CI: 1.08-8.4; p  = 0.035) and peaked ≥ 181 minutes (OR: 9.62; 95% CI: 2.57-36.0; p  = 0.001). Spline regression demonstrated no increase in risk of adverse outcomes if operative times were 50 minutes or less. Conclusion  Our findings demonstrate that prolonged operative time is correlated with increased odds of health care utilization and wound complications after DRF ORIF. Operative times greater than 60 minutes seem to carry higher odds of postoperative complications.

Risk Factors for Infection After Distal Radius Fracture Fixation: Analysis of Impact on Cost of Care

Purpose

Infection after distal radius fracture fixation can be a devastating complication, leading to potential hardware removal, prolonged antibiotic courses, multiple office visits, and increased costs. This study aimed to identify potential risk factors for infectious complications after distal radius fracture fixation and assess the impacts on cost.

Methods

This study used the PearlDiver national database, encompassing 53 million unique patients from January 1, 2010, to March 31, 2020. The cohort included patients undergoing distal radius fracture fixation. The endpoint was postoperative infection within 180 days of fixation. Two-sample t test was used to compare rates of infection between open and percutaneous fracture fixation techniques. A propensity-matched cohort was created using patient age, gender, and open fracture. Logistic regression analyses defined independent risk factors for developing a postoperative infection among all patients and within the matched cohorts. A Mann-Whitney U test was used to compare costs of care with and without infection.

Results

The database included 87,169 patients who underwent distal radius fracture fixation. Postoperative infections were identified in 781 patients (0.9%). There was a significant difference in rates of postoperative infection with percutaneous fixation (1.3%) versus open fixation (0.8%). Logistic regression analysis identified male gender, open fracture, lung disease, chronic kidney disease, diabetes, hypertension, liver disease, obesity, and tobacco to be independent risk factors for developing a postoperative infection. Logistic regression analysis of the propensity-matched cohorts identified tobacco use as a significant risk factor. The average cost of care for patients undergoing fracture fixation without an infection was $6,383, versus $23,355 for those with an infection, which was significantly different.

Conclusions

Multiple risk factors for postoperative infection were identified. Cost is significantly increased after postoperative infection, by almost 4-fold. Attempts to correct or optimize modifiable risk factors may lead to substantial cost savings, and potentially decreased rates of infection.

Type of study/level of evidence

Prognostic III.

Association Between Body Mass Index and Functional Outcomes in Elderly Patients with Extra-articular Distal Radius Fracture: A Prospective Observational Study

INTRODUCTION

The association between body mass index (BMI) and functional outcomes is unknown in elderly individuals with distal radius fracture (DRF).

OBJECTIVE

The aim of this study is to evaluate if there is association between BMI and functional outcomes in patients older than 60 years with DRF treated conservatively.

MATERIALS AND METHODS

A prospective observational study was performed. A total of 228 patients with extra-articular DRF were prospectively recruited. All patients were categorized by their BMI as normal, overweight, or obese. Functional outcomes were assessed after cast removal and at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH), and Patient-Rated Wrist Evaluation (PRWE) questionnaires were used to assess upper limb and wrist/hand function, respectively, while the Jamar Dynamometer was used to assess grip strength.

RESULTS

Of the total number of patients, 184 were female (80.7%), 87 were overweight (38.2%), and 111 were obese (48.7%). After cast removal, the correlations between BMI and functional outcomes were DASH 0.06 (p = 0.578), PRWE 0.04 (p = 0.692), and grip strength - 0.02 (p = 0.763). At 1-year follow-up, the correlations were DASH 0.55 (p = 0.036), PRWE 0.32 (p = 0.041), and grip strength - 0.21 (p = 0.043).

CONCLUSION

This study suggests that at 1-year follow-up, there was a low-to-moderate association between BMI and poor functional outcomes in elderly patients with extra-articular DRF treated conservatively.

LEVEL OF EVIDENCE

Level IV, observational prospective study.

Fracture nonunion in long bones: A literature review of risk factors and surgical management

Nonunion following a long bone fracture causes considerable morbidity when it occurs. Risk factors depend on specific fractures but there is a complex interplay of injury severity, comorbidities, patient medication and infection. The majority of nonunions occur after long bone fractures with the tibia, femur, forearm, humerus and clavicle predominating. Despite interest in the biological augmentation of fracture healing, the majority of nonunions can be effectively managed with conventional surgical techniques. In this review we present a review of risk factors for nonunion and the outcome following surgical management.

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.

The Impact of Smoking on Early Postoperative Complications in Hand Surgery

PURPOSE

Smoking is a prevalent modifiable risk factor that has been associated with adverse postoperative outcomes across numerous surgical specialties. We examined the impact of smoking on 30-day complications in patients undergoing hand surgery procedures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program data sets were queried for patients who underwent common hand surgery procedures from 2011 to 2016. Cohorts were divided into smoking and nonsmoking and compared in terms of demographic characteristics, comorbidities, and postoperative complications. Multivariable logistic regression models were used to control for demographic characteristics and comorbidities in assessing the association between smoking and postoperative infections as well as other major and minor complications.

RESULTS

We identified a cohort of 48,370 patients in the National Surgical Quality Improvement Program who underwent certain outpatient and inpatient hospital facility-based hand surgery procedures from 2011 to 2016. Up to 22% of these patients reported active smoking. Compared with nonsmokers, smokers were more likely to be younger and male and to have a lower body mass index. In addition, they were more likely to have a higher American Society of Anesthesiologists classification and to report dyspnea and chronic obstructive pulmonary disease. Multivariable logistic regression identified an independent association between smoking and major complications. Smoking was not significantly associated with minor complications. When regrouped by complication type, smoking was associated with infectious and wound healing complications. In subgroup analysis, smokers undergoing elective hand surgery had increased odds of wound healing complications but not major, minor, or infectious complications.

CONCLUSIONS

Smokers may be at a significantly higher odds of certain complications compared with nonsmokers. For patients undergoing the elective procedures evaluated in this study, perioperative smoking may increase the risk of wound-healing complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

A Matched Comparison of Postoperative Complications Between Smokers and Nonsmokers Following Open Reduction Internal Fixation of Distal Radius Fractures

PURPOSE

The purpose of the present study was to identify differences in 30-day adverse events, reoperations, readmissions, and mortality for smokers and nonsmokers who undergo operative treatment for a distal radius fracture.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients who had operatively treated distal radius fractures between 2005 and 2017. Patient characteristics and surgical variables were assessed. Thirty-day outcome data were collected on serious (SAEs) and minor adverse events (MAEs), as well as on infection, return to the operating room, readmission, and mortality. Multivariable logistic analyses with and without propensity-score matching was used to compare outcome measures between the smoker and the nonsmoker cohorts.

RESULTS

In total, 16,158 cases were identified, of whom 3,062 were smokers. After 1:1 propensity-score matching, the smoking and nonsmoking cohorts had similar demographic characteristics. Based on the multivariable propensity-matched logistic regression, cases in the smoking group had a significantly higher rate of any adverse event (AAE) (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.28-2.38), serious adverse event (SAE) (OR, 1.75; 95% CI, 1.22-2.50), and minor adverse event (MAE) (OR, 1.84; 95% CI, 1.04-3.23). Smokers also had higher rates of infection (OR, 1.73; 95% CI, 1.26-2.39), reoperation (OR, 2.07; 95% CI, 1.13-3.78), and readmission (OR, 1.83; 95% CI, 1.20-2.79). There was no difference in 30-day mortality rate.

CONCLUSIONS

Smokers who undergo open reduction internal fixation of distal radius fractures had an increased risk of 30-day perioperative adverse events, even with matching and controlling for demographic characteristics and comorbidity status. This information can be used for patient counseling and may be helpful for treatment/management planning.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Using the QuickDASH to Model Clinical Recovery Trajectory After Operative Management of Distal Radius Fracture

Purpose

There is a paucity of literature examining the trajectory of meaningful clinical improvement after distal radius fracture (DRF) fixation. We sought to answer the following questions: (1) When do patients meet the minimum clinically important difference (MCID) in the Quick-Disabilities in Arm, Shoulder, and Hand questionnaire (QuickDASH) score change after DRF fixation? (2) What gains in terms of number of MCIDs achieved (as measured by QuickDASH) do patients make as they recover from DRF fixation? (3) What patient and injury factors are characteristic of patients who meet or do not meet the average recovery trajectory?

Methods

We performed a retrospective review of an institutional database of DRF patients treated with operative fixation. The change in QuickDASH scores from before surgery to approximate follow-up intervals of 0 to 2 months, 3 to 6 months, and a minimum of 9 of 12 months was assessed, in which a delta of 14 reflected the MCID. The change in QuickDASH score from before surgery to each follow-up interval was divided by 14 to determine the number of MCIDs, representing appreciable clinical improvement. Patient characteristics were compared between those who did and did not reach average levels of clinical improvement.

Results

The study included 173 patients. Mean QuickDASH score before surgery was 74 (SD, 19; range, 0-100). After surgery, this improved to 50 (SD, 24; range, 0-100) by 0 to 2 months, 22 (SD, 22; range, 0-98) by 3 to 6 months, and 9.8 (SD, 15; range, 0-75) by a minimum of 9 to 12 months. Overall, 96% of patients reached the MCID by 1 year. Mean cumulative number of MCIDs achieved (ie, number of 14-point decreases in QuickDASH score) at each interval was 1.57, 3.64, and 4.43, respectively. Assuming 4.43 represents maximum average improvement at 1 year, patients achieved 35% (1.57 of 4.43) of recovery from 0 to 2 months after surgery and 82% (3.64 of 4.43) of recovery by 3 to 6 months after surgery. There appeared to be no difference in terms of age, sex, or body mass index with respect to these findings.

Conclusions

Overall, 96% of patients undergoing DRF fixation will achieve one QuickDASH MCID by 1 year after surgery. Patients achieved over 80% of total expected functional improvement by 3 to 6 months after surgery, which appeared to be irrespective of age, sex, or body mass index.

Type of study/level of evidence

Therapeutic IV.

Elevated BMI is associated with intra-articular comminution, prolonged operative time, and postoperative complications in distal radius fractures

INTRODUCTION

Obesity continues to be a problem in the United States with greater than 35% of the adult population affected. Obesity influences fracture care as it affects impact forces, alters cellular pathways of healing, and is often associated with higher complication rates. Distal radius fractures are among the most common fracture patterns in the adult population. The purpose of this study was to evaluate the effect of BMI on the degree of intra-articular fracture comminution, operative time, and return to the OR in obese patients who underwent operation for distal radius fractures.

METHODS

A retrospective analysis of the American College of Surgeons National Surgical Improvement Program's (ACS-NSQIP) database was performed and logistic regressions were used to assess the relationship between BMI and open treatment of distal radius fractures. Three separate CPT codes were used to distinguish between extra-articular fractures, intra-articular split fracture, and intra-articular fracture with comminution. Percutaneous or closed treatment of distal radius fractures were excluded.

RESULTS

A total of 11,228 patients (mean age 65.1 years) with open reduction and internal fixation of distal radius fractures were identified. For every increase in BMI point, there was an increased risk of intra-articular split fracture by 1.7% (OR 1.017, 95% CI 1.010-1.023, p < 0.01) and increased risk of intra-articular comminution by 3.1% (OR 3.1, 95% CI 1.025-1.037, p < 0.01). Additionally, for every increase in BMI point, the risk of a surgical complication increased by 2.3% DISCUSSION: This nationally representative, population-based study demonstrates that elevated BMI is associated with increased risk for intra-articular involvement and higher risk for post-operative complications. Our results can be useful to patients and orthopedic surgeons as prognostic information for counseling patients on expectations following open reduction and surgical fixation of distal radius fractures.

LEVEL OF EVIDENCE

Case-control study. Level III.

Does surgical approach affect sagittal plane alignment and pilon fracture outcomes?

PURPOSE

Sagittal plane alignment beyond articular reduction and its effect on clinical outcomes has not been emphasized. Surgical approach may influence a surgeon's ability to correct the sagittal plane alignment. The purpose of our study was to evaluate how surgical approach impacts anterior distal tibial angle (ADTA) and lateral talar station (LTS). Our hypothesis was that the anterolateral (AL) approach would improve the sagittal plane parameters due to the primary plate placement.

PATIENTS AND METHODS

A retrospective review was performed on patients who underwent operative management for pilon fractures at 2 ACS Level 1 Academic Trauma Centers. Clinical data points including demographics, comorbidities, AO/OTA classification, surgical approach, and complications were recorded. Quality of reduction was measured using the ADTA, lateral distal tibia angle (LDTA), and lateral talar station (LTS) from radiographs.

RESULTS

580 pilon fractures met inclusion criteria. When compared to the AL approach, the modified anteromedial (AM) approach had decreased rates of local wound care, and unplanned reoperations. The AM approach had increased rates of superficial infection, deep infection, non-union, and amputations. There was no difference in ADTA, LDTA, or LTS between the AM and AL approach (P = 0.49, P = 0.41, P = 0.85). There was a difference in LTS with tobacco users (P = 0.02).

CONCLUSIONS

The sagittal plane alignment does not appear to be affected by the surgical approach. Therefore, the surgical approach to pilon fractures should be based on the fracture pattern and the patient's soft tissue envelope. This study shows that the AM is a relatively safe and effective approach to complex fractures and the surgeon should consider the specific fracture pattern and patient soft tissue envelope when choosing the specific approach.