Differences in the Treatment of Distal Radius Fractures by Hand Fellowship Trained Surgeons: A Study of ABOS Candidate Data

The Impact of Social Determinants of Health on the Treatment of Distal Radius Fracture

BACKGROUND

Disparities in social determinants of health (SDH) have been shown to play an increasingly important role in the equitable delivery of health care. Distal radius fractures (DRFs) are among the most common upper-extremity injuries encountered. This study aims to examine the influence of economic, educational, social, environmental, and healthcare disparities on management of these injuries.

METHODS

PearlDiver Mariner insurance claims database was analyzed for treatment patterns of DRF in patients aged 18 to 65 years based on the presence or absence of social determinants of health disparities (SDHDs). Outcome variables included the primary mode of management of DRF, including operative versus non-operative, as well as concomitant procedures. Multivariate logistic regression was used to compare fracture management modality in patients with and without SDHDs.

RESULTS

Of 161 704 patients identified with DRF, 38.3% had at least 1 reported SDHD. The majority of SDHDs were economic. Patients identified with 1 or more SDHDs had a higher medical comorbidity index. Patients with environmental SDHD were more likely to receive non-operative management. Within any SDHD and economic subgroups, odds of operative management were higher. No relationship was identified between SDHD and concomitant procedures.

CONCLUSIONS

The presence of environmental disparities in SDH may predispose patients disproportionately to non-operative management. The presence of SDHDs may influence medical decision-making in favor of open reduction and internal fixation in patients with DRF treated operatively. In treating at-risk populations, providers should be aware of the potential for implicit bias associated with SDHDs and prioritize shared decision-making between patients and physicians.

Increasing Value in Subspecialty Training: A Comparison of Variation in Surgical Complications for Pediatric Versus Other Fellowship-trained American Board of Orthopaedic Surgery Candidates in the Treatment of Supracondylar Fractures

INTRODUCTION

The effect of orthopaedic fellowship subspecialization on surgical complications for patients with supracondylar fracture is unknown. This study seeks to compare the effect of subspecialty training on supracondylar fracture complications.

METHODS

The American Board of Orthopaedic Surgery Part II Examination Case List database was reviewed for all supracondylar fractures from 1999 to 2016. Procedures were divided by fellowship subspecialty (trauma, pediatric, or other) and case volume and assessed by surgeon-reported surgical complications. Predictive factors of complications were analyzed using a binary multivariate logistic regression.

RESULTS

Of 10,961 supracondylar fractures identified, 53.47% were done by pediatric fellowship-trained surgeons. Pediatric-trained surgeons had fewer surgical complications compared with their trauma or other trained peers (4.54%, 5.67%, and 6.24%; P = 0.001). Treatment by pediatric-trained surgeons reduced surgical complications (OR = 0.79, 95% CI: 0.66 to 0.94; P = 0.010), whereas increased case volume (31+ cases) showed no significant effect (OR = 0.79, 95% CI: 0.62 to 1.02; P = 0.068). Patient sex, age, and year of procedure did not affect complication rates, while those treated in the Southeast region of the United States and those with a complex fracture type were at increased odds.

DISCUSSION

Treatment of supracondylar fractures by pediatric-trained surgeons demonstrates reduced surgeon-reported complications compared with their other fellowship-trained counterparts, whereas case volume does not. This suggests the value of fellowship training beyond pertinent surgical caseload among pediatric-trained surgeons and may lie in targeted education efforts.

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.

Comparison of Differences in Surgical Complications Between Fellowship-Trained Orthopedic Foot and Ankle Surgeons and All Other Orthopedic Surgeons Using the ABOS Database

During the past decade, US orthopedic residency graduates have become increasingly subspecialized presumably for decreased patient complications; however, no study has examined this clinical utility for foot and ankle (F&A) surgeries among different fellowship subspecialties. Data from American Board of Orthopaedic Surgery 1999 to 2016 Part II Board Certification Examinations were used to assess patients treated by F&A fellowship-trained, trauma fellowship-trained, and all other fellowship-trained orthopedic surgeons performing ankle fracture repair. Adverse events were compared by surgical complexity and fellowship status. Factors independently associated with surgical complications were identified using a binary multivariate logistic regression. A total of 45,031 F&A cases met inclusion criteria. From 1999 to 2016, the percentage of F&A procedures performed by F&A fellowship surgeons steadily increased. Surgical complications were significantly different between fellowship trainings (F&A, 7.23%; trauma, 6.65%; and other, 7.84%). This difference became more pronounced with more complicated fracture pattern. On multivariate regression, F&A fellowship training was associated with significantly decreased likelihood of surgeon-reported complications (odds ratio, 0.83; 95% CI, 0.76-0.92; P<.001), as was trauma fellowship training (odds ratio, 0.90; 95% CI, 0.81-0.99; P=.035). Despite presumed increased complexity of cases treated by F&A fellowship-trained surgeons, these patients had significantly decreased risk of surgeon-reported surgical complications, thus highlighting the value of F&A fellowship training. In the absence of vital patient comorbidity data in the American Board of Orthopaedic Surgery database, further research must examine specific patient comorbidities and case acuity and their influence on treatments and surgical complications between fellowship-trained and other orthopedic surgeons to further illuminate the value of subspecialty training. [Orthopedics. 2023;46(4):e237-e243.].

Implant cost variation in surgically treated distal radius fractures

Aims & objectives

The purpose of this study was to evaluate for cost variation in distal radius fractures (DRFs) treated with a volar locking plate (VLP) and to identify key factors that affect the total construct cost.

Materials & methods

A retrospective case series was conducted for a single healthcare system. A total of 140 patients with a DRF treated with a VLP from May 2014 to December 2021 were identified. Patients were excluded for polytrauma, open fractures, and skeletal immaturity.

Results

Most patients were female (n = 120, 85.7%) and were on average 59 ± 13.7 years old. Patients most often injured their dominant hand (n = 75, 53.6%) and presented with an AO/OTA 23C fracture (n = 93, 66.4%). Twenty-two surgeons were included with fellowship training in hand or trauma and orthopaedic or plastic surgery residency. Orthopaedic hand-trained surgeons treated the highest proportion of 23C fractures (69.8%). Ninety patients (64.3%) were treated at a surgery center. The average cost was $1289.67 ± $215.32 (range: $857.83-$2156.95). The most expensive fixation constructs used a variable angle locking screw ($1316.75 ± $264.99) or a multidirectional threaded peg ($1321.67 ± $192.94). Multivariable regression analysis revealed none of the study variables to be significant contributors to construct cost (all p-values >0.27).

Conclusions

Surgically treated DRFs with a VLP demonstrated similar total implant costs regardless of fracture pattern, surgeon specialty, or treatment facility. Contrary to previous literature, VLPs showed minimal cost variation, although some surgeons were able to decrease the overall cost by reducing the number of screws used.

Hand Surgeons Are Tackling Tougher Scaphoids: A Study of ABOS Candidate Data

BACKGROUND

This study will evaluate whether those who have completed a hand fellowship treat a disproportionate number of scaphoid fractures based on recent American Board of Orthopaedic Surgery (ABOS) data. We hypothesize that surgeons who have completed a fellowship in hand surgery will address most surgically treated scaphoid fractures, particularly those with fracture nonunions or requiring graft.

METHODS

We queried the ABOS database for case log information submitted for part II of the ABOS examination. This search included all cases with Current Procedural Terminology codes for procedures related to scaphoid fixation. Demographic information, case volume, type of case, and complication rate were compared for hand fellowship-trained surgeons and those who had completed other fellowships as well as non-fellowship-trained surgeons.

RESULTS

During the study period, 1686 surgeons reported treating 4244 scaphoid fractures. Of these surgeons, 1180 had completed a hand surgery fellowship. Hand fellowship-trained surgeons were shown to have operatively treated more scaphoid fractures both in total volume and on a per-surgeon basis. Hand fellowship-trained surgeons were also found to have performed a significantly higher proportion of difficult cases, which were those listed as being a malunion/nonunion or those incorporating a pedicle graft. There was no difference in the complication rate between the 2 groups.

CONCLUSION

Among those orthopedic surgeons reporting case information for part II of the ABOS certification examination, statistically significant differences exist in case volume and case difficulty among surgeons with different areas of fellowship training. Complication rates increase with patient age and examination year.

Charges for Distal Radius Fracture Fixation Are Affected by Fracture Pattern, Location of Service, and Anesthesia Type

BACKGROUND

This study sought to characterize charges associated with operative treatment of distal radius fractures and identify sources of variation contributing to overall cost.

METHODS

A retrospective study was performed using the New York Statewide Planning and Research Cooperative System database from 2009-2017. Outpatient claims were identified using the International Classification of Diseases-9/10-Clinical Modification diagnosis codes for distal radius fixation surgery. A multivariable mixed model regression was performed to identify variables contributing to total charges of the claim, including patient demographics, anesthesia method, surgery location (ambulatory surgery center [ASC] versus a hospital outpatient department [HOPD], operation time, insurance type, Charlson Comorbidity Index, and billed procedure codes.

RESULTS

A total of 9029 claims were included, finding older age, private primary insurance, surgery performed in a HOPD, and use of local anesthesia (vs general or regional) associated with increased total charges. There was no difference between gender, race, or ethnicity. Additionally, open reduction and internal fixation (ORIF), increased operative time/fracture complexity, and use of perioperative medications contributed significantly to overall costs.

CONCLUSIONS

Charges for distal radius fracture surgery performed in a HOPD were 28.3% higher than compared to an ASC, and cases with local anesthesia had higher billed claims compared to regional or general anesthesia. Furthermore, charges for percutaneous fixation were 54.6% lower than ORIF of extraarticular fracture, and claims had substantial geographic variation. These findings may be used by providers and payers to help improve value of distal radius fracture care.

LEVEL OF EVIDENCE

Level III.

Surgeon Volume Impacts Outcomes Following Ankle Fracture Repair

Background:

The purpose of this study was to determine the impact of surgeon volume on outcomes following ankle fracture fixation.

Methods:

Over 7 years, 362 patients who met inclusion criteria (>18 years with rotational ankle fractures) were identified and treated by orthopaedic surgeons at several hospitals within an academic medical center and were retrospectively reviewed. Surgeons that completed less than 24 ankle fixations per year (<90th percentile) during the study period were classified as low-volume (LV) and surgeons completing 24 or more ankle fixations per year (>90th percentile) were classified as high-volume (HV). Chart review was conducted to gather data regarding perioperative, radiographic, inpatient, and long-term outcome data (average 12-month follow-up).

Results:

One hundred thirty-four patients (37.0%) were treated by LV surgeons and 228 (63.0%) were treated by HV surgeons. Although both cohorts had a similar breakdown of fracture patterns (P = .638), the LV cohort had a greater incidence of open fractures (P = .024). No differences were found regarding wait time to surgery, surgery duration, and LOS. Radiographically, more patients in the HV cohort achieved anatomic mortise after surgery (96.5% vs 89.6%, P = .008). Patients in the LV cohort took longer to heal radiographically (4.27 ± 2.4 months vs 5.59 ± 2.9 months, P < .001), and also had higher rates of reoperation and hardware removal (P < .05). Lastly, all cost variables were lower for high-volume surgeons (P < .05).

Conclusion:

In this single-center study, we found that patients treated by LV surgeons took 30% longer to heal radiographically and had greater reoperation rates than those treated by HV surgeons. Additionally, patients treated by high-volume surgeons had more anatomic postoperative radiographic ankle mortise reductions and was less cost-effective than when performed by high-volume surgeons.

Level of Evidence:

Level III, retrospective comparative study.

The case for decreased surgeon-reported complications due to surgical volume and fellowship status in the treatment of geriatric hip fracture: An analysis of the ABOS database

Introduction

American orthopaedists are increasingly seeking fellowship sub-specialization. One proposed benefit of fellowship training is decrease in complications, however, few studies have investigated the rates of medical and surgical complications for hip fracture patients between orthopedists from different fellowship backgrounds. This study aims to investigate the effect of fellowship training and case volume on medical and surgical outcomes of patient following hip fracture surgical intervention.

Methods

1999–2016 American Board of Orthopedic Surgery (ABOS) Part II Examination Case List data were used to assess patients treated by trauma or adult reconstruction fellowship-trained orthopedists versus all-other orthopaedists. Rates of surgeon-reported medical and surgical adverse events were compared between the three surgeon cohorts. Using binary multivariate logistic regression to control of demographic factors, independent factors were evaluated for their effect on surgical complications.

Results

Data from 73,427 patients were assessed. An increasing number of hip fractures are being treated by trauma fellowship trained surgeons (9.43% in 1999–2004 to 60.92% in 2011–2016). In multivariate analysis, there was no significant difference in type of fellowship, however, surgeons with increased case volume saw significantly decreased odds of complications (16–30 cases: OR = 0.91; 95% CI: 0.85–0.97; p = 0.003; 31+ cases: OR = 0.68; 95% CI: 0.61–0.76; p<0.001). Femoral neck hip fractures were associated with increased odds of surgical complications.

Discussion

Despite minor differences in incidence of surgical complications between different fellowship trained orthopaedists, there is no major difference in overall risk of surgical complications for hip fracture patients based on fellowship status of early orthopaedic surgeons. However, case volume does significantly decrease the risk of surgical complications among these patients and may stand as a proxy for fellowship training. Fellows required to take hip fracture call as part of their training regardless of fellowship status exhibited decreased complication risk for hip fracture patients, thus highlighting the importance of additional training.

Kirschner Wire Fixation of Distal Radius Fractures, Indication, Technique and Outcomes

Distal radius fractures are the most common upper extremity fracture that present to US emergency departments. Given the variable presentation, including age and fracture pattern, there are many techniques that have been utilized to treat them. Closed reduction and percutaneous pin (CRPP) fixation remains a viable option in extra-articular and simple intra-articular fracture patterns. CRPP techniques flourished in the mid-twentieth century until the treatment patterns shifted to primarily volar-locked plating in the twenty-first century. Although several meta-analyses have been performed comparing outcomes and complications of CRPP versus alternative methods, controversy remains over which treatments are superior.

Incidence of Flexor Pollicis Longus Complications Following Volar Locking Plate Fixation of Distal Radius Fractures

Background: Distal radius fractures are among the most common orthopedic injuries presenting to emergency departments. The complications of distal radius open reduction and internal fixation (ORIF) range from paresthesia to tendon ruptures. The Soong grading system was designed to evaluate volar plate position to predict postoperative flexor pollicis longus (FPL) ruptures. This study evaluates post-distal radius volar fixation FPL ruptures and other postoperative complication rates relative to Soong grade, surgical training, and plate design. Methods: A retrospective chart review was conducted to assess recorded complications after distal radius ORIF. Soong grade was determined on postoperative radiographs. Other demographic features, along with the surgeon fellowship training and plate design, were noted. Analysis was performed via t test, χ² test, rank sum test, and Fisher exact test. Results: A total of 522 patients met inclusion criteria. Flexor tenosynovitis was the most commonly recorded complication (21% of total complications). No FPL ruptures were recorded. Soong grades between patients with and without complications were not significantly different. Soong grades between patients with flexor tenosynovitis and other complications were not significantly different. Flexor tenosynovitis had higher odds of occurring compared with other complications when the surgeon was hand-trained or when the plate type was designed by Acumed. These higher odds were not maintained under multivariate regression analysis. Conclusion: Lack of FPL ruptures in this large series may reflect improved plate technology and increased awareness. The association between flexor tenosynovitis and hand fellowship-trained surgeons may be associated with more complex cases being referred to specialists.

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.

Pre-injury activity predicts outcomes following distal radius fractures in patients age 60 and older

INTRODUCTION

One out of every 5 elderly patients will suffer a distal radius fracture and these injuries are often related to poor bone health. Several surgical subspecialties have demonstrated that pre-injury activity level can impact patient outcomes. To determine the importance of physical activity, we examined the relationship between pre-injury activity and patient-reported and functional outcomes among fracture patients.

METHODS

This is a retrospective analysis of prospectively collected data from participants enrolled in the Wrist and Radius Injury Surgical Trial (WRIST) from April 10, 2012 to December 31, 2016. This study included 304 adults, 60 years or older with isolated unstable distal radius fractures; 187 were randomized to one of three surgical treatments and 117 opted for casting. Participants opting for surgery were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Participants who chose not to have surgery were treated with casting. All participants were stratified prior to analysis into highly and less-active groups based on pre-injury Rapid Assessment of Physical Activity Scores.

RESULTS

280 patients had 12-month assessments of outcomes. Highly active participants scored 8 and 5 points greater on the Michigan Hand Questionnaire at 6 weeks and 3 months respectively, p<0.05. Highly active participants demonstrated greater grip strength at the 3-month (p = 0.017) and 6-month (p = 0.007) time-points. Highly active participants treated with volar locking plate scored 10+ points greater on the Michigan Hand Questionnaire compared to the less-active group at the 6-week (p = 0.032), 3-month (p = 0.009) and 12-month (0.004) time points, with an effect size larger than 0.50, suggesting pre-injury level of activity had a significant clinical impact.

CONCLUSIONS

Higher levels of pre-injury activity are predictive of patient-reported and functional outcomes following distal radius fracture. Because of the greater PROs, the early mobility and lower risk of hardware infection reported in the literature, volar plating is preferable to other treatments for highly active patients who request and meet indications for surgery.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT01589692.

Intra- and interobserver reliability for predicting hip preservation versus hip arthroplasty utilizing plain radiographs with comparison of surgeon specialization

Surgeon subspecialty training and practice landscape are formative in diagnostic evaluation and treatment recommendations. Varying recommendations can have substantial impact on patients’ care pathways and outcomes. We investigated intra- and interobserver reliability of treatment predictions for total hip arthroplasty (THA) between surgeons performing arthroplasty and/or arthroscopic hip preservation surgery. Anterior–posterior (AP) hip radiographs cropped to include the lateral sourcil, medial sourcil and foveal region of 53 patients with Tönnis Grade 0–3 were evaluated by five surgeons (two performing arthroplasty, two performing arthroscopic hip preservation and one performing both interventions). Surgeons predicted THA versus no THA as the treatment for each image. Predictions were repeated three times with image order randomized, and intra- and interobserver reliability were calculated. Surgeons were blinded to patient characteristics and clinical information. Interobserver reliability was 0.452 whereas intraobserver reliability ranged from 0.270 to 0.690. Arthroscopic hip preservation surgeons were more likely to predict THA (36.9%) than arthroplasty surgeons (32.7%), P = 0.041. Intra- and interobserver reliabilities of surgeons predicting THA versus no THA based on an AP hip radiograph were average at best. Arthroscopic hip preservation surgeons were more likely to predict THA than arthroplasty surgeons. Subjective surgeon interpretation can lead to variability in recommendations to patients; potentially complicating care pathways.