1
|
Willinge GJA, Boulidam D, Salentijn DA, Twigt BA, Goslings JC, van Veen RN. The Value of Routine Radiography in the Nonoperative Treatment of Metatarsal Fractures: A Retrospective Cohort Study. J Foot Ankle Surg 2024; 63:700-704. [PMID: 39033847 DOI: 10.1053/j.jfas.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 06/23/2024] [Accepted: 07/13/2024] [Indexed: 07/23/2024]
Abstract
Although widely used in follow-up treatment protocols, the added value of routine radiographs to clinical decision-making in nonoperative treatment of patients with metatarsal fractures is unclear. This retrospective cohort study aimed to determine whether routine follow-up radiographs contributed to changes in treatment strategies in nonoperative treatment of patients with a metatarsal fracture. Adult (aged ≥ 18 years) patients who received nonoperative follow-up treatment for a metatarsal fracture between May first, 2020 and May second, 2022 were included. All relevant data were extracted from patient records. Radiographs without a documented clinical indication were classified as routine. Outcomes included changes in treatment strategies based on routine radiographs during follow-up treatment and secondarily, changes in treatment strategy based on clinically indicated radiographs. A total of 168 patients were included, with 135 single and 33 multiple metatarsal fractures. During follow-up, 223 radiographs were performed, of which 154 (69%) were routine and 69 (31%) were on clinical indication. Of routine radiographs, 9 (6%) led to a change in treatment which only included additional imaging. No switch to operative treatment or prolonging of immobilization was observed based on routine radiographs. Of clinically indicated radiographs, 16 (23%) led to a change of treatment, including prolonged immobilization (n = 2), additional follow-up appointments (n = 1) and additional imaging (n = 12). Our results show routinely performed radiographs seldom affect treatment strategies in nonoperative treatment of metatarsal fractures, indicating minimal added value to clinical decision-making. Omitting routine radiographs from treatment protocols may contribute to the reduction of unnecessary healthcare resource utilization in clinical practice.
Collapse
Affiliation(s)
- Gijs J A Willinge
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands.
| | - Dries Boulidam
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands
| | - Dorien A Salentijn
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands
| | - Bas A Twigt
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands
| | - J Carel Goslings
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands
| | - Ruben N van Veen
- Department of Trauma Surgery, OLVG Hospital, Amsterdam, AE, Amsterdam, The Netherlands
| |
Collapse
|
2
|
Parry JA, Salimi M, Stacey SC, Mauffrey C. There is no correlation between differences in adverse events and differences in patient-reported outcome measures in orthopaedic trauma randomized controlled trials: A systematic review. Injury 2024; 55:111909. [PMID: 39332228 DOI: 10.1016/j.injury.2024.111909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 08/21/2024] [Accepted: 09/15/2024] [Indexed: 09/29/2024]
Abstract
INTRODUCTION A recovery without adverse events is a top priority of orthopaedic trauma patients, however many randomized controlled trials (RCTs) are only powered to detect a difference in patient-reported outcome measures (PROMs). While it may be assumed that differences in major adverse event rates between treatment groups will result in differences in PROMs, this has not been established. The purpose of this study was to perform a systematic review of RCTs to evaluate if differences in these outcomes were correlated. METHODS A systematic search was conducted of online databases to identify RCTs in orthopaedic trauma fracture management that reported both major adverse events and PROMs. Adverse events included secondary surgeries or complications that could negatively affect long-term outcomes (nonunion, chronic regional pain syndrome, etc.). The correlation between a difference (p < 0.05) in adverse events and a difference in PROMs was assessed. RESULTS The systematic review yielded 30 RCTs involving 6,769 patients. The primary outcome was a continuous PROM in 70.0 % (21/30). A difference in major adverse events was reported in 23.3 % (7/30) and a difference in PROMs was reported in 6.7 % (2/30). Studies reporting a difference in adverse events, compared to those that did not, were not more likely to report a difference in PROMs (14.3 % (1/7) vs. 4.3 % (1/23); p = 0.42). CONCLUSIONS There was no correlation between differences in adverse event rates and differences in PROMs in orthopaedic trauma RCTs. Investigators should consider powering studies to detect differences in the major adverse events that both patients and surgeons wish to avoid. LEVEL OF EVIDENCE Level I.
Collapse
Affiliation(s)
- Joshua A Parry
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, United States.
| | - Maryam Salimi
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, United States
| | - Stephen C Stacey
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, United States
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, United States
| |
Collapse
|
3
|
Kärnä L, Launonen AP, Luokkala T, Reito A. Routine follow-up imaging is not necessary in uneventful early recovery after distal radius fractures treated with volar locking plate in working-aged patients: A retrospective single-center cohort study. Scand J Surg 2024; 113:189-196. [PMID: 38618994 DOI: 10.1177/14574969241234740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
BACKGROUND AND OBJECTIVE The purpose of our study was to evaluate whether routine follow-up radiographs after distal radius fracture (DRF) treated with volar locking plate (VLP) influenced clinical decision-making and treatment in working-aged patients (18-65 years). We evaluated the possible correlation between clinical status and problems with follow-up radiographs and analyzed the overall reoperation rate. METHODS The study population of this retrospective cohort study consisted of working-aged (18-65 years) patients with DRF who were treated with VLP between January 2010 and December 2020. Baseline data, follow-up visits, and radiographs were collected. Radiographs were classified as either routinely assigned or according to clinical findings. Patients were divided into four groups based on abnormal radiographic findings or major symptoms leading to reoperation. Patients also received patient-rated wrist evaluation (PRWE) questionnaire, which were analyzed. RESULTS A total of 861 patients were included in this study. Routine follow-up radiographs were available for 844 (98%) patients. In 7.0% of patients, 6-week radiographs led to a change of standard treatment protocol, most commonly additional imaging and/or clinical follow-up. Nine (1.1%) patients underwent an urgent reoperation, and 15 (1.8%) patients underwent reoperation later in the follow-up period. All these patients were exceptionally painful/symptomatic. In addition, 33 (3.9%) patients who underwent additional imaging and follow-up after abnormal radiograph, but did not undergo reoperation, were asymptomatic or suffered only mild pain. A total of 89 (10.5%) patients had reoperation for any reason during the follow-up period. CONCLUSIONS Routine follow-up radiographs after the treatment of DRF with VLP in the working-aged population rarely leads to changes in treatment strategy or reoperation in asymptomatic patients suggesting that it would be safe and cost-effective to reduce routine follow-up radiographs and focus instead on those patients with moderate-to-severe symptoms.
Collapse
Affiliation(s)
- Laura Kärnä
- Tampere University Hospital Elämänaukio 2 Tampere 33521 Finland
| | | | | | | |
Collapse
|
4
|
Mulakaluri A, Julian KR, Fernandez A, Kamal RN, Shapiro LM. Are Clinical Practice Guidelines Representative of Patients With Distal Radius Fractures? A Review of Patient Demographics and Patient-Reported Outcome Measures Used to Inform Guidelines. J Hand Surg Am 2024; 49:649-655. [PMID: 38739072 DOI: 10.1016/j.jhsa.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 03/03/2024] [Accepted: 03/20/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE Clinical practice guidelines (CPGs) are recommendations developed for broad application to optimize high-quality care and decision-making. The composition of patients and outcome measures used in studies informing CPGs; however, has not been rigorously evaluated. With growing evidence that outcomes in musculoskeletal surgery vary by sociocultural factors, we aimed to: (1) review the linguistic, racial, and ethnic representation of the patients in the studies informing CPGs for distal radius fractures and (2) assess their use of linguistically and culturally adapted patient-reported outcome measures (PROMs). METHODS The American Academy of Orthopaedic Surgeons website was used to identify relevant studies. Key variables were extracted, including inclusion and exclusion criteria, language of study, patient language and proficiency, patient race and ethnicity, and use of translated or culturally adapted PROMs. If provided, the clinical trial registration page for the study was evaluated. Descriptive statistics were used to describe the frequency of each variable. RESULTS Fifty-four published texts were evaluated. Participant language was reported in four (7%) of the published texts and six (11%) when including the clinical trial registration information. Of the published texts, one (2%) reported ethnic group/race data and 40 (74%) used PROMs. Of those using PROMs, eight (20%) of 40 reported the use of translated PROMs, and three (8%) of 40 reported the use of culturally adapted PROMs. CONCLUSIONS There is a lack of reporting of linguistic, racial, and ethnic data and inconsistent use of PROMs, particularly those that are translated and culturally adapted, in studies included in the American Academy of Orthopaedic Surgeons CPG for distal radius fractures. As sociocultural characteristics and PROMs are associated with outcomes, ensuring they are broadly represented in studies, may improve equity and shared decision-making. CLINICAL RELEVANCE Greater inclusion and reporting of demographic data and PROMs are required in musculoskeletal studies to ensure broad applicability and advance health equity.
Collapse
Affiliation(s)
- Ashley Mulakaluri
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Kaitlyn R Julian
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Alicia Fernandez
- Department of Medicine, University of California, San Francisco, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, CA
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California, San Francisco, CA.
| |
Collapse
|
5
|
Julian KR, Mulakaluri A, Truong NM, Fernandez A, Kamal RN, Shapiro LM. Are Orthopaedic Clinical Trials Linguistically and Culturally Diverse? A Systematic Review. JBJS Rev 2024; 12:e24.00012. [PMID: 39021638 PMCID: PMC11250675 DOI: 10.2106/jbjs.rvw.24.00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Purpose Underrepresentation and misrepresentation of historically underrepresented populations in randomized controlled trials (RCTs) may have implications for the validity of research results and their application for diverse populations. To evaluate the representation of historically linguistically, racially, and ethnically underrepresented participants in orthopaedic randomized controlled trials (RCTs) and to assess the use of translated and culturally adapted patient reported outcome measures (PROMs). Methods Separate and comprehensive literature searches of PubMed, Web of Science, and Embase databases were performed to identify RCTs utilizing PROMs between the years 2012 - 2022 among the top five highest 5-year impact factor orthopaedic journals according to the 2021 Journal Citation Reports database. The primary outcomes of interest included reporting of linguistic, racial and ethnic demographic characteristics of trial participants and the utilization of translated PROMs. The methodological quality of each clinical trial was assessed using the Jadad Criteria. Results 230 RCTs met inclusion criteria. The language of participants was reported in 14% of trials and in 17% of trials when searching both the published text and clinical trial registration information. In addition, race and/or ethnicity was reported in 11% of trials, and the use of translated PROMs was reported in 7% of trials. Among the six multinational studies, none reported the language of the study population nor the use of translated PROMs. Notably, four studies (2%) reported utilizing culturally adapted PROMs. The average Jadad score was 3.07. Conclusion Participant language, race, and ethnicity are infrequently reported in orthopaedic clinical trials, potentially limiting the application and interpretation of study results. Similarly, the linguistic and cultural adaptation of PROMs utilized are often not reported, which also limits interpretations of the validity and generalizability of orthopedic study results. Researchers and journals should promote standard reporting of demographic data and methods of PROM adaptation to ensure results are generalizable to diverse patient populations. Level of Evidence III.
Collapse
Affiliation(s)
- Kaitlyn R. Julian
- Department of Orthopaedic Surgery, University of California – San Francisco, 1500 Owens St., San Francisco, CA 94158
| | - Ashley Mulakaluri
- Department of Orthopaedic Surgery, University of California – San Francisco, 1500 Owens St., San Francisco, CA 94158
| | - Nicole M. Truong
- Department of Orthopaedic Surgery, University of California – San Francisco, 1500 Owens St., San Francisco, CA 94158
| | - Alicia Fernandez
- Department of Medicine, University of California – San Francisco, 1001 Potrero Ave #107, San Francisco, CA 94110
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, 450 Broadway St., Redwood City, CA
| | - Lauren M. Shapiro
- Department of Orthopaedic Surgery, University of California – San Francisco, 1500 Owens St., San Francisco, CA 94158
| |
Collapse
|
6
|
Quax MLJ, Krijnen P, Schipper IB, Termaat MF. Managing patient expectations about recovery after a distal radius fracture based on patient reported outcomes. J Hand Ther 2023; 36:903-912. [PMID: 36914490 DOI: 10.1016/j.jht.2022.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 03/16/2023]
Abstract
INTRODUCTION PROMs are increasingly used by clinicians to evaluate recovery after distal radius fractures, but can also be used as benchmark data to help patients managing their expectations about recovery after DRF. PURPOSE OF THE STUDY The study aimed to determine the general course of patient-reported functional recovery and complaints during 1 year after a DRF, depending on fracture type and age. The study aimed to determine the general course of patient-reported functional recovery and complaints during one year after a DRF, depending on fracture type and age. METHODS Retrospectively analyzed PROMs of 326 patients with DRF from a prospective cohort at baseline and at 6, 12, 26 and 52 weeks included PRWHE questionnaire for measuring functional outcome, VAS for pain during movement, and items of the DASH for measuring complaints (tingling, weakness, stiffness) and limitations in work and daily activities. The effect of age and fracture type on outcomes were assessed using repeated measures analysis. RESULTS PRWHE scores after one year were on average 5.4 points higher compared to the patients' pre-fracture scores. Patients with type B DRF had significantly better function and less pain than those with types A or C at every time point. After six months, more than 80% of the patients reported mild or no pain. Tingling, weakness or stiffness were reported by 55-60% of the overall cohort after six weeks, while 10-15% had persisting complaints at one year. Older patients reported worse function and more pain, complaints and limitations. CONCLUSIONS Functional recovery after a DRF is predictable in time with functional outcome scores after one-year follow-up that are similar to pre-fracture values. Some outcomes after DRF differ between age and fracture type groups.
Collapse
Affiliation(s)
- M L J Quax
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands.
| | - P Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - I B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - M F Termaat
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
7
|
Al Salman A, Fatehi A, Crijns TJ, Ring D, Doornberg JN. Surgeon preferences are associated with utilization of telehealth in fracture care. Eur J Trauma Emerg Surg 2023; 49:261-272. [PMID: 35882636 PMCID: PMC9323880 DOI: 10.1007/s00068-022-02065-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 06/30/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The SARS-CoV-2 (COVID-19) pandemic has the potential to evoke lasting changes in the delivery of care, and the utilization of telehealth. We sought associations between surgeon personal factors and greater use of telehealth to treat fractures relative to in-person care. METHODS Seventy-five fracture surgeons participated in a survey-based experiment. All surgeons were asked about their preferences regarding remote compared to in-person communication. Participants rated the following items on slider scales: their degree of introversion, the importance of a hands-on/physical exam and surgeon preferences regarding telehealth. We identified factors associated with the use of, and comfort with, telehealth. RESULTS The use of telehealth during the pandemic was associated with comfort evaluating wounds via telehealth. A greater proportion of remote visits was associated with comfort evaluating wounds and confidence teaching exercises via telehealth. There was consensus that telehealth did not alter utilization rates of radiographs or offer of discretionary surgery. The use of absorbable sutures to limit in-person visits was associated with a preference for working from home and greater comfort with evaluating wounds remotely. The use of 2- and 6-week post-operative telehealth visits and plans to use telehealth after the pandemic (52%) were associated with greater comfort in evaluating wounds through telehealth and greater confidence with video instruction of exercises. CONCLUSIONS The finding that personal factors are associated with utilization of telehealth helps target strategies for increased use of telehealth and other technologies as the pandemic wanes. Given that telehealth adds convenience for people with ambulatory difficulties or in remote areas, such efforts are warranted. LEVEL OF EVIDENCE Not applicable.
Collapse
Affiliation(s)
- Aresh Al Salman
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX, 78712, USA
- Department of Orthopaedic Surgery, Universitair Medisch Centrum Groningen, Rijksuniversiteit Groningen at Groningen, Groningen, The Netherlands
| | - Amirreza Fatehi
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX, 78712, USA
| | - Tom J Crijns
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX, 78712, USA
- Department of Orthopaedic Surgery, Universitair Medisch Centrum Groningen, Rijksuniversiteit Groningen at Groningen, Groningen, The Netherlands
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Health Discovery Building, MC Z0800, 1701 Trinity St., Austin, TX, 78712, USA.
| | - Job N Doornberg
- Department of Orthopaedic Surgery, Universitair Medisch Centrum Groningen, Rijksuniversiteit Groningen at Groningen, Groningen, The Netherlands
| |
Collapse
|
8
|
Haas Y, Stimmer H, Biberthaler P. [Postoperative imaging of the musculoskeletal system : Clinical aspects]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:817-824. [PMID: 35796756 DOI: 10.1007/s00117-022-01039-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Postoperative imaging in trauma surgery is an essential part of documenting optimal osteosynthetic care. A precise and goal-oriented analysis with a justifiable indication is essential. The clinical information has a great impact on the quality of imaging. An objective evaluation and structured reporting complete the postoperative imaging procedure. MATERIALS AND METHODS Conventional x‑rays in two planes is the standard of postoperative imaging in musculoskeletal surgery. In specific anatomic structures, additional images may be necessary. The postoperative x‑ray is the simplest way to visualize a successful osteosynthesis and combines the most important points of postoperative management. Computed tomography (CT) is mostly used in emergencies, but also in the postoperative management of some elective procedures, including patients with surgery of the spine, hip or to the proximal long bones of the extremities. Furthermore, CT is useful in postoperative imaging of complicated ankle fractures. Magnetic resonance imaging (MRI) plays a modest role in postoperative imaging and is mostly used in musculoskeletal cancer surgery. Ultrasound rather plays a subordinated role in postoperative management, but it is increasingly becoming established as a tool for postoperative quality control. The great advantage is dynamic visualization in real time. CONCLUSION Postoperative imaging remains challenging, but can detect most issues regarding osteosynthesis, which can be then be treated or monitored. Various imaging modalities are available to make reliable statements on osteosynthetic material, bone and soft tissue.
Collapse
Affiliation(s)
- Y Haas
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland.
| | - H Stimmer
- Institut für Radiologische und interventionelle Diagnostik, Klinikum rechts der Isar, München, Deutschland
| | - P Biberthaler
- Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Ismaninger Str. 22, 81675, München, Deutschland
| |
Collapse
|
9
|
Taljanovic MS, Omar IM, Weaver JS, Becker JL, Mercer DM, Becker GW. Posttreatment Imaging of the Wrist and Hand: Update 2022. Semin Musculoskelet Radiol 2022; 26:295-313. [PMID: 35654096 DOI: 10.1055/s-0042-1743538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Common indications for surgical procedures of the wrist and hand include acute fractures or fracture-dislocations; nonunited fractures; posttraumatic, degenerative, and inflammatory arthritides and tendinopathies; injuries to tendons, ligaments, and the triangular fibrocartilage complex; and entrapment neuropathies. Soft tissue or osseous infections or masses may also need surgical treatment. Several of these procedures require surgical hardware placement, and most entail clinical follow-up with periodic imaging. Radiography should be the first imaging modality in the evaluation of the postoperative wrist and hand. Computed tomography, magnetic resonance imaging, diagnostic ultrasonography, and occasionally nuclear medicine studies may be performed to diagnose or better characterize suspected postoperative complications. To provide adequate evaluation of postoperative imaging of the wrist and hand, the interpreting radiologist must be familiar with the basic principles of these surgical procedures and both the imaging appearance of normal postoperative findings as well as the potential complications.
Collapse
Affiliation(s)
- Mihra S Taljanovic
- Department of Medical Imaging, The University of Arizona, College of Medicine, Tucson, Arizona.,Department of Radiology, University of New Mexico, Albuquerque, New Mexico
| | - Imran M Omar
- Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Jennifer S Weaver
- Department of Radiology, University of New Mexico, Albuquerque, New Mexico
| | - Jennifer L Becker
- Department of Medical Imaging, The University of Arizona, College of Medicine, Tucson, Arizona
| | - Deana M Mercer
- Department of Orthopaedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico
| | - Giles W Becker
- Department of Orthopaedic Surgery, University of Arizona, Tucson, Arizona
| |
Collapse
|
10
|
Practical Application of the 2020 Distal Radius Fracture AAOS/ASSH Clinical Practice Guideline: A Clinical Case. J Am Acad Orthop Surg 2022; 30:e714-e720. [PMID: 35383613 PMCID: PMC9035062 DOI: 10.5435/jaaos-d-21-01194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/27/2021] [Indexed: 02/08/2023] Open
Abstract
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.
Collapse
|
11
|
Oehme F, Kremo V, van Veelen N, Mühlhäusser J, Brunner J, Peek J, van de Wall BJM, Link BC, Knobe M, Babst R, Beeres FJP. Routine x-rays after the osteosynthesis of distal radius and ankle fractures—a prospective randomized controlled trial on the necessity of routine imaging. DEUTSCHES ÄRZTEBLATT INTERNATIONAL 2022; 119:279-284. [PMID: 35140009 PMCID: PMC9437839 DOI: 10.3238/arztebl.m2022.0099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 01/17/2021] [Accepted: 01/03/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The utility of routine x-rays after the osteosynthesis of distal radius fractures and ankle fractures is questionable. We performed a trial to determine whether such x-rays are justified in patients who have undergone standardized imaging with C-arm fluoroscopy during surgery. METHODS Patients requiring surgery for a distal radius fracture or an ankle fracture were candidates for inclusion in this prospective, randomized, controlled, non-blinded trial. Standardized intraoperative images were obtained with C-arm fluoroscopy and stored at the end of the operation. The next day, patients in the control group underwent imaging with a standard postoperative x-ray, while those in the intervention group did not. The primary endpoint was a change in the treatment plan, defined as additional imaging or a second operation. The secondary endpoints included the range of motion, pain as rated on the Visual Analog Scale, and a functional outcome analysis (PRWE/FAOS). RESULTS 316 patients were included in the trial (163 in the control group, 153 in the intervention group), of whom 202 (64%) had radius fractures and 114 (36%) had ankle fractures. The treatment plan changed in twelve patients (3.8%; four in the control group and eight in the intervention group), seven of whom (2.2%; three in the control group and four in the intervention group) underwent a second operation. The frequency of changes in the treatment plan and of reoperations was comparable in the two groups (p = 0.36). On follow-up at six weeks and one year, the results with respect to functional outcomes and pain were comparable. CONCLUSION In this trial, routine postoperative x-rays after the osteosynthesis of distal radial fractures and ankle fractures did not improve the care of patients who had undergone standardized intraoperative imaging.
Collapse
|
12
|
Kjelle E, Andersen ER, Krokeide AM, Soril LJJ, van Bodegom-Vos L, Clement FM, Hofmann BM. Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review. BMC Med Imaging 2022; 22:73. [PMID: 35448987 PMCID: PMC9022417 DOI: 10.1186/s12880-022-00798-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. METHODS A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. RESULTS A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. CONCLUSIONS A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42020208072.
Collapse
Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Eivind Richter Andersen
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Arne Magnus Krokeide
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
| | - Lesley J. J. Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O’Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6 Canada
| | - Leti van Bodegom-Vos
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Fiona M. Clement
- Department of Community Health Sciences and The Health Technology Assessment Unit, O’Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB T2N 4Z6 Canada
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802 Gjøvik, Norway
- Centre of Medical Ethics, The University of Oslo, Blindern, Postbox 1130, 0318 Oslo, Norway
| |
Collapse
|
13
|
American Academy of Orthopaedic Surgeons/American Society for Surgery of the Hand Clinical Practice Guideline Summary Management of Distal Radius Fractures. J Am Acad Orthop Surg 2022; 30:e480-e486. [PMID: 35143462 PMCID: PMC9196973 DOI: 10.5435/jaaos-d-21-00719] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/28/2021] [Indexed: 02/01/2023] Open
Abstract
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.
Collapse
|
14
|
Bérubé M, Moore L, Tardif PA, Berry G, Belzile É, Lesieur M, Paquet J. Low-value injury care in the adult orthopaedic trauma population: A systematic review. Int J Clin Pract 2021; 75:e15009. [PMID: 34816530 DOI: 10.1111/ijcp.15009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/19/2021] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Fifteen potentially low value practices in adult orthopaedic trauma care were previously identified in a scoping review. The aim of this study was to synthesise the evidence on these practices. METHODS We searched four databases for systematic reviews, randomised controlled trials (RCTs), cohort studies and case series that assessed the effectiveness of selected practices. Methodological quality was evaluated using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2) for systematic reviews and the Critical Appraisal Checklist for Case Series. We evaluated risk of bias with the Cochrane revised tool for RCTs and the risk of bias in non-randomised studies of interventions tool for observational studies. We summarised findings with measures of frequency and association for primary outcomes. RESULTS Of the 30,670 records screened, 70 studies were retained. We identified high-level evidence of lack of effectiveness or harm for routine initial imaging of ankle injury, orthosis for A0-A3 thoracolumbar burst fracture in patients <60 years of age, cast or splint immobilisation for suspected scaphoid fracture negative on MRI or confirmed fifth metacarpal neck fracture, and routine follow-up imaging for distal radius and ankles fractures. However, evidence was mostly based on studies of low methodological quality or high risk of bias. CONCLUSION In this review, we identified clinical practices in orthopaedic injury care which are not supported by current evidence and whose use may be questioned. In future research, we should measure their frequency, assess practice variations and evaluate root causes to identify practices that could be targeted for de-implementation.
Collapse
Affiliation(s)
- Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
- Faculty of Nursing, Université Laval, Québec City, Québec, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
| | - Pierre-Alexandre Tardif
- Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec-Université Laval (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
| | - Gregory Berry
- Division of Orthopaedic Surgery, McGill University Health Center, Montréal, Québec, Canada
| | - Étienne Belzile
- Division of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Martin Lesieur
- Division of Orthopaedic Surgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Jérôme Paquet
- Division of Neurosurgery, CHU de Québec-Université Laval, Québec City, Québec, Canada
| |
Collapse
|
15
|
Shapiro LM, Kamal RN. Distal Radius Fracture Clinical Practice Guidelines-Updates and Clinical Implications. J Hand Surg Am 2021; 46:807-811. [PMID: 34384642 DOI: 10.1016/j.jhsa.2021.07.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 02/02/2023]
Abstract
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.
Collapse
Affiliation(s)
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
| | | | | | | | | |
Collapse
|
16
|
Martin SD, Abraham PF, Varady NH, Nazal MR, Conaway W, Quinlan NJ, Alpaugh K. Hip Arthroscopy Versus Physical Therapy for the Treatment of Symptomatic Acetabular Labral Tears in Patients Older Than 40 Years: A Randomized Controlled Trial. Am J Sports Med 2021; 49:1199-1208. [PMID: 33656950 DOI: 10.1177/0363546521990789] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous observational studies have suggested poor results of arthroscopic surgery for the treatment of acetabular labral tears in patients older than 40 years. PURPOSE To compare hip arthroscopy versus nonoperative management for symptomatic labral tears in patients older than 40 years who have limited radiographic osteoarthritis. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS In this single-surgeon, parallel randomized controlled trial, patients older than 40 years who had symptomatic, MRI-confirmed labral tears and limited radiographic osteoarthritis (Tönnis grades 0-2) were randomized 1:1 to arthroscopic surgery with postoperative physical therapy (SPT) or physical therapy alone (PTA) using an electronic randomization program. PTA patients who achieved unsatisfactory improvement were permitted to cross over to SPT after completing ≥14 weeks of physical therapy. The primary outcomes were International Hip Outcome Tool (iHOT-33) and modified Harris Hip Score (mHHS) at 12 months after randomization, and secondary outcomes included other patient-reported outcome measures and the visual analog scale. Outcomes were assessed at baseline and at 3, 6, and 12 months after randomization. Primary analysis was performed on an intention-to-treat basis using linear mixed-effect models. Sensitivity analyses included modified as-treated analysis and treatment-failure analysis. Due to infeasibility, patients and health care providers were both unblinded. RESULTS The study enrolled 90 patients (46 [51.1%] SPT; 44 [48.9%] PTA); of these, 81 patients (42 [51.9%] SPT; 39 (48.1%) PTA) completed 12-month follow-up. A total of 28 of the 44 PTA patients crossed over to SPT within the study period (63.6% crossover). Intention-to-treat analysis revealed significantly greater iHOT-33 scores (+12.11; P = .007) and mHHS scores (+6.99 points; P = .04) in the SPT group than the PTA group at 12 months. Modified as-treated analysis revealed that these differences exceeded the minimal clinically important difference of 10.0 points (SPT-PTA iHOT-33, +11.95) and 8.0 points (SPT-PTA mHHS, +9.76), respectively. CONCLUSION In patients older than 40 years with limited osteoarthritis, arthroscopic acetabular labral repair with postoperative physical therapy led to better outcomes than physical therapy alone. Thus, age over 40 years should not be considered a contraindication to arthroscopic acetabular labral repair. REGISTRATION NCT03909178 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Scott D Martin
- Massachusetts General Hospital Department of Orthopaedic Surgery, Sports Medicine Center, Boston, Massachusetts, USA
| | - Paul F Abraham
- Massachusetts General Hospital Department of Orthopaedic Surgery, Sports Medicine Center, Boston, Massachusetts, USA
| | - Nathan H Varady
- Massachusetts General Hospital Department of Orthopaedic Surgery, Sports Medicine Center, Boston, Massachusetts, USA
| | - Mark R Nazal
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - William Conaway
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Noah J Quinlan
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Kyle Alpaugh
- Department of Orthopaedic Surgery, University of Massachusetts, Worcester, Massachusetts, USA
| |
Collapse
|
17
|
Jeantet QWA, Coveney EI, O'Daly BJ. Saving time in the fracture clinic: 2 weeks post-operative plain films following open reduction and internal fixation of distal radius fractures do not affect management. Ir J Med Sci 2020; 190:1041-1044. [PMID: 33140295 DOI: 10.1007/s11845-020-02420-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 10/21/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Distal radius fractures represent up to one in every sixth treated fracture. The majority of these are intra-articular and require operative management. Many recent studies advocate for the use of volar plating fixation. Following fixation, most patients attend the fracture clinic at 2 and 6 weeks post-operatively and may get repeat imaging at both visits, resulting in longer wait times and repeat exposure to radiation. Revision surgery is however rarely performed in the 2- to 6-week period, raising the question of the necessity of plain film at 2 weeks. AIM Improve patient satisfaction in the fracture clinic by reducing wait time in fracture clinic and limiting exposure to radiation. METHOD The number of distal radius open reduction and internal fixation (ORIF) over a 12-month period was retrieved using theatre logbooks. Patient details were used to check whether a plain film radiograph had been performed 2 weeks post-operatively. Subsequently, patients' records were used to determine if revision surgery was performed or planned. RESULTS In total, 123 distal radius ORIF were performed between January 2018 and January 2019. Two-week check radiographs were performed for 82 patients (67%). One patient (0.8%) underwent revision surgery following review of intra-operative imaging. No patients underwent revision ORIF following 2-week plain film. CONCLUSION Repeat imaging at 2 weeks following distal radius ORIF did not change management of distal radius fractures in this study. Therefore, our data suggests 2-week plain films should not routinely be ordered for these patients which will reduce wait time and exposure to radiation.
Collapse
Affiliation(s)
- Quentin W A Jeantet
- Department of Trauma & Orthopaedic Surgery, Tallaght University Hospital, Dublin 24, Republic of Ireland.
| | - Eamonn I Coveney
- Department of Trauma & Orthopaedic Surgery, Tallaght University Hospital, Dublin 24, Republic of Ireland
| | - Brendan J O'Daly
- Department of Trauma & Orthopaedic Surgery, Tallaght University Hospital, Dublin 24, Republic of Ireland
| |
Collapse
|
18
|
van Gerven P, Krijnen P, Zuidema WP, El Moumni M, Rubinstein SM, van Tulder MW, Schipper IB, Termaat MF. Omitting Routine Radiography of Traumatic Ankle Fractures After Initial 2-Week Follow-up Does Not Affect Outcomes: The WARRIOR Trial: A Multicenter Randomized Controlled Trial. J Bone Joint Surg Am 2020; 102:1588-1599. [PMID: 32604381 DOI: 10.2106/jbjs.19.01381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The clinical consequences of routine follow-up radiographs for patients with ankle fracture are unclear, and their usefulness is disputed. The purpose of the present study was to determine if routine radiographs made at weeks 6 and 12 can be omitted without compromising clinical outcomes. METHODS This multicenter randomized controlled trial with a noninferiority design included 246 patients with an ankle fracture, 153 (62%) of whom received operative treatment. At 6 and 12 weeks of follow-up, patients in the routine-care group (n = 128) received routine radiographs whereas patients in the reduced-imaging group (n = 118) did not. The primary outcome was the Olerud-Molander Ankle Score (OMAS). Secondary outcomes were the American Academy of Orthopaedic Surgeons (AAOS) foot and ankle questionnaire, health-related quality of life (HRQoL) as measured with the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L) and Short Form-36 (SF-36), complications, pain, health perception, self-perceived recovery, the number of radiographs, and the indications for radiographs to be made. The outcomes were assessed at baseline and at 6, 12, 26, and 52 weeks of follow-up. Data were analyzed with use of mixed models. RESULTS Reduced imaging was noninferior compared with routine care in terms of OMAS scores (difference [β], -0.9; 95% confidence interval [CI], -6.2 to 4.4). AAOS scores, HRQoL, pain, health perception, and self-perceived recovery did not differ between groups. Patients in the reduced-imaging group received a median of 4 radiographs, whereas those in the routine-care group received a median of 5 radiographs (p < 0.05). The rates of complications were similar (27.1% [32 of 118] in the reduced-imaging group, compared with 22.7% [29 of 128] in the routine-care group, p = 0.42). The types of complications were also similar. CONCLUSIONS Implementation of a reduced-imaging protocol following an ankle fracture has no measurable negative effects on functional outcome, pain, and complication rates during the first year of follow-up. The number of follow-up radiographs can be reduced by implementing this protocol. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- P van Gerven
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - P Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - W P Zuidema
- Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - M El Moumni
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - S M Rubinstein
- Amsterdam Movement Science Research Institute, Department of Health Sciences, VU University, Amsterdam, the Netherlands
| | - M W van Tulder
- Amsterdam Movement Science Research Institute, Department of Health Sciences, VU University, Amsterdam, the Netherlands.,Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - I B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - M F Termaat
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | |
Collapse
|
19
|
van Gerven P, van Dongen JM, Rubinstein SM, Termaat MF, El Moumni M, Zuidema WP, Krijnen P, Schipper IB, van Tulder MW. Is reduction of routine radiograph use in patients with distal radius fractures cost effective? Analysis of data from the multicentre, randomised controlled WARRIOR trial. BMJ Open 2020; 10:e035370. [PMID: 32624472 PMCID: PMC7337891 DOI: 10.1136/bmjopen-2019-035370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To assess the cost effectiveness of a reduced imaging follow-up protocol of distal radius fractures compared with usual care. DESIGN An economical evaluation conducted alongside a multicentre randomised controlled trial (RCT). SETTING Four level-one trauma centres in the Netherlands. PARTICIPANTS 341 patients participated (usual care (n=172), reduced imaging (n=169)). INTERVENTIONS Patients were randomised to usual care (routine radiography at 1, 2, 6 and 12 weeks) or a reduced imaging strategy (radiographs at 6 and 12 weeks only for a clinical indication). OUTCOME MEASURES Functional outcome was assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and quality-adjusted life years (QALYs) using the EuroQol-5Dimensions-3 Levels (EQ-5D-3L). Costs were measured using self-reported questionnaires and medical records, and analysed from a societal perspective. Multiple imputation, seemingly unrelated regression analysis and bootstrapping were used to analyse the data. RESULTS Clinical overall outcomes of both groups were comparable. The difference in DASH was -2.03 (95% CI -4.83 to 0.77) and the difference in QALYs was 0.025 (95% CI -0.01 to 0.06). Patients in the reduced imaging group received on average 3.3 radiographs (SD: 1.9) compared with 4.2 (SD: 1.9) in the usual care group. Costs for radiographic imaging were significantly lower in the reduced imaging group than in the usual care group (€-48 per patient, 95% CI -68 to -27). There was no difference in total costs between groups (€-401 per patient, 95% CI -2453 to 1251). The incremental cost-effectiveness ratio (ICER) for QALYs was -15 872; the ICER for the DASH was 198. The probability of reduced imaging being cost effective compared with usual care ranged from 0.8 to 0.9 at a willingness to pay of €20 000/QALY to €80 000/QALY. CONCLUSIONS Implementing a reduced imaging strategy in the follow-up of distal radius fractures has a high probability of being cost effective for QALYs, without decreasing functional outcome. We, therefore, recommend imaging only when clinically indicated. TRIAL REGISTRATION NUMBER The Netherlands trial register (NL4477).
Collapse
Affiliation(s)
- Pieter van Gerven
- Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna M van Dongen
- Health Sciences, Faculty of Science, Amsterdam Movement Sciences research institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Sidney M Rubinstein
- Health Sciences, Faculty of Science, Amsterdam Movement Sciences research institute, Vrije Universiteit, Amsterdam, The Netherlands
| | - Marco F Termaat
- Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Mostafa El Moumni
- Trauma Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Wietse P Zuidema
- Trauma Surgery, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Pieta Krijnen
- Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Inger B Schipper
- Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Maurits W van Tulder
- Health Sciences, Faculty of Science, Amsterdam Movement Sciences research institute, Vrije Universiteit, Amsterdam, The Netherlands
- Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|