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Aryee JNA, Frias GC, Haddad DK, Guerrero KD, Chen V, Ling F, Kirschenbaum D, Monica JT, Katt BM. Understanding Variations in the Management of Displaced Distal Radius Fractures With Satisfactory Reduction. Hand (N Y) 2024:15589447241233709. [PMID: 38456481 DOI: 10.1177/15589447241233709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND The American Academy of Orthopaedic Surgeons has set forth Clinical Practice Guidelines (CPGs) to help guide management of closed, displaced distal radius fractures (DRFs). There still exists variation in practice regarding operative vs nonoperative decision-making. This study aims to identify which factors influence the decision to treat DRFs not indicated for surgery by the CPGs after initial closed reduction. METHODS Fifteen sets of DRFs and clinical vignettes were distributed via email to over 75 orthopedic residency programs, Orthopaedic Trauma Association, and New York Society for Surgery of the Hand membership. A Qualtrics survey collected respondent demographics, choice of treatment, and rationale. RESULTS Responses were received from 106 surgeons and resident trainees. The odds of selecting operative management for fractures with 5 or more radiographic instability signs versus 3 or 4 was 3.11 (P < .05). Age over 65, higher patient activity level, and dominant-hand injury were associated with greater odds of operative management (3.4, 30.28, and 2.54, respectively). In addition, surgeons with more years in practice and high-volume surgeons had greater odds of selecting operative management (2.43 and 2.11, respectively). CONCLUSIONS Assessment of instability at the time of injury, patient age and activity level, as well as surgeon volume and time in practice independently affect the decision to manage well-reduced DRF with surgical or nonsurgical treatment. The source of heterogeneity in the treatment of these fractures is borne at least in part from a lack of formal direction on the importance of prereduction instability from the CPGs.
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Affiliation(s)
- Jomar N A Aryee
- Department of Orthopedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Giulia C Frias
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Daniel K Haddad
- Department of Orthopedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Kevin D Guerrero
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Vivian Chen
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Fan Ling
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - David Kirschenbaum
- Department of Orthopedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - James T Monica
- Department of Orthopedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Brian M Katt
- Department of Orthopedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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Nordback PH, Ragupathi T, Cheah A. A proposed paradigm shift in the management of distal radius fractures. J Orthop 2024; 49:117-122. [PMID: 38152426 PMCID: PMC10749825 DOI: 10.1016/j.jor.2023.11.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/25/2023] [Indexed: 12/29/2023] Open
Abstract
Background and objective Distal radius fractures represent a remarkable orthopaedic entity. Most distal radius fractures can be treated conservatively with closed reduction and immobilisation with satisfactory results, while open reduction and internal fixation is reserved for displaced fractures. Our objective was to propose a paradigm shift in the management of distal radius fractures. Methods A literature search of management of distal radius fractures was conducted. PubMed and Cochrane databases were used for the search. English articles with open access or institutional subscription availability were included. Key content and finding Current literature supports operative management for younger active patients with defined radiographic inclusion parameters, but among the elderly there is little evidence of benefit. Most orthopaedic literature defines "elderly" as patients above 65 years of age. Non-surgical treatment for fractures of the distal radius tends to yield satisfactory functional results, and these favourable outcomes do not necessarily align with normal radiological parameters. For the minority of patients that have symptomatic malunion, corrective osteotomy is a good option to improve the function provided the symptoms can be clearly attributed to the malalignment. Conclusion The vast majority of distal radius fractures can be managed conservatively. Further studies are recommended to explore the feasibility of advocating for universal conservative treatment for patients with less functional demands while still having the option of staged surgery in the form of corrective osteotomy where there is symptomatic malunion amenable to anatomical correction. Future research should also aim to identify patients who would benefit most from surgical intervention by considering the type of functional recovery needed, rather than relying predominantly on the patient's chronological age as the determining factor in the decision-making process.
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Affiliation(s)
- Panu H. Nordback
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
- Musculoskeletal and Plastic Surgery, Department of Hand Surgery, University of Helsinki and Helsinki University Hospital, Finland
| | - Tharun Ragupathi
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
| | - Andre.E.J. Cheah
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore
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3
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Román-Veas J, Gutiérrez-Espinoza H, Campos-Jara C, Martínez-García D. Arthroscopic Assistance in Surgical Management of Distal Radius Fractures: A Systematic Review and Meta-analysis. J Wrist Surg 2024; 13:86-95. [PMID: 38264129 PMCID: PMC10803148 DOI: 10.1055/s-0042-1757768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/05/2022] [Indexed: 10/17/2022]
Abstract
Background Wrist arthroscopy has become a commonly used tool for the management of adults with distal radius fractures (DRFs), although its implementation requires technical competence. This systematic review and meta-analysis appraised the available evidence concerning the contribution of wrist arthroscopy to the functional and radiological outcomes of patients with DRFs operated with arthroscopic assistance. Methods Randomized control trials were identified through five principal electronic databases on May 31, 2022: Web of Science, Scopus, EBSCO, Embase, and PubMed. Two authors independently performed the search and data extraction and assessed risk of bias (RoB) using the Cochrane RoB tool. Results A total of 1,780 relevant abstracts and citations were extracted in the preliminary search, which yielded 6 trials that met the eligibility criteria, and 3 studies were included in the quantitative synthesis. The overall pooled mean difference (MD) estimate showed no significant difference in the Disabilities of the Arm, Shoulder, and Hand scores between surgical groups with and without arthroscopic assistance (MD = 0.77 points, 95% confidence interval = -6.58 to 5.03, p = 0.79), with substantial heterogeneity (I 2 = 85%). Conclusion There was low-quality evidence that wrist arthroscopy conveyed not clinically or statistically significant difference to functional outcomes of patients with DRFs. However, our findings are limited by the numbers of studies included and lack of long-term follow-up, although they do provide a good starting point for future quality research.
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Affiliation(s)
| | | | - Christian Campos-Jara
- Exercises and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Santiago, Chile
| | - Darío Martínez-García
- Department of Physical Education and Sports, Faculty of Sports Sciences, University of Granada, Granada, Spain
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4
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Nielsen C, Merrell D, Reichenbach R, Mayolo P, Qubain L, Hustedt JW. An Evaluation of Patient-reported Outcome Measures and Minimal Clinically Important Difference Usage in Hand Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5490. [PMID: 38111720 PMCID: PMC10727676 DOI: 10.1097/gox.0000000000005490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/31/2023] [Indexed: 12/20/2023]
Abstract
Background This study was designed to examine the current use of patient-reported outcome measures (PROMs) and minimal clinically important difference (MCID) calculations in the hand surgery literature in an effort to standardize their use for research purposes. Methods A systematic review of the hand surgery literature was conducted. All nonshoulder upper extremity articles utilizing PROMs were compared between different journals, different surgical indications, and differing usage. MCID values were reported, and calculation methods assessed. Results In total, 4677 articles were reviewed, and 410 met the inclusion criteria of containing at least one PROM. Of the 410 articles reporting PROMs, 148 also mentioned an associated MCID. Of the articles that mentioned MCIDs, 14 calculated MCID values based on their specific clinical populations, whereas the remainder referenced prior studies. An estimated 35 different PROMs were reported in the study period; 95 different MCID values were referenced from 65 unique articles. Conclusions There are many different PROMs currently being used in hand surgery clinical reports. The reported MCIDs from their related PROMs are from multiple different sources and calculated by different methods. The lack of standardization in the hand surgery literature makes interpretation of studies utilizing PROMs difficult. There is a need for a standardized method of calculating MCID values and applying these values to established PROMs for nonshoulder upper extremity conditions.
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Affiliation(s)
- Colby Nielsen
- From the Department of Orthopedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Ariz
| | - Dallin Merrell
- From the Department of Orthopedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Ariz
| | - Rachel Reichenbach
- From the Department of Orthopedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Ariz
| | - Patrick Mayolo
- From the Department of Orthopedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Ariz
| | - Leeann Qubain
- From the Department of Orthopedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Ariz
| | - Joshua W Hustedt
- From the Department of Orthopedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Ariz
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5
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Thorninger R, Romme KL, Wæver D, Henriksen MB, Tjørnild M, Lind M, Rölfing JD. Posttraumatic arthritis and functional outcomes of nonoperatively treated distal radius fractures after 3 years. Sci Rep 2023; 13:21102. [PMID: 38036760 PMCID: PMC10689758 DOI: 10.1038/s41598-023-48630-3] [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] [Received: 03/10/2023] [Accepted: 11/28/2023] [Indexed: 12/02/2023] Open
Abstract
Recent studies have shown that distal radius fractures (DRFs) in elderly patients can be treated nonoperatively with good functional results after 1 year. However, scientific evidence regarding longer follow-up to assess posttraumatic arthritis (PA), complications, and functional outcomes is scarce. This prospective case series aimed to evaluate these outcomes in a cohort of patients ≥ 65-year-old with nonoperatively treated DRFs after a minimum of 3 years. The primary outcome was PA. Secondary outcomes were complications, Quick Disabilities of the Arm, Shoulder and Hand Outcome Measure (QuickDASH), Patient-Rated Wrist/Hand Evaluation (PRWHE), pain, range of motion and grip strength. The full data of 32 patients with a mean follow-up of 3.3 years were available: 10/32 patients had radiological signs of PA, but only 2 of these patients reported pain. A total of 11/32 fractures healed in malunion (> 10° dorsal angulation). There was no significant difference in QuickDASH or PRWHE from 1 year to the latest follow-up after more than 3 years. This study thus adds to the literature stating that radiological signs, including PA and malunion, do not necessarily result in symptoms. Moreover, it underpins that nonoperative treatment of these patients results in good functional outcomes after 1 and 3 years.
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Affiliation(s)
- Rikke Thorninger
- Department of Orthopaedics, Regional Hospital Randers, Skovlyvej 15, 8930, Randers, Denmark.
- Department of Clinical Medicine, HEALTH, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus, Denmark.
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark.
| | - Karen Larsen Romme
- Department of Orthopaedics, Regional Hospital Randers, Skovlyvej 15, 8930, Randers, Denmark
| | - Daniel Wæver
- Department of Orthopaedics, Regional Hospital Randers, Skovlyvej 15, 8930, Randers, Denmark
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Martin Bille Henriksen
- Department of Orthopaedics, Regional Hospital Randers, Skovlyvej 15, 8930, Randers, Denmark
| | - Michael Tjørnild
- Department of Orthopaedics, Regional Hospital Randers, Skovlyvej 15, 8930, Randers, Denmark
| | - Martin Lind
- Department of Clinical Medicine, HEALTH, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus, Denmark
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Jan Duedal Rölfing
- Department of Clinical Medicine, HEALTH, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200, Aarhus, Denmark
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
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Tai TH, Chu PJ, Lu KY, Wu JJ, Wong CC. Current Management and Volar Locking Plate Fixation with Bone Cement Augmentation for Elderly Distal Radius Fractures-An Updated Narrative Review. J Clin Med 2023; 12:6801. [PMID: 37959267 PMCID: PMC10648218 DOI: 10.3390/jcm12216801] [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: 09/09/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Distal radius fractures (DRFs) are the most common among all kinds of fractures with an increase in incidence due to the rapidly expanded size of the elderly population in the past decades. Both non-surgical and surgical treatments can be applied for this common injury. Nowadays, more and more elderly patients with DRFs undergo surgical treatments to restore pre-injury activity levels faster. However, optimal treatment for geriatric DRFs is still debated, and careful evaluation and selection of patients are warranted considering clinical and functional outcomes, and complications following surgical treatments. Furthermore, osteoporosis is a predominant factor in elderly DRFs mostly deriving from a low-energy trauma, so many treatment modalities are developed to enhance better bone healing. Among various options for bone augmentation, bone cement is one of the most widely used measures. Bone cement such as calcium phosphate theoretically improves fracture stability and healing, but whether the elderly patients with DRFs can significantly benefit from surgical fixation with bone cement augmentation (BCA) remains controversial. Hence, in the present review, the latest literature regarding current concepts of management and evidence about volar locking plate fixation (VLPF) with BCA for elderly DRFs was searched in MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science; out of >1000 articles, full texts of 48 and 6 articles were then examined and analyzed separately for management and VLPF with BCA for elderly DRFs. We aim to provide the readers with updates concerning the above issues.
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Affiliation(s)
- Ting-Han Tai
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan (P.-J.C.)
| | - Po-Jui Chu
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan (P.-J.C.)
- Department of Primary Care Medicine, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan
| | - Kuan-Yu Lu
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan (P.-J.C.)
| | - Jeffrey J. Wu
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan (P.-J.C.)
| | - Chin-Chean Wong
- Department of Orthopedics, Taipei Medical University Shuang Ho Hospital, New Taipei City 235041, Taiwan (P.-J.C.)
- Department of Orthopedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan
- Research Center of Biomedical Devices, Taipei Medical University, Taipei 110301, Taiwan
- International PhD Program for Cell Therapy and Regenerative Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan
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7
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Michael R, Nakhouzi A, Kahhaleh E, Pelet S. Volar Locking Plating Compared to Conservative Treatment in Distal Radius Fractures in Elderly Patients (>60 years old): A Systematic Review and Meta-Analysis of Randomized Controlled Trials. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:589-594. [PMID: 37790832 PMCID: PMC10543768 DOI: 10.1016/j.jhsg.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 04/15/2023] [Indexed: 10/05/2023] Open
Abstract
Purpose We performed a systematic review and meta-analysis to compare the efficacy of volar locking plating (VLP) to conservative treatment in distal radius fractures in patients aged >60 years old. Methods English articles were searched in electronic databases including MEDLINE, CENTRAL, Embase, Web of science, and ClinicalTrial.gov from inception to October 2020. Relevant article reference lists also were reviewed. Two reviewers independently screened and extracted data from trials comparing VLP to nonsurgical treatment in distal radial fractures in the elderly. Starting with 3052 citations, 5 trials (539 patients) met the inclusion criteria. The primary outcomes were disabilities of the arm, shoulder, and hand, and patient-rated wrist evaluation scores, grip strength, and range of motion. Results All trials of this random effect meta-analysis were at a moderate risk of bias due to the lack of blinding. Differences in the disabilities of the arm, shoulder, and hand score (mean difference [MD] -5,91; 95% confidence interval [CI], -8,83; -3,00), patient-rated wrist evaluation score (MD -9.07; 95% CI, -14.57, -3.57), and grip strength (MD 5,12; 95% CI, 0,59-9,65) were statistically significant and favored VLPs, however without reaching clinical significance. No effect was observed in terms of the range of motion and reoperation rates. Conclusion This review was not able to demonstrate any clinical benefit to the surgical treatment of distal radius fractures with VLP in patients aged >60 years old compared to nonsurgical treatment. Type of study/level of evidence Therapeutic I.
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Affiliation(s)
- Reinemary Michael
- CHU de Québec-Hôpital Enfant-Jésus, 1401, 18ème Rue, Québec (QC) Canada G1J1Z4
| | - Andréa Nakhouzi
- CHU de Québec-Hôpital Enfant-Jésus, 1401, 18ème Rue, Québec (QC) Canada G1J1Z4
| | - Edward Kahhaleh
- CHU de Québec-Hôpital Enfant-Jésus, 1401, 18ème Rue, Québec (QC) Canada G1J1Z4
| | - Stéphane Pelet
- CHU de Québec-Hôpital Enfant-Jésus, 1401, 18ème Rue, Québec (QC) Canada G1J1Z4
- Centre de Recherche du CHU de Québec - Axe Médecine Régénératrice
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8
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Cooke HL, Schaeffer CV, Gabig AM, Karzon A, Savani U, Gottschalk MB, Wagner ER. Total Wrist Arthroplasty as a Motion-Sparing Option for Distal Radius Malunion in a Patient of Advanced Age: A Case Report. JBJS Case Connect 2023; 13:01709767-202309000-00058. [PMID: 37590422 DOI: 10.2106/jbjs.cc.23.00167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
CASE A 62-year-old woman presented with wrist pain secondary to a distal radius fracture malunion 4 months after a fall onto an outstretched hand. She was not an ideal candidate for osteotomy and bone graft because of the degree of displacement and osteoporosis, so after nonoperative treatment was unsuccessful, she was offered total wrist arthroplasty (TWA) or arthrodesis and opted for TWA. CONCLUSION At 14-month follow-up, the patient reported significant improvement in her pain and function. The current generation of TWA implants may allow use in the management of symptomatic distal radius malunions in older, low-demand patients.
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Affiliation(s)
- Hayden L Cooke
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Lawson A, Naylor J, Mittal R, Kale M, Xuan W, Harris IA. Does Radiographic Alignment Correlate With Patient-Reported Functional Outcomes and Posttreatment Complications in Older Patients Treated for Wrist Fractures? J Hand Surg Am 2023:S0363-5023(23)00115-6. [PMID: 37115143 DOI: 10.1016/j.jhsa.2023.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 02/05/2023] [Accepted: 02/15/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE Surgical treatment of distal radius fractures provides better fracture alignment than closed reduction; however, surgical treatment does not lead to better patient-reported function at 12 months. The aims of this study were to report the radiographic outcomes from the Combined Randomized and Observational Study of Surgery for Fractures In the distal Radius in the Elderly trial, investigate the association between radiographic outcomes and patient-reported function, and explore whether this association was affected by posttreatment complications and direction of malalignment. METHODS This study used the outcomes of the Combined Randomized and Observational Study of Surgery for Fractures In the distal Radius in the Elderly trial, which is a combined randomized and observational trial that compared volar-locking plate fixation with closed reduction and cast immobilization, to treat distal radius fractures in patients aged ≥60 years. Four radiographic outcomes (dorsal angulation, radial inclination, ulnar variance, and articular step) were reported at the following three time frames: (1) baseline, (2) after treatment, and (3) ≥6 weeks by treatment group. Secondary analysis was correlation of 12-month patient-reported function scores with 6-week radiographic measures for each of four radiographic parameters, and a subgroup analysis was conducted to investigate if this was affected by posttreatment complications. Tertiary analysis investigated if direction of malalignment affected the secondary analysis. RESULTS We recruited 300 participants (166 randomized and 134 observational); 113 had volar-locking plate fixation, and 187 had closed reduction. There were no between-group differences for each of the four pretreatment radiographic parameters, but there were between-treatment group differences for all four radiographic parameters apart from articular step. We found no association between patient-reported function at 12 months and each of the four radiographic parameters at 6 weeks. This lack of association was unaffected by posttreatment complications and the direction of malalignment. CONCLUSIONS For patients with wrist fractures aged ≥60 years, final radiographic alignment did not correlate with patient-reported function at 12 months. These findings were not affected by treatment type, and there was no association between radiographic alignment and posttreatment complications. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Andrew Lawson
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia; South Western Sydney Clinical School, UNSW Sydney, Sydney, Australia.
| | - Justine Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia; South Western Sydney Clinical School, UNSW Sydney, Sydney, Australia
| | - Rajat Mittal
- South Western Sydney Clinical School, UNSW Sydney, Sydney, Australia
| | - Michael Kale
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
| | - Wei Xuan
- Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia; South Western Sydney Clinical School, UNSW Sydney, Sydney, Australia
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10
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Bohn DC. What's New in Hand and Wrist Surgery. J Bone Joint Surg Am 2023; 105:428-434. [PMID: 36727929 DOI: 10.2106/jbjs.22.01326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Deborah C Bohn
- Department of Orthopedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
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11
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Prospective Evaluation of Two Cohorts of Non-Operatively Treated Patients with Displaced vs. Minimally and Non-Displaced Distal Radius Fractures. J Clin Med 2023; 12:jcm12052076. [PMID: 36902861 PMCID: PMC10004318 DOI: 10.3390/jcm12052076] [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: 02/17/2023] [Revised: 03/01/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Distal radius fractures (DRFs) in the elderly are common. Recently, the efficacy of operative treatment of displaced DRFs in patients above 65 years of age has been questioned and it has been suggested that non-operative treatment should be the gold standard. However, the complications and functional outcome of displaced vs. minimally and non-displaced DRFs in the elderly has not been evaluated yet. The aim of the present study was to compare non-operatively treated displaced DRFs vs. minimally and non-displaced DRFs in terms of complications, PROMs, grip strength and range of motion (ROM) after 2 weeks, 5 weeks, 6 months and 12 months. METHODS We used a prospective cohort study that compared patients with displaced DRFs (n = 50), i.e., >10 degrees of dorsal angulation after two reduction attempts, with patients with minimally or non-displaced DRFs after reduction. Both cohorts received the same treatment of 5 weeks of dorsal plaster casting. Complications and functional outcomes (quick disabilities of the arm, shoulder and hand (QuickDASH), patient-rated wrist/hand evaluation (PRWHE), grip strength and EQ-5D scores) were assessed after 5 weeks, 6 months and 12 months post-injury. The protocol of the VOLCON RCT and present observational study has been published (PMC6599306; clinicaltrials.gov: NCT03716661). RESULTS One year after 5 weeks of dorsal below-elbow casting of low-energy DRFs in patients ≥ 65 years old, we found a complication rate of 6.3% (3/48) in minimally or non-displaced DRFs and 16.6% (7/42) in displaced DRFs (p = 0.18). However, no statistically significant difference was observed in functional outcomes in terms of QuickDASH, pain, ROM, grip strength or EQ-5D scores. DISCUSSION In patients above 65 years of age, non-operative treatment, i.e., closed reduction and dorsal casting for 5 weeks, yielded similar complication rates and functional outcomes after 1 year regardless of whether the initial fracture was non-displaced/minimally displaced or still displaced after closed reduction. While the initial closed reduction should still be attempted in order to restore the anatomy, failure to achieve the stipulated radiological criteria may not be as important as we thought in terms of complications and functional outcome.
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12
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Factor S, Druckmann I, Atlan F, Rosenblatt Y, Tordjman D, Krespi R, Kazum E, Pritsch T, Eisenberg G. The Effects of Novel Pulsed Electromagnetic Field Therapy Device on Acute Distal Radius Fractures: A Prospective, Double-Blind, Sham-Controlled, Randomized Pilot Study. J Clin Med 2023; 12:jcm12051866. [PMID: 36902653 PMCID: PMC10003714 DOI: 10.3390/jcm12051866] [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: 02/14/2023] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND this pilot study aimed at determining whether the application of a novel new method of generating pulsed electromagnetic field (PEMF), the Fracture Healing Patch (FHP), accelerates the healing of acute distal radius fractures (DRF) when compared to a sham treatment. METHODS 41 patients with DRFs treated with cast immobilization were included. Patients were allocated to a PEMF group (n = 20) or a control (sham) group (n = 21). All patients were assessed with regard to functional and radiological outcomes (X-rays and CT scans) at 2, 4, 6 and 12 weeks. RESULTS fractures treated with active PEMF demonstrated significantly higher extent of union at 4 weeks as assessed by CT (76% vs. 58%, p = 0.02). SF12 mean physical score was significantly higher in PEMF treated group (47 vs. 36, p = 0.005). Time to cast removal was significantly shorter in PEMF treated patients, 33 ± 5.9 days in PEMF vs. 39.8 ± 7.4 days in sham group (p = 0.002). CONCLUSION early addition of PEMF treatment may accelerate bone healing which could lead to a shorter cast immobilization, thus allowing an earlier return to daily life activities and work. There were no complications related to the PEMF device (FHP).
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Affiliation(s)
- Shai Factor
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
- Correspondence: ; Tel.: +972-52-7360753; Fax: +972-74-7219810
| | - Ido Druckmann
- Division of Radiology, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Franck Atlan
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Yishai Rosenblatt
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Daniel Tordjman
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Raphael Krespi
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Efi Kazum
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Tamir Pritsch
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Gilad Eisenberg
- Division of Orthopedic Surgery, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
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Gutiérrez-Espinoza H, Araya-Quintanilla F, Cuyul-Vásquez I, Gutiérrez-Monclus R, Reina-Gutiérrez S, Cavero-Redondo I, de Arenas-Arroyo SN. Effectiveness and Safety of Different Treatment Modalities for Patients Older Than 60 Years with Distal Radius Fracture: A Network Meta-Analysis of Clinical Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3697. [PMID: 36834390 PMCID: PMC9965012 DOI: 10.3390/ijerph20043697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/08/2023] [Accepted: 02/13/2023] [Indexed: 06/18/2023]
Abstract
The aim of this study was to compare the clinical effectiveness and complications of different treatment modalities for elderly patients with distal radius fracture (DRF). METHODS We performed a network meta-analysis (NMA) of randomized clinical trials (RCTs). Eight databases were searched. The eligibility criteria for selecting studies were RCTs that compared different treatment modalities (surgical or nonoperative) in patients older than 60 years with displaced or unstable intra-articular and/or extra-articular DRFs. RESULTS Twenty-three RCTs met the eligibility criteria (2020 patients). For indirect comparisons, the main findings of the NMA were in volar locking plate (VLP) versus cast immobilization, with the mean differences for the patient-rated wrist evaluation (PRWE) questionnaire at -4.45 points (p < 0.05) and grip strength at 6.11% (p < 0.05). Additionally, VLP showed a lower risk ratio (RR) of minor complications than dorsal plate fixation (RR: 0.02) and bridging external fixation (RR: 0.25). Conversely, VLP and dorsal plate fixation showed higher rates of major complications. CONCLUSIONS Compared with other treatment modalities, VLP showed statistically significant differences for some functional outcomes; however, most differences were not clinically relevant. For complications, although most differences were not statistically significant, VLP was the treatment modality that reported the lowest rate of minor and overall complications but also showed one of the highest rates of major complications in these patients. PROSPERO Registration: CRD42022315562.
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Affiliation(s)
| | - Felipe Araya-Quintanilla
- Escuela de Kinesiología, Facultad de Odontología y Ciencias de la Rehabilitación, Universidad San Sebastián, Santiago 7510157, Chile
| | - Iván Cuyul-Vásquez
- Faculty of Health, Therapeutic Process Department, Temuco Catholic University, Temuco 4780000, Chile
| | | | - Sara Reina-Gutiérrez
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
| | - Iván Cavero-Redondo
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca 7500912, Chile
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14
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Linnanmäki L, Hevonkorpi T, Repo J, Karjalainen T. Anterior locking plate versus non-operative treatment in different age groups with distal radial fractures: a systematic review and meta-analysis. J Hand Surg Eur Vol 2023; 48:532-543. [PMID: 36624925 DOI: 10.1177/17531934221143636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This meta-analysis compared anterior locking plate and non-operative treatment for distal radial fractures and assessed if the age of the patients is associated with the treatment effect. We searched the MEDLINE, Embase and CENTRAL databases and included 12 studies with 1366 patients. Compared with non-operative care, anterior locking plate treatment does not seem to provide clinically important benefits in mean DASH score, mean pain or their mean quality of life at 12 to 24 months if the patients' ages are not considered (moderate to low certainty evidence). However, the younger the patients, the larger the benefit for surgery. Meta-regression with the DASH score suggested that while people over 70 likely experience no clinically relevant benefit from surgery, the mean effects cannot be generalized to people under 60. The evidence regarding the risk of adverse events is too uncertain to make firm conclusions.
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Affiliation(s)
| | | | - Jussi Repo
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
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15
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Franovic S, Pietroski AD, Druskovich K, Page B, Burdick GB, Fathima B, McIntosh MJ, King EA, Muh SJ. A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 5:169-177. [PMID: 36974282 PMCID: PMC10039314 DOI: 10.1016/j.jhsg.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 11/28/2022] [Indexed: 12/29/2022] Open
Abstract
Purpose To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns. Methods We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis. Results Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness. Conclusions The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation. Type of study/level of evidence Economic/decision analysis II.
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Affiliation(s)
- Sreten Franovic
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | | | | | - Brendan Page
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Gabriel B. Burdick
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Bushra Fathima
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | | | - Elizabeth A. King
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
| | - Stephanie J. Muh
- Department of Orthopaedic Surgery, Henry Ford Health System, Detroit, MI
- Corresponding author: Stephanie J. Muh, MD, Division of Hand and Upper Extremity, Department of Orthopaedic Surgery, Henry Ford Health System, West Bloomfield, MI 48202.
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16
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Davidson A, Feldman G, Mosheiff R, Suna A, Joskowicz L, Weil YA. Computer-Generated Radiographic Measurements of Distal Radius Fractures: Does It Help With Decision Making? J Hand Surg Am 2022:S0363-5023(22)00574-3. [PMID: 36336570 DOI: 10.1016/j.jhsa.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 08/30/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Operative management of distal radius fractures (DRFs) has become increasingly common. Age, activity levels, and comorbid conditions are major factors influencing the treatment decision, although operative indications are still controversial. Radiographic parameters (RPs), such as radial inclination, dorsal tilt, and articular step-off, can provide objective support for effective decision making. However, manual measurement of RPs may be imprecise and subject to inconsistency. To address this problem, we developed custom software of an algorithm to automatically detect and compute 6 common RPs associated with DRF in anteroposterior and lateral radiographs. The aim in this study was to assess the effect of this software on radiographic interobserver variability among orthopedic surgeons. Our hypothesis was that precise and consistent measurement of RPs will improve radiographic interpretation variability among surgeons and, consequently, may aid in clinical decision making. METHODS Thirty-five radiograph series of DRFs were presented to 9 fellowship-trained hand and orthopedic trauma surgeons. Each case was presented with basic clinical information, together with plain anteroposterior and lateral radiographs. One of the 2 possible treatment options was selected: casting or open reduction with a locking plate. The survey was repeated 3 weeks later, this time with computer-generated RP measurements. Data were analyzed for interobserver and intraobserver variability for both surveys, and the interclass coefficient, kappa value, was calculated. RESULTS The interobserver reliability (interclass coefficient value) improved from poor to moderate, 0.35 to 0.50, with the provided RP. The average intraobserver interclass coefficient was 0.68. When participants were assessed separately according to their subspecialties (trauma and hand), improved interobserver variability was found as well. CONCLUSIONS Providing computed RPs to orthopedic surgeons may improve the consistency of the radiographic judgment and influence their clinical decision for the treatment of DRFs. CLINICAL RELEVANCE Orthopedic surgeons' consistency in the radiographic judgment of DRFs slightly improved by providing automatically calculated radiographic measurements to them.
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Affiliation(s)
- Amit Davidson
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem, Israel; Orthopedic Department, Shaare Zedek Medical Center, Jerusalem, Israel.
| | - Guy Feldman
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem, Israel; Orthopedic Department, Emek Medical Center, Afula, Israel
| | - Rami Mosheiff
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Avigail Suna
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Leo Joskowicz
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yoram A Weil
- Orthopaedic Department, Hadassah Hebrew University Hospital, Jerusalem, Israel
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17
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Heifner JJ, McIver ND, Salas C, Mercer DM. A Volar Locking Plate With Fossa Specific Fixation Provides Comparable Stability Between Articular and Nonarticular Cadaveric Models of Distal Radius Fracture. Hand (N Y) 2022; 19:15589447221122825. [PMID: 36168723 PMCID: PMC11067853 DOI: 10.1177/15589447221122825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Distal radius fractures often present with a 3-part articular fragmentation pattern, with separation of the dorsal and volar lunate fossa. The column concept of distal radius fixation addresses the importance of stabilizing both the scaphoid fossa lateral column and the lunate fossa intermediate column. Recent evidence strengthens the value of immediate postoperative mobilization. Satisfactory outcomes following these protocols are predicated on volar locking plates (VLPs) providing adequate stability to the fracture repair. We hypothesize that a VLP which individually supports both lateral and intermediate distal radius columns may provide comparable stability between articular and non-articular cadaveric fracture models under parameters meant to simulate postoperative loading. METHODS Eleven cadaveric matched pair specimens were randomized to receive a simulated AO Type A2 non-articular distal radius fracture on one side with an AO Type C3 articular fracture on the contralateral side. Stiffness during cyclic loading was compared between fracture groups. A matched-paired Student t-test was used to determine statistical significance (P = .05). RESULTS There were no significant differences (P = .35) in stiffness between the articular models (mean 370.0 N/mm, +/-93.5) and the non-articular models (360.4 N/mm, +/-60.0) of distal radius fracture. CONCLUSION A VLP that individually supports the scaphoid and lunate fossa with fixed angle subchondral support may provide comparable fixation strength with resistance to displacement between articular and non-articular fracture patterns. The current results suggest that fossa-specific VLP fixation in articular fractures can maintain construct stability during postoperative loading.
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Affiliation(s)
- John J. Heifner
- St. George’s University School of Medicine, Great River, NY, USA
| | - Natalia D. McIver
- University of New Mexico School of Engineering, Albuquerque, NM, USA
| | - Christina Salas
- University of New Mexico School of Engineering, Albuquerque, NM, USA
| | - Deana M. Mercer
- University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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18
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Alter TH, Varghese BB, DelPrete CR, Katt BM, Monica JT. Reduction Techniques in Volar Locking Plate Fixation of Distal Radius Fractures. Tech Hand Up Extrem Surg 2022; 26:168-177. [PMID: 35132046 DOI: 10.1097/bth.0000000000000380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Distal radius fractures are the most common upper extremity fracture and volar locking plate fixation has become a common modality for operative management of these injuries over the last 2 decades. However, despite the widespread use of volar locking plates, there remains no comprehensive guide detailing the available reduction techniques using these systems. This review aims to consolidate the reduction techniques from the literature along with the authors' experiences into a blueprint for distal radius fracture reduction when using a volar plate. Techniques described include those with and without use of the plate and with supplementary means of fixation for both extra-articular and intra-articular fracture patterns.
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Affiliation(s)
- Todd H Alter
- Department of Orthopaedic Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
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19
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Volar Locking Plate Compared With Combined Plating of AO Type C Distal Radius Fractures: A Randomized Controlled Study of 150 Cases. J Hand Surg Am 2022; 47:813-822. [PMID: 35842329 DOI: 10.1016/j.jhsa.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/20/2022] [Accepted: 04/29/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The optimal way to stabilize intra-articular distal radius fractures is unclear despite recent advances in surgical management. Volar plating is the most common treatment but may not be sufficient for more complex intra-articular AO type C fractures. The purpose of this randomized controlled study was to evaluate the radiographic and clinical outcomes following surgical treatment of AO type C distal radius fractures, comparing volar with combined plating. METHODS In this study, 150 patients were randomized to volar locking plate (n = 75) or combined plating (n = 75) following a distal radius fracture AO type C. The 1-year follow-up included radiographic outcome (Batra score), visual analog scale pain score, hand grip strength, wrist range of motion, Patient-Rated Wrist Evaluation score, and Quick Disabilities of the Arm, Shoulder, and Hand score. RESULTS Overall, 147 patients (median age 61 years) completed the 1-year follow-up (73 patients with volar plate and 74 with combined plating). No difference was found in radiographic outcome between the treatment groups. The volar plate group had significantly better Patient-Rated Wrist Evaluation scores, Quick Disabilities of the Arm, Shoulder, and Hand scores, hand grip strength, visual analog scale scores during activity, and flexion, extension, ulnar and radial deviation than the combined plate group. Hardware removal was performed in 10% in the volar plate group and in 31% in the combined plate group. There was no postoperative infection in the volar plate group but 3 cases in the combined plate group. CONCLUSIONS In patients with complex AO type C intra-articular fractures, volar and combined plating yielded the same radiographic result. The differences in Patient-Rated Wrist Evaluation and Quick Disabilities of the Arm, Shoulder, and Hand scores between the groups did not reach the thresholds for minimal clinically important differences, suggesting similar clinical outcome. The combined plating group had a considerably higher frequency of hardware removal and postoperative infections. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.
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20
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Gutiérrez-Espinoza H, Araya-Quintanilla F, Olguín-Huerta C, Gutiérrez-Monclus R, Valenzuela-Fuenzalida J, Román-Veas J, Campos-Jara C. Effectiveness of surgical versus conservative treatment of distal radius fractures in elderly patients: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2022; 108:103323. [PMID: 35589085 DOI: 10.1016/j.otsr.2022.103323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/25/2021] [Accepted: 12/06/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The aim of this study was to determine whether surgical treatment is more effective than conservative treatment in terms of functional outcomes in elderly patients with distal radius fractures (DRFs). METHODS An electronic search of the Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases was performed, from inception until July 2021. The eligibility criteria for selecting studies were randomized clinical trials that compared surgical versus conservative treatment in subjects older than 60 years with DRFs. Two authors independently performed the search, data extraction, and assessed risk of bias (RoB) using the Cochrane RoB tool. RESULTS Twelve trials met the eligibility criteria, and nine studies were included in the quantitative synthesis. For volar plate versus cast immobilization at 1-year follow-up, the mean difference (MD) for PRWE was -5.36 points (p=0.02), for DASH was -4.03 points (p=0.02), for grip strength was 8.32% (p=0.0004), for wrist flexion was 4.35 degrees (p=0.10), for wrist extension was -1.52 degrees (p=0.008), for pronation was 2.7 degrees (p=0.009), for supination was 4.88 degrees (p=0.002), and for EQ-VAS was 2.73 points (p=0.0007), with differences in favor of volar plate. For K-wire versus cast immobilization at 12 months, there were no statistically significant differences in wrist range of motion (p>0.05). CONCLUSIONS There was low to high evidence according to GRADE ratings, with a statistically significant difference in functional outcomes in favor of volar plate versus conservative treatment at 1-year follow-up. However, these differences are not minimally clinically important, suggesting that both types of management are equally effective in patients older than 60 years with DRFs. LEVEL OF EVIDENCE I; Therapeutic (Systematic review and meta-analysis of randomized clinical trials).
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Affiliation(s)
- Héctor Gutiérrez-Espinoza
- Exercise and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Fernández Concha Street 700, Santiago, Chile.
| | - Felipe Araya-Quintanilla
- Rehabilitation in Health Research Center (CIRES), University of the Americas, Manuel Montt Avenue 948, Santiago, Chile
| | - Cristian Olguín-Huerta
- Rehabilitation in Health Research Center (CIRES), University of the Americas, Manuel Montt Avenue 948, Santiago, Chile
| | | | - Juan Valenzuela-Fuenzalida
- Departamento de Ciencias Químicas y Biológicas, Facultad de Ciencias de la Salud, Universidad Bernardo O'Higgins, Santiago, Chile
| | | | - Christian Campos-Jara
- Exercise and Rehabilitation Sciences Laboratory, School of Physical Therapy, Faculty of Rehabilitation Sciences, Universidad Andres Bello, Fernández Concha Street 700, Santiago, Chile
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21
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Goodman AD, Blood TD, Benavent KA, Earp BE, Akelman E, Blazar PE. Implicit and Explicit Factors That Influence Surgeons' Decision-Making for Distal Radius Fractures in Older Patients. J Hand Surg Am 2022; 47:719-726. [PMID: 35660336 DOI: 10.1016/j.jhsa.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 02/12/2022] [Accepted: 03/23/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate factors that influence surgeons' decision-making in the treatment of distal radius fractures in older patients. METHODS Fourteen clinical vignettes of a 72-year-old patient with a distal radius fracture were sent to 185 orthopedic hand and/or trauma surgeons. The surgeons were surveyed regarding the demographic/practice details, treatment decision (surgical or nonsurgical), and factors that influenced management, including the Charlson Comorbidity Index, functional status, radiographic appearance, and handedness. Multivariable regression analyses were used to assess the effect of both surgeon-described (explicit) and given clinical (implicit) factors on the treatment decision and to evaluate for discrepancies. RESULTS Sixty-six surgeons completed the survey, and 7 surgeons completed 10-13 vignettes. Surgeons made the explicit determination to pursue nonsurgical treatment based on the presence of comorbidities (odds ratio [OR], 0.02 for surgery; 95% confidence interval [CI], 0.01-0.05), but the observation of the underlying clinical data suggested that the recommendation for surgical treatment was instead based on a higher functional status (OR, 3.54/increase in functional status; 95% CI, 2.52-4.98). Those employed by hospitals/health systems were significantly less likely to recommend surgery than those in private practice (OR, 0.42; 95% CI, 0.23-0.79) CONCLUSIONS: This study demonstrates that the presence of comorbidities, functional status, and practice setting has a significant impact on a surgeon's decision to treat distal radius fractures in older patients. The discrepancy between the surgeon-described factors and underlying clinical data demonstrates cognitive bias. CLINICAL RELEVANCE Surgeons should be aware of cognitive biases in clinical reasoning and should work through consequential patient decisions using an analytical framework that attempts to reconcile all available clinical data.
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Affiliation(s)
- Avi D Goodman
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston MA; Department of Orthopaedics, Rhode Island Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI.
| | - Travis D Blood
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston MA
| | - Kyra A Benavent
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston MA
| | - Brandon E Earp
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston MA; Harvard Medical School, Boston, MA
| | - Edward Akelman
- Department of Orthopaedics, Rhode Island Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI; University Orthopedics, East Providence, RI
| | - Philip E Blazar
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston MA; Harvard Medical School, Boston, MA
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22
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Adie S, Griffin XL, Harris IA, Gorelik A, Chang WJ. Surgical (percutaneous pinning or plate fixation) versus non-surgical interventions for distal radius fractures in adults: an individual participant data review. Hippokratia 2022. [DOI: 10.1002/14651858.cd014933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Sam Adie
- School of Clinical Medicine; UNSW Medicine & Health; UNSW Sydney Australia
| | | | - Ian A Harris
- School of Clinical Medicine; UNSW Medicine & Health; UNSW Sydney Australia
| | - Alexandra Gorelik
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Malvern Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | - Wei-Ju Chang
- Centre for Pain IMPACT; Neuroscience Research Australia; Randwick Australia
- School of Health Sciences, College of Health, Medicine and Wellbeing; The University of Newcastle; Callaghan Australia
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23
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Südow H, Severin S, Wilcke M, Saving J, Sköldenberg O, Navarro CM. Non-operative treatment or volar locking plate fixation for dorsally displaced distal radius fractures in patients over 70 years - a three year follow-up of a randomized controlled trial. BMC Musculoskelet Disord 2022; 23:447. [PMID: 35549696 PMCID: PMC9097389 DOI: 10.1186/s12891-022-05394-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/03/2022] [Indexed: 02/02/2023] Open
Abstract
Background Surgical treatment of displaced distal radius fractures (DRF) in older patients has increased, despite lacking evidence of its superiority over non-operative treatment. How treatment choice affects these patients after the initial 12-month period remains unknown. This study presents a clinical and radiographic follow up at an average of 3 years after treatment in the context of a randomized clinical trial comparing outcomes in patients aged ≥70 years, with a dorsally displaced distal radius fracture treated either surgically with volar locking plate or non-operatively. Methods Between 2009 and 2017, 140 patients aged ≥70 years with dorsally displaced DRF were randomized to surgery with volar locking plate (VLP) or non-operative treatment. At an average of 3 years after inclusion the participants were invited to an additional follow-up. The primary outcome was Patient Rated Wrist Evaluation (PRWE). Secondary outcomes included additional Patient Reported Outcome Measures (PROM), grip strength, range of motion, complications and radiological results. Results Sixty six patients were available for a 3 year follow-up, 33 in the non-operatively treated group and 33 in the VLP-group. The mean age at injury was 77 years. At 3 years the median PRWE was better (0 points) in the VLP-group than in the non-operative treatment group (9 points) p-value: 0.027. No statistically significant difference was found in Disabilities of the Arm, Hand, and Shoulder (DASH), EuroQol 5 Dimensions (EQ-5D) or grip strength. Total arc of range of motion was larger in the operatively treated group. No significant difference in osteoarthritis was found. Both groups had regained grip strength. The complication rate was similar. Outcomes improved from the 1 year to the 3 year follow-up. Conclusions Surgery with volar locking plate gave less long-term disability compared to non-operative treatment for severely displaced distal radius fractures in patients aged ≥70 years. Our findings were statistically significant but in the lower range of clinical importance. Trial registration The study was registered at : NCT02154620 03/06/2014 and NCT01268397 30/12/2010. Ethical approval was obtained from Ethical Committee in Stockholm, Sweden (2009/37–31/3, 2013/105–31/2, 2014/1041–32, 2017/611–32).
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Affiliation(s)
- Hanna Südow
- Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, SE-118 83, Stockholm, Sweden. .,Department of Orthopedics, Södersjukhuset Hospital, Stockholm, Sweden.
| | - Sara Severin
- Karolinska Institute, Department of Clinical Science, Danderyd Hospital, Stockholm, Sweden.,Department of Orthopedics, Danderyd University Hospital Corp, Stockholm, Sweden
| | - Maria Wilcke
- Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, SE-118 83, Stockholm, Sweden.,Department of Hand Surgery, Södersjukhuset Hospital, Stockholm, Sweden
| | - Jenny Saving
- Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, SE-118 83, Stockholm, Sweden.,Capio Artro Clinic, Stockholm, Sweden
| | - Olof Sköldenberg
- Karolinska Institute, Department of Clinical Science, Danderyd Hospital, Stockholm, Sweden.,Department of Orthopedics, Danderyd University Hospital Corp, Stockholm, Sweden
| | - Cecilia Mellstrand Navarro
- Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, SE-118 83, Stockholm, Sweden.,Department of Hand Surgery, Södersjukhuset Hospital, Stockholm, Sweden
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Lawson A, Naylor J, Buchbinder R, Ivers R, Balogh ZJ, Smith P, Xuan W, Howard K, Vafa A, Perriman D, Mittal R, Yates P, Rieger B, Smith G, Adie S, Elkinson I, Kim W, Sungaran J, Latendresse K, Wong J, Viswanathan S, Landale K, Drobetz H, Tran P, Page R, Beattie S, Mulford J, Incoll I, Kale M, Schick B, Li T, Higgs A, Oppy A, Harris IA. Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Secondary Analysis of a Randomized Clinical Trial. JAMA Surg 2022; 157:563-571. [PMID: 35476128 PMCID: PMC9047748 DOI: 10.1001/jamasurg.2022.0809] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Distal radius fractures are common and are managed with or without surgery. Current evidence indicates surgical treatment is not superior to nonsurgical treatment at 12 months. Objective Does surgical treatment for displaced distal radius fractures in patients 60 years or older provide better patient-reported wrist pain and function outcomes than nonsurgical treatment at 24 months? Design, Setting, and Participants In this secondary analysis of a combined multicenter randomized clinical trial (RCT) and a parallel observational study, 300 patients were screened from 19 centers in Australia and New Zealand. Of these, 166 participants were randomized to surgical or nonsurgical treatment. Participants who declined randomization (n = 134) were included in the parallel observational group with the same treatment options and follow-up. Participants were followed up at 3, 12, and 24 months by a blinded assessor. The 24-month outcomes are reported herein. Data were collected from December 1, 2016, to December 31, 2020, and analyzed from February 4 to October 21, 2021. Interventions Surgical treatment consisting of open reduction and internal fixation using a volar-locking plate (VLP group) and nonsurgical treatment consisting of closed reduction and cast immobilization (CR group). Main Outcomes and Measures The primary outcome was patient-reported function using the Patient-Rated Wrist Evaluation (PRWE) questionnaire. Secondary outcomes included health-related quality of life, wrist pain, patient-reported treatment success, patient-rated bother with appearance, and posttreatment complications. Results Among the 166 randomized and 134 observational participants (300 participants; mean [SD] age, 71.2 [7.5] years; 269 women [89.7%]), 151 (91.0%) randomized and 118 (88.1%) observational participants were followed up at 24 months. In the RCT, no clinically important difference occurred in mean PRWE scores at 24 months (13.6 [95% CI, 9.1-18.1] points for VLP fixation vs 15.8 [95% CI, 11.3-20.2] points for CR; mean difference, 2.1 [95% CI, -4.2 to 8.5]; P = .50). There were no between-group differences in all other outcomes except for patient-reported treatment success, which favored VLP fixation (33 of 74 [44.6%] in the CR group vs 54 of 72 [75.0%] in the VLP fixation group reported very successful treatment; P = .002). Rates of posttreatment complications were generally low and similar between treatment groups, including deep infection (1 of 76 [1.3%] in the CR group vs 0 of 75 in the VLP fixation group) and complex regional pain syndrome (2 of 76 [2.6%] in the CR group vs 1 of 75 [1.3%] in the VLP fixation group). The 24-month trial outcomes were consistent with 12-month outcomes and with outcomes from the observational group. Conclusions and Relevance Consistent with previous reports, these findings suggest that VLP fixation may not be superior to CR for displaced distal radius fractures for patient-rated wrist function in persons 60 years or older during a 2-year period. Significantly higher patient-reported treatment success at 2 years in the VLP group may be attributable to other treatment outcomes not captured in this study. Trial Registration ANZCTR.org Identifier: ACTRN12616000969460.
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Affiliation(s)
| | - Andrew Lawson
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Justine Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia
| | - Rebecca Ivers
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Zsolt J Balogh
- Department of Orthopedics, John Hunter Hospital, Newcastle, Australia.,Department of Orthopedics, University of Newcastle, Newcastle, Australia
| | - Paul Smith
- Department of Orthopedics, Canberra Hospital, Canberra, Australia
| | - Wei Xuan
- Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Arezoo Vafa
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Diana Perriman
- Department of Orthopedics, Canberra Hospital, Canberra, Australia
| | - Rajat Mittal
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Piers Yates
- Department of Orthopedics, Fiona Stanley Hospital, Perth, Australia
| | - Bertram Rieger
- Department of Orthopedics, Fiona Stanley Hospital, Perth, Australia
| | - Geoff Smith
- Department of Orthopedics, St George and Sutherland Hospitals, Sydney, Australia
| | - Sam Adie
- Department of Orthopedics, St George and Sutherland Hospitals, Sydney, Australia.,St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia
| | - Ilia Elkinson
- Department of Orthopedics, Wellington Hospital, Wellington, New Zealand
| | - Woosung Kim
- Department of Orthopedics, Wellington Hospital, Wellington, New Zealand
| | - Jai Sungaran
- Department of Orthopedics, Concord Hospital, Sydney, Australia
| | - Kim Latendresse
- Department of Orthopedics, Nambour Hospital and Sunshine Coast University Hospital, Nambour, Australia
| | - James Wong
- Department of Orthopedics, Westmead Hospital, Sydney, Australia
| | | | - Keith Landale
- Department of Orthopedics, Campbelltown Hospital, Sydney, Australia
| | - Herwig Drobetz
- Department of Orthopedics, Mackay Base Hospital, Mackay, Australia
| | - Phong Tran
- Department of Orthopedics, Western Health, Melbourne, Australia
| | - Richard Page
- Department of Orthopedics, University Hospital Geelong, Barwon Health, Geelong, Australia.,Barwon Centre for Orthopaedic Research and Education, School of Medicine, Deakin University, Geelong, Australia
| | - Sally Beattie
- Barwon Centre for Orthopaedic Research and Education, School of Medicine, Deakin University, Geelong, Australia
| | | | - Ian Incoll
- Gosford and Wyong Hospitals, Gosford, Australia
| | | | | | - Trent Li
- Prince of Wales Hospital, Sydney, Australia
| | | | - Andrew Oppy
- Royal Melbourne Hospital, Melbourne, Australia
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.,Liverpool Hospital, Sydney, Australia
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Zeidan M, Stephens AR, Zhang C, Presson AP, Kazmers NH. Evaluating the Impact of Social Deprivation on Mid-Term Outcomes Following Distal Radius Open Reduction Internal Fixation. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2021; 3:235-239. [PMID: 34632351 PMCID: PMC8496877 DOI: 10.1016/j.jhsg.2021.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose Although baseline biopsychosocial factors are associated with short-term patient-reported outcomes following distal radius fracture open reduction internal fixation (ORIF), their effect on mid-term outcomes is unclear. We aimed to evaluate the effect of social deprivation, previously established as a surrogate for depression, pain interference, and anxiety, on quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores >1 year following distal radius ORIF. Methods Adult patients (≥18 years) with an isolated distal radius fracture treated with ORIF by orthopedic trauma and hand surgeons at a single tertiary academic center over a 3-year period were included. Outcomes at ≥1 year postoperatively were evaluated using QuickDASH. Age, follow-up duration, area deprivation index (ADI; a measure of social deprivation), subspecialty (hand vs trauma), and postoperative alignment were assessed using linear regression with 95% confidence intervals after bootstrapping and a permutation test for P values to test for their association with the final QuickDASH score. Results Follow-up data were obtained for 98 of 220 (44.5%) patients at a mean of 3.1 ± 1.0 years after surgery. Mean age and ADI were 53.2 ± 15.4 years and 26.8 ± 18.7, respectively. Most fractures were intra-articular (67.3%), and 72.4% had acceptable postoperative alignment parameters, as defined by the American Academy of Orthopaedic Surgeons clinical practice guidelines. The mean QuickDASH score was 13.0 ± 16.5. There were no significant associations between the final QuickDASH score and any studied factor, including ADI, as determined using univariable analysis. Multivariable analysis showed no association between ADI and the final QuickDASH score, independent of age, sex, treating service, follow-up duration, and fracture alignment or pattern. Conclusions At mid-term follow up after distal radius ORIF, ADI did not correlate with QuickDASH scores, and the QuickDASH scores of the patients did not differ from those of the general population. However, our cohort mostly comprised patients with levels of deprivation below the national median. Although studies have shown that the short-term outcomes of distal radius ORIF are influenced by biopsychosocial factors, outcomes at the time of final recovery may not be associated with social deprivation. Type of study/level of evidence Prognostic IV.
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Affiliation(s)
- Michelle Zeidan
- Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | | | - Chong Zhang
- Division of Public Health, University of Utah, Salt Lake City, UT
| | - Angela P Presson
- Division of Public Health, University of Utah, Salt Lake City, UT
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Objective Outcome Measures Continue to Improve from 6 to 12 Months after Conservatively Treated Distal Radius Fractures in the Elderly-A Prospective Evaluation of 50 Patients. J Clin Med 2021; 10:jcm10091831. [PMID: 33922371 PMCID: PMC8122793 DOI: 10.3390/jcm10091831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 04/18/2021] [Accepted: 04/20/2021] [Indexed: 12/20/2022] Open
Abstract
Distal radius fractures (DRF) in the elderly population above 65 years represent 18% of all fractures and are thereby the second most frequent fracture in the elderly. Fracture dislocation and comminution are often used to determine whether non-operative or operative treatment is indicated. The purpose of this prospective case series of minimally displaced DRF treated with a dorsal cast was to assess the complication rate and patient-reported outcome measures. This single-centre, single-blinded, prospective case series followed 50 conservatively treated DRF patients for one year. Primary outcomes were complications and Quick Disability of Arm Shoulder and Hand (qDASH) score. Secondary outcomes were range of motion (ROM), grip strength and pain, and Patient-Rated Wrist/Hand Evaluation (PRWHE). Results showed only minor complications with a return to prior ROM, qDASH, and pain after 12 months and improvement in outcomes after 6-12 months. In conclusion, the majority of DRF patients who were treated non-operatively with five-week dorsal casting recover fully after minimally displaced DRF. This standard approach is thus considered safe, and the present results provide a reference for other studies.
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Abstract
The field of hand surgery continues to evolve in new and exciting directions. Advances in diagnosis and management for common complaints and complex injuries allow higher-level care, while still being cognizant of the cost of health care delivery. Indications and protocols for past paradigm shifts, such as volar locked plating for distal radial fractures, continue to be honed, and the outcomes seen for modern flexor tendon repairs are impressive. Open questions remain, but promising results for scaphoid nonunion surgery and peripheral nerve reconstruction with processed allograft will continue to shed light on these unsolved problems.
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Affiliation(s)
- Travis A Doering
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 500, Memphis, TN 38104, USA.
| | - Benjamin M Mauck
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 500, Memphis, TN 38104, USA
| | - James H Calandruccio
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee-Campbell Clinic, 1211 Union Avenue, Suite 500, Memphis, TN 38104, USA
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28
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Lawson A, Naylor JM, Buchbinder R, Ivers R, Balogh ZJ, Smith P, Xuan W, Howard K, Vafa A, Perriman D, Mittal R, Yates P, Rieger B, Smith G, Adie S, Elkinson I, Kim W, Sungaran J, Latendresse K, Wong J, Viswanathan S, Landale K, Drobetz H, Tran P, Page R, Beattie S, Mulford J, Incoll I, Kale M, Schick B, Li T, Higgs A, Oppy A, Harris IA. Surgical Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Randomized Clinical Trial. JAMA Surg 2021; 156:229-237. [PMID: 33439250 DOI: 10.1001/jamasurg.2020.5672] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance The burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence. Objective To assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older. Design, Setting, and Participants In this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses. Intervention Surgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR). Main Outcomes and Measures The primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use. Results In the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI -5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48; P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69; P = 0.02). Conclusions and Relevance This randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people. Trial Registration http://anzctr.org.au identifier: ACTRN12616000969460.
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Affiliation(s)
| | - Andrew Lawson
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Justine M Naylor
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia
| | - Rebecca Ivers
- School of Population Health, University of New South Wales, Sydney, Australia
| | - Zsolt J Balogh
- John Hunter Hospital, Newcastle, Australia.,University of Newcastle, Newcastle, Australia
| | | | - Wei Xuan
- Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Arezoo Vafa
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
| | | | - Rajat Mittal
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | | | | | - Geoff Smith
- St George and Sutherland Hospitals, Sydney, Australia
| | - Sam Adie
- St George and Sutherland Hospitals, Sydney, Australia.,St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia
| | | | - Woosung Kim
- Wellington Hospital, Wellington, New Zealand
| | | | - Kim Latendresse
- Nambour General Hospital, Nambour, Australia.,Sunshine Coast University Hospital, Nambour, Australia
| | | | | | | | | | | | - Richard Page
- University Hospital Geelong, Barwon Health, Geelong, Australia.,Barwon Centre for Orthopaedic Research and Education, School of Medicine, Deakin University, Geelong, Australia
| | - Sally Beattie
- Barwon Centre for Orthopaedic Research and Education, School of Medicine, Deakin University, Geelong, Australia
| | | | - Ian Incoll
- University of Newcastle, Newcastle, Australia.,Gosford and Wyong Hospitals, Gosford, Australia
| | | | | | - Trent Li
- Prince of Wales Hospital, Sydney, Australia
| | | | - Andrew Oppy
- Royal Melbourne Hospital, Melbourne, Australia
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.,Liverpool Hospital, Sydney, Australia
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