Cost-Effectiveness of Treatments after Closed Extraarticular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial

BACKGROUND

This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures.

METHODS

This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio.

RESULTS

Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year.

CONCLUSIONS

Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.

Comparison of 24-Month Outcomes After Treatment for Distal Radius Fracture: The WRIST Randomized Clinical Trial

IMPORTANCE

Distal radius fractures (DRFs) are common injuries among older adults and can result in substantial disability. Current evidence regarding long-term outcomes in older adults is scarce.

OBJECTIVE

To compare outcomes across treatment groups at 24 months among adults with DRFs who participated in the WRIST trial.

DESIGN, SETTING, AND PARTICIPANTS

The Wrist and Radius Injury Surgical Trial (WRIST) randomized, international, multicenter trial was conducted from April 1, 2012, through December 31, 2016. Participants were adults aged 60 years or older with isolated, unstable DRFs at 24 health systems in the US, Canada, and Singapore. Data analysis was performed from March 2019 to March 2021.

INTERVENTIONS

Participants were randomized to open reduction and volar locking plate system (VLPS), external fixation with or without supplementary pinning (EFP), and percutaneous pinning (CRPP). The remaining participants chose closed reduction and casting.

MAIN OUTCOMES AND MEASURES

The primary outcome was the 24-month Michigan Hand Outcomes Questionnaire (MHQ) summary score. Secondary outcomes were scores on the MHQ subdomains hand strength and wrist motion.

RESULTS

A total of 304 adults were recruited for the study, and 187 were randomized to undergo surgery, 65 to VLPS, 64 to EFP, and 58 to CRPP; 117 participants opted for closed reduction and casting. Assessments were completed at 24 months for 182 participants (160 women [87.9%]; mean [SD] age, 70.1 [8.5] years). Mean MHQ summary scores at 24 months were 88 (95% CI, 83-92) for VLPS, 83 (95% CI, 78-88) for EFP, 85 (95% CI, 79-90) for CRPP, and 85 (95% CI, 79-90) for casting, with no clinically meaningful difference across groups after adjusting for covariates (χ23 = 1.44; P = .70). Pain scores also did not differ across groups at 24 months (χ23 = 2.64; P = .45). MHQ summary scores changed from 82 (95% CI, 80-85) to 85 (95% CI, 83-88) (P = .12) between 12 and 24 months across groups. The rate of malunion was higher in the casting group (26 participants [59.1%]) than in the other groups (4 participants [8.0%] for VLPS, 8 participants [17.0%] for EFP, and 4 participants [9.8%] for CRPP; χ23 = 43.6; P < .001), but malunion was not associated with the 24-month outcome difference across groups.

CONCLUSIONS AND RELEVANCE

The study did not find clinically meaningful patient-reported outcome differences 24 months after injury across treatment groups, with little change between 12 and 24 months. These findings suggest that long-term outcomes need not necessarily be considered in deciding between treatment options. Patient needs and recovery goals that fit to relative risks and benefits of each treatment type will be more valuable in treatment decision-making.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01589692.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT01589692.

Patient-Reported and Functional Outcomes After Revision Amputation and Replantation of Digit Amputations: The FRANCHISE Multicenter International Retrospective Cohort Study

Importance

Optimal treatment for traumatic digit amputation is unknown.

Objective

To compare long-term patient-reported and functional outcomes between patients treated with revision amputation or replantation for digit amputations.

Design, Setting, and Participants

Retrospective cohort study at 19 centers in the United States and Asia. Participants were 338 individuals 18 years or older with traumatic digit amputations with at least 1 year of follow-up after treatment. Participants were enrolled from August 1, 2016, to April 12, 2018.

Exposures

Revision amputation or replantation of traumatic digit amputations.

Main Outcomes and Measures

The primary outcome was the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were the 36-Item Short Form Health Survey (SF-36), Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity module scores and functional outcomes.

Results

Among 338 patients who met all inclusion criteria, the mean (SD) age was 48.3 (16.4) years, and 85.0% were male. Adjusted aggregate comparison of patient-reported outcomes (PROs) between patients with revision amputation and replantation revealed significantly better outcomes in the replantation cohort measured by the MHQ (5.93; 95% CI, 1.03-10.82; P = .02), DASH (-4.29; 95% CI, -8.45 to -0.12; P = .04), and PROMIS (3.44; 95% CI, 0.60 to 6.28; P = .02) scores. In subgroup analyses, DASH scores were significantly lower (6 vs 9, P = .05), indicating less disability and pain, and PROMIS scores higher (78 vs 75, P = .04) after replantation. Patients with 3 or more digits amputated (including thumb) had significantly better PROs after replantation than those managed with revision amputation (22 vs 42, P = .03 for DASH and 61 vs 36, P = .01 for PROMIS). Patients who underwent replantation after 3 or more digits amputated (excluding thumb) had higher MHQ scores, which did not reach statistical significance (69 vs 65, P = .06). Revision amputation in the subgroup with single-finger amputation distal to the proximal interphalangeal joint resulted in better 2-point discrimination (6 vs 8 mm, P = .05). Compared with revision amputation, replantation resulted in better 9-hole peg test times in the subgroup with 3 or more digits amputated (including thumb) (46 vs 81 seconds, P = .001), better Semmes-Weinstein monofilament test in the subgroup with 3 or more digits amputated (excluding thumb) (3 vs 21 g, P = .008), and better 3-point pinch test in the subgroup with 2 digits amputated (excluding thumb) (6.7 vs 5.6 kg, P = .03).

Conclusions and Relevance

When technically feasible, replantation is recommended in 3 or more digits amputated and in single-finger amputation (excluding thumb) distal to the proximal interphalangeal joint because it achieved better PROs, with long-term functional benefit. Thumb replantation is still recommended for its integral role in opposition.

Assessment of Anatomic Restoration of Distal Radius Fractures Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

The value of precise anatomic restoration for distal radius fractures (DRFs) in older adults has been debated for many decades, with conflicting results in the literature. In light of the growing population of adults aged 60 years and older, both fracture incidence and associated treatment costs are expected to increase.

OBJECTIVE

To determine the association between radiographic measures of reduction and patient outcomes after DRF in older patients.

DESIGN, SETTING, AND PARTICIPANTS

Data were collected from the Wrist and Radius Injury Surgical Trial (WRIST), a multicenter randomized clinical trial of DRF treatments for adults aged 60 years and older (enrollment from April 10, 2012, to December 31, 2016, with a 2-year follow-up). Data analysis was performed from January 3, 2019, to August 19, 2019. WRIST participants who completed 12-month assessments were included in the study. According to the biomechanical principle of alignment, 2-phase multivariable regression models were adopted to assess the association between radiographic measures of reduction and functional and patient-reported outcomes 12 months following treatment.

INTERVENTIONS

Participants were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Those who opted for nonoperative treatment received casts.

MAIN OUTCOMES AND MEASURES

Hand grip strength, wrist arc of motion, radial deviation, ulnar deviation, the Michigan Hand Outcomes Questionnaire (MHQ) total score, MHQ function score, and MHQ activities of daily living score were measured at 12 months following treatment.

RESULTS

Data from 166 WRIST participants (144 [86.7%] women; mean [SD] age, 70.9 [8.9] years) found that only 2 of the 84 correlation coefficients calculated were statistically significant. For patients aged 70 years or older, every degree increase in radial inclination away from normal (22°) grip strength in the injured hand was 1.1 kg weaker than the uninjured hand (95% CI, 0.38-1.76; P = .004) and each millimeter increase toward normal (0 mm) in ulnar variance was associated with a 10.4-point improvement in MHQ ADL score (95% CI, -16.84 to -3.86; P = .003). However, neither of these radiographic parameters appeared to be associated with MHQ total or function scores.

CONCLUSIONS AND RELEVANCE

The study results suggest that precise restoration of wrist anatomy is not associated with better patient outcomes for older adults with DRF 12 months following treatment. Surgeons can consider this evidence to improve quality of care by prioritizing patient preferences and efficient use of resources over achieving exact realignment.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01589692.

Patient satisfaction after treatment of distal radial fractures in older adults

The Wrist and Radius Injury Surgical Trial (WRIST) collaboration is the largest clinical trial ever conducted in hand surgery. We applied data from this study to examine the relationship between functional outcomes and patient satisfaction after treatment of distal radial fractures. Patients aged 60 years and older with isolated distal radial fractures were enrolled at 24 health systems. Grip strength and the arc of wrist motion were measured after treatment. The Michigan Hand Outcomes Questionnaire was used to measure patient satisfaction. Receiver operating characteristic curves were created using patient satisfaction as the reference standard and each functional measure as a predictor. At 12 months after treatment, mean grip strength was 82% of normal and mean arc of motion was 88% of normal. The optimal cut-off points to distinguish satisfaction from dissatisfaction occurred when patients recovered 59% of hand strength and 79% of wrist motion. Continuing therapy to increase functional gains beyond this point unnecessarily utilizes healthcare resources without additional patient-reported gains. Level of evidence: IV.

The Complexity of Conducting a Multicenter Clinical Trial: Taking It to the Next Level Stipulated by the Federal Agencies

Randomized controlled trials are becoming increasingly difficult to organize and conduct efficiently. This, in turn, hinders the ability to derive the highest level of evidence. Often, investigators forget or remain unaware of essential practices that will help them fulfill their study goals. This article emphasizes the common issues that a study team experiences during the planning and conducting of randomized controlled trials. The authors sought to share remedies to overcome these issues with the experience garnered in conducting several multicenter clinical trials and observational studies. In addition, the authors list resources from sponsors such as the National Institutes of Health and the U.S. Food and Drug Administration that study teams can apply to undertake studies effectively.

Predicting Outcomes After Distal Radius Fracture: A 24-Center International Clinical Trial of Older Adults

PURPOSE

Current evidence on predictors of outcomes after distal radius fracture is often based on retrospective analyses or may be confounded by fracture type. Using data from the Wrist and Radius Injury Surgical Trial (WRIST), a 24-site randomized study of distal radius fracture treatment, in which all fractures are severe enough to warrant surgery, we set out to perform a secondary data analysis to explore predictors of better or worse hand outcomes.

METHODS

The primary outcome measure was the Michigan Hand Outcomes Questionnaire (MHQ) summary score 12 months after treatment. We used a regression tree analysis with recursive partitioning to identify subgroups of participants who experienced similar outcomes (ie, MHQ score) and to determine which baseline or treatment factors they had in common.

RESULTS

Factors most predictive of 12-month MHQ score were pain at enrollment, education, age, and number of comorbidities. Specifically, participants who had a high school education or less and also reported severe pain had the lowest MHQ scores. Conversely, participants with less pain and more education and who were age 87 years or younger with one or no comorbid condition had the highest MHQ scores. Treatment type or radiographic measurements assessed on post-reduction films did not affect 12-month outcomes.

CONCLUSIONS

These results identified patient characteristics that can be used by surgeons to identify subgroups of patients who may experience similar hand outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Variation in the Treatment of Distal Radius Fractures in the United States: 2010 to 2015

BACKGROUND

It remains unknown whether treatment trends for distal radius fracture have changed in light of value-based care initiatives during recent years. The authors aimed to characterize modern practice patterns for distal radius fracture management.

METHODS

Truven MarketScan databases from 2009 to 2015 were used to extract demographic characteristics, geographic location, and comorbidities for patients receiving treatment for a distal radius fracture. Regression modeling and Joinpoint analysis were used to assess treatment trends and the association of patient factors with treatment provided.

RESULTS

Among 499,766 eligible encounters, the rate of internal fixation fluctuated around 13 percent. Casting/splinting remained the most frequent treatment across all populations. Treatment trends varied by age; children and adolescents almost exclusively received closed treatment (mean, 97 percent), yet rates of internal fixation increased among adults and elderly patients. Patients aged 55 to 64 years were most likely to undergo internal fixation (OR, 1.89; 95 percent CI, 1.82 to 1.96). Higher median household income also significantly increased odds of receiving internal fixation (p < 0.001). Despite declining rates of external fixation and percutaneous pinning, regional variations among surgical modalities persist.

CONCLUSIONS

The increased use of internal fixation for distal radius fractures may be slowing. Treatment type continues to differ widely across demographic groups, underscoring the need for standardization. In accordance with value-based care initiatives, treatment decisions should be made to combine patient needs with financial implications on the health system. Comparative effectiveness data to derive optimal management strategies are still warranted.

The golden year: How functional recovery sets the stage for tendon transfer surgery among patients with tetraplegia-a qualitative analysis

BACKGROUND

Tendon transfer surgery can effectively improve hand function for patients with tetraplegia but remains poorly utilized. Little is known regarding how patients' rehabilitation experiences influence their perception of function, identity, and coping to shape their reconstructive context.

METHODS

We performed a cross-sectional qualitative analysis of 19 participants with C4-C7 cervical spinal injuries: 9 patients had undergone reconstruction; 10 had not. Semistructured interviews were conducted using an interview guide focusing on rehabilitation experience, the relationship between function and identity, and how patient experience evolved. Interview transcripts were analyzed using grounded theory.

RESULTS

The study sample was predominantly male (79%), white (89%), and American Spinal Injury Association grades A-D (grade A: 42%; grade B: 32%; grade C: 16%; grade D: 10%). Recognizing rehabilitation's necessity, functional gains, and constructive patient-therapist relationships promoted engagement in therapy. Poor insurance coverage and financial constraints decreased rehabilitation access. Function affected identity through the degree to which it tied participants to a "patient" role. Early in recovery, patients' function, roles, and attitudes were fluid but solidified over time; how satisfied patients were with these final positions influenced how they coped.

CONCLUSION

The balance of patients' positive and negative coping has been found to influence patients' progression to surgery. This study describes how function and identity contribute to coping. Participants' function and identity evolved during a finite period we call "the golden year," before reaching a fixed point around which they built their lives. The norms patients establish during this time may affect receptiveness to surgery.

Assessment of Distal Radius Fracture Complications Among Adults 60 Years or Older: A Secondary Analysis of the WRIST Randomized Clinical Trial

IMPORTANCE

Complications affect treatment outcomes and quality of life in addition to increasing treatment costs.

OBJECTIVES

To evaluate complication rates after the treatment of a distal radius fracture, to determine whether the rate or complication type is associated with treatment method, and to determine predictors of complications.

DESIGN, SETTING, AND PARTICIPANTS

The multicenter Wrist and Radius Injury Surgical Trial (WRIST), a randomized clinical trial, enrolled participants from April 10, 2012, to December 31, 2016. The study included 304 adults 60 years or older with isolated unstable distal radius fractures; 187 were randomized and 117 opted for casting. The study was conducted at 24 health systems in the United States, Canada, and Singapore. Data for this secondary analysis were collected from April 24, 2012, to February 28, 2018.

INTERVENTIONS

Participants opting for surgery were randomized to receive the volar locking plate system (n = 65), percutaneous pinning (n = 58), or bridging external fixation with or without supplemental pinning (n = 64). Patients who chose not to have surgery (n = 117) were not randomized and were enrolled for casting.

MAIN OUTCOMES AND MEASURES

Complication rate.

RESULTS

The WRIST enrolled a total of 304 participants, of whom 8 casting group participants were later found to be ineligible and were excluded from the analysis, leaving 296 participants. Randomized participants' mean (SD) age was 68 (7.2) years, 163 (87%) were female, and 165 (88%) were white. Casting participants' mean (SD) age was 75.6 (9.6) years, 93 (84%) were female, and 85 (85%) were white. The most common type of complications varied by treatment. Twelve of 65 participants (18.5%) in the internal fixation group reported a median nerve compression, while 16 of 26 participants (25.8%) who received external fixation and 13 of 56 participants (23.2%) who received pinning sustained pin site infections. Compared with the internal fixation group, complication rate for any severity complication was higher in participants who initially received casting (adjusted rate ratio, 1.88; 95% CI, 1.22-2.88), whereas the rate for moderate complications was higher in the external fixation group (adjusted rate ratio, 2.52; 95% CI, 1.25-5.09).

CONCLUSIONS AND RELEVANCE

The distal radius fracture treatment decision-making process for older patients should incorporate a complication profile for each treatment type. For example, external fixation and pinning could be used for patients after apprising them of pin site infection risk. Internal fixation can be done in patients with high functional demands who are willing to receive surgery. Internal fixation use should be substantiated owing to the time and cost involved.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01589692.

The Desired Role of Health Care Providers in Guiding Older Patients With Distal Radius Fractures: A Qualitative Analysis

PURPOSE

Understanding patient preferences for shared decision making is valuable for surgeons to advance patient-centered care, particularly in cases where there is not a clearly superior treatment option, like distal radius fracture. The existing evidence presents conflicting views on the desired role of the provider among older patients when making medical decisions. We aimed to investigate the perceived versus desired role of the provider in older adult patients with distal radius fracture.

METHODS

Thirty patients (≥62 years old) who had sustained a distal radius fracture within the past 5 years were recruited from the screening process of the Wrist and Radius Injury Surgical Trial at the principal investigator's site using purposive sampling. A trained member of the research team conducted interviews in a semistructured format with the help of an interview guide. Findings were derived following the principles of grounded theory.

RESULTS

Participants experienced varied levels of shared decision making with the hand surgeon. Subjects' perceived role of the surgeon did not always match their desired role. Most patients placed distinct trust in the recommendations of hand specialists regarding the technical aspects of the treatment. Nonetheless, respondents wanted to provide input when decisions pertained to outcomes or functionality. Many patients sought outside support from family or friends in the health care field, regardless of the outside source's medical specialty.

CONCLUSIONS

Despite conflicting evidence, most older adult patients desire a shared approach when making treatment decisions. Exchanging information and preferences on outcomes of each treatment option may be more important to the patient than detailing the specific technical aspects of their care.

CLINICAL RELEVANCE

To provide high quality care, surgeons should evaluate the desired role of the patient to make treatment decisions at the start of their interaction. Surgeons must be aware of outside medical influences that guide their patients' decision-making processes.

Leveraging the Medical Context to Increase Upper Extremity Reconstruction Among Patients With Tetraplegia: A Qualitative Analysis

OBJECTIVES

To (1) characterize patients' medical experiences from initial injury until they become candidates for upper extremity reconstruction (UER); and (2) identify points in this medical context that may be most amenable to interventions designed to increase UER utilization.

DESIGN

A qualitative cross-sectional study using grounded theory methodology and constant comparative analysis of data collected through semistructured individual interviews.

SETTING

Community.

PARTICIPANTS

A sample of individuals with C4 to C8 cervical spinal injuries (N=19) who sustained injuries at least 1 year before interview. Nine patients had undergone reconstruction, and 10 had not. The study sample was predominantly male (79%) and white (89%), and American Spinal Injury Association grades A through D were represented (A, 42%; B, 32%; C, 16%; D, 10%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants' self-report of their medical experiences from the time of injury through the early recovery period.

RESULTS

We identified 3 domains that formed patients' medical context before UER candidacy: (1) their ability to achieve and maintain health; (2) their relationship with health care providers; and (3) their expectations regarding clinicians' tetraplegia-specific expertise. Trust emerged as a major theme driving potential intervention targets. Patients transferred to referral centers had higher trust in tertiary providers relative to local physicians. In the outpatient setting, patients' trust correlated with the tetraplegia-specific expertise level they perceived the specialty to have (high for physical medicine and rehabilitation, intermediate for urology, low for primary care).

CONCLUSIONS

In appropriate candidates, UER produces substantial functional gains, but reconstruction remains underused in the tetraplegic population. By analyzing how patients achieve health and build trust in early recovery/injury, our study provides strategies to improve UER access. We propose that interventions targeting highly trusted points of care (transfer hospitals) and avoiding low-trust points (primary care physicians, home health) will be most effective. Urology may represent a novel entry point for UER interventions.

Effect of Policy Change on the Use of Long-Distance Transport and Follow-Up Care for Patients With Traumatic Finger Amputations

PURPOSE

In January 2006, the American College of Emergency Physicians released updated guidelines for air transfer. Digit amputation and near-amputation were no longer an indication for this costly service. We analyzed the effect of this update on the use of air transport and associated care outcomes for finger amputation patients and examined factors involved in providing follow-up care for these patients.

METHODS

A retrospective chart review identified all patients treated for traumatic finger amputation between 1995 and 2012 at a major hand trauma referral center. Analysis of available outcome measures was conducted using multiple logistic and linear regression models. Analysis of factors affecting frequency of return visits was performed via negative binomial regression.

RESULTS

We identified 724 patients with isolated traumatic finger amputations. A total of 267 patients (37%) were transferred from an outside hospital. Patients injured after 2006 were less likely to be transferred via air, with a decrease from 29.5% pre-2006 to 14.9% post-2006. There was no difference in likelihood of replantation success, length of hospital stay, or number of return visits pre- versus post-2006. Patients transferred via helicopter after 2006 were more likely to be younger than 20 years of age and injured in a winter month. Following successful replantation, work-relatedness was associated with a higher number of return visits, whereas increasing age and transfer from farther than 100 miles away were associated with fewer.

CONCLUSIONS

After the American College of Emergency Physicians policy update, decreased use of emergency air transport to a hand trauma referral center for patients with traumatic finger amputations did not adversely affect care delivery and outcomes. These changes may be successfully implemented on a center-by-center basis to reduce costs without detriment to patient care; however, coordination of follow-up care for long-distance transport patients may require special focus when designing policy around referral centers.

TYPE PF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Checkpoints to Progression: Qualitative Analysis of the Personal and Contextual Factors That Influence Selection of Upper Extremity Reconstruction Among Patients With Tetraplegia

PURPOSE

Patients with tetraplegia consistently rank better use of the upper extremity as their top functional priority. Multiple case series have demonstrated that upper extremity reconstruction (UER) is well-tolerated and can produce substantial functional improvements for appropriate candidates; however, UER remains critically underutilized. The mechanisms that drive differences in provider practice and referral patterns have been studied, but comprehensive examination of the patient factors that influence UER decisions has not been performed for American patients.

METHODS

Nineteen patients with C4-8 cervical spinal injuries were selected using purposive sampling: 9 patients had undergone UER, 10 had not undergone UER. Semistructured interviews were conducted and transcripts evaluated using grounded theory methodology.

RESULTS

Our study yielded a conceptual model that describes the characteristics common to all patients who undergo UER. Patients who selected reconstruction proceeded stepwise through a shared sequence of steps: (1) functional dissatisfaction, (2) awareness of UER, and (3) acceptance of surgery. Patients' ability to meet these criteria was determined by 3 checkpoints: how well they coped, their access to information, and the acceptability of surgery. Extremely positive or negative coping prevented patients from moving from the Coping to the Information Checkpoint; thus, they remained unaware of UER and did not undergo surgery. A lack of knowledge regarding reconstruction was the strongest barrier to surgery among our participants.

CONCLUSIONS

We built a conceptual model that outlines how patients' personal and contextual factors drive their progression to UER. Moving from functional dissatisfaction to understanding that they were candidates for UER was a substantial barrier for participants, particularly those with very high and very low coping skills.

CLINICAL RELEVANCE

To improve utilization for all patients, interventions are needed to increase UER awareness. Standardizing introduction to UER during the rehabilitation process or improving e-content may represent key awareness access points.

Identifying barriers to the care of the rheumatoid hand in China: comparing attitudes of rheumatologists and hand surgeons

AIM

In China, hand surgeons treat fewer rheumatoid arthritis (RA) patients compared to other countries. We investigated whether physician and surgeon knowledge, attitudes and practices regarding RA hand deformities reflect current evidence and may contribute to the low utilization of surgery.

METHOD

We surveyed hand surgeons and rheumatologists at three tertiary hospitals in Beijing, China. Questionnaires were developed from literature and expert review to assess their knowledge, attitudes and practice patterns related to rheumatoid hand surgery.

RESULTS

Thirty-five hand surgeons and 59 rheumatologists completed the survey. Roughly one-third felt that the rheumatologists and hand surgeons agree on how to manage RA hand deformities. One-fifth of rheumatologists and 29% of hand surgeons believed that drug therapy can correct hand deformities, which contradicts current evidence. Likewise, 30% and 14%, respectively, recommended surgery for early-stage hand sequelae that do not meet current indications for surgery. Over 80% of surgeons and rheumatologists had no exposure to the other specialty during training and felt their training on the treatment of rheumatoid hand deformities was inadequate.

CONCLUSION

Although we found similar interspeciality disagreement in China as is seen in the United States, there appears to be less interaction through training and consultations. Our results also indicate potential deficits in training and unawareness of evidence and indications for rheumatoid hand surgery. These findings help to explain why surgery for rheumatoid hand deformities is rare in China; doctors have fewer opportunities to collaborate across specialties and may not be able to select appropriate candidates for surgery.

Risk of Prolonged Opioid Use Among Opioid-Naïve Patients Following Common Hand Surgery Procedures

PURPOSE

To evaluate prolonged opioid use in opioid-naïve patients after common hand surgery procedures in the United States.

METHODS

We studied insurance claims from the Truven MarketScan databases to identify opioid-naïve adult patients (no opioid exposure 11 months before the perioperative period) who underwent an elective (carpal tunnel release, carpometacarpal arthroplasty/arthrodesis, cubital tunnel release, or trigger finger release) or trauma-related (closed distal radius fracture fixation, flexor tendon repair, metacarpal fracture fixation, or phalangeal fracture fixation) hand surgery procedure between 2010 and 2012 (N = 77,573 patients). Patients were observed for 6 months to determine the number, timing, duration, and oral morphine equivalent dosage of postoperative opioid prescriptions. We assessed prolonged postoperative opioid use, defined as patients who filled a perioperative opioid prescription followed by a prescription between 90 and 180 days after surgery, and evaluated associated risk factors using multivariable logistic regression.

RESULTS

In this cohort, 59,725 opioid-naïve patients (77%) filled a perioperative opioid prescription. Of these, 13% of patients continued to fill prescriptions between 90 and 180 days after surgery. Elective surgery patients were more likely to continue to fill opioid prescriptions after 90 days compared with trauma patients (13.5% vs 10.5%). Younger age, female gender, lower income, comprehensive insurance, higher Elixhauser comorbidity index, mental health disorders, and tobacco dependence or abuse were associated with prolonged opioid use.

CONCLUSIONS

Approximately 13% of opioid-naïve patients continue to fill opioid prescriptions after hand surgery procedures 90 days after surgery. Preoperative interventions centered on opioid alternatives and early cessation, particularly among patients at risk for long-term use, is critical to addressing the prescription opioid crisis in the United States.

CLINICAL RELEVANCE

The current national opioid use epidemic requires an assessment of the prevalence of hand surgery patients who receive and fill opioid prescriptions after common hand surgery procedures.

Cross-cultural variation in preference for replantation or revision amputation: Societal and surgeon views

Treatment decisions after an injury like finger amputation are made based on injury and patient factors. However, decisions can also be influenced by provider and patient preferences. We compared hand surgeon and societal preferences and attitudes regarding finger amputation treatment in Japan and the US. We performed a cross-sectional survey with subjects derived from large tertiary care academic institutions in the US and Japan. We secured 100% participation of American hand surgeon members of the Finger Replantation and Amputation Multicenter Study and presenting hand surgeons at the 32nd Annual meeting of the Central Japanese Society for Surgery of the Hand. Societal preferences were gathered from volunteers at the 2 universities in the US and Japan. There were no significant differences in estimations of function, sensation, or appearance after replantation; American and Japanese societal participants preferred replantation compared to surgeons, although this was more pronounced in Japan. The Japanese society displayed more negative attitudes toward finger amputees than did Japanese surgeons. American respondents anticipated more public stigmatisation of amputees than did American surgeons. Societal preference for replantation was not caused by inflated expectations of outcomes after replantation. Japanese societal preference was likely driven by negative views of finger amputees. American society noted no decrease in physical health after amputation, but did note a quality of life decrease attributed to public stigmatisation. Japanese society and surgeons had a stronger preference for replantation than American society and surgeons, possibly attributed to cultural differences.

Mortality after distal radial fractures in the Medicare population

The occurrence of a low energy fracture of the distal radius increases the risk for another, more serious fracture, such as a proximal femoral fracture. Early mortality after a proximal femoral fracture has been widely studied, but the association between a distal radial fracture and mortality is unknown. The date of death for all Medicare beneficiaries who sustained an isolated distal radial fracture in 2007 was determined using Medicare Vital Statistics files. The adjusted mortality rate for each age-sex group was calculated and compared with published US mortality tables. Distal radial fractures were not associated with an increased mortality rate. In fact, beneficiaries had a significantly lower mortality rate after distal radial fractures than the general population. This may be related to the injured beneficiaries' involvement in the healthcare system. Mortality rate did not vary significantly based on time from injury. Our results indicate that any mortality is unlikely to be attributable to the distal radial fracture or its treatment. Level of evidence: III.

Analysis of four recruitment methods for obtaining normative data through a Web-based questionnaire: a pilot study

BACKGROUND

Quality normative data requires a diverse sample of participants and plays an important role in the appropriate use of health outcomes. Using social media and other online resources for survey recruitment is a tempting prospect, but the effectiveness of these methods in collecting a diverse sample is unknown. The purpose of this study is to pilot test four methods of recruitment to determine their ability to produce a sample representative of the general US population.

METHODS

This project is part of a larger study to gather normative data for the Michigan Hand Outcomes Questionnaire (MHQ). We used flyers, e-mail, Facebook, and an institution-specific clinical research recruitment Web site to direct participants to complete an online version of the MHQ. Participants also provided comorbidity and demographic information.

RESULTS

The institution-specific recruitment Web site yielded the greatest number of respondents in an age distribution that mirrored the US population. Facebook was effective for recruiting young adults, and e-mail was successful for recruiting the older adults. None of the methods was successful in reaching an ethnically diverse sample.

CONCLUSIONS

Obtaining normative data that is truly representative of the US population is a difficult task. The use of any one recruitment method is unlikely to result in a representative sample, but a greater understanding of these methods will empower researchers to use them to target specific populations. This pilot analysis provides support for the use of Facebook and clinical research sites in addition to traditional methods of e-mail and paper flyers.

A Comparative Study of Attitudes Regarding Digit Replantation in the United States and Japan

PURPOSE

To compare the societal preferences for finger replantation between the United States (US) and Japan and to investigate factors influencing the preferences.

METHODS

A sample of the general population without current hand disease or condition was recruited via flyers posted in public areas of 2 major academic centers in the US and Japan. The recruited subjects completed a survey presenting finger amputation scenarios and various factors that may affect treatment decisions. We performed univariate analysis using treatment preference as the outcome and all other factors as possible predictors using the chi-square test.

RESULTS

Most respondents in both countries preferred replantation and there was no significant difference between the US and Japan. Treatment preference was significantly associated with the importance of appearance, recovery time, and the chance of survival of the replanted digit. There was no association between treatment preference and attitudes regarding body integrity or estimate of stigma toward finger amputees. Japanese participants agreed more with statements of body integrity, and Japanese respondents rated appearance, sensation, and chance of survival of the replant as more important than did American participants.

CONCLUSIONS

Patient preference is not driving the decrease in finger replantations in the US. The general public in both countries prefer replantation over wound closure for digit amputations.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and decision analysis III.

Management of Acute Postoperative Pain in Hand Surgery: A Systematic Review

PURPOSE

To conduct a systematic review to guide hand surgeons in an evidenced-based approach in managing postoperative pain.

METHODS

We performed a literature review for primary research articles on management of postoperative pain in hand surgery patients using Medical Literature Analysis and Retrieval System Online (MEDLINE; PubMed), Excerpta Medica database (EMBASE), and the Cochrane Collaboration Library. Inclusion criteria were primary journal articles examining treatment of acute postoperative pain based on any modality. Data related to pain assessment, postoperative recovery, and total postoperative analgesic consumption were extracted.

RESULTS

A total of 903 publications were reviewed; 184 publications underwent abstract review. After applying inclusion and exclusion criteria, 10 primary articles were selected for inclusion in this review. Data were noted to be heterogeneous and findings were compiled. Results were divided into groups evaluating postoperative pain medications or pain infusion catheters.

CONCLUSIONS

Although this review did not demonstrate a best practices model for postoperative pain management, it provides evidence for alternative medications and treatment strategies. The evidence available suggests that postoperative pain control should begin before surgery and that combining multiple strategies for pain treatment is beneficial. Given the increasing attention paid to narcotic prescriptions and the potential for abuse, surgeons should adopt evidence-based pain management practices. We provide an example algorithm for pain treatment in hand surgery based on available data and the authors' experience.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Patient satisfaction and self-reported outcomes after complete brachial plexus avulsion injury

PURPOSE

Reconstructive surgery for complete brachial plexus avulsion injuries only partially restores function, and many patients are dissatisfied with results that surgeons consider good. Preoperative expectations have been shown to influence postoperative satisfaction but are poorly understood in patients with complete brachial plexus avulsion injuries. Qualitative methodology can elucidate patient beliefs and attitudes, which are difficult to quantify. The purpose of this study was to examine patient-reported outcomes, including satisfaction, and to understand the patient perspective.

METHODS

We used qualitative interviews and questionnaires to assess patient-reported outcomes. Two members of the research team analyzed interview data using Grounded Theory methodology. Data from participants who had and did not have reconstructive surgery were compared.

RESULTS

Twelve patients participated in this study. Of the 7 participants who had reconstructive surgery, 4 felt their expectations had been met and 5 were satisfied with their outcomes. Reconstruction did not produce statistically significant improvements in upper extremity function, pain, or work ability. All patients reported dissatisfaction with upper extremity ability, and 9 expressed hope for innovative treatments (e.g., stem cell therapy, nerve reinsertion) that could potentially provide better outcomes than existing procedures and enable return to work.

CONCLUSIONS

Satisfaction with surgical outcomes after complete avulsion brachial plexus injury depends heavily on whether preoperative expectations are met, but patients are unfamiliar with nerve avulsion and do not always know what to expect. Low satisfaction with upper extremity ability and the lack of statistically significant differences produced by reconstruction suggest that current treatments may not be meeting patients' needs. Physicians must provide robust preoperative education to encourage realistic expectations and direct patients toward resources for pain management to facilitate comprehensive rehabilitation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Contribution of functional parameters to patient-rated outcomes after surgical treatment of distal radius fractures

PURPOSE

Outcomes of distal radius fractures can be measured radiographically, functionally, or via patient-rated questionnaires, but previous studies report conflicting results regarding the relationship between these outcomes. Our specific aim was to explore the role that functional outcomes have in the score of the Michigan Hand Outcomes Questionnaire (MHQ), a patient-rated hand instrument.

METHODS

We obtained data for 207 patients. Demographic information was collected as part of the MHQ. Function (wrist motion and grip and pinch strength) was assessed 3 and 6 months after fracture fixation. We applied linear regression analysis to determine each item's contribution to the total MHQ score.

RESULTS

After we applied linear regression analysis, we determined that 3 months after fixation, all included factors contributed 37% of the MHQ score. Only the grip strength difference between the injured and uninjured hands was significantly associated, contributing 22% of the MHQ score. Six weeks and 6 months after fixation, all included factors contributed 43% and 34%, respectively, of the MHQ score. No individual factors were significant contributors.

CONCLUSIONS

Measured functional outcomes variables account for less than 40% of the total MHQ score. Identifying the unmeasured factors that make up the additional 60% of the total MHQ score would be beneficial in the continued examination of patient-rated outcomes. Furthermore, the use of multiple outcomes assessment modalities should be considered in any study measuring patient-rated outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

A systematic review of outcomes of revision amputation treatment for fingertip amputations

PURPOSE

The purpose of this study was to conduct a systematic review of outcomes of fingertip revision amputation for fingertip amputation injuries in the English-language literature to provide best evidence of functional outcomes.

METHODS

A MEDLINE literature search was performed to identify studies that met the following criteria: (1) reported primary data; (2) included at least five cases of primary revision amputation treatment following digit amputation injury; (3) reported finger or thumb amputation at or distal to the distal interphalangeal (DIP) joint or interphalangeal (IP) joint, respectively; (4) presented at least one of the following outcomes: static two-point discrimination (2PD), cold intolerance, arc of motion (AOM) of metacarpophalangeal (MCP) joints, proximal interphalangeal joints (PIP), DIP joints, or return-to-work time.

RESULTS

Thirty-eight studies met the inclusion criteria. Twenty-seven studies reported 2PD, 20 studies reported cold intolerance, eight studies reported AOM, and 18 studies reported return-to-work time after revision amputation of fingertip injuries. The mean 2PD was 5.6 mm. On average, 24 % of patients experienced cold intolerance. AOM at the PIP joint was reported in four studies and averaged 94°. DIP joint AOM was presented in four studies and averaged 66°. Thumb MCP and IP joint AOM was presented in three and four studies, respectively. Mean thumb MCP joint AOM was 54° and that of the IP joint was 71°. The mean return-to-work time was 47 days.

CONCLUSIONS

On average, fingertip revision amputation can achieve almost normal sensibility and satisfactory motion and patients can expect to return to work on average approximately 7 weeks after surgery.

Applying economic principles to outcomes analysis

This article presents an introduction to economic outcomes for the plastic surgeon investigator. Types of economic outcomes are introduced and the matter of perspective is discussed. Examples from the plastic surgery literature are presented. The current and future importance of economic outcome measures is emphasized.

Applicability of large databases in outcomes research

Outcomes research serves as a mechanism to assess the quality of care, cost effectiveness of treatment, and other aspects of health care. The use of administrative databases in outcomes research is increasing in all medical specialties, including hand surgery. However, the real value of databases can be maximized with a thorough understanding of their contents, advantages, and limitations. We performed a literature review pertaining to databases in medical, surgical, and epidemiologic research, with special emphasis on orthopedic and hand surgery. This article provides an overview of the available database resources for outcomes research, their potential value to hand surgeons, and suggestions to improve their effective use.

Variations in the use of internal fixation for distal radial fracture in the United States medicare population

BACKGROUND

Distal radial fractures affect an estimated 80,000 elderly Americans each year. Although the use of internal fixation for the treatment of distal radial fractures is becoming increasingly common, there have been no population-based studies to explore the dissemination of this technique. The aims of our study were to determine the current use of internal fixation for the treatment of distal radial fractures in the Medicare population and to examine regional variations and other factors that influence use of this treatment. We hypothesized that internal fixation of distal radial fractures would be used less commonly in male and black populations compared with other populations because the prevalence of osteoporosis is lower in these populations, and that use of internal fixation would be correlated with the percentage of the patients who were treated by a hand surgeon in a particular region.

METHODS

We performed an analysis of complete 2007 Medicare data to determine the percentage of distal radial fractures that were treated with internal fixation in each hospital referral region. We then analyzed the association of patient and physician factors with the type of fracture treatment received, both nationally and within each hospital referral region.

RESULTS

We identified 85,924 Medicare beneficiaries with a closed distal radial fracture who met the inclusion criteria, and 17.0% of these patients were treated with internal fixation. Fractures were significantly less likely to be treated with internal fixation in men than in women (odds ratio, 0.84; 95% confidence interval, 0.80 to 0.89) and in black patients than in white patients (odds ratio, 0.74; 95% confidence interval, 0.65 to 0.85). Patients were more likely to be treated with internal fixation rather than with another treatment if they were treated by a hand surgeon than if they were treated by an orthopaedic surgeon who was not a hand surgeon (odds ratio, 2.49; 95% confidence interval, 2.29 to 2.70). Use of internal fixation ranged from 4.6% to 42.1% (nearly a ten-fold difference) among hospital referral regions. The percentage of patients treated with internal fixation within a hospital referral region was positively correlated with the percentage of patients in that region who were treated by a hand surgeon (correlation coefficient, 0.34; p &lt; 0.0001).

CONCLUSIONS

The use of internal fixation for the treatment of a distal radial fracture differs widely among geographical regions and patient populations. Such variations highlight the need for improved comparative-effectiveness data to guide the treatment of this fracture.

An economic analysis of outcomes and complications of treating distal radius fractures in the elderly

PURPOSE

There is a lack of scientific data regarding which treatment provides the best outcome for distal radius fractures (DRFs) in the elderly. Currently, casting is used to treat the majority of these fractures, although open reduction and internal fixation (ORIF) has been used increasingly in recent years. Given the recent emphasis on the wise use of medical resources, we conducted a cost-utility analysis to assess which of 4 common DRF treatments (casting, wire fixation, external fixation, or ORIF) optimizes the cost-to-patient preference ratio.

METHODS

We created a decision tree to model the process of choosing a DRF treatment and experiencing a final outcome. Fifty adults aged 65 and older were surveyed in a time trade-off, one-on-one interview to obtain utilities for DRF treatments and possible complications. We gathered Medicare reimbursement rates and calculated the incremental cost-utility ratio for each treatment.

RESULTS

Participants rated DRF treatment relatively high, assigning utility values close to perfect health to all treatments. The ORIF was the most preferred treatment (utility, 0.96), followed by casting (utility, 0.94), wire fixation (utility, 0.94), and external fixation (utility, 0.93). The ORIF was the most expensive treatment (reimbursement, $3,516), whereas casting was the least expensive (reimbursement, $564). The incremental cost-utility ratio for ORIF, when compared to casting, was $15,330 per quality-adjusted life years, which is less than $50,000 per quality-adjusted life year, thereby indicating that, from the societal perspective, ORIF is considered a worthwhile alternative to casting.

CONCLUSIONS

There is a slight preference for the faster return to minimally restricted activity provided by ORIF. Overall, patients show little preference for one DRF treatment over another. Because Medicare patients pay similar out-of-pocket costs regardless of procedure, they are not particularly concerned with procedure costs. Considering the similar long-term outcomes, this study adds to the uncertainty surrounding the choice of DRF treatment in the elderly, further indicating the need for a high-powered, randomized trial.

Cost-effectiveness of open partial fasciectomy, needle aponeurotomy, and collagenase injection for dupuytren contracture

PURPOSE

We undertook a cost-utility analysis to compare traditional fasciectomy for Dupuytren with 2 new treatments, needle aponeurotomy and collagenase injection.

METHODS

We constructed an expected-value decision analysis model with an arm representing each treatment. A survey was administered to a cohort of 50 consecutive subjects to determine utilities of different interventions. We conducted multiple sensitivity analyses to assess the impact of varying the rate of disease recurrence in each arm of the analysis as well as the cost of the collagenase injection. The threshold for a cost-effective treatment is based on the traditional willingness-to-pay of $50,000 per quality-adjusted life years (QALY) gained.

RESULTS

The cost of open partial fasciectomy was $820,114 per QALY gained over no treatment. The cost of needle aponeurotomy was $96,474 per QALY gained versus no treatment. When we performed a sensitivity analysis and set the success rate at 100%, the cost of needle aponeurotomy was $49,631. When needle aponeurotomy was performed without surgical center or anesthesia costs and with reduced hand therapy, the cost was $36,570. When a complete collagenase injection series was priced at $250, the cost was $31,856 per QALY gained. When the injection series was priced at $945, the cost was $49,995 per QALY gained. At the market price of $5,400 per injection, the cost was $166,268 per QALY gained.

CONCLUSIONS

In the current model, open partial fasciectomy is not cost-effective. Needle aponeurotomy is cost-effective if the success rate is high. Collagenase injection is cost-effective when priced under $945.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analysis II.

A systematic review of outcomes of fasciotomy, aponeurotomy, and collagenase treatments for Dupuytren's contracture

BACKGROUND

Needle aponeurotomy and collagenase injection are alternative treatments of Dupuytren's contracture to open partial fasciectomy; however, reported data are difficult to interpret without a formal systematic review.

METHODS

A Medline, EMBASE, and Cochrane database search was performed, and 277 articles were identified. Articles were stratified by level of evidence, and those of the highest level for each technique were included. Evidence available for needle aponeurotomy was of low quality so only cohorts larger than 100 patients were included.

RESULTS

The sample size of patients for open partial fasciectomy ranged from 37-261. The recurrence rate ranged from 12-39%, with mean follow-up time of 1.5-7.3 years. The complication rate ranged from 14-67%. Complications included nerve division (2-5%), infection (4-12%), neurapraxia (0.4-52%), and regional pain syndrome (2-13%). For needle aponeurotomy the sample size ranged from 117-211. The recurrence rate ranged from 50-58%, with mean follow-up time of 3-5 years. With regard to collagenase injection, the sample size ranged from 13-204. The recurrence rate ranged from 10-31%, with mean follow-up time of 120 days to 4 years. For the two latter procedures, adverse effects consisted primarily of skin tears (9-25%). Kruskal-Wallis testing demonstrated that the recurrence rate was significantly higher for needle aponeurotomy than for open partial fasciectomy (p = 0.001), and the recurrence rate was significantly higher for open partial fasciectomy than for collagenase injection (p = 0.001).

CONCLUSIONS

The recurrence rates and types of complications differ between open partial fasciectomy and needle aponeurotomy or collagenase injection. Long-term outcomes have not been well reported.

The relationship between ASSH membership and the treatment of distal radius fracture in the United States Medicare population

PURPOSE

Internal fixation for distal radius fractures (DRFs) in the elderly has increased from 3% in 1997 to 17% in 2007. This increase has been uneven across regions of the United States. There is some evidence that patients treated by hand surgeons receive internal fixation at an increased rate and that hand surgeons might be driving the increased usage in regions where their presence is greatest. The specific aim of this study was to explore this relationship by analyzing Medicare beneficiaries treated by members of the American Society for Surgery of the Hand (ASSH).

METHODS

Surgeons who were members of ASSH in 2007 were matched with surgeons treating Medicare beneficiaries for DRFs in the same year. We then fit a series of multilevel models to estimate the proportion of total variance in internal fixation usage explained by ASSH membership status, patient demographic data, patient comorbidity, and/or type of fracture diagnosed.

RESULTS

Beneficiaries treated by ASSH members received internal fixation significantly more often than beneficiaries who were treated by surgeons who were not ASSH members. ASSH member status accounts for 12% of the total variance in internal fixation utilization.

CONCLUSIONS

Medicare beneficiaries who were treated by ASSH member surgeons receive internal fixation at a significantly higher rate than do patients of other physicians. When there is uncertainty about the optimal treatment for a condition, there is the possibility for specialty-related disparities. This specialty effect contributes to the national variations in the treatment of DRFs in the Medicare population.

Current and future national costs to medicare for the treatment of distal radius fracture in the elderly

PURPOSE

Distal radius fractures (DRFs) are the second most common fracture experienced by elderly individuals. In 2005, 16% of DRFs in the Medicare population were being treated with internal fixation, up from 3% in 1997. This shift in treatment strategy can have substantial financial impact on Medicare and the health care system in general. The specific aims of this project were to quantify the current and future Medicare expenditures attributable to DRF and to compare Medicare payments for the 4 treatment options for elderly DRF.

METHODS

We analyzed the 100% 2007 Medicare dataset for annual DRF-attributable spending. Payments were obtained for claims that were identified as attributable to DRF by International Classification of Diseases, 9th Revision, Clinical Modification codes for DRF in conjunction with a Current Procedural Technology code for relevant treatment or service. We projected annual payments based on increasing internal fixation treatment. All payments are reported in 2007 U.S. dollars.

RESULTS

In 2007, Medicare made $170 million in DRF-attributable payments. If the usage of internal fixation were to reach 50%, DRF-attributable payments could be nearly $240 million. The mean attributable payment made for each patient in 2007 was $1,983. Most of this is due to facility and staffing cost for the treatment procedure.

CONCLUSIONS

This analysis provides an accurate quantification of Medicare DRF-attributable expenditure. Use of 100% Medicare data allows for the summation of actual patient experience rather than modeling or estimation. The burden of DRF is going to grow as the U.S. population ages and as internal fixation becomes more widely used. The Medicare payment data can help in allocating resources nationally to address the increasing disease burden of DRF.

A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly

PURPOSE

As the population in developed countries continues to age, the incidence of osteoporotic distal radius fractures (DRFs) will increase as well. Treatment of DRF in the elderly population is controversial. We systematically reviewed the existing literature for the management of DRFs in patients aged 60 and over with 5 common techniques: the volar locking plate system, nonbridging external fixation, bridging external fixation, percutaneous Kirschner wire fixation, and cast immobilization (CI).

METHODS

We reviewed articles retrieved from MEDLINE, Embase, and CINAHL Plus that met predetermined inclusion and exclusion criteria in 2 literature reviews. Outcomes of interest included wrist arc of motion, grip strength, functional outcome measurements, radiographic parameters, and the number and type of complications. We statistically analyzed the data using weighted means and proportions based on the sample size in each study.

RESULTS

We identified 2,039 papers and selected 21 papers fitting the inclusion criteria in the primary review of articles with a mean patient age of 60 and older. Statistically significant differences were detected for wrist arc of motion, grip strength, and Disabilities of the Arm, Shoulder, and Hand score, although these findings may not be clinically meaningful. Volar tilt and ulnar variance revealed significant differences among groups, with CI resulting in the worst radiographic outcomes. The complications were significantly different, with CI having the lowest rate of complications, whereas the volar locking plate system had significantly more major complications requiring additional surgical intervention.

CONCLUSIONS

This systematic review suggests that despite worse radiographic outcomes associated with CI, functional outcomes were no different from those of surgically treated groups for patients age 60 and over. Prospective comparative outcomes studies are necessary to evaluate the rate of functional recovery, cost, and outcomes associated with these 5 treatment methods.

A decision analysis of amputation versus reconstruction for severe open tibial fracture from the physician and patient perspectives

Although reconstruction is often the primary choice of surgeons after an open tibial fracture, there is no evidence to support the long-term effectiveness of flap reconstruction over below-knee amputation. The aim of this study was to perform a decision analysis to evaluate treatment preferences for type IIIB and IIIC tibial fractures. Reconstructive microsurgeons, physical medicine physicians, and patients with lower extremity trauma completed a Web-based standard gamble utility survey to generate quality-adjusted life years (QALYs). Physicians assigned quite high utility values, and there was a slight preference for reconstruction over amputation, with a gain of only 0.55 QALY. Patients assigned significantly lower utility values and also favored reconstruction over amputation, but with a larger gain of 5.54 QALYs. The disparate utilities assigned by the physicians and the patients highlight the necessity of realistic discussion of outcomes, regardless of the management methods.

An economic analysis of hand transplantation in the United States

BACKGROUND

Hand transplantation has received international attention in recent years; however, the economic impact of this innovative treatment is uncertain. The aim of this study was to assess the utility and estimate the costs of hand transplantation and the use of hand prostheses for forearm amputations.

METHODS

One hundred medical students completed a time trade-off survey to assess the utilities of single and double hand transplantation and the use of hand prostheses. Quality-adjusted life years (QALYs) were calculated for each outcome to create decision trees. Cost data for medical care were estimated based on Medicare fee schedules using the Current Procedural Terminology code for forearm replantation. The cost of immunosuppressive therapy was estimated based on the wholesale price of drugs. The incremental cost-utility ratio was calculated from the differences in costs and utilities between transplantation and prosthesis. Sensitivity analyses were performed to assess the robustness of the results.

RESULTS

For unilateral hand amputation, prosthetic use was favored over hand transplantation (30.00 QALYs versus 28.81 QALYs; p = 0.03). Double hand transplantation was favored over the use of prostheses (26.73 QALYs versus 25.20 QALYs; p = 0.01). The incremental cost-utility ratio of double transplantation when compared with prostheses was $381,961/QALY, exceeding the traditionally accepted cost-effectiveness threshold of $50,000/QALY.

CONCLUSIONS

Prosthetic adaption is the dominant strategy for unilateral hand amputation. For bilateral hand amputation, double hand transplantation exceeds the societally acceptable threshold for general adoption. Improvements in immunosuppressive strategies may change the incremental cost-utility ratio for hand transplantation.

The effect of ulnar styloid fractures on patient-rated outcomes after volar locking plating of distal radius fractures

PURPOSE

Ulnar styloid fractures commonly occur with distal radius fractures (DRFs). Ulnar styloid fractures that involve the insertion of the radioulnar ligaments can cause distal radioulnar joint (DRUJ) instability, and the literature suggests that these fractures should be treated with open reduction internal fixation (ORIF). However, in the absence of DRUJ instability, the effects of ulnar styloid fractures are unknown. The purpose of this study is to evaluate the outcome of ulnar styloid fractures without DRUJ instability on patient-rated outcomes after DRF ORIF.

METHODS

Between 2003 and 2008, a cohort of DRF patients treated with volar plating was enrolled. Patients with DRUJ instability treated at the time of distal radius ORIF were excluded. Radiographs were evaluated to identify and characterize ulnar styloid fractures. Patient-rated outcomes were measured at 6 weeks, 3 months, 6 months, and 12 months postoperatively using the Michigan Hand Outcomes Questionnaire (MHQ). Regression analysis was performed to determine whether the presence of an ulnar styloid fracture, the size or displacement of the fracture, or the healing status of the fracture was predictive of MHQ scores.

RESULTS

One-hundred and forty-four patients were enrolled; 88 patients had ulnar styloid fractures. During the collection period, DRUJ instability was found intraoperatively in 3 patients; these patients had ulnar styloid ORIF and were not enrolled. The 144 patients with a stable DRUJ after DRF ORIF maintained DRUJ stability after surgery. In these patients, the presence of an ulnar styloid fracture did not affect MHQ scores. Furthermore, the size of the ulnar styloid fracture, the degree of displacement, and the healing status of the ulnar styloid did not affect MHQ scores.

CONCLUSIONS

In patients with a stable DRUJ after DRF ORIF ulnar styloid fractures did not affect subjective outcomes as measured by the MHQ.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Crafting practice guidelines in the world of evidence-based medicine

BACKGROUND

In the era of exponential increase in the medical literature, physicians and health policy-makers are relying on well-constructed, evidence-based practice guidelines to help ensure that the care given to patients is based on valid, scientific data. The construction of practice guidelines, however, may not always adhere to accepted research protocol.

METHODS

In this article, the authors detail the steps required to produce effective, evidence-based practice guidelines.

RESULTS

The seven essential steps in crafting a practice guideline are presented: (1) defining a topic, (2) selecting a work group, (3) performing a literature review, (4) writing the guideline, (5) peer review, (6) making plans for review and revision, and (7) dissemination.

CONCLUSION

Given the importance of practice guidelines in supporting everyday practice, this article strives to provide a practical guide in the development of this key component of evidence-based medicine.

Trends in the United States in the treatment of distal radial fractures in the elderly

BACKGROUND

Traditionally, distal radial fractures in the elderly have been treated nonoperatively with casting. However, since the introduction of the volar locking plating system in 2000, there has been an interest in the use of more aggressive treatment methods. The purpose of the present study was to assess changing trends in the treatment of distal radial fractures in elderly patients in the United States.

METHODS

We evaluated a 5% sample of Medicare data from 1996 to 1997 and a 20% sample from 1998 to 2005. Information on four treatment methods (closed treatment, percutaneous pin fixation, internal fixation, and external fixation) was extracted from the dataset. Other available data were diagnosis, physician specialty, and patient age, sex, and race. We calculated frequencies and rates to compare the utilization of different treatments over time.

RESULTS

Over the ten-year time period examined, the rate of internal fixation of distal radial fractures in the elderly increased fivefold, from 3% in 1996 to 16% in 2005. Closed treatment, however, remained the predominant method (used for 82% of the fractures in 1996 and 70% in 2005). Fractures in patients with an age of eighty-five years or more were significantly more likely to be treated in a closed fashion (p < 0.0001). There was a large variation among physician specialties with regard to the fixation methods that were used. Orthopaedic surgeons were significantly more likely to use closed treatment than hand surgeons were, whereas hand surgeons were significantly more likely to use internal fixation than orthopaedic surgeons were.

CONCLUSIONS

Since 2000, although the majority of distal radial fractures are still treated nonoperatively, there has been an increase in the use of internal fixation and a concurrent decrease in the rate of closed treatment of distal radial fractures in the elderly in the United States.

The minimal clinically important difference of the Michigan hand outcomes questionnaire

PURPOSE

To determine the change in score required in various domains of the Michigan Hand Outcomes Questionnaire (MHQ) to indicate meaningful patient improvement, or the minimal clinically important difference (MCID), for 3 common hand conditions: rheumatoid arthritis (RA), carpal tunnel syndrome (CTS) and distal radius fracture (DRF).

METHODS

The MHQ was administered to patients at 2 time points. Patient satisfaction was defined as a satisfaction score > or =80% of the standard deviation of that patient sample. The minimal change in score in specific MHQ domains that corresponded with patient satisfaction was determined using receiver operating characteristic curves.

RESULTS

For CTS patients, MCIDs of 23, 13, and 8 were identified for the pain, function, and work domains, respectively. For RA patients, pain and function were also identified as having discriminative ability, with MCIDs of 11 and 13, respectively. An MCID of 3 was identified for the activities of daily living domain. For DRF patients, no MHQ domains showed discriminative ability because of the ceiling effect at the 3-month assessment period.

CONCLUSIONS

Individual domains of the MHQ can be used to discriminate between patients who are satisfied and those who are not after either carpal tunnel release or silicone arthroplasty of the metacarpophalangeal joints for RA. Pain and function are the domains of the MHQ that are best able to discriminate between patients who are satisfied and those who are not. The identical function MCID for both RA patients and CTS patients, despite markedly different preoperative values, indicates that a standard amount of functional change may indicate patient satisfaction. High postoperative satisfaction, even only 3 months after surgery, prevented any domains from showing discriminative ability for the DRF patients.

Measuring quality in health care and its implications for pay-for-performance initiatives

The quality of health care is important to American consumers, and discussion on quality will be a driving force toward improving the delivery of health care in America. Funding agencies are proposing a variety of quality measures, such as centers of excellence, pay-for-participation, and pay-for-performance initiatives, to overhaul the health care delivery system in this country. It is quite uncertain, however, whether these quality initiatives will succeed in curbing the unchecked growth in health care spending in this country, and physicians understandably are concerned about more intrusion into the practice of medicine. This article outlines the genesis of the quality movement and discusses its effect on the surgical community.