Andrew Lawson1,2, Justine M Naylor1,2, Rachelle Buchbinder3,4, Rebecca Ivers5, Zsolt J Balogh6,7, Paul Smith8, Wei Xuan9, Kirsten Howard10, Arezoo Vafa1, Diana Perriman8, Rajat Mittal2, Piers Yates11, Bertram Rieger11, Geoff Smith12, Sam Adie12,13, Ilia Elkinson14, Woosung Kim14, Jai Sungaran15, Kim Latendresse16,17, James Wong18, Sameer Viswanathan19, Keith Landale19, Herwig Drobetz20, Phong Tran21, Richard Page22,23, Sally Beattie23, Jonathan Mulford24, Ian Incoll7,25, Michael Kale25, Bernard Schick26, Trent Li26, Andrew Higgs27, Andrew Oppy28, Ian A Harris1,2,29. 1. Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia. 2. South Western Sydney Clinical School, University of New South Wales, Sydney, Australia. 3. Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia. 4. Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia. 5. School of Population Health, University of New South Wales, Sydney, Australia. 6. John Hunter Hospital, Newcastle, Australia. 7. University of Newcastle, Newcastle, Australia. 8. Canberra Hospital, Canberra, Australia. 9. Ingham Institute for Applied Medical Research, Sydney, Australia. 10. School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, Australia. 11. Fiona Stanley Hospital, Perth, Australia. 12. St George and Sutherland Hospitals, Sydney, Australia. 13. St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia. 14. Wellington Hospital, Wellington, New Zealand. 15. Concord Hospital, Sydney, Australia. 16. Nambour General Hospital, Nambour, Australia. 17. Sunshine Coast University Hospital, Nambour, Australia. 18. Westmead Hospital, Sydney, Australia. 19. Campbelltown Hospital, Sydney, Australia. 20. Mackay Base Hospital, Mackay, Australia. 21. Western Health, Melbourne, Australia. 22. University Hospital Geelong, Barwon Health, Geelong, Australia. 23. Barwon Centre for Orthopaedic Research and Education, School of Medicine, Deakin University, Geelong, Australia. 24. Launceston Hospital, Launceston, Australia. 25. Gosford and Wyong Hospitals, Gosford, Australia. 26. Prince of Wales Hospital, Sydney, Australia. 27. St Vincent's Hospital, Sydney, Australia. 28. Royal Melbourne Hospital, Melbourne, Australia. 29. Liverpool Hospital, Sydney, Australia.
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.
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.
Authors: Andrew Lawson; Justine Naylor; Rachelle Buchbinder; Rebecca Ivers; Zsolt J Balogh; Paul Smith; Wei Xuan; Kirsten Howard; Arezoo Vafa; Diana Perriman; Rajat Mittal; Piers Yates; Bertram Rieger; Geoff Smith; Sam Adie; Ilia Elkinson; Woosung Kim; Jai Sungaran; Kim Latendresse; James Wong; Sameer Viswanathan; Keith Landale; Herwig Drobetz; Phong Tran; Richard Page; Sally Beattie; Jonathan Mulford; Ian Incoll; Michael Kale; Bernard Schick; Trent Li; Andrew Higgs; Andrew Oppy; Ian A Harris Journal: JAMA Surg Date: 2022-07-01 Impact factor: 16.681
Authors: Rikke Thorninger; Daniel Wæver; Jonas Pedersen; Jens Tvedegaard-Christensen; Michael Tjørnild; Martin Lind; Jan Duedal Rölfing Journal: J Clin Med Date: 2021-04-22 Impact factor: 4.241
Authors: Joanna F Dipnall; Richard Page; Lan Du; Matthew Costa; Ronan A Lyons; Peter Cameron; Richard de Steiger; Raphael Hau; Andrew Bucknill; Andrew Oppy; Elton Edwards; Dinesh Varma; Myong Chol Jung; Belinda J Gabbe Journal: PLoS One Date: 2021-09-23 Impact factor: 3.240