Andrew Lawson1,2, Justine 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, James Wong17, Sameer Viswanathan18, Keith Landale18, Herwig Drobetz19, Phong Tran20, Richard Page21,22, Sally Beattie22, Jonathan Mulford23, Ian Incoll24, Michael Kale24, Bernard Schick25, Trent Li25, Andrew Higgs26, Andrew Oppy27, Ian A Harris1,2,28. 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. Department of Orthopedics, John Hunter Hospital, Newcastle, Australia. 7. Department of Orthopedics, University of Newcastle, Newcastle, Australia. 8. Department of Orthopedics, 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. Department of Orthopedics, Fiona Stanley Hospital, Perth, Australia. 12. Department of Orthopedics, St George and Sutherland Hospitals, Sydney, Australia. 13. St George and Sutherland Clinical School, University of New South Wales, Sydney, Australia. 14. Department of Orthopedics, Wellington Hospital, Wellington, New Zealand. 15. Department of Orthopedics, Concord Hospital, Sydney, Australia. 16. Department of Orthopedics, Nambour Hospital and Sunshine Coast University Hospital, Nambour, Australia. 17. Department of Orthopedics, Westmead Hospital, Sydney, Australia. 18. Department of Orthopedics, Campbelltown Hospital, Sydney, Australia. 19. Department of Orthopedics, Mackay Base Hospital, Mackay, Australia. 20. Department of Orthopedics, Western Health, Melbourne, Australia. 21. Department of Orthopedics, University Hospital Geelong, Barwon Health, Geelong, Australia. 22. Barwon Centre for Orthopaedic Research and Education, School of Medicine, Deakin University, Geelong, Australia. 23. Launceston Hospital, Launceston, Australia. 24. Gosford and Wyong Hospitals, Gosford, Australia. 25. Prince of Wales Hospital, Sydney, Australia. 26. St Vincent's Hospital, Sydney, Australia. 27. Royal Melbourne Hospital, Melbourne, Australia. 28. Liverpool Hospital, Sydney, Australia.
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.
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.
Authors: Amelia A Sorensen; Daniel Howard; Wen Hui Tan; Jeffrey Ketchersid; Ryan P Calfee Journal: J Hand Surg Am Date: 2013-03-06 Impact factor: 2.230
Authors: Taylor Woolnough; Daniel Axelrod; Anthony Bozzo; Alex Koziarz; Frank Koziarz; Colby Oitment; Lauren Gyemi; Jessica Gormley; Kyle Gouveia; Herman Johal Journal: Clin Orthop Relat Res Date: 2021-02-01 Impact factor: 4.755
Authors: Andrew R Stephens; Angela P Presson; Mary M McFarland; Chong Zhang; Kai Sirniö; Marjolein A M Mulders; Niels W L Schep; Andrew R Tyser; Nikolas H Kazmers Journal: J Bone Joint Surg Am Date: 2020-07-15 Impact factor: 6.558