Cost Analysis of Volar Plate Fixation Versus Plaster Cast Immobilization for Intra-Articular Distal Radial Fractures.

BACKGROUND: The aim of this study was to compare the cost-effectiveness and cost-utility between plaster cast immobilization and volar plate fixation for acceptably reduced intra-articular distal radial fractures. METHODS: A cost-effectiveness analysis was conducted as part of a randomized controlled trial comparing operative (volar plate fixation) with nonoperative (plaster cast immobilization) treatment in patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Health-care utilization and use of resources per patient were documented prospectively and included direct medical costs, direct non-medical costs, and indirect costs. All analyses were performed according to the intention-to-treat principle. RESULTS: The mean total cost per patient was $291 (95% bias-corrected and accelerated confidence interval [bcaCI] = -$1,286 to $1,572) higher in the operative group compared with the nonoperative group. The mean total number of quality-adjusted life-years (QALYs) gained at 12 months was significantly higher in the operative group than in the nonoperative group (mean difference = 0.15; 95% bcaCI = 0.056 to 0.243). The difference in the cost per QALY (incremental cost-effectiveness ratio [ICER]) was $2,008 (95% bcaCI = -$9,608 to $18,222) for the operative group compared with the nonoperative group, which means that operative treatment is more effective but also more expensive. Subgroup analysis including only patients with a paid job showed that the ICER was -$3,500 per QALY for the operative group with a paid job compared with the nonoperative group with a paid job, meaning that operative treatment is more effective and less expensive for patients with a paid job. CONCLUSIONS: The difference in QALYs gained for the operatively treated group was equivalent to an additional 55 days of perfect health per year. In adult patients with an acceptably reduced intra-articular distal radial fracture, operative treatment is a cost-effective intervention, especially in patients with paid employment. Operative treatment is slightly more expensive than nonoperative treatment but provides better functional results and a better quality of life. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

Volar Plate Fixation Versus Cast Immobilization in Acceptably Reduced Intra-Articular Distal Radial Fractures: A Randomized Controlled Trial.

BACKGROUND: The evidence for the treatment of acceptably reduced intra-articular distal radial fractures remains inconclusive. We therefore compared the functional outcomes of cast immobilization (nonoperative) and volar plate fixation (operative) for patients with these fractures. METHODS: This multicenter randomized controlled trial enrolled patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Patients were randomized to nonoperative treatment or to operative treatment. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score after 12 months. Secondary outcome measures were the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; the Short Form-36 (SF-36) questionnaire; a visual analog scale for pain; range of motion; grip strength; radiographic parameters; and complications. Analyses followed the intention-to-treat principle. RESULTS: A total of 96 patients were randomized, and 90 (46 in the nonoperative group and 44 in the operative group) were included in the analysis. Patients treated in the operative group had significantly better functional outcomes measured with the PRWE at 6 weeks, 3 months, 6 months, and 1 year. Additionally, a 28% rate of subsequent surgery was identified in the nonoperative group. CONCLUSIONS: Adult patients with an acceptably reduced intra-articular distal radial fracture have better functional outcomes for 12 months when treated operatively instead of nonoperatively. We therefore recommend surgical treatment for patients with these fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Functional Outcomes after Corrective Osteotomy of Symptomatic Distal Radius Malunions in Children.

Background Closed reduction and cast immobilization of displaced distal radius fractures carries the risk of secondary displacement, which could result in a symptomatic malunion. In patients with a symptomatic malunion, a corrective osteotomy can be performed to improve pain and functional impairment of the wrist joint. Objective The aim of this study was to assess the functional outcomes of children who underwent a corrective osteotomy due to a symptomatic malunion of the distal radius. Methods Between 2009 and 2016, all consecutive corrective osteotomies of the distal radius of patients younger than 18 years were reviewed. The primary outcome was functional outcome assessed with the ABILHAND-Kids score. Secondary outcomes were QuickDASH (Quick Disabilities of Arm, Shoulder, and Hand) score, range of motion, complications, and radiological outcomes. Results A total of 13 patients with a median age of 13 years (interquartile range [IQR]: 12.5-16) were included. The median time to follow-up was 31 months (IQR: 26-51). The median ABILHAND-Kids score was 42 (range: 37-42), and the median QuickDASH was 0 (range: 0-39). Range of motion did not differ significantly between the injured and the uninjured sides for all parameters. One patient had a nonunion requiring additional operative treatment. The postoperative radiological parameters showed an improvement of radial inclination, radial height, ulnar variance, dorsal tilt, and dorsal tilt. Conclusion Corrective osteotomy for children is an effective method for treating symptomatic malunions of the distal radius. Level of Evidence This is a Level IV study.

The Value of Intraoperative 3-Dimensional Fluoroscopy in the Treatment of Distal Radius Fractures: A Randomized Clinical Trial.

PURPOSE: This study attempted to determine the clinical effectiveness of the intraoperative use of 3-dimensional fluoroscopy compared with conventional 2-dimensional fluoroscopy in patients with distal radius fractures. METHODS: We performed a multicenter randomized clinical trial in which 206 patients were randomized between the use of 3-dimensional fluoroscopy or not during operative treatment of the distal radius fracture. The primary outcome was the quality of fracture reduction and fixation assessed on a postoperative computed tomography scan with a dichotomous outcome: indication for revision, yes or no. RESULTS: There was no significant difference in whether the fracture required revision surgery: 31% (2-dimensional group) versus 24% (3-dimensional group). In 11% of distal radius fractures allocated to the 3-dimensional group, additional intraoperative corrections (screw replacements) were performed. CONCLUSIONS: Compared with 2-dimensional fluoroscopy, the use of intraoperative 3-dimensional fluoroscopy does not appear to improve the quality of reduction and fixation in the management of patients with a distal radius fracture. However, the use of 3-dimensional fluoroscopy appears to have advantages such as more intraoperative revisions and less revision surgeries that this study could not clearly demonstrate. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Carpal Alignment: A New Method for Assessment.

Background Carpal alignment may be used as a tool to evaluate fracture reduction in patients with distal radius fractures. However, there is little consensus on how to measure and quantify carpal alignment. Purpose The aim of this study was to compare the inter- and intraobserver variability of a new perpendicular method with the existing method in fractured and unfractured wrists. Additionally, the normal distribution of carpal alignment in unfractured wrists was investigated. Patients and Methods Carpal alignment was assessed on lateral plain radiographs using two different methods, one described by Ng and McQueen and another newly proposed method, the perpendicular method. Using the perpendicular method, the observer draws one line along the inner rim of the volar cortex of the radius and one perpendicular line to the center of the capitate. The carpus is aligned when the line along the inner rim transects the center of the capitate. Three examiners measured the carpal alignment in 50 patients with nonfractured and 50 patients with fractured distal radius. Intra- and interobserver variability for both methods were determined. Results The interobserver coefficient for the perpendicular method was 0.98 and that for the Ng method was 0.86. The intraobserver coefficients for three examiners were 0.89, 0.62, and 0.63, respectively, for the Ng method. For the perpendicular method, the intraobserver variability was 0.96, 0.89, and 0.72, respectively. In patients with unfractured wrists, the mean perpendicular to the center of the capitate was 0.25 mm dorsally. Conclusion The new proposed method is a reproducible method for measuring carpal alignment with a high inter- and intraclass coefficient. Clinical Relevance This method of measurement allows for a reproducible technique for measuring carpal alignment.

Tranexamic acid therapy for postoperative bleeding after bariatric surgery.

BACKGROUND: Tranexamic acid reduces blood loss associated with various surgical procedures. Postoperative bleeding caused by dissection or bleeding of the enteric staple lines is a well-known complication following bariatric surgery. Reoperation in order to restore hemostasis is frequently necessary (up to 2.5% in literature). The effect of conservative therapy using tranexamic acid for postoperative hemorrhage after bariatric surgery is still very much a novel technique. The aim is to present our results (reoperation rate and thrombo-embolic complication rate) of tranexamic acid therapy for postoperative bleeding after bariatric surgery in comparison to those in existing literature. METHODS: We retrospectively reviewed 1388 patients who underwent bariatric surgery (laparoscopic gastric bypass or laparoscopic gastric sleeve). Use of tranexamic acid, reoperation rate, transfusion rate and rate of thrombo-embolic complications were reviewed. RESULTS: Forty-five of 1388 (3.2%) total patients experienced significant hemorrhage after bariatric surgery. Tranexamic acid was administered in 44 of these patients. A failure of the treatment with tranexamic acid was observed in four patients. The incidence of reoperation was 0.4% for the entire population. No thrombo-embolic complications were registered for patients receiving tranexamic acid. CONCLUSION: These findings suggest that the administration of tranexamic acid appears to be safe in reducing the reoperation rate for bleeding after bariatric surgery.

[Analysis of variation in the surgical treatment of distal radius fracture]. / Aanzienlijke variatie in chirurgische behandeling van distale radiusfractuur.

OBJECTIVE: The optimum treatment of patients with distal radius fracture has not been entirely clarified resulting in possible major variations between hospitals in the number of patients undergoing surgical treatment. The objective of this study was to examine the variation in surgical treatment rates of patients with distal radius fractures across Dutch hospitals. DESIGN: Retrospective study. METHOD: Aggregated data for all patients with a distal radius fracture were obtained for 2012 and 2013 on the basis of reimbursement codes. The surgical rate across hospitals was corrected for several variables using linear regression analysis. RESULTS: We analysed a total of 95,754 reimbursements. The operative rate ranged from 0% to 23%, with a mean of 9.6%. Hospital type, the percentage of females, the percentage of patients over 65, the mean age, average socioeconomic status, and the total number of patients treated explained only 2.6% of the observed differences in operative rate between hospitals in 2012 and 11.6% in 2013. CONCLUSION: Our results suggest that non-scientific factors, such as surgeon's age, background, and local culture, influence therapeutic decisions in patients with distal radius fractures.