The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue 9

Scientific Articles | September 01, 2009

Is Early Internal Fixation Preferred to Cast Treatment for Well-Reduced Unstable Distal Radial Fractures?

Karl M. Koenig, MD, MS¹; Garrett C. Davis, MD¹; Margaret R. Grove, MS¹; Anna N.A. Tosteson, ScD¹; Kenneth J. Koval, MD¹

¹ Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Sep 01;91(9):2086-2093. doi: 10.2106/JBJS.H.01111

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Abstract

Background: In the treatment of distal radial fractures, physicians often advocate internal fixation over cast treatment for potentially unstable fracture patterns, citing the difficulties of successful nonoperative treatment and a decrease in patient tolerance for functional deficiencies. This study was performed to evaluate whether early internal fixation or nonoperative treatment would be preferred for displaced, potentially unstable distal radial fractures that initially had an adequate reduction.

Methods: A decision analytic model was created to compare early internal fixation with use of a volar plate and nonoperative management of a displaced, potentially unstable distal radial fracture with an acceptable closed reduction. To identify the optimal treatment, quality-adjusted life expectancy was estimated for each management approach. Data from the literature were used to estimate rates of treatment complications (e.g., fracture redisplacement with nonoperative treatment) and of treatment outcomes. Mean health-state utilities for treatment outcomes of painless malunion, functional deficit, and painful malunion were derived by surveying fifty-one adult volunteers with use of the time trade-off method. Sensitivity analysis was used to determine which model parameters would change the treatment decision over a plausible range of values.

Results: Early internal fixation with volar plating was the preferred strategy in most scenarios over the ranges of parameters available, but the margins were small. The older patient (mean age, 57.8 years) who sustains a distal radial fracture can expect 0.08 more quality-adjusted life years (29.2 days) with internal fixation compared with nonoperative treatment. Sensitivity analysis revealed no single factor that changed the preferred option within the reported ranges in the base case. However, the group of patients sixty-five years or older, who had lower disutility for painful malunion, derived a very small benefit from operative treatment (0.01 quality-adjusted life year or 3.7 days) and would prefer cast treatment in some scenarios.

Conclusions: Internal fixation with use of a volar plate for potentially unstable distal radial fractures provided a higher probability of painless union on the basis of available data in the literature. This long-term gain in quality-adjusted life years outweighed the short-term risks of surgical complications, making early internal fixation the preferred treatment in most cases. However, the difference was quite small. Patients, especially those over sixty-four years old, who have lower disutility for the malunion and painful malunion outcome states may prefer nonoperative treatment.

Level of Evidence: Economic and decision analysis Level II. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Distal radial fractures are common and can be associated with substantial morbidity¹. Initial treatment usually consists of closed reduction and splint immobilization^2,3. If the reduction fails to meet certain acceptable radiographic parameters at the time of follow-up, the patient may be advised to have operative fracture management. However, if the reduction is within acceptable parameters, there are multiple methods of treatment including continued immobilization and operative treatment.

Early operative treatment is sometimes advised by the physician, despite achieving an adequate initial fracture reduction, because a certain percentage of distal radial fractures collapse over time and these patients can be left with a poor result. Potentially, early operative treatment may reduce the rate of malunion and its associated problems^4,5. Several parameters in the literature that can be used to predict which fractures are more likely to collapse over time include initial fracture displacement, patient age, and comminution. However, none have been validated prospectively⁶.

Cast immobilization avoids the potential complications of surgery and can yield good outcomes, but it carries a certain risk of late fracture collapse and malunion and may be inconvenient for the patient^2,6,7. Early operative intervention carries the risk of surgical complications, but it may reduce the rates of late fracture collapse and malunion as well as the duration of immobilization^8-10. Physicians sometimes advocate operative treatment over cast immobilization for potentially unstable fracture patterns, citing the difficulties of successful nonoperative treatment and a decrease in patient tolerance for a functional deficit or cosmetic deformity.

This study was performed to evaluate whether early internal fixation or nonoperative treatment would be preferred for displaced, potentially unstable distal radial fractures that have an acceptable reduction. If a person sustains a closed distal radial fracture requiring reduction and has acceptable radiographic alignment at the first follow-up visit, should he or she undergo early operative intervention to forgo the possibility of late fracture collapse or continue with immobilization and avoid the risk of surgery? It was hypothesized that early surgical intervention would be preferred by most patients, given the currently reported rates of fracture collapse and low risks of operative treatment with use of volar plates. We also hypothesized that some elderly patients would prefer nonoperative treatment because they might place a lower value on functional outcome and want to avoid the risk of surgery.

Materials and Methods

A decision analysis tree was constructed to model the treatment dilemma of a patient with a distal radial fracture that has an adequate reduction at the first postoperative visit. Data were extracted from the literature to represent complication rates and outcome probabilities. Health state utilities were derived from an institutional review board-approved patient survey of fifty-one volunteers. A detailed description of these methods follows, and a glossary of terms is displayed in Table I.

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TABLE I Glossary of Terms

Term	Definition
Utility	A quantitative measure of preference for health outcomes, ranging from 0 to 1. Utility of 1 represents perfect health and 0 represents death.
Disutility	Toll or cost exacted against the final value of a health state. A disutility represents inconvenience to the patient, lost time from normal activities, or a health deficit acquired by complications of treatment.
Quality-adjusted life year	A measure of disease burden, including both the quality and the quantity of life lived. It is based on the number of years of life that would be gained by a patient undergoing an intervention. Each year in perfect health is assigned the value of 1 and is decreased according to disease burden down to a value of 0 for death. If the extra years would not be lived in full health (i.e., if the patient would lose a limb or be confined to a wheelchair), then the extra life-years are given a value between 0 and 1 to account for this.
Time trade-off	A method of measuring health state utilities. Subjects are given the choice between a certain period of time in a suboptimal health state compared with a shorter time in "perfect health." Decreasing lengths of time in perfect health are suggested until the subject reaches a point of indifference and chooses the suboptimal health state. This point, compared with the time scale, represents the utility of that health state.
Sensitivity analysis	A method of sweeping variables through the range of plausible values to determine if optimal action changes.

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TABLE I Glossary of Terms

Term	Definition
Utility	A quantitative measure of preference for health outcomes, ranging from 0 to 1. Utility of 1 represents perfect health and 0 represents death.
Disutility	Toll or cost exacted against the final value of a health state. A disutility represents inconvenience to the patient, lost time from normal activities, or a health deficit acquired by complications of treatment.
Quality-adjusted life year	A measure of disease burden, including both the quality and the quantity of life lived. It is based on the number of years of life that would be gained by a patient undergoing an intervention. Each year in perfect health is assigned the value of 1 and is decreased according to disease burden down to a value of 0 for death. If the extra years would not be lived in full health (i.e., if the patient would lose a limb or be confined to a wheelchair), then the extra life-years are given a value between 0 and 1 to account for this.
Time trade-off	A method of measuring health state utilities. Subjects are given the choice between a certain period of time in a suboptimal health state compared with a shorter time in "perfect health." Decreasing lengths of time in perfect health are suggested until the subject reaches a point of indifference and chooses the suboptimal health state. This point, compared with the time scale, represents the utility of that health state.
Sensitivity analysis	A method of sweeping variables through the range of plausible values to determine if optimal action changes.

Model

Two alternatives of care were evaluated: (1) early operative intervention to stabilize the fracture and (2) cast immobilization (Fig. 1). With early operative intervention, the risk of late fracture collapse and malunion are minimized, but potential surgical complications are introduced. With cast treatment, follow-up is required at two, four, and six weeks after injury. If the fracture loses acceptable alignment and operative intervention is required, then some amount of time and productivity secondary to the period of cast immobilization would be lost.

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Fig. 1: The basic tree structure, with the subtrees collapsed. The "+" sign represents further branching collapsed for visualization. ORIF = open reduction and internal fixation, and OR = operating room.

For the purposes of our model, the operative intervention was open reduction and internal fixation through a volar approach with use of a plate-and-screw construct. The issue of external fixation or percutaneous pinning compared with plate fixation for the treatment of unstable distal radial fractures has not been settled in the literature. However, open treatment with volar plate fixation has become much more popular in recent years^9-11. Therefore, to remove the issue of pin-site complications and simplify risk comparisons for the operative treatment arm, only one type of surgical intervention was modeled.

Nonoperative treatment included six weeks of immobilization with use of any of several different methods. Although there are differences among short arm cast, long arm cast, and functional bracing from the patient perspective, no consensus has been reached in the literature regarding the preferred type of immobilization. Therefore, we combined the available data on complication rates and treatment outcomes from the different methods to create the nonoperative treatment pathway.

Complication Rates and Treatment Outcomes

A literature search was undertaken with use of PubMed (Bethesda, Maryland) to identify appropriate studies, from 1965 to the present, from which to derive parameters for the decision model. Data were selected from a previously performed meta-analysis⁷, and results from several studies^4,7-10,12-17 were pooled with use of weighted averages to estimate complication rates (Table II).

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TABLE II Model Parameters from Meta-Analysis and Pooled Results

	Probability*
	Nonoperative Treatment			Operative Treatment
Parameter	Mean	Range	Mean	Range†
Malunion	0.383	0-0.52	0.044	—
Painful malunion	0.123	0-0.40	0.102	0-0.625
Functional deficit	0.303	0-0.56	0.152	0-0.368
Complex regional pain syndrome	0.077	0.009-0.22	0.025	—
Late fracture collapse	0.156	0-0.165	NA
Major complications
Removal of hardware	NA		0.159	—
Deep infection	NA		0.001	—
Tendon rupture	0.027	0-0.027	0.026	—
Hardware failure	NA		0.003	—
Revision	NA		0.005	—
Carpal tunnel syndrome	0.054	0-0.055	0.056
Overall probability of major complication	0.041	0-0.055	0.042	0.001-0.159
Minor complications
Loss of reduction (not requiring surgery)	0.336	0-0.38	0.044	—
Tenosynovitis	0.030	0-0.054	0.052	—
Neuritis	0.048	0-0.055	0.016	—
Superficial infection	NA		0.008	—
Overall probability of minor complication	0.183	0-0.378	0.030	0.008-0.052

NA = not applicable.A dash indicates that data were taken directly from the meta-analysis, and a range was unavailable.

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TABLE II Model Parameters from Meta-Analysis and Pooled Results

	Probability*
	Nonoperative Treatment			Operative Treatment
Parameter	Mean	Range	Mean	Range†
Malunion	0.383	0-0.52	0.044	—
Painful malunion	0.123	0-0.40	0.102	0-0.625
Functional deficit	0.303	0-0.56	0.152	0-0.368
Complex regional pain syndrome	0.077	0.009-0.22	0.025	—
Late fracture collapse	0.156	0-0.165	NA
Major complications
Removal of hardware	NA		0.159	—
Deep infection	NA		0.001	—
Tendon rupture	0.027	0-0.027	0.026	—
Hardware failure	NA		0.003	—
Revision	NA		0.005	—
Carpal tunnel syndrome	0.054	0-0.055	0.056
Overall probability of major complication	0.041	0-0.055	0.042	0.001-0.159
Minor complications
Loss of reduction (not requiring surgery)	0.336	0-0.38	0.044	—
Tenosynovitis	0.030	0-0.054	0.052	—
Neuritis	0.048	0-0.055	0.016	—
Superficial infection	NA		0.008	—
Overall probability of minor complication	0.183	0-0.378	0.030	0.008-0.052

NA = not applicable.A dash indicates that data were taken directly from the meta-analysis, and a range was unavailable.

For the operative treatment branches, major complications were defined as hardware failure, revision surgery, deep infection (requiring surgical drainage), tendon rupture, carpal tunnel syndrome, and removal of hardware, all of which require additional surgery. Minor complications were defined as superficial infection, loss of reduction, neuritis, and tendon irritation. On the nonoperative side, major complications requiring surgical intervention were tendon rupture and carpal tunnel syndrome, while minor complications included loss of reduction (not requiring operative treatment), neuritis, and finger stiffness. Loss of reduction that required operative intervention is captured as "fracture collapse." Complex regional pain syndrome and malunion were considered separately from the other complications, given their potential for long-term effects. Nonunion rates were assumed to be negligibly low for both treatment arms on the basis of the available literature^{7,8,10,12,13,15}. Figure 2 is an example of the basic structure of the subtree for each treatment arm demonstrating the way complications were incorporated.

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Fig. 2: The basic structure of the outcomes subtree for both treatment arms. Regardless of treatment pathway, the patient has the possibility of experiencing these complications and outcomes at differing rates. The "+" sign represents further branching collapsed for visualization. OR = operating room. CRPS = complex regional pain syndrome, and ORIF = open reduction and internal fixation.

Two parameters for operative treatment were not adequately reported in the meta-analysis for use in the model: the rates of functional deficit and painful malunion. To derive estimates for these values, data from five studies of open reduction and internal fixation of the distal end of the radius were extracted and pooled^8,9,11,16,18. Taken together, these studies represent the outcome of 198 fractures.

Fracture collapse represented the rate of lost reduction with cast immobilization requiring intervention with operative treatment. Pooled rates were derived from the Cochrane review by Handoll and Madhok¹⁵ as described above. A mean rate of 15.6% with nonoperative treatment was derived with a range of 0% to 16.5%.

Outcome Measure

The decision tree was designed to identify the treatment that maximized quality-adjusted life expectancy. To estimate quality-adjusted life expectancy, patient preferences for health outcomes were incorporated into the tree. This was done by assigning a health state value, or utility, on a scale from 0 (death) to 1 (perfect health) to each health state of interest. Given that the model represents patients who have sustained a wrist fracture, painless union was assumed to be the best possible outcome and was assigned a utility of 1.0. The utilities for the four other health states were obtained from a convenience sample of fifty-one orthopaedic patients who completed a time trade-off utility assessment for the following: (1) painless malunion, (2) painless functional deficit without a deformity, (3) painful malunion, and (4) complex regional pain syndrome. The survey was conducted by a single interviewer, and volunteers who did not have a history of wrist fracture were specifically chosen to avoid the bias of previous experiences (see Appendix). The average age of volunteer participants (57.8 years) closely matched that reported by Mackenney et al.⁶ (fifty-nine years), in a review of over 4000 distal radial fractures.

Disutilities were applied to the outcomes of patients experiencing complex regional pain syndrome, late fracture collapse, major complications, and minor complications. Each disutility represents inconvenience to the patient or time lost from normal activities during the treatment course. Minor complications experienced in the treatment period yielded lesser tolls against the final health states. Major complications were defined as those requiring operative intervention and were treated more seriously. Late fracture collapse was penalized by the additional time lost from normal activity: two weeks, four weeks, or six weeks. Complex regional pain syndrome was treated as a period of time with lower utility on the basis of the average length of symptoms reported by Duman et al.¹⁹ and utility derived from the time trade-off survey. These disutilities were then incorporated into the model by reducing the value of the final health states according to which complications affected each pathway.

Statistical Analysis

The decision model was constructed with use of TreeAge software (TreeAge Software, Williamstown, Massachusetts). One-way and two-way sensitivities as well as threshold analysis were used to explore the treatment decision. Tests of trend were performed on the utilities as derived from the time trade-off exercise.

Source of Funding

No outside funding was received for this study.

Results

Utility Data: Time Trade-Off

Utilities associated with four outcome states were estimated as shown in Table III for the base case (mean age, 57.8 years) as well as three different age groups: less than fifty-five years, fifty-five to sixty-four years, and sixty-five years and older. Tests of trend for utilities across age groups were all significant (p < 0.001), with the highest utilities for the group of subjects who were sixty-five years of age or older.

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TABLE III Utility Values for Health Outcome States*

Age Group	No. of Subjects	Painless Malunion	Painless Functional Deficit	Painful Malunion	Complex Regional Pain Syndrome
Base case (mean age, 57.8 yr)	51	0.992 (0.989-0.997)	0.985 (0.974-0.996)	0.957 (0.932-0.982)	0.912 (0.870-0.955)
<55 yr	19	0.992 (0.983-1)	0.989 (0.976-1)	0.936 (0.876-0.997)	0.852 (0.757-0.947)
55-64 yr	21	0.989 (0.981-0.998)	0.976 (0.950-1)	0.963 (0.935-0.991)	0.936 (0.882-0.990)
=65 yr	11	0.999 (0.998-1)	0.995 (0.989-1)	0.981 (0.967-0.996)	0.975 (0.954-0.995)

The values are from the time trade-off survey and are given as the mean with the 95% confidence interval.

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TABLE III Utility Values for Health Outcome States*

Age Group	No. of Subjects	Painless Malunion	Painless Functional Deficit	Painful Malunion	Complex Regional Pain Syndrome
Base case (mean age, 57.8 yr)	51	0.992 (0.989-0.997)	0.985 (0.974-0.996)	0.957 (0.932-0.982)	0.912 (0.870-0.955)
<55 yr	19	0.992 (0.983-1)	0.989 (0.976-1)	0.936 (0.876-0.997)	0.852 (0.757-0.947)
55-64 yr	21	0.989 (0.981-0.998)	0.976 (0.950-1)	0.963 (0.935-0.991)	0.936 (0.882-0.990)
=65 yr	11	0.999 (0.998-1)	0.995 (0.989-1)	0.981 (0.967-0.996)	0.975 (0.954-0.995)

The values are from the time trade-off survey and are given as the mean with the 95% confidence interval.

Base Case Analysis

Parameters derived from the literature were entered into the decision model, and an analysis was performed. Life expectancy was determined from 2002 United States Life Tables²⁰ and was 24.4 years in the base case. For patients (with an average age of 57.8 years) seen with a distal radial fracture, the early operative intervention strategy was preferred (24.33 compared with 24.25 quality-adjusted life years). This represents a gain of 0.08 quality-adjusted life year (29.2 days). The analysis was repeated with use of the life expectancies and utilities of differing age groups. The operative strategy continued to dominate, and younger patients had greater marginal gains in quality-adjusted life years (Table IV). Conversely, the gain from operative intervention in the group of individuals who were more than sixty-four years old was only 0.01 quality-adjusted life year (3.7 days).

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TABLE IV Expected Value of Decision Model by Age Group

Age Group	Open Reduction and Internal Fixation*	Cast Treatment*	Quality-Adjusted Life Years Gained with Open Reduction and Internal Fixation†
Base case (mean age, 57.8 yr)	24.33	24.25	0.08 (29.2)
<55 yr	32.92	32.78	0.14 (51.1)
55-64 yr	22.70	22.62	0.08 (29.2)
=65 yr	13.38	13.37	0.01 (3.7)

The values are given as quality-adjusted life years.The values are given as a fraction of a year with the equivalent days in parentheses.

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TABLE IV Expected Value of Decision Model by Age Group

Age Group	Open Reduction and Internal Fixation*	Cast Treatment*	Quality-Adjusted Life Years Gained with Open Reduction and Internal Fixation†
Base case (mean age, 57.8 yr)	24.33	24.25	0.08 (29.2)
<55 yr	32.92	32.78	0.14 (51.1)
55-64 yr	22.70	22.62	0.08 (29.2)
=65 yr	13.38	13.37	0.01 (3.7)

The values are given as quality-adjusted life years.The values are given as a fraction of a year with the equivalent days in parentheses.

Sensitivity Analysis

The probability of fracture collapse was hypothesized before the analysis to be a driver of the preference for early operative treatment. However, sensitivity analysis revealed that the preferred strategy remained open reduction and internal fixation, regardless of the risk of late fracture collapse with cast treatment (Fig. 3). Even if the risk is zero, surgery is preferred, suggesting that other treatment benefits are more important within the model.

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Fig. 3: One-way sensitivity analysis on the probability of late fracture collapse, demonstrating that operative treatment is preferred throughout the range of values. ORIF = open reduction and internal fixation, and QALY = quality-adjusted life year.

The disutility of late fracture collapse was similarly examined and found to have little effect on the results. Even with no disutility against the health states for late fracture collapse, operative treatment was preferred.

The outcome state of malunion had more effect on the model, but only at extreme values. The probability of malunion after surgery did not change the outcome until it reached 50% (Fig. 4). Two-way sensitivity analysis on the rate of malunion with surgery compared with cast treatment is shown in Figure 5. Cast treatment would become the preferred option in the case of surgical malunion rates of >10%. However, one would have to assume a higher malunion rate with surgery compared with cast treatment in order to prefer nonoperative treatment.

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Fig. 4: One-way sensitivity analysis on the probability of malunion after open reduction and internal fixation (ORIF). This figure demonstrates that cast treatment would be preferred if the probability exceeds 0.50. QALY = quality-adjusted life year.

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Fig. 5: Two-way sensitivity analysis with use of the probabilities of malunion with surgery compared with cast treatment. If the probability of malunion with surgery is less than 0.10, then operative treatment is preferred regardless of the rate with cast treatment.

The rates of complex regional pain syndrome also did not change the preferred strategy within reported ranges or beyond them. Thus, the utility of the complex regional pain syndrome state did not strongly affect the preferred decision. A variable was created to assess the differential in the rates of complex regional pain syndrome between cast and surgical treatment. However, no change was seen over the range of equal rates to a fivefold differential.

The probabilities and disutilities of major and minor complications were similarly examined. Varying the rates of either of these over the expected as well as the extreme ranges did not alter the preferred option. We suspected before the analysis that the inclusion of removal of hardware as a major complication would be a driver of the outcome, but that was not borne out. This highlights the minor effect of short-term disutilities in a long-term decision model.

Analysis of the health state utilities revealed that the probability of accessing the health state of painless union was the major driver. When the utilities of painless union and painless malunion were compared in a two-way sensitivity analysis (Fig. 6), the preferred strategy changed when the utility of union and malunion approached equality. This implies that patients with a high utility for the painless malunion state (i.e., elderly patients who care little about wrist deformity) might prefer cast treatment. The time trade-off for the health state of painless malunion revealed a utility range of 0.989 to 0.999, which generally increased with patient age. However, the preferred strategy did not change within the utility values obtained in our survey. Similarly, the remaining utilities did not alter strategy within allowed ranges.

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Fig. 6: Two-way sensitivity analysis on the utilities of painless union compared with painless malunion. Operative treatment is preferred in most cases, but with only a slight margin.

Discussion

A decision tree was created to model the scenario of adult patients with a distal radial fracture who undergo closed reduction and present at the initial follow-up visit with acceptable alignment. Should this patient continue conservative management or have early internal fixation to forgo the possibility of fracture collapse?

For nearly all scenarios, early operative fixation was the preferred treatment. The difference was small (0.08 quality-adjusted life year or 29.2 days) but robust over most changes in the model. The most important driver of the decision was the likelihood of attaining a painless union, which was higher in the early operative arm according to reports in the literature^{8-10,13,16,18}. The short-term disutilities of fracture collapse and treatment complications were not influential in the face of gains in long-term health outcomes.

Using data from Hanmer et al.²¹, we estimated that a clinically meaningful difference in quality-adjusted life years for this group would range from 0.02 to 0.03 quality-adjusted life year. They analyzed seven different health-related quality-of-life scores from a very large group of noninstitutionalized adults (>20,000 subjects) in the United States. The mean health-related quality-of-life scores were reported with 95% confidence intervals that spanned an average of 0.02 to 0.03. Therefore, a difference in quality-adjusted life years of >0.03 would fall outside the 95% confidence interval and likely represents a meaningful difference. Given this information, the expected value gain demonstrated by the model is worthwhile for the base case and younger age groups, but is probably not meaningful for the group of patients over sixty-four years old.

Patient utilities for the different health outcome states were the key factor. The utility differential between painless malunion and painful malunion was quite influential in the decision, and our utility assessment revealed that this difference generally decreased with age. If a patient places equal utility on these two states, then nonoperative treatment would be preferred. Therefore, helping a patient to determine his or her individual preferences can assist the surgeon with the treatment decision.

An increasing number of surgeons are offering internal fixation to patients with complex or unstable fracture patterns as an alternative to nonoperative treatment, given the risk of lost reduction and potential for poor outcomes^{8,10,11,13,18,22}. The reasons cited include decreased tolerance of functional deficits by patients, decreased satisfaction with poor cosmetic appearance, and the difficulty of successful nonoperative treatment in complex fracture patterns^{8,10,11,13,18}. To our knowledge, no other model of this patient decision has been reported nor has there been a randomized trial comparing cast treatment and plate fixation for this fracture type. Mackenney et al. performed a linear regression analysis on a group of >4000 patients with distal radial fractures⁶. Those authors produced equations that predict the probability of late failure of nonoperative treatment on the basis of age and initial radiographic parameters. Similarly, Lafontaine et al., in a study of 112 patients over the age of sixty years who had an acceptable reduction after nonoperative treatment of a distal radial fracture, noted an increased risk of secondary displacement associated with dorsal comminution, initial angulation, and radial shortening as well as an age of more than sixty years²³. With use of this information, patients may be advised of the probability of treatment failure despite an acceptable reduction at the time of the initial follow-up.

The most common treatment of a distal radial fracture remains closed reduction and immobilization with a cast or functional brace^22,24. As reported by Vogt et al., 75% of extra-articular distal radial fractures are amenable to nonoperative treatment if fracture reduction can be maintained²⁵, and satisfactory functional outcomes have been reported by multiple authors using a variety of treatment algorithms^2,3,26.

Many physicians also argue that patients are more tolerant of functional deficits or imperfect outcomes as age increases, and therefore they are more amenable to nonoperative management. Several authors have concluded as much in our review of the literature^2,3,13,26. Additionally, our own utility sampling demonstrated a general trend toward higher utilities for malunion and functional deficiency with increased age.

Despite these findings, the preferred strategy of the model remains open reduction and internal fixation for both young and elderly patients, although gains in quality-adjusted life years decrease with age. Perhaps if utilities were discounted in later life years to account for decreased productivity, the differences would be further diminished and cast treatment would be preferred. However, we believed that such a discount would be inappropriate, when one could also argue that today's more active elderly individuals are less tolerant of disability or that a person who requires walking aids later in life will require adequate wrist function.

As with any attempt to model a complex patient decision, our effort has limitations. The most important of these lies in the pooling of available data from the literature to estimate complication rates. A combination of meta-analyses and case series cohorts were used to derive the best estimation of the actual data. However, there are no means to remove the bias of each individual study when pooling results. Sensitivity analysis was used to test each variable and revealed no single complication rate that altered the preferred solution. Therefore, a single inaccurate estimate should not be overly detrimental.

We made the assumption that patients who experienced late fracture collapse while undergoing nonoperative treatment would then receive surgical treatment. For the purposes of the decision we are modeling, this is accurate. However, we acknowledge that the situation in the clinical setting could be quite different. We were also unable to differentiate between locking and nonlocking plate techniques, given the data currently available in the literature, although some surgeons would argue that modern fixation techniques provide an even lower risk of malunion after surgery.

Utilities for the model were gathered from a cohort of adult patients without a previous wrist fracture. The average age was 57.8 years, and the sample had essentially equal numbers of men and women. The average age at the time of wrist fracture in the United States is fifty-nine years, but 85% occur in women²². Thus, men are likely overrepresented in our sample. While this represents a limitation, the optimum decision was robust across the ranges of each health state utility and remained so when different age groups were considered individually.

In conclusion, on the basis of decision modeling, early fixation with a volar plate was found to be the preferred strategy by a small margin in most scenarios. Internal fixation of potentially unstable distal radial fractures provided a higher probability of painless union on the basis of the available parameters in the literature, and this long-term gain in quality-adjusted life years outweighed the short-term risk of surgical complications. However, patients have different tolerances for cosmetic and functional deficits on the basis of age, activity level, and personal values. In certain cases, such as a patient who is elderly or has low functional demands, he or she may have a relatively high utility for the painless and painful malunion outcome states and will not demonstrate a meaningful gain from open reduction and internal fixation. This decision is highly preference-sensitive, and therefore the individual patient should drive the treatment algorithm.

Appendix

The health state time trade-off questionnaire is available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on "Supplementary Material") and on our quarterly CD/DVD (call our subscription department, at 781-449-9780, to order the CD or DVD). Image Not Available

References

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Topics

fracture ; casts, surgical ; fracture fixation, internal ; pain ; open reduction with internal fixation ; radius fracture, distal ; sensitivity analysis

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Karl M. Koenig, MD

Posted on September 29, 2009

Drs. Koenig and Koval respond to Dr. Slobogean

Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

We sincerely appreciate the commentary posted by Dr. Slobogean regarding our decision model. His points are well taken. Our results should be interpreted with caution by the practitioner in the treatment of distal radius fractures. While we believe the decision model to be robust in its findings, the QALY gain by operative treatment is small and its true clinical significance remains to be seen. The utility data is taken from a relatively small sample and may be subject to reliability questions. However, the lack of such data in the literature highlights the importance of our unique time-trade off exercise in wrist fracture outcome evaluations.

Further work is necessary to evaluate the clinical outcomes and economic implications of changes in wrist fracture treatment. However, given the widespread increase in the rates of ORIF for distal radius fractures, it is necessary to make an attempt to quantify our patientsâ€™ preferences in this matter. In that light, our model gives some credence to the notions that 1) the average patient may prefer an early operation to cast treatment, despite the inherent risks of surgery, if the chance of a good functional outcome is improved, and 2) more elderly patients are less inclined to take those risks. However, we agree that further evaluation of this treatment strategy is needed before widespread adoption should be considered.

Gerard P. Slobogean, MD, MPH

Posted on September 21, 2009

Is Early Fixation Preferred to Cast Treatment for Well-Reduced Unstable Distal Radial Fractures?

University of British Columbia, Vancouver, Canada

To the Editor:

I wish to comment on the recently published work by Koenig and colleagues (1). Using their base case analysis, early internal fixation results in an additional 0.08 quality-adjusted life years (29 days) compared to non-operative treatment (24.33 vs 24.25 years). Although the authors present one- and two-way sensitivity analyses to demonstrate the relative stability of their model, I believe it is premature to adopt an early internal fixation strategy based on their results.

Koenigâ€™s model describes utilities for five health states. The utilities for each health state were obtained using a time-tradeoff (TTO) method in a convenience sample of 51 orthopaedic patients. The difference in utility between the perfect health and other fracture health states was extremely small (0.008 for painless malunion, 0.015 for painless functional deficit, and 0.043 for painful malunion). Without information regarding the measurement error and retest reliability of the TTO technique, it is difficult to know if these utility estimates are statistically or psychometrically meaningful. Regardless, it should be noted that the reported differences in utilities between the health states might not be clinically significant. A minimum important difference for the following three generic health utility questionnaires has been estimated: Health Utilities Index Mark 3 (0.06), Short-Form-6D (0.03), Euroqol-5D (0.05) (2).

Furthermore, it should also be recognized that there are several methods for obtaining utility values, and that different values are obtained depending on the method used (3). In fact, the variation in the resultant quality-adjusted life years (QALYs) can affect the conclusions of economic attractiveness in a cost-effectiveness analysis (4).

Finally, although not an objective of the current study, one should be encouraged to consider the costs associated with a new technology or treatment strategy. What is the incremental cost the healthcare system would be willing to pay for a gain of 29 quality-adjusted life days over a 25-year time horizon?

The work presented by Koenig et al. is an initial step towards answering a relevant clinical question; however, significant uncertainty regarding the true expected value of each strategy remains. Additional modeling, clinical studies, and economic analyses should be performed before early internal fixation of well-reduced unstable distal radius fractures is routinely practiced.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

References

1. Koenig KM, Davis GC, Grove MR, Tosteson AN, Koval KJ. Is early internal fixation preferred to cast treatment for well-reduced unstable distal radial fractures? J Bone Joint Surg Am. 2009;91:2086-93.

2. Marra CA, Woolcott JC, Kopec JA, Shojania K, Offer R, Brazier JE, Esdaile JM, Anis AH. A comparison of generic, indirect utility measures (the HUI2, HUI3, SF-6D, and the EQ-5D) and disease-specific instruments (the RAQoL and the HAQ) in rheumatoid arthritis. Soc Sci Med. 2005;60:1571-82.

3. Hunink M, Glasziou P, Siegel J, Weeks J, Pliskin J, Elstein A, Weinstein M. Decision making in health and medicine. New York: Cambridge University Press; 2001.

4. Marra CA, Marion SA, Guh DP, Najafzadeh M, Wolfe F, Esdaile JM, Clarke AE, Gignac MA, Anis AH. Not all "quality-adjusted life years" are equal. J Clin Epidemiol. 2007;60:616-24.

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Karl M. Koenig, Garrett C. Davis, Margaret R. Grove, Anna N.A. Tosteson, Kenneth J. Koval; Is Early Internal Fixation Preferred to Cast Treatment for Well-Reduced Unstable Distal Radial Fractures?. The Journal of Bone & Joint Surgery. 2009 Sep;91(9):2086-2093.

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