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Distal Radial Fractures in the Elderly: Operative Compared with Nonoperative Treatment
K.A. Egol, MD1; M. Walsh, PhD1; S. Romo-Cardoso, MD1; Seth Dorsky, BS1; N. Paksima, DO1
1 New York University Hospital for Joint Diseases, 301 East 17th Street, Suite 1401, New York, NY 10003. E-mail address for K.A. Egol: kenneth.egol@nyumc.org
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from commercial entities (Stryker, Synthes, and Biomet).

A commentary by Lisa Cannada, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.
Investigation performed at New York University Hospital for Joint Diseases, New York, and Jamaica Hospital Medical Center, Jamaica, New York

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Aug 04;92(9):1851-1857. doi: 10.2106/JBJS.I.00968
A commentary by Lisa K. Cannada, MD, is available here
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: 

There is much debate regarding the optimal treatment of displaced, unstable distal radial fractures in the elderly. The purpose of this retrospective review was to compare outcomes for elderly patients with a displaced distal radial fracture who were treated with or without surgical intervention.

Methods: 

This case-control study examined ninety patients over the age of sixty-five who were treated with or without surgery for a displaced distal radial fracture. All fractures were initially treated with closed reduction and splinting. Patients who failed an acceptable closed reduction were offered surgical intervention. Patients who did not undergo surgery were treated until healing with cast immobilization. Patients who underwent surgery were treated with either plate-and-screw fixation or external fixation. Baseline radiographs and functional scores were obtained prior to treatment. Follow-up was conducted at two, six, twelve, twenty-four, and fifty-two weeks. Clinical and radiographic follow-up was completed at each visit, while functional scores were obtained at the twelve, twenty-four, and fifty-two-week follow-up evaluations. Outcomes at fixed time points were compared between groups with standard statistical methods.

Results: 

Forty-six patients with a mean age of seventy-six years were treated nonoperatively, and forty-four patients with a mean age of seventy-three years were treated operatively. Other than age, there was no difference with respect to baseline demographics between the cohorts. At twenty-four weeks, patients who underwent surgery had better wrist extension (p = 0.04) than those who had not had surgery. At one year, this difference was not seen. No difference in functional status based on the Disabilities of the Arm, Shoulder and Hand scores and pain scores at any of the follow-up points was seen between the groups. Grip strength at one year was significantly better in the operative group. Radiographic outcome was superior for the patients in the operative group at each follow-up interval. There was no difference between the groups with regard to complications.

Conclusions: 

Our findings suggest that minor limitations in the range of wrist motion and diminished grip strength, as seen with nonoperative care, do not seem to limit functional recovery at one year.

Level of Evidence: 

Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Kenneth A. Egol, MD
    Posted on October 24, 2010
    Dr. Egol and colleagues respond to Dr. Nichols
    NYU Hospital for Joint Diseases, New York, New York

    We appreciate Dr. Nichols interest in our paper. This study sought to identify potential differences between non-operative and operative procedures in a population that may be particularly sensitive to more aggressive treatment, i.e. elderly patients. It is important to have some baseline from which to determine what patient characteristics might predispose to poorer outcomes. As such, we did not have an a priori determination of what constitutes a “good” outcome or what constitutes a “bad” outcome and so it would have been inappropriate for us to make such a determination with no evidence and proceed with the analysis suggested by this letter. Instead, our objective was to determine, simply, what difference, if any, exists in a wide selection of established valid outcomes. We feel our conclusion that a subset of elderly patients function well with non-operative fracture care despite radiographic malunion holds true. We believe this information is helpful for surgeons treating patients who sustain this injury.

    Kenneth A. Egol, MD
    Posted on October 06, 2010
    Dr. Egol and colleagues respond to Dr. Budoff
    NYU Hospital for Joint Diseases, New York City, New York

    We regret that Dr. Budoff was disappointed with our study. We feel the selection bias that Dr. Budoff refers to is tempered by the fact that our groups were similar with respect to fracture pattern (instability) and other socio-demographic factors. This study sought to identify potential differences between non-operative and operative procedures in a population that may be particularly sensitive to more aggressive treatment, i.e. elderly patients. It is important to have some baseline from which to determine what patient characteristics might predispose to poorer outcomes. As such, we did not have an a priori determination of what constitutes a “good” outcome or what constitutes a “bad” outcome and so it would have been inappropriate for us to make such a determination with no evidence and proceed with the analysis suggested by this letter. Instead, our objective was to determine, simply, what difference, if any, exists in a wide selection of established valid outcomes. We feel our conclusion that a subset of elderly patients function well with non-operative fracture care despite radiographic malunion holds true.

    Kenneth A. Egol, MD
    Posted on September 18, 2010
    Dr. Egol and colleagues respond to Dr. Schep and colleagues
    NYU Hospital for Joint Diseases, New York City, New York

    In response to the letter’s first point, a case-control study does not, by definition, require matching on any factor. In epidemiology, there are more unmatched case-control studies than there are matched, although the latter is nevertheless quite common and certainly relevant in many settings. However, matching would have been inappropriate given our overall goals in this work, as elucidated below. Matching, simply put, is a method used to control confounding in the design of a study. If one is to match on a specific factor, say age, then one is controlling the potential confounding effect of age with respect to some other exposure-outcome relationship of interest. When one controls for a factor by design (i.e. by matching), one cannot also simultaneously assess that factor’s relationship with the outcome. One can only conclude that another exposure-outcome association is not confounded by the controlled factor. In the present study, we sought to assess operative treatment on distal radius fracture outcomes in the elderly. However, we were unwilling to accept the elderly as a homogeneous group since musculoskeletal dynamics change across the aging process. As such, we wanted to consider age as a possible relevant factor even among this narrower age group. Had we matched on age this would not have been possible. Nevertheless, controlling the effect of age was still possible statistically.

    In the letter’s second point, the author has misunderstood general statistical principles. The family level of significance, which is what the letter is referring to in the second paragraph, must be adjusted for multiple comparisons when such comparisons are conducted. This is without a doubt an important correction that always must be undertaken in such circumstances. However, the author of this letter has misunderstood the nature of a multiple comparison. When one is comparing a single outcome (or multiple outcomes) across more than two levels of a factor, it is insufficient to simply compare with t-tests each possible combination of each level of the factor. In such situations because one is making “multiple comparisons” across the multiple levels of the factor of interest, one must consider that there is, in reality, a family level of significance and correct for this by one of the appropriate methods such as Tukey or Scheffe, based on the nature of the data. The nature of the multiple comparison is that an outcome, or outcomes, is being compared across a factor of interest that has more than two levels. It has nothing to do with the assessment of multiple outcomes, by the same or different factors, unless that factor(s) has more than two levels of comparison. In our study, we compared several outcomes across the two levels of therapy (our factor of interest) that defined the operative and non-operative elderly patient population. Therefore there is absolutely no statistical basis for adjusting for multiple comparisons, as no multiple comparisons exist.

    Jeffrey E. Budoff
    Posted on September 16, 2010
    Letter to the Editor
    University of Texas, Houston, Texas

    To the Editor:

    I read the article, "Distal Radial Fractures in the Elderly: Operative Compared with Nonoperative Treatment", by Egol et al. (2010;92:1851-7) with interest.

    However, I must admit that I was disappointed with the authors' study design and conclusions. Essentially, this article compares those distal radius fractures that were successfully treated by closed reduction and splinting to fractures too unstable to be treated successfully by closed means. It then goes on to conclude that there were no significant differences in many outcomes for fractures treated surgically or treated closed.

    It should be obvious that the fractures that were not amenable to closed treatment were quite probably more unstable than those that could maintain an acceptable reduction during closed treatment. In addition, fractures that were clearly ‘inherently unstable’, i.e. intraarticular fractures or fractures with dorsal angulation of >20°, shortening >5 mm, >50% of dorsal angulation, an associated ulnar fracture, shear fractures, fracture-dislocations, or those in patients aged 60 years or greater (with presumed osteopenia) were treated surgically.

    Clearly, if surgery was able to take unstable fractures and produce results equal to/slightly better those those found for stable fractures, than the major stated conclusion should not be that “...older patients who were treated nonoperatively had pain and functional scores equivalent to those of elderly patients who had surgical treatment”. Rather, a far more valid conclusion is that surgery, when necessary in this patient population due to fracture instability, can lead to pain relief and function as good as or even better than that enjoyed by wrists that merely experienced stable fractures amenable to closed treatment.

    Even more disturbing, at least to me, was that this rather obvious selection bias was not mentioned in the limitations section or taken into consideration in the discussion, analysis or conclusions.

    I thank you for the opportunity to comment on this paper.

    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.

    David P. Nichols, MD, MPH
    Posted on September 08, 2010
    Letter to the Editor
    NULL

    To the Editor:

    I read with interest the article published in the August 4, 2010 issue of The Journal of Bone and Joint Surgery entitled, "Distal Radial Fractures in the Elderly: Operative Compared with Nonoperative Treatment" (2010;92:1851-7), by Egol et al.

    The authors describe the study as a "case-control study". I would expect, in a case-control study, to see outcome measures defined. While they list differences in various measurements such as grip strength and DASH scores, they do not define what a desirable or acceptable grip strength measure or DASH score would be in terms of good or bad outcome.

    I would assume that the research question for this study would be, "Does exposure to nonoperative treatment lead to a greater likelihood of poor outcome compared with exposure to operative treatment?" Merely listing the differences between measurements in the nonoperative and operative group does not shed much light on this question. The authors report a nonoperative group DASH score of 27.2+/-27.8, and 21.3+/-25.8. No confidence intervals are given. It is unclear exactly what this difference means without defining good and bad results in the outcome measure.

    One would expect to see, if this was in fact a case-control study, the number of patients with a defined bad result who were exposed to operative and to nonoperative treatment. One would also expect to see the number of patients with a defined good result who were exposed to operative and to nonoperative treatment. An odds ratio could be calculated to determine the odds of a poor result in the exposed group. Also, the confidence interval for the odds ratio should be reported to give the reader knowledge of the precision of the result.

    If I have defined the research question correctly above, it cannot be answered after reading this study. I believe that answering this question with proper design and analysis would be very helpful to orthopaedic surgeons who treat this injury daily.

    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.

    Niels W. Schep
    Posted on August 29, 2010
    Beware of the Multiple Testing Problem
    Trauma Unit, Amsterdam Medical Center, Amsterdam, The Netherlands

    To the Editor:

    We read the article, "Distal Radial Fractures in the Elderly: Operative Compared with Nonoperative Treatment"(2010;92:1851-7), by Egol et al. with great interest. However, some points should be discussed. Egol and coworkers call their study a case-control study. However, the matching procedure is not clearly described in the Materials and Methods section. Moreover, one of the most obvious things to match is age and, in this study, age does not correspond between the non-operative and operative group. Therefore, it should be more appropriate to classify this study as a retrospective comparative cohort study.

    More importantly, we are concerned about the statistical analysis used in the study. Every time a test is performed there is a change(á) of a type one error. If á = 0.05 this means that when we perform 100 tests we find five significant test results based on chance, in other words 1 in 20 tests! Egol et al. use a total of 39 T-Tests to calculate their results. When the chance of making a type one error is 0.05. That means that the chance of no type one error is 1-0.05 = 0.95. Consequently, the chance of making no type one error in 39 tests is (0.95) 39 = 0.14. Therefore, the chance of making a type one error in this study is 1 - 0.14 = 0.86 (86%).

    It is possible to statistically correct for this phenomenon with, for example, a Bonferroni, Scheffe or Tukey correction. Unfortunately, this is not described in the statistical section. For that reason the results of this study have to be interpreted with great caution.

    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.

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