Open Fracture Reductions

Our prospective cohort study was conducted alongside two ongoing clinical trials that are coordinated from our institution, an academic Level-1 trauma center in The Netherlands. The medical ethical review committee granted approval before initiation of this parallel study, without the need for informed consent from patient participants.
Patients for our cohort study were recruited from the two ongoing clinical trials between January 2011 and July 2014, during their first visit to the outpatient clinic. To increase the size of our cohort study population, we also recruited patients with distal radius fractures at the outpatient clinic who were not enrolled in the clinical trials. The patients who were not participants of the clinical trial were enrolled in our study between January 2014 and July 2014.
Our study population consisted of 102 patients with distal radius fractures. Patients were excluded if they: (1) did not want to complete the questionnaire at the outpatient clinic; (2) did not complete the anchor questions; (3) were unable to understand the study information; or (4) had sustained their distal radius fracture more than 1 year before their visit to the outpatient clinic.
Of the two concurrent clinical trials occurring during our prospective cohort study, the first trial [3 (link)] included 42 patients who underwent a study of two- and three-dimensional imaging. This trial provided 42 adult patients with intraarticular distal radius fractures who were treated with open reduction and internal fixation with a volar locking plate.
The second trial [25 (link)] randomized patients with displaced extraarticular distal radius fractures (AO types A2 and A3 [17 ]) between treatment with either open reduction and internal fixation with a volar locking plate or plaster immobilization. This trial provided 39 patients.
Additionally, during the first 6 months of 2014, we identified 55 patients who were not enrolled in either clinical trial but who were eligible for participation in our study. All adult patients with a distal radius fracture were eligible for inclusion, regardless of the type of treatment they received. After exclusion, an additional 21 patients with a distal radius fracture who were not enrolled in either of the two trials were included in our study cohort.
There are two methods to define the MCID: (1) a distribution-based and (2) an anchor-based approach [5 (link)]. The distribution-based approach is used to evaluate if the observed effect is attributable to true change or simply the variability of the questionnaire. It examines the distribution of observed scores in a group of patients. The magnitude of the effect is interpreted in relation to variation of the instrument [9 (link)]. In other words, is the observed effect attributable to true change or simply the variability of the questionnaire?
The anchor-based approach uses an external criterion (the anchor) to determine the MCID. Possible anchors include objective measurements, such as prehensile grip strength and ROM, or patient-reported anchor questions. The purpose of a patient-reported anchor question is to “anchor” the changes observed in the PRWE score to patients’ perspectives of what is clinically important [13 (link)].
Anchor-based methods to determine the MCID are preferred because an external criterion is used to define what is clinically important [7 (link)]; however, the anchor-based method does not take into account the measurement error of the instrument, so it is valuable to use the anchor- and distribution-based approaches [7 (link)]. To avoid confusion, the distribution-based method generally is referred to as minimum detectable change (MDC), and the anchor-based method as MCID [7 (link)]. We use the same terms to identify the methods.
Data were collected prospectively. Patients completed the Dutch version of the PRWE questionnaire during two visits at approximately 6 to 12 weeks and approximately 12 to 52 weeks after distal radius fracture injury.
At the second visit, patients were asked to indicate the degree of clinical change they had noticed since the previous visit for each domain (pain and function). Patients noted their answers on a global rating of change scale (GRC) from −5 (much worse) to +5 (much better) (Fig. 1) [11 (link)]. The purpose of this question was to “anchor” the changes observed in the PRWE score to patients’ perspectives regarding what is clinically important [13 (link)].Fig. 1

The global rating of change (GRC) scale used in the Patient-rated Wrist Evaluation (PRWE) questionnaire is shown. The anchor questions allowed patients to assess their current health status regarding wrist function and wrist pain, and compare their status with that of their previous visit.

There is no consensus regarding the required sample size to determine the MCID [19 (link)]. We made a sample size estimation based on a conservatively estimated MCID of 12 points, with a SD of ± 14 [12 (link), 20 (link), 22 (link)]. To achieve an α of 0.05 and a power of 80%, we required 18 data points representing no change, and 18 data points representing minimal improvement.

The statistical package SAS was used for the analyses in this study. SAS was used to select the study and comparison groups (SAS Institute Inc., Cary, NC, USA). Descriptive analyses of the independent variables (patient characteristics, demographics, personal history at baseline, surgical interventions, the amount of time between fracture and the onset of depression and other comorbidities) are reported as percentages or the mean ± standard deviation (SD). The X² test was used to make between-groups comparisons of patient demographics, including economic status (monthly income: USD$>1000, USD$601∼1000, USD$<600), urbanization of their home city (level 1 to 4), the geographic location of patients’ residence (northern, central, southern, and eastern Taiwan), personal history at baseline (diabetes mellitus, hypertension, renal failure, liver cirrhosis, stroke and osteoporosis) and mortality rate between patients with fracture and non-fracture. The urbanization of patients’ home city was defined by population and certain indicators of the city’s level of development. Level 1 urbanization was defined as having a population greater than 1,250,000 people and a specific status of political, economic, cultural and metropolitan development. Level 2 urbanization was defined as having a population between 500,000 and 1,250,000 and an important role in the Taiwanese political system, economy and culture. Urbanization levels 3 and 4 were defined as having a population between 150,000 and 500,000 and less than 150,000, respectively. Furthermore, a crude hazard ratio (HR) was calculated using Cox’s stratified proportional hazards model (stratified with age, sex and the number of years since index hospitalization) to analyze the risk of new-onset major depression between the study and comparison groups. The covariate-adjusted HR was analyzed after adjusting for diabetes mellitus, hypertension, renal failure, liver cirrhosis, stroke, osteoporosis, geographic regions, post-fracture co-morbidities, monthly income and urbanization of patients’ home cities. In addition, we used SAS to analyze the eight most common post-fracture comorbidities during the study period. The relationship between post-fracture comorbidities and major depression was also analyzed. We used the Kaplan-Meier method and Log-rank test to estimate survival curves and compare the 3-year major depression-free survival rate between patients with femoral neck fracture and those without. Among the femoral neck fracture patients, the amount of time before the onset of major depression was recorded and divided into 6 periods (<200, 201–400, 401–600, 601–800, 801–1000 and >1000 days). Additionally, the relationship between surgical interventions (including hip replacement and open reduction of internal fixation of the hip) and the chance of suffering new-onset major depression was analyzed for this group (X² test). Hip replacement included hip arthroplasty in this study. A p-value <0.05 was considered to be statistically significant.

Records from the Korean NHI claims database from 2002 and 2004 were used to identify patients with hip fractures and to monitor their 1-year mortality. The incidence of hip fractures was defined as patients having a claim record with a diagnosis of hip fracture and a hip fracture-related operation. Since identifying hip fracture cases solely based on diagnosis is likely to cause misclassification problems due to potential miscoding, we combined the information from both diagnosis and surgical records. This conservative approach underestimates the real incidence rate of hip fractures in Korea, but improves the validity of the incidence cases identified from insurance claims data.
All claims records of outpatient visits or hospital admissions of patients aged 50 or older containing a diagnosis of femur fracture (fracture of femur [International Classification of Diseases (ICD)-10 diagnostic code: S72], fracture of the neck of the femur [S72.0, S72.00], pertrochanteric fracture [S72.1, S72.10]) and hip fracture-related operation (open reduction & internal fixation [ICD-10 procedure code: N0601], closed reduction and percutaneous fixation [N0991], total hip replacement [N0711], or hip hemiarthroplasty [N0715]) from January 1 to December 31, 2003 were identified from the NHI claims database. The diagnosis and operation code for hip fracture was selected based on previous epidemiologic studies [1 (link),14 (link)] and was confirmed by a panel of four orthopedic clinicians working in four different general hospitals in Korea. The cases having more than one claim record that satisfied the inclusion criteria during 2003 were counted only once.
In general, not all operations are carried out during the first fracture visit or admission. However, most of the operations are performed within a month following the first visit, according to a consultation of orthopedic clinicians in Korea. Thus, we additionally defined the incidence cases as patients who did not have a record of a hip fracture-related operation in the claim record of the initial visit or admission, but had it within a month after the initial visit.
The 6-month period prior to 2003 (i.e., July - December, 2002) was set as a 'window period,' such that patients were defined as incident cases only if their first record of a fracture visit or admission was observed after this 6-month period. Since most of the follow-up treatments for hip fracture are completed within 6 months after the initial fracture, we assumed that the absence of any claims record with a diagnosis of hip fracture and hip-fracture-related operation in the previous 6 months assured that the fracture was a new case.
NHI claims data were merged with national mortality data provided by the National Statistical Office to determine the survival status of individual patients at the 12 months following the incidence.

A 63-year-old male patient (height 180cm, weight 95 kg) suffered from a closed fracture of the lower leg with a distal diaphyseal fracture of the tibia, a proximal and a distal fibular fracture (Figure 1A). Computed tomography (CT) scans of the injured lower leg and the ankle joint were taken upon admission, and immediate Damage Control surgery was conducted on the day of the accident by closed reduction and the application of an ankle-joint-crossing, external fixator overspanning the fracture gap. After consolidation of the soft-tissue injury, the tibial fracture was surgically treated by implantation of an intramedullary nail (9 × 345 mm, Expert, Synthes, Umkirch, Germany). The distal fibular fracture was treated by open reduction and plate osteosynthesis (VariAx 2 Distal fibula system, Stryker, Kalamazoo, USA) including restoration of a syndesmotic injury by using a set screw, whereas the proximal fibular fracture was not treated surgically (Figure 1B). Postoperatively, the patient was mobilized on forearm crutches with a partial weight-bearing recommendation of 20 kg for the first 6 weeks (Figure 1C). A postoperative CT scan early after surgery and follow-up radiographs at 6 weeks and approximately 6 months after surgery were taken.

A prospective cohort study was conducted evaluating differences in treatment between CAQ hand surgeons and board-certified orthopaedic surgeons who take call at a level 1 or level 2 trauma center (non-CAQ surgeons). The two cohorts included 25 CAQ hand surgeons and 25 non-CAQ surgeons, with a total N of 50. After institutional review board approval, a retrospective chart review was done for any patient aged 18 years or older who sustained a DRF between January 1, 2018, and January 1, 2020. All subjects had plain radiographs with both prereduction and postreduction images, and a CT scan was required for at least 15 of the 30 fractures. Subjects were excluded if they had multiple concurrent injuries to the ipsilateral ulnar shaft or distal ulna. After a review of the >75 fractures that fit these criteria during this period, 30 DRFs were selected based on their age and fracture AO/OTA classification (15 AO/OTA type A and B and 15 AO/OTA type C) to create a standardized patient data set. Fifteen AO/OTA type C were selected, given their propensity to be an injury that would require surgical intervention. The classification was done by three CAQ hand surgeons independently. Any discrepancies between fracture classifications were discussed and agreed upon before the final selection of fractures.
A deidentified presentation was used to sequentially display radiographic images followed by patient-specific demographics. The surgeons being evaluated were provided a treatment survey document (Appendix A, http://links.lww.com/JG9/A272) before testing. The survey included nine questions that were sequentially asked for each of the 30 DRFs. All testing was done remotely using the Zoom platform. The data points as presented during analysis included (1) prereduction and postreduction radiographic images, (2) CT radiographs (15 of 30 fractures), (3) patient's age, (4) notable medical comorbidities, (5) patient's manual laborer status, and (6) associated polytrauma. The surgeon's fracture management was inquired after each of the above data points was consecutively provided based on the treatment survey. Treatment options included both closed (splint in situ and closed reduction and casting) and open management options (closed reduction and pinning ± external fixator, open reduction and internal fixation with fragment specific or volar locking plate, and dorsal spanning plate ± adjuvant fixation). After the survey was completed, demographic information about the surgeon was ascertained, including number of DRF treated per year, number of years postfellowship training, and their current practice setting.