With contemporary teaching and advanced-imaging diagnostic protocols, the incidence of advanced wrist arthritis related to scaphoid nonunion and carpal instability seems to be decreasing. When this condition does present, the longstanding debate about treatment pits preserving the carpal bone mass with a 4-corner arthrodesis (FCA) against resecting the proximal row of carpal bones (proximal row carpectomy, or PRC) to provide better motion. At issue have been concerns about the durability and reoperation rates for these two treatment approaches.
In the June 17, 2020 issue of The Journal, Garcia et al. tap into the Veterans Health Administration data warehouse to help clarify this treatment dilemma. The authors identified 1,168 patients with stage-II SLAC (scapholunate advanced collapse) or SNAC (scaphoid nonunion advanced collapse) patterns of wrist arthritis. The outcomes of interest were subsequent conversion to total wrist arthrodesis and secondary surgical procedures after FCA and PRC.
Using propensity score analysis, the authors established matched cohorts of 251 cases of each procedure. The rate of conversion to total wrist arthrodesis was virtually identical in both matched groups, but far fewer patients who underwent FCA avoided a subsequent nonarthrodesis operation compared with those who underwent PRC (83.5% vs 99.7%, respectively).
Based on these findings and the evidence in previously published literature, the authors say, “We believe that PRC may be preferable to FCA in patients with symptomatic stage-II SLAC/SNAC wrist arthritis.” I think this choice should always be the result of shared decision making that itemizes the pros and cons of both procedures—especially taking into account patient preferences related to expected functional outcomes.
Marc Swiontkowski, MD
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of OrthoBuzz summaries of these “What’s New” articles. This month, author Christopher J. Dy, MD, MPH selected the 5 most clinically compelling findings from the more than 50 studies summarized in the March 18, 2020 “What’s New in Hand and Wrist Surgery.”
—A retrospective case series investigating 3 treatments for scaphoid nonunion among >100 patients1 found the following:
- Those receiving iliac crest bone graft (n=31), most of whom had carpal collapse with preserved proximal pole vascularity, had a union rate of 71%, a time-to-union of 19 weeks, and a reoperation rate of 23%.
- Those receiving an intercompartmental supraretinacular artery flap (n=33), most of whom had osteonecrosis of the proximal pole and half of whom had carpal collapse, had a union rate of 79%, a time-to-union of 26 weeks, and a reoperation rate of 12%.
- Those receiving a free vascularized medial femoral condyle flap (n=45), most of whom had carpal collapse, osteonecrosis, and prior surgery, had a union rate of 89%, a time-to-union of 16 weeks, and a reoperation rate of 16%.
—Among 13 patients with scaphoid nonunion and osteonecrosis who were treated with cancellous autograft packing and volar-plate fixation,2 there was 100% fracture union, with most achieving union within 18 weeks. However, preoperative carpal-collapse rates were not reported, making it difficult to assess the role of this procedure.
Finger Replantation: Financial Issues
—The frequency and success rates of finger replantation have been decreasing in the US. A review of physician reimbursement for these procedures3 found that replantation has lower reimbursement per work relative value unit (RVU) than many other common hand surgeries, including revision amputation, carpal tunnel release, and trigger finger surgery. This “relative devaluation” may help explain the decline in frequency and success of finger replantation.
Socioeconomics of Carpal Tunnel Syndrome
—Among patients seeking treatment for carpal tunnel syndrome, those from areas of “increased social deprivation” had worse physical function, pain interference, anxiety, and depression than patients from more affluent areas.4
Cubital Tunnel Syndrome
—A study of preoperative dynamic ultrasound in patients with cubital syndrome5 found that ultrasound was far more reliable than preoperative clinical examinations in predicting ulnar nerve stability within the cubital tunnel (88% match with intraoperative findings vs 12% match, respectively). Preoperative ultrasound may therefore help surgeons counsel patients about the possible need for nerve transposition.
- Aibinder WR, Wagner ER, Bishop AT, Shin AY. Bone grafting for scaphoid nonunions: is free vascularized bone grafting superior for scaphoid nonunion?Hand (N Y). 2019 Mar;14(2):217-22. Epub 2017 Oct 27.
- Putnam JG, DiGiovanni RM, Mitchell SM, Castañeda P, Edwards SG. Plate fixation with cancellous graft for scaphoid nonunion with avascular necrosis. J Hand Surg Am.2019 Apr;44(4):339.e1-7. Epub 2018 Aug 10.
- Hooper RC, Sterbenz JM, Zhong L, Chung KC. An in-depth review of physician reimbursement for digit and thumb replantation. J Hand Surg Am.2019 Jun;44(6):443-53. Epub 2019 Apr 17.
- Wright MA, Beleckas CM, Calfee RP. Mental and physical health disparities in patients with carpal tunnel syndrome living with high levels of social deprivation. J Hand Surg Am.2019 Apr;44(4):335.e1-9. Epub 2018 Jun 23.
- Rutter M, Grandizio LC, Malone WJ, Klena JC. The use of preoperative dynamic ultrasound to predict ulnar nerve stability following in situ decompression for cubital tunnel syndrome. J Hand Surg Am.2019 Jan;44(1):35-8. Epub 2018 Nov 27.
Distal radial fractures are common, especially in the elderly, but the best management for these fractures in older patients remains controversial. Clinical practice guidelines issued in 2011 by the AAOS recommend operative treatment when certain angulation and shortening criteria are met. Meanwhile, some studies show that age >65 years is an independent risk factor for poor radiographic outcomes,1 while other studies suggest that older patients have acceptable functional outcomes despite radiographic loss of reduction.2 We may want to believe that anatomic reduction and normal-appearing radiographs will ensure improved outcomes, but the science has not always confirmed that connection, leaving us and our older patients in a bit of a conundrum.
In the January 2, 2020 issue of The Journal, DeGeorge et al. tackle this subject in a large retrospective analysis of data from patients ≥65 years old who had been managed for a distal radial fracture between 2009 and 2014. Among >13,000 distal radial fractures analyzed, 9,973 were treated nonoperatively and 3,740 were treated operatively. The average age of the entire cohort was 75.4 years, but the authors found that the operative group was significantly younger, and that nonoperative treatment was more commonly performed in patients with a greater number and severity of medical comorbidities, including cardiovascular disease, diabetes, cancer, and dementia.
At 90 days, the overall complication rate was low (36.5 complications per 1,000 fractures), and the authors found no significant differences between the operative and nonoperative groups. However, the complication rate at 1 year was significantly higher in the operative group (307.5 per 1,000 fractures) compared to the nonoperative group (236.2 complications per 1,000 fractures). Stiffness was the most common complication across both groups, but it was significantly more common in the group that underwent operative management (occurring in 16% of that cohort). Also of note: approximately 10% of patients in each group developed chronic regional pain syndrome.
Despite the inherent weaknesses in retrospective database analyses (including, in this case, the inability to analyze indications for surgery), this study reveals some important facts that may help us better counsel older patients. Operative management of distal radial fractures in the elderly may yield better radiographic outcomes than nonoperative treatment, but that comes with a significantly increased risk of 1-year complications. Accepting a less-than-perfect reduction on radiographs and casting the fracture may be more beneficial than surgery for many of our elderly patients.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
- Mackenny PJ, McQueen MM, Elton R. Prediction of instability in distal radius fractures. J Bone Joint Surg Am. 2006 Sep; 88(9):1944-1951.
- Grewal R, MacDermid JC. The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg Am. 2007 Sep; 32(7):962-70.
Editor’s Note: Here is a list of previous OrthoBuzz posts about managing distal radial fractures:
- “Appropriate” Management of Distal Radial Fractures Improves Outcomes, Lowers Cost
- How Many X-Rays Does It Take to Treat a Distal Radial Fracture?
- Immobilization after Fixation of Distal Radial Fractures
- Association Between Distal Radial Fracture Malunion and Patient-Reported Activity Limitations
- Fixation Costs for Distal Radial Fracture
- Plate–Tendon Contact: How Important Is It?
Many surgeons realize that to improve value, we must improve the quality of care while decreasing its cost. Clinical Practice Guidelines (CPGs) developed by the AAOS and other medical societies are designed to help improve the quality of care and safety for patients, while also reducing inappropriate care and decreasing cost. Unfortunately, the evidence used for the development of CPGs is often of mixed quality. It is therefore crucial that studies evaluate patient outcomes when clinicians do and do not adhere to CPGs, so we can ensure that the guidelines are achieving their objective of improving care.
In the October 16, 2019 issue of The Journal of Bone and Joint Surgery, Giladi et al. hypothesize that adhering to Recommendation 3 of the AAOS CPG regarding radiographic indications for operative management of distal radial fractures would yield improved patient outcomes and cost benefits. Recommendation 3 of the CPG suggests that fractures with post-reduction radial shortening of >3 mm, dorsal tilt of >10°, or intra-articular displacement or step-off of >2 mm should be operatively treated. The authors retrospectively reviewed 266 patients, 145 of whom were treated operatively and 121 of whom were treated nonoperatively. Based on the guideline recommendation, only 6 patients were determined to have undergone inappropriate operative fixation, but 68 patients in the nonoperative cohort received inappropriate treatment; many of those had higher-grade fractures that, per the guideline, should have been surgically treated.
Using QuickDASH outcome scores at 4 time points up to 1 year and 1-year direct cost data, the authors compared the appropriately treated operative cohort to both the appropriate and inappropriate nonoperative groups. They also compared the appropriate and inappropriate nonoperative groups to each other. QuickDASH outcomes for appropriate nonoperative treatment were better than those for inappropriate nonoperative treatment at 1 year. In addition, inappropriate nonoperative treatment cost 60% more than appropriate nonoperative treatment. Although this cost comparison did not reach statistical significance, (p=0.23), it does suggest a cost savings with adherence to the CPGs. Appropriately treated operative patients reported less disability than the inappropriately nonoperative group.
As we continue to work at increasing health-care value, it is critical that we review CPGs in action, as Giladi et al. have done in this study. A potential next step would be to investigate whether the modest improvements in QuickDASH scores noted between appropriate operative treatment and inappropriate nonoperative treatment justify the 6-fold higher cost of operative treatment.
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
There are few things more discouraging for an orthopaedic surgeon than a late postoperative complication after what was an otherwise successful surgery. One such scenario occurs when patients who have undergone open reduction/internal fixation (ORIF) for a distal radial fracture subsequently experience a flexor pollicis longus (FPL) tendon rupture. While previous literature has suggested that plate positioning plays a role in that complication, no studies have evaluated whether newer plate designs decrease contact with the FPL tendon and therefore reduce the risk of rupture.
With that question in mind, Stepan et al. evaluated two cohorts of patients who had undergone ORIF for a distal radial fracture. In the September 4, 2019 issue of JBJS, they report on findings from 40 patients, 20 of whom received a standard distal radial volar locking plate, and 20 of whom received a plate designed with a distal cutout to afford the FPL more room to traverse.
Ultrasound analysis revealed that similar percentages of patients in each group had FPL–plate contact (65% in the FPL-plate group and 79% in the standard-plate group), and there were no differences between groups in terms of FPL tendon degeneration as seen on ultrasound. However, patients who received the FPL plate had significantly less of the tendon come in contact with the plate at 0° and 45° of wrist extension. The authors noted, however, that this difference may have been influenced by the fact that patients with the FPL-specific plate also had significantly lower volar tilt than patients with the standard locking plate. It is therefore not possible to determine whether it was the plate design or the bone position (or both) that led to these results.
It is also noteworthy that the two senior authors of this study work as consultants for the company that manufactures the plates that were evaluated. It is also important to note that because all the patients in this study were asymptomatic, further research is needed to determine the clinical importance of reduced tendon–plate contact area. We should temper our excitement about specially designed volar plates until we have more clinical data supporting their success in avoiding the problem for which they were designed.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
We orthopaedists obtain radiographs for many reasons—to diagnose an unknown problem, to determine the progress of healing, and occasionally because we follow X-ray “dogma” acquired over time. That last reason prompted van Gerven et al. to undertake a multicenter, prospective, randomized controlled trial, the findings of which appear in the August 7, 2019 issue of The Journal.
The authors set out to evaluate the clinical utility of radiographs taken after a distal radial fracture in >300 patients. Some of those fractures were treated nonoperatively, while others underwent operative fixation. Surgeons of the patients randomized to the “usual-care” pathway were instructed to obtain radiographs at 1, 2, 6, and 12 weeks following the injury/surgery. Surgeons of patients in the “reduced-imaging” arm did not obtain radiographs beyond 2 weeks after the injury/surgery unless there was a specific clinical reason for doing so.
The authors found no significant differences between groups in any of the 6 patient-reported outcomes measured in the study, including the DASH score. Furthermore, the complication rates were almost identical between the usual-care (11.4%) and reduced-imaging (11.3%) groups. Not surprisingly, patients in the reduced-imaging group had fewer radiographs obtained (median 3 vs 4) and were exposed to a lower overall dose of ionizing radiation than those in the usual-care group.
Probably because the study was conducted in the Netherlands, it did not address the widespread practice of “defensive medicine” in the US—the unnecessary overuse of medical tests and procedures to reduce the risk of a malpractice claim. While that may limit the external validity of these findings among orthopaedists in the United States, this relatively simple yet well-designed study should remind us that it is important to have a definite clinical purpose when ordering a test of any type. A picture may be worth a thousand words, but sometimes it takes only 2 pictures to tell the full story of a healing distal radial fracture.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
It goes almost without saying that a patient’s return to work after an orthopaedic injury or musculoskeletal disorder would correlate with the severity of the condition. But what about the connection between return to work and a more “touchy-feely” parameter, such as the patient-surgeon relationship?
Dubert et al. conducted a longitudinal observational study of 219 patient who were 18 to 65 years of age and had undergone operations for upper-limb injuries or musculoskeletal disorders. In the August 7, 2019 issue of JBJS, they report that a positive relationship between patient and surgeon hastened return to work and reduced total time off from work.
At the time of enrollment (a mean of 149 days after surgery), the authors assessed the patient-surgeon relationship with a validated, 11-item questionnaire called Q-PASREL, and they collected patients’ functional and quality-of-life scores at the same time. The authors then tracked which patients had returned to work 6 months later, and they calculated how many workdays those who did return had missed.
The Q-PASREL questionnaire explores surgeon support provided to the patient, the patience of the surgeon, the surgeon’s appraisal of when the patient can return to work, the cooperation of the surgeon regarding administrative issues, the empathy perceived by the patient, and the surgeon’s use of appropriate vocabulary.
Here is a summary of the findings:
- At 6 months after enrollment, 74% of patients who had returned to work had given their surgeon a high or medium-high Q-PASREL score. By contrast, 64% of the patients who had not returned to work had given their surgeon a low or medium-low Q-PASREL score.
- The odds of returning to work were 56% higher among patients who gave surgeons the highest Q-PASREL scores compared with those who gave surgeons the lowest scores.
- The “body structure” subscore on one of the functional measurements and the Q-PASREL quartile were the only two independent predictors of total time off from work among patients who had returned to work.
After asserting that their study “confirms that surgeons’ relationships with their patients can influence the patients’ satisfaction and outcomes,” Dubert et al. go on to suggest that the findings should prompt surgeons to “work on empathy, time spent with their patients, and communication.” While they rightly claim that such improvements would entail “little financial investment and no side effects,” perhaps the authors, who practice in France, underestimate the effort that goes into changing behavior—and into addressing the time constraints imposed by the US health care system?
See what JBJS Deputy Editor for Social Media Chad Krueger, MD thinks about the just-published Level-I trial comparing nonoperative treatment to volar locking plate fixation among 140 elderly patients with dorsally displaced distal radial fractures.
Every month, JBJS publishes a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in one of 13 subspecialties. Click here for a collection of all OrthoBuzz subspecialty summaries.
This month, Christopher J. Dy, MD, MPH, author of the March 20, 2019 “What’s New in Hand Surgery,” selected the five most compelling findings from among the 47 noteworthy studies summarized in the article.
Distal Radial Fractures
—A randomized trial comparing volar plate fixation to cast management in patients >60 years of age who had AO type-C distal radial fractures1 found that the volar plating group had better Patient-Rated Wrist Evaluation scores than the casting group after a minimum 24 months of follow-up. Maintenance of reduction was also better in the volar plating group. These findings are contrary to those of a similar randomized trial published in 2011, suggesting that there are patient-level and surgeon-level differences between the 2 environments in which the studies were conducted.
—Among 175 elderly patients with distal radial fractures treated nonoperatively and who showed acceptable radiographic reduction at 1 to 2 weeks, 28% had late displacement or malunion at the 3-month follow-up.2 Relative to cases in which reduction was maintained, cases with late displacement or malunion had lower grip strength and loss of the total wrist range of motion. However, there was no between-group difference in patient-reported functional measures, and the incidence of the most common complication—carpal tunnel syndrome—was the same in both groups.
—Findings from a biomechanical study with cadavers suggest that 50% cortical healing of a scaphoid fracture after open reduction and internal fixation with a compression screw is sufficient to allow unrestricted activity.3 Constructs with a 50% osteotomy and compression screw showed the same load to failure as intact scaphoids, but load to failure in a group with a 75% osteotomy and compression screw was lower than that in the intact scaphoid group.
—Traditionally, surgeons have emphasized proximal pole vascularity in cases of scaphoid nonunion. However, a study of 35 scaphoid nonunions treated with nonvascularized bone grafting and a headless compression screw4 found that 33 fractures went on to union, despite evidence of compromised proximal pole vascularity in 14 of 32 patients who had histopathological data available.
Carpal Tunnel Syndrome
—A cross-sectional study analyzing data from 367 patients who presented for evaluation of carpal tunnel syndrome (CTS)5 found that those with the poorest socioeconomic status had worse PROMIS scores for physical function, pain interference, depression, and anxiety, compared with those in the least-deprived quartile. Deprived patients were also more likely to have a higher comorbidity burden and to use tobacco, both of which may influence outcomes after CTS treatment.
- Martinez-Mendez D, Lizaur-Utrilla A, de-Juan-Herrero J. Intra-articular distal radius fractures in elderly patients: a randomized prospective study of casting versus volar plating. J Hand Surg Eur Vol.2018 Feb;43(2):142-7. Epub 2017 Sep 4
- Wadsten MÅ, Sjödén GO, Buttazzoni GG, Buttazzoni C, Englund E, Sayed-Noor AS. The influence of late displacement in distal radius fractures on function, grip strength, range of motion and quality of life. J Hand Surg Eur Vol.2018 Feb;43(2):131-6. Epub 2017 Jul 31.
- Guss MS, Mitgang JT, Sapienza A. Scaphoid healing required for unrestricted activity: a biomechanical cadaver model. J Hand Surg Am.2018 Feb;43(2):134-8. Epub 2017 Nov 7.
- Rancy SK, Swanstrom MM, DiCarlo EF, Sneag DB, Lee SK, Wolfe SW; Scaphoid Nonunion Consortium. Success of scaphoid nonunion surgery is independent of proximal pole vascularity. J Hand Surg Eur Vol.2018 Jan;43(1):32-40. Epub 2017 Sep 24.
- Wright MA, Beleckas CM, Calfee RP. Mental and physical health disparities in patients with carpal tunnel syndrome living with high levels of social deprivation. J Hand Surg Am.2018 Jun 23. [Epub ahead of print].
When planning for any type of surgical procedure, the orthopaedist considers many patient and injury-specific variables. With a distal radius fracture, for example, the main goal of the surgery—anatomic reconstruction of the distal radius—remains constant. However, there are numerous other variables (fracture morphology and patient age, just to name 2) that have to be considered to achieve that goal. Yet, when it comes to postoperative pain control, I imagine that most orthopaedic surgeons prescribe the same amount of opioids to almost every patient undergoing an open reduction/internal fixation of a distal radius fracture, regardless of unique patient characteristics. Our medical mantra that “no two patients are the same” seems to fall by the wayside when it comes to postoperative pain control.
This disconnect is what I thought about while reading the article by Stepan et al. in the January 2, 2019 issue of The Journal. The authors’ institution developed and disseminated to all prescribers a 1-hour opioid education program and consensus-based postoperative opioid prescription guidelines. They then compared the number of opioid pills and total oral morphine equivalents prescribed after 9 ambulatory procedures within 3 subspecialty services (sports medicine, hand, and foot and ankle) prior to and after implementation of the guidelines. Stepan et al. found a significant decrease in the amount of narcotics prescribed after 6 of the 9 surgery types after implementation of the guidelines. Over the course of a year, those decreases would have equaled about 30,000 fewer opioid pills!
Interestingly, there was no significant post-guideline decrease in opioid prescribing after any of the 3 foot-and-ankle procedures. The authors attribute that finding to the slow adoption of the guidelines due to adherence to previously developed pain-management recommendations in this subspecialty.
It has become apparent that we tend to overprescribe opioids postoperatively (see related OrthoBuzz post). This study supports previous data showing that prescription guidelines can be useful in decreasing the amount of postoperative narcotics prescribed to patients, while maintaining adequate pain management and good levels of patient satisfaction. While further work in developing educational tools and procedure-specific “standards” to help surgeons guide their postoperative prescribing practices would be useful, a surgeon’s mindfulness is equally important. We need first to recognize that orthopaedic surgeons tend to overprescribe postoperative opioids—and second, we must be willing to change our habits. Without both awareness and willingness, the best guidelines and recommendations will be ignored, and an opportunity for us to help curb the opioid crisis in our country will be wasted.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media