January 22, 2020
By Will Boggs MD
NEW YORK (Reuters Health) - The precise anatomic restoration of distal radius fractures (DRF) is not associated with improved patient outcomes in older adults, according to data from the WRIST clinical trial.
Previous studies of the importance of precise anatomic reduction for good DRF outcomes in patients aged 60 years and older have yielded inconsistent results.
Older studies reporting that precise restoration of wrist anatomy is not necessary to achieve satisfactory functional results lack relevance in the current population of older adults who are much more active and functionally independent, Dr. Kevin C. Chung of the University of Michigan Medical School, in Ann Arbor, and colleagues note in JAMA Network Open.
They used data from the WRIST trial that evaluated DRF treatment options in older adults to investigate whether radiographic measures of anatomic restoration are associated with functional and patient-reported outcomes 12 months after DRF treatment.
In the younger group (aged 60-69 years), every degree increase in radial inclination away from normal was associated with 1.1-kg weaker handgrip strength but with a 1.3-point worsening of the patient-reported Michigan Hand Outcomes Questionnaire (MHQ) score, compared with the uninjured hand.
Among patients 70 years and older, each 1-mm increase in ulnar variance towards normal was associated with a 10.4-point greater improvement in the MHQ activities of daily living score for the injured hand versus the uninjured hand.
Only three of 14 models and two of 84 correlation coefficients showed statistically significant associations of radiographic measures with outcomes.
"Clinically, this finding implies that precise anatomic realignment of the wrist is not necessary for satisfactory outcomes," the authors conclude. "With this evidence, surgeons may elect to decrease operative time, use of resources, and associated costs that would have been spent to achieve perfect or near-perfect reduction."
"In the treatment decision-making process, surgeons can prioritize patient preferences over the need to achieve exact realignment," they add. "Our study results may help to improve the quality of care in DRF management for older patients."
Dr. Matthew Costa of John Radcliffe Hospital, in Oxford, U.K., who wrote an invited commentary on the study, told Reuters Health by email, "The rationale for surgeons operating on wrist fractures is to restore the patient's normal anatomy. It is therefore surprising that the position of the bone as measured on x-rays taken after surgery doesn't seem to predict the patient's function after their fracture has healed."
"Given that the exact position of the bone fragments doesn't appear to be as important as we thought, it makes sense for surgeons to simply restore the overall alignment of the wrist using the quickest and least risky option available," he said. "It's really about a change of mindset - moving away from using x-rays to determine the success or failure of the treatment towards the patient's own view of their recovery."
"It's really important that we don't throw the baby out with the bathwater," Dr. Costa said. "All of the patients in this study had their broken wrist manipulated into a position that the treating surgeon thought was acceptable. While the exact position of the bones on x-ray may not be as important as we believed, restoring the overall alignment of the wrist is still important for pain relief and to reduce the risk of complications such as tendon or nerve damage."
Dr. Nick Johnson, a hand and wrist surgeon at Pulvertaft Hand Centre, in Derby, U.K., said, "This study provides further evidence that the radiographic position of the distal radius following a fracture is not related to functional outcome. Several studies have suggested this previously, and older people in particular seem to be able to tolerate a distal radius fracture which heals in a malunited position."
"Deciding when a distal radius fracture is displaced enough to require surgical intervention is difficult," Dr. Johnson, who was not involved in the study, told Reuters Health by email. "A decision should be made by the patient and surgeon taking into account the pre-injury functional status, activity level and past medical history of the patient, the radiographic position of the fracture, and the risks and benefits of any intervention and rehabilitation."
Dr. Johnson added, "I carried out a study where we asked a large panel of expert wrist surgeons how much malunion would cause functional problems for a patient, and the expert panel agreed that older patients were unlikely to have significant functional problems despite quite a significant amount of displacement."
Dr. Chung did not respond to a request for comments.
SOURCE: https://bit.ly/2RArahO and https://bit.ly/2GcuudF JAMA Network Open, online January 17, 2020.
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