OTA 2008 Posters

Scientific Poster #120 Upper Extremity OTA-2008

Is Early Open Reduction and Internal Fixation Preferred to Nonoperative Treatment for Well-Reduced Unstable Distal Radius Fractures? A Patient-Based Decision Model

Karl M. Koenig, MD (n); Garrett C. Davis (n);
Kenneth J. Koval, MD (b-Lippincott; b,c,e-Biomet; b,e-Stryker); Anna N. Tosteson, PhD (n);
Department of Orthopaedics, Dartmouth-Hitchcock Medical Center,
Lebanon, New Hampshire, USA

Purpose: Treatment of distal radius fractures has become increasingly aggressive in recent years. Physicians often choose internal fixation over cast treatment for potentially unstable fracture patterns, citing the difficulties of successful conservative treatment and decreasing patient tolerance for functional deficit. This study was performed to evaluate whether early internal fixation with volar plating or nonoperative treatment would be preferred for displaced, potentially unstable distal radius fractures that initially had an adequate reduction, using patient-based decision modeling.

Methods: A decision analysis model was created to compare early internal fixation versus nonoperative management after a displaced, potentially unstable distal radius fracture with an acceptable closed reduction. To identify the optimal treatment, quality-adjusted life expectancy was estimated for each management approach. Data from the published literature were used to estimate rates of both treatment complications (eg, fracture displacement with nonoperative treatment) and treatment outcomes. Sensitivity analysis was used to determine which model parameters would change the treatment decision over a plausible range of values.

Results: Mean health state utilities for treatment outcomes of painless malunion (.992 ± 0.016), functional deficit (.985 ± .040), and painful malunion (.957 ± 0.087) were derived by surveying a cohort of 51 adult volunteers using the time trade-off method. Early internal fixation with volar plating was found to be the preferred strategy in most scenarios over the ranges of parameters available, but the margins were small. The average-aged patient who sustains a distal radius fracture (57.8 years) can expect 0.15 more quality-adjusted life years (QALYs) with internal fixation versus nonoperative treatment. Sensitivity analysis revealed no single factor that changed the preferred option within the reported ranges. Older age groups that had lower disutility for painless malunion derived a lesser benefit, but internal fixation remained the preferred treatment.

Conclusion: Internal fixation using volar plating of potentially unstable distal radius fractures provided a higher probability of painless union based on available data in the literature. This long-term QALY gain outweighed the short-term risks of surgical complications, making early internal fixation the preferred treatment.

If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.

• The FDA has not cleared this drug and/or medical device for the use described in this presentation   (i.e., the drug or medical device is being discussed for an “off label” use).  ◆FDA information not available at time of printing. Δ OTA Grant.