Session IV Scientific Basis for Fracture Care

Who Needs the X-Ray, the Patient or the Doctor? Efficacy and Cost of Postoperative Xrays in Stable Fracture Fixation Cases

Tracy E. Barwick, BS, Michael J. Bosse, MD, Stephen H. Sims, MD, Brian Howard, MD, James F. Kellam, MD

Dept. of Orthopaedic Surgery, Carolinas Medical Center, Charlotte NC

A retrospective study was designed to investigate the clinical impact and cost of follow-up radiography utilization in patients treated with stable internal fixation techniques. Inclusion criteria were met by 126 patients for the one-year study period (Follow-up with the authors of at least 3 months, if healed, or 6 months if healing delayed). Hand and foot fractures, 20 patients with unstable fracture fixation, and ten patients with incomplete x-ray files were excluded, leaving 96 patients with 110 fractures for evaluation.

Three orthopaedic trauma surgeons and a musculoskeletal radiologist agreed that 79 patients had stable fixation and should be radiographed at 6 weeks from surgery and 31 patients with stable fixation should be radiographed at 12 weeks from surgery unless clinical evaluation directed otherwise. The time to first x-ray was based on the point when a major limb rehabilitation decision would be provided or therapy intervention advised from the radiographic findings (i.e., full weight bearing, bone graft recommendations).

In the first 12 weeks 172% of the predicted x-rays were ordered; 133 x-rays were taken prior to the defined "evaluation need". Only 8 were performed to assess clinical complaints. During the study period 436 total x-rays were obtained; 48% of these films resulted in no change in treatment or reaffirmed previously documented "healed fractures". The remaining x-rays either defined fracture union or were related to alteration of either weight-bearing, joint range of motion, immobilization or a combination of the three. No patient experienced a loss of reduction or fixation.

X-ray use can be planned for each patient at the time of hospital discharge based on the fracture location, pattern and fixation stability. Use of a post-fixation x-ray evaluation protocol would have eliminated unnecessary x-ray charges without compromising care. In a capitated care environment, these practice alterations are mandated; in a fee-for-service environment these alterations are needed in order to maintain a credible leadership role in the health care delivery reform efforts.