International Survey: Factors Associated With Operative Treatment of Distal Radius Fractures and Implications for the American Academy of Orthopaedic Surgeons' Appropriate Use Criteria. Issue 10 (October 2019)

• Record Type: Journal Article
• Authors: Kyriakedes, James C.; Crijns, Tom J.; Teunis, Teun; Ring, David; Bafus, Blaine T.
• Is Part Of: Journal of orthopaedic trauma. Volume 33:Issue 10(2019)
• Publication Date: 2019-10
• Subjects: distal radius fractures -- appropriate use criteria -- clinical practice guidelines -- treatment decision making -- intra-articular fractures -- American Academy of Orthopaedic Surgeons -- international survey; Orthopedics -- Periodicals; Wounds and injuries -- Periodicals; Orthopedics -- Periodicals; Wounds and Injuries -- therapy -- Periodicals; Periodicals; 617.47044
• DOI: 10.1097/BOT.0000000000001517
• Languages: English
• ISSNs: 0890-5339

Abstract

Abstract : Objectives: Through an international survey, we assessed whether deciding to operatively treat an intra-articular distal radius fracture (DRF) is guided by identifiable patient and surgeon factors. In addition, we compared surgeons' treatment decisions with the American Academy of Orthopaedic Surgeons' Appropriate Use Criteria (AUC) treatment recommendations. Methods: This cross-sectional survey asked 224 surgeons to operatively or nonoperatively treat 28 hypothetical patients with radiographs of an intra-articular DRF. We randomized patient age (50/70 years), gender, mechanism of injury, activity level, and OTA/AO fracture type. We classified 6 fractures as "nonclinically significant displacement" and 22 as "potentially clinically significant displacement." Multilevel logistic regression analysis was performed. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Statistical significance was P < 0.05. Results: Patient factors independently associated with surgery included younger age (OR 6.7, P = 0.003), clinically significant fracture displacement (type B: OR 122, CI, 20–739, P < 0.001; type C: OR 59, CI, 12–300, P < 0.001), normal activity level (OR 5.0, P < 0.001), and high-energy mechanisms (OR 1.3, P = 0.002). Surgeon factors associated with recommending surgery included practicing outside the United States (Europe: OR 2.6, P < 0.001; "other": OR 4.8, P < 0.001). Hand surgeons most often selected surgery, as compared to orthopaedic trauma surgeons (OR 2.3, P = 0.001) and "other orthopaedists" (OR 2.2, P = 0.022). Thirty-seven percent of treatment decisions for patients with normal activity levels were rated by AUC recommendations as "rarely appropriate, " which included 91% disagreement for 70-year-olds with nonclinically significant displacement. Conclusions: Surgeons use patient age and fracture displacement to make treatment recommendations for intra-articular DRF. We recommend that the AUC be updated to include these clinical factors as essential components in its algorithm. Level of Evidence: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence. Abstract : Supplemental Digital Content is Available in the Text.