What Are the Tradeoffs in Outcomes after Casting Versus Surgery for Closed Extraarticular Distal Radius Fractures in Older Patients? A Statistical Learning Model. Issue 12 (18th December 2021)

• Record Type: Journal Article
• Authors: Yoon, Alfred P.; Wang, Yibo; Wang, Lu; Chung, Kevin C.
• Other Names: Chung H. Myra Kim Kevin C. author non-byline.; Haase Steven C. author non-byline.; Lawton Jeffrey N. author non-byline.; Lien John R. author non-byline.; Momoh Adeyiza O. author non-byline.; Ozer Kagan author non-byline.; Sears Erika D. author non-byline.; Waljee Jennifer F. author non-byline.; Brown Matthew S. author non-byline.; Cho Hoyune E. author non-byline.; Michelotti Brett F. author non-byline.; Malay Sunitha author non-byline.; Shauver Melissa J. author non-byline.; Rozental Tamara D. author non-byline.; Appleton Paul T. author non-byline.; Rodriguez Edward K. author non-byline.; Deschamps Laura N. author non-byline.; Mattfolk Lindsay author non-byline.; Philip Blazar Katiri Wagner. author non-byline.; Earp Brandon E. author non-byline.; Floyd W. Emerson author non-byline.; Louie Dexter L. author non-byline.; Leversedge raser J author non-byline.; Richard Marc J. author non-byline.; Ruch David, S. author non-byline.; Finley Suzanne author non-byline.; Howe Cameron author non-byline.; Manson Maria author non-byline.; Whitfield Janna author non-byline.; Perey Bertrand H author non-byline.; Apostle Kelly author non-byline.; Boyer Dory author non-byline.; Moola Farhad author non-byline.; Stone Trevor author non-byline.; Viskontas Darius author non-byline.; Zomar Mauri author non-byline.; Moon Karyn author non-byline.; Moon Raely author non-byline.; Kalliainen Loree K. author non-byline.; Ward Christina M. author non-byline.; Fletcher James W. author non-byline.; Heinrich Cherrie A. author non-byline.; Pico Katharine S. author non-byline.; Mahajan Ashish Y. author non-byline.; Hill Brian W. author non-byline.; Vang Sandy author non-byline.; Laporte Dawn M. author non-byline.; Hasenboehler Erik A. author non-byline.; Lifchez Scott D. author non-byline.; Osgood Greg M. author non-byline.; Shafiq Babar author non-byline.; Shores Jaimie T. author non-byline.; Laljani Vaishali author non-byline.; Bamberger H. Brent author non-byline.; Harman Timothy W. author non-byline.; Martineau David W. author non-byline.; Robinson Carla author non-byline.; Ruby Grewal Brandi Palmer. author non-byline.; Faber Ken A. author non-byline.; MacDermid Joy C. author non-byline.; Kelly Kate author non-byline.; Munro Katrina author non-byline.; Vincent Joshua I. author non-byline.; Ring David author non-byline.; Jupiter Jesse B. author non-byline.; Finger Abigail author non-byline.; Gruber Jillian S. author non-byline.; Reddy Rajesh K. author non-byline.; Pong Taylor M. author non-byline.; Thornton Emily R. author non-byline.; Dennison David G. author non-byline.; Kakar Sanjeev author non-byline.; Rizzo Marco author non-byline.; Shin Alexander Y. author non-byline.; Scrabeck Tyson L. author non-byline.; Chepla Kyle author non-byline.; Malone Kevin author non-byline.; Hoyen Harry A. author non-byline.; Bafus Blaine Todd author non-byline.; Jordan Roderick B. author non-byline.; Kaufman Bram author non-byline.; Totonchil Ali author non-byline.; Hromyak Dana R. author non-byline.; Humbert Lisa author non-byline.; Sebastin Sandeep author non-byline.; Tay Sally author non-byline.; Nellans Kate W. author non-byline.; Merwin Sara L. author non-byline.; Blackburn Ethan W. author non-byline.; Hanlin Sandra J. author non-byline.; Glenn Gaston Barbara Patterson. R. author non-byline.; Cadderdon R. Christopher author non-byline.; Gantt Erika Gordon author non-byline.; Gaul John S. author non-byline.; Lewis Daniel R. author non-byline.; Loeffler Bryan J. author non-byline.; Osier Lois K. author non-byline.; Perlik Paul C. author non-byline.; Ward W. Alan author non-byline.; Connell Benjamin author non-byline.; Haug Pricilla author non-byline.; Michalek Caleb author non-byline.; Clark Tod A. author non-byline.; McRae Sheila author non-byline.; Moriatis Wolf Jennifer author non-byline.; Rodner Craig M. author non-byline.; Coyle Katy author non-byline.; Lehman Thomas P. author non-byline.; Lansinger Yuri C. author non-byline.; O'Mahony Gavin D. author non-byline.; Carl Kathy author non-byline.; Wells Janet author non-byline.; Bozentka David J. author non-byline.; Levin L. Scott author non-byline.; Steinberg David P. author non-byline.; Horan Annamarie D. author non-byline.; Knox Denise author non-byline.; John Fowler Kara Napolitano. author non-byline.; Goitz Robert author non-byline.; Naccarelli Cathy A. author non-byline.; Tighe Joelle author non-byline.; Hammert Warren C. author non-byline.; McIntyre Allison W. author non-byline.; Noble Krista L. author non-byline.; Waldrick Kaili author non-byline.; Friedrich Jeffery B. author non-byline.; Bowman David author non-byline.; Zhongyu Li Angela Wilson. author non-byline.; Koman L. Andrew author non-byline.; Graves Benjamin R. author non-byline.; Smith Beth P. author non-byline.; Bullard Debra author non-byline.;
• Is Part Of: Clinical orthopaedics and related research. Volume 479:Issue 12(2021)
• Page Start: 2691
• Page End: 2700
• Publication Date: 2021-12-18
• Subjects: Orthopedic surgery -- Periodicals; Orthopedics -- Periodicals; Orthopedics -- Research -- Periodicals; Orthopedics -- Periodicals; Research -- Periodicals; Chirurgie orthopédique -- Périodiques; 616.7005
• DOI: 10.1097/CORR.0000000000001865
• Languages: English
• ISSNs: 0009-921X

Abstract

Abstract: Background: Distal radius fractures (DRFs) are one of the most common major fractures. Despite their frequency, the tradeoffs in different outcomes after casting or surgery for closed extraarticular DRFs in older adults are unknown. Questions/purposes: (1) For adults older than 60 years with closed extraarticular DRFs, what are the tradeoffs in outcomes for choosing casting versus surgery? (2) In what settings would surgery be preferred over casting? Method: This is a secondary analysis of data from the Wrist and Radius Injury Surgical Trial (WRIST), a randomized, multicenter clinical trial that enrolled patients from April 10, 2012 to December 31, 2016. For WRIST, researchers recruited patients older than 60 years who sustained closed extraarticular distal radius fractures from 24 sites in the United States, Canada, and Singapore. We conducted a secondary analysis using data from WRIST, which had longitudinal data from a robust collection of covariates for patients who underwent surgery and casting. Among the 296 patients recruited in the WRIST study, 59% (174) of patients (mean age 71 ± 9 years) with complete sociodemographic data and 12-month follow-up for each primary outcome were included in the main analysis. More patients underwent surgery than casting (72% [126 of 174] versus 28% [48 of 174]). Most sociodemographic variables were similar between the surgery and casting groups, except for age and volar tilt. The surgical cohort was composed of patients randomized to external fixation, closed reduction percutaneous pinning, or volar locking plate internal fixation. The casting cohort consisted of patients who elected to be treated with closed reduction and casting. A tree-based reinforcement statistical learning method was used to determine the best treatment, either surgery or casting, to maximize functional and esthetic outcomes while minimizing pain. Tree-based reinforcement learning is a statistical learning method to build an unsupervised decision tree within a causal inference framework that will identify useful variables and their cutoff values to tailor treatment assignment accordingly to achieve the best health outcome desired. The primary outcome was minimization of pain (12-month Michigan Hand Outcomes Questionnaire pain subdomain score), maximization of grip strength, total ROM (supination and wrist arc of motion), and esthetics (12-month Michigan Hand Outcomes Questionnaire esthetics subdomain score). Results: Casting was the best treatment to reduce pain and maximize esthetics, whereas surgery maximized grip strength and ROM. When the patient favored gaining ROM over pain reduction (more than 80:20), surgery was the preferred treatment. When the patient prioritized the importance of grip strength over pain reduction (more than 70:30), surgery was also the preferred treatment. Conclusion: There are tradeoffs in outcomes after treating patients older than 60 years with closed extraarticular distal radius fractures with casting or surgery. When patients are attempting to balance minimizing pain and improving functional outcomes, unless they desire maximal functional recovery, casting may be the better treatment. Surgery may be beneficial if patients want to regain as much grip strength and ROM as possible, even with the possibility of having residual pain. These findings can be referenced for more concrete preoperative counseling and patient expectation management before treatment selection. Level of Evidence: Level III, therapeutic study.