Paper 1 showed that closed reduction of a displaced fracture improved the alignment, but that most of the fractures to some extent redisplaced. However, especially the dorsal tilt was better after the immobilization period than before reduction. The natural history of the development of displacement without primary closed reduction of a displaced DRF in patients 65 and older is as far as I know not described. It is reasonable to believe that the displacement would increase from injury throughout the immobilization period.
Most of the fractures had some loss of radial length. However, the fractures that were reduced with volar cortices on the proximal and distal fragment connected and aligned, had less shortening of the radius compared those without the volar cortices connected. In sum, closed reduction improved long term alignment, even though these fractures were unstable.
During my training in orthopaedic surgery, I have several times heard arguments for not reducing a displaced radius fracture in elderly patients:
1) The fracture will return to previous position
2) The risk of a displacement to a worse than the original displacement is high
Beumer et al136 argued against closed reduction in frail elderly because of redisplacement resulting in unacceptable alignment in more than 80% of the cases. Study 1 contradicted Beumers finding and indicate that the above arguments should be considered as myths, and that closed reduction improve average radiological alignment also in elderly patients with unstable and displaced fractures. Our degree of loss of reduction aligns well with Sim et al findings in patients over 50 years. 137 They did not compare to pre-reduction displacement but looked at radiological parameters after reduction and after 1, 2, 3, 6, 9 and 12 weeks.
Radial inclination did not change after 3 weeks, and dorsal tilt and ulnar variance did not deteriorate further after 6 weeks post reduction.
In paper 2 we found a weak trend towards better results in the operative group also after one year in Quick-DASH, PRWHE, grip strength, ROM, and patient satisfaction. However, at follow-up after 6 and 12 months, we could not find clinically relevant differences favoring operation in Quick-DASH, PRWHE, grip strength or ROM. The main outcome measure, the non-inferiority analysis of Quick-DASH after 12 months, showed that non-operative
treatment was non-inferior to operation, meaning that non-operative treatment was equal to or almost equal to operative treatment.
The difference in the generic score, EQ-5D-5L, was in the lower range of the reported MCIDs.
We were not expecting that a generic health state score could identify a difference between these groups better than the specific scores and the clinical evaluation. However, we saw the same tendency in the “satisfaction with wrist function”. We cannot rule out that these scores picked up an overall difference between the groups that the other scores missed.
Some would argue that these scores together with the small differences in Quick-DASH, PRWHE, grip strength and ROM, all favoring surgery, indicate that surgery provided a better clinical result than non-operative treatment. Further, as Figure 15 suggests, more patients in the operative group had optimal scores for Quick-DASH, PRWHE and “satisfaction”. This may indicate that a perfect result was more common after operation. However, I believe that we must evaluate each score separately and compare the result to what is believed to be a clinically relevant difference. Further, conclusions in research should be based on predefined research questions and hypothesis. The choice of the non-inferiority test based on the
Quick-DASH score as the main outcome measure, at least to a certain degree, dictates the conclusion of the study.
Further, the EQ-5D-5L- and “satisfaction with wrist function”-score might have picked up a general contentment in another way than the specific scores. The difference in both
radiological and clinical alignment was obvious, and an evident malunion might also bother some of the patients even though the function might be good. This dissatisfaction might have a cosmetic reason, at least for some of the patients. We also know that the placebo effect of surgery might be a confounding factor comparing surgery with non-operative treatment. 138. Unfortunately, the attempt of blinding at follow-up would have been for sight only and was abandoned.
Both paper 1 and 2 showed relatively few complications after non-operative treatment despite the significant malunion. However, some complications might have been missed in study 1 as the study was retrospective. In paper 1, all patients ³ 65 who underwent primary closed reduction after a distal radius fracture and had available follow-up radiographs were included, while Study 2 only included healthier, independently living patients. Some patients with malalignment after non-operative treatment experience pain and impaired function and clinical experience has shown that correction of malalignment often benefit these patients. 139 In study 2, the two patients who underwent corrective osteotomy experienced improvement in clinical result. The most common surgical procedure in these patients were CTR, two patients in Study 1 and three in Study 2. These surgical procedures led to
prolonged recovery. Further, some patients in Study 2, both in the operative and the non-operative group, scored far worse than average in clinical outcome scores. Even though most patients over 65 years of age experience good function after a displaced DRF, it is of great importance to look for and examine the patients with less favorable results. These patients must be carefully evaluated to look for ways to improve function and often reduce pain. This must be done though multi-disciplinary system both considering surgical
treatment i.e. corrective osteotomy or CTR and evaluation of pain-control and follow-up with hand therapy. Some of the outliers experienced worse outcome due to health problems not related to the DRF, e.g. rheumatic disorders. Despite optimal fracture treatment, a good
Mulders et al 44 recently compared non-operative treatment with volar locking plate fixation in an adult population and found better clinical results after surgery. This was supported by metaanalyses by Ochen and by Vannabouathong. 140,141 However, our finding of non-inferiority for non-operative treatment in an elderly population is supported by the findings in earlier RCT in the elderly population. Both Arora, Bartl and the Crossfire-study39,40,129 demonstrated similar clinical results after one year. Therefore, new guidelines for treatment of patients over the age of 65 with DRFs recommend non-operative treatment as the
primary treatment. Both the updated guidelines from AAOS (2020) 142 and guidelines from British Society for Surgery of the Hand (BSSH, 2018) 143 concluded that operative treatment does not provide superior outcome in elderly. In a recent review, Luokkala et al went through six RCTs comparing non-operative treatment with volar locking plate fixation (from 2011-2019) and concluded the same way, that non-operative treatment should be regarded as the primary treatment in this age group.
However, Luokkala et al19 also supported our finding that the operative group recover faster.
A faster recovery might be of great significance for some patients. However, when recruiting for the RCT, we experienced that almost the same number of patients that we included, denied participating in the trial. The main reason for not participating was to avoid randomization, because they wanted one specific treatment. These patients chose non-operative treatment almost eight times more often than surgery despite information that prolonged recovery could be expected. We believe that especially in this age-group, many patients want to avoid surgery despite some possible benefits. This contradicts the results from Nasser et al´s report on patient preferences in this age group, where VPL was
preferred. 96 In our experience, thorough information about the treatment options and expectations, and the small differences in functional outcome scores between the operative and non-operative treatment seem to reduce the number of patients consenting to surgery after displaced distal radius fractures. This is likely to be further enlightened in the years to come.
Paper 3 concludes that non-operative treatment has 55 % chance to be cost effective. The analysis is based on the observed difference in QALY (resulting from the difference in
EQ-5D-5L) and the difference in costs. Total health care costs during first year in the operative group were 3589 Euro. 39 of 50 patients were treated as same-day surgery. The costs in the operative group were comparable to the costs Hammer et al 144 found in an adult population and we do not believe it is possible to reduce these costs substantially, at least not in a high-cost country like Norway.
In the cost analysis, we included costs from follow-ups and radiographs. Some of these were a part of the study protocol and would have been avoided in a clinical setting. Previously, we followed these patients with control the day after closed reduction, and usually after 1 and 2 weeks. Both study 1 and 2 can be used to argue for less routine follow-ups for patients treated non-operatively.
Costs related to loss of production were not included in the analysis. This was because few patients were working, and the working patients were not evenly distributed between the groups. However, loss of production per working patient was more than 9.700 Euro in average, which was far more than the total health-care costs per patient. Based on our findings of faster recovery in the operative group, we would expect to find lower loss of production in operatively treated patients in a population of working elderly, like Mulders and Hammer found in younger patients. 144,145 These studies found significant reduction in costs related to loss of production in the volar locking plate group compared to external fixation (Hammer) or non-operative treatment (Mulders) because of the shorter
rehabilitation time. Tobeuf et al 79 did not find similar differences. This inconsistency might be due to differences in sick pay schemes between countries. Within Europe the Nederlands and Norway has one of the most generous sick pay arrangements. The UK, however, is in the opposite end of the scale. 146,147 Lower sick pay might result in shorter sick leave, but is not necessarily an in indicator of faster recovery. The patients might return to work to get paid, even though they need time before they manage normal workload. On the other hand, patients in countries with generous sick pay like Norway might experience that they are asked not to return to work until they are fully recovered.
Faster recovery in the operative group might explain the difference in QALY. However, we
to analyze the EQ-5D-5L at the next planned follow-up, two years after injury, to look for a continued difference between the groups. If the difference continues, this might change the cost-effectiveness ratio. However, the difference in EQ-5D-5L was small, and a difference in quality of life was not reported by Bartl or in the Crossfire-study. 12940 Therefore, it is still unclear if the EQ-5D-5L-difference is relevant and reproducible.
In study 1, we found that over 40 % of the reduced fractures still had acceptable alignment after final follow-up, and therefore not fulfilled the indication for operation from AAOS. 142 These patients would not have been included in the randomized trial 41, because
redisplacement beyond the thresholds was one of the inclusion criteria (despite a possible displacement beyond the criteria before reduction). Loukkala et at 19 concluded in their review of RCTs that also elderly patients recover faster after operation with a volar locking plate compared to non-operative treatment. The faster recovery might be due to the possibility for early active motion after volar plate fixation, and not the improvement in alignment. Most of the studies in the review included patients based on displacement on radiographs before closed reduction. We do not know whether the patients without redisplacement also would have experienced faster recovery after surgery. However, if the early active motion is the most important factor for the faster recovery, this might be the case. 44
There is solid evidence to advocate for non-operative treatment in displaced distal radius fractures in elderly as a general rule. However, we do not know how to identify the patients that would benefit from an early operation. It is reasonable to argue that patients with special needs, i.e. use of walking aids, would benefit from primary operation. Also, it is reasonable to believe that the patients that ended up with a corrective osteotomy would have benefited on primary surgery. However, we do not know how to predict which patients that will tolerate the malunion poorly, and later end up with a corrective osteotomy.
Recently, two papers based on data from the Wrist and Radius Injury Surgical Trial (WRIST) discussed factors improving function. In this trial, the patients aged 60 years and older were randomized to one of 3 surgeries: volar locking plate, external fixation, or percutaneous pinning. Further, the patients that did not want surgery were treated with cast
immobilization and followed as an observation group. Chung and colleges 148 concluded that improved radiological parameters did not correlate with improved function.
However, Hooper and colleagues149 found that active elderly patients had better functional scores after operation with a volar locking plate compared to less active patients. This indicates that pre-injury function might be a better indicator for the clinical result than radiological alignment. The active elderly seems to benefit from good alignment, while the less active patients experience almost the same clinical result regardless of alignment.
Further, the threshold between active and less active can be discussed, but the patient´s needs and function are obviously important in the treatment decision process. The Swedish guidelines on treatment of distal radius fractures from 2021 also focus on the patients´
activity level. Treatment recommendations are provided for patients with high, moderate, and low functional requirements, and radiological thresholds for treatment are provided for each group. Adolfsson et al recently published a new scale that assess activity level, the Adolfsson-Björnsson Activity Scale (ABAS). The main purpose was to present a scale to determine the patients´ subjective activity level for patients with upper limb disorders. They believe this can be used to assess the patients´ preinjury function and as a tool in RCTs to ensure comparable groups.150 The importance of preinjury activity level and the relative effect on outcome after different treatment regimens is still, however, largely unknown.