Outcomes and financial implications of intra-articular distal radius fractures: A comparative study of open reduction internal fixation (ORIF) with volar locking plates versus non-operative management

Toon DH, Premchand RAX, Sim J, Vaikunthan R

Declaration of conflict of interest

Our study members have no conflicting interest and financial interest related to the research study and has not received financial aid/sponsorship from any parties

with regards to implants used in our study

Background• Fractures of the distal radius are among the most common

orthopaedic injuries, impose a significant financial burden on healthcare

• 2009 AAOS Clinical Practice Guideline (CPG) was unable to recommend for or against any one specific surgical method

• ORIF has become increasingly popular, particularly volar locking plates– With the rise in cost-consciousness, it is important to

determine the outcomes and financial implications

Study Aim• To evaluate

1. the functional and radiographic outcomes at 12 months2. the treatment costs

of closed displaced intra-articular distal radius fractures treated with ORIF with the volar locking plates versus non-operative treatment with immobilisation in plaster cast

Material and Methods• Retrospective study• Khoo Teck Puat Hospital (KTPH),

Singapore• 1st January 2011 and 1st January

2012• Inclusion criteria: adult patients (>

21 yo) with a closed displaced intra-articular distal radius fracture (AO group B and group C)

• Exclusion criteria: Ipsilateral upper limb fractures, pathological fractures, open fractures, a delay in presentation of more than 14 days, or those who did not follow the hand occupational therapy protocol

Material and Methods• ORIF group:

– ORIF using the Synthes 2.4mm variable angle LCP volar distal radius plate/Medartis 2.5 distal radius system

• Non-operative group: – Below elbow full cast for 4-6 weeks

Rehabilitation by the hand occupational therapist ORIF: within the first week after surgery Non-operative: same day of cast removal

Material and Methods• Treatment costs (standardised to remove difference in class)

– Hospital finance department

– Estimated financial impact to the economy: • patients’ median salaries (based on occupation, in

accordance to the Singapore Ministry of Manpower Median Gross Wages of Common Occupations By Industry, June 2013) multiplied by the number of days of medical leave

Total outpatient costs (for both groups)Accident and Emergency consultation, plaster casts, radiological investigations, outpatient clinic appointments and OT sessions

Total inpatient costs (for ORIF group) Costs of surgery (including surgical implants) and inpatient hospital admission

Ministry of Manpower, Government of Singapore. Singapore: Ministry of Manpower 30 June 2015 http://stats.mom.gov.sg/Pages/Occupational-Wages-Tables-2013.aspx.

±

Statistical analysis

• Power analysis performed based on the wrist function outcome and the scores utilised

• Categorical data was compared with Pearson’s Chi-Square test, continuous data was compared with Mann-Whitney test for non-parametric data and independent T-test for parametric data

• Statistical significance was considered for p-value < 0.05

Patient and injury characteristics

  Operative (ORIF) Non-operative

Number of patients 32 28

Gender Male Female

1418

1117

Mean age (years) 52.1 (23 - 77) 57.4 (26 – 79)

Dominant side Right Left

293

244

Injured side Right Left

1418

1216

Dominant side injured Yes No

15 (46.88%)

17 (53.12%) 12 (42.86%)

16 (57.14%) AO fracture classificationB (Total) B1 B2 B3

C (Total) C1 C2 C3

10 (31.25%) 316

22 (68.75%) 1165

6 (21.43%) 411

22 (78.57%) 1282

Results  Operative (ORIF) Non-operative

 

p-value

DASH score 16.2±17.4 16.1±17.7 0.9878

MAYO wrist score 76.7±12.7 78.0±8.6 0.6449

Strength (% compared to contralateral side) 83.29±14.1 81.26±22.9 0.6778

Pain on visual analog scale (VAS) 1.8±1.6 1.1±1.1 0.5321

Range of motion

Extension (º)

Flexion (º)

Ulnar deviation (º)

Radial deviation (º)

 

67.5±13.7

63.1±10.2

22.8±8.0

15.6±7.3

 

72.9±13.2

64.1±13.0

17.9±6.0

15.7±5.2

 

0.1288

0.7445

0.0096

0.6449

Radiographic parameters

Volar tilt (º)

Radial height (mm)

Radial inclination (º)

Articular step-off (mm)

 

5.6±8.9

9.6±3.3

21.6±6.1

0.71±0.58

 

0.1±11.6

7.2±3.4

16.9±6.3

1.50±0.93

 

0.0399

0.0087

0.0051

0.0002

Results• Mean medical leave (days)

– 85±64 for the ORIF– 46±39 for the non-operative (p=0.046)

• A 37-fold difference in the mean treatment costs– ORIF (SGD 7951.23±6774.94) – Non-operative (SGD 230.52±113.72) (p<0.001)

• Estimated financial impact to the economy– ORIF: SGD 140,192.57– Non-operative: SGD 55,029.14

Study limitations• Retrospective study; No randomisation of treatment groups

• Only short term outcomes (12 months) were measured • Radiographic assessment did not assess radiographic

changes of osteoarthritis – perceived short duration – early radiographic changes not always progress and result in clinically

relevant post-traumatic osteoarthritis

Conclusion• There is no difference in overall functional outcomes for

closed displaced intra-articular distal radius fracture treated with ORIF with volar locking plates or non-operatively at 12 months

• This is independent of the superior radiographic outcomes in the ORIF group

• The vast difference in financial costs of treatment should be taken into consideration in treatment decision

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