American Association for Hand Surgery
Theme: Beyond Innovation

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Science of Variation Group: Factors Associated with Operative Treatment of Distal Radius Fractures and Implications for the American Academy of Orthopaedic Surgeons Appropriate Use Criteria
James C Kyriakedes, MD1; Tom Crijns, BS2; Teun Teunis, MD3; David Ring, MD, PhD2; Blaine Bafus, MD1
1MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, 2Dell Medical School, Austin, TX, 3Hand & Upper Extremity Service, Massachusetts General Hospital - Harvard Medical School, Boston, MA

Introduction
The American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUC) reviewed the appropriateness of various treatments for distal radius fractures (DRF). We hypothesized that deciding to operatively treat an intraarticular DRF would be guided by patient factors (age, gender, activity level, injury mechanism, fracture type, fracture displacement) and surgeon factors (age, gender, years in practice, patient volume, practice location, subspecialty). If surgeons identify certain factors outside of the AUC's algorithm as necessary information, then it would be reasonable to recommend that the AUC be updated.
Materials & Methods
This cross-sectional survey asked 227 surgeons to operatively or nonoperatively treat 28 hypothetical patients with radiographs of intraarticular DRF. The following were randomized: patient age (50 vs. 70 years), gender, mechanism of injury (low vs. high-energy), activity level (normal vs. homebound), and fracture type (AO/OTA type B or C). The authors systematically classified six fractures as "non-clinically-significant displacement" and 22 as "potentially clinically-significant displacement" (Figure A). Fracture type and displacement were pooled, because no type C fractures displayed "non-clinically-significant displacement." Multilevel logistic regression analysis was performed. Odds ratios (OR) and 95% confidence intervals were reported. Statistical significance was P<0.05.
Results
Overall, 50% of treatment recommendations were for surgery. Patient factors independently associated with operative treatment included younger age (OR 7.1, P=0.002), clinically-significant fracture displacement (type B: OR 125, CI 21-750, P<0.001; type C: OR 59, CI 12-302, P<0.001), normal activity level (OR 4.9, P<0.001), and high-energy mechanisms (OR 1.3, P=0.002). Surgeon factors associated with recommending surgery included practicing in Europe (OR 2.6, P<0.001) and the "other" group (OR 4.7, P<0.001), as compared to the United States. Hand surgeons more often selected surgery, as compared to orthopaedic trauma surgeons (OR 2.2, P=0.001) or "other orthopaedists" (OR 2.1, P=0.024). Sixty percent of treatment decisions for patients with normal activity levels matched the AUC recommendations for the "appropriate" treatment (surgery), which included 84% (50-year-olds, clinically-significant displacement), 60% (70-year-olds, clinically-significant displacement), 22% (50-year-olds, non-clinically-significant displacement), and 9% (70-year-olds, non-clinically-significant displacement).
Conclusions
- 227 experienced surgeons from around the world, in different subspecialties, affirmed the roles for both operative and nonoperative management of intraarticular DRF.
- Predictors for surgery included younger patient age, clinically-significant fracture displacement, normal patient activity level, high-energy mechanisms, and practicing outside of the United States or with hand surgery subspecialization.
- These findings suggest that the AUC be updated to include all factors consistently used to treat intraarticular DRF- primarily patient age and fracture displacement.


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