Comparison of Lumbar Fusion With and Without Interbody Fusion for Lumbar Stenosis Using Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Testing (CAT).

Study design This was a retrospective analysis of patient-reported outcomes across a two-year period. Summary of background data Patients suffering from lumbar stenosis may experience low back pain, neurogenic claudication, and weakness. Patients can benefit from surgical intervention, including decompression with or without fusion. However, the superiority of any single fusion construct remains controversial. Objective The goal of this study was to compare Patient-Reported Outcomes Measurement Information System (PROMIS®) Computer Adaptive Testing (CAT) measures in patients with lumbar spinal stenosis treated surgically with lumbar decompression and fusion with or without interbody fusion. Methods A retrospective review of patients with lumbar stenosis undergoing lumbar decompression and one-level fusion was performed. PROMIS® CAT Physical Function (PF) and Pain Interference (PI) assessments were administered using a web-based platform pre and postoperatively. Results Sixty patients with lumbar stenosis undergoing one-level lumbar fusion were identified. Twenty-seven patients underwent posterior lumbar fusion (PSF) alone and 33 underwent one-level lumbar interbody fusion (IF). Patients undergoing IF had better absolute PF scores compared to patients undergoing PSF at one-year postoperatively (48.9 v 41.6, p=0.002) and greater relative improvement in PF scores from baseline at one-year postoperatively (D13.6 v D8.6, p=0.02). A subgroup analysis of patients undergoing TLIF v PSF showed better absolute PF scores at the one-year follow-up in the TLIF group (47.1 v 42.3, p=0.04). No differences were found in PI scores at any time point between the PSF and IF groups. Patients undergoing IF had significantly shorter hospital stays (2.5 v 3.3 days, p=0.02) compared to patients undergoing PSF. Conclusions Patients with lumbar spinal stenosis treated with one-level IF reported higher absolute PF scores and experienced greater relative improvement in PF scores from baseline at one-year follow-up compared to patients treated with PSF alone. Additionally, IF is associated with a decreased length of hospital stay as compared to PSF.

Using Rasch Analysis to Validate the Michigan Hand Outcomes Questionnaire from the Wrist and Radius Injury Surgical Trial.

BACKGROUND: The Michigan Hand Outcomes Questionnaire is a patient-reported outcome measure that has been validated in many upper extremity disorders using classic test theory. Rasch measurement analysis is a rigorous method of questionnaire validation that offers several advantages over classic test theory and was used to assess the psychometric properties of the Michigan Hand Outcomes Questionnaire. This study used Rasch analysis to evaluate the questionnaire for distal radius fractures in older adults. The incidence and costs of distal radius fractures are rising, and reliable assessment tools are needed to measure outcomes in this growing concern. METHODS: Rasch analysis was performed using 6-month assessment data from the Wrist and Radius Injury Surgical Trial. Each domain in the Michigan Hand Outcomes Questionnaire was independently analyzed for threshold ordering, person-item targeting, item fit, differential-item functioning, response dependency, unidimensionality, and internal consistency. RESULTS: After collapsing disordered thresholds and removing any misfitting items from the model, five domains (Function, Activities of Daily Living, Work, Pain, and Satisfaction) demonstrated excellent fit to the Rasch model. The Aesthetics domain demonstrated high reliability and internal consistency but had poor fit to the Rasch model. CONCLUSIONS: Rasch analysis further supports the reliability and validity of using the Michigan Hand Outcomes Questionnaire to assess hand outcomes in older adults following treatment for distal radius fractures. Results from this study suggest that questionnaire scores should be interpreted in a condition-specific manner, with more emphasis placed on interpreting individual domain scores, rather than the summary Michigan Hand Outcomes Questionnaire score.

An Analysis of the Impact of Timing and Technique on Outcomes after Surgery for Distal Radius Fractures: The Wrist and Radius Injury Surgical Trial Collaborative Study.

BACKGROUND: Surgical treatment of closed distal radius fractures varies based on treatment, surgeon schedule, and patient preferences. The authors examined how timing and technique impact surgeon-perceived procedural difficulty and quality of reduction, outcomes, and complications. METHODS: This was a retrospective study of participants in the randomized, multicenter Wrist and Radius Injury Surgical Trial with isolated unstable distal radius fractures. Participants were randomized to treatment with a volar locking plate system, closed reduction and percutaneous pinning, or external fixation. The authors analyzed surgeon-perceived procedural difficulty and reduction quality based on time to operation. RESULTS: Of 184 participants, 88 underwent surgery less than 7 days after fracture (mean, 4.6 days) and 96 underwent surgery at more than 7 days after fracture (mean, 12.3 days). Surgery performed at more than 7 days was rated more difficult versus surgery at less than 7 days [4.6 versus 3.8 of 10 (1 = easiest); p = 0.05]. When the volar locking plate technique was performed, there was no difference in surgeon-perceived difficulty or reduction quality between the groups; however, surgeons performing closed reduction and percutaneous pinning more than 7 days after injury reported greater procedure difficulty (4.1 versus 2.9; p = 0.05) and poorer reduction quality compared to less than 7 days (7.2 versus 8.1; p = 0.03). Participants who underwent surgery at less than 7 days scored 8 and 7 points greater on the Michigan Hand Outcomes Questionnaire Satisfaction (p = 0.05) and Activities of Daily Living (p = 0.03) domains, respectively. CONCLUSIONS: Surgery performed less than 7 days after fracture leads to better surgeon-perceived reduction quality and less procedural difficulty. If surgery cannot be performed before 7 days, the authors recommend patients undergo treatment with the volar locking plate system, given the comparable level of surgeon-perceived procedural difficulty and reduction quality when surgery was performed less than 7 days after injury. CLINICAL QUERSTION/LEVEL OF EVIDENCE: Therapeutic, III.

Epidemiology of Upper Extremity Firearm Injuries among Major Trauma Hospitals in the United States.

BACKGROUND: As many as 34 percent of nonfatal firearm injuries involve the upper extremity. Although not lethal, these injuries cause substantial morbidity. The authors conducted an epidemiologic study characterizing upper extremity firearm-related injuries presenting to U.S. trauma centers over a 10-year period. METHODS: The authors used the National Trauma Databank from 2007 to 2017 to identify isolated upper extremity firearm-related injuries. Descriptive statistics were performed to characterize patient demographic data, firearm type, extremity injury patterns, treatments received, hospital length of stay, and regional variation. RESULTS: The authors identified 48,254 upper extremity firearm-related injuries. The patients were largely male patients (85 percent), and over half were between the ages of 20 and 39 years. Handguns (34 percent) were the most frequently used firearm. Shoulder and upper arm were the most frequently injured areas (54 percent); however, 18 percent of patients injured two or more areas. Patients were most often treated at university hospitals (59 percent) with Level I or II trauma designation. Seventy percent were admitted and/or taken directly to the operating room. The mean hospital length of stay was 3 days. Payer mix among these patients was variable: Medicaid, 20 percent; private insurance, 20 percent; and self-pay, 29 percent. CONCLUSIONS: Upper-extremity firearm injuries are resource intensive, with three-quarters of patients requiring operative intervention and/or hospitalization. Level I and II trauma centers were the site of care for the majority of patients. Targeted gun policy reform and prevention measures directed toward at-risk groups have the potential to limit the unnecessary morbidity and costs associated with these injuries.

Comparison of 24-Month Outcomes After Treatment for Distal Radius Fracture: The WRIST Randomized Clinical Trial.

Importance: Distal radius fractures (DRFs) are common injuries among older adults and can result in substantial disability. Current evidence regarding long-term outcomes in older adults is scarce. Objective: To compare outcomes across treatment groups at 24 months among adults with DRFs who participated in the WRIST trial. Design, Setting, and Participants: The Wrist and Radius Injury Surgical Trial (WRIST) randomized, international, multicenter trial was conducted from April 1, 2012, through December 31, 2016. Participants were adults aged 60 years or older with isolated, unstable DRFs at 24 health systems in the US, Canada, and Singapore. Data analysis was performed from March 2019 to March 2021. Interventions: Participants were randomized to open reduction and volar locking plate system (VLPS), external fixation with or without supplementary pinning (EFP), and percutaneous pinning (CRPP). The remaining participants chose closed reduction and casting. Main Outcomes and Measures: The primary outcome was the 24-month Michigan Hand Outcomes Questionnaire (MHQ) summary score. Secondary outcomes were scores on the MHQ subdomains hand strength and wrist motion. Results: A total of 304 adults were recruited for the study, and 187 were randomized to undergo surgery, 65 to VLPS, 64 to EFP, and 58 to CRPP; 117 participants opted for closed reduction and casting. Assessments were completed at 24 months for 182 participants (160 women [87.9%]; mean [SD] age, 70.1 [8.5] years). Mean MHQ summary scores at 24 months were 88 (95% CI, 83-92) for VLPS, 83 (95% CI, 78-88) for EFP, 85 (95% CI, 79-90) for CRPP, and 85 (95% CI, 79-90) for casting, with no clinically meaningful difference across groups after adjusting for covariates (χ23 = 1.44; P = .70). Pain scores also did not differ across groups at 24 months (χ23 = 2.64; P = .45). MHQ summary scores changed from 82 (95% CI, 80-85) to 85 (95% CI, 83-88) (P = .12) between 12 and 24 months across groups. The rate of malunion was higher in the casting group (26 participants [59.1%]) than in the other groups (4 participants [8.0%] for VLPS, 8 participants [17.0%] for EFP, and 4 participants [9.8%] for CRPP; χ23 = 43.6; P < .001), but malunion was not associated with the 24-month outcome difference across groups. Conclusions and Relevance: The study did not find clinically meaningful patient-reported outcome differences 24 months after injury across treatment groups, with little change between 12 and 24 months. These findings suggest that long-term outcomes need not necessarily be considered in deciding between treatment options. Patient needs and recovery goals that fit to relative risks and benefits of each treatment type will be more valuable in treatment decision-making. Trial Registration: ClinicalTrials.gov Identifier: NCT01589692.

Cost-Effectiveness of Treatments after Closed Extraarticular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial.

BACKGROUND: This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures. METHODS: This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio. RESULTS: Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year. CONCLUSIONS: Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.

Pre-injury activity predicts outcomes following distal radius fractures in patients age 60 and older.

INTRODUCTION: One out of every 5 elderly patients will suffer a distal radius fracture and these injuries are often related to poor bone health. Several surgical subspecialties have demonstrated that pre-injury activity level can impact patient outcomes. To determine the importance of physical activity, we examined the relationship between pre-injury activity and patient-reported and functional outcomes among fracture patients. METHODS: This is a retrospective analysis of prospectively collected data from participants enrolled in the Wrist and Radius Injury Surgical Trial (WRIST) from April 10, 2012 to December 31, 2016. This study included 304 adults, 60 years or older with isolated unstable distal radius fractures; 187 were randomized to one of three surgical treatments and 117 opted for casting. Participants opting for surgery were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Participants who chose not to have surgery were treated with casting. All participants were stratified prior to analysis into highly and less-active groups based on pre-injury Rapid Assessment of Physical Activity Scores. RESULTS: 280 patients had 12-month assessments of outcomes. Highly active participants scored 8 and 5 points greater on the Michigan Hand Questionnaire at 6 weeks and 3 months respectively, p<0.05. Highly active participants demonstrated greater grip strength at the 3-month (p = 0.017) and 6-month (p = 0.007) time-points. Highly active participants treated with volar locking plate scored 10+ points greater on the Michigan Hand Questionnaire compared to the less-active group at the 6-week (p = 0.032), 3-month (p = 0.009) and 12-month (0.004) time points, with an effect size larger than 0.50, suggesting pre-injury level of activity had a significant clinical impact. CONCLUSIONS: Higher levels of pre-injury activity are predictive of patient-reported and functional outcomes following distal radius fracture. Because of the greater PROs, the early mobility and lower risk of hardware infection reported in the literature, volar plating is preferable to other treatments for highly active patients who request and meet indications for surgery. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01589692.

The Wrist and Radius Injury Surgical Trial: 12-Month Outcomes from a Multicenter International Randomized Clinical Trial.

BACKGROUND: Optimal treatment for distal radius fractures in older adults remains uncertain. No randomized trials comparing the most frequently used treatments in this population have been conducted. Surgical treatment rates vary widely, and the sustained benefits of surgery are uncertain. METHODS: The Wrist and Radius Injury Surgical Trial, a randomized, multicenter trial, enrolled 304 adults aged 60 years and older with isolated, unstable distal radius fractures at 24 institutions. Patients who wanted surgery (n = 187) were randomized to internal fixation, external fixation, or percutaneous pinning; patients who preferred conservative management (n = 117) received casting. The primary outcome was the 12-month Michigan Hand Outcomes Questionnaire (MHQ) summary score. RESULTS: At 12 months, there were no differences by treatment in primary outcome. Twelve-month MHQ summary scores differed between internal fixation and external fixation by 3 points (97.5 percent CI, 6.0 to 11.5) and between internal fixation and pinning by -0.14 (97.5 percent CI, -9.2 to 8.9). However, at 6 weeks, the mean MHQ summary score for internal fixation was greater than for external fixation by 19 (p < 0.001), pinning by 11 (p < 0.001), and casting by 7 (p = 0.03). Internal fixation participants demonstrated significantly better radiologic alignment throughout the follow-up period. Malunion was experienced by 48 percent of casting participants. CONCLUSIONS: Recovery was fastest for internal fixation and slowest for external fixation according to most measures, but by 12 months there were no meaningful differences in outcomes. Casting participants experienced satisfactory results despite loss of radiologic alignment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Assessment of Anatomic Restoration of Distal Radius Fractures Among Older Adults: A Secondary Analysis of a Randomized Clinical Trial.

Importance: The value of precise anatomic restoration for distal radius fractures (DRFs) in older adults has been debated for many decades, with conflicting results in the literature. In light of the growing population of adults aged 60 years and older, both fracture incidence and associated treatment costs are expected to increase. Objective: To determine the association between radiographic measures of reduction and patient outcomes after DRF in older patients. Design, Setting, and Participants: Data were collected from the Wrist and Radius Injury Surgical Trial (WRIST), a multicenter randomized clinical trial of DRF treatments for adults aged 60 years and older (enrollment from April 10, 2012, to December 31, 2016, with a 2-year follow-up). Data analysis was performed from January 3, 2019, to August 19, 2019. WRIST participants who completed 12-month assessments were included in the study. According to the biomechanical principle of alignment, 2-phase multivariable regression models were adopted to assess the association between radiographic measures of reduction and functional and patient-reported outcomes 12 months following treatment. Interventions: Participants were randomized to receive volar locking plate, percutaneous pinning, or external fixation. Those who opted for nonoperative treatment received casts. Main Outcomes and Measures: Hand grip strength, wrist arc of motion, radial deviation, ulnar deviation, the Michigan Hand Outcomes Questionnaire (MHQ) total score, MHQ function score, and MHQ activities of daily living score were measured at 12 months following treatment. Results: Data from 166 WRIST participants (144 [86.7%] women; mean [SD] age, 70.9 [8.9] years) found that only 2 of the 84 correlation coefficients calculated were statistically significant. For patients aged 70 years or older, every degree increase in radial inclination away from normal (22°) grip strength in the injured hand was 1.1 kg weaker than the uninjured hand (95% CI, 0.38-1.76; P = .004) and each millimeter increase toward normal (0 mm) in ulnar variance was associated with a 10.4-point improvement in MHQ ADL score (95% CI, -16.84 to -3.86; P = .003). However, neither of these radiographic parameters appeared to be associated with MHQ total or function scores. Conclusions and Relevance: The study results suggest that precise restoration of wrist anatomy is not associated with better patient outcomes for older adults with DRF 12 months following treatment. Surgeons can consider this evidence to improve quality of care by prioritizing patient preferences and efficient use of resources over achieving exact realignment. Trial Registration: ClinicalTrials.gov identifier: NCT01589692.

Patient satisfaction after treatment of distal radial fractures in older adults.

The Wrist and Radius Injury Surgical Trial (WRIST) collaboration is the largest clinical trial ever conducted in hand surgery. We applied data from this study to examine the relationship between functional outcomes and patient satisfaction after treatment of distal radial fractures. Patients aged 60 years and older with isolated distal radial fractures were enrolled at 24 health systems. Grip strength and the arc of wrist motion were measured after treatment. The Michigan Hand Outcomes Questionnaire was used to measure patient satisfaction. Receiver operating characteristic curves were created using patient satisfaction as the reference standard and each functional measure as a predictor. At 12 months after treatment, mean grip strength was 82% of normal and mean arc of motion was 88% of normal. The optimal cut-off points to distinguish satisfaction from dissatisfaction occurred when patients recovered 59% of hand strength and 79% of wrist motion. Continuing therapy to increase functional gains beyond this point unnecessarily utilizes healthcare resources without additional patient-reported gains. Level of evidence: IV.

The Complexity of Conducting a Multicenter Clinical Trial: Taking It to the Next Level Stipulated by the Federal Agencies.

Randomized controlled trials are becoming increasingly difficult to organize and conduct efficiently. This, in turn, hinders the ability to derive the highest level of evidence. Often, investigators forget or remain unaware of essential practices that will help them fulfill their study goals. This article emphasizes the common issues that a study team experiences during the planning and conducting of randomized controlled trials. The authors sought to share remedies to overcome these issues with the experience garnered in conducting several multicenter clinical trials and observational studies. In addition, the authors list resources from sponsors such as the National Institutes of Health and the U.S. Food and Drug Administration that study teams can apply to undertake studies effectively.

The Relationship between Hand Therapy and Long-Term Outcomes after Distal Radius Fracture in Older Adults: Evidence from the Randomized Wrist and Radius Injury Surgical Trial.

BACKGROUND: Older patients are frequently referred to hand therapy after distal radius fracture. Supervised therapy sessions place a transportation burden on patients and are costly on both the individual and systematic levels. Furthermore, there is little evidence that supervised therapy or home exercises improve long-term outcomes. METHODS: Data were collected for the Wrist and Radius Injury Surgical Trial, a multicenter, international, pragmatic, randomized trial of distal radius fracture treatment in patients aged 60 years and older. Referral to therapy and therapy protocol were at the discretion of the treating surgeon and therapist. The authors examined outcomes between participants who underwent therapy and those who did not and assessed the duration of therapy. The authors also analyzed the effect of therapy on subgroups at risk for poor outcomes: older participants and those who had more comorbidities or lower baseline activity. RESULTS: Eighty percent of participants underwent therapy; 70 percent participated in both supervised therapy and home exercises. Participants had a mean 9.2 supervised sessions over 14.2 weeks. There were no differences in patient-reported outcomes between participants who underwent therapy and those who did not. Participants who did not have therapy recovered more grip strength. Participants who engaged in therapy for a shorter time reported greater function, ability to work, and satisfaction. There were no relationships revealed in subgroup analyses. CONCLUSIONS: Hand therapy after distal radius fracture may not be necessary for older patients. Encouraging participants to resume activities of daily living as soon as possible may be as effective as formal therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Predicting Outcomes After Distal Radius Fracture: A 24-Center International Clinical Trial of Older Adults.

PURPOSE: Current evidence on predictors of outcomes after distal radius fracture is often based on retrospective analyses or may be confounded by fracture type. Using data from the Wrist and Radius Injury Surgical Trial (WRIST), a 24-site randomized study of distal radius fracture treatment, in which all fractures are severe enough to warrant surgery, we set out to perform a secondary data analysis to explore predictors of better or worse hand outcomes. METHODS: The primary outcome measure was the Michigan Hand Outcomes Questionnaire (MHQ) summary score 12 months after treatment. We used a regression tree analysis with recursive partitioning to identify subgroups of participants who experienced similar outcomes (ie, MHQ score) and to determine which baseline or treatment factors they had in common. RESULTS: Factors most predictive of 12-month MHQ score were pain at enrollment, education, age, and number of comorbidities. Specifically, participants who had a high school education or less and also reported severe pain had the lowest MHQ scores. Conversely, participants with less pain and more education and who were age 87 years or younger with one or no comorbid condition had the highest MHQ scores. Treatment type or radiographic measurements assessed on post-reduction films did not affect 12-month outcomes. CONCLUSIONS: These results identified patient characteristics that can be used by surgeons to identify subgroups of patients who may experience similar hand outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Cross-sectional International Multicenter Study on Quality of Life and Reasons for Abandonment of Upper Limb Prostheses.

BACKGROUND: This multicenter study aimed to examine the reasons for prosthesis rejection and assess the quality of life (QOL) among patients with upper limb deficiency. METHODS: Three rehabilitation centers in Japan and 1 academic medical center in the United States participated. Patients between the age of 12 and 75 years with unilateral or bilateral upper limb absence from the level of wrist to shoulder disarticulation were included. Two questionnaires were used, an original questionnaire on prosthesis use and the EQ-5D, which were completed by both the participant and a live-in proxy. RESULTS: Of the 367 patients with upper limb loss invited, 174 patients participated in this study. Eighty percent of the study population were male patients. The most common amputation level was transradial. Trauma was the most common cause of limb loss. The prosthesis rejection rate was 9% (n = 16). The most common reason for abandonment was a lack of prosthesis functionality. Ten of 16 prosthesis nonusers (63%) and 59 prosthesis users (38%) were unemployed or students. The mean EQ-5D utility score was significantly higher in prosthesis users than in nonusers (0.762 versus 0.628, P < 0.01). Live-in proxies significantly overestimated QOL in male patients (0.77 versus 0.807, P=0.01). CONCLUSIONS: The current prosthesis rejection rate is low. QOL was significantly higher in prosthesis users than in nonusers. More prosthesis users were employed compared with nonusers. Care should be taken not to overestimate the QOL of male patients with upper limb loss as their proxies often did.

Patient-Reported and Functional Outcomes After Revision Amputation and Replantation of Digit Amputations: The FRANCHISE Multicenter International Retrospective Cohort Study.

Importance: Optimal treatment for traumatic digit amputation is unknown. Objective: To compare long-term patient-reported and functional outcomes between patients treated with revision amputation or replantation for digit amputations. Design, Setting, and Participants: Retrospective cohort study at 19 centers in the United States and Asia. Participants were 338 individuals 18 years or older with traumatic digit amputations with at least 1 year of follow-up after treatment. Participants were enrolled from August 1, 2016, to April 12, 2018. Exposures: Revision amputation or replantation of traumatic digit amputations. Main Outcomes and Measures: The primary outcome was the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were the 36-Item Short Form Health Survey (SF-36), Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity module scores and functional outcomes. Results: Among 338 patients who met all inclusion criteria, the mean (SD) age was 48.3 (16.4) years, and 85.0% were male. Adjusted aggregate comparison of patient-reported outcomes (PROs) between patients with revision amputation and replantation revealed significantly better outcomes in the replantation cohort measured by the MHQ (5.93; 95% CI, 1.03-10.82; P = .02), DASH (-4.29; 95% CI, -8.45 to -0.12; P = .04), and PROMIS (3.44; 95% CI, 0.60 to 6.28; P = .02) scores. In subgroup analyses, DASH scores were significantly lower (6 vs 9, P = .05), indicating less disability and pain, and PROMIS scores higher (78 vs 75, P = .04) after replantation. Patients with 3 or more digits amputated (including thumb) had significantly better PROs after replantation than those managed with revision amputation (22 vs 42, P = .03 for DASH and 61 vs 36, P = .01 for PROMIS). Patients who underwent replantation after 3 or more digits amputated (excluding thumb) had higher MHQ scores, which did not reach statistical significance (69 vs 65, P = .06). Revision amputation in the subgroup with single-finger amputation distal to the proximal interphalangeal joint resulted in better 2-point discrimination (6 vs 8 mm, P = .05). Compared with revision amputation, replantation resulted in better 9-hole peg test times in the subgroup with 3 or more digits amputated (including thumb) (46 vs 81 seconds, P = .001), better Semmes-Weinstein monofilament test in the subgroup with 3 or more digits amputated (excluding thumb) (3 vs 21 g, P = .008), and better 3-point pinch test in the subgroup with 2 digits amputated (excluding thumb) (6.7 vs 5.6 kg, P = .03). Conclusions and Relevance: When technically feasible, replantation is recommended in 3 or more digits amputated and in single-finger amputation (excluding thumb) distal to the proximal interphalangeal joint because it achieved better PROs, with long-term functional benefit. Thumb replantation is still recommended for its integral role in opposition.

Assessment of Distal Radius Fracture Complications Among Adults 60 Years or Older: A Secondary Analysis of the WRIST Randomized Clinical Trial.

Importance: Complications affect treatment outcomes and quality of life in addition to increasing treatment costs. Objectives: To evaluate complication rates after the treatment of a distal radius fracture, to determine whether the rate or complication type is associated with treatment method, and to determine predictors of complications. Design, Setting, and Participants: The multicenter Wrist and Radius Injury Surgical Trial (WRIST), a randomized clinical trial, enrolled participants from April 10, 2012, to December 31, 2016. The study included 304 adults 60 years or older with isolated unstable distal radius fractures; 187 were randomized and 117 opted for casting. The study was conducted at 24 health systems in the United States, Canada, and Singapore. Data for this secondary analysis were collected from April 24, 2012, to February 28, 2018. Interventions: Participants opting for surgery were randomized to receive the volar locking plate system (n = 65), percutaneous pinning (n = 58), or bridging external fixation with or without supplemental pinning (n = 64). Patients who chose not to have surgery (n = 117) were not randomized and were enrolled for casting. Main Outcomes and Measures: Complication rate. Results: The WRIST enrolled a total of 304 participants, of whom 8 casting group participants were later found to be ineligible and were excluded from the analysis, leaving 296 participants. Randomized participants' mean (SD) age was 68 (7.2) years, 163 (87%) were female, and 165 (88%) were white. Casting participants' mean (SD) age was 75.6 (9.6) years, 93 (84%) were female, and 85 (85%) were white. The most common type of complications varied by treatment. Twelve of 65 participants (18.5%) in the internal fixation group reported a median nerve compression, while 16 of 26 participants (25.8%) who received external fixation and 13 of 56 participants (23.2%) who received pinning sustained pin site infections. Compared with the internal fixation group, complication rate for any severity complication was higher in participants who initially received casting (adjusted rate ratio, 1.88; 95% CI, 1.22-2.88), whereas the rate for moderate complications was higher in the external fixation group (adjusted rate ratio, 2.52; 95% CI, 1.25-5.09). Conclusions and Relevance: The distal radius fracture treatment decision-making process for older patients should incorporate a complication profile for each treatment type. For example, external fixation and pinning could be used for patients after apprising them of pin site infection risk. Internal fixation can be done in patients with high functional demands who are willing to receive surgery. Internal fixation use should be substantiated owing to the time and cost involved. Trial Registration: ClinicalTrials.gov Identifier: NCT01589692.

The golden year: How functional recovery sets the stage for tendon transfer surgery among patients with tetraplegia-a qualitative analysis.

BACKGROUND: Tendon transfer surgery can effectively improve hand function for patients with tetraplegia but remains poorly utilized. Little is known regarding how patients' rehabilitation experiences influence their perception of function, identity, and coping to shape their reconstructive context. METHODS: We performed a cross-sectional qualitative analysis of 19 participants with C4-C7 cervical spinal injuries: 9 patients had undergone reconstruction; 10 had not. Semistructured interviews were conducted using an interview guide focusing on rehabilitation experience, the relationship between function and identity, and how patient experience evolved. Interview transcripts were analyzed using grounded theory. RESULTS: The study sample was predominantly male (79%), white (89%), and American Spinal Injury Association grades A-D (grade A: 42%; grade B: 32%; grade C: 16%; grade D: 10%). Recognizing rehabilitation's necessity, functional gains, and constructive patient-therapist relationships promoted engagement in therapy. Poor insurance coverage and financial constraints decreased rehabilitation access. Function affected identity through the degree to which it tied participants to a "patient" role. Early in recovery, patients' function, roles, and attitudes were fluid but solidified over time; how satisfied patients were with these final positions influenced how they coped. CONCLUSION: The balance of patients' positive and negative coping has been found to influence patients' progression to surgery. This study describes how function and identity contribute to coping. Participants' function and identity evolved during a finite period we call "the golden year," before reaching a fixed point around which they built their lives. The norms patients establish during this time may affect receptiveness to surgery.

Impact of Economic Downturn on the Surgical Volumes of Common Hand Procedures.

BACKGROUND: Economic conditions affect surgical volumes, particularly for elective procedures. In this study, the authors aimed to identify the effects of the 2008 U.S. economic downturn on hand surgery volumes to guide surgeons and managers when facing future economic crises. METHODS: The authors used the California State Ambulatory Surgery and Services Database from January of 2005 to December of 2011, which includes the entire period of the Great Recession (December of 2007 to June of 2009). The authors abstracted the monthly volume of five common hand procedures using International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes. Pearson statistics were used to identify the correlation between unemployment rate and surgical volume for each procedure. RESULTS: The total number of operative cases was 345,583 during the 7-year study period. Most common elective hand procedures, such as carpal tunnel release and trigger finger release, had a negative correlation with unemployment rate, but the volume of distal radius fracture surgery did not show any correlation. Compared with carpal tunnel release (r = -0.88) or trigger finger release volumes (r = -0.85), thumb arthroplasty/arthrodesis volumes (r = -0.45) showed only a moderate correlation. CONCLUSIONS: The economic downturn decreased elective hand procedure surgical volumes. This may be detrimental to small surgical practices that rely on revenue from elective procedures. Taking advantage of the principle that increased volume reduces unit cost may mitigate the lost revenue from these elective procedures. In addition, consolidating hand surgery services at larger, regional centers may reduce the effect of the economic environment on individual hand surgeons.

Variation in the Treatment of Distal Radius Fractures in the United States: 2010 to 2015.

BACKGROUND: It remains unknown whether treatment trends for distal radius fracture have changed in light of value-based care initiatives during recent years. The authors aimed to characterize modern practice patterns for distal radius fracture management. METHODS: Truven MarketScan databases from 2009 to 2015 were used to extract demographic characteristics, geographic location, and comorbidities for patients receiving treatment for a distal radius fracture. Regression modeling and Joinpoint analysis were used to assess treatment trends and the association of patient factors with treatment provided. RESULTS: Among 499,766 eligible encounters, the rate of internal fixation fluctuated around 13 percent. Casting/splinting remained the most frequent treatment across all populations. Treatment trends varied by age; children and adolescents almost exclusively received closed treatment (mean, 97 percent), yet rates of internal fixation increased among adults and elderly patients. Patients aged 55 to 64 years were most likely to undergo internal fixation (OR, 1.89; 95 percent CI, 1.82 to 1.96). Higher median household income also significantly increased odds of receiving internal fixation (p < 0.001). Despite declining rates of external fixation and percutaneous pinning, regional variations among surgical modalities persist. CONCLUSIONS: The increased use of internal fixation for distal radius fractures may be slowing. Treatment type continues to differ widely across demographic groups, underscoring the need for standardization. In accordance with value-based care initiatives, treatment decisions should be made to combine patient needs with financial implications on the health system. Comparative effectiveness data to derive optimal management strategies are still warranted.