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Forecasting effects of "fast-tracks" for surgery in the Swedish national guidelines for distal radius fractures
Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Ortopedi.ORCID-id: 0000-0002-8727-9555
Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden, Department of Hand Surgery, Södersjukhuset, Stockholm, Sweden.
Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Ortopedi.
Department of Clinical Sciences Lund, Orthopedics, Lund University, Lund, Sweden.
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2022 (Engelska)Ingår i: PLOS ONE, E-ISSN 1932-6203, Vol. 17, nr 2, artikel-id e0260296Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND AND PURPOSE: National guidelines for treatment of distal radius fractures (DRFs) were presented in Sweden in 2021. In the guidelines, a fast-track is recommended for 4 subgroups of highly unstable DRFs. Regardless of the results of the closed reduction these are recommended for surgery within 1 week of injury. This study aims to evaluate the potential consequences of the newly presented national guidelines on incidence of surgical interventions.

PATIENTS AND METHODS: In all, 1,609 patients (1,635 DRFs) with primary radiographs after a DRF between 2014 and 2017 at two Swedish hospitals were included in a retrospective cohort study. An estimation was made of the percentage of patients in the historical pre-guidelines cohort, that would have been recommended early primary surgery according to the new national guidelines compared to treatment implemented without the support of these guidelines.

RESULTS: On a strict radiological basis, 32% (516 out of 1635) of DRFs were classified into one of the 4 defined subgroups. At 9-13 days follow-up, cast treatment was converted into delayed primary surgery in 201 cases. Out of these, 56% (112 out of 201) fulfilled the fast-track criteria and would with the new guidelines have been subject to early primary surgery.

INTERPRETATION: The fast-track regimen in the new guidelines, has a high likelihood of identifying the unstable fractures benefitting from early primary surgery. If the proposed Swedish national guidelines for DRF treatment are implemented, a greater proportion of fractures would be treated with early primary surgery, and a delayed surgery avoided in the majority of cases. The potential benefits in relation to possible costs when using the fast-track criteria in every day practice are still unknown.

Ort, förlag, år, upplaga, sidor
Public Library of Science , 2022. Vol. 17, nr 2, artikel-id e0260296
Nationell ämneskategori
Ortopedi
Identifikatorer
URN: urn:nbn:se:umu:diva-192459DOI: 10.1371/journal.pone.0260296ISI: 000797657800004PubMedID: 35143508Scopus ID: 2-s2.0-85124387217OAI: oai:DiVA.org:umu-192459DiVA, id: diva2:1637433
Forskningsfinansiär
Region Västernorrland, LVNFOU921951Tillgänglig från: 2022-02-14 Skapad: 2022-02-14 Senast uppdaterad: 2024-04-03Bibliografiskt granskad
Ingår i avhandling
1. Fractures of the distal radius: radiological measurements and clinical outcome
Öppna denna publikation i ny flik eller fönster >>Fractures of the distal radius: radiological measurements and clinical outcome
2024 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Alternativ titel[sv]
Distala radiusfrakturer : radiologiska mätningar och kliniskt utfall
Abstract [en]

The most common fracture is the distal radius fracture (DRF). Wrist function is of importance for the ability to perform activities of daily living, work-related tasks and leisure activities. Treatment generally focuses on restoring anatomical alignment and providing adequate rehabilitation.

To improve our knowledge of DRFs, this thesis explores factors affecting clinical and radiological outcomes in the short- and long-term after a DRF.

Paper I analysed the magnitude of radiographic malalignment leading to deterioration in clinical outcomes. Some 366 patients with prospective data were analysed 1 year after fracture. A nonlinear association between radiographic and clinical outcome was found for dorsal tilt. Larger malalignment resulted in increasingly worse outcomes, starting from about 5 degrees of dorsal tilt and progressing with increasing malalignment.

In Paper II, a novel predictor of instability was assessed, namely marginal secondary displacement. The study included 165 patients with prospective data treated non-operatively with complete radiological follow-up and acceptable alignment 10-14 days after injury. Marginal secondary displacement was an important predictor of late displacement with malunion in DRFs. Clinicians should not unequivocally accept general guidelines for alignment. They should also assess the deterioration in fracture alignment at radiographic follow-up and be aware of the potential need for surgery to avoid malunion, even if radiographic measures are within acceptable limits.

Paper III investigated the long-term effects of DRFs in a large prospective study 11 to 13 years post-injury and found that clinical outcomes improve with time. A decade after the fracture, patient-reported function, health-related quality of life, grip strength and range of motion were restored at the group level. Neither osteoarthritis nor pseudoarthrosis of the ulnar styloid affected the outcomes. Dorsal tilt, radial inclination and ulnar variance did not affect long-term clinical outcomes or the risk of osteoarthritis. Recovery after a DRF is an ongoing process lasting years. A decade after injury, recovery was achieved regardless of radiological outcomes.

Paper IV evaluated the potential consequences of the fast-tracks introduced in the Swedish National Guidelines in a retrospective study. Some 1,609 patients with DRFs 4-7 years before the introduction of the national guidelines were studied. The patients' treatment was compared to how they would have been treated had the guidelines been followed. The results suggest that the fast-track treatment pathway will probably i) identify unstable fractures, ii) lead to more patients being treated with early primary surgery and iii) result in delayed primary surgery being avoided in most cases.

To conclude, clinical outcomes are affected by the degree of radiological alignment 1 year after a DRF. However, patients continue to recover over a long period. After a decade, normal function is restored at the group level, irrespective of the radiological outcome. Clinical outcomes at 1 year can most likely be ameliorated by identifying unstable fractures and following protocols promoting early surgery for these fractures.

Ort, förlag, år, upplaga, sidor
Umeå: Umeå University, 2024. s. 112
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 2279
Nyckelord
Radius, distal radius fracture, fracture, orthopedics, radiology, outcome, clinical outcome, Radius, distal radius fraktur, fraktur, ortopedi, radiologi, utfall, kliniskt utfall
Nationell ämneskategori
Ortopedi Kirurgi
Forskningsämne
ortopedi
Identifikatorer
urn:nbn:se:umu:diva-222962 (URN)978-91-8070-249-2 (ISBN)978-91-8070-250-8 (ISBN)
Disputation
2024-05-08, Aulan, Sundsvalls sjukhus, Sundsvall, 09:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2024-04-17 Skapad: 2024-04-03 Senast uppdaterad: 2024-04-09Bibliografiskt granskad

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