The purposes of the present study were (1) to document the changing use of open treatment as compared with percutaneous fixation for the operative treatment of distal radial fractures and (2) to evaluate the surgeon self-reported outcomes and complication rates associated with each of these surgical options.
The ABOS Part II database was searched for all distal radial fractures (ICD-9 codes 813.42, 813.44) for the year 1999 through 2007. The procedures that were performed for the treatment of distal radial fractures were separated into two groups on the basis of CPT codes: (1) those involving percutaneous skeletal fixation with or without external fixation (CPT code 25611 [in 2007, this CPT code was changed to 25606]) and (2) those involving open treatment with or without internal or external fixation (CPT code 25620 [in 2007, this CPT code was changed to 25607-25609]). It should be noted that the database provides no information regarding surgical approach (volar or dorsal) or fixation method (plate or fragment-specific).
Over the nine-year period (1999 to 2007), a total of 12,061 distal radial fractures (ICD-9 813.42 and 813.33) were treated surgically by candidates during the case-collection periods. A total of 6,714 candidates submitted case lists, of whom 3,621 performed no operative fixation for this type of fracture. The number of distal radial fractures treated operatively per candidate increased almost every year. From 1999 to 2007, there was a distinct shift in surgical technique. Nationwide, the use of open treatment increased from approximately 42% in 1999 to 81% in 2007. The percentage of fractures that were stabilized with open treatment was significantly greater for hand-fellowship trained surgeons than for non-fellowship trained surgeons.
The overall complication rate was higher for patients who had been managed with percutaneous fixation than for those who had been managed with open treatment (14% compared with 12.3%). There was a higher infection rate in association with use of percutaneous fixation (5% compared with 2.6%) and a higher nerve palsy and/or injury rate in association with open treatment (2% compared with 1.2%). No other differences in complication rates were found between the two techniques.
This paper begs the question as to how we have arrived at the amazing popularity of open reduction of distal radius fractures using volar locked plating. While the study is not a perfect database, it does show that the two methods of fixation are fairly similar on paper. The question is really why? Reimbursement does not seem to play a part. Is the trend simply a response to our training? Are we using a superior product or has marketing reached the point to where it can influence medical care?
One aspect that the study does not address is the more rapid return of motion, function and independence with the current internal fixation systems. This aspect of rehabilitation and recovery may be the most important variable that has led to such widespread use of volar locked plating for unstable distal radius fractures.