Abstract
Dear Editor,
We read this study with interest. The study addresses a frequently encountered clinical problem and raises some important points to consider when advising patients. We were struck by the high rate of secondary procedures identified in Table 5, with an overall rate of secondary procedures in the non-operatively managed group of 42.6%. Table 4 details the rates of complications in both groups, with higher rate of carpal tunnel syndrome (OR 1.22, p < 0.01) with operative (8.3%) versus non-operative management (7%). Carpal tunnel release was stated to be the most common secondary surgical procedure in non-operatively managed patients at a rate of 4.8% and a further 37.8% of the non-operatively managed group had a secondary surgical procedure, the precise nature of which not being specified within the manuscript or appendices. Given this high rate of secondary intervention in this initially non-operatively managed group, we would be grateful if the authors could clarify precisely what surgery the remaining 37.8% underwent, as this would be useful for readers in their interpretation of the study’s findings with due context.
Nuffield Orthopaedic Centre, Oxford, UK
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Reply
Dear Editor,
We thank Drs Dean and Little for their insightful observations. They observed the proportion of patients with a reported secondary procedure in the non-operatively managed group as 42.6% (n = 1495). In order to rigorously define groups for this study, we defined initial ‘operative’ or ‘non-operative’ fracture management as follows: if codes for operative treatments were included in the initial encounter it was recorded as ‘operative’ or if any encounters occurred within 90 days of the initial encounter for distal radial fracture (DRF) we classified them as the same encounter/same fracture. We classified ‘non-operative’ initial management as the absence of a same side operative treatment within 90 days of the initial diagnosis of DRF. Consequently, if patients were treated with an operative procedure between 91 days and 1 year following initial fracture claim, the patients were classified as having received a secondary procedure. To further clarify, the rows in Table 5 are not mutually exclusive so those patients that underwent carpal tunnel release could have also had a DRF surgical procedure.
That said, the majority of patients in question are those that were initially classified as non-operative management, however, went on to have a same laterality operative procedure 90 days after initial fracture management, but within 1 year. Of the non-operative patients, 1327 had an open procedure during this time period, which accounts for 37.8%. Breaking these patients with secondary open DRF treatment down further: 12.3% had internal fixation, 10.9% had secondary management with internal fixation of two fragments, 14.6% with internal fixation of 3 + fragments and 3.3% had external fixation, pinning or both (however, numbers are too small to share separately).
Hopefully, these additional details help to address the questions raised by Drs Dean and Little. These patients are a specific subgroup in which the decision to manage the fractures operatively extended beyond the initial 90-day period, and as such were classified as initial non-operative managed fractures.
Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
*Corresponding author: