Orthopedics

Feature Article 

Outcomes and Cost of Care for Patients With Distal Radius Fractures

Scott Farner, MD; Arthur Malkani, MD; Edmund Lau, MS; Judd Day, PhD; Jorge Ochoa, PhD; Kevin Ong, PhD

Abstract

This study was designed to evaluate treatment patterns in open treatment and percutaneous fixation of distal radius fractures, compare morbidity rates for the 2 types of treatment, and compare costs associated with the procedure and treatment of complications up to 1 year after surgery. From a 5% sample of nationwide Medicare claims records (1997–2009), patients with distal radius fractures were identified with International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM), codes. Patients who underwent percutaneous fixation and open treatment were tracked with appropriate Current Procedural Terminology codes. Complications were identified at 3 and 12 months. Medicare charges and payments associated with the treatment groups were compiled from the claims data. The rate of surgical treatment increased from 44.7 to 82.0 surgeries per 100,000 persons (+83.0%) over the study period. A total of 9343 procedures met the inclusion criteria between 1998 and 2008. The proportion of open treatment procedures increased from 25.5% in 1998 to 73.4% in 2008. Percutaneous fixation was associated with lower adjusted risk of carpal tunnel syndrome and release and mononeuritis at 3 and 12 months. The percutaneous fixation group had lower adjusted risk of malunion/nonunion at 3 months and tendon rupture at 12 months. Average charges were lower in the percutaneous fixation group for the index operation as well as for treatment of morbidities at 3 and 12 months. The operative fixation rate for distal radius fractures in the Medicare population continues to rise, with a significant trend toward open fixation. Charges and payments associated with open treatment are significantly higher than those for percutaneous fixation.

The authors are from the Department of Orthopaedic Surgery (SF, AM), University of Louisville, Louisville, Kentucky; Exponent, Inc (EL), Menlo Park, California; Exponent, Inc (JD, KO), Philadelphia, Pennsylvania; and Exponent, Inc (JO), Bellevue, Washington.

Dr Farner has no relevant financial relationships to disclose. Dr Malkani has received consulting fees and royalties from Stryker. Mr Lau and Drs Day, Ochoa, and Ong received a grant from Stryker to Exponent, Inc, for preparation of a portion of this manuscript.

Correspondence should be addressed to: Scott Farner, MD, Department of Orthopaedic Surgery, University of Louisville, 550 S Jackson St, 1st Fl ACB, Louisville, KY 40202 ( scottfarner@gmail.com).

Received: December 09, 2013
Accepted: February 20, 2014

Abstract

This study was designed to evaluate treatment patterns in open treatment and percutaneous fixation of distal radius fractures, compare morbidity rates for the 2 types of treatment, and compare costs associated with the procedure and treatment of complications up to 1 year after surgery. From a 5% sample of nationwide Medicare claims records (1997–2009), patients with distal radius fractures were identified with International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM), codes. Patients who underwent percutaneous fixation and open treatment were tracked with appropriate Current Procedural Terminology codes. Complications were identified at 3 and 12 months. Medicare charges and payments associated with the treatment groups were compiled from the claims data. The rate of surgical treatment increased from 44.7 to 82.0 surgeries per 100,000 persons (+83.0%) over the study period. A total of 9343 procedures met the inclusion criteria between 1998 and 2008. The proportion of open treatment procedures increased from 25.5% in 1998 to 73.4% in 2008. Percutaneous fixation was associated with lower adjusted risk of carpal tunnel syndrome and release and mononeuritis at 3 and 12 months. The percutaneous fixation group had lower adjusted risk of malunion/nonunion at 3 months and tendon rupture at 12 months. Average charges were lower in the percutaneous fixation group for the index operation as well as for treatment of morbidities at 3 and 12 months. The operative fixation rate for distal radius fractures in the Medicare population continues to rise, with a significant trend toward open fixation. Charges and payments associated with open treatment are significantly higher than those for percutaneous fixation.

The authors are from the Department of Orthopaedic Surgery (SF, AM), University of Louisville, Louisville, Kentucky; Exponent, Inc (EL), Menlo Park, California; Exponent, Inc (JD, KO), Philadelphia, Pennsylvania; and Exponent, Inc (JO), Bellevue, Washington.

Dr Farner has no relevant financial relationships to disclose. Dr Malkani has received consulting fees and royalties from Stryker. Mr Lau and Drs Day, Ochoa, and Ong received a grant from Stryker to Exponent, Inc, for preparation of a portion of this manuscript.

Correspondence should be addressed to: Scott Farner, MD, Department of Orthopaedic Surgery, University of Louisville, 550 S Jackson St, 1st Fl ACB, Louisville, KY 40202 ( scottfarner@gmail.com).

Received: December 09, 2013
Accepted: February 20, 2014

Distal radius fracture is the second most common fracture type in the Medicare population,1–3 numbering approximately 85,000 per year.4 This type of fracture is more common in women because rates of osteoporosis are higher.5,6 Approximately 10% of women 65 years old will experience a distal radius fracture in their remaining lifetime.3 Medicare expenditures for treating these fractures are considerable, exceeding $170 million annually.7

The optimal treatment of distal radius fractures in the elderly is controversial8–13 and includes immobilization, external fixation, percutaneous fixation, and locking and nonlocking plate fixation. Traditionally, operative treatment has been recommended for unstable distal radius fractures in which reduction cannot be maintained with immobilization,14 although the benefits of surgical management have been questioned.15–17

The current study evaluated treatment patterns for open and percutaneous fixation of distal radius fractures in the Medicare population. The introduction and popularization of volar locking plate fixation,18–21 with promising results in young patient populations, theoretically transfers well to elderly populations because this technique offers better fragment control and decreased reported rates of malunion in osteoporotic bone.22

The authors also compared morbidity rates for the 2 treatment types and followed the costs associated with the index procedure and treatment of subsequent complications. Although open treatment of distal radius fractures is more expensive than immobilization,23 to the authors’ knowledge, no studies have directly compared the cost of percutaneous fixation with open treatment in the elderly.

Materials and Methods

Patients diagnosed with distal radius fractures were identified from a 5% nationwide sample of Medicare administrative claims data (1997–2009) using International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM), diagnosis codes 813.40 to 813.45 for closed fractures and 813.50 to 813.54 for open fractures. The Medicare database has been used previously to conduct longitudinal studies of revision and complication risk after total joint arthroplasty.24,25 Patients who underwent percutaneous fixation were identified with Current Procedural Terminology (CPT-4) code 25611 (before 2007) or 25606 (from 2007 onward), and those who underwent open treatment were identified with CPT-4 code 25620 (before 2007) or 25607-25609 (from 2007 onward).

Patients who were not enrolled in both Medicare Parts A (hospital claims) and B (carrier/physician claims) or who were not US residents were excluded from the study to limit patients with incomplete health and claims history. Those younger than 65 years who were receiving Medicare coverage were excluded. Patients who had both procedures on the same claim or who had a procedure performed in the office were also excluded to minimize potential confounding effects from undergoing both procedures and from the site of service, respectively. To limit patients with incomplete health and claims history, patients who did not have at least 1 year of postoperative follow-up or claims history in the full 12 months before surgery were also excluded. The authors also excluded patients who had any major orthopedic surgery within 12 months after the wrist fracture surgery to limit confounding effects. These were identified based on the corresponding ICD-9-CM or CPT-4 codes from the claims records (Table 1).

ICD-9-CM and CPT-4 Procedure Codes for Identifying Other Orthopedic Surgeries in the 12 Months After Wrist Fracture Surgery, for Exclusion Purposes

Table 1:

ICD-9-CM and CPT-4 Procedure Codes for Identifying Other Orthopedic Surgeries in the 12 Months After Wrist Fracture Surgery, for Exclusion Purposes

The overall prevalence of patients with distal radius fractures undergoing percutaneous fixation or open treatment, before applying exclusion criteria, was evaluated to determine trends in treatment patterns. The mortality rate for the pre-exclusion patients (overall cohort) was also assessed. Each beneficiary’s enrollment status and date of death were identified in the annual Medicare denominator files and were used to determine mortality. After application of the exclusion criteria, patients who had morbidities were identified with relevant diagnosis and procedure codes (Table 2). These morbidities included deep venous thrombosis, infection, mechanical complications, malunion/nonunion, newly diagnosed mononeuritis, newly diagnosed carpal tunnel syndrome, pulmonary embolism, cardiac complications, reoperation with subsequent fixation, newly diagnosed wrist and carpus enthesopathy, newly diagnosed tendon rupture, newly diagnosed contracture, newly diagnosed wrist osteoarthritis, newly diagnosed late effect of tendon injury, and hemorrhage/hematoma/seroma. Newly diagnosed morbidities were defined as those that were not present in the 12 months before the wrist fracture surgery. The incidence of postoperative carpal tunnel release and carpal tunnel injection was also evaluated. The cumulative incidence of these morbidities was evaluated to 1 year after surgery.

Morbidity Diagnosis and Procedure Codes

Table 2:

Morbidity Diagnosis and Procedure Codes

A subgroup analysis of patients who underwent open treatment was also performed to compare the morbidity risk for patients with extra-articular and intra-articular fractures. Extra-articular and intra-articular fractures were identified with CPT-4 codes 25607 and 25608 to 25609, respectively. Because these CPT-4 codes were only effective from 2007 onward, the subgroup analysis was limited to patients treated in 2007 and 2008.

Treatment charges and reimbursements (Medicare payments) associated with the index surgery were determined from the claims data. Additionally, subsequent charges and reimbursements from claims associated with treating morbidities through 1 year after the index surgery were also evaluated (Table 2). Charges and reimbursements were converted to January 2011 dollars using the relevant consumer price index for medical services.

Multivariate Cox regression (adjusted) was used to compare the morbidity risk after percutaneous fixation and open treatment. Covariates for the analysis included age, sex, race, census region, socioeconomic status, comorbidity, site of service (inpatient/outpatient), type of fracture (open/closed), year of procedure, and treatment (percutaneous fixation/open treatment). The general health status of each patient was determined using the Charlson comorbidity index and categorized according to overall degree of comorbidity as follows: 0 (none), 1 to 2 (low), 3 to 4 (moderate), and ≥5 (high).26 These ratings were based on comorbid conditions in the 12 months before the index surgery. The year 1997 was used to determine health status in the 12 months before the index surgery for those operated on in 1998; therefore, only procedures performed from 1998 to 2008 were considered for this study. Patient health status was also evaluated based on the presence of 14 specific conditions in the 12 months before the index surgery (Table 3). Each patient’s Medicare buy-in status was used as a proxy for the patient’s socioeconomic status because this information identified patients whose Medicare premiums and deductibles were subsidized by the state because of financial status. Socioeconomic status was also based on per capita income for the county of residence for the beneficiary, which is provided in the Medicare data. Treatment charges and payments were also compared between treatment groups using a general linear model, accounting for the covariates described earlier.

Diagnosis Codes for Identifying Specific Comorbid Conditions

Table 3:

Diagnosis Codes for Identifying Specific Comorbid Conditions

Results

A total of 17,993 percutaneous fixation and open procedures with a corresponding diagnosis of closed or open distal radius fracture were identified from the 1997 to 2009 5% Medicare dataset. The annual number of procedures increased from 902 in 1997 to 2000 in 2009 (Figure 1), with the annual proportion of open procedures increasing from 26.7% to 79.6% during this period. The rate of operative treatment also increased from 44.7 to 82.0 surgeries per 100,000 persons over the 13-year period (Figure 2). After application of the exclusion criteria, the study cohort included 5103 percutaneous fixation procedures and 4240 open procedures performed between 1998 and 2008 (total n=9343). The trend in the annual number of procedures for the study cohort was similar to that of the overall Medicare population (Figure 1), with the annual proportion of open procedures increasing from 25.5% to 73.4%.

Annual number of percutaneous fixation and open treatment procedures for distal radius fractures in the 5% Medicare claims data. Overall data (A); study cohort, after exclusion criteria (B). Annual proportion of open treatment procedures is also noted.

Figure 1:

Annual number of percutaneous fixation and open treatment procedures for distal radius fractures in the 5% Medicare claims data. Overall data (A); study cohort, after exclusion criteria (B). Annual proportion of open treatment procedures is also noted.

Rate of percutaneous fixation and open treatment procedures for distal radius fractures in the Medicare population.

Figure 2:

Rate of percutaneous fixation and open treatment procedures for distal radius fractures in the Medicare population.

For the study cohort, the authors found that there were more operatively treated women with distal radius fractures (Table 4). Specifically, there were only 1096 operatively treated men, compared with 8247 operatively treated women. Women were treated more frequently with percutaneous fixation (55.3%) than with open treatment (44.7%), whereas the treatments were equally prevalent for men (percutaneous fixation, 49.7%; open treatment, 50.3%). Older patients were also treated more frequently with percutaneous fixation. For example, 62.3% of patients 85 years and older had percutaneous fixation compared with 49.3% of patients 65 to 69 years old. The overall comorbidity profile, based on Charlson score, was similar within both treatment cohorts. Percutaneous fixation was used more frequently, regardless of Charlson score group. The percutaneous fixation cohort tended to be of slightly lower socioeconomic status, with 12.6% receiving Medicare buy-in compared with 11.6% for patients undergoing open treatment. Similarly, there was a greater proportion of open treatment procedures (22.3%) compared with percutaneous fixation procedures (14.7%) in the highest per capita income group. For those in the highest per capita income group, 55.8% were treated with open treatment. In contrast, in the lowest per capita income group, 37.6% underwent open treatment. Approximately three-fourths of both procedures were performed on an outpatient basis.

Patient Demographics of the Study Cohort

Table 4:

Patient Demographics of the Study Cohort

For the overall cohort, the mortality risks at 3 and 12 months postsurgery were higher for the percutaneous fixation cohort than for the open treatment cohort (Figure 3). At 3 months and 12 months, the mortality risk was 1.7% (95% confidence interval [CI], 1.4%–2.0%) and 5.5% (95% CI, 5.0%–6.0%), respectively, for the percutaneous fixation cohort and 1.3% (95% CI, 1.0%–1.5%) and 4.3% (95% CI, 3.9%–4.8%), respectively, for the open treatment cohort. However, after adjusting for the covariates, the mortality risk at both time points was similar between both treatment cohorts (3 months, P=.871; 12 months, P=.374).

Unadjusted Kaplan-Meier mortality risk for percutaneous fixation and open treatment cohorts (overall cohort). After adjusting for the covariates, the mortality risk data at 3 months and 12 months were similar in both treatment cohorts (3 months, P=.871; 12 months, P=.374).

Figure 3:

Unadjusted Kaplan-Meier mortality risk for percutaneous fixation and open treatment cohorts (overall cohort). After adjusting for the covariates, the mortality risk data at 3 months and 12 months were similar in both treatment cohorts (3 months, P=.871; 12 months, P=.374).

For the study cohort, the percutaneous fixation group was found to have lower adjusted risk of newly diagnosed carpal tunnel syndrome, carpal tunnel release, and newly diagnosed upper-limb mononeuritis than the open treatment group at both 3 months and 12 months (Table 5). At 12 months, the adjusted risk of newly diagnosed carpal tunnel syndrome, carpal tunnel release, and newly diagnosed upper-limb mononeuritis was lower by 35% (adjusted hazard ratio, 0.65; 95% CI, 0.53–0.78; P<.001), 57% (adjusted hazard ratio, 0.43; 95% CI, 0.33–0.57; P<.001), and 34% (adjusted hazard ratio, 0.66; 95% CI, 0.55–0.79; P<.001) for the percutaneous fixation cohort. In addition, the percutaneous fixation cohort had lower adjusted risk of malunion or nonunion at 3 months and newly diagnosed tendon rupture at 12 months. However, the percutaneous fixation cohort had a 44% higher adjusted risk of mechanical complications at 3 months (adjusted hazard ratio, 1.44; 95% CI, 1.08–1.91; P=.013). For subgroup analysis of the open treatment cohort from 2007 to 2008, no significant differences in adjusted morbidity risk between patients with extra-articular fracture and intra-articular fracture were found.

Morbidity Risk (Unadjusted) and Adjusted Hazard Ratios With Open Treatment as the Reference Group (Study Cohort)Morbidity Risk (Unadjusted) and Adjusted Hazard Ratios With Open Treatment as the Reference Group (Study Cohort)Morbidity Risk (Unadjusted) and Adjusted Hazard Ratios With Open Treatment as the Reference Group (Study Cohort)

Table 5:

Morbidity Risk (Unadjusted) and Adjusted Hazard Ratios With Open Treatment as the Reference Group (Study Cohort)

Treatment charges and payments for the initial surgery as well as the initial surgery plus treatment of morbidities at 3 months and 12 months postsurgery were significantly lower for the percutaneous fixation cohort (Table 6). Adjusted treatment charges and payments were approximately 35% and 25% lower, respectively.

Treatment Charges and Payment Comparison With Open Treatment as the Reference Group

Table 6:

Treatment Charges and Payment Comparison With Open Treatment as the Reference Group

Discussion

The optimal treatment of distal radius fractures in the elderly continues to be controversial despite the large body of literature on the subject.8–13 With increasing patient age and fracture comminution there is increasing fracture instability and likelihood of loss of reduction with nonoperative treatment methods.5 Cast immobilization of distal radius fractures in this population leads to loss of reduction and radiographic evidence of malunion in more than 50% of cases.5,6

The decision to intervene surgically for distal radius fractures in the elderly is often made based on probable or demonstrated instability and displacement, and this population is unlikely to benefit from re-reduction and further cast immobilization.14 Although formulas can predict early or late fracture instability in elderly patients with distal radius fracture,5 the effect on outcomes is more difficult to predict. Anatomic restoration is more closely associated with subsequent function and pain levels in younger populations.27 The need for restoration of normal anatomy is less defined in elderly patients. Numerous studies have reported that good functional results can be achieved in older populations with distal radius fractures despite residual deformity after treatment.5,6,17,28–32 A recent randomized trial of outcomes at 12 months showed no difference with volar locking plates or nonoperative management; however, grip strength was improved in the group treated with volar locking plates and better Disabilities of the Arm, Shoulder and Hand and patient-rated wrist evaluation scores were noted in the very early postoperative period.17 Other studies have recommended open reduction and internal fixation in the elderly, based on their results, but the number of subjects was small.20–21,33–35

The current study showed a trend toward operative intervention, with the rate nearly doubling during the 13-year study period (increasing from 44.7 to 82.0 surgeries per 100,000 persons). Additionally, the authors identified a clear trend toward operative intervention with open treatment. Previous studies showed an increasing trend toward operative intervention for distal radius fractures in all age groups, including the elderly.4,36 Treatment has been shown to be dependent on the region and the surgeon.36–38 Introduction of the volar locking plate led to a dramatic shift in the treatment of distal radius fractures, especially among younger surgeons.36 A recent study by Chung et al4 showed a greater than 5-fold increase in the likelihood of open reduction and internal fixation for the treatment of distal radius fractures in the Medicare population from 1996 to 2005. Among all Medicare patients undergoing operative intervention, the current study showed a nearly 3-fold increase in the percentage of those undergoing open treatment during the study period (25.5% in 1998 to 73.4% in 2008). The reasons for this increase are not entirely clear; however, certain surgeons perceive lower complication rates, better function, and increased patient satisfaction with open reduction and internal fixation.19 Chung et al39 suggested that elderly patients and younger populations see similar benefits with the use of volar locking plate fixation for the management of inadequately reduced distal radius fractures.

Age has been shown to be the most important variable in determining whether operative or nonoperative management is appropriate, with advanced age more predictive of nonoperative management.37 In the current study cohort, advanced age directed treatment toward percutaneous fixation. Previous studies showed decreased rates of internal fixation with increased patient age.38 This may be the result of reluctance to pursue more invasive treatments because surgical risks increase and functional demands decrease with age.

Volar locking plate fixation offers several theoretical advantages, including better fracture stabilization and prevention of collapse that often occurs in the setting of osteoporotic bone.5,6 Although small, the increased incidence of nonunion and malunion with open treatment in 1 study cohort5 is somewhat surprising and is contrary to previous reports that showed excellent radiographic parameters and union rates with open treatment.17,21,33,39,40 The Medicare database does not allow discrimination between the 2 diagnoses. Therefore, it is not possible to determine the number of nonunions or malunions. It is possible that malunion is more likely to be diagnosed and documented in the open treatment group because it is perceived as less likely to occur or that it is documented when the patient is symptomatic as a result of hardware irritation or other complications related to surgery. Asymptomatic malunion and nonunion may go unreported in either group.

When directly comparing the results of percutaneous fixation with open treatment of intra-articular distal radius fractures in patients in whom acceptable closed reduction could not be achieved, open reduction and internal fixation offered superior results; however, this population averaged 42 years of age and did not include those older than 60 years.18 A recent meta-analysis comparing open and percutaneous fixation also showed better outcomes with open treatment, although the population was not limited to the elderly.16 A systematic review of the treatment of distal radius fractures in the elderly did not show a benefit of operative treatment compared with cast immobilization. The greatest proportion of major complications requiring reoperation occurred in the open treatment group, and 18 of 32 reported complications were listed as tendon rupture or adhesion.22 The current study cohort also showed a statistically significant increase in tendon rupture with open treatment at 3 and 12 months after the index operation.

In the current study cohort, patients undergoing open treatment showed an increased likelihood of new carpal tunnel syndrome at 3 and 12 months (4% and 6.9%, respectively) as well as an increase in treatment with injection or surgical release. Previous studies of distal radius fractures showed an increased incidence of carpal tunnel syndrome with increased dorsal angulation41 and with volar plating, although published rates vary widely (0%–25%).42–47 Retraction of the median nerve during surgery, hardware irritation, or scar tissue as a result of the volar approach may contribute to the increase in carpal tunnel syndrome in these patients.

The cost and rate of complications associated with open treatment have been shown to be higher than those with conservative management because expensive implants are often used, anesthesia is required, and the procedure itself is invasive.23 To the authors’ knowledge, the current study is the first to show higher costs associated with open treatment and subsequent complications compared with percutaneous fixation in the elderly. The authors’ data also showed a slightly increased likelihood of percutaneous fixation over open treatment in the lowest per capita income groups and those whose Medicare premiums were subsidized by the state.37

There are limitations to this study. The authors were limited by the accuracy of the data in the Medicare database in this retrospective study. Although a large proportion of distal radius fractures in the elderly are a result of low-energy falls, no information was available about the mechanism of injury, severity of injury, fracture pattern, or effect of those variables on the choice of surgical intervention and subsequent complications. Fracture pattern and severity have been shown to affect outcomes in distal radius fractures.48 It is possible that patients with more severe distal radius fractures were more likely to undergo open treatment because this method may be presumed to be superior. In this case, the complication rate associated with that form of treatment may be artificially increased. Although the Charlson comorbidity index can be used to compare medical comorbidities, it may not be an accurate surrogate for patient functional status or expectations, factors likely to affect surgical management decisions. The current study is also limited in that it cannot take patient treatment preferences or clinical and radiographic outcomes into account. Follow-up of only 12 months is less likely than longer follow-up to identify subsequent arthrosis of the radiocarpal joints, which may affect outcomes. With the recent interest in volar locking plate fixation, it is inferred that this enthusiasm is a factor in the increasing trend toward open fixation. However, the database did not allow the authors to determine exactly what implant type or surgical approach was used. Similarly, percutaneous fixation includes Kirschner wire fixation with or without spanning or nonspanning external fixation. The database did not allow differentiation according to the type of percutaneous fixation method.

Conclusion

With the increasing elderly population and the increased trend toward treating distal radius fractures operatively in the elderly, overall expenditures in the Medicare population are expected to increase if current trends continue. Surgeons must consider cost in the treatment algorithm for the management of displaced distal radius fractures in the elderly. Further studies are necessary to determine which patients are more likely to benefit from operative treatment and which intervention is appropriate.

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  33. Orbay JL, Fernandez DL, Ray NF, Chan JK. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg Am. 2004; 29:96–102. doi:10.1016/j.jhsa.2003.09.015 [CrossRef]
  34. Beharrie AW, Beredjiklian PK, Bozentka DJ. Functional outcomes after open reduction and internal fixation for treatment of displaced distal radius fractures in patients over 60 years of age. J Orthop Trauma. 2004; 18:680–686. doi:10.1097/00005131-200411000-00005 [CrossRef]
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  36. Koval KJ, Harrast JJ, Anglen JO, Weinstein JN. Fractures of the distal part of the radius: the evolution of practice over time. Where’s the evidence?J Bone Joint Surg Am. 2008; 90(9):1855–1861. doi:10.2106/JBJS.G.01569 [CrossRef]
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  48. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg Am. 1994; 19:325–340. doi:10.1016/0363-5023(94)90028-0 [CrossRef]

ICD-9-CM and CPT-4 Procedure Codes for Identifying Other Orthopedic Surgeries in the 12 Months After Wrist Fracture Surgery, for Exclusion Purposes

ProcedureICD-9-CM CodesCPT-4 Codes
Primary total hip replacement81.5127130, 27132
Partial hip replacement81.5227125
Revision hip replacement81.53, 00.70–00.7327134, 27137, 27138
Primary knee replacement81.5427437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447
Revision knee replacement81.55, 00.80–00.8427486, 27487, 27488
Shoulder replacement81.80, 81.83, 81.8123472, 23470, 23332
Spine procedures81.61, 84.51, 81.00–81.09, 81.30–81.39 03.53 81.65, 81.66 84.58, 84.59 84.80–84.8522800, 22802, 22804, 22808, 22810, 22812, 22840–22849, 22851, 22532, 22533, 22534, 22548, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632 22305, 22310, 22315, 22318, 22319, 22325, 22326, 22327, 22328, 22899 22520–22525
Ankle fusion and fusion of other joints, ankle replacement, toe replacement81.1, 81.2, 81.56, 81.57, 81.5927700, 27702, 27703, 27704, 27808, 27810, 27814, 27816, 27818, 27822, 27823, 27870, 28400, 28405, 28406, 28415, 28420, 28430, 28435, 28436, 28445, 28450, 28455, 28456, 28465, 28470, 28475, 28476, 28485, 28490, 28495, 28496, 28505, 28510, 28515, 28525, 28530, 28531, 28705, 28715, 28725, 28730, 28735, 28737, 28740, 28750, 28755, 28760, 23800, 23802, 24800, 24802, 25800, 25805, 25810, 25820, 25825, 25830, 26841–26844, 26850, 26852, 26860–26863, 27280, 27282, 27284, 27286, 27580, 27871
Wrist replacement/finger arthroplasty81.725332, 25441–25447, 25449, 26530, 26531, 26535, 26536
Elbow replacement81.8424360–24366, 24587
Spinal disk replacement84.60–84.6922856, 22857, 22861, 22862, 22864, 22865

Morbidity Diagnosis and Procedure Codes

MorbidityDiagnosis or Procedure Code
Deep venous thrombosis451, 452, 453
Infection or inflammation996.60, 996.66, 996.67, 998.5
Mechanical complication of internal orthopedic device, implant, and graft996.40–996.49
Malunion/nonunion733.8
New diagnosis of mononeuritis of upper limb354.0–354.5, 354.8, 354.9
Pulmonary embolism415
Cardiac complications410, 997.1
Reoperation with subsequent fixationCPT 25611, 25606, 25620, 25607–25609 ICD-9-CM 79.02, 79.12, 79.22, and 79.32
New diagnosis of enthesopathy of wrist and carpus726.4
New diagnosis of tendon rupture727.63, 727.64
New diagnosis of contracture718.44
New diagnosis of carpal tunnel syndrome354.0
New diagnosis of wrist osteoarthritis715.04, 715.14, 715.24, 715.34, 715.84, 715.94
New diagnosis of late effect of tendon injury905.8
Hemorrhage/hematoma/seroma998.11, 998.12, 998.13
Carpal tunnel releaseCPT 29848, 64721
Carpal tunnel injectionCPT 20526

Diagnosis Codes for Identifying Specific Comorbid Conditions

Comorbid ConditionICD-9-CM Codes
Arterial disease (including atherosclerosis, aneurysm)440–448
Chronic obstructive pulmonary disease (including emphysema, chronic bronchitis)490–496
Cancer (including malignant neoplasm, carcinoma)140–176, 179–208, 210–239, V10
Diabetes250
Hip fracture820
Hypertensive disease (including arrhythmias, ventricular hypertrophy)401–405
Ischemic heart disease (including coronary artery disease)410–414
Other heart disease (including acute myocarditis, conduction disorders)420–429
Pneumonia480–487, V12.6
Pulmonary heart disease415–417, V12.5
Stroke430–438
Wrist fracture813.4, 813.5, 814.0, 814.1
Osteoporosis733.0X
Polytrauma (except distal radius fracture)800–829 (except 813.40–813.45 and 813.50–813.54)

Patient Demographics of the Study Cohort

Demo-graphicMaleFemaleAll

FixationOpenFixationOpenFixationOpen

No.% Between Group% Within GroupNo.% Between Group% Within GroupNo.% Between Group% Within GroupNo.% Between Group% Within GroupNo.% Between Group% Within GroupNo.% Between Group% Within Group
Age, y
  65–6916142.729.521657.339.287650.719.285249.323.1103749.320.3106850.725.2
  70–7414953.627.312946.423.4100252.622.090447.424.5115152.722.6103347.324.4
  75–7911152.920.49947.118.0113156.924.885843.123.3124256.524.395743.522.6
  80–848553.815.67346.213.287956.419.367943.618.496456.218.975243.817.7
  85+3953.47.23446.66.267062.914.739637.210.770962.313.943037.810.1
Charlson score
  024851.845.523148.241.9226955.049.8186045.050.4251754.649.3209145.449.3
  1–219747.436.221952.639.8181556.539.8139543.537.8201255.539.4161444.538.1
  3–47451.713.66948.312.536150.87.935049.29.543550.98.541949.19.9
  5+2644.84.83255.25.811357.42.58442.62.313954.52.711645.52.7
Per capita income
  Unknown21000.4---233.30.04466.70.1450.00.1450.00.1
  $0–<$17K12053.322.010546.719.1117563.525.867536.518.3129562.425.478037.618.4
  $17K–<$19K11655.821.39244.216.792157.020.269443.018.8103756.920.378643.118.5
  $19K–<$21K10355.118.98444.915.378255.817.261944.216.888555.717.370344.316.6
  $21K–<$24K12647.923.113752.124.9100753.222.188646.824.0113352.622.2102347.424.1
$24K+7837.014.313363.024.167145.314.781154.722.074944.214.794455.822.3
Medicare buy-in status
  Without buy-in49349.190.551150.992.7396555.087.0323845.087.8445854.387.4374945.788.4
With buy-in5256.59.54043.57.359356.813.045143.212.264556.812.649143.211.6
Site of service
  Inpatient15650.028.615650.028.3131756.428.9101843.627.6147355.628.9117444.427.7
  Outpatient38749.671.039450.471.5321554.770.5266445.372.2360254.170.6305845.972.1
  Unknown266.70.4133.30.22678.80.6721.20.22877.80.6822.20.2
All54549.710055150.3100455855.3100368944.7100510354.6100424045.4100

Morbidity Risk (Unadjusted) and Adjusted Hazard Ratios With Open Treatment as the Reference Group (Study Cohort)

Morbidity/Treatment3 Months12 Months

Unadjusted Risk (95% CI)Adjusted Hazard Ratio (95% CI)Unadjusted Risk (95% CI)Adjusted Hazard Ratio (95% CI)
Cardiac complication
  Percutaneous fixation1.0% (0.7%–1.3%)1.00 (0.63–1.58) P=.9942.0% (1.7%–2.4%)0.91 (0.67–1.24) P=.552
  Open treatment0.9% (0.6%–1.2%)2.0% (1.5%–2.4%)
Carpal tunnel syndrome (new diagnosis)
  Percutaneous fixation1.5% (1.1%–1.8%)0.35 (0.26–0.47) P<.001*4.3% (3.8%–4.9%)0.65 (0.53–0.78) P<.001*
  Open treatment4.0% (3.4%–4.6%)6.9% (6.1%–7.6%)
Carpal tunnel injection
  Percutaneous fixation0.1% (0.0%–0.1%)0.48 (0.11–2.09) P=.3280.2% (0.1%–0.3%)0.70 (0.29–1.69) P=.430
  Open treatment0.2% (0.1%–0.3%)0.4% (0.2%–0.6%)
Carpal tunnel release
  Percutaneous fixation0.5% (0.3%–0.7%)0.27 (0.17–0.42) P<.001*1.7% (1.4%–2.1%)0.43 (0.33–0.57) P<.001*
  Open treatment2.3% (1.8%–2.7%)4.0% (3.4%–4.5%)
Contracture (new diagnosis)
  Percutaneous fixation0.4% (0.2%–0.5%)0.65 (0.33–1.27) P=.2090.9% (0.6%–1.1%)0.67 (0.43–1.02) P=.062
  Open treatment0.6% (0.3%–0.8%)1.3% (1.0%–1.7%)
Deep venous thrombosis
  Percutaneous fixation1.7% (1.3%–2.0%)0.76 (0.54–1.05) P=.0993.3% (2.8%–3.7%)0.89 (0.70–1.14) P=.363
  Open treatment1.9% (1.5%–2.3%)3.2% (2.7%–3.8%)
Enthesopathy of wrist and carpus (new diagnosis)
  Percutaneous fixation0.1% (0.0%–0.2%)0.50 (0.16–1.59) P=.2410.2% (0.1%–0.3%)0.57 (0.24–1.37) P=.207
  Open treatment0.2% (0.1%–0.4%)0.4% (0.2%–0.5%)
Hemorrhage/hematoma/seroma
  Percutaneous fixation0.4% (0.2%–0.5%)0.89 (0.44–1.82) P=.7540.8% (0.5%–1.0%)1.12 (0.68–1.87) P=.650
  Open treatment0.4% (0.2%–0.6%)0.8% (0.5%–1.0%)
Infection/inflammation
  Percutaneous fixation1.9% (1.5%–2.3%)1.28 (0.89–1.84) P=.1822.8% (2.3%–3.2%)1.26 (0.94–1.69) P=.121
  Open treatment1.3% (0.9%–1.6%)2.0% (1.5%–2.4%)
Malunion/nonunion
  Percutaneous fixation1.7% (1.3%–2.1%)0.67 (0.49–0.91) P=.011*3.1% (2.7%–3.6%)0.83 (0.65–1.05) P=.116
  Open treatment2.3% (1.8%–2.7%)3.6% (3.1%–4.2%)
Mechanical complication
  Percutaneous fixation3.1% (2.6%–3.5%)1.44 (1.08–1.91) P=.013*4.3% (3.8%–4.9%)1.07 (0.86–1.33) P=.546
  Open treatment2.0% (1.5%–2.4%)3.7% (3.2%–4.3%)
Wrist osteoarthritis (new diagnosis)
  Percutaneous fixation1.0% (0.7%–1.2%)1.01 (0.65–1.58) P=.9552.5% (2.1%–3.0%)0.96 (0.74–1.26) P=.783
  Open treatment1.0% (0.7%–1.3%)2.8% (2.3%–3.3%)
Pulmonary embolism
  Percutaneous fixation0.6% (0.4%–0.8%)1.35 (0.72–2.56) P=.3531.0% (0.7%–1.3%)0.95 (0.61–1.47) P=.806
  Open treatment0.4% (0.2%–0.6%)1.1% (0.8%–1.4%)
Reoperation with subsequent fixation
  Percutaneous fixation24.1% (22.9%–25.2%)1.00 (0.92–1.10) P=.93724.4% (23.2%–25.5%)0.99 (0.91–1.09) P=.891
  Open treatment24.9% (23.6%–26.2%)25.4% (24.1%–26.7%)
Late effect of tendon injury (new diagnosis)
  Percutaneous fixation0.0% (0.0%–0.1%)N/A0.1% (0.0%–0.1%)0.44 (0.10–1.92) P=.273
  Open treatment0.1% (0.0%–0.2%)0.2% (0.0%–0.3%)
Tendon rupture (new diagnosis)
  Percutaneous fixation0.1% (0.0%–0.2%)0.45 (0.15–1.36) P=.1580.2% (0.1%–0.3%)0.30 (0.14–0.65) P=.003*
  Open treatment0.3% (0.1%–0.4%)0.6% (0.4%–0.8%)
Upper-limb mononeuritis (new diagnosis)
  Percutaneous fixation1.7% (1.4%–2.1%)0.37 (0.28–0.49) P<.001*4.9% (4.3%–5.5%)0.66 (0.55–0.79) P<.001*
  Open treatment4.7% (4.0%–5.3%)7.7% (6.9%–8.5%)

Treatment Charges and Payment Comparison With Open Treatment as the Reference Group

Time/Treatment GroupChargesPayment

Average (±SD)Median (Interquartile Range)Adjusted Relative RatioAverage (±SD)Median (Interquartile Range)Adjusted Relative Ratio
Initial surgery
  Percutaneous fixation$13,119 (±$17,009)$8260 ($3441; $15,654)0.65 (95% CI, 0.63–0.67) P<.001*$3670 (±$5311)$2116 ($791; $4697)0.74 (95% CI, 0.72–0.77) P<.001*
  Open treatment$20,405 (±$21,933)$16,137 ($9453; $24,873)$4633 (±$6659)$3557 ($2070; $5314)
Initial surgery and treatment of morbidities (3 months postoperatively)
  Percutaneous fixation$14,434 (±$21,255)$8473 ($3680; $16,578)0.65 (95% CI, 0.63–0.68) P<.001*$4101 (±$6721)$2182 ($841; $4867)0.74 (95% CI, 0.71–0.76) P<.001*
  Open treatment$22,049 (±$28,754)$16,715 ($9941; $25,901)$5114 (±$9208)$3639 ($2165; $5568)
Initial surgery and treatment of morbidities (12 months postoperatively)
  Percutaneous fixation$16,111 (±$27,092)$8871 ($3949; $17,746)0.68 (95% CI, 0.66–0.71) P<.001*$4652 (±$8646)$2246 ($978; $5198)0.77 (95% CI, 0.74–0.80) P<.001*
  Open treatment$23,498 (±$31,108)$17,355 ($10,249; $27,002)$5564 (±$9942)$3720 ($2244; $5942)

10.3928/01477447-20140924-52

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