Evaluation of the Incidence and Etiology of Unplanned Return to Operating Room Following Open Reduction Internal Fixation of Distal Radius Fractures

Abstract

Background:

Distal radius fractures (DRF) are the most common upper extremity fractures in adults. The purpose of this study was to determine the incidence, causes, and independent predictors for unplanned return to the operating room (URTO) in a single institution within 90 days following distal radius open reduction internal fixation (ORIF).

Methods:

A retrospective study of 2933 consecutive patients from January 2015 to December 2019 who underwent distal radius ORIF was undertaken. Patients who returned to the operating room within 90 days of the index procedure were identified. Patients with planned return to the operating room for staged procedures were excluded, yielding a patient cohort of those with URTO. Demographic data, causes for reoperation, and final Quick Disabilities of the Arm, Shoulder and Hand DASH (QuickDASH) scores were collected.

Results:

Overall, 45 patients had URTO (1.5%) occurring a mean of 44 (6-89) days from the index procedure. Reasons for reoperation included nerve complications (n = 14), loss of fixation (n = 11), hardware complications (n = 9), wound complications (n = 7), and tendon complications (n = 4). Neurologic reasons for return included carpal tunnel release (n = 13) and ulnar nerve decompression (n = 1). QuickDASH scores were higher for URTO compared with control cohort at the final follow-up (33 [range: 0-91] vs 14 [range: 0-100], P < .01).

Conclusions:

Mechanical hardware failure and neurologic symptoms were the most common reasons for URTO after distal fracture ORIF.

Introduction

Distal radius fractures (DRF) are the most common upper extremity fractures in adults, with a reported incidence of 440 per 100 000 people.^1,2 Fractures of the distal radius are estimated to lead to 2.5% of all emergency department visits and comprise 18% of all fractures in patients aged >65 years.^3,4 As the population in the United States continues to age, the incidence of DRF is predicted to continue to rise. ⁵ Although most patients are typically treated with nonoperative management, internal fixation is becoming more common. ⁶ Although surgical management of DRF has its benefits, there are associated risks and potential for complications.

There is substantial variation in reported postoperative complications following surgical management of DRF with rates of overall complications ranging between 11% and 31%.^6-14 The reported rate of unplanned return to the operating room (URTO) following fracture fixation also ranges widely from 1.1% to 10.4%.^10,12,14,15 Commonly cited reasons for URTO are hardware removal, median nerve compression, tendon irritation and/or rupture, and infection.^14,15 However, given the relatively low incidence of URTO for DRF, prior studies have either been underpowered or have used national administrative databases.^11-14,16

The primary purpose of the study was to determine the incidence and causes for URTO following distal radius ORIF at a high-volume single institution. The secondary purpose was to compare the clinical outcomes of patients who underwent URTO with those who did not. We hypothesize that patient-specific factors, including elevated body mass index (BMI) and advanced age, are associated with URTO.

Methods

Institutional review board approval was obtained with a waiver of informed consent per institutional protocol. A retrospective review of billing records was performed to identify DRF open reduction internal fixation (ORIF) procedures from January 2015 to December 2019. Common Procedural Terminology billing codes 25607, 25608, and 25609 were used to identify a total of 3177 procedures. All procedures were performed by 22 board-certified, hand fellowship–trained orthopedic surgeons. All patients who underwent a second surgery within 90 days of their index DRF surgery were identified and included in the case cohort.

An electronic chart query was performed to collect patient demographic information including age, BMI, and smoking status. In addition, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) functional outcome questionnaire scores were collected at final follow-up for all patients included in this analysis. A manual chart review was performed to investigate the reason for return to the operating room (OR) and timing of reoperation relative to index procedure. Reasons for URTO were grouped into 5 categories: nerve complications, tendon complications, wound complications, hardware complications, and loss of fixation. Patients were included if they were at least 18 years old and underwent a distal radius ORIF. Patients were excluded if they were less than 18 years old or if they underwent a planned or staged procedure requiring return to the OR. Of the 3177 procedures initially identified, 156 were excluded as they were younger than 18 years old. Eighty-eight patients with planned return to the OR for staged procedures were excluded from the analysis, resulting in a case cohort of 45 patients. Patients who did not return to the OR within 90 days were included in the analysis as controls (n = 2888).

Descriptive statistics were calculated for variables of interest, including patient demographics and etiology of return to OR. Univariate analysis was performed using independent Student t test and χ² analysis to evaluate differences in patient factors between those who underwent unplanned reoperation and those who did not. An α of 0.05 was used to determine statistical significance. A post hoc power analysis using QuickDASH score as the outcome variable was conducted under the assumption of an α of 0.05, β of 0.80, and effect size of 0.88, which yielded a power of 0.99. All statistical analyses were performed using SPSS 25.0 (SPSS Inc., Armonk, New York).

Results

There were 2933 total DRF included in the study. The average age of the cohort was 60 (range: 18-99) years, the average BMI was 27 (range: 14-60) kg/m², and 80% were women. Overall, 45 patients (1.5%) had URTO occurring a mean of 44 (range: 6-89) days from index procedure. When comparing URTO and control cohorts, age was found to be significantly different (64 vs 59, P = .015). Between the 2 groups, BMI (27.1 vs 27.0, P = .861), sex (79.8% female vs 82.2% female, P = .697), or smoking status (19.2% vs 20%, P = .909) was not found to be statistically different. QuickDASH scores were higher for URTO compared with the control cohort at the final follow-up (33 [range: 0-91] vs 14 [range: 0-100], P < .01). The period of time between the initial surgery and the recording of the final QuickDASH score was not significantly different between the URTO group and the control group (335 days vs 411 days, P = .098).

Reasons for reoperation included nerve complications (n = 14), loss of fixation (n = 11), hardware complications (n = 9), wound complications (n = 7), and extensor pollicis longus (EPL) tendon rupture (n = 2) and EPL tendon irritation (n = 2) (Table 1). Of the 45 patients who returned to the OR, 16 (35.5%) returned within 30 days of the initial surgery, with loss of fixation (6, 37.5%) being the most common reason for return. There were 14 (31.1%) patients who returned to the OR between 30 and 60 days of the initial surgery and 15 (33.3%) patients who returned between 60 and 90 days. See Table 2 for a detailed description of complications requiring URTO.

Table 1.

Causes for Unplanned Return to the Operating Room Following Distal Radius Open Reduction Internal Fixation Within 90 Days.

Causes	No. (%)	Days to return to the OR
Nerve complications
CTR	13 (28.9)	45.5 (6-84)
Ulnar nerve decompression at Guyon canal	1 (2.2)	70.0 (70)
Loss of reduction
Loss of reduction	11 (24.4)	30.3 (14-61)
Hardware complications
Pin irritation	4 (8.9)	63.7 (29-82)
Hardware breakage	3 (6.7)	45.7 (35-53)
Removal of prominent volar plate	1 (2.2)	70.0 (70)
Loose screws	1 (2.2)	29.0 (29)
Wound complications
Wound complications	7 (15.5)	32.0 (9-63)
Tendon complications
EPL rupture	2 (4.4)	60.5 (16-77)
EPL tendon irritation	2 (4.4)	46.5 (32-89)

Note. Data presented as mean (range) or count (%). CTR, carpal tunnel release; OR = operating room; EPL = extensor pollicis longus.

Table 2.

Time of Return to the OR by Month.

Causes	Total, No. (%)	No. (%) returning to the OR within 30 days	No. (%) returning to the OR from 30 to 60 days	No. (%) returning to the OR between 60 and 90 days
Nerve complications
CTR	13 (28.9)	4 (8.9)	3 (6.7)	6 (13.3)
Ulnar nerve decompression at Guyon canal	1 (2.2)	0 (0)	0 (0)	1 (2.2)
Loss of fixation
Loss of reduction	11 (24.4)	6 (13.3)	4 (8.9)	1 (2.2)
Hardware complications
Pin irritation	4 (8.9)	0 (0)	1 (2.2)	3 (6.7)
Hardware breakage	3 (6.7)	0 (0)	3 (6.7)	0 (0)
Removal of prominent volar plate	1 (2.2)	0 (0)	0 (0)	1 (2.2)
Loose screws	1 (2.2)	1 (2.2)	0 (0)	0 (0)
Wound complications
Wound complications	7 (15.5)	4 (8.9)	2 (4.4)	1 (2.2)
Tendon complications
EPL rupture	2 (4.4)	1 (2.2)	0 (0)	1 (2.2)
EPL tendon irritation	2 (4.4)	0 (0)	1 (2.2)	1 (2.2)

Note. OR = open reduction; CTR, carpal tunnel release; EPL = extensor pollicis longus.

Discussion

Several studies have evaluated early (<30 day) return to the OR following DRF fixation and have reported variable incidence of URTO.^{8,10,12,14,15,17} Schick et al ¹⁴ in a retrospective registry study of 1673 patients identified early return to the OR (rate of 0.95%, 16 of 1673) as the most common cause of early major morbidity following DRF fixation. In another retrospective registry study of 3003 DRF patients, Jiang et al ¹² report a 1.1% 30-day reoperation rate (30 of 3003). Although both of these studies have provided insight into the incidence of early OR return, they do not address the indications for early URTO. Furthermore, complications necessitating operative intervention can occur beyond the 30-day period. In fact, in our series, the mean time for URTO was beyond 30 days, with 64% occurring past 30 days, which may explain the slightly higher rate we report in comparison with these prior studies.

Reoperation rates at long-term time points following DRF have been previously described. Li et al, ⁸ in a retrospective review of 1175 DRF treated with volar locking plate, reported 5.8% (68 of 1175) of patients who required a secondary procedure at a median follow-up of 6 months. In a retrospective study evaluating long-term complications following 576 DRF fixed with volar locking plate performed by orthopedic trainees and attending physicians, Thorninger et al ¹⁰ found an overall reoperation rate of 10.4% (60 of 576) after a minimum of 2-year follow-up; however, reoperation time from index procedure is not reported. Both Esenwein et al, ¹⁵ at an average follow-up of 13 months, and Sirnio et al, ¹⁸ at an average follow-up of 4.3 months, describe a revision surgery rate of 10%. A recent systematic review analyzing the incidence of complications following volar plating of DRF found the overall reoperation rate due to major complication to be 5%. ¹⁶ Ultimately, it is possible that these studies suffer from heterogeneity of time points and thus capture both early-term and mid-late-term complications.

The most commonly cited indication for repeat surgical intervention after DRF is median nerve compression.^{8,14,15,17,19} A single-institution respective study of 647 DRF patients by DeGeorge et al ¹⁷ reported a 90-day reoperation rate of 0.57% (37 of 647), of which 18 were open carpal tunnel release. Li et al ⁸ also reported that 27.8% (n = 19/68) of URTO following DRF were performed for carpal tunnel release. These findings are consistent with our results as well.

In our reoperation cohort, we also found that a substantial number (nearly half) of patients with URTO did so because they required revision for implant-related complications including loss of fixation. Looking at overall cases, our series demonstrated a hardware complication rate requiring URTO to be less than 1%. However, a review performed by Bentohami et al ²⁰ indicated the rate of screw or plate-related complications requiring reoperation between 6 and 24 months to be between 3% and 6%. It is unclear why our rate of hardware complications is so low. One possibility is our exclusion of planned reoperations for hardware removals, such as wrist-spanning bridge plates.

Complications after DRF that necessitate a return to the OR have been shown to occur at varying short-term time periods following index surgery. In our study, we found that the most common reason for URTO within the first 30 days was due to loss of fixation. Soong et al ²¹ describe similar findings, with 7 (58%) of 12 patients with early complications after DRF volar plating developing loss of fixation requiring reoperation. Also, the development of carpal tunnel syndrome occurred throughout the 90-day period consistent with previously published reports, as our study included both acute and secondary cases of carpal tunnel syndrome. ²² Hardware complications (8 of 9) and tendon complications (3 of 4) requiring reoperation were more likely to occur after the initial 30 days following fixation. This indicates that 30 days may be inadequate to capture complications occurring during the healing phase of the postoperative period.

Our analysis indicates that increased age was significantly associated with higher URTO, although the magnitude of this difference is not likely to be clinically significant. In their study of complications following volar plate fixation of DRF, Sirnio et al ¹⁸ reported an increased risk of plate-related secondary operations in patients aged <40 years compared with those aged >40 years. However, the authors attribute this finding to the likelihood of younger, working-age patients having a lower tolerance toward irritation and having higher functional demands of the arm. In addition, their study included patients younger than 18 years of age. Mosenthal et al ¹⁶ found age and tobacco use to be correlated with higher risk of complications following DRF surgery. These 2 studies examined incidence of all complications rather than those complications in particular that required URTO. Contrary to our hypothesis, we did not find BMI to be associated with URTO.

The results of our study indicate that patients who undergo URTO demonstrate a difference in function at final follow-up compared with patients who do not need a second surgery. We found a difference of 17.5 points on QuickDASH scores between the 2 groups, which indicates significant functional impairment in the reoperation group. This difference meets the minimal clinically important difference values for the QuickDASH questionnaire, which have been reported to be from 6.8 to 14 points.^23-26

There are several strengths to our analysis. We evaluate the rate of reoperation occurring within 90 days within a large cohort of patients undergoing DRF ORIF. This time point therefore includes complications that occur beyond the early postoperative period. We report all etiologies for URTO, in addition to commonly reported complications resulting in reoperation, and have reported the time between surgeries for all reoperations. Our analysis includes functional outcomes of patients who underwent an unplanned surgery and compares long-term function with a similar cohort who did not require a second procedure.

This study has several limitations. First, the study has the inherent limitations of a retrospective study. Second, radiographic outcomes were not assessed to determine radiographic alignment, asymptomatic hardware complications, or bony union. Third, fracture patterns were not specifically assessed, and more complex, comminuted, or intra-articular fractures may have increased risk of complication in comparison with more simple patterns. Fracture type and method of fixation were not analyzed, which may have altered our results. It is also possible that there were patients who did undergo URTO at an outside institution and would not have been evaluated in our review. We would expect the incidence of this to be relatively low. For patients who did not undergo unplanned reoperation, we did not assess the length of follow-up, and patients who had incomplete follow-up at 90 days may have been included in the study. In addition, this study does not include late complications occurring past 90 days, which may have accounted for a considerable amount of reoperations that we did not identify. Although our study was sufficiently powered to detect differences in QuickDASH scores, it may not be sufficiently powered to detect significant differences in other variables for URTO. Finally, the need for URTO was based on the judgment of the attending surgeon rather than any specific diagnostic criteria. The threshold for URTO may differ between surgeons, a factor which we feel improves the generalizability of our findings.

In conclusion, the most common indications for URTO within 90 days of DRF ORIF were loss of fixation and neurologic symptoms. Patients who underwent unplanned surgery following DRF reported lower postoperative functional outcome scores than patients who did not require a second surgery. Surgeons should use strategies to try to minimize potential for early URTO. This includes careful neurologic assessment preoperatively to help identify patients at risk of development of carpal tunnel syndrome. Intraoperatively, risk of hardware-related complications may be decreased by ensuring appropriate plate positioning, maximizing strength and quality of fixation, and minimizing screw prominence.