The ageless approach: Nonoperative mastery competes head‐on with surgery for elderly distal radius fractures

The aim of the current study is to compare the clinical outcomes of cast immobilization (CI) versus surgical treatment after 1 year for distal radius fractures (DRFs) in the elderly population. The cohort included patients aged 70–89 who suffered an acute, closed, and displaced DRF and who were treated conservatively or surgically at our clinic between August 2018 and January 2022. Those who had pathological fractures, open fractures, concomitant ulna fractures (except ulna styloid fractures), were not between the ages of 70 and 89, or refused to participate were excluded from the study. The study gathered data on patient demographics, initial radiological measurements, clinical measurements after 1 year, treatment models employed, and rates of complications. Of the total number of patients (276), CI was used on 77.2% (213), whereas the other 25 had volar‐locked plates (VLP), 25 received external fixators with percutaneous pinning (EFPP), and 13 had isolated percutaneous pinning (IPP). 19 of 276 individuals had complications, with Complex Regional Pain Syndrome and Carpal Tunnel Syndrome being the most often documented. EFPP resulted in significantly higher Disability of the Arm, Shoulder, and Hand (DASH) score values than VLP and IPP at the 1st postoperative year (p < 0.05). No statistically significant difference was found between the DASH score and ROM values at the 1st postoperative year for patients who received CI versus those who underwent surgery (p > 0.05). In the first postoperative year, CI still retains its validity and performs similarly to surgery for DRFs in older individuals. VLPP and IPP methods outperformed EFPP surgeries.

0][11] Although cast immobilization (CI) was the standard of care for these fractures for many years, the introduction of volar locked plating (VLP) in the early 2000s led to an increase in the number of elderly patients undergoing surgery for DRFs. 12[14][15] Conservative treatment has often been used for older patients due to the widespread belief that they have fewer functional requirements. 12Unfortunately, the expanding older demographic and their increased activity levels over the last few decades have contributed to a rising prevalence of DRFs. 16The American Academy of Orthopaedic Surgeons' most current guidelines regarding DRFs are unclear on whether or not to suggest surgical intervention for older individuals. 17In spite of this, conservative treatment of DRFs continues to be the preferred option among senior individuals, with accumulating data demonstrating its non-inferiority compared with operative treatment. 12,18,19Due to the high risk of complications and high expense of operative intervention, nonsurgical care of DRFs in elderly individuals may be a preferable option.We hypothesized that traditional CI yields clinical results at 1 year that are almost equivalent to surgical therapies.Hence, the aim of the current study is to compare the clinical outcomes of conservative treatment versus surgical treatment after 1 year for DRFs in the elderly population.

| METHODS
The current study was a retrospective analysis of a single-centered database of DRFs.The study was approved by the local institutional ethical review board.In accordance with the recommendations of the

| THE DISABILITY OF THE ARM, SHOULDER, AND HAND
The DASH is considered a patient-reported outcome measure since it asks for an individual's subjective assessment of their recovery from an upper-extremity injury. 21The injured person must evaluate their condition by responding to a 30-item questionnaire on their level of pain and capacity to do various tasks.Seven questions are classified as measuring pain intensity, which belongs to the International Classification of Functioning, Disability, and Health Framework (ICF) 22 topic of Body Function/Structure, and 23 items are connected to the person's capacity to participate in various activities, which belongs to the ICF topic of Activity/Participation.For evaluating a person's function and impairment after a DRF, the DASH can be relied on as a valid and trustworthy patient-reported outcome measure. 21,23,24Its great sensitivity to alteration in measuring function after a DRF has been confirmed by a number of studies, and there is also evidence that it correlates with assessments of wrist functionality and ROM impairments. 25

| RANGE OF MOTION
ROM, as assessed using a goniometer, seems to be a performancebased outcome measure and a practical norm for measuring both wrist and hand ROM after a DRF. 26,27The Body Function/Structure subdomain of the ICF is the only one that ROM can measure, but after a DRF, ROM is a reliable assessment instrument for evaluating both wrist and hand functionality. 21A lower DASH score has been linked to a lack of extension and ulnar deviation, as documented by researchers. 28

| SURGICAL PROCEDURE AND FOLLOW-UP
Sixty minutes before the surgical incision, 1 g of parenteral cefuroxime sodium was administered to each patient.Every procedure was performed under either general or regional anaesthesia.All surgeries were conducted with the patient supine on the operating table, and either a closed or open reduction was performed via fluoroscopic assistance by the same team of five surgeons with a combined 5 years of expertise in orthopaedic trauma.Neither an autogenous bone graft nor an allograft was necessary for any of the individuals.On their initial postoperative day, patients began active and passive finger and elbow exercises.Three weeks, 6 weeks, and 6 months following surgery, routine images were obtained.In the 1st-year follow-up, the ROM values of the patients were measured by goniometry, and the patients were asked to fill out the DASH questionnaire.The presence of complications was investigated using clinical and radiological parameters.

| VOLAR LOCKED PLATING
A modified volar Henry approach via the space between the flexor carpi radialis and the radial artery was employed to treat all VLP fractures.Anatomical VLPs with locking screws (TST Medical Devices, Istanbul, Turkey ® ) were employed.Patients who underwent VLP had their sutures and short arm splints removed after 2 weeks.

| ISOLATED PERCUTANEOUS PINNING
Following the reduction of the fracture under fluoroscopic control, one or more K-wires of 1.5 or 2 mm in diameter were implemented medially.After making sure the fracture was stable, a short-arm splint was put on.IPP patients had their short arm splints removed 2 weeks later, were given clearance to begin exercising, and had their K-wires removed by the end of the sixth week.Furthermore, the one-way analysis of variance (ANOVA) test was utilized to compare normally distributed parameters across groups, while the Tukey HDS and LSD tests were employed to identify the group responsible for the observed differences.Using Pearson correlation analysis, the relationships between parameters with a normal distribution were analysed.The significance level was determined at the p < 0.05 level.

| RESULTS
There were a total of 276 cases evaluated, ranging in age from 70 to 89, with a mean age of 77.25 ± 4.38 years (Table 1).The vast majority of the individuals (77.2%; 213) were treated with CI, whereas 25 received VLP, 25 received EFPP, and 13 had IPP.In the current study, the mean DASH score at the 1st postoperative year was 45.52 ± 3.63 (Table 1).Table 1 displays the patients' postoperative 1st-year wrist ROM scores as well as their initial radial height, radial inclination, and volar tilt measurements.Additionally, 19 of 276 individuals had complications, with Complex Regional Pain Syndrome (CRPS) (7 patients) and Carpal Tunnel Syndrome (CTS) (6 patients) being the most often documented.A 77-year-old female patient was diagnosed with an EPL tendon rupture 4 months after VLP implementation, and the tendon was primarily fixed.Five patients were identified as having malunions, and revision surgery was recommended for those deemed appropriate.
A one-way ANOVA was employed to compare the four treatment groups in terms of some initial radiological parameters; pairwise comparisons revealed that the CI group's initial radial inclination values were significantly higher than those of the VLP and EFPP groups (Table 2).
The study compared four treatment modalities based on DASH score and ROM values at the 1st postoperative year and found that EFPP treatment resulted in significantly higher DASH score values than VLP and IPP treatments (p 1 : 0.011; p 2 : 0.009; p < 0.05) (Table 2).
No statistically significant difference was found between the DASH score and ROM values at the 1st postoperative year for patients who received CI versus those who underwent surgery (p > 0.05).No YALIN ET AL.
| 143 complications were seen in male patients, while several were seen in female patients (Table 3).There was no statistically significant relationship between DASH and ROM values at 1 year postoperatively, as measured by Pearson correlation analysis (p > 0.05) (Table 4).
Most notably, after a year, CI did not perform worse than any of the three different surgical procedures assessed in the current study on the DASH scores and ROM measurements of elderly participants.
The current study is one of very few that directly compares four distinct DRF treatment options for the elderly.Moreover, our results indicate that if surgery is opted for the treatment of geriatric DRFs, VLP and IPP seem to be the most beneficial surgical approaches in terms of functional outcomes, as they demonstrated a lower mean DASH score compared to the EFPP.
In an in-depth review of the literature by Diaz-Garcia et al., 29 minor and clinically irrelevant variations in clinical results were found among CI, VLP, and EFPP for distal radial fractures in the elderly.
Their prevalence of reoperation following VLP was greater than that of the other subgroups.The vascular and mechanical mechanisms of EPL tendon rupture after VLP treatment were investigated in a 2006 study by Eric et al. 30 Although the number of patients who underwent VLP was relatively limited in our study, one patient experienced an EPL tendon rupture as a complication.Malunion was identified in only 5 of the 213 patients who underwent CI, and when osteotomy was recommended, none of these patients consented to surgery.It is difficult to explore fracture outcomes in elderly patients due to the fact that comorbidities obstruct participation in investigations.Several individuals refused to take part due to other conditions or mentioned their advanced age as the primary cause.
In a randomized controlled trial conducted by Arora et al., 6 nonoperative therapy was compared to treatment with VLPs in older individuals.Their results supported surgical treatment in the immediate postoperative period but not at the 12-week follow-up, which is in line with the current study.Egol et al. 8 found that surgical treatment generated improved radiographic results but equal functional capacity 2 years later, providing reliability to the current study's findings.In contrast to the present study, Jenny et al. 31 found that patients in the VLP group had better functional outcomes than those in the CI group at 3 and 12 months after surgery.Furthermore, grip strength was also assessed, which was not the case in the current study.Grip strength values were higher in the VLP group than the CI group at the 3-month mark, but no significant difference was identified at the 12-month mark.
The current study discovered that, when comparing DASH scores 1 year after surgery, EFPP surgery scored higher than VLP and IPP.The primary benefits concerning EFPP include its simplicity of use, reduced risk of peroperative complications, maintenance of height and alignment, minimum surgical exposure, and the ability to accomplish and maintain reduction via fluoroscopy using ligamentotaxis. 32Nevertheless, there are drawbacks to using EF to treat DRFs.
These include pin-tract infections, over-distraction, stiffness of the joints, limitations in digit motions, diminished grip strength, superficial radial nerve damage, and chronic regional pain syndrome (CRPS).
Difficulty in managing these problems, which have a documented occurrence rate between 6% and 60%, has an unfavorable impact on functional outcomes. 33Similarly to the current study, clinical outcomes in the EFPP group were shown to be poorer than those in the VLP group at the 2-year mark, according to a 2018 study by Duramaz et al. 34  | 145 literature.The study found that CI was administered to the majority of patients, regardless of the severity of their fracture.Especially with DRFs in the elderly, we believe that determining the most suitable kind of treatment that may be administered to the patient is the most significant problem, rather than focusing on the X-ray results.
The data reported here are restricted, as is the case with any study based on a retrospective chart review.First, the information was not In conclusion, when the scores at the 1st postoperative year are analysed, CI therapy still retains its validity and performs similarly to surgical therapies for DRFs in older individuals.When comparing clinical outcomes 1 year after surgery, VLP and IPP procedures stand out among the other surgical choices.There is a requirement for multi-center prospective studies that compare the four types of treatment models using larger patient populations.
hospital's ethical review board, all patients signed an informed consent form.Patients aged 70-89 who suffered an acute, closed, and displaced DRF (both intraarticular and extraarticular) and were treated either conservatively or surgically at our hospital between August 2018 and January 2022 were considered for inclusion in the cohort.Excluded from the study were individuals who had pathological fractures, had open fractures, had concomitant ulna fractures (except ulna styloid fractures), were not between the ages of 70 and 89, or had refused to take part.The information was gathered at the time of admission as well as at subsequent following appointment until the treatment was over.Patient demographics, initial radiological measurements, patient-reported outcome measures like the Disability of the Arm, Shoulder, and Hand (DASH), performance-based outcome measures like ROM after 1 year, types of treatment models, and complication rates were all collected.Patients whose initial emergency room (ER) radiographs were assessed and who were being considered for CI underwent closed reduction and CI with sedation anaesthesia before ER staff took control radiographs.The radiological outcome was assessed based on specific parameters, including dorsal and volar angulation, ulnar variance, radial inclination, radial length or height, and radial shortening, to decide whether the reduction was deemed acceptable or unacceptable.The criteria for an acceptable reduction in the presented instance encompassed a radial inclination of 15 degrees or higher, a dorsal angulation below 15 degrees, a volar angulation below 20 degrees, radial shortening below 5 mm, and a positive ulnar variance below 2 mm. 20When satisfactory results were not obtained in the control graphs, the reduction process was repeated and after talking with the patient and, if necessary, other caretakers, the surgeon in charge decided how to treat the patient.Patient lifestyle, specific needs, mobility, and willingness to take risks and experience discomfort were all discussed before the choice.The surgeon in charge determined which individuals would need surgery and what kind of surgery was required, considering the patient's overall level of activity, the structure of the injury, and the existence of comorbid problems.The surgeon's choice of implant and model determined whether the patient had open reduction and internal fixation with VLPs with a short-arm splint, closed reduction and internal fixation with isolated percutaneous pinning (IPP) with a short-arm splint, or an external fixator with percutaneous pinning (EFPP).

8 |
EXTERNAL FIXATOR WITH PERCUTANEOUS PINNINGA Multiaxial Distal Radius Wrist Fixator (TST Medical Devices, Istanbul, Turkey ® ) was attached to the patient's wrist using 3 or 4 mm Schanz pins, depending on the choice of the operating surgeons.Two Schanz pins were inserted into the second metacarpal and two were inserted in the shaft of the radius in patients who underwent EFPP.Closed reduction and alignment were accomplished utilizing the fixator's distraction feature, and fixation was achieved with 2 mm K-wires.Patients who received an EFPP initiated ROM exercises on the first postoperative day without wearing a splint.Patients had their Schanz pins removed after 4 weeks and their K-wires removed after 6 weeks.9| STATISTICSThe results of the research were analysed statistically via the IBM SPSS Statistics 22 (IBM) program.Using the Shapiro-Wilks test, the conformity of the parameters to the normal distribution was determined when evaluating the study data.During the analysis of the study data, the researchers employed descriptive statistical techniques such as mean, standard deviation, and frequency.
gathered systematically or prospectively.Second, all of the participants in the study were treated at a single tertiary clinic in Elazig, Turkey.Clinician variation in follow-up techniques is another source of variation that undermines consistency.Third, the measurement of patient-reported outcomes is a particular domain where clinical trials involving older people run into challenges.To the best of our knowledge, the extent to which the reliability of patient-reported outcome measure data may vary between young and elderly study subjects is entirely unclear.There have been no verified studies of the DASH questionnaire among the elderly.The DASH survey remains the gold standard for patient-reported outcomes after DRFs in the elderly population due to the lack of alternative validated outcome measures.ROM measurement was utilized since it is the most commonly used performance-based outcome measure.Additionally, the grip strength assessment was not included in our research, which is a significant restriction.Fourth, the assessment of clinical scores among patients during the initial postoperative phase is not conducted.The present study solely took into account the clinical assessments conducted in the first year following the surgical procedure.The study's strength lies in its evaluation of clinical outcomes across four methods of treatment for DRFs in the elderly population.Furthermore, another notable strength is its ability to maintain the validity and popularity of traditional CI for DRFs in the elderly population.

1
The distribution of patients' parameters.Comparative analysis of study variables between different treatment groups.
T A B L E 2 *p < 0.05.
Evaluation of complications by gender.Analysis of the relationship between the DASH score and range-of-motion in the first year after surgery.
38rformance of our surgical team in administering closed reduction casting treatment.Furthermore, the results demonstrate that the decision to employ CI application treatment is not based on the severity of the fracture.Marcus et al.38conducted a study on DRFs in the superelderly, which is the largest and most comprehensive review in the T A B L E 3