Koval Kenneth J, Harrast John J, Anglen Jeffrey O, Weinstein James N
Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA.
J Bone Joint Surg Am. 2008 Sep;90(9):1855-61. doi: 10.2106/JBJS.G.01569.
During the administration of the oral (Part II) examinations for the American Board of Orthopaedic Surgery over the past nine years, it has been observed that orthopaedic surgeons are opting more often for open treatment as opposed to percutaneous fixation of distal radial fractures. Evidence to support this change in treatment is thought to be deficient. The present study was designed to identify changes in practice patterns regarding operative fixation of distal radial fractures between 1999 and 2007 and to assess the results of those treatments over time.
As a part of the certification process, Part II candidates submit a six-month case list to the American Board of Orthopaedic Surgery. In the present study, we searched the American Board of Orthopaedic Surgery Part II database to evaluate changes in treatment over time and to identify available outcomes and associated complications of open and percutaneous fixation of distal radial fractures. All distal radial fractures that had been treated surgically over a nine-year period (1999 to 2007) were reviewed. The fractures were categorized according to fixation method with use of surgeon self-reported surgical procedure codes. Comparisons of percentage treatment type by year were made. Utilization was analyzed by geographic region, and open and percutaneous fixation were compared with regard to complications and outcomes as self-reported by candidates during the online application process.
The proportion of fractures that were stabilized with open surgical treatment increased from 42% in 1999 to 81% in 2007 (p < 0.0001). Although the differences were small, surgeon-reported outcomes revealed that a higher percentage of patients who had been managed with percutaneous fixation had no pain and normal function but some deformity as compared with patients who had had open treatment. Patients who had been managed with percutaneous fixation had a higher overall complication rate (14.0% compared with 12.3%; p < 0.006) and a higher rate of infection (5.0% compared with 2.6%; p < 0.0001) than those who had been managed with open treatment. Patients who had had open treatment had a higher rate of nerve palsy and/or injury (2.0% compared with 1.2%; p = 0.001). No other differences in the reported complication rates were found between the two techniques.
A striking shift in fixation strategy for distal radial fractures occurred over the past decade among younger orthopaedic surgeons in the United States. These changes occurred despite a lack of improvement in surgeon-perceived functional outcomes.
在过去九年美国骨科医师协会口试（第二部分）的管理过程中，观察到骨科医生相较于桡骨远端骨折的经皮固定，更常选择切开治疗。支持这种治疗方式改变的证据被认为是不足的。本研究旨在确定1999年至2007年间桡骨远端骨折手术固定的实践模式变化，并评估这些治疗随时间推移的结果。
作为认证过程的一部分，第二部分的考生向美国骨科医师协会提交一份为期六个月的病例清单。在本研究中，我们搜索了美国骨科医师协会第二部分数据库，以评估治疗方式随时间的变化，并确定桡骨远端骨折切开和经皮固定的可用结果及相关并发症。回顾了在九年期间（1999年至2007年）所有接受手术治疗的桡骨远端骨折。根据固定方法，利用外科医生自行报告的手术操作代码对骨折进行分类。对各年份治疗类型的百分比进行比较。按地理区域分析利用率，并比较切开和经皮固定在考生在线申请过程中自行报告的并发症和结果。
切开手术治疗稳定骨折的比例从1999年的42%增加到2007年的81%（p < 0.0001）。尽管差异较小，但外科医生报告的结果显示，与接受切开治疗的患者相比，经皮固定治疗的患者中无痛且功能正常但有一些畸形的比例更高。经皮固定治疗的患者总体并发症发生率更高（14.0% 对比12.3%；p < 0.006），感染率更高（5.0% 对比2.6%；p < 0.0001）。接受切开治疗的患者神经麻痹和/或损伤发生率更高（2.0% 对比1.2%；p = 0.001）。两种技术在报告的并发症发生率方面未发现其他差异。
在过去十年中，美国年轻骨科医生对桡骨远端骨折的固定策略发生了显著转变。尽管外科医生认为功能结果没有改善，但这些变化仍然发生了。
