Physical Performance Level and Patient-Reported Outcomes in Female Patients with Distal Radius Fracture
Article information
Abstract
Background
This study aimed to evaluate the influence of physical performance level on patient-reported outcomes after surgery for distal radius fractures (DRF).
Methods
We retrospectively reviewed 157 women with DRF who underwent surgery and completed the short physical performance battery (SPPB) within one month of trauma between January 2019 and August 2022. Patient-reported outcomes were assessed one year postoperatively using the disabilities of the arm, shoulder, and hand (DASH) and patient-rated wrist evaluation (PRWE) questionnaires. Multivariate linear regression analysis was conducted using patient characteristics, fracture type, treatment-related factors, and SPPB results to evaluate the factors associated with patient-reported outcomes.
Results
Multivariate linear regression model revealed that dominant hand involvement (B=7.329; 95% confidence interval [CI], 2.901–11.757; P=0.001) and lower SPPB scores (B=−2.145; 95% CI, −3.194 to −1.096; P<0.001) were significantly associated with higher DASH and PRWE scores.
Conclusions
Physical performance level evaluated using the SPPB was significantly associated with poor clinical outcomes of DRF after surgery. Physicians should implement a systematic approach to enhance physical performance along with appropriate fracture treatment to improve clinical outcomes following surgery for DRF.
INTRODUCTION
Distal radius fractures (DRF) are the most common upper-extremity osteoporotic fractures.[1] Since DRF occurs earlier than other osteoporotic fractures,[2] related treatment outcomes influence the quality of life relatively longer than other osteoporotic fractures. In addition, recently developed technologies require more delicate hand functions in the daily lives of older adults.[3] Several studies have revealed that age and radiological parameters, including fracture type, socioeconomic status, and pain incongruity, are related to treatment outcomes after DRF. [4–8] However, few studies have analyzed the relationship between physical performance levels and treatment outcomes after DRF.
The short physical performance battery (SPPB) is a well-established functional assessment tool used to screen and assess frailty and sarcopenia.[9] SPPB includes tests for balance, gait speed, and lower-limb strength. It has been widely used to assess physical performance levels in elderly patients because it is characterized by a comprehensive assessment, sensitivity to change, and ease of administration.[10,11] SPPB score is the strongest predictor of physical function at 3 and 12 months after a hip fracture,[12] is significantly associated with the risk of falls.[13] Furthermore, lower SPPB scores were associated with re-hospitalization risk,[14] and all-cause mortality in elderly patients.[15]
Grip strength, the major component of the diagnostic criteria for sarcopenia,[16] is related to physical performance level in elderly patients.[17] However, it could not be measured immediately after DRF and changed dynamically until four years after DRF in the involved hand.[18] Although the grip strength of the non-involved hand could be measured in patients with DRF, it could not correctly reflect the patient’s status if the dominant hand was injured. Therefore, the evaluation of physical performance levels using the SPPB is more meaningful in patients with DRF than in those with other osteoporotic fractures. This study aimed to evaluate the influence of physical performance levels on patient-reported outcomes after surgery for DRF.
METHODS
1. Study population
The study protocol was approved by our Institutional Review Board. This study was conducted at a single referral training hospital in a metropolitan area. We retrospectively reviewed consecutive female patients with DRF who were treated with open reduction and internal fixation (ORIF) by a single surgeon between January 2019 and August 2022 and met the following inclusion criteria: (1) age equal to or more than 18 years; (2) acute DRF caused by trauma; (3) complete the physical performance level evaluation using SPPB within 1 month after trauma; (4) a dual energy X-ray absorptiometry (DXA; Lunar Prodigy Advance; GE Healthcare, Madison WI, USA) performed within six months before or after the DRF; (5) followed more than 12 months. We excluded patients with multiple traumas or fractures, including bilateral DRF, which could interfere with correct SPPB measurements. Finally, 157 patients were enrolled in the study.
2. Intervention
All surgeries were performed by a single fellowship-trained orthopedic surgeon. The patients underwent surgery with a standard volar approach to the distal part of the radius, followed by ORIF using a single-type volar locking plate (Synthes, Oberdorf, Switzerland) under a brachial plexus block. A suction drain remained at the operation site until postoperative 2 days. Until postoperative 4 weeks, a volar short-arm splint was applied. Active-assisted wrist range of motion (ROM) exercises were started at postoperative 4 weeks. Full activity was allowed three months postoperatively after confirming fracture union.
The SPPB comprises three tests: standing static balance in three positions, lower limb strength, and power assessed by getting up and sitting on a chair, and walking speed at a normal pace.[11] Since each test was scored from 0 (inability to perform the task) to 4 points (best test performance), the total score ranged from 0 to 12, with a high score indicating better performance. As this instrument assesses physical performance by measuring lower limb function, it may be applicable to patients with acute upper extremity trauma. We evaluated the SPPB at least 2 weeks after the operation, but not after 1 month, to minimize bias related to DRF-induced pain and discomfort. The SPPB measurements were conducted by a single research nurse in a separate space. For elderly patients who did not understand the measurement process, our research nurses showed them by themselves.
3. Evaluations
Demographic information and fracture characteristics, including fracture type, trauma type, and time from trauma to surgery, were assessed. The fracture type was classified according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification. The trauma type was divided into minor trauma, such as a fall from a standing height, and major trauma, such as injuries caused by a motor vehicle accident or a fall from a ladder or stairs. At our institute, bone mineral density (BMD; g/cm2) was measured in the lumbar spine, femoral neck, trochanter, and total hip using DXA scans (GE Healthcare), whereas Encore software (version 11.0; GE Healthcare) was used for analysis. For lumbar spine BMD, the L1 to L4 value was used for the analysis. We used the lowest T-score of the spine (the mean value from at least two evaluable vertebrae from L1 to L4) or femur (the T-score of the neck, trochanter, and total femur in the unfractured femur) to assess osteoporosis.
The grip strength of both hands; ROM of both wrists; visual analog scale (VAS) for pain at the injury site; disabilities of the arm, shoulder, and hand (DASH); and patient-rated wrist evaluation (PRWE) questionnaires, comprising symptom and functional disability scores, were used to assess the symptoms and functional disability of the hand and wrist. All measurements were performed 3 months and 1 year postoperatively. Grip strength was standardized as a percentage of the mean value of the general population.[19] The wrist ROM was measured for flexion/extension/supination/pronation, with the total ROM used for the assessment. The wrist ROM at the injury site was adjusted to that of the contralateral side. Higher pain VAS, DASH, and PRWE scores indicated more pain or severe symptoms.
4. Statistical analysis
All statistical analyses were performed using IBM-SPSS version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including means with 95% confidence intervals (CIs) and percentages, were calculated. Differences in clinical outcomes between the periods were compared using paired t-tests. Pearson’s correlation coefficient was used to evaluate the association between age and SPPB scores. The correlation coefficients were interpreted using the scale proposed by Evans [20]: 0.00–0.19 for very weak, 0.20–0.39 for weak, 0.40–0.59 for moderate, 0.60–0.79 for strong, and 0.80–1.00 for very strong. Univariate analysis was conducted using linear regression between independent variables (patient baseline characteristics, fracture type, treatment-related factors, lowest T-scores, and SPPB results) and dependent variables (DASH and PRWE-Total scores at 3 months and 1 year postoperatively). All variables used in the univariate analysis were used in a multivariate linear regression model (stepwise selection method) to identify associations with the DASH and PRWE-Total scores at 3 months and 1 year postoperatively. Additional analyses were performed on the two subgroups. One subgroup included only patients with the best SPPB scores, and the other included patients without the best SPPB scores. A multivariate linear regression model (stepwise selection method) was estimated for each group to identify associations with the DASH scores at 1 year postoperatively. All dichotomous and trichotomous variables were analyzed using a dummy code. Statistical significance was set at a P value less than 0.05.
RESULTS
The mean age of the 157 enrolled patients was 65.4±7.5 years (range, 35–80 years). The mean body mass index was 23.8±3.6 kg/m2 (17.6–42.6 kg/m2), and the dominant hand was involved in 79 patients (50.3% of 157 patients). The mean time to operation after trauma was 6.1±4.0 days (range, 0–23 days), and 50 patients experienced major trauma (31.8% of 157 patients). According to the AO/OTA classification, 21, 36, and 100 fractures were classified as Types A, B, and C, respectively. The mean SPPB scores of enrolled patients was 10.5±2.1 (range, 3–12). Seventy-three patients (46.5% of 157 patients) had the best scores, whereas two patients (1.3% of 157 patients) had the worst scores. Figure 1 shows the distribution of the patients’ SPPB scores. SPPB scores were significantly correlated with age, but the strength of the correlation was weak (r=−0.305; P<0.001) (Fig. 2).
The distribution of short physical performance battery (SPPB) scores in enrolled patients.
Correlation between age and short physical performance battery (SPPB) scores.
Radiologic fracture union was achieved in all patients within 3 months postoperatively. All patients were followed up and completed postoperative evaluations at 3 months, but nine patients did not visit the clinic and completed the functional questionnaire by telephone at 1 year postoperatively. The clinical outcomes at 3 months and 1 year after surgery are shown in Table 1. All clinical outcomes, including wrist ROM, grip strength, pain, and DASH and PRWE total scores, improved significantly between 3 months and 1 year postoperatively (P<0.001 for all variables).
The comparisons of the clinical outcomes between postoperative 3 months and 1 year
The results of univariate and multivariate linear regression analyses for predictors of DASH and PRWE Total scores at 3 months postoperatively are described in Table 2 and 3, respectively. In the multivariate linear regression model, dominant hand involvement (B=11.959; 95% CI, 6.529–17.390; P<0.001) and lower SPPB scores (B=−2.068; 95% CI, −3.355 to −0.782; P=0.002) were significantly associated with higher DASH scores. In the same analysis, only the lower SPPB score (B=−1.693; 95% CI, −3.092 to −0.294; P=0.018) was significantly associated with the higher PRWE-total score.
Univariate and multivariable linear regression analyses for the predictors of disabilities of the arm, shoulder, and hand scores at postoperative 3 months
Univariate and multivariable linear regression analyses for the predictors of patient-rated wrist evaluation total scores at postoperative 3 months
The results of univariate and multivariate linear regression analyses for the predictors of DASH and PRWE Total scores at 1 year postoperatively are described in Table 4 and 5. In a multivariate linear regression model, dominant hand involvement (B=7.329; 95% CI, 2.901–11.757; P=0.001) and lower SPPB scores (B=−2.145; 95% CI, −3.194 to −1.096; P<0.001) were significantly associated with higher DASH scores. In the same analysis, dominant hand involvement (B=5.718; 95% CI, 1.126–10.310; P=0.015) and lower SPPB scores (B=−2.007; 95% CI, −3.095 to −0.920; P<0.001) were significantly associated with higher PRWE-Total scores.
Univariate and multivariable linear regression analyses for the predictors of disabilities of the arm, shoulder, and hand scores at postoperative 1 year
Univariate and multivariable linear regression analyses for the predictors of patient-rated wrist evaluation total scores at postoperative 1 year
In subgroup analysis, dominant hand involvement (B= 6.854; 95% CI, 2.300–11.407; P=0.004) and major trauma (B=−8.454; 95% CI, −13.344 to −3.564; P=0.001) were significantly associated with higher DASH scores at postoperative 1 year in patients with best SPPB scores. In addition, lower SPPB scores (B=−2.844; 95% CI, −4.536 to −1.152; P=0.001) were significantly associated with higher DASH scores at postoperative 1 year in patients without best SPPB scores (Table 6).
Multivariable linear regression analyses for the predictors of disabilities of the arm, shoulder, and hand scores at postoperative 1 year in patients with best short physical performance battery scores and those without best short physical performance battery scores
DISCUSSION
Instead of fracture severity, trauma type, and bone quality, lower physical performance level, which was evaluated using the SPPB, and dominant hand involvement were significantly associated with poor patient-reported outcomes in women after ORIF for DRF at postoperative 3-month and 1-year in this study.
Although the physical performance levels of patients with DRF have been explored, most studies have focused on decreased physical performance. Hakestad et al.[21] showed that patients with healed wrist fractures scored significantly lower on quadriceps strength, dynamic balance, and physical capacity than matched controls. Cho et al.[22] compared the physical performance levels between patients with DRF and age-matched controls and revealed significantly poor chair standability in the SPPB and grip strength in patients with DRF. Physical performance level has recently been suggested as a criterion for the decision regarding surgery for DRF. In a study evaluating physical performance levels using a rapid assessment of physical activity, Jayaram et al.[23] suggested that surgeons should emphasize the patient’s baseline activity level to guide surgical decisions for DRF in older adults. Considering our results, operative treatment may be conservatively applied in patients with DRF and poor physical performance levels. [24] In addition, clinicians should be aware of the possibility of poor postoperative clinical outcomes in this cohort.
The association between the physical performance level and patient-reported outcomes after DRF fixation can be explained in several ways. After DRF fixation, early rehabilitation and mobilization of the involved hand and wrist are important for functional recovery. Generally, physically active patients are more motivated and tend to regain strength, mobility, and function faster than less motivated and less active individuals.[25] SPPB reflects the general muscle status of an individual and suggests a cut-off value for sarcopenia diagnosis.[26,27] Therefore, individuals with impaired SPPB performance may have low grip strength. [28] Since reduced grip strength after DRF complicates the use of the hands during many daily activities,[29] impaired SPPB could be associated with poor patient-reported outcomes after DRF fixation. The SPPB may not directly reflect the functional status of the upper extremity because it focuses on the measurement of lower extremity function. However, previous studies have revealed that physical function tests, including the SPPB, which are designed to assess a specific domain of an individual, can adequately capture a person’s physiological status.[30,31]
Dominant hand involvement is significantly associated with poor patient-reported outcomes after ORIF for DRF. This result is consistent with those of the previous studies. Hosokawa et al.[32] reported that dominant-hand involvement significantly worsened the QuickDASH score 1 year after DRF fixation. Ratajczak et al.[33] reported that injury to the right side, which is usually the dominant hand in the general population, could affect the assessment of the quality of life in patients with DRF after conservative treatment. As the DASH and PRWE questionnaires measure patient-reported outcomes and not physician-reported outcomes, even if patients have the same functional deficit, the functional deficit on the dominant side might be felt more sensitively by the patients.
Our study had several limitations. First, because we only collected data from patients who underwent surgery, the results cannot be generalized to patients who received conservative treatment after DRF. Second, we could not consider other potential variables that might impact the clinical outcomes in DRF, including comorbidities, radiologic parameters other than fracture severity, and the patient’s psychological status, owing to the retrospective nature of the study.[34] Finally, the participants were treated at a referral hospital; therefore, they might have experienced more severe injuries and comorbidities.
In conclusion, the physical performance level evaluated using the SPPB was significantly associated with poor clinical outcomes after ORIF for DRF. Physicians should implement a systematic approach to enhance physical performance, along with appropriate fracture treatment, to improve clinical outcomes following ORIF for DRF. Furthermore, physicians should be aware of the possibility of poor clinical outcomes in patients with low physical activity levels.
Notes
Funding
This work was supported by the Korea Medical Device Development Fund grant conferred by the Korean government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, the Ministry of Food and Drug Safety) (KMDF_PR_20200901_0039).
Ethics approval and consent to participate
The study protocol conformed to the ethical guidelines of the World Medical Association Declaration of Helsinki and was approved by the Institutional Review Board of Asan Medical Center (IRB No. 2023-1320).
Conflict of interest
No potential conflict of interest relevant to this article was reported.