The aim of this recent follow-up study was to re-evaluate our cohort of DRF treated with VPF after ten years and to compare the data with the last follow-up as well as with HRQOL data of the norm population. Today, a comprehensive evaluation after surgically treated DRF requires reliable, validated measures of functional and subjective outcomes. It is reported that with improper restoration of DRF patients very likely develope posttraumatic arthritis and poor functional outcome, on the other hand functional outcome and radiographic parameters do not necessarily correlate especially in the elderly and might not influence HRQOL [3–6, 19, 20]. We aimed to evaluate and compare clinical and subjective results after VPF of intra-articular DRF over a ten-year follow-up period. We found that ten years after VPF of intra-articular DRF, patients had good HRQOL compared to norm populations. Good long-term clinical results of operatively treated DRF with varying methods have already been reported [11, 21–23]. The results after VPF are especially promising and seem to be superior to other procedures [7, 8]. There is sufficient data to indicate that VPF has become more popular in recent years. VPF might move towards a status of gold standard method in the treatment of DRF, however data are lacking to show the unique superiority in comparison to other operation methods [4, 5, 7, 24].
However, in the age of evidence-based medicine, health technology assessment (HTA) mandates the full and explicit evaluation not only of efficacy and safety but also of every other aspect that impacts on society (e.g. economic aspects) [15]. Furthermore, patients are demanding effective treatments that also yield the maximum HRQOL postoperatively. As a decrease in HRQOL after trauma is a major reason why patients seek surgical treatment, the patient has high expectations for resuming normal activities and to returning to work after surgery. The soon return to work is also an interest shared by health insurers and ultimately by the general public as well. It has become increasingly clear that priority should be given not only to clinical outcomes but also to the patient’s perception of HRQOL [10, 16, 25]. HRQOL is not measured directly but rather indirectly with measurement scales derived from questionnaires. We chose the SF-36 over other available instruments based on its widespread use in orthopedics and the strong evidence of validity [14]. The SF-36 is considered an attractive method for assessing HRQOL because of its brevity, rigorous psychometric development, and patient acceptance [14]. In terms of DRF very few studies included HRQOL outcomes as study end points [16] and there are no such data for VPF of intra-articular DRFs in the long term.
In the present study, the SF-36 was administered for self-completion by patients two, six and ten years postoperatively. The final follow-up results of PCS and MCS in our study did not show any statistically significant changes compared to the follow-ups at two and six years postoperatively. The results of the SF-36 questionnaire at the two-, six- and ten-year follow-ups compared with sex- and age-matched norms for the United States population and with data of an Austrian control group showed no significant changes in the PCS and MCS but there was a significant difference for the MH subscale (p = 0.045). In this subscale we found deterioration for our ten-year follow-up results compared to the Austrian norm, but no difference in comparison with the US norm population. The reason for this might ultimately be found in differences between the two health care systems. There was a decrease over time for the VT subscale that can be explained by the aging of our cohort. We found a positive correlation between VT and age but it may be assumed that general vitality will tend to deteriorate with increasing age. There were no significant differences in any other subscale of the SF-36 compared to the follow-up six years after surgery. There was a significant positive correlation between the MCS of the SF-36 and DASH scores, showing that patients with better DASH scores had better MCS results.
The overall results of the DASH score did not show significant differences within the follow-up period. However, with a median score of 0.8 (IQR 25-75; 0.0-30) at the ten-year follow-up the DASH score improved from 1.7 (IQR 25-75) at the six-year follow-up and almost reached its level for two years after the surgery, reflecting a low degree of upper extremity disability and symptoms. Similar results have been described in the literature [22, 26]. Care must be taken that there might be a floor effect with the use of scoring systems that underestimates worse results. Upmost attention must be given when comparing DASH scores as they usually have a nonparametric distribution, due to the construction of the score. It is difficult to compare studies using the DASH as there are so few studies with a ten-year follow-up period.
The DASH score results and the Gartland and Werley score correlated over the ten-year period, showing that patients with higher DASH scores presented poorer functional outcomes.
Over the ten-year long study period we found that both the SF-36 and the DASH score were easy to process although it was difficult to motivate patients to participate in the study ten years after the operation. Fernandez et al. [27] encountered similar difficulties and concluded that the SF-36 and the DASH questionnaires are too long and too complicated to administer, in spite of their general acceptance as described above. Abramo and his group argue that the DASH requires substantial administrative work to ensure an acceptable frequency of replies [26].
In a recent systematic review, Van Son et al. [16] evaluated twenty-six studies dealing with HRQOL or health status (HS). The majority of studies had low methodological quality [16]. Van Son et al. report that representative statements regarding the HRQOL after DRF can be made by considering just the three domains of physical, psychological and social function in a balanced way. They [16] concluded that with the inconclusive results of mostly low-quality studies, there is a need for high-quality prospective follow-up studies measuring HRQOL and pointed out an information gap for HRQOL outcomes after DRF.
As a part of the SF-36 evaluation we detected a correlation between HRQOL and lifestyle. Patients with a history of smoking and alcohol consumption were associated with a lower HRQOL. These findings correspond to the result of Bhandari et al. [13] who evaluated HRQOL of patients with unstable ankle fractures.
It has to be considered that lifestyle habits influence the HRQOL independent of the injury and treatment. In any case, the identification of modifiable predictors of patient HRQOL could help in the choice of surgical approach and treatment [13].
The primary limitation of the present study is it’s rather small sample size, although adequate to detect moderate changes over time it may still limit the precision of our estimates. Due to demographic evolution, twenty-six patients died during the follow-up period, leaving a group of thirty-nine patients at the ten-year follow-up. Another limitation of our study is that we did not include non-operatively treated patients with intra-articular DRF as a control group. However, it would have been difficult to compare such groups as unstable and more complex fractures need surgical treatment. A drawback of our study is that we did not assess preoperative and immediate postoperative SF-36 data so that we were not able to compare these data with our long-term follow-up results. The two- and six-year assessments were made at the hospital outpatient clinic, while some of the final follow-up evaluations were scheduled as home visits to accommodate patients and to minimize drop-out. This course of action might have created bias in the patient’s subjective outcome. Although we used sex- and age-matched Austrian and US normative SF-36 data, these are historical controls that may not be generalizable to our patients. As the age- and gender-matched controls did not exclude people with chronic conditions, the findings represent a cross section of the population and not the health status of “normal” individuals. However, it can be estimated that chronic disorders and comorbidities equally influence the general outcome of SF-36 in both the DRF study group and the norm population. Furthermore there are general limitations that arise in studies that use questionnaires such as the SF-36: they do not account for the specific settings of the patients who have undergone surgical repair of the distal radius. Some authors argue that the SF-36 is an instrument for measurement of general HS rather than a HRQOL assessment tool [16]. For HRQOL assessment, the WHOQOL-Bref [28] would have been an alternative suitable instrument, although specific problem areas in DRF might have been missed, because of its generic nature. Ideally, the constructions of a valid and specific subjective DRF outcome measure would provide more information on HRQOL in these patients. To minimize and to account for this problem we also used the DASH questionnaire in our study as it describes patient-related outcome assessment including disabilities of the hand [18]. Several studies have demonstrated usefulness of the DASH questionnaire [10, 24, 25, 29] although it mainly assesses physical functioning and only touches on psychological and social functioning, which fails to meet the requirement of multidimensionality of HS and HRQOL as defined by the WHOQOL group [30].
In addition to the SF-36 and the DASH, we evaluated the Gartland and Werley score. In the most recent follow-up we were not able to assess Castaing score as we did in our previous follow-ups, as it would have been unethical to recall the patients for another radiological follow-up visit ten years after the initial operation. Since HRQOL and clinical results did not change significantly over time, it seems unlikely that x-ray studies would have provided relevant new information.
