Date of Award

2012

Document Type

Thesis

Degree Name

Master of Science in Clinical Research

Department

Surgery

College

College of Graduate Studies

First Advisor

Thomas C. Hulsey

Second Advisor

Milton B. Armstrong

Third Advisor

Kevin O. Delaney

Fourth Advisor

Daniel T. Lackland

Fifth Advisor

Lydia B. King

Abstract

Introduction: Outcomes based research on trauma-related orthopaedic injuries is imperative for gauging the effectiveness of current surgical procedures and thereby maximizing the patient's functional status. In patients sustaining perilunate dislocations (PLD) and fracture-dislocations (PLFD) following a traumatic fall on an outstretched hand, early open reduction and internal fixation (ORIF) is widely considered the standard of care for acute cases, but evidence supporting optimal techniques and materials is limited in a body of literature consisting mainly of small retrospective case series and expert opinion. The aims of this study were to compare functional outcomes of PLD and PLFD by surgical technique and to identify the barriers and limitations to conducting research on these injuries, which has potential implications for other types of traumatic orthopedic surgeries as well, through a systematic review of the literature. Methods: An English-limited Pubmed search was performed using the phrase "(radiocarpal OR perilunate OR midcarpal OR lunate OR wrist) AND (dislocation OR fracture) AND (research OR study OR studies OR trial OR retrospective OR prospective OR cohort OR follow-up OR meta-analysis OR systematic review)." Studies were included if they presented original data on ORIF for acute (<45 days) PLD and PLFD, described at least 5 cases, included details of the procedure and materials, had follow-up data for at least one year incorporating objective measures of wrist function, and were published no earlier than 1990. The extracted information included study design, patient demographics, injury type, surgical materials and techniques, complications, additional interventions, and functional measurements. Results: Of the 654 citations returned by the search phrase, 12 met the inclusion criteria. All articles were retrospective case-series with the most common reasons for exclusion being inappropriate subject, inadequate sample size, inclusion of non-acutely treated cases, and insufficient measures of wrist function. 179 wrists were represented (122 PLFD, 57 PLD) in 177 patients with mean ages from 24 to 38 years. The average delay to surgery was 4.1 days, and follow-up periods ranged from 12 months to 10 years. Substantial variability in reported functional measurements in association with variance in case mix and follow-up duration primarily limited comparisons between techniques. Selection bias through loss to follow-up was problematic with rates as high as 67%. Discussion: While systematic review and meta-analysis are the best available tools for overcoming the evidential limitations of inherently small sample sizes collected on rare injuries, the clinical and methodological heterogeneity encountered among the included articles in this review makes direct comparison and pooling of studies misleading. Additional case-series are needed with consistent validated outcome measurements collected at standardized intervals. Thorough data presentation and appropriate grouping will facilitate not only current practices but also future attempts at data comparison and will ultimately advance knowledge on the optimal tactics for handling these significant injuries. This study identified a significant risk for selection bias due to loss to follow-up, which is a threat to internal validity and a prohibitive factor for data availability that must be addressed in all orthopaedic trauma patients.

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