A Claims Based Natural History of the Post-Treatment Period after a Unilateral Wrist
Fracture

Amanda Dempsey MD1, Maha Karim BS2, Samantha J Beckley PhD2, Shaun K Stinton PhD2, Thomas P Branch MDb

1Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA

a ArthroResearch LLC, 441 Armour Place NE, Atlanta, GA, 30324, United States

b Ermi LLC, 2872 Woodcock Blvd. Suite 100, Atlanta, GA, 30341, United States

Address for correspondence:

Samantha Beckley, 441 Armour Place NE, Atlanta, GA, 30324, USA

Phone: +1 404-579-1546

Email: s.beckley@arthroresearch.com.

Abstract: 250 words Objective: The aim of this paper was to determine a claims-based timeline of unilateral wrist fracture recovery including the effect of comorbidities and post-treatment complications on recovery. Methods: Healthcare claims data were analyzed to determine the costs and recovery timeline after unilateral wrist fracture treatment. Costs related to: 1) index surgery, ii) complication surgery, iii) Wrist fracture revision, iv) non-operative hospitalization, v) motion restoring surgery

(MRS) and vi) outpatient surgery were reported. The effect of comorbidities was determined using data from patients with: diabetes, obesity, peripheral vascular disease, joint infection, cardiovascular disease, and joint contracture. The effect of post-index surgical complications was determined using data from patients who were re-hospitalized (with or without additional surgery). Perioperative complications including joint fibrosis/contracture, infection, and pulmonary embolus were also reported. Results: Index surgery median cost was $4,532 ($919 to $10,702). Median length of post-treatment recovery (from Index Surgery to last physical therapy claim) was 99 days (40-514 days). 59% of patients completed their post-treatment period in 6 months with 41% of patients taking over 6 months. The recovery period and cost for patients that required a complication surgery were over 3 times longer and added 6 times the cost in comparison to patients not requiring any complication surgeries. Conclusion: Comorbidities and complications after wrist fracture lead to dramatically increased costs and recovery times. Knowing the timeline of recovery in the typical wrist fracture patient and in outlier patients can help manage recovery and determine appropriate interventions.

2

2500 word limit for Orthopedics Introduction: Wrist fractures are among the most painful and devastating injuries in orthopedics accounting for up to 18% of fractures in patients who present to the emergency room 1,2,3 . They are some of the most challenging surgeries to perform due to the complexity and technical demands 3,4 . Typically, wrist fractures are treated with immobilization of some kind whether they are treated conservatively or surgically. The length of immobilization time impacts the length of post-treatment recovery 5,6,7 . A delay in surgery for any reason influences the length of time for recovery 8 . While the majority of wrist fractures involve the distal radius, fractures of the scaphoid are particularly troublesome due to their blood supply and can add significant weeks to post-treatment recovery 9-13 . Understanding and defining the current common recovery period after a treatment intervention is the first critical step in the process towards improving it. With most treatments reported as a case series with a minimum of 2 year follow-up, the short-term treatment recovery period has been ignored. Yet, a significant amount of resources are required to recover during this period after a treatment. A “Natural History” of the short-term recovery period requires a substantially larger data set than typically available to a standard case series in order to include all possible pathways as outcomes. Claims databases such as the IBM MarketScan Commercial Claims and Encounters Database, include large amounts of de-identified healthcare claims data that can help establish recovery patterns for all possible recovery pathways 14 . The aim of this study was to perform a claims-based timeline analysis of unilateral wrist fracture, from the initial surgery/treatment to the final physical therapy (PT) session, to outline a natural

3

recovery timeline. Additionally, we sought to quantify the impact of comorbidities and post-treatment complications on this recovery trajectory. Methods: Study Population Healthcare claims data from the IBM MarketScan database from the years 2015–2018 were used for this study. Patient data were eligible for inclusion in this study if the patient had at least two consecutive years of continuous insurance coverage. Wrist fracture patients were identified by CPT codes for wrist fractures (Addendum #1), and those with bilateral wrist fracture (simultaneous or staged) were excluded to avoid skewing the recovery period both longer and with greater cost. Both patients treated with open (surgical) and closed (casting) techniques were included in the analysis. The post-treatment period was defined as the timeline from the index wrist fracture surgery/treatment to the last HCPCS CPT charge for PT. Only patients with at least one PT CPT charge (codes >=97000 & <98000) post-treatment were included, resulting in a study sample of 6,058 patients. The distribution of inpatient and outpatient treatment of wrist fractures is shown in Tables 5 and 6. Cost Analysis Index surgery costs included all healthcare dollars spent during inpatient hospitalization or within 8 days of outpatient treatment. Subsequent procedures were grouped into four categories: i) complication-related surgery, ii) revision surgery after wrist fracture (Salvage) iii) non-operative hospitalization, and iv) MRS. Total costs in each group represent all healthcare

4

dollars spent which included the cited index surgery/treatment and any additional events to encompass the event and the risk of related subsequent events. CPT codes for post-treatment costs including PT/Occupational Therapy (>=97000 & <98000), physician visits (>=99200 & <99300, plus injection CPT codes 20610/20611), and radiology, were also analyzed (Addendum #1) and costs without wrist-related ICD 9/10 codes on the HCPCS form were excluded. All reported costs were the amount paid by insurance. Comorbidities The effect of comorbidities on recovery was determined through the grouping of patients with diabetes (codes 25.0 & E11.9), obesity (codes 278., E66., & Z68.4), peripheral vascular disease (PVD, codes 440.:444., 785., & I73.9), joint infection (codes 711., 996., M00., M01, & M02), cardiovascular disease (CVD, codes 390.:459., I11, I20, I21, & I25), and knee contracture ICD 9/10 codes 718.46 & M24.56). The median cost and interquartile (IQR) cost range were calculated for each group. Infection (Addendum #6) and pulmonary embolus (PE, Addendum #7) incidence rates were also determined. Index Surgery/Treatment All costs associated with the index surgery/treatment were associated with a case identifier (CaseID) for inpatient surgery. For outpatient treatment, all costs over a 8 day period were included as submitted claims were spread out over time. If the wrist fracture started with outpatient treatment and then was transferred to a hospital creating a new CaseID within 8 days, these costs were included in the outpatient index treatment costs. If a patient received inpatient treatment and then was later transferred to an inpatient rehabilitation hospital, this was counted as separate hospitalizations.

5

Additional Post-Treatment Surgeries The impact of post-treatment complications on recovery was analyzed, focusing on rehospitalizations with and without additional surgeries, including wrist fracture revisions (Addendum #2), MRS (Addendum #3), and other complication-related surgeries (Addendum #4). Hospitalizations were identified by a new CaseID linked to or following the index surgery. Perioperative complications such as joint contracture (Addendum #5), infection (Addendum #6), and PE (Addendum #7) were also reported. Presentation of Recovery Pathway A recovery pathway without any complications would be the patient undergoes the index surgery/treatment and is discharged, and then the patient attends PT and recovers within six months. A disability such as an injury or surgery changes from acute to chronic at the 6 month mark, and most states and insurance providers cap temporary or short-term disability insurance at 6 months 15,16 . Figure 1 shows possible recovery pathways from simple to complex and the aggregate impact of multiple post-treatment events can be seen, especially the decision point of having a MRS. This chart highlights the cumulative risk impact of multiple complications during the post-treatment period but does not correlate to specific time points. Data Analysis The R statistical programming language (version 4.3.3) was used for analysis with results presented as medians and IQR due to the large sample size. Results:

6

Study Group Demographics The study group was composed of 6058 patients within the IBM Watson Database with a minimum of 2 years continuous coverage. The group was 62% female and 38% male. The median age was 48 with a range from 1 to 62 years (IQR:18-57 years); however, age appears bimodal with a concentration younger than 20 and over 40 years of age (see Figure 2). No height or weight data were available. Open repair was performed in 36.7% of cases and closed repair was performed in 63.3% of cases. Index Surgery Costs Of the 6,058 patients, 189 had inpatient treatment only, 5850 were outpatient and 19 started as outpatient, but ended as inpatient. The median cost of the index surgery/treatment was $4,532(IQR:$919-$10,702). The median cost was $14,671 (IQR:$4,110-$29,828) for inpatient treatment and $4,306(IQR:$890-$10,341) for outpatient treatment. If the patient started as an outpatient but ended as an inpatient the median cost was $19,276 (IQR:$12,808-$36,528). Recovery Period The median length of post-treatment recovery (from index surgery/treatment to last PT claim) for a unilateral wrist fracture was 99 days (IQR:40-514 days). Only 59% of patients completed their post-treatment period in 6 months with 41% of patients taking over 6 months to complete PT (See Figure 3). Patients who completed their post-treatment course in less than 6 months, spent a median of 43 days in structured outpatient PT whereas patients who completed their post-treatment course in over 6 months, spent a median of 604 days in structured outpatient PT.

7

The additional post-treatment costs incurred after 6 months for patients undergoing PT beyond that point have a median of $3,295(IQR: $1,154 to $8740). Complicating Events We examined whether a difference exists in the length of the post-treatment recovery period after four major events that may occur after a unilateral wrist fracture: 1) MRS, 2) Complication surgery related to the wrist fracture, 3) Revision surgery after wrist fracture and 4) Nonoperative hospitalizations related to infection or pulmonary embolus in the post-treatment period. After MRS, such as a MUA, arthroscopy for lysis of adhesions or synovectomy, the median number of days in structured PT and the costs of post-treatment care both nearly tripled (Table 1). The median recovery period and cost for patients that required a complication surgery after a unilateral wrist fracture were 3 times longer and added 6 times the cost in comparison to patients that did not require any complication surgeries (Table 1). Salvage wrist surgery was uncommon but expensive (Table 1). Nonoperative hospitalizations after wrist fracture treatment costs a median of $36,497 compared to only $2,316 and takes almost 3 times longer for recovery (Table 1). The cumulative effect on costs and recovery time as a result of multiple events in the post-treatment period can be seen in Figure 4 and Table 2. A single wrist fracture with no complications, no revisions and no MRS had a median post-index treatment cost of $1,919. We found that 14% of single wrist fractures required a secondary surgery including complication-, revision-, and MRS. This median cost surged dramatically to $95,867 with a revision surgery. Out of the 2,680 patients that were observed with a unilateral wrist fracture, 5,548 patients did not undergo a MRS. These patients had a median of 91 PT days

8

and the median out of pocket cost was $2,074. The median cost with a MRS in this group of patients was $12,061(IQR:$6,482-$21,334) with a median of 265 PT days for recovery. Joint Contracture The presence of joint contracture at the time of index surgery had no impact on recovery costs but doubled the time to recover whereas the development of joint contracture after the index surgery had a major impact on both recovery costs (doubled) and recovery time (2.8 times longer) (Table 3). Impact of Comorbidities on Recovery The effect of the presence of diabetes, obesity, PVD and CVD is shown in Table 4. The clinical impact of these conditions on recovery was small. However, both PVD and CVD increased the risk of PE. Discussion: The primary finding of this study was the establishment of a benchmark for the post-treatment period following unilateral wrist fracture which can provide a standardized framework to monitor and manage patient progress during the early recovery phase. The median post-treatment recovery time was 102.5 days, measured from the index surgery/treatment to the final PT claim. In this study, 41% of patients required more than six months to complete their post-treatment care. This prolonged recovery in a portion of patients was also described previously in a study of distal radius fractures in which 37% of patients still experienced at least mild pain on a regular basis and 25% of patients still experienced difficulties with their usual activities after six months

9

of recovery 17 . These large variations in recovery timelines underscore the complexity of wrist fracture recovery and are consistent with previous literature 5,18-20 . A second key finding is that critical post-treatment events—MRS, complication surgery, revision surgery, and non-operative hospitalizations—substantially affected both recovery duration and healthcare costs following unilateral wrist fracture. The reoperation rate after ORIF fracture repair in the distal radius was previously reported to be 12.9% 21 . Complication surgery caused a significant increase in both post-treatment costs ($12,785) and time (200 days) which is consistent with the literature 20 . MRS was identified in 510 patients, yet only 10 patients had ICD-9/10 diagnosis of wrist/hand contracture. Clearly, there is a disconnect between the need for MRS and the diagnosis of wrist/hand contracture indicating a reluctance to make that diagnosis. The third important finding in this study was that the diagnosis of a wrist/hand contracture (M24.53,M24.53) in the recovery period after a unilateral wrist fracture led to a considerable increase in costs and time to recover. The presence of a wrist/hand contracture before surgery resulted in a longer recovery period after treatment but not an increase in cost. The median cost and recovery time for patients who developed a joint contracture after surgery were both significantly higher than for those who did not develop a contracture. A solution for these patients has yet to be identified as standard mobilization techniques and dynamic splinting have failed to make a significant difference in resolving wrist contracture 22-25 . The fourth key finding in this study highlights the impact of comorbidities on the cost and recovery time following unilateral wrist fracture. While the presence of obesity has been shown

10

to increase the risk of complications, length of hospital stay and operating time, this study demonstrated only a nominal increase in post-treatment total cost of a median $630 26 [Gonuguntla 2023]. On the other hand, the presence of obesity in this study added 74 days to the post-treatment recovery time. Both PVD and CVD increased the risk of PE which was significantly more than obesity. A HCPCS claims-based analysis has several limitations. One challenge is the presence of standard coding inconsistencies, especially given that this study encompasses the transition from ICD-9 to ICD-10 codes. Additionally, the definition of the post-treatment period in this study assumes that medical care concludes with the final physical therapy visit, which may not capture all aspects of recovery. Another limitation is the exclusion of prescribed drug costs from the database claims, which would contribute additional healthcare expenses to the total costs. Conclusion: This study establishes a recovery benchmark for wrist fracture treatment, offering a standardized framework for tracking patient progress during the initial stages of recovery. This timeline is essential for assessing the impact of new treatment approaches aimed at improving recovery outcomes. The substantial delays in recovery, with over 40% of patients requiring more than six months to heal, underscore the pressing need for enhanced post-treatment care protocols for wrist fractures.

11

References 1. Meena S, Sharma P, Sambharia AK, Dawar A. Fractures of distal radius: an overview. J Family Med Prim Care. 2014 Oct-Dec;3(4):325-32. doi: 10.4103/2249-4863.148101. PMID: 25657938; PMCID: PMC4311337. 2. Meijer HAW, Graafland M, Obdeijn MC, Schijven MP, Goslings JC. Validity and reliability of a wearable-controlled serious game and goniometer for telemonitoring of wrist fracture rehabilitation. Eur J Trauma Emerg Surg. 2022 Apr;48(2):1317-1325. doi: 10.1007/s00068-021-01657-5. Epub 2021 Apr 22. PMID: 33885912; PMCID: PMC9001232. 3. Xu W, Liu Y, Zhang B, Ma J. Dynamic risk factors for complex regional pain syndrome after distal radius fracture surgery: multivariate analysis and prediction. BMC Musculoskelet Disord. 2024 Nov 12;25(1):899. doi: 10.1186/s12891-024-07948-3. PMID: 39533288; PMCID: PMC11558875. 4. Mayfield CK, Gould DJ, Dusch M, Mostofi A. Distal Scaphoid Excision in Treatment of Symptomatic Scaphoid Nonunion: Systematic Review and Meta-analysis. HAND. 2019;14(4):508-515. doi:10.1177/1558944718760002 5. Dennison DG, Blanchard CL, Elhassan B, Moran SL, Shin AY. Early Versus Late Motion Following Volar Plating of Distal Radius Fractures. Hand (N Y). 2020 Jan;15(1):125-130. doi: 10.1177/1558944718787880. Epub 2018 Jul 15. PMID: 30009627; PMCID: PMC6966284. 6. Kärnä L, Launonen AP, Karjalainen T, Luokkala T, Ponkilainen V, Halonen L, Helminen M, Mattila VM, Reito A. LIMPER trials: immediate mobilisation versus 2-week cast immobilisation after distal radius fracture treated with volar locking plate - a study protocol for a prospective, randomised, controlled trial. BMJ Open. 2022 Nov 11;12(11):e064440. doi: 10.1136/bmjopen-2022-064440. PMID: 36368761; PMCID: PMC9660569. 7. Pedersen J, Mortensen SO, Rölfing JD, Thorninger R. A protocol for a single-center, single-blinded randomized-controlled trial investigating volar plating versus conservative treatment of unstable distal radius fractures in patients older than 65 years. BMC Musculoskelet Disord. 2019 Jun 29;20(1):309. doi: 10.1186/s12891-019-2677-y. PMID: 31253145; PMCID: PMC6599306. 8. Liu K, Grigor EJM, Antflek D, Ho G, Baltzer HL, Paul R. Time to surgical management of distal radius fractures: effects on health care utilization and functional outcomes. Can J Surg. 2024 Jul 4;67(4):E286-E294. doi: 10.1503/cjs.010223. PMID: 38964758; PMCID: PMC11233172. 9. Alluri RK, Yin C, Iorio ML, Leland H, Wong J, Patel K. Vascularized Bone Grafting in Scaphoid Nonunion: A Review of Patient-Centered Outcomes. Hand (N Y). 2017 Mar;12(2):127-134. doi: 10.1177/1558944716643080. Epub 2016 Jul 7. PMID: 28344522; PMCID: PMC5349405.

12

10. Huang YC, Liu Y, Chen TH. Long-term results of scaphoid nonunion treated by intercalated bone grafting and Herbert's screw fixation--a study of 49 patients for at least five years. Int Orthop. 2009 Oct;33(5):1295-300. doi: 10.1007/s00264-008-0663-3. Epub 2008 Oct 28. PMID: 18956188; PMCID: PMC2899133. 11. Naranje S, Kotwal PP, Shamshery P, Gupta V, Nag HL. Percutaneous fixation of selected scaphoid fractures by dorsal approach. Int Orthop 2010;34:997-1003. 12. Rinaldi A, Pilla F, Chiaramonte I, Pederiva D, Vita F, Schilardi F, Gennaro A, Faldini C. Arthroscopic surgery for scaphoid nonunion: a 10-year systematic literature review. Musculoskelet Surg. 2024 Jun;108(2):125-132. doi: 10.1007/s12306-023-00805-x. Epub 2024 Feb 10. PMID: 38340306; PMCID: PMC11133090. 13. Yeh CW, Hsu CE, Wang WC, Chiu YC. Wrist function recovery course in patients with scaphoid nonunion treated with combined volar bone grafting and a dorsal antegrade headless screw. J Orthop Surg Res. 2020 Nov 10;15(1):519. doi: 10.1186/s13018-020-02055-0. PMID: 33168036; PMCID: PMC7653748. 14. Butler, A.M., Nickel, K.B., Overman, R.A., Brookhart, M.A. (2021). IBM MarketScan Research Databases. In: Sturkenboom, M., Schink, T. (eds) Databases for Pharmacoepidemiological Research. Springer Series on Epidemiology and Public Health. Springer, Cham. https://doi.org/10.1007/978-3-030-51455-6_20 15. Nakamura, M., Nishiwaki, Y., Sumitani, M. et al. Investigation of chronic musculoskeletal pain (third report): with special reference to the importance of neuropathic pain and psychogenic pain. J Orthop Sci 19, 667–675 (2014). https://doi.org/10.1007/s00776-014-0567-6 16. Nakamura M, Nishiwaki Y, Ushida T, Toyama Y. Prevalence and characteristics of chronic musculoskeletal pain in Japan. J Orthop Sci. 2011;16(4):424-432. doi:10.1007/s00776-011-0102-y 17. MacDermid JC, Roth JH, Richards RS. Pain and disability reported in the year following a distal radius fracture: a cohort study. BMC Musculoskelet Disord. 2003 Oct 31;4:24. doi: 10.1186/1471-2474-4-24. PMID: 14588078; PMCID: PMC270028. 18. Björk M, Niklasson J, Westerdahl E, Sagerfors M. Self-efficacy corresponds to wrist function after combined plating of distal radius fractures. J Hand Ther. 2020 Jul-Sep;33(3):314-319. doi: 10.1016/j.jht.2020.01.001. Epub 2020 Feb 20. PMID: 32088082. 19. Diaz-Garcia RJ, Oda T, Shauver MJ, Chung KC. A systematic review of outcomes and complications of treating unstable distal radius fractures in the elderly. J Hand Surg Am. 2011 May;36(5):824-35.e2. doi: 10.1016/j.jhsa.2011.02.005. PMID: 21527140; PMCID: PMC3093102. 20. Larose G, Roffey DM, Broekhuyse HM, Guy P, O'Brien P, Lefaivre KA. Trajectory of Recovery following ORIF for Distal Radius Fractures. J Wrist Surg. 2023 Jul 13;13(3):230-235. doi: 10.1055/s-0043-1771045. PMID: 38808181; PMCID: PMC11129881. 21. Farrell N, Samade R, Farrar N, Goyal KS.. Predictors of Reoperation after Open Reduction and Interal Fixation for Distal Radius Fractures. Presented at the 2020 annual meeting of the American Association for Hand Surgery, Ft. Lauderdale, FL.

13

22. Gutiérrez-Espinoza H, Araya-Quintanilla F, Olguín-Huerta C, Valenzuela-Fuenzalida J, Gutiérrez-Monclus R, Moncada-Ramírez V. Effectiveness of manual therapy in patients with distal radius fracture: a systematic review and meta-analysis. J Man Manip Ther. 2022 Feb;30(1):33-45. doi: 10.1080/10669817.2021.1992090. Epub 2021 Oct 20. PMID: 34668847; PMCID: PMC8865096. 23. Heiser R, O'Brien VH, Schwartz DA. The use of joint mobilization to improve clinical outcomes in hand therapy: a systematic review of the literature. J Hand Ther. 2013 Oct-Dec;26(4):297-311; quiz 311. doi: 10.1016/j.jht.2013.07.004. Epub 2013 Sep 14. PMID: 24044954. 24. Jongs RA, Harvey LA, Gwinn T, Lucas BR. Dynamic splints do not reduce contracture following distal radial fracture: a randomised controlled trial. J Physiother. 2012;58(3):173-80. doi: 10.1016/S1836-9553(12)70108-X. PMID: 22884184. 25. Kay S, Haensel N, Stiller K. The effect of passive mobilisation following fractures involving the distal radius: a randomised study. Australian Journal of Physiotherapy 2000;46(2):93‐101. 26. Gonuguntla R, Ghali A, Prabhakar G, Momtaz D, Ahmad F, Slocum D, Kotzur T, Cushing T, Saydawi A, Wu C. The Effect of Obesity on Distal Radius Fractures: An Analysis from the NSQIP Database. Plast Reconstr Surg Glob Open. 2023 Jun 9;11(6):e5049. doi: 10.1097/GOX.0000000000005049. PMID: 37305201; PMCID: PMC10256334. Figures:

14

Figure 1. Potential recovery pathways for unilateral Wrist Fracture patients. The more events accumulate in the post-treatment period, the more expensive and longer is the recovery.

A Claims Based Natural History of the Post-Treatment Period after a Unilateral Wrist Fracture