Rev. bras. ortop. vol.52 número3

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SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

PRWE

application

in

distal

radius

fracture:

comparison

and

correlation

with

established

outcomes

夽

Vinícius

Ferreira

Paranaíba

∗

_,

_João

_Baptista

_Gomes

_dos

_Santos,

_Jorge

_Raduan

_Neto,

Vinícius

Ynoe

Moraes,

João

Carlos

Belotti,

Flávio

Faloppa

UniversidadeFederaldeSãoPaulo,EscolaPaulistadeMedicina,DepartamentodeOrtopediaeTraumatologia,SãoPaulo,SP,Brazil

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Articlehistory:

Received3June2016 Accepted26July2016 Availableonline14May2017

Keywords:

Radiusfractures Outcomeassessment Wrist

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Objective:ThestudyaimedtoevaluatethecorrelationbetweenthePRWEscorewithother measurementsthatarealreadywidelyused.

Methods:Thiswasaprospective,cross-sectional,single-centerstudy.Sixty-eight consecu-tivepatientsunderwentsurgicaltreatmentfordistalradiusfractures(internalfixationby lockedvolarplateortransarticularexternalfixation).Theywereevaluatedindependentlyby PRWE,DASH,VASrangeofmotion,strength,andradiographiccriteria,inoneyearoffollow up.TheMann–WhitneytestwasusedtocomparecontinuousvariablesandtheSpearman correlationtocorrelatetheoutcomesofinterest.

Results:PRWEcorrelatedsignificantlywithDASH(p<0.001)andVAS(p<0.001).Therewere nosignificantcorrelationswithotheroutcomemeasures.

Conclusion:PRWEpresentssignificantmoderatecorrelationonlywithDASHandVAS.Range ofmotion,strength,andradiographiccriteriadonotinterfereinthePRWEoutcome.

夽

StudyconductedattheUniversidadeFederaldeSãoPaulo,EscolaPaulistadeMedicina,DepartamentodeOrtopediaeTraumatologia, DisciplinadeCirurgiadaMãoeMembroSuperior,SãoPaulo,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:viniciusparanaiba@gmail.com(V.F.Paranaíba).

http://dx.doi.org/10.1016/j.rboe.2016.07.007

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Aplicac¸ão

do

PRWE

na

fratura

da

extremidade

distal

do

rádio:

comparac¸ão

e

correlac¸ão

com

desfechos

consagrados

Palavras-chave:

Fraturasdorádio Avaliac¸ãoderesultados Punho

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e

s

u

m

o

Objetivo:Esteestudotevecomoobjetivoavaliaracorrelac¸ãoentreoescorePRWEcomoutras medidasjáamplamenteusadas.

Métodos: Estudotransversalprospectivo,decentroúnico;68pacientesconsecutivosforam submetidosa tratamentocirúrgicoparafraturadaextremidadedistaldorádio(fixação internacomplacavolarbloqueadaoufixaçãoexternatransarticular).Foramavaliados,de formaindependente,pormeiodaPatient-RatedWristEvaluation(PRWE),doDisabilitiesofthe Arm,ShoulderandHand(DASH),daescalavisualanalógica(EVA),daamplitudede movi-mento,daforçaedoscritériosradiográficos,noseguimentodeumano.Usaram-seoteste deMann–WhitneyparacomparaçãodevariáveiscontínuaseacorrelaçãodeSpearmanpara osdesfechosdeinteresse.

Resultados:PRWEcorrelacionou-sesignificativamentecomDASH(p<0,001)eEVA(p<0,001). Nãohouvecorrelac¸ãosignificativacomasdemaismedidasdedesfecho.

Conclusão: PRWEapresentacorrelac¸ãosignificativamoderadaapenascomDASHeEVA.As medidasdeamplitudedemovimento,forc¸aeoscritériosradiográficosnãosecorrelacionam comPRWE.

Introduction

Fractures of the distal end of the radius are among the mostcommon inadults,1 _and _there _are _several _treatment

modalities.2–5 _However,_there_is_no_consensus_on_treatment

and on which outcome measures are the most suitable for research and clinical practice.6 _To _evaluate _the

effec-tiveness ofany treatment, it isessential tohave adequate measuringtools,becausetheyensurethereproducibilityof theresultsandtheirexternalvalidity(generalizationofthe results).7

Initially,theoutcomesoftreatmentofthesefractureswere groundedinobjectiveaspects,suchasrangeofmotion,grip strength,andradiographicmeasurements,8_but_these

assess-ments do not take into account the performance of daily activitiesand,morebroadly,theydonotconsiderthe subjec-tiveassessmentofthepatientsandtheirexpectationsafter treatment.9 _Meanwhile, _efforts _are_being _made_to _measure

outcomesfocusedonthesubjectofintervention,aparadigm shiftfromsurgeon-centeredcaretopatient-centeredcare.10

Inthiscontext,recentlygreateremphasishasbeengiven toself-reportedmeasuresofsymptomsandpost-injury func-tion, which assess the patient’s perceived disability and consider aspects ofthe patient’s life that may be affected as a result of the disease and treatment.6,8 _The

Disabil-ities of the Arm, Shoulder and Hand (DASH)11 _and _the

Patient-RatedWristEvaluation(PRWE)12_are_structured

ques-tionnairesthatarewidelyusedinpatientswithwristdiseases. TheDASH has been validated for Brazilian Portuguese for sometime13_;_it_is_the_most_frequently_used_score_in_studies

thataddresswristdiseases.14 _PRWE_was_recently_translated

intoBrazilianPortuguese15_and_is_increasingly_being

demon-strated tobe an importanttool, especially indistal radius fractures.7

ThereisalackofstudiesevaluatingthepropertiesofPRWE inclinicalresearch.Inthisscenario,it seemsreasonableto compareitwiththetoolsthatarecommonlyusedinstudies involvingfracturesofthedistalendoftheradiusinorderto assessitspsychometriccapabilities,whichwouldvalidateits widespreaduse.

Thisstudyaimedtoevaluatethecorrelationbetweenthe PRWEscoreandotherobjectiveandsubjectiveoutcome meas-uresforthesurgicaltreatmentofdistalradiusfracturesafter oneyearofpostoperativefollow-up.

Material

and

methods

This study was approved by the Institution Review Board, registered in Plataforma Brasil under CAAE No. 30904214.0.0000.5505. Themethodsofdisseminationofthe resultsofthisstudyfollowedtheguidelinesofthe Strength-eningtheReportingofObservationalStudiesinEpidemiology (STROBE)initiative.16

This was a cross-sectionalstudy witha sample from a prospectivestudy(randomizedcontrolledtrial),17_conducted

inasinglecenterinaservicespecializedinhandandupper limbsurgery.

Patientssubmittedtosurgicaltreatmentforunilateral frac-turesofthedistalendoftheradius,withlockedvolarplateor externalfixatorwereincluded. Evaluationofoutcomeswas doneafteroneyearoffollow-up,afteraninformedconsent formwasreadandsigned.

Patientswereassessedusingthefollowingmeasures:

• PRWE15; • DASH13;

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• Rangeofmotionofthewristandforearm(flexion,

exten-sion, pronation, supination, radial deviation, and ulnar deviation).Comparisonoftheoperatedsidewiththe con-tralateralside;

• Strength(gripstrength,pinchstrength:pulppinch,lateral

pinch,and three-digit pinch); three measurements were madeandtheaveragevaluewasused.Comparisonofthe operatedsidewiththecontralateralside;

• Radiographicmeasurements(radialheight,ulnarvariance,

radialinclinationandvolarinclinationangles,step-off,and gapbetweenarticularfragments).19,20 _Comparison_of_the

operatedsidewiththecontralateralside.

Patientswithprevioushistoryofdegenerativeortraumatic diseaseintheaffectedorcontralateralwristjoint,identified throughclinicalhistory,orthosewhohadacognitivedeficit orrefusedtosigntheinformedconsentformwereexcluded fromthestudy.

All information collected in this research was initially presented in a descriptive way.21 _The _inferential _analysis

consistedoftheMann–Whitneytest22_in_the_comparison_of

thePRWEscore,accordingtogenderanddominantand oper-atedsides.TheSpearmancorrelationcoefficient22_was_used

toquantifythe correlation betweenPRWEand DASH, VAS, strength,rangeofmotion,andradiographiccriteria.

Fortheconclusionsobtainedafterstatisticaltests,analpha significancelevellowerthan5%wasadopted.

Results

Generalcharacteristicsofpatientsevaluated,aswell asthe mean,minimum,andmaximumPRWEandDASHscores,are describedinTable1.

Descriptive statistical analysis between PRWE, gender, operated side, and dominant side indicated that men had statistically lower PRWE scores when compared with women (p=0.005). In turn, the dominant and operated sideswere notstatisticallycorrelated withthe PRWEscore (p>0.05).

Measurementsofwristrange ofmotionanddifferences betweenthecontralateraland operatedsidesare described inTable2.

In the assessment of pain, measured by VAS, 49 (72%) patients reported no pain (VAS=0). Of the 19 (28%) who reportedpain,meanvaluewas2.4,rangingfrom0.3to7.1.

Table3presentstheradiographicmeasurementsmadeon theaffectedandcontralateralside,aswellasthedifference betweenthem.

Table4 summarizes the results ofthe Spearman corre-lationcoefficientforPRWEandother measuresofoutcome evaluated.

This coefficient ranges from −1.00 to +1.00. The

closer to −1.00 or +1.00, the more evident is the

cor-relation between the pair of variables involved. Thus, coefficients from 0.00 to 0.19 show very weak correlation; between 0.20 and 0.39, weak correlation; between 0.40 and 0.69, moderate correlation; between 0.70 and 0.89, strong correlation; and between0.90 and 1.00,very strong correlation.21,22

Table1–Generalcharacteristicsofpatients.

Gender

Male 26 38.2%

Female 42 61.8%

Fixationdevices

Externalfixation 36 52.9%

Lockedvolarplate 32 47.1%

Age(years)

Mean 52.0

Minimum–maximum 19–87

Dominantside

Right 63 92.6%

Left 5 7.4%

Operatedside

Right 33 48.5%

Left 35 51.5%

Dominantsidewasoperated 36 52.9%

Non-dominantsidewasoperated 32 47.1%

PRWE

Mean 8.2

Minimum–maximum 0–80

DASH

Mean 3.0

Minimum–maximum 0.0–27.5

DASH,disabilitiesofthearm,shoulderandhand;PRWE, patient-ratedwristevaluation.

Discussion

Theoutcome ofatreatmentdependsnotonlyonthetype

ofintervention,butalsoonthewayitismeasured.9,23_With

the developmentofself-reportedoutcome measures, focus shiftedtopatient-centeredresults;thishasledtothecreation ofvalidinstrumentstoobtainquantitativeinformationabout theeverydayexperienceofapatientwithacertaindisease.24

Studiesdirectedtothemeasurementofthepropertiesofthese instrumentsarearelativelyrecentphenomenon,andmanyof thehistoricallyrelevantscoringsystemshavenotyetpassed thescrutinyofrigorousevaluations.14

Studies have suggested that the DASH is an adequate instrumenttoassesspatientswithupperlimbdiseases,but it isnotspecifictothewrist.7,14,25 _Conversely,_according_to

Changulanietal.,7_the_DASH_has_a_weak_correlation_with_the

intensityofpaininthewrist;ithaslessvalidityforthe spe-cificevaluationofthewrist.WefoundthatPRWEandDASH aresignificantlyanddirectlycorrelated.

Most ofthe patients didnotreport pain withVAS and, atthesame time,ameanPRWEscoreof8.2wasobtained. ConsideringthathalfofthePRWEscorecorrespondstopain, the instrument usedtogiveanobjective valuetopain felt bythepatientshowedasignificantstatisticalcorrelation,as expected,evidencingthatPRWEisaneffectivetoolforpain assessment.

Meanrangeofmotionmeasurementsonthecontralateral sidewerehigherwhencomparedwiththeoperatedside;the differencesbetweenthefracturedsideandthecontralateral side forany assessed movement didnot present a signifi-cantcorrelationwiththePRWEscore.Kasapinova26_also_failed

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Table2–Measuresofrangeofmotionandstrengthoftheoperatedandcontralateralsides.

Operatedside(n=68) Contralateralside(n=68) Differencea_(n₌₆₈₎

Flexion(degrees)

Mean 70.8 78.8 8.0

Minimum–maximum 45–90 45–95 −25to35

Extension(degrees)

Mean 61.4 68.2 6.8

Pronation(degrees)

Mean 83.2 86.6 3.4

Supination(degrees)

Mean 90.1 93.3 3.2

Radialbending(degrees)

Mean 21.9 24.6 2.7

Ulnarbending(degrees)

Mean 39.7 42.8 3.0

Minimum–maximum 10–60 20–70 −15.0to25

Gripstrength(kgf)

Mean 24.8 28.2 3.4

Minimum–maximum 6.7–60.2 13.3–50.9 −13.2to20.2

Pulppinch(kgf)

Mean 3.5 4.0 0.4

Lateralpinch(kgf)

Mean 5.8 5.6 −0.2

Three-digitpinch(kgf)

Mean 4.5 4.8 0.3

a _Measurement_of_the_{contralateral}_{side–measurement}_of_the_operated_side.

Table3–Radiographicmeasurementsoftheoperatedandcontralateralsides.

Operatedside(n=68) Contralateralside(n=68) Differencea_(n₌₆₈₎

Radialheight(mm)

Mean 10.1 11.3 1.2

Radialinclination(degrees)

Mean 19.9 21.2 1.3

Ulnarvariance(mm)

Mean −0.4 0.8 1.1

Minimum–maximum −8to4 −4to5 −2to8

Volarinclination(degrees)

Mean 6.9 13.3 6.4

Minimum–maximum −8to20 2–24 −6to24

Step-off(mm)

Mean 0.2 0 −0.2

Jointgap(mm)

Mean 0.3 0 −0.3

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Table4–Spearmancorrelationcoefficientbetween PRWEandotheroutcomes.

Pairofcorrelated measures

Spearman’scorrelation coefficient

p

PRWEandDASH 0.609 <0.001a

PRWEandVAS 0.495 <0.001a

PRWEandflexion 0.075 0.545

PRWEandextension 0.111 0.366

PRWEandpronation 0.033 0.788

PRWEandsupination 0.066 0.595

PRWEandradial bending

0.011 0.932

PRWEandulnar bending

0.023 0.851

PRWEandgripstrength 0.095 0.440

PRWEandpulppinch 0.144 0.240

PRWEandlateralpinch 0.124 0.315

PRWEandthree-digit pinch

0.096 0.438

PRWEandradialheight −0.041 0.738

PRWEandradial inclination

−0.042 0.733

PRWEandulnar variance

−0.106 0.389

PRWEandvolar inclination

−0.161 0.189

PRWEandstep-off −0.095 0.443

PRWEandjointgap 0.063 0.610

DASH,disabilitiesofthearm,shoulderandhand;VAS,visualanalog scale;PRWE,patient-ratedwristevaluation.

a _{Statistically}_significant_correlations_(p_<_0.05).

Takingintoaccountthestrengthmeasurements,the con-tralateralsidewasstrongerthantheoperatedside.Theonly exception found was forlateral pinch strength, wherethe meanvalueontheoperatedsidewasslightlyhigherthanthat ofthecontralateralside.Thestrengthdifferencesbetweenthe fracturedand the contralateralsides werenot significantly correlated withthe PRWEscore inthe present study. Con-versely,Karnezisetal.27_indicated_that_grip_strength_appears

tobeasensitivemarkerofwristfunctionrecovery.Intheir study,thedifferencebetweenthecontralateralandfractured sides,aftercorrectionofthevaluesforthenon-dominantside, wasasignificantpredictorforPRWE.

Regarding radiographic parameters, the mean values of thecontralateralsidewerealsohigherwhencomparedwith theoperatedside,butthedifferencesofthesemeasurements werenotsignificantlycorrelatedwiththePRWEscore. Kas-apinovaetal.26_also_did_not_observe_a_significant_correlation

betweenradiographicparametersand PRWE;theseauthors concludedthattreatmentandrehabilitationofdistalradius fractureshouldnotbeassessedonlybythefollow-up radio-graph.

In the present study, through inferential analysis, we observedthatwomenpresentedasignificantlyhigherPRWE scorethan men. Limb side, aswell as dominance,did not interfereinPRWEscore.Nootherstudyintheliteraturehas performedthisanalysis.

Theapplicationofself-reportedoutcomemeasures,when donelongitudinally,allowshealthcareprofessionalstoassess thecourseoftreatment;furthermore,itfacilitatescomparison

betweengroupsinclinicaltrials.28_Goldhahn_et_al.25

recom-mendedtheuseofmultipleinstrumentsthathavesymptoms andfunctionasseparatedomainsforadefinitive classifica-tionofthepatientwithdistalradiusfracture,sincethereis not yetacomplete instrument forthis purpose.In clinical research, instruments should beusedintheir most exten-siveanddetailedform;forday-to-daymedicalpractice,rapid instrumentssuchasPRWEfacilitatedatacollection.25

System-aticreviewsonthesubjectalwaysdiscusstheheterogeneity ofoutcomemeasuresasabarriertodrawfurtherconclusions fromthereviewormeta-analysis.29

Itisimportanttoinferthatthevastmajorityofthepatients whoattendedtothisserviceandwereincludedinthisstudy areusersoftheBrazilianUnifiedHealthSystemandpresented difficultieswhenansweringtheself-reportedquestionnaires. Anotherimportantpointtoconsideristhepossible“desireto notimprove”observedinsomepatientswhowantsecondary gains (retirement, indemnities, insurance, pension rights, etc.),whichmayhaveinfluencedtheinformationcollected.30

Theauthorsbelievethat,toincreasethestatisticalpowerof thepresentstudy,itwouldbenecessarytoconducta longi-tudinal prospectivestudywithalargernumberofpatients, including treatmentsbynon-surgical techniquesand other surgicalmethods.

Conclusion

PRWE has a moderate statistical correlation with DASH and withVAS.Regarding gender, females presentedhigher PRWEvaluesthanmales.Measurementsofrangeofmotion, strength,andradiographiccriteriadidnotinterferewiththe PRWEresult,nordidtheoperatedsideorlimbdominance.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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