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Risk Factors for Infection After Distal Radius Fracture Fixation: Analysis of Impact on Cost of Care

Open AccessPublished:January 31, 2022DOI:https://doi.org/10.1016/j.jhsg.2021.12.011

      Purpose

      Infection after distal radius fracture fixation can be a devastating complication, leading to potential hardware removal, prolonged antibiotic courses, multiple office visits, and increased costs. This study aimed to identify potential risk factors for infectious complications after distal radius fracture fixation and assess the impacts on cost.

      Methods

      This study used the PearlDiver national database, encompassing 53 million unique patients from January 1, 2010, to March 31, 2020. The cohort included patients undergoing distal radius fracture fixation. The endpoint was postoperative infection within 180 days of fixation. Two-sample t test was used to compare rates of infection between open and percutaneous fracture fixation techniques. A propensity-matched cohort was created using patient age, gender, and open fracture. Logistic regression analyses defined independent risk factors for developing a postoperative infection among all patients and within the matched cohorts. A Mann-Whitney U test was used to compare costs of care with and without infection.

      Results

      The database included 87,169 patients who underwent distal radius fracture fixation. Postoperative infections were identified in 781 patients (0.9%). There was a significant difference in rates of postoperative infection with percutaneous fixation (1.3%) versus open fixation (0.8%). Logistic regression analysis identified male gender, open fracture, lung disease, chronic kidney disease, diabetes, hypertension, liver disease, obesity, and tobacco to be independent risk factors for developing a postoperative infection. Logistic regression analysis of the propensity-matched cohorts identified tobacco use as a significant risk factor. The average cost of care for patients undergoing fracture fixation without an infection was $6,383, versus $23,355 for those with an infection, which was significantly different.

      Conclusions

      Multiple risk factors for postoperative infection were identified. Cost is significantly increased after postoperative infection, by almost 4-fold. Attempts to correct or optimize modifiable risk factors may lead to substantial cost savings, and potentially decreased rates of infection.

      Type of study/level of evidence

      Prognostic III.

      Key words

      Distal radius fractures are among the most common upper extremity traumas encountered by hand surgeons, with an incidence of approximately 16.2 per 10,000 person-years.
      • Karl J.W.
      • Olson P.R.
      • Rosenwasser M.P.
      The epidemiology of upper extremity fractures in the United States, 2009.
      There are various indications for fixation of distal radius fractures; however, trends in fracture fixation techniques evolve over time.
      Although nonsurgical management remains the most common treatment, fracture fixation has increasingly transitioned from percutaneous pinning to a variety of open treatments over the last 2 decades.
      • Azad A.
      • Kang H.P.
      • Alluri R.K.
      • Vakhshori V.
      • Kay H.F.
      • Ghiassi A.
      Epidemiological and treatment trends of distal radius fractures across multiple age groups.
      More recently, many hand surgeons have transitioned to a volar locking plate fixation technique, as it has been shown to lead to an earlier functional recovery within 3 months.
      • Rozental T.D.
      • Blazar P.E.
      • Franko O.I.
      • Chacko A.T.
      • Earp B.E.
      • Day C.S.
      Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial.
      ,
      • Hammer O.L.
      • Clementsen S.
      • Hast J.
      • Benth J.Š.
      • Madsen J.E.
      • Randsborg P.H.
      Volar locking plates versus augmented external fixation of intra-articular distal radial fractures: functional results from a randomized controlled trial.
      Although relatively rare, infection after distal radius fracture fixation can be a devastating complication, leading to potential hardware removal, prolonged antibiotic courses, multiple office visits, and increased overall costs.
      • Margaliot Z.
      • Haase S.C.
      • Kotsis S.V.
      • Kim H.M.
      • Chung K.C.
      A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures.
      As health care costs continue to increase each year, private- and government-based insurance programs are developing innovative reimbursement models, like episode-based payments, which should accurately account for the impact of potential postoperative complications like infection.
      • Huetteman H.E.
      • Zhong L.
      • Chung K.C.
      Cost of surgical treatment for distal radius fractures and the implications of episode-based bundled payments.
      This study aims to identify potential risk factors for infectious complications after distal radius fracture fixation and assess the impacts on overall costs as a result of postoperative infection within a large national database. We hypothesized that modifiable risk factors like smoking would lead to higher rates of infection in distal radius fracture fixation, which potentially affords the hand surgeon an opportunity for decreasing rates of infection.

      Materials and Methods

      Database

      The study used the PearlDiver (PearlDiver, Inc) patient database of privately insured patients across all regions of the country, encompassing 53 million unique patients from January 1, 2010, to March 31, 2020, in all treatment settings, including inpatient (hospital-based) and outpatient (hospital-, ambulatory surgical center-, and office-based) facilities. The information was accessed through a secure server using PearlDiver’s proprietary software. The study used deidentified patient data from the database; however, studied groups with 10 patients or fewer were not reported by the database to protect privacy. Institutional review board approval for this study was not required, as the data studied are publicly available and are completely deidentified; thus the study was exempt from institutional review board approval. In order to ensure the validity of the study, we used the Strengthening the Reporting of Observational Studies in Epidemiology guidelines and checklists in performing the study.
      • von Elm E.
      • Altman D.G.
      • Egger M.
      • et al.
      The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.

      Study cohort

      The study cohort included patients undergoing distal radius fracture fixation, identified by Current Procedural Terminology (CPT) codes 25606–25609, who actively had insurance 30 days prior to fixation and throughout the 180-day follow-up period. Patients exclusively undergoing percutaneous fixation (CPT code 25606) were assessed, as well as those undergoing open reduction and internal fixation (CPT codes 25607–25609). Patients undergoing external fixator placement alone (CPT code 20690) were excluded from the analysis, as this code is not specific to patients with radius fractures. Patient demographic data were collected, including age, gender, geographic region, and treatment setting. Pediatric patients were included in the cohort.
      A study endpoint of postoperative infection within 180 days of surgical fixation was chosen. This 180-day period includes the global period; is likely to capture infections related to fracture fixation, given the nonspecificity of postoperative infection codes; and is within the typical follow-up period for bony infection.
      • Conterno L.O.
      • Turchi M.D.
      Antibiotics for treating chronic osteomyelitis in adults.
      Infection in our study was defined as a postoperative infection (both superficial and deep), periprosthetic infection, acute osteomyelitis, or hardware infection (Appendix, available on the Journal’s website at www.jhsgo.org), in order to account for all types of infection associated with fixation.

      Statistical analysis

      Frequencies of baseline patient demographics, comorbidities, fixation methods, and types of fracture were tabulated. A 2-sample t test was used to compare rates of infection between open and percutaneous fracture fixation techniques. The total direct cost of care to insurance related to the distal radius fracture fixation was assessed and calculated, which includes costs for all appointments, medications, surgical interventions, and postoperative rehabilitation. Indirect costs were not included in the analysis. Total costs for open reduction and internal fixation were compared to total costs of percutaneous fixation using a t test. A Mann-Whitney-Wilcoxon test was used to compare costs of care in cases with and without an infection, given that cost data are typically nonparametric.
      We used a multivariable logistic regression analysis to define independent risk factors for developing postoperative infections after overall (percutaneous and open) distal radius fracture fixation. The 2 methods of surgical fixation were combined to represent the vast majority of distal radius fixation techniques. Common comorbid conditions, modeled off the Charlson Comorbidity Index, were included in the analysis. A cohort was propensity-matched 1-to-1 with calipers of 0.05, which represents the maximum tolerated distance between subjects matched, based on patient age, gender, and open fracture in order to control for the prospect of gross contamination associated with an open wound. A logistic regression analysis was then used on the propensity-matched cohorts to assess risk factors for developing infection within these matched cohorts. Throughout the study, a P value < .05 was considered statistically significant.

      Results

      The database included 87,169 patients who underwent distal radius fracture fixation (Table 1); of these, 75,139 (86.2%) underwent open fixation and 12,029 (13.8%) underwent percutaneous fixation. The majority of patients were female (76.7%) and were adults between 18 and 64 years of age (50.6%) or were 65 years of age or older (41.3%). Treatment was predominantly in the outpatient setting (87.6%) versus the inpatient setting (11.7%).
      Table 1Demographics of Patients Undergoing Distal Radius Fixation (n = 87169)
      DemographicsNo.Percentage, %
      Age, y
       <1870778.1
       18–644412350.6
       ≥653596941.3
      Region
       Midwest2355827.0
       Northeast1520317.4
       South3560940.9
       Unknown1880.2
       West1261114.5
      Gender
       Female6684276.7
       Male2032723.3
      Comorbidities
       Chronic obstructive pulmonary disease2886833.1
       Cerebrovascular disease1947822.3
       Chronic kidney disease1187413.6
       Coronary artery disease1949122.4
       Diabetes2647930.4
       Hypertension5508463.2
       Liver disease1251214.4
       Previous cancer diagnosis1327615.2
       Obesity2333026.8
       Tobacco use2091424.0
       Open fracture42944.9
      Treatment location
       Inpatient1020411.7
       Office3790.4
       Outpatient7639787.6
       Unknown1800.3
      Approximately 4.9% (4294) of patients undergoing distal radius fracture fixation had an open fracture. Of the studied population, 24% of patients were tobacco users and nearly a third (30.4%) were diabetic. Demographic characteristics are summarized in Table 1.
      Postoperative infections were identified in 781 patients (0.9%). An analysis of a 2-sample t test demonstrated a statistically significant difference in postoperative infections with percutaneous fixation (1.3%) versus open fixation (0.8%; P < .005).
      A logistic regression analysis identified male gender, open fracture, lung disease, chronic kidney disease, diabetes, hypertension, liver disease, obesity, and tobacco used to be independent risk factors for developing a postoperative infection (Table 2); an age greater than 65 appeared to be protective against a postoperative infection. Histories of cancer, cerebrovascular disease, or coronary artery disease did not have statistically significant impacts on postoperative infections after distal radius fracture fixation (Table 2). Propensity-matched cohorts comparing patients with and without infection based on age, gender, and open versus closed fracture yielded 1,562 total patients in a 1:1 match (781 infected and 781 controls). A logistic regression analysis of these cohorts demonstrated that tobacco use was the only statistically significant risk factor within this subgroup (Table 3).
      Table 2Logistic Regression Analysis of Risk Factors for Infection After Distal Radius Fracture Fixation
      VariableOdds Ratio95% Confidence IntervalP Value
      Age >650.620.52–0.73<.005
      Male gender1.601.37–1.87<.005
      Chronic lung disease/chronic obstructive pulmonary disease1.261.08–1.47.003
      History of cancer1.050.86–1.27.628
      History of cerebrovascular disease1.180.99–1.40.067
      History of chronic kidney disease1.281.05–1.55.014
      History of coronary artery disease0.990.83–1.19.933
      History of diabetes1.241.06–1.46.008
      History of hypertension1.351.12–1.62.002
      History of liver disease1.201.00–1.43.005
      History of obesity1.281.10–1.50.002
      Tobacco use1.551.33–1.81<.005
      Open fracture2.542.03–3.14<.005
      Table 3Logistic Regression Analysis of Risk Factors after Propensity Matching
      VariableOdds Ratio95% Confidence IntervalP Value
      Age >650.970.76–1.24.806
      Male gender1.050.84–1.30.689
      Chronic lung disease/chronic obstructive pulmonary disease0.910.69–1.19.390
      History of cancer1.100.88–1.37.486
      History of cerebrovascular disease1.160.90–1.49.242
      History of chronic kidney disease1.160.87–1.54.310
      History of coronary artery disease0.990.76–1.29.954
      History of diabetes0.900.71–1.13.354
      History of hypertension1.210.94–1.56.142
      History of liver disease1.160.89–1.51.274
      History of obesity1.170.94–1.46.161
      Tobacco use1.311.05–1.64.017
      The average direct cost of care for open reduction and internal fixation with and without infection was $9,917 (SD $19,192). The average direct cost of care for percutaneous fixation with and without infection was $7,531 (SD $23,692). There was a significant difference between these 2 costs (t[87694] = −12.69; P < .005). The average cost of care for patients undergoing distal radius fracture fixation, both open and percutaneous, without an infection was $6,383 (SD $13,903). The average cost of care for patients who developed a postoperative infection was $23,355 (SD $40,412). A Mann-Whitney-Wilcoxon test demonstrated a significant difference in these costs (P ≤ .005; difference 5,543; 95% confidence interval, 4,899–6,234).

      Discussion

      This study used a national database to examine risk factors for infection after distal radius fracture fixation and to assess the impact of an infection on costs. Despite a postoperative infection appearing to be a relatively rare complication, occurring in only 0.9% of patients studied, the significant cost difference experienced by this population likely signifies a cascade of costly clinical events. Although limited in the setting of an acute trauma like a distal radius fracture, there appear to be both modifiable and nonmodifiable risk factors for infection after fracture fixation.
      Open reduction and internal fixation for distal radius fractures has become increasingly more common than percutaneous techniques over the past 2 decades.
      • Rozental T.D.
      • Blazar P.E.
      • Franko O.I.
      • Chacko A.T.
      • Earp B.E.
      • Day C.S.
      Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial.
      ,
      • Mattila V.M.
      • Huttunen T.T.
      • Sillanpää P.
      • Niemi S.
      • Pihlajamäki H.
      • Kannus P.
      Significant change in the surgical treatment of distal radius fractures: a nationwide study between 1998 and 2008 in Finland.
      This trend is mirrored in our study, as over 86% of patients underwent internal fixation. While volar locking plates have been demonstrated to have earlier short-term recovery of function, recent studies within the literature suggest that there is no significant difference in radiological or patient-reported outcomes between surgical fixation techniques in the long term.
      • Marcheix P.S.
      • Dotzis A.
      • Benkö P.E.
      • Siegler J.
      • Arnaud J.P.
      • Charissoux J.L.
      Extension fractures of the distal radius in patients older than 50: a prospective randomized study comparing fixation using mixed pins or a palmar fixed-angle plate.
      ,
      • Goehre F.
      • Otto W.
      • Schwan S.
      • Mendel T.
      • Vergroesen P.P.
      • Lindemann-Sperfeld L.
      Comparison of palmar fixed-angle plate fixation with K-wire fixation of distal radius fractures (AO A2, A3, C1) in elderly patients.
      Our study demonstrated a significant cost difference between percutaneous fixation and open reduction and internal fixation, as percutaneous methods were overall less expensive in terms of direct costs. These results are similar to those previously reported in the literature, with percutaneous methods being a lower-cost methodology.
      • Nandyala S.V.
      • Giladi A.M.
      • Parker A.M.
      • Rozental T.D.
      Comparison of direct perioperative costs in treatment of unstable distal radial fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning.
      ,
      • Tubeuf S.
      • Yu G.
      • Achten J.
      • et al.
      Cost effectiveness of treatment with percutaneous Kirschner wires versus volar locking plate for adult patients with a dorsally displaced fracture of the distal radius: analysis from the DRAFFT trial.
      This study, however, demonstrates that there is a significant difference in the rates of postoperative infection between open reduction and internal fixation and percutaneous pinning; the significant, 4-fold increase in cost of care as a result of these infections is another potential reason for the evolving trend in fracture fixation. Prior cost analyses comparing percutaneous fixation to open reduction and internal fixation have demonstrated a substantial cost difference between the 2 methodologies.
      • Huetteman H.E.
      • Zhong L.
      • Chung K.C.
      Cost of surgical treatment for distal radius fractures and the implications of episode-based bundled payments.
      These cost savings, however, are theoretically diminished given the significantly higher rate of infection and the significant cost difference associated with a postoperative infection. Previous studies have identified external fixation as conferring a higher infection risk compared to internal fixation, with a meta-analysis identifying rates of infection of 11% in external fixation and 0.8% in open reduction.
      • Margaliot Z.
      • Haase S.C.
      • Kotsis S.V.
      • Kim H.M.
      • Chung K.C.
      A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures.
      While rates of infection within our studied cohort appear to be similar to those of previous studies for open reduction, our rates of infection for percutaneous pinning are lower than those previously reported. This may be due to a lack of billing and coding for superficial infections.
      • Chaudhry H.
      • Kleinlugtenbelt Y.V.
      • Mundi R.
      • Ristevski B.
      • Goslings J.C.
      • Bhandari M.
      Are volar locking plates superior to percutaneous K-wires for distal radius fractures? A meta-analysis.
      Although current evidence-based guidelines indicate no need for perioperative antibiotics for soft tissue operations on the hand and wrist, there is no consensus guideline on the use of perioperative antibiotics for bony fixation.
      • Johnson S.P.
      • Zhong L.
      • Chung K.C.
      • Waljee J.F.
      Perioperative antibiotics for clean hand surgery: a national study.
      ,
      • Ariyan S.
      • Martin J.
      • Lal A.
      • et al.
      Antibiotic prophylaxis for preventing surgical-site infection in plastic surgery: an evidence-based consensus conference statement from the American Association of Plastic Surgeons.
      Current recommendations do suggest the utility of perioperative antibiotics in the setting of a distal radius fracture fixation.
      • Eberlin K.R.
      • Ring D.
      Infection after hand surgery.
      We identified multiple risk factors for postoperative infection, including male gender, open fracture, lung disease, chronic kidney disease, diabetes, hypertension, liver disease, obesity, and tobacco use. Open fracture was the strongest predictor for a postoperative infection. Open fracture has long been known to have an increased risk of infection, given the potential for contamination of the wound bed.
      • Gustilo R.B.
      • Anderson J.T.
      Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses.
      Treatment guidelines and quality metrics advocate for expedient administration of antibiotics in long bone fractures, as these measures have been shown to improve infections and overall outcomes.
      • Chang Y.
      • Bhandari M.
      • Zhu K.L.
      • et al.
      Antibiotic prophylaxis in the management of open fractures: a systematic survey of current practice and recommendations.
      ,
      • Hauser C.J.
      • Adams II, C.A.
      • Eachempati S.R.
      Council of the Surgical Infection Society. Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline.
      Data for open hand and wrist fractures are limited, and no consensus guidelines exist; however, 1 meta-analysis demonstrated a significant reduction in postinjury infections, from 9.4% to 4.4%, with antibiotic prophylaxis.
      • Ketonis C.
      • Dwyer J.
      • Ilyas A.M.
      Timing of debridement and infection rates in open fractures of the hand: a systematic review.
      Overall risk factors that conferred a level of immunocompromise, like chronic kidney disease, liver disease, and diabetes, seemed to incur a risk of postoperative infection. Diabetes has been well-established as conferring an increased risk of surgical site infection, and this was corroborated in our study.
      • Martin E.T.
      • Kaye K.S.
      • Knott C.
      • et al.
      Diabetes and risk of surgical site infection: a systematic review and meta-analysis.
      Obesity also was an independent risk factor in our study for a postoperative infection after fracture fixation. Recent meta-analyses of the orthopedic surgery population have established obesity as a risk factor for infection.
      • Yuan K.
      • Chen H.L.
      Obesity and surgical site infections risk in orthopedics: a meta-analysis.
      Recent studies have also highlighted obesity as a risk factor for higher-complexity fractures or overall more severe fracture patterns.
      • Ebinger T.
      • Koehler D.M.
      • Dolan L.A.
      • McDonald K.
      • Shah A.S.
      Obesity increases complexity of distal radius fracture in fall from standing height.
      ,
      • Montague M.D.
      • Lewis J.T.
      • Moushmoush O.
      • Ryu J.
      Distal radius fractures: does obesity affect fracture pattern, treatment, and functional outcomes?.
      Older age may serve as a protective factor against a postoperative infection, because distal radius fractures suffered in this population are more likely as a result of lower-energy mechanisms, like a fall from a standing height, compared to those suffered in younger populations.
      • Nellans K.W.
      • Kowalski E.
      • Chung K.C.
      The epidemiology of distal radius fractures.
      • Flinkkilä T.
      • Sirniö K.
      • Hippi M.
      • et al.
      Epidemiology and seasonal variation of distal radius fractures in Oulu, Finland.
      • Sigurdardottir K.
      • Halldorsson S.
      • Robertsson J.
      Epidemiology and treatment of distal radius fractures in Reykjavik, Iceland, in 2004. Comparison with an Icelandic study from 1985.
      • Garner M.R.
      • Sethuraman S.A.
      • Schade M.A.
      • Boateng H.
      Antibiotic prophylaxis in open fractures: evidence, evolving issues, and recommendations.
      The most recent joint guidelines from the American Association of Orthopedic Surgeons and American Society for Surgery of the Hand delineate fracture fixation by patient age.
      American Academy of Orthopaedic Surgeons
      Management of Distal Radius Fractures Evidence-Based Clinical Practice Guideline.
      In the nongeriatric population, the guideline suggests with moderate strength evidence that operative fixation with postreduction radial shortening greater than 3 mm, dorsal tilt beyond 10°, or intraarticular displacement or step-off of 2 mm or more leads to improved radiographic and patient-reported outcomes, whereas in the geriatric population it suggests with strong evidence that operative fixation does not necessarily lead to improved outcomes. While treatment decisions, including the decision to operate, should be individualized to the patient in light of these recommendations, our study highlights multiple risk factors that may help further influence the decision on whether or not to operate in the setting of a closed fracture in a high-risk patient.
      Propensity matching was used to control for age, gender, and open fracture. Regression based on
      this cohort demonstrated that tobacco use conferred a significantly higher risk for a postoperative infection. Tobacco use has long been established as a significant risk factor for postoperative infections, wound healing problems, and bone-healing problems.
      • Sørensen L.T.
      Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review.
      While smoking has not been identified as an independent risk factor for fracturing the distal radius itself, osteoporosis, which is strongly associated with smoking, is a strong risk factor for distal radius fracture.
      • Xu W.
      • Ni C.
      • Yu R.
      • Gu G.
      • Wang Z.
      • Zheng G.
      Risk factors for distal radius fracture in postmenopausal women.
      Within hand surgery, smoking is associated with overall surgical site complications and infections, and this can be seen within the logistic regression analyses of both the overall cohort and the propensity-matched cohort.
      • Garner M.R.
      • Sethuraman S.A.
      • Schade M.A.
      • Boateng H.
      Antibiotic prophylaxis in open fractures: evidence, evolving issues, and recommendations.
      Complication rates, including infectious complications, were demonstrated to be higher in current smokers in 2 recent studies.
      • Hall M.J.
      • Ostergaard P.J.
      • Dowlatshahi A.S.
      • Harper C.M.
      • Earp B.E.
      • Rozental T.D.
      The impact of obesity and smoking on outcomes after volar plate fixation of distal radius fractures.
      ,
      • Hess D.E.
      • Carstensen S.E.
      • Moore S.
      • Dacus A.R.
      Smoking increases postoperative complications after distal radius fracture fixation: a review of 417 patients from a level 1 trauma center.
      Given the acute time frame of distal radius fracture fixation—typically within 2 weeks of injury—tobacco use and smoking cessation represent the most likely modifiable risk factor for preventing infection after distal radius fracture fixation. Smoking cessation can have demonstrable physiologic effects from 1 hour of cessation, and data indicate that cessation does have a positive impact on infectious healing complications.
      • Sørensen L.T.
      Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review.
      Clinical care pathways for tobacco cessation for orthopedic trauma have been proposed, and are based on models with significant demonstrable success in other fields.
      • Cho B.H.
      • Aziz K.T.
      • Giladi A.M.
      The impact of smoking on early postoperative complications in hand surgery.
      These pathways rely on multilevel cessation resources and therapies that trigger as soon as the patient is designated a tobacco user in the electronic medical record.
      There are a number of limitations with this study. An epidemiological study indicated that distal radius fractures have a bimodal distribution, with peaks occurring in patients younger than 18 years old and those above 65 years old; however, this study focused on surgical management of these fractures, creating a bias toward the studied population that predominantly includes patients older than 18 years.
      • Truntzer J.
      • Comer G.
      • Kendra M.
      • Johnson J.
      • Behal R.
      • Kamal R.N.
      Perioperative smoking cessation and clinical care pathway for orthopaedic surgery.
      There is a female preponderance of distal radius fractures requiring fixation, and this is more common in patients older than 65, which has been noted in previously in analyses of a similar cohort within the PearlDiver cohort.
      • MacIntyre N.J.
      • Dewan N.
      Epidemiology of distal radius fractures and factors predicting risk and prognosis.
      These trends have been cited as a result of a rise in the number of active advanced-age patients, and a concomitant rise in this patient population seeking a highly functioning outcome after an injury.
      • Nellans K.W.
      • Kowalski E.
      • Chung K.C.
      The epidemiology of distal radius fractures.
      Given that the PearlDiver software utilizes insurance claims–based data, the data are only as accurate as is allowed by International Classification of Diseases Ninth and Tenth Edition and CPT codes. Clinical nuances and data are inherently limited by this type of database, and results may be biased by improper or nonspecific coding. These codes cannot accurately account for the surgical technique or clinical context. Furthermore, coding for postoperative infections is not directly related to index procedures; thus, it is plausible that codes from other surgeries were captured within the data set. A cost analysis within the PearlDiver database only considers direct payment costs associated with fracture fixation and is unable to include indirect costs, like those due to lost time working or costs to employers.
      Infection after distal radius fracture fixation is a rare complication. Given that costs are significantly increased after postoperative infection by almost 4-fold, attempts to address risk factors may lead to substantial cost savings and decreased rates of infection.

      Supplementary Data

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