Early Plain Film After Volar Plate Fixation for Distal Radius Fractures: Is Reallly Useful?


 Background: The value of early postoperative radiographs is generally questioned after volar plate fixation(VLP) for distal radius fractures(DRFs). The purpose of this study was to evaluate the utility of early routine radiographs following volar plate fixation.Methods:A restropective study was developed on distal radius fractures treated with volar plate fixation between 1 January 2016 and 1 January 2020 in our hospital. We obtain relevant information from patient electronic records including basic patient information and treatment information.Reoperation or further checking after early postoperative radiographs was defined as management change，which illustrates early postoperative radiographs influence postoperative treatment.Results: A total of 213 patients treated with VLP were included. There are 179 patients having early postoperative radiographs in included patients. Two out of 179 patients were altered management,which underwent further imaging with computed tomography(CT) due to pain and swelling.This two patients were in line with Type C(AO/OTA classification). No patient has surgery again.Conclunsion: Early postoperative radiographs can not bring about an adjustment in postoperative management with VLP after DRF.But intra-articular fractures may still benefit from early postoperative radiographs compared with extra-articular fractures.


Introduction
Distal radius fractures are the most common fracture in the hand and forearm fracture, more than 600,000 individuals suffer distal radius fractures each year in the United States [1,2]. Recently, the percentage of patients having volar plate xation(VLP) for distal radius fractures(DRFs) is increasing rapidly with superiority including low damage and fast recovery [3,4]. Meanwhile, Obtaining postoperative radiographs in the postoperative period after VLP is common practice [5]. However, The use of routine early postoperative radiographs provides an example where a service may be overused beyond its costeffectiveness because it seems meaningless. This may pose an increasing burden on healthcare resources because it can not play a role in the management of patients with VLP [6].
Currently, scholars have no consensus on the early postoperative radiographs on account of there is no clinical evidence to indicate routine postoperative radiographs alter clinical management [7,8]. Sharma et al. [9] retrospectively reviewed postoperative radiographs after volar locking plate xation and found that 94% of 172 patients had early postoperative radiographs, which rarely in uenced clinical decisionmaking. Stone et al [10] found that three out of 268 (1%) patients were decided to undergo reoperation at the 2-week visit due to the loss of xation. Routine 2-week post-operative radiographs rarely led to a change in patient management, which may have added ineffective cost to the health care system.
Huffaker et al. [11] suggested the patients with AO type A DFRs(AO/OTA classi cation) do not require routine postoperative lms, but the value of early postoperative radiographs in AO type B and C fractures should be further studied.
In our institution, early routine postoperative radiographs seem to be generally accepted. Recent studies have shown that this may not bene t patients, but increase medical costs and radiation risks [12]. Thus, the purpose of this study was to evaluate the utility of early postoperative radiographs following VLP.

Patients
We retrospectively analyzed consecutive patients in a tertiary hospital. All patients who were aged 18 years or older with a distal radius fracture and had VLP xation within 2 weeks after injury.The exclusion criteria were an absence of follow-up data,pathologic fractures, open fractures, and multiple fractures. We de ne the early postoperative examination as the examination within two weeks after the operation.In our hospital, All patients were informed to have about 2-week postoperative radiographs after surgery.

Data Collection
We utilized hospital electronic databases to search the recording of patients undergoing VLP for DRFs by diagnosis. the hospitalization number of each patient was used to retrieve the medical history of each patient and sort out the treatment process. furthermore, postoperative clinical information including treatment process was collected from electronic health records, radiographs were gathered by archiving and communication systems (PACS). Existence of radiographs on PACS was exploited to recognize whether early radiographs had been performed. Changed postoperative management was de ned as breaking in the routine rehabilitation process after surgery, such as further inspection or further revision surgery. Basic demographic information was recorded: patients age at operation, gender, injured side, type of fracture basing on the Orthopaedic Trauma Association (AO/OTA) classi cation, treatment strategy after early postoperative radiographs. Because of the retrospective of this study, ethics committee approval was not required. But patients' informed consent was required.

Statistical analysis
Descriptive statistics are reported for baseline data, fracture type. statistical results are reported separately for patients who alter postoperative management and patients who do not alter postoperative management. The process of inclusion and exclusion can be seen in Fig. 1( A ow chart). Average time from operation to rst plain lms 12-16 days. Of the 179 patients with early radiographs, 87 patients had extra-articular fractures (49%) and 92 had intra-articular fractures (51%). According to the early postoperative radiographs, the treatment plan of 2 patients needs to be adjusted. 2 patients having comminuted intra-articular fracture underwent a CT examination due to pain and swelling in the surgical incision area and nally used plaster external xation to ensure the fracture is stable. This two patients were in line with Type C(AO/OTA classi cation).

Discussion
The cores of operative treatment for DRFs include keeping reduction and strong xation [4,13].Orthopedic surgeons always evaluate the reduction and healing progress of the fracture in the light of postoperative imaging.However, more and more investigators question the signi cance of early postoperative imaging because this not only may increase the cost of medical management and radiation dose,but also can't display fracture healing progress early [14]. The purpose of this study is to evaluate the worth of routine postoperative radiographs for patients following VLP through a retrospective analysis of patients.
As far as we know, This is the rst study assessing postoperative visit x-rays for patients treated with volar locking plates in China.In this study, the effect of early radiographs after VLP was evaluated with a retrospective analysis of 213 patients. We committed to revealing whether early routine plain lms will change clinical treatment strategies. In our sample, 179 patients had routine early radiographs after their operation, of which 2 (1.1%) had their clinical management altered. The fracture type of all 2 were consistent with AO C3 fractures, which have the highest risk of complications due to their complexity. These results suggest that early postoperative radiographs offer little clinical information in the assessment and management of operatively xed DRFs with a volar locking plate, particularly in the extra-articular. In other words, early postoperative radiographs rarely change the postoperative clinical management of patients.
At the same time, we also noticed 94% of patients had extra-articular fractures among patients who did not undergo early imaging,it may be bacause they were told that their fracture is not serious by surgeons in the rst visiting.
Our results are consistent with the ndings of prior studies. Chaudhry et al. [15] demonstrated that serial radiographs in acute settings do not alter fracture management in minimally displaced fractures. Besides, Teo et al. [16] reported that current literature suggested immediate postoperative radiography can't result in management change in the great majority of patients after orthopedic surgery. Added profound reporting and further prospective comparative research should be encouraged. Furthermore, Johnson et al. [6] showed that 96% of patients did not undergo further treatment after early plain lms. Based on their study, this may provide a basis for reducing early postoperative imaging examinations.Weil et al. [17] demonstrated only 1.5% of routine radiographs affect post-operative management after VLP for DRFs, high medical costs associated should be weighed, many radiographs are taken on routine without altered clinical decision-making and can be removed. Schultz et al. [7] found early postoperative radiographs had no obvious effect on patient satisfaction, but it may play an important role in the surgeon's explanation of their injury.
These studies concluded that early routine radiographs did not signi cantly in uence clinical decision making, but did increase health care costs and radiation exposure. our study performs all 2 patients who had AO type C fractures(AO/OTA classi cation)were altered treatment,it mays be related to AO type C fractures resulted in the highest risk of complications.Although current research shows that early postoperative examination is of little signi cance, we consider it is not advisable to arbitrarily reduce early postoperative inspections.We believe that decisions should be made on a case-by-case basis based on the individual risk of each patient.This emphasizes the importance of risk strati cation, and routine early postoperative X-ray examinations for some patients with DRFs. By the current results, DRFs patients with type C (AO/OTA classi cation) need more early postoperative radiographs.
There are some limitations in our research. First of all, we neither introduced a functional rating scale to evaluate the postoperative situation nor did we investigate patient satisfaction, whether to undergo revision surgery may not be enough to explain the problem. Secondly, this study is retrospective and may limit the interpretation of data, a prospective study could easily be developed to increase the numbers and reliability of the data. At last, The small sample size may make it di cult to obtain reliable conclusions.

Conclusion
Although the practice of evaluating the quality of reduction by early postoperative radiographs at the postoperative follow-up is very common, we nd that early postoperative radiographs do not bring about an adjustment in postoperative management, rather depose a nancial burden on the medical insurance system and increase radiation risk. Moreover,intra-articular fractures may still bene t from early postoperative radiographs compared with extra-articular fractures.Thus, we call for the reduction of unnecessary postoperative radiographs in the clinical visit.

Declarations
Availability of data and materials The data and materials contributing to this article may be made available upon request by sending an email to the rst author. Figure 1 ow chart of study