Complications After Open Reduction and Internal Fixation for Distal Radius Fractures in Patients With and Without Rheumatoid Arthritis

Published:October 07, 2022DOI:


      Rheumatoid arthritis (RA) can have severe impact on patients’ functional abilities and increase the risk of fragility fractures. Little is known about how patients with RA fare after operative management of distal radius fractures. The purpose of this study was to compare postoperative complications after surgical fixation in patients with RA and controls, hypothesizing that patients with RA would have higher levels of postoperative complications.


      Patients were identified using Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes for open treatment of distal radius fractures and RA at 3 level 1 trauma centers over a 5-year period (2015–2019). Chart abstraction provided details regarding injuries and treatment. Age- and sex-matched controls were identified in a 2:1 ratio. Postoperative complications were classified according to the Clavien-Dindo-Sink classification system and divided into early (less than 90 days) and late groups.


      Sixty-four patients (21 with RA and 43 controls) were included. The patients were predominantly women, with a mean age of 62 years and a mean Charlson comorbidity index of 2.1. The RA medications at the time of injury included conventional synthetic disease-modifying antirheumatic drugs (5/21), biologic disease-modifying antirheumatic drugs (5/21), or chronic oral prednisone (6/21). Rheumatoid medications, except hydroxychloroquine, were withheld for 2–3 weeks after surgery. Rheumatoid patients were significantly more likely to sustain a complication compared with the control group, although this was no longer significant on adjusted analysis. Class I complications were the most common. The incidence of early versus late complications was similar between the groups. A high rate of early return to surgery for fixation failure occurred in the RA group compared with none in the control group.


      Patients with RA undergoing operative management of distal radius fractures are at risk of postoperative complications, particularly fracture fixation failure, necessitating return to the operative room. High levels of pain, stiffness, and mechanical symptoms were noted in the RA group.

      Type of study/level of evidence

      Prognostic IV.

      Key words

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        • Cross M.
        • Smith E.
        • Hoy D.
        • et al.
        The global burden of rheumatoid arthritis: estimates from the global burden of disease 2010 study.
        Ann Rheum Dis. 2014; 73: 1316-1322
        • Hunter T.M.
        • Boytsov N.N.
        • Zhang X.
        • Schroeder K.
        • Michaud K.
        • Araujo A.B.
        Prevalence of rheumatoid arthritis in the United States adult population in healthcare claims databases, 2004-2014.
        Rheumatol Int. 2017; 37: 1551-1557
        • Xue A.L.
        • Wu S.Y.
        • Jiang L.
        • Feng A.M.
        • Guo H.F.
        • Zhao P.
        Bone fracture risk in patients with rheumatoid arthritis: a meta-analysis.
        Medicine (Baltimore). 2017; 96e6983
        • Kim S.Y.
        • Schneeweiss S.
        • Liu J.
        • et al.
        Risk of osteoporotic fracture in a large population-based cohort of patients with rheumatoid arthritis.
        Arthritis Res Ther. 2010; 12: 1-10
        • Yamamoto Y.
        • Turkiewicz A.
        • Wingstrand H.
        • Englund M.
        Fragility fractures in patients with rheumatoid arthritis and osteoarthritis compared with the general population.
        J Rheumatol. 2015; 42: 2055-2058
        • Ochi K.
        • Go Y.
        • Furuya T.
        • et al.
        Risk factors associated with the occurrence of distal radius fractures in Japanese patients with rheumatoid arthritis: a prospective observational cohort study.
        Clin Rheumatol. 2014; 33: 477-483
        • Zhu T.Y.
        • Griffith J.F.
        • Qin L.
        • et al.
        Structure and strength of the distal radius in female patients with rheumatoid arthritis: a case-control study.
        J Bone Miner Res. 2013; 28: 794-806
        • Kocijan R.
        • Finzel S.
        • Englbrecht M.
        • Engelke K.
        • Rech J.
        • Schett G.
        Decreased quantity and quality of the periarticular and nonperiarticular bone in patients with rheumatoid arthritis: a cross-sectional HR-pQCT study.
        J Bone Miner Res. 2014; 29: 1005-1014
        • Koyama K.
        • Ohba T.
        • Ebata S.
        • Haro H.
        Postoperative surgical infection after spinal surgery in rheumatoid arthritis.
        Orthopedics. 2016; 39: e430-e433
        • Hresko A.M.
        • Got C.J.
        • Gil J.A.
        Perioperative management of immunosuppressive medications for rheumatoid arthritis.
        J Hand Surg Am. 2022; 47: 370-378
        • Jauregui J.J.
        • Kapadia B.H.
        • Dixit A.
        • et al.
        Thirty-day complications in rheumatoid patients following total knee arthroplasty.
        Clin Rheumatol. 2016; 35: 595-600
        • Park J.S.
        • Shim K.D.
        • Song Y.S.
        • Park Y.S.
        Risk factor analysis of adjacent segment disease requiring surgery after short lumbar fusion: the influence of rheumatoid arthritis.
        Spine J. 2018; 18: 1578-1583
        • Tanouchi T.
        • Shimizu T.
        • Fueki K.
        • Ino M.
        • Toda N.
        • Manabe N.
        Adjacent-level failures after occipito-thoracic fusion for rheumatoid cervical disorders.
        Eur Spine J. 2014; 23: 635-640
        • Kang C.N.
        • Kim C.W.
        • Moon J.K.
        The outcomes of instrumented posterolateral lumbar fusion in patients with rheumatoid arthritis.
        Bone Joint J. 2016; 98: 102-108
        • Klifto K.M.
        • Cho B.H.
        • Lifchez S.D.
        The management of perioperative immunosuppressant medications for rheumatoid arthritis during elective hand surgery.
        J Hand Surg Am. 2020; 45: 779-e1
        • Xiong G.
        • Greene N.E.
        • Lightsey I.V. H.M.
        • et al.
        Telemedicine use in orthopaedic surgery varies by race, ethnicity, primary language, and insurance status.
        Clin Orthop Relat Res. 2021; 479: 1417-1425
        • Fraenkel L.
        • Bathon J.M.
        • England B.R.
        • et al.
        2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis.
        Arthrit Care Res. 2021; 73: 924-939
        • Lin Y.J.
        • Anzaghe M.
        • Schulke S.
        Update on the pathomechanism, diagnosis, and treatment options for rheumatoid arthritis.
        Cells. 2020; 9: 880
        • Clavien P.A.
        • Sanabria J.R.
        • Strasberg S.M.
        Proposed classification of complications of surgery with examples of utility in cholecystectomy.
        Surgery. 1992; 111: 518-526
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Sink E.L.
        • Leunig M.
        • Zaltz I.
        • Gilbert J.C.
        • Clohisy J.
        Reliability of a complication classification system for orthopaedic surgery.
        Clin Orthop Relat Res. 2012; 470: 2220-2226
        • Dodwell E.R.
        • Pathy R.
        • Widmann R.F.
        • et al.
        Reliability of the modified Clavien-Dindo-Sink complication classification system in pediatric orthopaedic surgery.
        JB JS Open Access. 2018; 3e0020
        • 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.
        Int J Surg. 2014; 12: 1495-1499
        • Hresko A.M.
        • Got C.J.
        • Gil J.A.
        Perioperative management of immunosuppressive medications for rheumatoid arthritis.
        J Hand Surg Am. 2022; 47: 370-378
        • Dai S.M.
        • Nishioka K.
        • Yudoh K.
        Interleukin (IL) 18 stimulates osteoclast formation through synovial T cells in rheumatoid arthritis: comparison with IL1 beta and tumour necrosis factor α.
        Ann Rheum Dis. 2004; 63: 1379-1386
        • Kotake S.
        • Udagawa N.
        • Hakoda M.
        • et al.
        Activated human T cells directly induce osteoclastogenesis from human monocytes: possible role of T cells in bone destruction in patients with rheumatoid arthritis.
        Arthritis Rheum. 2001; 44: 1003-1012
        • Stromqvist B.
        Hip fracture in rheumatoid arthritis.
        Acta Orthop Scand. 1984; 55: 624-628
        • Hu Y.
        • Zhang T.
        • Huang H.
        • et al.
        Fracture healing in a collagen-induced arthritis rat model: radiology and histology evidence.
        J Orthop Res. 2018; 36: 2876-2885
        • Zura R.
        • Xiong Z.
        • Einhorn T.
        • et al.
        Epidemiology of fracture nonunion in 18 human bones.
        JAMA Surg. 2016; 151e162775
        • Feehan L.M.
        • Li L.L.
        • McKay H.A.
        Micro-structural bone changes in early rheumatoid arthritis persist over 1-year despite use of disease modifying anti-rheumatic drug therapy.
        BMC Musculoskelet Disord. 2017; 18: 1-13
        • MacIntyre N.J.
        • Dewan N.
        Epidemiology of distal radius fractures and factors predicting risk and prognosis.
        J Hand Ther. 2016; 29: 136-145
        • Grennan D.M.
        • Gray J.
        • Loudon J.
        • Fear S.
        Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery.
        Ann Rheum Dis. 2001; 60: 214-217
        • Sreekumar R.
        • Gray J.
        • Kay P.
        • Grennan D.M.
        Methotrexate and post operative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery—a ten year follow-up.
        Acta Orthop Belg. 2011; 77: 823-826
        • Barnard A.R.
        • Regan M.
        • Burke F.D.
        • Chung K.C.
        • Wilgis E.F.
        Wound healing with medications for rheumatoid arthritis in hand surgery.
        ISRN Rheumatol. 2012; 2012251962
        • Kasdan M.L.
        • June L.
        Postoperative results of patients with rheumatoid arthritis on methotrexate at the time of reconstructive surgery of the hand.
        Orthopedics. 1993; 16: 1233-1235
        • DeGeorge Jr., B.R.
        • Van Houten H.K.
        • Mwangi R.
        • Sangaralingham L.R.
        • Larson A.N.
        • Kakar S.
        Outcomes and complications in the management of distal radial fractures in the elderly.
        J Bone Joint Surg Am. 2020; 102: 37-44
        • Turner R.G.
        • Faber K.J.
        • Athwal G.S.
        Complications of distal radius fractures.
        Hand Clin. 2010; 26: 85-96