Discussion
DRFs
OSTEOPOROSIS
To our knowledge, this is the first study that analyzed data from a prospective, multicenter randomized clinical trial to determine associations between patient-reported outcomes and chronologic and physiologic age in DRF management. On the basis of PC analysis, chronologic age has the strongest correlation with MHQ outcomes in the casting cohort, suggesting chronologic age is a potential proxy for functional recovery in older adults who are conservatively managing DRFs. However, measures of physiologic age, such as activity level, had a more substantial association with DRF outcomes in the surgical and VLP cohorts. This analysis demonstrates that individuals with higher activity levels have faster recovery of patient-reported outcomes after surgical intervention regardless of their chronologic age. In addition, individuals with more than 3 comorbidities have poorer outcomes after casting compared with individuals with no comorbidities. Therefore, we recommend encompassing baseline activity level and number of comorbidities into personalized treatment decisions in older adults with DRFs. For individuals who undergo casting, activity status had no significant effect on overall recovery based on MHQ scores; therefore, preinjury physiologic health status assessment is less critical in this cohort.This study suggests that chronologic age is a poor proxy for functional demand. Increased chronologic age was associated with an increase in MHQ scores in the surgery cohort and a decrease in MHQ scores in the casting cohort. It is counterintuitive to expect increased chronologic age would result in improved MHQ scores in the surgical cohort, which further illustrates that age is a poor estimator of physiologic health. In addition, many guidelines use a chronologic age of 65 years as a proxy for low functional demand. However, evidence from this analysis demonstrates that clinically significant changes in patient-reported outcomes are observed in individuals 15 years older than baseline. In this study, a 75-year-old individual had a clinically significant difference in MHQ score compared with a 60-year-old individual; however, the difference between 60 years and 65 years was minimal. Our results indicate that further investigation is needed to develop a more efficient method for estimating a patient’s health status. Existing instruments, such as RAPA, are excellent tools to stratify by functional demand; however, RAPA does not incorporate comorbidities. Similarly, the modified frailty index (mFI) was developed to estimate functional status (independent, partial dependent, or fully dependent), but it does not include certain comorbidities, such as osteoporosis.Sustaining a DRF may impose severe restrictions on lifestyle for those who are active despite their chronologic age. These individuals can benefit from surgical treatment, which enables earlier return to daily function. Individuals with lower functional status or who live sedentary lifestyles are best treated with casting because they can still achieve recovery similar to that of patients who underwent surgery, albeit at a slower pace. Older adults are also limited by fewer remaining years of good health. The World Health Organization has noted healthy life expectancy has not increased at the same rate as overall life expectancy, placing even more value on each additional year of good health in older adults.To our knowledge, no study has investigated the breadth of factors that could represent a patient’s physiologic age; this topic should be a focus of future investigation. This analysis is a paradigm shift in the treatment of older adults with DRFs to consider personal attributes of a patient rather than a general data point, such as age. Evidence from other surgical specialties, such as cardiac, orthopedic, and thoracic surgery, has demonstrated that increased frailty is associated with worse postoperative outcomes. However, the overall interaction between chronologic age and frailty has not been fully characterized in the hand surgery literature.