Bilan arthroscopique des fractures articulaires du radius distal ostéosynthésées par des techniques d’embrochage percutanée

Arthroscopy assistance in the surgical management of distal radius fractures does not result in superior radiological and functional outcomes: A systematic review and meta-analysis of randomized controlled trials

PURPOSE

To evaluate the efficacy of assistant arthroscopy in the surgical treatment of distal radius fractures (DRFs) by the functional and radiological outcomes between the arthroscopic and control groups.

METHODS

We searched the PubMed, Embase, Web of Science, and Cochrane Library databases for studies that compared the clinical outcomes of patients who underwent surgery with or without adjuvant arthroscopy. After screening the studies, we identified six randomized controlled trials. We analyzed radiological outcomes, range of motion, functional scores, grip strength, operative time, and complication rates. The standardized mean difference (SMD) was used to analyze differences in outcomes between the two groups. Statistical significance was set at p < 0.05.

RESULTS

Six studies involving 455 patients were included. The findings of this analysis indicate that the utilization of arthroscopic assistance did not yield superior radiological outcomes and functional outcomes, except in radial deviation (SMD = 0.96; 95% CI = 0.36, 1.55; I2 = 69%) and ulnar deviation (SMD = 0.69; 95% CI = 0.38, 1.00; I2 = 16%). In addition, the arthroscopic group exhibited longer operation time (SMD = 0.65; 95% CI = 0.1, 1.2; I2 = 81%) compared to the control group. There were no significant differences in the grip strength or complication rates between the two groups.

CONCLUSION

The findings of this analysis indicate that arthroscopy-assisted surgery for DRF does not yield significantly enhanced outcomes in terms of radiological outcomes, functional scores, grip strength, and complications, even though range of motion (radial deviation and ulnar deviation) were superior in the arthroscopically assisted cases. Given the extended operational time associated with adjuvant arthroscopy, the efficacy of assistant arthroscopy in the surgical management of distal radius fractures with joint involvement is not justified.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and Level II studies.

Outcomes of Arthroscopic-Assisted Distal Radius Fracture Volar Plating: A Meta-Analysis

PURPOSE

The use of wrist arthroscopy to assist fixation of distal radius fractures with volar locking plates (VLPs) has been gaining popularity in recent years; however, there is no consensus on its benefits. This meta-analysis compares outcomes of arthroscopic-assisted VLP to fluoroscopic-assisted VLP in distal radius fractures through a systematic review of the published literature.

METHODS

A systematic search of publications from databases (Medline, EMBASE, Scopus, and Cochrane) was obtained from inception to May 2020. A random-effects meta-analysis was used to calculate effect sizes. Outcomes included postoperative radiographic reduction (gap, stepoff, radial inclination, volar tilt, and ulnar variance), procedural outcomes (operative time, additional soft tissue injuries and complications), and functional outcomes (range of motion; visual analog scale score; Disabilities of the Arm, Shoulder, and Hand score; Patient-Rated Wrist Evaluation score; Mayo clinic score; and grip strength).

RESULTS

Six studies, involving 280 patients, met the final inclusion criteria. The meta-analysis for postoperative stepoff was statistically significant, favoring arthroscopic-assisted VLP. In addition, there was greater identification of associated soft tissue injuries, increased wrist extension, and a longer operative duration when performing arthroscopic-assisted VLP fixation. There were no differences in other postoperative radiographic outcomes, complications, or functional outcomes.

CONCLUSIONS

The current literature suggests that arthroscopic-assisted VLP is a useful adjunct to intra-articular reduction and treatment of associated soft tissue injuries in distal radius fractures. Considerations should include operative time, costs, and the additional training required. Further studies are needed to assess functional outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Scapholunate, lunotriquetral and TFCC ligament injuries associated with intraarticular distal radius fractures: Arthroscopic assessment and correlation with fracture types

The aim of this study was to evaluate the prevalence of arthroscopic scapholunate (SL) and/or lunotriquetral (LQ) laxity and triangular fibrocartilaginous complex (TFCC) injuries in patients who have an intraarticular fracture of the distal radius and to correlate these lesions with fracture type. Fifty-seven intraarticular radius fractures, whether or not they were associated with an ulnar styloid fracture, were evaluated and treated by arthroscopy. Scapholunate and lunotriquetral ligament injuries were classified according to the EWAS classification. TFCC lesions were assessed according to Palmer's classification. Each injury was documented through preoperative X-rays and a CT scan. Fracture type and soft tissue injury were not significantly associated one to another. Arthroscopic examination revealed at least one soft tissue injury in 39 intraarticular fractures of the distal radius (68.4%). Twenty-five percent of arthroscopic SL laxities (including severe EWAS 3 injuries) were not detected on standard radiographs. Arthroscopic SL laxity was present in 8 of 11 cases (72.7%) of radial styloid fracture and in 15 of 25 cases (60%) of fractures with at least one radial styloid component. There was no association between LQ integrity and fracture type. Ulnar styloid fractures (base or tip) and TFCC lesions were significantly correlated (P<0.0001). The prevalence of soft tissue lesions secondary to intraarticular fractures of the distal radius was 68.4%. However, there was no statistically significant relationship between the different types of radius fractures and soft tissue injuries. On the other hand, ulnar styloid fracture was predictive of TFCC injury.

Contribution of arthroscopy to the management of intra-articular distal radius fractures: Knowledge update based on a systematic 10-year literature review

The objective of this study was to review current data on the contribution of wrist arthroscopy to the management of intra-articular distal radius fractures (IADRFs). The literature published over the last 10 years was reviewed by searching databases with the key indexing terms 'distal radius fracture', 'articular', and 'wrist arthroscopy'. The information in the 21 articles thus retrieved was used to answer the following questions: (i) Can arthroscopy improve the reduction of IADRFs? (ii) How does arthroscopy contribute to the diagnosis and treatment of concomitant ligament injuries? and (iii) Does arthroscopy help to improve the functional scores? The contribution of arthroscopy to IADRF reduction remains controversial. Follow-ups were limited (15 months on average) and some of the studies provided only level IV evidence. The data do not consistently suggest that arthroscopically assisted surgery may improve the quality of reduction. In contrast, they highlight the usefulness of arthroscopy in allowing the same-stage management of carpal ligament injuries. In the 12 studies providing data on this point, scapholunate inter-osseous ligament injuries were present in 41% of cases; one-fourth of these injuries were full-thickness tears that were successfully repaired by arthroscopy. The triangular fibrocartilage complex was injured in 48% of cases, and 30% of these injuries were peripheral ulnar detachments that were successfully repaired by arthroscopy. At present, arthroscopy does not allow the repair of all diagnosed ligament injuries. Comparative studies with longer follow-ups will shed light on the ability of arthroscopy to improve functional scores. LEVEL OF EVIDENCE: IV.

Wrist arthroscopy in the management of articular distal radius fractures

INTRODUCTION

Fractures of the distal radius account for 15% of all fractures. The use of arthroscopy is increasingly popular in the last years, with the goal to achieve a better anatomical reduction of the articular fragments.

SOURCES OF DATA

We searched the literature on Medline (PubMed), Web of Science and Scopus databases using the combined keywords 'wrist', 'distal radial fracture', 'distal radius fracture' and 'arthroscopy'. Twenty-eight studies were identified. The quality of the studies was assessed using the Coleman Methodological Score.

AREAS OF AGREEMENT

Arthroscopy allows to detect intra-articular, ligamentous and triangular fibrocartilage complex injuries in an acute setting with a better prognosis. Arthroscopy increases the quality of the intra-articular reduction compared to fluoroscopy.

AREAS OF CONTROVERSY

The main limitation of the selected studies is the short follow-up: the average follow-up in 20 studies was 12 months, a period long enough to assess functional outcomes, but not to assess the occurrence of post-traumatic degenerative changes and their impact on function. Better stratification of the fracture population is needed.

GROWING POINTS

The shorter recovery time and the low incidence of adverse effects are the main advantages of this new technology.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is need to perform randomized controlled trials reporting on the use of volar locking plates as, at the present time, they are the standard management for these fractures. In addition, the different pattern of fracture should be better classified to manage the patients who will benefit after the management.