External fixation versus closed treatment of displaced distal radial fractures in elderly patients: a randomized controlled trial

Effectiveness and Safety of Different Treatment Modalities for Patients Older Than 60 Years with Distal Radius Fracture: A Network Meta-Analysis of Clinical Trials

The aim of this study was to compare the clinical effectiveness and complications of different treatment modalities for elderly patients with distal radius fracture (DRF).

METHODS

We performed a network meta-analysis (NMA) of randomized clinical trials (RCTs). Eight databases were searched. The eligibility criteria for selecting studies were RCTs that compared different treatment modalities (surgical or nonoperative) in patients older than 60 years with displaced or unstable intra-articular and/or extra-articular DRFs.

RESULTS

Twenty-three RCTs met the eligibility criteria (2020 patients). For indirect comparisons, the main findings of the NMA were in volar locking plate (VLP) versus cast immobilization, with the mean differences for the patient-rated wrist evaluation (PRWE) questionnaire at -4.45 points (p < 0.05) and grip strength at 6.11% (p < 0.05). Additionally, VLP showed a lower risk ratio (RR) of minor complications than dorsal plate fixation (RR: 0.02) and bridging external fixation (RR: 0.25). Conversely, VLP and dorsal plate fixation showed higher rates of major complications.

CONCLUSIONS

Compared with other treatment modalities, VLP showed statistically significant differences for some functional outcomes; however, most differences were not clinically relevant. For complications, although most differences were not statistically significant, VLP was the treatment modality that reported the lowest rate of minor and overall complications but also showed one of the highest rates of major complications in these patients. PROSPERO Registration: CRD42022315562.

What Is the Relative Effectiveness of the Various Surgical Treatment Options for Distal Radius Fractures? A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

BACKGROUND

Many acceptable treatment options exist for distal radius fractures (DRFs); however, a simultaneous comparison of all methods is difficult using conventional study designs.

QUESTIONS/PURPOSES

We performed a network meta-analysis of randomized controlled trials (RCTs) on DRF treatment to answer the following questions: Compared with nonoperative treatment, (1) which intervention is associated with the best 1-year functional outcome? (2) Which intervention is associated with the lowest risk of overall complications? (3) Which intervention is associated with the lowest risk of complications requiring operation?

METHODS

Ten databases were searched from inception to July 25, 2019. Search and analysis reporting adhered to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Included studies were English-language RCTs that assessed at least one surgical treatment arm for adult patients with displaced DRFs, with less than 20% loss to follow-up. We excluded RCTs reporting on patients with open fractures, extensive bone loss, or ipsilateral upper extremity polytrauma. Seventy RCTs (n = 4789 patients) were included. Treatments compared were the volar locking plate, bridging external fixation, nonbridging external fixation, dynamic external fixation, percutaneous pinning, intramedullary fixation, dorsal plating, fragment-specific plating, and nonoperative treatment. Subgroup analyses were conducted for intraarticular fractures, extraarticular fractures, and patients with an average age greater than 60 years. Mean (range) patient age was 59 years (56 to 63) and was similar across all treatment groups except for dynamic external fixation (44 years) and fragment-specific plating (47 years). Distribution of intraarticular and extraarticular fractures was approximately equal among the treatment groups other than that for intramedullary fixation (73% extraarticular), fragment-specific plating (66% intraarticular) [13, 70], and dorsal plating (100% intraarticular). Outcomes were the DASH score at 1 year, total complications, and reoperation. The minimum clinically important different (MCID) for the DASH score was set at 10 points. The analysis was performed using Bayesian methodology with random-effects models. Rank orders were generated using surface under the cumulative ranking curve values. Evidence quality was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methodology. Most studies had a low risk of bias due to randomization and low rates of incomplete follow-up, unclear risk of bias due to selective reporting, and high risk of bias due to lack of patient and assessor blinding. Studies assessing bridging external fixation and/or nonoperative treatment arms had a higher overall risk of bias while studies with volar plating and/or percutaneous pinning treatment arms had a lower risk of bias.

RESULTS

Across all patients, there were no clinically important differences in terms of the DASH score at 1 year; although differences were found, all were less than the MCID of 10 points. Volar plating was ranked the highest for DASH score at 1 year (mean difference -7.34 [95% credible interval -11 to -3.7) while intramedullary fixation, with low-quality evidence, also showed improvement in DASH score (mean difference -7.75 [95% CI -14.6 to -0.56]). The subgroup analysis revealed that only locked volar plating was favored over nonoperative treatment for patients older than 60 years of age (mean difference -6.4 [95% CI -11 to -2.1]) and for those with intraarticular fractures (mean difference -8.4 [95% CI -15 to -2.0]). However, its clinical importance was uncertain as the MCID was not met. Among all patients, intramedullary fixation (odds ratio 0.09 [95% CI 0.02 to 0.84]) and locked volar plating (OR 0.14 [95% CI 0.05 to 0.39]) were associated with a lower complication risk compared with nonoperative treatment. For intraarticular fractures, volar plating was the only treatment associated with a lower risk of complications than nonoperative treatment (OR 0.021 [95% CI < 0.01 to 0.50]). For extraarticular fractures, only nonbridging external fixation was associated with a lower risk of complications than nonoperative treatment (OR 0.011 [95% CI < 0.01 to 0.65]), although the quality of evidence was low. Among all patients, the risk of complications requiring operation was lower with intramedullary fixation (OR 0.06 [95% CI < 0.01 to 0.85) than with nonoperative treatment, but no treatment was favored over nonoperative treatment when analyzed by subgroups.

CONCLUSION

We found no clinically important differences favoring any surgical treatment option with respect to 1-year functional outcome. However, relative to the other options, volar plating was associated with a lower complication risk, particularly in patients with intraarticular fractures, while nonbridging external fixation was associated with a lower complication risk in patients with extraarticular fractures. For patients older than 60 years of age, nonoperative treatment may still be the preferred option because there is no reliable evidence showing a consistent decrease in complications or complications requiring operation among the other treatment options. Particularly in this age group, the decision to expose patients to even a single surgery should be made with caution.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms

BACKGROUND

A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to determine benefits and harms of surgical compared to non-surgical treatments for traumatic skeletal fractures.

METHODS

We searched Medline, Embase, CINAHL, Web of Science, and CENTRAL until November 2018, for randomized trials of surgical treatment in comparison with or in addition to non-surgical treatment of fractures in adults. For harms, only trials with patient enrollment in 2000 or later were included, while no time restriction was applied to benefits. Two reviewers independently assessed studies for inclusion, extracted data from full-text trials, and performed risk of bias assessment. Outcomes were self-reported pain, function, and quality of life, and serious adverse events (SAEs). Random effects model (Hedges' g) was used.

RESULTS

Out of 28375 records screened, we included 61 trials and performed meta-analysis on 12 fracture types in 11 sites: calcaneus, clavicula, femur, humerus, malleolus, metacarpus, metatarsus, radius, rib, scaphoideum, and thoraco-lumbar spine. Seven other fracture types only had one trial available. For distal radius fractures, the standardized mean difference (SMD) was 0.31 (95% CI 0.10 to 0.53, n = 378 participants) for function, favoring surgery, however, with greater risk of SAEs (RR = 3.10 (1.42 to 6.77), n = 436). For displaced intra-articular calcaneus fractures, SMD was 0.64 (0.13 to 1.16) for function (n = 244) and 0.19 (0.01 to 0.36) for quality of life (n = 506) favoring surgery. Surgery was associated with a smaller risk of SAE than non-surgical treatment for displaced midshaft clavicular fractures (RR = 0.62 (0.42 to 0.92), n = 1394). None of the other comparisons showed statistical significance differences and insufficient data existed for most of the common fracture types.

CONCLUSIONS

Of 12 fracture types with more than one trial, only two demonstrated a difference in favor of surgery (distal radius fractures and displaced intra-articular calcaneus fractures), one of which demonstrated a greater risk of harms in the surgical group (distal radius fractures). Our results highlight the current paucity of high-quality randomized trials for common fracture types and a considerable heterogeneity and risk of bias in several of the available trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015020805.

Interventions for Distal Radius Fractures: A Network Meta-analysis of Randomized Trials

INTRODUCTION

The distal radius is the second most commonly fractured bone in the elderly population. Several approaches for management exist including both surgical and nonsurgical treatments. Evidence for alternative approaches remains inconclusive and often conflicting.

METHODS

Electronic database searches were conducted to identify randomized trials that (1) enrolled adults with a distal radius fracture; (2) compared external fixation, intramedullary nailing, K-wires, plaster casting (PC), or plate fixation (PF) to one of the other treatments listed; and (3) reported on a functional outcome that categorized patients as "excellent" and "good" or reported fracture healing complication (loss of reduction, malunion, delayed union, nonunion, and refracture). Data were synthesized using a Bayesian network meta-analysis. Odds ratios (ORs) with 95% credible intervals (CrIs) using a random-effects model were calculated.

RESULTS

Thirty-eight trials were included. Total sample sizes ranged from 30 to 461 patients. Although no differences were noted between treatments at 3 months, PF was ranked the highest for improving functional outcomes at 6 and 12 months, and it demonstrated a statistically significant difference compared with PC at 12 months (OR = 4.27; 95% CrI, 1.07 to 15.12). For reduction in fracture healing complications, PF was ranked the highest again, showing significantly more favorable results relative to the four other interventions: OR = 0.25 (95% CrI, 0.07 to 0.86) versus external fixation, OR = 0.09 (95% CrI, 0.02 to 0.36) versus K-wire, OR = 0.01 (95% CrI, 0.00 to 0.03) versus PC, and OR = 0.00 (95% CrI, 0.00 to 0.35) versus intramedullary nailing.

CONCLUSIONS

A network meta-analysis of randomized trials revealed that open reduction and internal fixation with a plate offers the best results for adult patients with a distal radius fracture, in terms of early and sustained functional recovery and a reduction in fracture healing complications. Determining whether one approach to PF or plate design is superior requires further study.

Treatment of radius or ulna fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and current practice

Background

The objective of the present study was to evaluate effectiveness, complications and cost-effectiveness of any surgical or non-surgical treatment for radius or ulna fractures in elderly patients. Secondary objectives were to analyze present treatment traditions of distal radius fractures (DRF) in Sweden and to calculate resource usage for its treatment.

Methods and findings

The assessment contains a systematic review of clinical and health economic studies comparing treatment options for radius or ulna fractures. The results regarding the effectiveness of the treatments are summarized in meta-analyses. In addition, the assessment contains a cost analysis for different treatment options commonly used for DRF care, and an analysis of registry data on the incidence and treatment of DRF. In total 31 randomized controlled trials were included in meta-analyses. When comparing functional outcome for plate fixation versus non-surgical treatment for DRF, there were no clinically important differences at one-year follow-up (mean difference [MD], -3.29, 95% CI, -7.03; 0.44). Similar results were found when comparing plating and percutaneous methods with respect to functional outcome (standardized mean difference [SMD], -0.07, 95% CI, -0.21; 0.07) and grip strength (MD, -3.47, 95% CI, -11.21; 4.28). There were no differences for minor complications, (risk difference [RD], -0.01, 95% CI, -0.07; 0.05) whereas major complications were less common for the percutaneous group, (RD, 0.02, 95% CI, 0.02; 0.03). Given the low number of studies, the evidence above was rated as moderate certainty. The cost for plate fixation versus plaster cast was estimated to 1698 compared to 137 US dollars. For DRF, plate fixation increased in Sweden between 2005 and 2013, and was the most common surgical method in 2013.

Conclusions

Surgical treatment of moderately displaced distal radius fractures in elderly patients offers no clear benefit compared to non-surgical treatment. Plating procedures have become more common during the second millennium and involve higher costs and higher risk of major complications than percutaneous options.

External Fixation Versus Volar Locking Plate for Unstable Dorsally Displaced Distal Radius Fractures-A 3-Year Follow-Up of a Randomized Controlled Study

PURPOSE

To determine if a volar locking plate (VLP) is superior to external fixation (EF) 3 years after surgery for unstable, dorsally displaced, distal radius fractures caused by low-energy injury in patients 50 to 74 years of age.

METHODS

During 2009 to 2013, 140 patients with an unstable dorsally displaced distal radius fracture were randomized to either VLP or EF. One hundred eighteen patients (EF 56, VLP 62) were available for a 3-year follow-up. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score at 3 years. Secondary outcomes were Patient-Related Wrist Evaluation (PRWE) score, EuroQol-5 Dimensions (EQ-5D) score, range of motion (ROM), grip strength, and radiological signs of osteoarthritis (OA) at 3 years. Moreover, reoperations and minor complications during the first 3 years were recorded.

RESULTS

There were no differences regarding DASH, PRWE, EQ-5D, ROM or grip strength. The reoperation rate was 21% (13 of 62) in the VLP group compared with 14% (8 of 56) in the EF group. The OA rate was 42% (25 of 59) in the VLP group compared with 28% (15 of 53) in the EF group.

CONCLUSIONS

Three years after surgery for unstable dorsally displaced distal radius fractures, the clinical and radiological results for VLP and EF were comparable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Volar Locking Plate or External Fixation With Optional Addition of K-Wires for Dorsally Displaced Distal Radius Fractures: A Randomized Controlled Study

OBJECTIVES

To compare the outcomes after open reduction and fixation with a volar locking plate or external fixation with optional addition of K-wires in patients aged 50-74 years.

DESIGN

Randomized controlled trial according to the Consolidated Standards of Reporting Trials criteria.

SETTING

Single-center second-level trauma center in the capital of Sweden.

PATIENTS

One hundred forty patients presenting with a dorsally displaced distal radius fracture were randomized to fixation with a volar locking plate (n = 70) or external fixation with optional addition of K-wires (n = 70).

MAIN OUTCOME MEASUREMENT

The primary outcome was the Disability of the Arm, Shoulder, and Hand (DASH) at 12 months. EuroQol-5D, radiography, and recordings of complications were performed at 2 and 6 weeks and at 3 and 12 months. Patients were investigated for DASH, the Patient-Rated Wrist Evaluation, range of motion, and grip strength at 3 and 12 months.

RESULTS

There were no significant differences between the groups in terms of DASH and Patient-Rated Wrist Evaluation at 3 months and 1 year (P > 0.05). EuroQol-5D was lower during the first 6 weeks in the external fixation group (P < 0.05), but the difference was no longer significant at 3 months. Radiographic restoration of alignment was better for the volar locking plate group in terms of volar tilt and radial length. The range of motion was equal in both groups except for radial deviation, which was better in the volar locking plate group at 1-year follow-up. The total rate of complications was equal for both groups.

CONCLUSIONS

Volar plating and external fixation with optional addition of K-wires are 2 equally suitable treatment options for dorsally displaced distal radius fractures after low-energy trauma in a population aged 50-74 years.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The operative treatment of fractures of the distal radius is increasing: results from a nationwide Swedish study

The aim of this study was to investigate the epidemiology of fractures of the distal radius in the Swedish population and to review the methods used to treat them between 2005 and 2010. The study population consisted of every patient in Sweden who was diagnosed with a fracture of the wrist between 1 January 2005 and 31 December 2010. There were 177 893 fractures of the distal radius. The incidence rate in the total population was 32 per 10 000 person-years. The mean age of the patients was 44 years (0 to 104). The proportion of fractures treated operatively increased from 16% in 2005 to 20% in 2010. The incidence rate for plate fixation in the adult population increased 3.61 fold. The incidence rate for external fixation decreased by 67%. The change was greatest in the 50 years to 74 years age group. In Sweden, there is an increasing tendency to operate on fractures of the distal radius. The previously reported increase in the use of plating is confirmed: it has increased more than threefold over a five-year period.