WITHDRAWN: Surgical interventions for treating distal radial fractures in adults

BACKGROUND

Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis.

OBJECTIVES

To determine when, and if so what type of, surgical intervention is the most appropriate treatment for fractures of the distal radius in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group specialised register (November 2002), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 8), CINAHL (1982 to February 2003), the National Research Register (Issue 1, 2003), PEDro, conference proceedings and reference lists of articles. No language restrictions were applied.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials involving skeletally mature patients with a fracture of the distal radius, which compared surgical treatment with conservative treatment, different types of surgical intervention or the duration of immobilisation after surgery. The main categories of surgical intervention were external fixation, percutaneous pinning, open reduction and internal fixation, and the insertion of bone scaffolding materials.

DATA COLLECTION AND ANALYSIS

All trials, meeting the selection criteria, were independently assessed by both reviewers for methodological quality. Data were extracted for anatomical, functional and clinical outcomes (including complications). The trials were grouped into categories relating to the main comparisons and types of surgical intervention. Despite clear heterogeneity in the characteristics of comparable trials, pooling of data was undertaken where possible and appropriate.

MAIN RESULTS

Forty eight trials, examining 25 treatment comparisons, met the inclusion criteria of this review. These involved a total of 3371 mainly female and older patients with generally displaced, often comminuted and potentially or evidently unstable fractures. Nearly half of the trials compared surgery with plaster cast immobilisation. Summarising the outcomes was hampered by the variation between the studies in participant characteristics, interventions, quality of trial methodology and reporting, and outcome measurement. Surgical methods were usually associated with better anatomical appearance after fracture healing, but there was inadequate evidence to confirm that these had resulted in better functional and clinical outcomes for the patients.

AUTHORS' CONCLUSIONS

The 48 randomised trials do not provide robust evidence for most of the decisions necessary in the management of these fractures. Although, in particular, there is some evidence to support the use of external fixation or percutaneous pinning, their precise role and methods are not established. It is also unclear whether surgical intervention of most fracture types will produce consistently better long-term outcomes.There is a need for good quality evidence for the surgical management of these fractures.

Bone grafts and bone substitutes for treating distal radial fractures in adults

BACKGROUND

Surgical treatment of fractures of the distal radius can involve the implantation of bone scaffolding materials (bone grafts and substitutes) into bony defects that frequently arise after fracture reduction.

OBJECTIVES

To review the evidence from randomised controlled trials evaluating the implanting of bone scaffolding materials for treating distal radial fractures in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (June 2007), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, conference proceedings and reference lists. No language restrictions were applied.

SELECTION CRITERIA

Randomised or quasi-randomised controlled clinical trials evaluating the use of bone scaffolding for treating distal radial fracture in adults.

DATA COLLECTION AND ANALYSIS

Two people independently selected studies and undertook assessment and data collection.

MAIN RESULTS

Ten heterogenous trials involving 874 adults with generally unstable fractures were grouped into six comparisons. No trial had proven allocation concealment. Four trials (239 participants) found implantation of bone scaffolding (autogenous bone graft (one trial); Norian SRS - a bone substitute (two trials); methylmethacrylate cement (one trial)) improved anatomical outcomes compared with plaster cast alone; and two found it improved function. Reported complications of bone scaffolding were transient discomfort resulting from extraosseous deposits of Norian SRS; with surgical removal of one intra-articular deposit. One trial (323 participants) comparing bone substitute (Norian SRS) versus plaster cast or external fixation found no difference in functional or anatomical outcomes at one year. Statistically significant complications in the respective groups were extraosseous Norian SRS deposits and pin track infection. One trial (48 participants with external fixation) found that autogenous bone graft did not significantly change outcome. There was one serious donor-site complication. One trial (21 participants) found some indication of worse outcomes for hydroxyapatite bone cement compared with Kapandji's intrafocal pinning. Three trials (180 participants) found bone scaffolding (autogenous bone graft (one trial); Norian SRS (one trial); methylmethacrylate cement (one trial)) gave no significant difference in functional outcomes but some indication of better anatomical outcomes compared with external fixation. Most reported complications were associated with external fixation; extraosseous deposits of Norian SRS occurred in one trial. One trial (93 participants with dorsal plate fixation) found autografts slightly improved wrist function compared with allogenic bone material but with an excess of donor site complications.

AUTHORS' CONCLUSIONS

Bone scaffolding may improve anatomical outcome compared with plaster cast alone but there is insufficient evidence to conclude on functional outcome and safety; or for other comparisons.

Norian SRS cement compared with conventional fixation in distal radial fractures. A randomized study

BACKGROUND

A prospective, randomized multicenter study was conducted to evaluate closed reduction and immobilization with and without Norian SRS (Skeletal Repair System) cement in the management of distal radial fractures. Norian SRS is a calcium-phosphate bone cement that is injectable, hardens in situ, and cures by a crystallization reaction to form dahllite, a carbonated apatite equivalent to bone mineral.

METHODS

A total of 323 patients with a distal radial fracture were randomized to treatment with or without Norian SRS cement. Stratification factors included fracture type (intra-articular or extra-articular), hand dominance, bone density, and the surgeon's preferred conventional treatment (cast or external fixator). The subjects receiving Norian SRS underwent a closed reduction followed by injection of the cement percutaneously or through a limited open approach. Wrist motion, beginning two weeks postoperatively, was encouraged. Control subjects, who had not received a Norian SRS injection, underwent closed reduction and application of a cast or external fixator for six to eight weeks. Supplemental Kirschner wires were used in specific instances in both groups. Patients were followed clinically and radiographically at one, two, four, and between six and eight weeks and at three, six, and twelve months. Patients rated pain and the function of the hand with use of a visual analog scale. Quality of life was assessed with use of the Short Form-36 (SF-36) health status questionnaire. Complications were recorded.

RESULTS

Significant clinical differences were seen at six to eight weeks postoperatively, with better grip strength, wrist range of motion, digital motion, use of the hand, and social and emotional function, and less swelling in the patients treated with Norian SRS than in the control group (p < 0.05). By three months, these differences had normalized except for digital motion, which remained significantly better in the group treated with Norian SRS (p = 0.015). At one year, no clinical differences were detected. Radiographically, the average change in ulnar variance was greater in the patients treated with Norian SRS (+2.0 mm) than in the control group (+1.4 mm) (p < 0.02). No differences were seen in the total number of complications, including loss of reduction. The infection rate, however, was significantly higher (p < 0.001) in the control group (16.7%) than in the group treated with Norian SRS (2.5%) and the infections were always related to external fixator pins or Kirschner wires. Four patients with intra-articular extravasation of cement were identified; no sequelae were observed at twenty-four months. Cement was seen in extraosseous locations in 112 (70%) of the SRS-treated patients; loss of reduction was highest in this subgroup (37%). The extraosseous material had disappeared in eighty-three of the 112 patients by twelve months.

CONCLUSIONS

Our results indicate that fixation of a distal radial fracture with Norian SRS cement may allow for accelerated rehabilitation. A limited open approach and supplemental fixation with Kirschner wires are recommended. Additional or alternate fixation is necessary for complex articular fractures.

Surgical interventions for treating distal radial fractures in adults

BACKGROUND

Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis.

OBJECTIVES

To determine when, and if so what type of, surgical intervention is the most appropriate treatment for fractures of the distal radius in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (November 2002), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to 2003 Week 8), CINAHL (1982 to February 2003), the National Research Register (Issue 1, 2003), PEDro, conference proceedings and reference lists of articles. No language restrictions were applied.

SELECTION CRITERIA

Randomised or quasi-randomised clinical trials involving skeletally mature patients with a fracture of the distal radius, which compared surgical treatment with conservative treatment, different types of surgical intervention or the duration of immobilisation after surgery. The main categories of surgical intervention were external fixation, percutaneous pinning, open reduction and internal fixation, and the insertion of bone scaffolding materials.

DATA COLLECTION AND ANALYSIS

All trials, meeting the selection criteria, were independently assessed by both reviewers for methodological quality. Data were extracted for anatomical, functional and clinical outcomes (including complications). The trials were grouped into categories relating to the main comparisons and types of surgical intervention. Despite clear heterogeneity in the characteristics of comparable trials, pooling of data was undertaken where possible and appropriate.

MAIN RESULTS

Forty eight trials, examining 25 treatment comparisons, met the inclusion criteria of this review. These involved a total of 4371 mainly female and older patients with generally displaced, often comminuted and potentially or evidently unstable fractures. Nearly half of the trials compared surgery with plaster cast immobilisation. Summarising the outcomes was hampered by the variation between the studies in participant characteristics, interventions, quality of trial methodology and reporting, and outcome measurement. Surgical methods were usually associated with better anatomical appearance after fracture healing, but there was inadequate evidence to confirm that these had resulted in better functional and clinical outcomes for the patients.

REVIEWER'S CONCLUSIONS

The 48 randomised trials do not provide robust evidence for most of the decisions necessary in the management of these fractures. Although, in particular, there is some evidence to support the use of external fixation or percutaneous pinning, their precise role and methods are not established. It is also unclear whether surgical intervention of most fracture types will produce consistently better long-term outcomes. There is a need for good quality evidence for the surgical management of these fractures.