Comparison of radiographic and functional results of die-punch fracture of distal radius between volar locking plating (VLP) and external fixation (EF)

Factors predicting complications following open reduction and internal fixation of intra-articular distal radius fracture

Objective

This study aimed to determine the incidence and predictors of the complications after open reduction and internal fixation (ORIF) of intra-articular distal radius fracture (IADRF) with a minimum follow-up of 12 months.

Methods

Medical records and outpatient follow-up records were retrospectively reviewed to collect medical, surgical, and complication data on consecutive patients who had undergone an ORIF procedure for an IADRF between January 2019 and June 2022. Data included demographics, comorbidities, injury, surgical characteristics, and laboratory findings on admission. A multivariate logistic regression model was constructed to identify the significant predictors, with a composite of any complications occurring within 12 months after the operation as the outcome variable and potentially a range of clinical data as the independent variables. The magnitude of the relationship was indicated by the odds ratio (OR) and the 95% confidence interval (CI).

Results

During the study period, 474 patients were included, and 64 had documented complications (n = 73), representing an accumulated rate of 13.5%. Among them, carpal tunnel syndrome was the most common, followed by tenosynovitis caused by tendon irritation/rupture, superficial or deep wound infection, complex regional pain syndrome (CRPS) type 1, radial shortening (≥4 mm), plate/screw problems, and others. The multivariate results showed the following factors significantly associated with increased risk of complications: experience of DRF surgery with <30 cases (OR: 2.2, 95% CI: 1.6-3.5), AO type C fracture (OR: 1.7, 95% CI: 1.2-2.9), initial lunate facet collapse of ≥5 mm (OR: 4.2, 95% CI: 1.4-8.9), and use of temporary external fixation before index surgery (OR: 2.4, 95% CI: 1.5-4.3).

Conclusions

These findings may aid in patient counseling and quality improvement initiatives, and IADRF should be directed by an experienced surgeon.

Comparison of Sociodemographic and Radiographic Features in Distal Radio Fracture Treatment: Hand Surgeons versus Non-specialists

Objective:  This study evaluated sociodemographic and radiographic features of patients with distal radial fractures treated at a trauma hospital in southern Brazil, comparing those treated by hand surgery specialists (group 1) and non-specialists (group 2). Methods:  This study consists of a retrospective cohort of 200 patients treated in 2020. After reviewing medical records and radiographs, the following parameters were analyzed: age, gender, trauma mechanism, laterality, associated comorbidities and fractures, fracture classification (AO), radial height, radial inclination, and volar inclination. Comparison of the two groups used the Student t-test, chi-square test, or Fisher exact test. Results:  Most subjects were women (54%), sustained low-energy traumas (58%), and were left-handed (53%). Group 1 had a lower mean age (50.2 years); most of their subjects sustained high-energy trauma (54%) and had type C fractures (73%); type A fractures prevailed in group 2 (72%). Radiographs showed a significant difference regarding the mean radial inclination (21.5° in group 1 and 16.5° in group 2 [ p  < 0.001] in women, and 21.3° in group 1 and 17° in group 2 [ p  < 0.001] in men) and volar inclination (10.1° and 12.8° in groups 1 and 2, respectively [ p  < 0.001]). In addition, the absolute number of cases with reestablished anatomical parameters per the three evaluated variables was also significantly different; all parameters were better in group 1. Conclusion:  Hand surgeons treated the most severe fractures and had the best radiographic outcomes.

Are Observational Studies on Distal Radius Fracture Treatment Robust? An E-value Approach to Analysis

BACKGROUND

Reported complication frequencies after distal radius fracture (DRF) treatment vary widely in the literature and are based mostly on observational evidence. Whether that evidence is sufficiently robust to use in practice is controversial. The E-value is an innovative sensitivity analysis that quantitates the robustness of observational evidence against unmeasured confounders, whereby a greater E-value usually implies more robust evidence and vice versa; with DRF complications, this approach can help guide readers to a more confident interpretation of the available evidence.

QUESTIONS/PURPOSES

In this study, we sought (1) to compare the complication frequencies among different DRF treatment modalities, and (2) to evaluate the robustness of these observational studies using the E-value as an index for unmeasured confounding.

METHODS

We searched PubMed, Embase, and SCOPUS for observational studies on the management of DRFs that were published from January 2001 to July 2021 with the last database search performed on July 31, 2021. All articles that compared different DRF treatment modalities with reported complication frequencies were included to accurately capture the quality of the observational studies in research about DRF. Risk ratios (RRs) of the overall complication and major complication risks were calculated for each subgroup comparison: volar plating versus dorsal plating, casting, external fixation, and percutaneous K-wire fixation. The RRs and their corresponding lower limits of the 95% confidence intervals (CIs) were used to derive the E-values. E-values can have a minimum possible value of 1, which signifies that the treatment-outcome association is not strong and can readily be overturned by unmeasured confounders. By contrast, a large E-value means that the observed treatment-outcome association is robust against unmeasured confounders. We averaged RRs and E-values for the effect estimates and lower limits of CIs across studies in each treatment comparison group. We identified 36 comparative observational studies that met the inclusion criteria. Seven studies compared volar with dorsal plating techniques. Volar plating was also compared with casting (eight studies), external fixation (15 studies), and percutaneous K-wire fixation (six studies).

RESULTS

Total and major complication risks did not differ among different DRF treatments. The mean RRs for total and major complications were 1.2 (95% CI 0.4 to 3.9; p = 0.74) and 1.8 (95% CI 0.4 to 11.4; p = 0.52) for the volar versus dorsal plating group; 1.2 (95% CI 0.3 to 11.2; p = 0.87) and 1.5 (95% CI 0.3 to 14.9; p = 0.74) for the volar plating versus casting group; 0.6 (95% CI 0.2 to 2.2; p = 0.33) and 0.8 (95% CI 0.2 to 6.7; p = 0.86) for the volar plating versus external fixation group; and 0.6 (95% CI 0.2 to 2.6; p = 0.47) and 0.7 (95% CI 0.2 to 4.0; p = 0.67) for the volar plating versus K-wire fixation group. The mean E-values for total and major complication frequencies for the between-group comparison ranged from 3.1 to 5.8; these were relatively large in the context of a known complication risk factor, such as high-energy impact (RR 3.2), suggesting a reasonable level of robustness against unmeasured confounding. However, the E-values for lower limits of CIs remained close to 1, which indicates the observed complication frequencies in these studies were likely to have been influenced by unmeasured confounders.

CONCLUSION

Complication frequencies did not differ among different DRF treatment modalities, but the observed complication frequencies from most comparative observational studies were less robust against potential unmeasured confounders. The E-value method, or another type of sensitivity analysis, should be implemented in observational hand surgery research at the individual-study level to facilitate assessment of robustness against potential unmeasured confounders.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Efficacy of electroacupuncture in assisting postoperative healing of distal radius fractures: study protocol for a randomized controlled trial

BACKGROUND

Manual reduction and surgical treatment are common methods for distal radius fractures (DRFs). The existing literature suggests that postoperative combined rehabilitation treatment and medication are effective for the healing of DRFs. However, the side effects of these treatments remain to be solved. Previous studies have shown that electroacupuncture (EA) can effectively relieve wrist swelling and improve the joint function in patients with DRFs, but more evidence is needed to prove the effectiveness of EA. This trial aims to explore the efficiency and feasibility of combined EA treatment in postoperative treatment of DRFs compared with routine treatment.

METHODS

This is a parallel randomized controlled trial. A total of 222 patients diagnosed with moderate DRFs will be recruited and randomly assigned to an EA group or a routine treatment group at a ratio of 1:1. Routine treatment group will receive medication and rehabilitation. Yangxi (LI 5), Yangchi (TE 4), Yanggu (SI 5), Hegu (LI 4), and Taiyuan (LU 9) will be selected in the EA group for intervention three times a week on the basis of routine treatment. Both groups will receive 8 weeks of treatment and 4 weeks of follow-up. The primary outcome will be ulnar positive variance. The secondary outcomes will include radiographic healing rate, bone strength, hemorheological indices, serum biochemical indicators and inflammatory factors, grip strength, wrist swelling score, patient-rated wrist evaluation, disabilities of arm, shoulder and hand, and visual analogue scale. Outcomes will be evaluated at baseline, postoperative 3rd day, 2nd, 4th, 6th, 8th, and 12th weeks.

DISCUSSION

The results of this study will help establish a more optimized scheme to treat patients with DRFs. Trial registration Chinese Clinical Trial Registry ChiCTR2200062857. Registered on 21 August 2022, www.chictr.org.cn/com/25/showproj.aspx?proj=175567 .

A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures

Purpose

To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns.

Methods

We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis.

Results

Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness.

Conclusions

The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation.

Type of study/level of evidence

Economic/decision analysis II.

Interventions for Distal Radius Fractures: A Meta-analysis of Comparison Studies

Background  Distal radius fractures are one of the most frequent orthopaedic injuries. There are many effective treatment methods, such as volar plate, dorsal plate, percutaneous pins, external fixation, and casting; however, comparison of the treatment outcomes has not been thoroughly investigated. Our purpose is to determine if volar plating is the superior treatment method for distal radius fractures. We will address this through the following questions: First, is volar plating superior to dorsal plating, percutaneous pins, external fixation, or casting in terms of reported complications? Second, does volar plating produce superior functional outcomes to dorsal plating, percutaneous pins, external fixation, or casting? Third, are the radiographic outcomes superior for volar plating when compared with dorsal plating, percutaneous pins, external fixation, or casting? Methods  MEDLINE, Academic Search Ultimate, Academic Search Complete, CINAHL Plus, and JSTOR databases, as well as manual search, were used to identify papers comparing complications and functional results of volar plating to other treatment methods for distal radius fractures published after the year 2000. Complication data and function scores were recorded. Risk of bias was assessed using the Cochrane Risk of Bias Tool and data was analyzed for meta-analysis using Cochrane ReviewManager software. Results  Compared with dorsal plate, volar plate performed significantly better in Gartland and Werley score. Volar plating outperformed percutaneous pins for loss of reduction, infection, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and ulnar deviation. Loss of reduction, malunion, Patient Related Wrist Evaluation (PRWE) score, DASH score, grip strength, ulnar deviation, and supination were significantly better for volar plating when compared with casting. When compared with external fixation, volar plating had significantly less cases of infection, lower QuickDASH score, and higher range of motion for flexion, pronation, and supination. All other complication and functional outcomes were not significantly different. Conclusions  Distal radius fractures treated with volar plating showed relatively better measures of complications, function scores, and range of motion than other treatment methods; however, there was no significant difference in healing time when compared with percutaneous pins. More studies are needed to compare the rest of the treatment methods with each other.

How to Treat Distal Radius Fractures: Right Patient, Right Care, Right Time, and Right Cost

Operative intervention for distal radius fractures is typically reserved for patients with displaced fractures that may result in bothersome compromises in function, although patient-specific factors (age, activity level, and preference) are considered. Operative intervention is associated with earlier improvement in function but exposes the patient to the risk of anesthesia and surgery. Although surgery is associated with an initial increase in cost of care, the benefits of earlier return to activity may offset these increases. Efforts to contain cost through implant selection, use of ambulatory surgical centers, and judicious referrals for postoperative therapy can aid surgeons in delivering high-value care.

The efficacy of 3D printing-assisted surgery in treating distal radius fractures: systematic review and meta-analysis

Aim: To compare the efficacy of 3D printing-assisted surgery with routine surgery in the treatment of distal radius fractures to evaluate whether 3D printing technology has more advantages. Materials & methods: To retrieve all published studies that compared the efficacy of 3D printing-assisted surgery with routine surgery for distal radius fractures. Operation time, frequency of intraoperative fluoroscopy, blood loss and other outcomes were assessed. Results: The results suggested that 3D printing-assisted surgery was better than routine surgery in the fields of operation time, frequency of intraoperative fluoroscopy, and blood loss. Conclusion: In the treatment of distal radius fractures, 3D printing-assisted surgery may be superior to routine surgery.