Outcomes of the Management of Distal Radius Fractures in the Last 5 Years: A Meta-analysis of Randomized Controlled Trials^*

 

ABSTRACT:

OBJECTIVE Over the last decades, volar locking plates (VLPs) have been the mainstay treatment for distal radius fractures (DRFs). With the growing body of evidence, we systematically reviewed studies on recent VLP modifications.
METHODS A systematic search was performed in the PubMed/MEDLINE database for studies published in English in the past five years. The inclusion criteria were randomized controlled trials (RCTs) on the operative treatment of DRFs. We excluded ongoing trials and studies not directly addressing DRF. The primary outcomes assessed were subjective (such as the scores on the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire, the Patient-rated Wrist Evaluation [PRWE], the European Quality of Life–5 Dimensions [EQ-5D], the 36-item Short Form Health Survey [SF-36], and the Visual Analog Scale [VAS]) and objective clinical outcomes (the complication rate).
RESULTS We identified 29 articles published from 2016 to 2020 with high quality of evidence, except for one, which had evidence of moderate quality. In total, 3,079 DRFs were analyzed in the present study. All studies except one had a greater proportion of female participants, and only in 1 study the mean age of the sample was < 40 years old. There were no significant differences between the VLP and external fixation (EF) in terms of the scores on the DASH (p= 0.18) and PRWE (p= 0.77). The VLP alone without pronator quadratus (PQ) repair yielded significantly better outcomes.
CONCLUSION In unstable fractures, the VLP and EF yielded comparable long-term results. There is no clear benefit of adding PQ repair to current the VLP surgical technique.Level of EvidenceLevel I

Keywords: bone plates; external fixators; radius fractures; wrist injuries.

RESUMO:

OBJETIVO Nas últimas décadas, a placa volar bloqueada (PVB) tem sido o tratamento principal para fraturas do rádio distal (FRDs). Com o crescente conjunto de evidências, revisamos sistematicamente estudos sobre modificações recentes na PVB.
MÉTODOS Uma pesquisa sistemática foi realizada utilizando o banco de dados PubMed/MEDLINE por estudos publicados em inglês nos últimos cinco anos. Os critérios de inclusão foram ensaios clínicos controlados e randomizados (ECCRs) sobre o tratamento cirúrgico de FRDs. Excluímos ensaios e estudos em andamento que não abordavam diretamente a FRD. Os desfechos primários avaliados foram desfechos clínicos subjetivos (como as pontuações no questionário de Deficiências do Braço, Ombro e Mão [Disabilities of the Arm, Shoulder and Hand, DASH, em inglês], na Avaliação do Punho Classificada pelo Paciente [Patient-rated Wrist Evaluation, PRWE, em inglês], no questionário Qualidade de Vida Europeia – 5 Dimensões [European Quality of Life–5 Dimensions, EQ-5D, em inglês], na Pesquisa de Saúde por Formulário Curto de 36 Itens [36-item Short Form Health Survey, SF-36, em inglês], e na Escala Visual Analógica [EVA]) e objetivos (taxa de complicações).
RESULTADOS Identificamos 29 artigos publicados entre 2016 e 2020 com alta qualidade de evidência, exceto por um, de qualidade moderada. Ao todo, foram analisadas 3.079 FRDs neste estudo, Todos os estudos analisados, exceto por um, tinham maior proporção de participantes do gênero feminino, e somente em 1 estudo a idade média da amostra foi < 40 anos. Não houve diferença significativa entre a PVB e fixação externa (FE) em termos das pontuações no DASH (p= 0,18) e na PRWE (p= 0,77). Os resultados da PVB isolada, sem qualquer reparo do pronador quadrado (PQ), foram significativamente melhores.
CONCLUSÃO Em fraturas instáveis, a PVB e a FE produziram resultados comparáveis no longo prazo. Não há um benefício claro em se adicionar reparo do PQ à técnica cirúrgica atual da PVB.Nível de EvidênciaNível I

Palavras-chave: placas ósseas; fixadores externos; fraturas do rádio; traumatismos do punho.

FIGURES

Citation: Asmara AAGY, Karna MB, Meregawa PF, Deslivia MF. Outcomes of the Management of Distal Radius Fractures in the Last 5 Years: A Meta-analysis of Randomized Controlled Trials* . 57(06):899. doi:10.1055/s-0042-1754379

Financial Support The authors declare that they have received no financial support for the research, authorship, and/or publication of the present article.

Conflict of Interests: The authors have no conflict of interests to declare.

*Work developed at the Orthopedics and Traumatology Department, Faculty of Medicine, Udayana University, Sanglah General Hospital, Bali, Indonesia.

Received: July 17 2021; Accepted: June 14 2022

 

INTRODUCTION

The transition from being quadrupedal to bipedal played an important role in making distal radius fractures (DRFs) one of the most common fractures in the human species. It rendered us vulnerable to “fall onto an outstretched hand” as a mechanism of injury.^{1 2} Operative techniques for DRFs started to gain popularity in the 1960s as a result of the increased incidence of malunion related to the conservative treatment.³ Early surgical techniques include the percutaneous pinning first described by Kapandji,⁴ external fixation (EF),⁵ and internal fixation using plates.⁶ Over the last decades the volar locking plate (VLP) has been the treatment of choice.⁷ However, there are still complications^{8 9} and technical difficulties^{10 11 12} reported regarding the VLP.

In an effort to improve the operative management of DRFs, an increasing number of randomized controlled trials (RCTs) and meta-analyses are studying the comparison between the VLP and other emerging methods of internal fixation,^{13 14 15 16 17 18} as well as improvements in the surgical technique for VLP.¹⁹ With this growing body of evidence concerning DRFs, it is imperative to systematically review the studies with the highest level of evidence and summarize the current findings. The objective of the present work to describe the current options of operative treatment for DRF, especially VLP and the modification in its surgical technique, as well as to examine the functional outcomes.

 

MATERIAL AND METHODS

The present systematic review and meta-analysis was performed in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the Quality of Reporting of Meta-analyses (QUOROM) flowchart. A review protocol was drafted and registered on the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD42020212627).

Search Strategy and Selection Criteria

We performed a systematic search of the literature published from October 2016 to October 2020 in English on the following databases: PubMed/MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov. The search terms included, but were not limited to, distal radius fracture, Colles fracture, management, treatment, external fixation, internal fixation, pinning, plate, and intramedullary nail.

The criteria for inclusion in the present study were RCTs on the operative treatment of DRFs. We excluded ongoing trials and studies not directly addressing DRF. The articles were also selected according to the Population, Intervention, Comparison, Outcome (PICO) strategy, as depicted in ►Table 1.

Data Extraction

The data were extracted by a research team using a standardized data collection form, and each selected article was screened independently by two reviewers. Disagreements between the reviewers regarding whether to include or exclude a study were resolved by consensus, and if necessary, consultation with a third reviewer.

The variables collected included age, gender, fracture classification, interventions performed, follow-up, the scores on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, the Patient-rated Wrist Evaluation (PRWE), the European Quality of Life–5 Dimensions (EQ-5D), the 36-item Short Form Health Survey (SF-36), and the Visual Analog Scale (VAS), the presence of complications (such as infection, for example), and reoperation.

Quality Assessment

The RCTs included were assessed in terms of quality by two independent reviewers based on the 13 items of the “2015 Updated Method Guideline for Systematic Reviews in the Cochrane Back and Neck Group”.²⁰

Data Synthesis

The studies selected in the systematic review were included in the meta-analysis if they contained one or more outcomes of interest, as aforementioned. The heterogeneity among the studies was calculated using the I-squared (I²) statistic. For outcomes reported as numeric variables, the mean differences (MDs) were reported with 95% confidence intervals (95%CIs). Any study with outcomes reported as a median value was submitted to an estimation of the mean using a previously reported method.²¹ The complications were presented using relative risk, 95%CIs, and number needed to treat, wherever it was appropriate. Comparisons were inferred to be statistically significant if the 95%CI of the MD was ≤ 0 or if the 95%CI of the relative risk was ≤ 1.

 

RESULTS

Literature Search and Study Characteristics

The preliminary electronic search of all databases resulted in 3,972 records (►Fig. 1). A total of 3,500 clinical studies other than RCTs were excluded, and 472 studies remained. In the second step, 384 studies were excluded due to: the performance of nonoperative treatments, pain treatment, rehabilitation after DRF, proposed protocol, treatment of injury around the DRF, and 88 studies remained. After examining the full text of the collected RCTs, we excluded ongoing studies, studies with the same cohort of patients, and those with incomplete reports of outcome measures, in a total of 65 studies. Finally, 20 articles were assessed, with 19 articles categorized as having high-quality evidence, and 1 identified as of moderate quality¹² (►Table 2).

Baseline Characteristics

In the present study, 2,103 DRFs were analyzed. All studies except for 1²² had a greater proportion of female participants, and only in 1 study²³ the sample had a mean age < 40 years old (►Table 2).^{11 12 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39}

Operative Treatment for Distal Radius Fractures

In total, five RCTs addressed modifications in surgical techniques: three were on pronator quadratus (PQ) muscle repair, one was on brachioradialis muscle release, and one was on the minimally-invasive technique. As for the comparison of different operative procedures, four RCTs compared the VLP and EF, and four compared the VLP and Kirschner wires. There were also comparisons of different plates based on their relationship to the watershed line (n= 1), the plate material (n= 1), and the use of fragment-specific fixation (n= 1). Two studies discussed the postoperative immobilization period, and another two discussed the importance of three-dimensional (3D) preoperative planning (►Table 3). The pooled scores on the DASH significantly favored the isolated use of the VLP without PQ repair (MD = 6.22; 95%CI = 2.96–9.48; p= 0.0002; I²= 0%) (►Fig. 2). Individually, the p-values of these studies showed non-significant differences between patients treated with and without PQ repair. A meta-analysis was also performed to compare the scores on the DASH (p= 0.18) and PRWE (p= 0.77) regarding VLP and EF, which resulted in non-significant differences between the two methods (►Fig. 3).

 

DISCUSSION

The present is the first study to summarize high-quality evidence regarding recent advancements in the management of DRFs. At first, DRF management seemed to reach its plateau of satisfactory outcomes, especially with the widespread use of the VLP. Despite that, there is still room for improvement, as well as for the performance of studies with better methodology, which will lead to more reliable results. In addition to that, the present study also investigated which modifications in the VLP will not result in additional benefits.

Patient Reported Outcome Measures (PROMs) for the Upper Extremity

The present meta-analysis focuses on studies using patient-reported outcome measures (PROMs), which are of particular importance in studies with short-term follow-ups, since there is recent strong evidence that PROMs do not correlate with radiological parameters.^{40 41 42} However, this should be done carefully. A constantly-reliable PROM measurement tool is a prerequisite to perform valid analyses regarding several treatment modalities. Previous studies^{43 44} have shown evidence of the reliability, validity, and responsiveness of tools such as the DASH and PRWE in the assessment of the outcomes of injuries to the upper limbs, as compared with other outcome measures.

It is crucial to assess studies using PROMs as the outcome score based on the length of the follow-up period, since it significantly correlates with the progress of the patients. In the short term, two treatment modalities may show significant differences, which may become non-significant in the long term.^{24 25} Despite the superiority of the VLP,⁷ a large multicenter study⁴⁵ found that at the 12-month assessment patients treated with VLPs and those treated with other modalities reported similar outcomes. Even compared with patients treated with plaster casting, no differences were found in terms of PROMs as soon as six weeks after the fracture.⁴⁵ This result is interesting since it defies the common notion that radiological parameters are of the utmost importance, and places more weight on how the patient perceives the result of the treatment. Moreover, the temporal relationship with PROMs for each treatment will be an interesting focus for future studies, since it will influence how we communicate treatment decisions to patients and manage their expectations.

Can we Improve Volar Plating?

One of the most debated questions in DRF management is whether anatomical restoration equates to a satisfactory long-term functional outcome. The VLP has been associated with a precise anatomical reduction, but its cost is higher when compared to that of other options of surgical treatment.⁴⁶ Furthermore, despite the clinical and biomechanical studies favoring anatomical reduction, it was later analyzed that very few studies used validated PROMs.^{7 47} This raised the question of whether anatomical reduction as provided by the VLP is necessary. Other options have been considered, such as EF and non-operative treatments. In the present study, we pooled the DASH and PRWE scores of recent RCTs that showed that VLP yielded long-term results comparable to those of EF,^{27 28} especially for unstable fractures. However, the VLP is still the treatment of choice when compared with plaster casting.^{48 49 50} More studies with larger cohorts and the use of PROMs are needed to explore further issues regarding the need for anatomical reduction in DRFs.

Several studies^{51 52 53 54} have also reported complications related to the VLP. One of the most reported complications is rupture of the finger flexor tendon due to plate prominence at the watershed line.^{8 9} Therefore, several authors have attempted to avoid the problem by performing PQ repair,⁵⁵ brachioradialis (BR) repair,²⁹ and changing the placement of the plate in relation to the watershed line.³⁰ Despite that, recent studies showed no additional benefits of the PQ repair in the short-³¹ and long-term follow ups.^{32 33} In addition to that, our pooled results showed significantly better functional outcomes in patients only submitted to the VLP. One possible explanation presented was the failure in repairing the PQ when the soft tissue is too damaged.³¹

Another emerging topic in DRF management is the use of 3D modelling. In intraarticular DRFs, identification of the fracture pattern, such as the angle of the fracture line or overlapping fracture patches, is difficult, which often leads to extended operative time, excessive blood loss, and an uneven joint surface. This will result in increasing incidence of postoperative complications. The 3D modelling technique was introduced to provide multi-angle and a comprehensive view of the fracture patterns.^{10 11 12}

Study Limitations

There are several limitations to the present study. We limited our search to studies published only in the past five years. Due to the rapid advances in information technology and the medical device industry in general, it is expected that surgical techniques as well as the function and design of plates will advance exponentially in the next decade. Another limitation is that the present meta-analysis only involved studies published in English. Despite the suspected bias toward studies published in English, especially those showing positive results, in the present systematic review we attempted to minimize this bias by collecting studies with diverse outcomes.

 

FINAL CONSIDERATIONS

In unstable fractures, the VLP and EF yielded comparable long-term results. Regarding improvement of the current VLP surgical technique, adding PQ repair to the procedure does not yield clear benefits. More studies with larger cohorts and reliable PROMs should be performed to confirm the results of previous studies and to explore promising modifications in the VLP, such as the use of preoperative 3D modelling.

 

ACKNOWLEDGMENTS

We would like to thank Ketut Gede Mulyadi Ridia, the head of the Orthopedics and Traumatology Department, Faculty of Medicine, Udayana University, Sanglah General Hospital, for all the support.

 

REFERENCES