Dataset Information

Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults: A Systematic Review and Meta-analysis.

ABSTRACT:

Importance

No consensus has been reached to date regarding the optimal treatment for distal radius fractures. The international rate of operative treatment has been increasing, despite higher costs and limited functional outcome evidence to support this shift.

Objectives

To compare functional, clinical, and radiologic outcomes after operative vs nonoperative treatment of distal radius fractures in adults.

Data sources

The PubMed/MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception to June 15, 2019, for studies comparing operative vs nonoperative treatment of distal radius fractures.

Study selection

Randomized clinical trials (RCTs) and observational studies reporting on the following: acute distal radius fracture with operative treatment (internal or external fixation) vs nonoperative treatment (cast immobilization, splinting, or bracing); patients 18 years or older; and functional outcome. Studies in a language other than English or reporting treatment for refracture were excluded.

Data extraction and synthesis

Data extraction was performed independently by 2 reviewers. Effect estimates were pooled using random-effects models and presented as risk ratios (RRs) or mean differences (MDs) with 95% CIs. Data were analyzed in September 2019.

Main outcomes and measures

The primary outcome measures included medium-term functional outcome measured with the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the overall complication rate after operative and nonoperative treatment.

Results

A total of 23 unique studies were included, consisting of 8 RCTs and 15 observational studies, that described 2254 unique patients. Among the studies that presented sex data, 1769 patients were women [80.6%]. Overall weighted mean age was 67 [range, 22-90] years). The RCTs included 656 patients (29.1%); observational studies, 1598 patients (70.9%). The overall pooled effect estimates the showed a significant improvement in medium-term (?1 year) DASH score after operative treatment compared with nonoperative treatment (MD, -5.22 [95% CI, -8.87 to -1.57]; P?=?.005; I2?=?84%). No difference in complication rate was observed (RR, 1.03 [95% CI, 0.69-1.55]; P?=?.87; I2?=?62%). A significant improvement in grip strength was noted after operative treatment, measured in kilograms (MD, 2.73 [95% CI, 0.15-5.32]; P?=?.04; I2?=?79%) and as a percentage of the unaffected side (MD, 8.21 [95% CI, 2.26-14.15]; P?=?.007; I2?=?76%). No improvement in medium-term DASH score was found in the subgroup of studies that only included patients 60 years or older (MD, -0.98 [95% CI, -3.52 to 1.57]; P?=?.45; I2?=?34%]), compared with a larger improvement in medium-term DASH score after operative treatment in the other studies that included patients 18 years or older (MD, -7.50 [95% CI, -12.40 to -2.60]; P?=?.003; I2?=?77%); the difference between these subgroups was statically significant (test for subgroup differences, P?=?.02).

Conclusions and relevance

This meta-analysis suggests that operative treatment of distal radius fractures improves the medium-term DASH score and grip strength compared with nonoperative treatment in adults, with no difference in overall complication rate. The findings suggest that operative treatment might be more effective and have a greater effect on the health and well-being of younger, nonelderly patients.

SUBMITTER: Ochen Y

PROVIDER: S-EPMC7180423 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults: A Systematic Review and Meta-analysis.

Ochen Yassine Y Peek Jesse J van der Velde Detlef D Beeres Frank J P FJP van Heijl Mark M Groenwold Rolf H H RHH Houwert R Marijn RM Heng Marilyn M

JAMA network open 20200401 4

<h4>Importance</h4>No consensus has been reached to date regarding the optimal treatment for distal radius fractures. The international rate of operative treatment has been increasing, despite higher costs and limited functional outcome evidence to support this shift.<h4>Objectives</h4>To compare functional, clinical, and radiologic outcomes after operative vs nonoperative treatment of distal radius fractures in adults.<h4>Data sources</h4>The PubMed/MEDLINE, Embase, CENTRAL (Cochrane Central Re ...[more]

PMID: 32324239

Similar Datasets

Project description:IntroductionThe aim of this systematic review and meta-analysis was to evaluate whether volar locking plate (VLP) fixation leads to better clinical and radiological outcomes than those of closed reduction and cast immobilization for the treatment of distal radius fractures (DRFs).Materials and methodsA comprehensive literature search was performed in PubMed, Web of Science, and Cochrane databases up to January 2022. Inclusion criteria included randomized controlled trial (RCT) studies comparing VLP fixation with cast immobilization for DRFs. Investigated parameters were Patient-Rated Wrist Evaluation questionnaire, Disabilities of the Harm, Shoulder, and Hand score (DASH), range of motion (ROM), grip strength, quality of life (QoL), radiological outcome, and complication and reoperation rate, both at short- and mid-/long-term follow-up. Assessment of risk of bias and quality of evidence was performed with Downs and Black's 'Checklist for Measuring Quality'.ResultsA total of 12 RCTs (1368 patients) were included. No difference was found for ROM, grip strength, QoL, and reoperation, while the DASH at 3 months was statistically better in the VLP group (P < 0.05). No clinical differences were confirmed at longer follow-up. From a radiological perspective, only radial inclination (4°) and ulnar variance (mean difference 1.1 mm) at >3 months reached statistical significance in favor of the VLP group (both P < 0.05). Fewer complications were found in the VLP group (P < 0.05), but they did not result in different reintervention rates.ConclusionsThis meta-analysis showed that the surgical approach leads to a better clinical outcome in the first months, better fracture alignment, and lower complication rate. However, no differences in the clinical outcomes have been confirmed after 3 months. Overall, these findings suggest operative treatment for people with higher functional demand requiring a faster recovery, while they support the benefit of a more conservative approach in less demanding patients.

Project description:BackgroundDistal radius fractures are the most frequently encountered fractures in Western societies, typically affecting patients aged 50 years and older. Although this is a common injury, the best treatment for these fractures in older patients is still under debate.ObjectiveThis prospective study aims to compare the outcome of operatively and nonoperatively treated distal radius fractures in the older population. Only patients with distal radius fractures for which equipoise regarding the optimal treatment exists will be included.MethodsThis prospective international multicenter observational cohort study will be designed as a natural experiment. Natural experiments are observational studies in which treatment allocation is determined by factors outside the control of the investigators but also (largely) independent of patient characteristics. Patients aged 65 years and older with an acute distal radius fracture will be considered for inclusion. Treatment allocation (operative vs nonoperative) will be based on the local preferences of the treating hospital either in Switzerland or the Netherlands. Hence, the process governing treatment allocation resembles that of randomization. Patients will be identified after treatment has been initiated. Based on the radiographs and baseline information of the patient, an expert panel of 6 certified trauma surgeons from 2 regions will provide their treatment recommendation. Only patients for whom the experts disagree on treatment recommendations will ultimately be included in the study (ie, for whom there is a clinical equipoise). For these patients, both operative and nonoperative treatment of distal radius fractures are viable, and treatment choice is predominantly determined by personal or local preference. The primary outcome will be the Patient-Rated Wrist Evaluation score at 12 weeks. Secondary outcomes will include the Physical Activity Score for the Elderly, the EQ questionnaire, pain, the living situation, range of motion, complications, and radiological outcomes. By including outcomes such as living situation and the Physical Activity Score for the Elderly, which are not relevant for younger cohorts, valuable information to tailor treatment to the needs of the older population can be gained. According to the sample size collection, which was based on the minimal important clinical difference of the Patient-Rated Wrist Evaluation, 92 patients will have to be included, with at least 46 patients in each treatment group.ResultsEnrollment began in July 2023 and is expected to continue until summer 2024. The final follow-up will be 2 years after the last patient is included.ConclusionsAlthough many trials on this topic have previously been published, there remains an ongoing debate regarding the optimal treatment for distal radius fractures in older patients. This observational study, which will use a fairly new methodological study design, will provide further information on treatment outcomes for older patients with distal radius fractures for which to date equipoise exists regarding the optimal treatment.International registered report identifier (irrid)DERR1-10.2196/52917.

Project description:PURPOSE:Displaced distal radius fractures in children are common and often treated by reduction and cast immobilization. Redisplacement occurs frequently and may be prevented by additional treatment with K-wire fixation after initial reduction. This meta-analysis aims to summarize available literature on this topic and determine if primary K-wire fixation is the preferred treatment for displaced distal radius fractures in children. METHODS:A search in eight databases identified studies that compared cast immobilization alone to additional K-wire fixation as treatment for displaced paediatric distal radius fractures. The primary outcome was the redisplacement rate. Secondary outcomes were secondary reduction rate, range of motion and complications. This meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement. RESULTS:Three RCTs and 3 cohort studies, analysing 197 patients treated with cast immobilization alone and 185 with additional K-wire fixation, were included in this meta-analysis. Redisplacement occurred less frequently after additional K-wire fixation than after cast alone (3.8 versus 45.7%; OR 0.07, 95% CI 0.03-0.15). Secondary reduction was performed in 59.8% of the redisplaced fractures. Complications, other than redisplacement, occurred more often after additional K-wire fixation than after cast alone (15.7 versus 3.6%). Range of motion did not differ after both treatments. CONCLUSIONS:Additional K-wire fixation is a suitable treatment to prevent redisplacement and secondary operations after initial reduction of displaced distal radius fractures in children, but is associated with post-procedural complications. Additional K-wire fixation does not result in a better range of motion than cast immobilization alone. More research is needed to identify those patients who will benefit the most from K-wire fixation as a treatment for displaced distal radius fractures in children.

Project description:ImportanceUnstable ankle fractures are routinely managed operatively. However, because of soft tissue and implant-related complications, recent literature has reported on the nonoperative management of well-reduced medial malleolus fractures after fibular stabilization, but with limited evidence supporting the routine application.ObjectiveTo assess the superiority of internal fixation of well-reduced (displacement ≤2 mm) medial malleolus fractures compared with nonfixation after fibular stabilization.Design, setting, and participantsThis superiority, pragmatic, parallel, prospective randomized clinical trial was conducted from October 1, 2017, to August 31, 2021. A total of 154 adult participants (≥16 years) with a closed, unstable bimalleolar or trimalleolar ankle fracture requiring surgery at an academic major trauma center in the UK were assessed. Exclusion criteria included injuries with no medial-sided fracture, open fractures, neurovascular injury, and the inability to comply with follow-up. Data analysis was performed in July 2022 and confirmed in September 2023.InterventionsOnce the lateral (and where appropriate, posterior) malleolus had been fixed and satisfactory intraoperative reduction of the medial malleolus fracture was confirmed by the operating surgeon, participants were randomly allocated to fixation (n = 78) or nonfixation (n = 76) of the medial malleolus.Main outcome and measureOlerud-Molander Ankle Score (OMAS) 1 year after randomization (range, 0-100 points, with 0 indicating worst possible outcome and 100 indicating best possible outcome).ResultsAmong 154 randomized participants (mean [SD] age, 56.5 [16.7] years; 119 [77%] female), 144 (94%) completed the trial. At 1 year, the median OMAS was 80.0 (IQR, 60.0-90.0) in the fixation group compared with 72.5 (IQR, 55.0-90.0) in the nonfixation group (P = .17). Complication rates were comparable. Significantly more patients in the nonfixation group developed a radiographic nonunion (20% vs 0%; P < .001), with 8 of 13 clinically asymptomatic; 1 patient required surgical reintervention for this. Fracture type and reduction quality appeared to influence fracture union and patient outcome.Conclusions and relevanceIn this randomized clinical trial comparing internal fixation of well-reduced medial malleolus fractures with nonfixation, after fibular stabilization, fixation was not superior according to the primary outcome. However, 1 in 5 patients developed a radiographic nonunion after nonfixation, and although the reintervention rate to manage this was low, the future implications are unknown. These results support selective nonfixation of anatomically reduced medial malleolar fractures after fibular stabilization.Trial registrationClinicalTrials.gov Identifier: NCT03362229.

Dataset Information

Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults: A Systematic Review and Meta-analysis.

Importance

Objectives

Data sources

Study selection

Data extraction and synthesis

Main outcomes and measures

Results

Conclusions and relevance

Publications

Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults: A Systematic Review and Meta-analysis.

Similar Datasets

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