Volar locking plate versus external fixation for unstable dorsally displaced distal radius fractures-A 3-year cost-utility analysis

Comparison between Volar Locking Plate and Kirschner Wire Fixation for Unstable Distal Radius Fracture: A Meta-Analysis of Randomized Controlled Trials

Objective  This study aims to compare the outcomes of volar locking plating (VLP) versus percutaneous Kirschner wires (K-wire) fixation for surgical management of unstable distal radius fractures. Methods  We systematically searched multiple databases, including MEDLINE, EMBASE, Cochrane Central till January 2022 for randomized controlled trials (RCTs) that met eligibility criteria. Following outcomes were evaluated at 6-week, 3-, 6-, and 12-month follow-up period: Disabilities of the Arm, Shoulder, and Hand (DASH) score, Patient Rated Wrist Evaluation (PRWE) score, grip strength, range of motion, and complication incidence. Meta-analysis was performed using random effects models and results presented as risk ratios (RRs) or mean differences (MDs) with 95% confidence interval. Results  Fourteen RCTs with 1,450 participants met the inclusion criteria. DASH scores were significantly better for VLP fixation at 6th week (MD = 19.02; p  < 0.001), 3rd (MD = 10.79; p  < 0.001), 6th (MD= 7.78; p  < 0.001), and 12th month (MD = 2.94; p  < 0.001) postoperation. At 3-month follow-up period, VLP treatment exhibited better grip strength (MD = - 10.32; p  < 0.001) and PRWE scores (MD = 8.78; p  < 0.001). There was a statistically significant early advantage in flexion, extension, pronation, supination, radial deviation, and ulnar deviation in the VLP group at 6-week follow-up, but at 1-year follow-up only significantly better extension was observed. At 1 year, radiographic outcomes were similar except for volar tilt favoring VLP fixation ( p  < 0.001). Superficial infections were more common in patients treated with K-wire (RR = 2.89; p  = 0.001), but there was no difference in total complications or reoperation rates ( p  > 0.05). Conclusion  This meta-analysis suggests that VLP fixation and K-wire fixation are both effective procedures, but existing literature does not provide sufficient evidence to demonstrate the superiority of either method. Although VLP fixation improves DASH score, extension and volar tilt at 12-month follow-up, the difference is small and unlikely to be noticeable to the patients.

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.

LIMPER trials: immediate mobilisation versus 2-week cast immobilisation after distal radius fracture treated with volar locking plate - a study protocol for a prospective, randomised, controlled trial

INTRODUCTION

Open reduction and internal fixation with volar locking plate has become the most common fixation method in the treatment of unstable distal radius fracture (DRF). There is, however, no consensus as to whether or for how long a wrist should be immobilised after operative treatment. To date, there have been relatively few studies that have evaluated the effect of immediate postoperative mobilisation on functional outcomes. The aim of postoperative rehabilitation is to obtain a good function and to reduce impairment, recovery time, socioeconomical costs and absence from work. Therefore, there is a need for studies that evaluate the optimal method of postoperative rehabilitation to optimise wrist function and return to work.

METHODS AND ANALYSIS

This study is a prospective, randomised, controlled trial in which a total of 240 working-age patients who undergo volar plating for DRF will be randomly assigned to either an early mobilisation group or a postoperative 2-week casting group. The aim of the study will be to compare early postoperative outcomes between the study groups. The primary outcome will be patient-rated wrist evaluation at 2 months after operation. A coprimary outcome will be the total length of sick leave. Our follow-up period will be 1 year, and secondary outcomes will include pain, patient satisfaction, perceived ability to work and complications identified at different time points. We expect those patients who undergo immediate mobilisation will have at least as rapid a return to work and function as those patients who undergo postoperative immobilisation, indicating/meaning that there will be no need for postoperative casting.

ETHICS AND DISSEMINATION

This study will be conducted according to the Standard Protocol Items: Recommendations for Interventional Trials statement. The Ethics committee of Tampere University Hospital has approved the protocol. Ethics committee approval number is R21111, and it is accepted on 7 September 2021. The results of this study will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05150925.

A comparative study protocol of external fixation versus volar plate in treating distal radius fracture

BACKGROUND

The superiority of the open reduction and internal fixation (ORIF) and external fixation remains uncertain owing to the limited sample size involved in the literature. This retrospective cohort research was implemented for the comparison of the efficiency of ORIF and external fixation utilizing the locked volar plating in treating the intra-articular fractures of distal radius. We hypothesized that compared with the external fixation, ORIF can improve the functional scores and reduce complications.

METHODS

We conducted a retrospective and single-center cohort trial that was approved by institutional review committee of Gansu Provincial Hospital. From June 2016 to July 2018, in our experiment, 178 patients with intra-articular fractures of the distal radius were recruited. Inclusion criteria in this cohort study were designed as follows: the age of patients is between 18 and 65 years, the patients with American Society of Anesthesiologists level I-III, and with the AO-type C3 or C2 fractures of distal radius confirmed by computed tomography scans, the patients with radiographic clinical follow-up for 1 year or >1 year. The patients participating in the trial would be divided into 2 groups: the patients treated via the external fixation and the patients treated by the ORIF utilizing volar plate. The main functional results were the grip strength and the range of motion of wrist. Radiographic measurement and complications were also evaluated in our study.

RESULTS

This study protocol will guide and clarify our assignments, and the final outcomes and conclusion will further enrich the clinical knowledge in the literature.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry6116).