PMID- 33165042
OWN - NLM
STAT- MEDLINE
DCOM- 20210805
LR  - 20230814
IS  - 1528-1132 (Electronic)
IS  - 0009-921X (Print)
IS  - 0009-921X (Linking)
VI  - 479
IP  - 2
DP  - 2021 Feb 1
TI  - What Is the Relative Effectiveness of the Various Surgical Treatment Options for 
      Distal Radius Fractures? A Systematic Review and Network Meta-analysis of 
      Randomized Controlled Trials.
PG  - 348-362
LID - 10.1097/CORR.0000000000001524 [doi]
AB  - BACKGROUND: Many acceptable treatment options exist for distal radius fractures 
      (DRFs); however, a simultaneous comparison of all methods is difficult using 
      conventional study designs. QUESTIONS/PURPOSES: We performed a network 
      meta-analysis of randomized controlled trials (RCTs) on DRF treatment to answer 
      the following questions: Compared with nonoperative treatment, (1) which 
      intervention is associated with the best 1-year functional outcome? (2) Which 
      intervention is associated with the lowest risk of overall complications? (3) 
      Which intervention is associated with the lowest risk of complications requiring 
      operation? METHODS: Ten databases were searched from inception to July 25, 2019. 
      Search and analysis reporting adhered to Preferred Reporting Items for Systematic 
      Reviews and Meta-analyses guidelines. Included studies were English-language RCTs 
      that assessed at least one surgical treatment arm for adult patients with 
      displaced DRFs, with less than 20% loss to follow-up. We excluded RCTs reporting 
      on patients with open fractures, extensive bone loss, or ipsilateral upper 
      extremity polytrauma. Seventy RCTs (n = 4789 patients) were included. Treatments 
      compared were the volar locking plate, bridging external fixation, nonbridging 
      external fixation, dynamic external fixation, percutaneous pinning, 
      intramedullary fixation, dorsal plating, fragment-specific plating, and 
      nonoperative treatment. Subgroup analyses were conducted for intraarticular 
      fractures, extraarticular fractures, and patients with an average age greater 
      than 60 years. Mean (range) patient age was 59 years (56 to 63) and was similar 
      across all treatment groups except for dynamic external fixation (44 years) and 
      fragment-specific plating (47 years). Distribution of intraarticular and 
      extraarticular fractures was approximately equal among the treatment groups other 
      than that for intramedullary fixation (73% extraarticular), fragment-specific 
      plating (66% intraarticular) [13, 70], and dorsal plating (100% intraarticular). 
      Outcomes were the DASH score at 1 year, total complications, and reoperation. The 
      minimum clinically important different (MCID) for the DASH score was set at 10 
      points. The analysis was performed using Bayesian methodology with random-effects 
      models. Rank orders were generated using surface under the cumulative ranking 
      curve values. Evidence quality was assessed using Grades of Recommendation, 
      Assessment, Development and Evaluation (GRADE) methodology. Most studies had a 
      low risk of bias due to randomization and low rates of incomplete follow-up, 
      unclear risk of bias due to selective reporting, and high risk of bias due to 
      lack of patient and assessor blinding. Studies assessing bridging external 
      fixation and/or nonoperative treatment arms had a higher overall risk of bias 
      while studies with volar plating and/or percutaneous pinning treatment arms had a 
      lower risk of bias. RESULTS: Across all patients, there were no clinically 
      important differences in terms of the DASH score at 1 year; although differences 
      were found, all were less than the MCID of 10 points. Volar plating was ranked 
      the highest for DASH score at 1 year (mean difference -7.34 [95% credible 
      interval -11 to -3.7) while intramedullary fixation, with low-quality evidence, 
      also showed improvement in DASH score (mean difference -7.75 [95% CI -14.6 to 
      -0.56]). The subgroup analysis revealed that only locked volar plating was 
      favored over nonoperative treatment for patients older than 60 years of age (mean 
      difference -6.4 [95% CI -11 to -2.1]) and for those with intraarticular fractures 
      (mean difference -8.4 [95% CI -15 to -2.0]). However, its clinical importance was 
      uncertain as the MCID was not met. Among all patients, intramedullary fixation 
      (odds ratio 0.09 [95% CI 0.02 to 0.84]) and locked volar plating (OR 0.14 [95% CI 
      0.05 to 0.39]) were associated with a lower complication risk compared with 
      nonoperative treatment. For intraarticular fractures, volar plating was the only 
      treatment associated with a lower risk of complications than nonoperative 
      treatment (OR 0.021 [95% CI < 0.01 to 0.50]). For extraarticular fractures, only 
      nonbridging external fixation was associated with a lower risk of complications 
      than nonoperative treatment (OR 0.011 [95% CI < 0.01 to 0.65]), although the 
      quality of evidence was low. Among all patients, the risk of complications 
      requiring operation was lower with intramedullary fixation (OR 0.06 [95% CI < 
      0.01 to 0.85) than with nonoperative treatment, but no treatment was favored over 
      nonoperative treatment when analyzed by subgroups. CONCLUSION: We found no 
      clinically important differences favoring any surgical treatment option with 
      respect to 1-year functional outcome. However, relative to the other options, 
      volar plating was associated with a lower complication risk, particularly in 
      patients with intraarticular fractures, while nonbridging external fixation was 
      associated with a lower complication risk in patients with extraarticular 
      fractures. For patients older than 60 years of age, nonoperative treatment may 
      still be the preferred option because there is no reliable evidence showing a 
      consistent decrease in complications or complications requiring operation among 
      the other treatment options. Particularly in this age group, the decision to 
      expose patients to even a single surgery should be made with caution. LEVEL OF 
      EVIDENCE: Level I, therapeutic study.
CI  - Copyright (c) 2020 by the Association of Bone and Joint Surgeons.
FAU - Woolnough, Taylor
AU  - Woolnough T
AD  - T. Woolnough, L. Gyemi, J. Gormley, K. Gouveia, Michael G. DeGroote School of 
      Medicine, McMaster University, Hamilton, ON, Canada.
AD  - D. Axelrod, A. Bozzo, C. Oitment, H. Johal, Division of Orthopaedic Surgery, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Bozzo, H. Johal, Department of Health Research Methods, Evidence, and Impact, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Koziarz, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
AD  - F. Koziarz, McMaster University, Hamilton, ON, Canada.
FAU - Axelrod, Daniel
AU  - Axelrod D
AD  - T. Woolnough, L. Gyemi, J. Gormley, K. Gouveia, Michael G. DeGroote School of 
      Medicine, McMaster University, Hamilton, ON, Canada.
AD  - D. Axelrod, A. Bozzo, C. Oitment, H. Johal, Division of Orthopaedic Surgery, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Bozzo, H. Johal, Department of Health Research Methods, Evidence, and Impact, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Koziarz, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
AD  - F. Koziarz, McMaster University, Hamilton, ON, Canada.
FAU - Bozzo, Anthony
AU  - Bozzo A
AD  - T. Woolnough, L. Gyemi, J. Gormley, K. Gouveia, Michael G. DeGroote School of 
      Medicine, McMaster University, Hamilton, ON, Canada.
AD  - D. Axelrod, A. Bozzo, C. Oitment, H. Johal, Division of Orthopaedic Surgery, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Bozzo, H. Johal, Department of Health Research Methods, Evidence, and Impact, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Koziarz, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
AD  - F. Koziarz, McMaster University, Hamilton, ON, Canada.
FAU - Koziarz, Alex
AU  - Koziarz A
AD  - T. Woolnough, L. Gyemi, J. Gormley, K. Gouveia, Michael G. DeGroote School of 
      Medicine, McMaster University, Hamilton, ON, Canada.
AD  - D. Axelrod, A. Bozzo, C. Oitment, H. Johal, Division of Orthopaedic Surgery, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Bozzo, H. Johal, Department of Health Research Methods, Evidence, and Impact, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Koziarz, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
AD  - F. Koziarz, McMaster University, Hamilton, ON, Canada.
FAU - Koziarz, Frank
AU  - Koziarz F
AD  - T. Woolnough, L. Gyemi, J. Gormley, K. Gouveia, Michael G. DeGroote School of 
      Medicine, McMaster University, Hamilton, ON, Canada.
AD  - D. Axelrod, A. Bozzo, C. Oitment, H. Johal, Division of Orthopaedic Surgery, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Bozzo, H. Johal, Department of Health Research Methods, Evidence, and Impact, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Koziarz, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
AD  - F. Koziarz, McMaster University, Hamilton, ON, Canada.
FAU - Oitment, Colby
AU  - Oitment C
AD  - T. Woolnough, L. Gyemi, J. Gormley, K. Gouveia, Michael G. DeGroote School of 
      Medicine, McMaster University, Hamilton, ON, Canada.
AD  - D. Axelrod, A. Bozzo, C. Oitment, H. Johal, Division of Orthopaedic Surgery, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Bozzo, H. Johal, Department of Health Research Methods, Evidence, and Impact, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Koziarz, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
AD  - F. Koziarz, McMaster University, Hamilton, ON, Canada.
FAU - Gyemi, Lauren
AU  - Gyemi L
AD  - T. Woolnough, L. Gyemi, J. Gormley, K. Gouveia, Michael G. DeGroote School of 
      Medicine, McMaster University, Hamilton, ON, Canada.
AD  - D. Axelrod, A. Bozzo, C. Oitment, H. Johal, Division of Orthopaedic Surgery, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Bozzo, H. Johal, Department of Health Research Methods, Evidence, and Impact, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Koziarz, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
AD  - F. Koziarz, McMaster University, Hamilton, ON, Canada.
FAU - Gormley, Jessica
AU  - Gormley J
AD  - T. Woolnough, L. Gyemi, J. Gormley, K. Gouveia, Michael G. DeGroote School of 
      Medicine, McMaster University, Hamilton, ON, Canada.
AD  - D. Axelrod, A. Bozzo, C. Oitment, H. Johal, Division of Orthopaedic Surgery, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Bozzo, H. Johal, Department of Health Research Methods, Evidence, and Impact, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Koziarz, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
AD  - F. Koziarz, McMaster University, Hamilton, ON, Canada.
FAU - Gouveia, Kyle
AU  - Gouveia K
AD  - T. Woolnough, L. Gyemi, J. Gormley, K. Gouveia, Michael G. DeGroote School of 
      Medicine, McMaster University, Hamilton, ON, Canada.
AD  - D. Axelrod, A. Bozzo, C. Oitment, H. Johal, Division of Orthopaedic Surgery, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Bozzo, H. Johal, Department of Health Research Methods, Evidence, and Impact, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Koziarz, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
AD  - F. Koziarz, McMaster University, Hamilton, ON, Canada.
FAU - Johal, Herman
AU  - Johal H
AD  - T. Woolnough, L. Gyemi, J. Gormley, K. Gouveia, Michael G. DeGroote School of 
      Medicine, McMaster University, Hamilton, ON, Canada.
AD  - D. Axelrod, A. Bozzo, C. Oitment, H. Johal, Division of Orthopaedic Surgery, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Bozzo, H. Johal, Department of Health Research Methods, Evidence, and Impact, 
      McMaster University, Hamilton, ON, Canada.
AD  - A. Koziarz, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
AD  - F. Koziarz, McMaster University, Hamilton, ON, Canada.
LA  - eng
PT  - Journal Article
PT  - Meta-Analysis
PT  - Systematic Review
PL  - United States
TA  - Clin Orthop Relat Res
JT  - Clinical orthopaedics and related research
JID - 0075674
SB  - IM
CIN - Clin Orthop Relat Res. 2021 Feb 1;479(2):363-365. PMID: 33475298
MH  - Bayes Theorem
MH  - Disability Evaluation
MH  - Fracture Fixation/*methods
MH  - Humans
MH  - Network Meta-Analysis
MH  - Postoperative Complications
MH  - Radius Fractures/*surgery
MH  - Randomized Controlled Trials as Topic
PMC - PMC7899542
COIS- Each author certifies that neither he nor she, nor any member of his or her 
      immediate family, has funding or commercial associations (consultancies, stock 
      ownership, equity interest, patent/licensing arrangements, etc.) that might pose 
      a conflict of interest in connection with the submitted article. All ICMJE 
      Conflict of Interest Forms for authors and Clinical Orthopaedics and Related 
      Research(R) editors and board members are on file with the publication and can be 
      viewed on request.
EDAT- 2020/11/10 06:00
MHDA- 2021/08/06 06:00
PMCR- 2022/02/01
CRDT- 2020/11/09 14:23
PHST- 2020/04/17 00:00 [received]
PHST- 2020/09/14 00:00 [accepted]
PHST- 2020/11/10 06:00 [pubmed]
PHST- 2021/08/06 06:00 [medline]
PHST- 2020/11/09 14:23 [entrez]
PHST- 2022/02/01 00:00 [pmc-release]
AID - 00003086-202102000-00025 [pii]
AID - CORR-D-20-00584 [pii]
AID - 10.1097/CORR.0000000000001524 [doi]
PST - ppublish
SO  - Clin Orthop Relat Res. 2021 Feb 1;479(2):348-362. doi: 
      10.1097/CORR.0000000000001524.