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
Authors: Woolnough Taylor , Axelrod Daniel , Bozzo Anthony , Koziarz Alex , Koziarz Frank , Oitment Colby , Gyemi Lauren , Gormley Jessica , Gouveia Kyle , Johal Herman 
Published: November 2020

Abstract

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.