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Meta-analysis
ACE Report #4520

ORIF for distal radius fractures may improve function vs. external fixation


Study Type:Meta-analysis/Systematic Review
OE Level Evidence:1
Journal Level of Evidence:N/A

External fixation versus open reduction with plate fixation for distal radius fractures: A meta-analysis of randomised controlled trials

Injury. 2013 Jan 5. pii: S0020-1383(12)00536-0. doi: 10.1016/j.injury.2012.12.003

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Synopsis

In this meta-analysis, 10 randomized controlled trials were examined to determine which treatment for distal radius fractures - external fixation or open reduction and internal fixation (ORIF) using plates - provided better outcomes. Following comparisons of the two treatments, results indicated that ORIF with plate fixation provided slightly better functional results with fewer complications.

Publication Funding Details +
Funding:
Non-funded
Conflicts:
Royalties

Risk of Bias

9/10

Reporting Criteria

16/20

Fragility Index

N/A

Were the search methods used to find evidence (original research) on the primary question or questions stated?

Was the search for evidence reasonably comprehensive?

Were the criteria used for deciding which studies to include in the overview reported?

Was the bias in the selection of studies avoided?

Were the criteria used for assessing the validity of the included studies reported?

Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?

Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?

Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?

Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?

How would you rate the scientific quality of this evidence?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.

4/4

Introduction

4/4

Accessing Data

3/4

Analysing Data

3/4

Results

2/4

Discussion

Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

The standard treatment for distal radius fractures is closed reduction and external fixation. Lately though, an alternative technique, ORIF using plates, has gained popularity. However, it is still unknown which of the two treatments is better for treating distal radius fractures. Hence, this meta-analysis was aimed to determine which method of treatment was more effective in treating distal radius fractures, in terms of functional and radiographic outcomes.

What was the principal research question?

From included randomized trials, did ORIF with plate fixation provide better functional and radiographic outcomes than external fixation when treating distal radius fractures?

Study Characteristics -
Data Source:
An electronic search was conducted in January 2011 using the databases MEDLINE, EMBASE, and COCHRANE.
Index Terms:
The index terms searched were (distal radius or distal radial) and (fracture or fractures) and (external fixation or external fixator) and (internal fixation or internal fixator or plate or plating).
Study Selection:
Studies were included if they had the following criteria: use of a random allocation of treatments, use of a treatment arm receiving external fixation, use of a treatment arm receiving ORIF with a plate, and results reporting at least one clinical outcome.
Data Extraction:
Two investigators independently searched and reviewed the studies using the inclusion criteria and independently extracted relevant data for each eligible study. Discrepancies were solved through discussion until a consensus was reached.
Data Synthesis:
Statistical analysis of the data from the studies used was achieved using RevMan 5.0. The mean difference (mean ORIF with plate fixation minus the mean for external fixation) along with the variance around the mean difference was calculated for wrist range of motion, radiographic parameters, grip strength, and DASH score. The relative risk and 95% C.I. were calculated for overall rate of complications, rates of specific complications, and rates of reoperation. To pool the relative risk estimates, the random-effects model was used. P<0.05 was considered statistically significant.

What were the important findings?

  • The type of plate used in the ORIF groups in this meta-analysis was not controlled. Four studies used only volar plates. The other 6 studies used either radial pin-plates, radial column plates, or dorsal Pi Plates.
  • The maximum follow-up time was 12 months in 5 of the studies, 24 in 4 of the studies, and not specified in one of the studies.
  • There was a significant difference in pooled treatment effect for mean difference in DASH scores between the two treatments, favouring the ORIF technique, with minimal heterogeneity (MD: -5.92; 95% CI: -9.89 to -1.96; p=0.003; I squared: 39%).
  • The pooled treatment effect from 3 studies for mean difference in range of motion (flexion, extension, radial and ulnar deviation, and pronation and supination) did not differ significantly between the two treatments techniques (p=0.26-0.98).
  • No significant differences existed between the two treatment methods regarding pooled treatment effect for mean difference in grip strength, but there was moderate heterogeneity (MD: 1.60; 95% CI: --6.59 to 9.80; p=0.70; I squared: 59%).
  • The pooled treatment effect for mean difference in ulnar variance differed significantly between the two treatments techniques, favouring the ORIF method (MD: -0.70; 95% CI: -1.20 to -0.19; p=0.006; I squared: 0%).
  • Using 9 studies, the pooled treatment effect for risk ratios of the rate of complications favoured neither intervention (RR = 0.86; 95%CI 0.57-1.31; p=0.48, I squared: 0%). However, removal of the only study to use dorsal plates exclusively in ORIF procedure indicated that the ORIF technique had significantly lower risk ratios than the external fixation method (RR: 0.65; 95% CI: 0.47-0.91; p=0.01; I squared: 0%).
  • Based on data from 7 studies, the pooled treatment effect for risk ratios of the rate of infections indicated that the ORIF technique had significantly lower risk ratios than the external fixation method (RR: 0.37; 95% CI: 0.19-0.73; p=0.004; I squared: 0%).

What should I remember most?

Results displayed that the ORIF with plate fixation technique for treating distal radius fractures provided lower DASH scores, and reduced infection rates than external fixation. Overall though, there was little clinical difference between the two methods.

How will this affect the care of my patients?

There is little clinical difference between outcomes using ORIF with plate fixation and external fixation groups, treatment should be assessed on a case by case basis and should be determined by both treating physician and the patient preference. Extent of mobilization and cost would be factors to take into consideration. Should any RCTs be conducted in the future then larger sample sizes, longer follow-up, and better blinding will be required.

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