Meta-analysis for dorsally displaced distal radius fracture fixation: volar locking plate versus percutaneous Kirschner wires

Abstract

Background: Dorsally displaced distal radius fractures (DDDRF) are frequent injuries in clinical practice. Traditional percutaneous Kirschner wires (K-wire) and open reduction with volar locking plate (VLP) are the two most common surgical fixation techniques used to manage DDDRF. However, there is no current consensual evidence to guide the selection of one technique over the other. Therefore, we undertook a systematic search and meta-analysis to compare clinical outcomes and complications of these two treatment approaches for DDDRF.

Methods: The following electronic databases were searched by two independent reviewers, up to April 2015: PubMed, ScienceDirect and Wiley Online Library. High-quality randomized controlled trials (RCTs) comparing VLP and percutaneous K-wire fixation for DDDRF were identified. Pooled mean differences were calculated for the following continuous outcome variables: disabilities of the arm, shoulder and hand (DASH) score, grip strength and wrist range of motion. Pooled odds ratios were calculated for rates of total postoperative complications, including superficial infection, deep infection, complex regional pain syndrome (CRPS), carpal tunnel syndrome (CTS), neurological injury, tendon rupture, tenosynovitis, loss of reduction and additional surgery to remove hardware. The meta-analysis was completed using RevMan 5.3 software.

Results: Seven RCTs, with a total of 875 patients, were included in our meta-analysis. Open reduction internal fixation (ORIF) with VLP fixation provided statistically lower DASH scores, reduced the incidence of total postoperative complications and specifically lowered the rate of superficial infection, when compared, over a 1-year follow-up, to percutaneous K-wire fixation. VLP fixation also provided significantly better grip strength and range of wrist flexion and supination in the early 6-month postoperative period, compared with percutaneous K-wire fixation.

Conclusion: ORIF with VLP fixation provided lower DASH scores and reduced total postoperative complications, most specifically lowering the risk for postoperative superficial infection compared to K-wire fixation over a 1-year follow-up period. However, superficial pin track infections do not cause clinical debility in the vast majority of cases. Thus, the claim of reduced superficial infection rate may not be clinically important. The only reasonable conclusion that can be drawn is that at present, there is insufficient data even on our meta-analysis to help the clinician make an informed choice.

Fig. 1

Flow chart summarizing the selection process of RCTs. RCT, randomized control trials

Fig. 2

Methodological quality of included RCTs. This ‘risk of bias’ tool incorporates assessment of randomization (sequence generation and allocation concealment), blinding (participants, personnel and outcome assessors), completeness of outcome data, selection of outcomes reported and other sources of bias. The items are scored a ‘yes’, ‘no’, or ‘unsure’. RCT, randomized control trials

Fig. 3

Risk of bias. Each item of the ‘risk of bias’ assessment is shown as a percentage across all included randomized control trials, indicating the proportion of different levels of risk of bias for each item

Fig. 4

Forest plot illustrating the meta-analysis of the DASH score at 3, 6 and 12 months postoperatively. DASH, disabilities of arm, shoulder and hand

Fig. 5

WMD estimates for grip strength 3, 6 and 12 months postoperatively. WMD, weighted mean difference

Fig. 6

WMD estimates for range of wrist flexion at 3, 6 and 12 months postoperatively. WMD, weighted mean difference

Fig. 7

WMD estimates for range of wrist supination at 3, 6 and 12 months postoperatively. WMD, weighted mean difference

Fig. 8

Forest plot illustrating the meta-analysis for rate of total postoperative complications

Fig. 9

Forest plot illustrating the meta-analysis for rate of superficial infection postoperatively

Fig. 10

A funnel plot of the total complications to assess publication bias