Surgical Plating No Better Than Closed Reduction for Distal Radius Fractures

By Lisa Rapaport

January 21, 2021

(Reuters Health) - Surgical plating is not superior to closed reduction at improving pain or function in older adults with displaced distal radius fractures, a new study suggests.

Researchers randomized 166 adults aged 60 years and older with displaced distal radius fractures to receive either surgical or nonsurgical treatment; they also followed an additional 134 patients with the same injury who declined randomization and could choose between surgical plating or closed reduction.

The primary endpoint was mean patient-rated wrist evaluation scores, derived from a 15-item questionnaire assessing pain and function; scores range from 0 to 100 with higher scores indicating worse outcomes.

At 12 months, there were no clinically meaningful differences between the surgical plating and closed reduction groups in mean patient-rated wrist evaluation scores (19.8 vs 21.5), the authors report in JAMA Surgery.

A difference of 14 points or more would have been considered clinically meaningful, according to the study team.

After multivariate analysis, adjusting for age and sex, there also was no statistically significant difference between treatment groups in 12-month patient-rated wrist outcome evaluation scores.

"I think the most likely explanation is that there simply is no difference: there is no long-term benefit to surgery using plates and screws compared to plaster for these fractures," said lead study author Andrew Lawson of the Whitlam Orthopedic Research Centre at the University of New South Wales in Sydney, Australia.

"The lack of difference also represents our incorrect reliance on making the X-ray look good, instead of making the patient better," Lawson said by email. "Surgery normally leads to better looking X-rays, but that doesn't translate into a better wrist, or a better outcome for the patient."

Researchers also found no meaningful difference between groups at 12 months in patient-rated pain scores.

However, patient-reported treatment success scores were slightly higher for people who received surgical plating than for those that received closed reduction for their fractures. At three months, 81% in the surgical group and 67% in the nonsurgical group rated their care as "very successful" or "successful."

At six months, four people in the closed reduction group had fracture non-union, with three of these cases requiring surgery; no cases of fracture non-union occurred in the group that received surgical plating.

In addition, 12 people in the closed reduction group had complications, compared with 6 in the surgical plating group. Complications required treatment with surgery for 6 people in the nonsurgical group and 2 in the surgical group.

One limitation of the study is the potential for performance bias to influence patient-reported outcomes, which might overestimate the benefit of surgery, the study team notes. There was also potential for unblinding, particularly when patients required additional treatment due to complications.

Results for older adults, who may be less active and more able to refrain from work or leisure activities that would negatively impact healing, also may not reflect what would happen with younger adults, said Dr. E. Gene Deune, a professor of hand and plastic surgery at the University of North Carolina, Chapel Hill, and author of a commentary accompanying the study.

"Given the higher activity demands in a younger population who need to use their extremities for their livelihood, it is less likely that they would be able to maintain levels of immobility that would be optimal for distal radius fracture healing with the closed treatment," Dr. Deune said by email. "This would then alter the results and give operative treatment a statistically improved result."

SOURCE: https://bit.ly/2KCXukM and https://bit.ly/360nrlL JAMA Surgery, online January 13, 2021.

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