A meta-analysis comparing volar locking plates and cast immobilization for distal radius fractures in the elderly (2024)

Background

The long-term outcomes (≥ 2 years of follow-up) of volar locked plate (VLP) fixation versus closed reduction and casting (CRC) for the treatment of displaced distal radial fractures (DRFs) remain unclear. This study aimed to conduct a meta-analysis comparing the long-term clinical outcomes of VLP and CRC in elderly patients (aged ≥ 60 years).

Methods

A comprehensive search of PubMed, Web of Science, and Cochrane Library was performed to identify studies comparing the long-term outcomes of VLP and CRC for DRFs. Only randomized controlled trials (RCTs) with a mean follow-up duration of at least 2 years and participants aged 60 years or older were included. The risk of bias in the included studies was assessed. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE). Secondary outcomes included the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, EuroQol 5 Dimension 5-level score (EQ-5D-5L), grip strength, and incidence of reoperation.

Results

Four RCTs, comprising 423 patients, were included. The meta-analysis revealed that VLP fixation was associated with significantly improved outcomes compared to CRC in terms of PRWE score (pooled mean difference: -6.21; 95% CI: -10.28 to -2.15; p = 0.003), DASH score (pooled mean difference: -8.18; 95% CI: -13.35 to -3.01; p = 0.002), and grip strength (pooled mean difference: -6.63; 95% CI: 0.25 to 13.01; p = 0.04). There were no significant differences in EQ-5D-5L score (95% CI: -0.08 to 0.05; p = 0.74) or incidence of reoperation (RR = 0.56; 95% CI: 0.22 to 1.42; p = 0.22).

Conclusions

A two-year follow-up of displaced DRFs in elderly patients showed no significant long-term clinical advantage of VLP fixation over CRC.

Distal radius fractures (DRFs) are the second most common type of fracture in individuals aged 65 and older, accounting for 18% of all fractures in this age group [1, 2]. Risk factors for DRFs include being of White race, female sex, and having osteoporosis [3, 4]. DRFs display a bimodal distribution, with high-energy fractures more frequently seen in young men, while older women are more likely to experience both high- and low-energy fractures [5, 6]. The prevalence of DRFs increases significantly in women after perimenopause and is four times higher in women over the age of 35 than in men [7].

Currently, there is limited evidence on the long-term outcomes of DRF treatments. Treatment options include surgical reduction and internal fixation with volar locked plates, Kirschner wires, percutaneous elastic-dynamic fixation, external fixation, or non-surgical closed reduction and casting [8,9,10]. In recent years, there has been a significant increase in the surgical management of DRFs, likely due to the growing preference among orthopedic surgeons for surgical intervention [11, 12]. As the population has aged over the past few decades, the incidence of DRFs and the rate of surgical treatment have both increased [13, 14]. Regardless of treatment modality—surgical or conservative—most patients regain optimal strength, range of motion, and function within three to six months [15]. However, in older patients with unstable DRFs, long-term complications such as tendon irritation, fracture non-union, and carpal tunnel syndrome may occur [16, 17]. The most common surgical complication is infection, while median neuropathy is the most frequent non-surgical complication, both of which often necessitate additional surgery.

The American Academy of Orthopaedic Surgeons (AAOS) and the American Society for Surgery of the Hand (ASSH) evidence-based clinical practice guidelines on DRFs do not recommend internal fixation to improve medium-term outcomes in older adults [18, 19]. These guidelines are based on two high-quality and 11 moderate-quality studies. While the literature indicates comparable short-term outcomes for volar locking plates and cast immobilization in elderly patients (aged > 60), whether surgical treatment improves long-term outcomes in this population remains unexamined [20, 21]. This review aims to compare the outcomes of elderly patients with DRFs treated with volar locked plate fixation versus closed reduction and casting, with a minimum follow-up of two years.

Search method and strategy

This review adhered to Cochrane review methods and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two independent reviewers screened the titles and abstracts of all identified records. The full texts of potentially eligible publications were retrieved and assessed for final selection. Reference lists of included studies and relevant reviews were also screened to identify additional articles. Only full-text, peer-reviewed articles published in English between 1 January 2000 and 1 August 2024 were included. The following search terms were used: “radius fracture,” “distal radius fracture,” “wrist fracture,” “forearm fracture,” “radial fracture,” “palmar plate,” “volar locked plate,” “palmar locking plate,” “internal fixation,” “randomized controlled trials,” and “RCTs.” The literature screening process (PRISMA diagram) is provided in Supplementary Fig.1.

Study selection and data extraction methods

Two independent reviewers extracted data from the selected studies using a predefined data extraction form. The extracted data included the first author, year of publication, study design, sample size, duration of follow-up, PRWE, DASH, EQ-5D-5L, grip strength, and patient-reported reoperations (including carpal tunnel release, fracture non-union, and postoperative infections requiring surgical washout).

If the patient-reported outcome data were unclear, we contacted the corresponding author for clarification. Relevant patient-reported outcome data were excluded from the meta-analysis if the author did not respond or if accurate data could not be obtained.

Inclusion and exclusion criteria

Studies were considered eligible when participant met following criteria: (1) Participants older than 60 with clinical and radiographic examination diagnostic of a closed DRF; (2) one of them receiving treatment with VLP and CRC for distal radius fractures; (3) published clinical RCTs; (4) studies with at least one of the following outcomes: PRWE, DASH, EQ-5D-5L, grip strength and patient-reported reoperation; (5) follow-up results for at least 2 years. Studies would be excluded from present meta-analysis for comminuted fracture, incomplete data, case reports, conference abstract, or review articles.

Study quality assessment

The Cochrane risk-of-bias tool was used to assess the risk of bias in the studies. This tool evaluates six domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, and selective reporting. Each domain was rated as having a “low risk of bias,” “high risk of bias,” or “unclear risk of bias.” In terms of selection bias, one study did not report the methodology used for randomization, making it unclear whether this process was conducted appropriately and rigorously. As a result, this study was deemed to have a high risk of selection bias. The remaining three studies employed randomization methods using opaque envelopes and automated, telephone-based computerized randomization, and were assessed as having a low risk of bias. It is important to note that blinding surgeons was not possible, as they were aware of the treatment being administered.

Study design

We selected RCTs comparing VLP fixation with CRC in patients with a displaced distal radius fracture and reporting data for ≥ 1 of the following outcome measures: PRWE, DASH, EQ-5D-5L, grip strength and patient-reported reoperation. Functional outcomes were assessed using the PRWE, DASH score and grip strength. Quality of life was assessed using the EQ-5D-5L. Results were followed up for 24 months or more. Studies were excluded if they were younger than 60 years old, had a follow-up period of less than 24 months, or if the full text article was not available.

Statistical analysis

RevMan 5.3.01 for Windows, developed by Cochrane, was used to perform meta-analyses. The mean differences (MD) and standardized mean differences with 95% CI were used to compare pooled continuous data. Reoperations using the number of events collected in each study. Pooled dichotomous data (reoperation) was expressed as a risk ratio (RR) with 95% CI. Subgroup analyses were not conducted in the present study, and heterogeneity was evaluated using the I² statistic. A value of 25% was considered low heterogeneity, 50% was considered moderate heterogeneity, and 75% was considered high heterogeneity. Forest plots were used to illustrate the results of each study, the pooled effect estimate, and the overall summarized effect. Significance was defined as p < 0.05.

Search results

A systematic search of PubMed, Web of Science, and Cochrane Library identified 5382 potentially eligible studies, and no additional records were found during manual searches of reference lists. After removing duplicates and ineligible records following an automated tool, we screened the remaining 3849 studies. Furthermore, 3083 citations were excluded after reading the abstract. Of these,67 articles were left for full-text review, and 63 articles were excluded according to the inclusion and exclusion criteria. Finally, 4 RCT studies [22,23,24,25] were included in the review.

Study characteristics and quality assessment

The four studies included in this analysis were published between 2017 and 2022 and involved a total of 423 patients. Of these, 214 were treated with VLP immobilization and 209 were treated with CRC. The primary outcome was the total score on the Patient-Rated Wrist Evaluation (PRWE) questionnaire. Two studies administered the questionnaire at the 24-month (within 1 month) follow-up, and one study administered it at the 3-year follow-up. Given the relatively small sample size in consideration of the potential for individual variability, we opted for a fixed effects model. Supplementary Table I summarizes the characteristics of the study design. Supplementary Fig.2 summarize the methodological quality and risk of bias of the included studies. Allocation concealment was reported in three randomized controlled trials, but blinding of outcome assessment was not possible.

PRWE score

PRWE scores were performed in all but 1 study. The fixed effects modelling revealed a statistically significant discrepancy in the PRWE scores, with a pooled mean difference of -6.21. (95%CI, -10.28 to -2.15; p = 0.003; I² = 54%) (Supplementary Fig.3). There was moderate heterogeneity in the effect sizes reported across studies, attributable to practical differences between studies.

DASH score

Two studies meta-analyzed the DASH scores. The fixed-effects models showed that VLP produced better DASH scores than CRC, with a mean difference of -8.18 (95%CI, -13.35 to -3.01; p = 0.002; I² = 56%), this difference was significant (Supplementary Fig.4). Moderate heterogeneity was observed in the effect sizes reported across studies due to practical differences between the studies. In one study [24], hand function was evaluated using the Michigan Hand Function Questionnaire (MHQ) and was not subjected to statistical analysis.

Grip strength

Meta-analyses were conducted on grip strength in three studies. The fixed-effects models showed a pooled difference in grip strength between the CRC phase and the VLP group. The pooled mean difference was − 6.63 (95% CI 0.25 to 13.01; p = 0.04; I² = 0%), this difference was significant (Supplementary Fig.5). There was no significant heterogeneity in reported effect sizes reported in the study.

EQ-5D-5L score

Two studies meta-analyzed the EQ-5D-5L. The fixed-effects model showed that the mean difference in EQ-5D-5L scores between the VLP and CRC groups was − 0.01 (95%CI -0.08 to 0.05; p = 0.74; I² = 0%) (Supplementary Fig.6). This difference was not significant, and there was no significant heterogeneity in the effect sizes across these studies.

Reoperation

Data on reoperations were extracted from the three studies. In the VLP group, 6 out of 157 patients underwent a second operation due to serious complications, while in the CRC group, 11 out of 154 patients required reoperation. The pooled analysis revealed no significant difference in the incidence of reoperation between the two groups (RR = 0.56; 95%CI 0.22 to 1.42; p = 0.22; I² = 0%) (Supplementary Fig.7). There was no significant heterogeneity in the reported effect sizes across the studies.

Distal radius fractures are common in older adults, and extensive research has compared various treatment methods. Most studies focus on short-term functional outcomes, typically at 3, 6, or 12 months [20, 26, 27]. However, this systematic review and meta-analysis evaluated outcomes with a minimum of two years of follow-up. The meta-analysis, which included 423 patients across four RCTs, demonstrated that the statistical results favored the VLP group. It has been suggested that a minimum clinically important difference (MCID) of 14 points on the PRWE and 10 points on the DASH score is necessary to justify the additional costs and risks of surgical intervention compared to non-surgical treatment [28]. Despite the statistical advantage of VLP, older patients treated with either VLP or CRC showed similar functional outcomes. Furthermore, there was no statistically significant difference in the rate of serious complications requiring surgery between the two treatment methods. This meta-analysis, based on a minimum of two years of follow-up, provides new evidence for the AAOS to develop updated treatment guidelines for DRFs.

Several meta-analyses have been published on short- and medium-term follow-up outcomes, yielding varying results. Oldrini et al. [29] conducted a meta-analysis of short- and medium-term follow-up, which included 12 RCTs comparing outcomes at 3, 6, and 12 months. The DASH score revealed a statistically significant difference between the two treatments at 3 months, favoring the surgical group. However, by 12 months, the difference between the groups had diminished and was no longer significant. Surgical treatment led to better clinical outcomes in the first few months, with improved fracture alignment and lower complication rates. Nonetheless, no significant differences in clinical outcomes were observed after three months. Patients treated surgically experienced faster functional recovery, improved fracture alignment, and fewer complications. The findings from Oldrini et al.‘s meta-analysis, which incorporated data on grip strength, DASH score, and incidence of reoperation, align closely with those of our study. To compare the long-term functional outcomes of volar locked plates and plaster immobilization for the treatment of DRFs in middle-aged and older adults, we included only studies with a minimum follow-up of two years. As a result, we identified just four RCTs, all of which were of high quality. This further reduces bias and increases confidence in our results. Jayaram et al. [30] conducted a network meta-analysis, which showed that open reduction and internal fixation with volar locking plates leads to early recovery following DRF treatment in elderly patients. The authors concluded that clinicians should not expect optimal outcomes to take a full year and should collaborate with patients to determine appropriate treatment options. Surgery should be considered for those who prioritize a more rapid recovery.

Zhang et al. [31] conducted a meta-analysis comparing interim outcomes at 12 months postoperative follow-up. The study found that elderly patients with distal radius fractures treated with volar plating exhibited better DASH scores and grip strength. The meta-analysis concluded that there may be no significant difference in pain scores, range of motion, or complication rates between the two types of treatment. Chen et al.‘s systematic review on the safety and efficacy of surgical versus conservative treatment of DRFs in elderly patients found no evidence to support the notion that surgical treatment yields better clinical outcomes after one year of follow-up [32]. While surgical treatment may provide better imaging results and improved grip strength compared to non-surgical treatment. However, the probability of complications necessitating additional surgical procedures did not increase. These complications include carpal tunnel syndrome, tendon rupture, the need for osteotomy, and other orthopedic surgeries [33, 34]. Gutiérrez-Espinoza et al. [35] reported similar findings. Although most differences were not statistically significant, the volar locked plate was associated with the lowest incidence of minor and overall complications. However, it also had one of the highest incidences of major complications requiring reoperation. Therefore, the indications for surgical fixation should be carefully considered when treating elderly patients [36, 37].

It is important to note that patient self-evaluation scores are inherently subjective, and various factors beyond the fracture itself may influence perceived levels of function or disability. While the DASH questionnaire is neither side-specific nor joint-specific, it is highly responsive to functional changes following a distal radius fracture (DRF). The MHQ score was used in the Chuang et al. [24] study, which excluded its findings from the meta-analysis. In the Chuang et al. study, participants in both groups reported low levels of pain, favorable recovery in activities of daily living, and high satisfaction. However, because participants had the option of non-surgical treatments, there may have been instances of selection bias or heterogeneity. The meta-analysis of the present study demonstrated that in individuals over 60, the VLP group exhibited superior functional outcomes and a lower complication rate compared to CRC group. It is essential to also consider the potential risks of surgery, the individual preferences of the elderly patient, and whether the body can tolerate the procedure. Physicians are ethically obligated to provide comprehensive informed consent, which includes a thorough discussion of the risks, benefits, and potential alternatives associated with a procedure [38]. Research suggests that older patients may require more extensive communication with their doctors due to a higher likelihood of experiencing decision-making conflicts compared to younger patients [39].

Limitations of the present study should be noted. We only included randomized controlled trials to reduce bias associated with patients receiving treatment for VLP and CRC and to reduce potential differences in baseline characteristics between treatment groups. Therefore, we only found four RCTs, but fortunately, their quality was high. Secondly, the term ‘elderly’ is commonly defined as 65 years of age and older. However, since almost all patients studied in the current published literature were 60 years of age or older, we screened the literature using 60 years of age as the minimum age. Ultimately, we included patients with an average age greater than 65. Thus, the results of the study are not applicable to young people who have more demanding hand functions. Thirdly, we did not evaluate other surgical techniques, such as Kirschner pin internal fixation. This was a deliberate decision for the reasons previously explained. It should be noted whether the conclusion applies only to patients over 60 or if it could apply to younger people too. Fourthly, the types of plaster fixation encompass open, closed, and above/below elbow techniques. However, some literature included in our study lacked sufficient detail on this topic, which constitutes a limitation of our research. Further investigation is needed to find out, further research is required.

Author notes

1. Jingyi Yang and Yating Li contributed equally to this work.

Authors and Affiliations

1. The Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China

   Jingyi Yang,Yating Li,Xiaoyan Li&Nari Wulan

Contributions

Jingyi Yang, Nari Wulan carried out the conception and design of the research, Jingyi Yang and Yating Li participated in the acquisition of data. Yating Li carried out the analysis and interpretation of data. Xiaoyan Li performed the statistical analysis. Xiaoyan Li drafted the manuscript and Nari Wulan participated in revision of manuscript for important intellectual content. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Xiaoyan Li or Nari Wulan.

Ethical approval

Not applicable.

Consent for publication

All authors have stated for their consent for publication.

CRD

42024532685.

Final statements

Not applicable.

Competing interests

The authors declare no competing interests.

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