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- Title
Surgical Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Randomized Clinical Trial.
- Authors
Lawson, Andrew; Naylor, Justine M.; Buchbinder, Rachelle; Ivers, Rebecca; Balogh, Zsolt J.; Smith, Paul; Xuan, Wei; Howard, Kirsten; Vafa, Arezoo; Perriman, Diana; Mittal, Rajat; Yates, Piers; Rieger, Bertram; Smith, Geoff; Adie, Sam; Elkinson, Ilia; Kim, Woosung; Sungaran, Jai; Latendresse, Kim; Wong, James
- Abstract
<bold>Importance: </bold>The burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence.<bold>Objective: </bold>To assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older.<bold>Design, Setting, and Participants: </bold>In this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses.<bold>Intervention: </bold>Surgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR).<bold>Main Outcomes and Measures: </bold>The primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use.<bold>Results: </bold>In the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI -5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48; P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69; P = 0.02).<bold>Conclusions and Relevance: </bold>This randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people.<bold>Trial Registration: </bold>http://anzctr.org.au identifier: ACTRN12616000969460.
- Subjects
NEW Zealand; AUSTRALIA; RESEARCH; ORTHOPEDIC implants; AGE distribution; RESEARCH methodology; EVALUATION research; TREATMENT effectiveness; COMPARATIVE studies; FRACTURE fixation; RADIUS fractures; LONGITUDINAL method
- Publication
JAMA Surgery, 2021, Vol 156, Issue 3, p229
- ISSN
2168-6254
- Publication type
journal article
- DOI
10.1001/jamasurg.2020.5672