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A Prospective Randomized Trial Comparing Nonoperative Treatment with Volar Locking Plate Fixation for Displaced and Unstable Distal Radial Fractures in Patients Sixty-five Years of Age and Older
Rohit Arora, MD1; Martin Lutz, MD1; Christian Deml, MD1; Dietmar Krappinger, MD, PhD1; Luzian Haug, MD1; Markus Gabl, MD1
1 Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck (MUI), Anichstrasse 35, A-6020 Innsbruck, Austria. E-mail address for R. Arora: rohit.arora@uki.at. E-mail address for M. Lutz: martin.lutz@i-med.ac.at. E-mail address for C. Deml: christian.deml@i-med.ac.at. E-mail address for D. Krappinger: dietmar.krappinger@i-med.ac.at. E-mail address for L. Haug: luzian.haug@uki.at. E-mail address for M. Gabl: markus.gabl@uki.at
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at the Department of Trauma Surgery and Sports Medicine, Medical University Innsbruck, Innsbruck, Austria

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Dec 07;93(23):2146-2153. doi: 10.2106/JBJS.J.01597
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Abstract

Background: 

Despite the recent trend toward the internal fixation of distal radial fractures in older patients, the currently available literature lacks adequate randomized trials examining whether open reduction and internal fixation (ORIF) with a volar locking plate is superior to nonoperative (cast) treatment. The purpose of the present randomized clinical trial was to compare the outcomes of two methods that were used for the treatment of displaced and unstable distal radial fractures in patients sixty-five years of age or older: (1) ORIF with use of a volar locking plate and (2) closed reduction and plaster immobilization (casting).

Methods: 

A prospective randomized study was performed. Seventy-three patients with a displaced and unstable distal radial fracture were randomized to ORIF with a volar locking plate (n = 36) or closed reduction and cast immobilization (n = 37). The outcome was measured on the basis of the Patient-Rated Wrist Evaluation (PRWE) score; the Disabilities of the Arm, Shoulder and Hand (DASH) score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including dorsal radial tilt, radial inclination, and ulnar variance.

Results: 

There were no significant differences between the groups in terms of the range of motion or the level of pain during the entire follow-up period (p > 0.05). Patients in the operative treatment group had lower DASH and PRWE scores, indicating better wrist function, in the early postoperative time period (p < 0.05), but there were no significant differences between the groups at six and twelve months. Grip strength was significantly better at all times in the operative treatment group (p < 0.05). Dorsal radial tilt, radial inclination, and radial shortening were significantly better in the operative treatment group than in the nonoperative treatment group at the time of the latest follow-up (p < 0.05). The number of complications was significantly higher in the operative treatment group (thirteen compared with five, p < 0.05).

Conclusions: 

At the twelve-month follow-up examination, the range of motion, the level of pain, and the PRWE and DASH scores were not different between the operative and nonoperative treatment groups. Patients in the operative treatment group had better grip strength through the entire time period. Achieving anatomical reconstruction did not convey any improvement in terms of the range of motion or the ability to perform daily living activities in our cohorts.

Level of Evidence: 

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Jeff A
    Posted on December 10, 2011
    Thanks for the study, comments
    Private Orthopaedic surgeon

    30% reoperation rate may have biased the surgical group. In practice, a reoperation rate of less than 5% is what I have seen and my colleagues. Bias of drop outs from study exists. Some patients would certainly complain about prominent ulna, in my experience. Type 2 error could exist---reason to repeat study as well. Excellent stat information provided, uncertainty still exists when using null hypothesis that is not rejected. Patients who have to use walker? were these excluded/included/asked? Any difference in bone density? in the two groups? DEXA performed? Very important variable, as the outcomes could be accounted for by osteoporotic patients instead of age???? Keeping the screws from protruding, decreasing repeat operations, not operating on extremely osteoporotic, could increase the scores on functional testing between the two groups. May also be a difference in rsd, stiffness, when ORIF is performed within 24 hours of fracture? A lot of variables to adjust for, when thinking about practical significance as well as statistical significance. Good study overall, authors spent good time and approach. Thanks to the authors for dedication and time.

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