VOLCON: a randomized controlled trial investigating complications and functional outcome of volar plating vs casting of unstable distal radius fractures in patients older than 65 years

Abstract

Background Primary aim: to compare complications of operative vs non-operative treatment of unstable distal radius fractures (DRF) fulfilling national clinical guidelines for operative treatment. Secondary aim: to compare the functional outcomes. Materials and methods A single-centre randomized controlled trial of unstable DRF. 50 patients: volar locking plate, 2 weeks casting + 3 weeks orthosis. 50 patients: 5 weeks casting. Primary outcome: complications assessed after 2 and 5 weeks and 6 and 12 months. Secondary outcomes: Quick-DASH, PRWHE, range of motion, grip strength, EQ-5D-3L. Results 148 patients were screened from November 2019 to March 2021. 48 patients did not want to participate or were unable to participate in the follow-up. 100 patients were randomized and 85 patients were available for full analysis due to there being 4 deaths, 6 withdrawals, 1 wrong inclusion, 1 emigration, 1 refracture, 1 patient with compartment syndrome, and 1 who was advised to undergo surgery after being randomized to non-operative treatment. Median age was 74 years (range 65–92), 81 women/19 men, 42 right/58 left side, 87 retired, 11 smokers, 86 ASA class 1 or 2. Complication rates did not statistical significantly vary between the operative and non-operative group: 20.9% (9/43) vs 16.6% (7/42), p = 0.78 (Fisher’s exact test). Complications were driven by sensory disturbances. Four reoperations were performed: two in the non-operative group: carpal tunnel syndrome; two in the operative group: one carpal tunnel syndrome, one protruding screw causing extensor tendon irritation. Mean difference in Quick-DASH varied from 2.3 (95% CI − 3 to 8) pre-injury to 4.2 (− 4 to 12) at 12 months. Quick-DASH and PRWHE were neither statistically nor clinically-relevant different between groups. Conclusions Complication rates after operative and non-operative treatment of DRF were similar. Volar plating did not improve the functional outcome after 5 weeks, 6 months, and 12 months. These findings are in line with recent RCTs and mandate a revision of guidelines towards more conservative treatment. Take home messages: (1) consider non-operative treatment in elderly patients sustaining unstable DRFs; (2) choosing operative treatment in patients older than 65 years should not be the gold standard; (3) however, non-operative treatment still carries a risk for complications. Level of evidence II. Trial registration Clinicaltrials.gov NCT03716661, registered 23rd Oct 2018; Published protocol PMC6599306.

Current Management and Volar Locking Plate Fixation with Bone Cement Augmentation for Elderly Distal Radius Fractures—An Updated Narrative Review

“…As to unstable DRFs, in an RCT by the Wrist and Radius Injury Surgical Trial (WRIST) Group, the authors found no clinically meaningful PRO difference 24 months after injury across VLPF, external fixation (EF), percutaneous pinning, and CRCI, with little changes between 12 and 24 months [43]. Thorninger et al also found that VLPF does not superiorly improve the functional outcomes after 5 weeks, 6 months, and 12 months compared to casting, and complication rates are similar [44]. However, modified K-wire fixation might be a safe, effective, rapid, and minimally invasive surgical option owing to higher patient satisfaction, shorter operation time, and a lower complication rate compared to ORIF [45].…”

Escalas de valoración de la discapacidad en el adulto mayor con patología musculoesquelética de miembro superior

“…Todos los artículos incluyeron intervenciones quirúrgicas tras una fractura de miembro superior, las fracturas se dan en mayor incidencia en mujeres que sufrieron la lesión debido a una caída (57,58), El uso del cuestionario DASH se utilizó para evaluar el nivel de funcionalidad antes de la lesión y después de la misma, para lo cual se realizó un seguimiento comprendido entre seis meses y doce meses en el que se mostraron mejores puntuaciones en la funcionalidad del paciente. A los 12 meses, la puntuación DASH fue 17,2 y 20, la diferencia clínicamente relevante mínima se definió como una diferencia de 16 a 20 puntos en DASH(53, 59, 60).…”