Treatment of radius or ulna fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and current practice

Abstract

Background The objective of the present study was to evaluate effectiveness, complications and cost-effectiveness of any surgical or non-surgical treatment for radius or ulna fractures in elderly patients. Secondary objectives were to analyze present treatment traditions of distal radius fractures (DRF) in Sweden and to calculate resource usage for its treatment. Methods and findings The assessment contains a systematic review of clinical and health economic studies comparing treatment options for radius or ulna fractures. The results regarding the effectiveness of the treatments are summarized in meta-analyses. In addition, the assessment contains a cost analysis for different treatment options commonly used for DRF care, and an analysis of registry data on the incidence and treatment of DRF. In total 31 randomized controlled trials were included in meta-analyses. When comparing functional outcome for plate fixation versus non-surgical treatment for DRF, there were no clinically important differences at one-year follow-up (mean difference [MD], -3.29, 95% CI, -7.03; 0.44). Similar results were found when comparing plating and percutaneous methods with respect to functional outcome (standardized mean difference [SMD], -0.07, 95% CI, -0.21; 0.07) and grip strength (MD, -3.47, 95% CI, -11.21; 4.28). There were no differences for minor complications, (risk difference [RD], -0.01, 95% CI, -0.07; 0.05) whereas major complications were less common for the percutaneous group, (RD, 0.02, 95% CI, 0.02; 0.03). Given the low number of studies, the evidence above was rated as moderate certainty. The cost for plate fixation versus plaster cast was estimated to 1698 compared to 137 US dollars. For DRF, plate fixation increased in Sweden between 2005 and 2013, and was the most common surgical method in 2013. Conclusions Surgical treatment of moderately displaced distal radius fractures in elderly patients offers no clear benefit compared to non-surgical treatment. Plating procedures have become more common during the second millennium and involve higher costs and higher risk of major complications than percutaneous options.

Surgical site infections after distal radius fracture surgery: a nation-wide cohort study of 31,807 adult patients

“…While a majority of all DRFs can be managed non-surgically, about 20% are treated surgically [ 1 , 2 ]. Recent studies have reported that the proportion of surgically managed fractures is increasing, and that the preferred surgical method has shifted from percutaneous techniques to ORIF over the last two decades [ 1 – 7 ].…”

Volar locking plate vs cast immobilization for distal radius fractures: a systematic review and meta-analysis

“…On the other hand, the small advantages in terms of faster recovery should be also weighted in terms of health care costs. For example, Tahir et al reported overall costs of 12 033 USD for the surgical management ( 25 ), while Navarro et al quantified in 137 USD the cost of the conservative cast treatment ( 15 ).…”

“…Different treatment options have been developed through the years, the most common being non-operative closed reduction and cast immobilization (CR) or operative open reduction and internal fixation (ORIF) with volar locking plate (VLP) ( 10 , 11 ). Each treatment has pros and cons: cast treatment requires longer recovery time and offers a less perfect radiological reduction of the fracture, but it is safer and more economic, on the opposite, ORIF is thought to offer good fracture alignment, faster clinical improvement, and early return to routine activities but at the price of surgical risks such as infection, cut-out, and higher costs ( 12 , 13 , 14 , 15 ). Up to now, there is a lack of evidence and consensus in the literature regarding the best treatment for DRFs.…”

“…Even the guidelines of the American Academy of Orthopedic Surgeons do not recommend for or against the conservative or surgical approach ( 16 ). Previous systematic reviews and meta-analyses on this topic either lack data or are based on heterogeneous studies of low quality, thus not leading to conclusive and solid evidence ( 12 , 15 , 17 , 18 ).…”

Volar locking plate versus external fixation for unstable dorsally displaced distal radius fractures–A 3-year cost-utility analysis

“…All unit costs are presented in Table 2 . Unit costs for operating theatre including staff were derived from a report by the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) [ 11 ]. Costs regarding in-and outpatient care including emergency ward visits were collected from the diagnose-related group (DRG [ 12 ]) financial reimbursement system used at the hospital.…”