Abstract
IMPORTANCE: Randomized clinical trials (RCTs) and meta-analyses have reported inconsistent conclusions regarding optimal distal radius fracture (DRF) treatment in older adults and are limited due to the inclusion of cohort studies with small sample sizes. A network meta-analysis (NMA) addresses these limitations by only synthesizing direct and indirect evidence from RCTs and may clarify optimal DRF treatment in older adults. OBJECTIVE: To examine DRF treatment results in optimal short-term and intermediate-term patient-reported outcomes. DATA SOURCES: Searches of MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials were conducted for RCTs that investigated DRF treatment outcomes in older adults between January 1, 2000, and January 1, 2022. STUDY SELECTION: Randomized clinical trials including patients with a mean age of 50 years or older that compared the following DRF treatments were eligible for inclusion: casting, open reduction and internal fixation with volar lock plating (ORIF), external fixation, percutaneous pinning, and nail fixation. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently completed all data extraction. An NMA aggregated all direct and indirect evidence among DRF treatments. Treatments were ranked by surface under the cumulative ranking curve score. Data are reported as standard mean differences (SMDs) and 95% CIs. MAIN OUTCOMES AND MEASURES: The primary outcome was short-term (≤3 months) and intermediate-term (>3 months to 1 year) Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores. Secondary outcomes included Patient-Rated Wrist Evaluation (PRWE) scores and 1-year complication rates. RESULTS: In this NMA, 23 RCTs consisting of 3054 participants (2495 women [81.7%]) with a mean (SD) age of 66 (7.8) years were included. At 3 months, DASH scores were significantly lower for nail fixation (SMD, -18.28; 95% CI, -29.93 to -6.63) and ORIF (SMD, -9.28; 95% CI, -13.90 to -4.66) compared with casting. The PRWE scores were also significantly lower for ORIF (SMD, -9.55; 95% CI, -15.31 to -3.79) at 3 months. In the intermediate term, ORIF was associated with lowered DASH (SMD, -3.35; 95% CI, -5.90 to -0.80) and PRWE (SMD, -2.90; 95% CI, -4.86 to -0.94) scores. One-year complication rates were comparable among all treatments. CONCLUSIONS AND RELEVANCE: The findings of this NMA suggest that ORIF may be associated with clinically significant improvements in short-term recovery compared with casting for multiple patient-reported outcomes measures with no increase in 1-year complication rates. Shared decision-making with patients may be useful to identify patient preferences regarding recovery to determine optimal treatment.