Adjuvant Arthroscopy Does Not Improve the Functional Outcome of Volar Locking Plate for Distal Radius Fractures: A Randomized Clinical Trial

Abstract

El estudio es un ensayo clínico aleatorizado que evalúa si el uso de artroscopia en pacientes intervenidos quirúrgicamente de fractura de muñeca mediante placa volar mejora los resultados funcionales en la osteosíntesis. Se incluyeron 186 pacientes adultos funcionalmente independientes con indicación quirúrgica para placa volar, divididos en dos grupos: uno con asistencia artroscópica y otro sin ella. No hubo diferencias significativas en el Patient-Rated Wrist Evaluation (PRWE) a un año postoperatorio entre los grupos (mediana AG: 5.0 vs CG: 7.5, p = 0.328). El porcentaje de pacientes que superaron la diferencia mínima clínicamente importante (12.81 puntos en PRWE) fue similar (86.4% vs 85.1%, p = 0.819). Se observó mayor reducción de escalones articulares y detección de lesiones asociadas en el grupo artroscópico (p < 0.001), pero sin impacto funcional significativo. No hubo diferencias en fuerza, rango de movimiento ni en complicaciones (16.9% vs 20.9%, p = 0.842). La artroscopia adyuvante no mejoró significativamente los resultados funcionales a un año, aunque permitió una mejor identificación de lesiones articulares y reducción de escalones articulares.

Purpose: To evaluate the outcomes of adding arthroscopy to osteosynthesis of distal radius fractures (DRF) with volar locking plate (VLP), by Patient-Rated Wrist Evaluation (PRWE) 1 year after surgery.

Methods: In total, 186 functionally independent adult patients who met the inclusion criteria (DRF and a clinical decision for surgery with a VLP) were randomized to arthroscopic assistance or not. Primary outcome was PRWE questionnaire results 1 year after surgery. For the main variable, PRWE, we obtained the minimal clinically important difference based on a distribution-based method. Secondary outcomes included Disabilities of the Arm, Shoulder and Hand and 12-Item Short Form Health Survey questionnaires, range of motion, strength, radiographic measures, and presence of joint step-offs by computed tomography. Data were collected preoperatively and at +1 and +4 weeks, +3 and +6 months, and +1 year after surgery. Complications were recorded throughout the study.

Results: In total, 180 patients (mean age: 59.0 ± 14.9 years; 76% women) were analyzed by modified intention to treat. A total of 82% of the fractures were intra-articular (AO type C). No significant difference between arthroscopic (AG) and control (CG) groups in median PRWE was found at +1 year (median AG: 5.0, median CG: 7.5, difference in medians 2.5; 95% confidence interval [CI] -2.0, 7.0, P = .328). The proportion of patients who exceeded the minimal clinically important difference of 12.81 points in the AG and CG was 86.4% vs 85.1%, P = .819, respectively. Percentage of associated injuries and step-offs reduction maneuvers was greater with arthroscopy (mean differences: 17.1 95% CI -0.1, 26.1, P < .001) and 17.4 (95% CI 5.0, 29.7, P = .007). The difference in percentage of residual joint step-offs at the postsurgical computed tomography in radioulnar, radioscaphoid, and radiolunate joints was not significant (P = .990, P = .538, and P = .063). Complications were similar between groups (16.9% vs 20.9%, P = .842).

Conclusions: Adjuvant arthroscopy did not significantly improve PRWE score +1 year after surgery for DRF with VLP, although the statistical power of the study is below the initially estimated to detect the expected difference.