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Moulded cast compared with K-wire fixation after manipulation of an acute dorsally displaced distal radius fracture : the DRAFFT 2 RCT
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Costa, Matthew L., Achten, Juul, Ooms, Alexander, Png, May Ee, Cook, Jonathan, Dritsaki, Melina, Lamb, Sarah E., Lerner, Robin, Draper, Kylea, Campolier, Marta, Dakin, Helen, McGibbon, Alwin, Parsons, Nicholas R., Hedley, Helen and Dias, Joseph (2022) Moulded cast compared with K-wire fixation after manipulation of an acute dorsally displaced distal radius fracture : the DRAFFT 2 RCT. Health Technology Assessment, 26 (11). pp. 1-80. doi:10.3310/rlcf6332
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WRAP-moulded-cast-compared-K-wire-fixation-manipulation-acute-dorsally-displaced-distal-radius-fracture-Parsons-2022.pdf - Published Version - Requires a PDF viewer. Available under License Creative Commons Attribution 4.0. Download (2002Kb) | Preview |
Official URL: https://doi.org/10.3310/rlcf6332
Abstract
Background: Patients with a displaced fracture of the distal radius are frequently offered surgical fixation. Manipulation of the fracture and moulded plaster casting is an alternative treatment that avoids metal implants, but evidence of its effectiveness is lacking. Objective: To compare functional outcomes, quality-of-life outcomes, complications and resource use among patients with a dorsally displaced fracture of the distal radius treated with manipulation and surgical fixation with Kirschner wires (K-wires) and those treated with manipulation and moulded cast. Design: Pragmatic, superiority, multicentre, randomised controlled trial with a health economic evaluation. Setting: A total of 36 orthopaedic trauma centres in the UK NHS. Participants: Patients (aged ≥ 16 years) treated for an acute dorsally displaced fracture of the distal radius were potentially eligible. Patients were excluded if their injury had occurred > 2 weeks previously, if the fracture was open, if it extended > 3 cm from the radiocarpal joint or if it required open reduction, or if the participant was unable to complete questionnaires. DOI: 10.3310/RLCF6332 Health Technology Assessment 2022 Vol. 26 No. 11 Copyright © 2022 Costa et al. This work was produced by Costa et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaption in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/. For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited. vii Interventions: Participants were randomly assigned in theatre (1 : 1) to receive a moulded cast (i.e. the cast group) or surgical fixation with K-wires (i.e. the K-wire group) after fracture manipulation. Main outcome measures: The primary outcome measure was the Patient-Rated Wrist Evaluation score at 12 months, analysed on an intention-to-treat basis. Health-related quality of life was recorded using the EuroQol-5 Dimensions, five-level version, and resource use was recorded from a health and personal social care perspective. Results: Between January 2017 and March 2019, 500 participants (mean age 60 years, 83% women) were randomly allocated to receive a moulded cast (n = 255) or surgical fixation with K-wire (n = 245) following a manipulation of their fracture. A total of 395 (80%) participants were included in the primary analysis at 12 months. There was no difference in the Patient-Rated Wrist Evaluation score at 1 year post randomisation [cast group: n = 200, mean score 21.2 (standard deviation 23.1); K-wire group: n = 195, mean score 20.7 (standard deviation 22.3); adjusted mean difference –0.34 (95% confidence interval –4.33 to 3.66); p = 0.87]. A total of 33 (13%) participants in the cast group required surgical fixation for loss of fracture position in the first 6 weeks, compared with one participant in the K-wire group (odds ratio 0.02, 95% confidence interval 0.001 to 0.10). The base-case cost-effectiveness analysis showed that manipulation and surgical fixation with K-wires had a higher mean cost than manipulation and a moulded cast, despite similar mean effectiveness. The use of K-wires is unlikely to be cost-effective, and sensitivity analyses found this result to be robust. Limitations: Because the interventions were identifiable, neither patients nor clinicians could be blind to their treatment. Conclusions: Surgical fixation with K-wires was not found to be superior to moulded casting following manipulation of a dorsally displaced fracture of the distal radius, as measured by Patient-Rated Wrist Evaluation score. However, one in eight participants treated in a moulded cast required surgery for loss of fracture reduction in the first 6 weeks. After a successful closed reduction, clinicians may consider a moulded cast as a safe and cost-effective alternative to surgical fixation with K-wires. Future work: Further research should focus on optimal techniques for immobilisation and manipulation of this type of fracture, including optimal analgesia, and for rehabilitation of the patient after immobilisation. Trial registration: This trial is registered as ISRCTN11980540 and UKCRN Portfolio 208830. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 11. See the NIHR Journals Library website for further project information.
| Item Type: | Journal Article | ||||||
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| Subjects: | R Medicine > RD Surgery | ||||||
| Divisions: | Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School | ||||||
| SWORD Depositor: | Library Publications Router | ||||||
| Library of Congress Subject Headings (LCSH): | Wrist -- Fractures -- Treatment, Bone wiring (Orthopedics), Bone screws (Orthopedics) | ||||||
| Journal or Publication Title: | Health Technology Assessment | ||||||
| Publisher: | NIHR Health Technology Assessment programme | ||||||
| ISSN: | 1366-5278 | ||||||
| Official Date: | February 2022 | ||||||
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| Volume: | 26 | ||||||
| Number: | 11 | ||||||
| Page Range: | pp. 1-80 | ||||||
| DOI: | 10.3310/rlcf6332 | ||||||
| Status: | Peer Reviewed | ||||||
| Publication Status: | Published | ||||||
| Access rights to Published version: | Open Access | ||||||
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