Surgical fixation with K-wires versus casting in adults with fracture of distal radius: DRAFFT2 multicentre randomised clinical trial
BMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2021-068041 (Published 19 January 2022) Cite this as: BMJ 2022;376:e068041
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Dear editor,
We read “Surgical fixation with K-wires versus casting in adults with fracture of distal radius: DRAFFT2 multicentre randomised clinical trial” with great interest. In this study, Manipulation and moulded cast was compared with manipulation and surgical fixation with K-wires plus cast.[1] The primary outcome measure was the Patient Rated Wrist Evaluation (PRWE) score at 12 months (five questions about pain and 10 about function and disability. The results show that no statistically significant difference in the PRWE score was seen at 12 months. Finally, the authors concluded that among patients with a dorsally displaced distal radius fracture that needed manipulation, surgical fixation with K-wires did not improve patients’ wrist function at 12 months compared with a cast. We really appreciate this achievement that the authors have made. As readers, we have some questions or suggestions that we hope the authors could take into consideration.
In this study, the majority of cases are female, with an average age of 60.1 years, at which most people are accompanied by osteoporosis. Osteoporosis was not described in this study. For patients with osteoporosis, internal fixation with K-wires may be unreliable.
From the index of reduction loss rate, the K-wire group is significantly better than the cast group, and there are statistical differences, indicating that in the fixed reliability, the K-wire group is still better than the cast group, and this result still shows that the K-wire fixation has a certain effect. As for no difference in function, it may be too short in the follow-up period, and the patient's tolerance, subjective degree and other factors, may not necessarily reflect the difference.
In some cases, the fractures are involving the joint surface. Does the K-wire fix the bone block of the joint surface specifically after the reduction? This should also be described.
There was a loss of 13% reduction in the cast group, indicating that the vast majority of cases in the control group was stable after reduction, which has little clinical significance for the comparison. That is to say, the selected cases should be judged whether stable after reduction, if unstable, whether fixed with a K-wire. If it is stable after the reductiont, it is not meaningful to compare whether to add K-wires. The following conditions are unstable after reduction: the dorsal fracture obvious displacement, obvious loss of palm inclination, the dorsal comminuted fracture, combined with ulna fracture, and age more than 60 with osteoporosis. In the majority of the author's cases, fracture reduction of the cases was not lost, so stability fracture should account for the majority of cases. More significance should be made to compare the two treatments for unstable fractures.
Bao-Fu Yu [1], Hao Shen [2]
1 Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200011, China.
Address: No 639, Zhizaoju Road, Shanghai, 200011, China.
Email: yubaofu2008@126.com
2 Department of Orthopaedic Surgery, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China.
Address: No 1665, Kongjiang Road, Shanghai, 200092, China
Email: shenhao@xinhuamed.com.cn
References:
1. Costa ML, Achten J, Ooms A, et al. Surgical fixation with K-wires versus casting in adults with fracture of distal radius: DRAFFT2 multicentre randomised clinical trial. BMJ. 2022;376:e068041.
Competing interests: No competing interests
Dear Editor,
Like Mr. Shaerf, I, too, read the print version of the article first and agree with his comments on the x-ray shown. An additional lesion is present: the intra-articular fracture of the radius which is undisplaced in this view. Did the correct picture(s) get lost in transmission?
Competing interests: No competing interests
Dear Editor,
Thank you for publishing this important article which I read with great interest. I had the benefit of reading it in the print journal which was a nice bite-size summary before reading the full manuscript. I was, however, rather confused by the accompanying image showing an upside-down radiograph of a surgically fixed scaphoid with a trans-carpal k-wire most likely due to a trans-scaphoid peri-lunate fracture dislocation. The article was about casting versus k-wires and casts in dorsally displaced distal radius fractures and not major carpal trauma. This is quite confusing for the readership and detracts from the authors valid conclusions. I would recommend either using appropriate images or tables/figures from the paper instead.
Yours sincerely,
Daniel A Shaerf
Consultant Hand & Wrist Surgeon
London
Competing interests: No competing interests
Re: Surgical fixation with K-wires versus casting in adults with fracture of distal radius: DRAFFT2 multicentre randomised clinical trial
Dear Editor,
The DRAFFT-2 study paper noted that “a recent Cochrane review summarized the existing evidence for surgical fixation with wires for treating distal radial fractures in adults” and that the trials summarized were at “high risk of bias”, and so the authors could not draw a “conclusion about the effect of the intervention on patient reported function”.
The principal objective of the study was to minimize such biases, in order to come to a much clearer comparative conclusion on patient outcomes after either surgical intervention. But there may still yet be a significant level of selection bias; 495 patients were excluded from the study, not because they didn’t meet the criteria, but because the presiding surgeon had expressed a preference for a given treatment prior to enrolment and 222 patients were excluded over doubts about their ability to adhere to trial procedures or complete questionnaires. Whilst the study population and their interventions aimed to be representative of that of the wider UK population treated at NHS hospitals, specifically, the high level of intervention by surgeons deciding upon treatment of those eligible to participate in the target population is concerning. This meant, they were directly excluded from trial. The 500 patients assigned to either treatment, account for only 36.4% of those that met the criteria for inclusion and the 395 included in the intention to treat analysis, account for only 28.7%. This directly brings the external validity of the study into question – how generalizable are the results to the wider population? This was not a feature in the original DRAFFT study, where the outcome measures of patients with distal radius fractures assigned to K-wire fixation and volar-plate fixation were compared and analyzed. By comparison, in that study 72.2% of those eligible participated and there were no reports of surgeons deciding on interventions, pre-enrolment. Without being too presumptive (as the circumstances around why these surgeons intervened may perhaps be legitimate, but the reasons may never be known), this may suggest skewed perceptions of the efficacy of both casting and K-wire fixation with perhaps a disproportionally favourable one towards K-wire fixation amongst surgeons.
Knowing that there was stratification according to age, in the randomization sequence is encouraging. The study used age as a surrogate marker for bone mineral density, which is both cheap and representative of general orthopaedic practice – patients are not routinely sent for DEXA scans pre-operatively; this can be done at a later date. However, knowing that bone mineral density continues to fall particularly in females over 50 years and further still over 65 years, the categorization could have been more granular with further subdividing categories than just age<50 and age≥50. This may have in turn given clearer and greater insight into the efficacy of casting and K-wire fixation in a range of age groups over 50.
Competing interests: No competing interests