Complications after volar plate synthesis for distal radius fractures

in EFORT Open Reviews
Authors:
Luca Pacchiarini Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland

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Lorenzo Massimo Oldrini Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland

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Pietro Feltri Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland

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Stefano Lucchina Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
Surgical Department, Hand Surgery Unit EOC, Locarno’s Regional Hospital, Locarno, Switzerland
Locarno Hand Center, Locarno, Switzerland

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Giuseppe Filardo Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland

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Christian Candrian Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland

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Correspondence should be addressed to P Feltri: pietro.feltri@eoc.ch
Open access

Purpose

  • Distal radius fractures (DRFs) represent up to 18% of all fractures in the elderly population, yet studies on the rate of complications following surgery are lacking in the literature. This systematic review aimed to quantify the rate of complications and reinterventions in patients treated with volar plate for distal radius fractures, and analyze if there was any predisposing factor.

Methods

  • A comprehensive literature search was performed on three databases up to January 2023, following PRISMA guidelines. Studies describing volar plate complications and hardware removal were included. A systematic review was performed on complications and rate of reintervention. Assessment of risk of bias and quality of evidence was performed with the ‘Down and Black’s Checklist for measuring quality’.

Results

  • About112 studies including 17 288 patients were included. The number of complications was 2434 in 2335 patients; the most frequent was carpal tunnel syndrome (CTS), representing 14.3% of all complications. About 104 studies reported the number of reinterventions, being 1880 with a reintervention rate of 8.5%. About 84 studies reported the reason of reintervention; the most common were patient’s will (3.0%), pain (1.1%), CTS (1.2%), and device failure (1.1%).

Conclusion

  • The complication rate after DRFs is 13.5%, with the main complication being CTS (14.3%), followed by pain and tendinopathy. The reintervention rate is 8.5%, mainly due to the patient’s willingness, and all these patients had plate removal. Correct positioning of the plate and correct information to the patient before surgery can reduce the number of hardware removal, thereby reducing costs and the risk of complications associated with VLP for distal radius fractures.

Abstract

Purpose

  • Distal radius fractures (DRFs) represent up to 18% of all fractures in the elderly population, yet studies on the rate of complications following surgery are lacking in the literature. This systematic review aimed to quantify the rate of complications and reinterventions in patients treated with volar plate for distal radius fractures, and analyze if there was any predisposing factor.

Methods

  • A comprehensive literature search was performed on three databases up to January 2023, following PRISMA guidelines. Studies describing volar plate complications and hardware removal were included. A systematic review was performed on complications and rate of reintervention. Assessment of risk of bias and quality of evidence was performed with the ‘Down and Black’s Checklist for measuring quality’.

Results

  • About112 studies including 17 288 patients were included. The number of complications was 2434 in 2335 patients; the most frequent was carpal tunnel syndrome (CTS), representing 14.3% of all complications. About 104 studies reported the number of reinterventions, being 1880 with a reintervention rate of 8.5%. About 84 studies reported the reason of reintervention; the most common were patient’s will (3.0%), pain (1.1%), CTS (1.2%), and device failure (1.1%).

Conclusion

  • The complication rate after DRFs is 13.5%, with the main complication being CTS (14.3%), followed by pain and tendinopathy. The reintervention rate is 8.5%, mainly due to the patient’s willingness, and all these patients had plate removal. Correct positioning of the plate and correct information to the patient before surgery can reduce the number of hardware removal, thereby reducing costs and the risk of complications associated with VLP for distal radius fractures.

Introduction

Distal radius fractures (DRFs) are one of the most common types of fractures, representing around 25% of fractures in the pediatric population and up to 18% of all fractures in the elderly population, with data from last year documenting an increasing prevalence trend of this injury (1). Despite the frequency of these fractures, there is still no consensus on the right treatment, ranging from closed reduction technique and cast immobilization to surgical operation (2, 3). Moreover, there are multiple types of fixation for the surgical treatment of DRFs: percutaneous K-wires fixation, volar or dorsal plates (LCP or conventional), external fixators, or a combination of these techniques.

Even though the optimal treatment remains without consensus (4), during the past 20 years, operative treatment has increased due to the development of new surgical techniques and materials. Volar locking plate fixation has become the first choice for the treatment of unstable DRFs (5). However, despite its encouraging results, a high percentage of complication rates have been reported (6), including nerve dysfunction, tendon injury, and hardware-related issues (7). Moreover, these complications require hardware removal, and even in the absence of complications, hardware removal is sometimes performed as a routine practice or at the patient’s request, thus necessitating a secondary surgery (8, 9, 10).

The aim of this systematic review was to evaluate the incidence of complications and secondary surgeries for plate removal in DRFs, to quantify the risks of volar locking plate surgery, and to assess whether particular populations are more prone to surgery-related complications, helping surgeons and patients in the choice of the treatment approach for DRFs.

Materials and methods

Literature search

A review protocol was developed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement (www.prisma-statement.org) (11). The study was registered on PROSPERO no. CRD42021276083. A comprehensive search of the literature was independently performed by two reviewers in the bibliographic databases PubMed, Web of Science, and Wiley Cochrane Library from inception up to January 2023 without any filters. The following research terms were used: (‘bone plates’ OR ‘palmar plate’ OR ((volar OR palmar) AND (plate OR plates OR fixation)) AND (‘radius fractures’ OR ((radial OR radius) AND (fracture OR fractures))). Clinical studies describing medium- (12 months) and long-term (>12 months) complications of DRFs synthesis using the volar locking plate were included. Only articles with a follow-up of at least 12 months were considered. Case reports or case series describing ≤5 cases and articles in languages other than English were excluded. Preclinical and ex vivo studies, dorsal locking plate, pathologic fractures, fixation with augmentation, lacking description of the complications, and review articles were also criteria for exclusion.

Data extraction

Two independent reviewers screened manually all titles and abstracts without any automated tool. After this initial screening, articles that met the inclusion criteria were screened for full-text eligibility and were excluded if they met one of the exclusion criteria. In case of disagreement between the two reviewers, a third reviewer was consulted. An electronic table for data extraction was created using Excel (Microsoft) prior to the study. The following data were extracted: title, first author, year of publication, journal, study type, population characteristics, follow-up, fracture type, complications, reinterventions, and plate removal reasons. In case of doubt regarding the data, at least two attempts to contact the authors were made. Plate removal carried out at the patient’s request without explanation was not included in the complication count. The analysis was performed using Excel (Microsoft). All continuous data were expressed in terms of the mean and s.d., and a meta-analysis was not feasible due to the heterogeneity of the included studies.

Assessment of risk of bias and quality of evidence

The Downs and Black’s ‘Checklist for Measuring Quality’ was used to evaluate the risk of bias (12). It provides a numeric score out of 32 points. It contains 27 ‘yes’ or ’no’ questions across five sections. The five sections include questions about the overall quality of the study (10 items), the ability to generalize study findings (3 items), the study bias (7 items), confounding and selection bias (6 items), and the power of the study (1 item). Assessment of risk of bias and quality of evidence was completed independently for all outcomes by two authors, and a third author resolved any possible discrepancies. The quality of evidence for all outcomes was graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE), which classifies the quality of evidence as high, moderate, low, or very low (13).

Results

Details of the included studies

A total of 5814 articles were retrieved. After the removal of duplicates, and screening of the titles, abstracts, and full texts, 112 articles were included in the systematic review (Fig. 1) (6, 10, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124). These include 59 case series, 29 comparative studies and 24 RCTs. In total, 17 288 patients (63.8% females) with 17 288 fractures were included; the mean age was 56.8 years old, and the mean follow-up was 18.6 months. Ninety-eight studies reported the C type of fracture according to the AO classification, constituting 59.3% of the fractures (for further details see Table 1).

Figure 1
Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRIMSA) flowchart of the study selection process.

Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0188

Table 1

Details of the included studies.

Study Year Country Patients (M/F) C type ratio Mean FU (months) RoB score
Abdel-Wahed et al. (15) 2022 Egypt 96 (72/24) N/A 14 21
Ali Fazal et al. (16) 2020 UK 105 (31/74) N/A 18.3 18
Al-Shahwanii et al. (17) 2021 USA 13 (6/7) N/A 12 19
Andersen et al. (18) 2022 Denmark 509 N/A 12 17
Anakwe et al. (19) 2010 UK 21 (8/13) 100 15 13
Arora et al. (20) 2007 Austria 114 (21/93) 52 15 21
Arora et al. (21) 2022 Austria 28 (22/6) 71.4 12.2 19
Bajwa et al. (22) 2015 UK 25 (11/14) 44 24 23
Brennan et al. (23) 2015 Ireland 151 (61/90) 19 32.2 18
Child et al. (24) 2022 Switzerland 41 (12/29) 100 26 22
Chirpaz-Cerbat et al. (25) 2011 France 25 (11/14) N/A 14 16
Chung et al. (26) 2006 USA 87 (37/50) 51 12 15
Chung et al. (27) 2020 USA 65 (10/55) 37 12 28
Costa et al. (28) 2014 UK 231 (37/194) 33 12 27
Dario et al. (29) 2014 Italy 51 (17/24) 82 40.5 16
DeGeorge et al. (10) 2020 USA 636 (308/328) 67.2 12 18
Egol et al. (30) 2008 USA 39 (14/25) 39 12 25
Eikrem et al. (31) 2021 Norway 60 (7/53) 0 12 25
Elerian et al. (32) 2021 UK 61 (20/41) 54.1 12 16
Esenwein et al. (33) 2013 Switzerland 665 (405/260) 70 13 13
Figl et al. (34) 2009 Austria 80 (30/50) 43 12 14
Florek et al. (35) 2021 Poland 28 (22/6) N/A 12 19
Fowler et al. (36) 2013 USA 37 (11/26) 81 14 17
Frattini et al. (37) 2009 Italy 48 (20/28) 100 26 15
Gamo et al. (38) 2022 Japan 57 (N/A) 64.9 12 24
Garces-Zarzalejo et al. (39) 2015 Spain 60 (19/41) 36 12 15
Gerald et al. (38) 2008 Austria 55 (18/37) 100 29 19
Gallacher et al. (41) 2010 UK 40 (13/27) 45 18 16
Goorens et al. (42) 2017 Belgium 10 (5/5) 100 12 12
Gradl et al. (43) 2014 Germany 55 (5/50) 0 24 24
Grewal et al. (44) 2005 Canada 29 (19/10) 100 18 21
Gruber et al. (45) 2010 Austria 54 (17/37) 100 72 19
Gruber et al. (46) 2006 Austria 93 (24/69) 65.5 15.6 18
Hakimi et al. (47) 2010 Germany 89 (30/89) 100 12 14
Hall et al. (48) 2019 USA 200 (40/160) 74.5 12 17
Hollevoet et al. (49) 2011 Belgium 16 (4/12) N/A 12 24
Huang et al. (50) 2023 Taiwan 25 (15/10) 28 15 22
Jakubietz et al. (51) 2012 Germany 22 (3/19) 100 12 25
Javed et al. (52) 2015 UK 62 (22/40) 19 12 15
Johnson et al. (53) 2014 UK 204 (77/127) N/A 36 14
Jorge-Mora et al. (54) 2012 Spain 40 (16/24) 5 12 14
Jose et al. (55) 2017 India 53 (42/11) 34 21 12
Khan et al. (56) 2016 Pakistan 43 (27/16) 100 17.2 14
Karantana et al. (57) 2013 UK 66 (N/A) 59 12 22
Kato et al. (58) 2014 Japan 100 (50/50) 84 18 18
Kaya et al. (59) 2022 Istanbul 14 (6/8) N/A 12 14
Kilic et al. (60) 2009 Turkey 27 (15/12) 81.5 18 13
Koehler et al. (61) 2015 USA 99 (33/66) 78 12 18
Knight et al. (6) 2009 UK 40 (5/35) 58 14 16
Kumar et al. (62) 2016 UK 27 (4/23) N/A 12 21
Laohaprasitiporn et al. (63) 2022 Thailand 44 (16/28) 62.5 12 20
Lattmann et al. (64) 2011 Switzerland 228 (55/173) 53 12 17
Lawson et al. (65) 2022 Australia 81 (11/70) 32.1 24 20
Lee et al. (66) 2012 Taiwan 31 (N/A) 45 19 21
Lee et al. (67) 2016 Republic of Korea 89 (19/70) 60 12 17
Lee et al. (68) 2020 Republic of Korea 1921 (587/1334) 48.8 12 16
Lee et al. (69) 2020 Republic of Korea 806 (264/542) 77.4 12.1 17
Lee et al. (70) 2022 Republic of Korea 28 (16/12) 100 13.2 15
Li et al. (71) 2019 China 1152 (432/720) 10.2 12 18
Loveridge et al. (72) 2013 UK 109 (N/A) 60 25 14
Ludvigsen et al. (73) 2020 Norway 69 (8/61) 0 12 21
Lutsky et al. (74) 2015 USA 374 (N/A) 78.8 20 13
Macfarlane et al. (75) 2015 UK 187 (N/A) 60 31 16
Machado et al. (76) 2012 Brazil 30 (16/14) 12 17.5 15
Marlow et al. (77) 2012 UK 107 (26/81) 63 27 18
Moirangthem et al. (78) 2015 India 24 (17/7) 12.5 18 15
Nishiwaki et al. (79) 2021 USA 109 (34/65) 61.5 12 28
Orbay et al. (80) 2000 USA 29 (12/17) 45 16 13
Osada et al. (81) 2008 Japan 49 (16/33) 88 12 18
Patel et al. (82) 2022 India 30 (18/12) N/A 13 20
Perregaard et al. (83) 2023 Denmark 822 (158/664) N/A 30 22
Phadnis et al. (84) 2012 UK 183 (51/132) 45 30 19
Plate et al. (85) 2015 USA 30 (11/19) 0 24 24
Quadlbauer et al. (86) 2018 Austria 392 (259/133) 67 12 17
Quadlbauer et al. (87) 2020 Austria 230 (76/154) 61 20 18
Rein et al. (88) 2007 Germany 15 (7/8) 100 22 19
Richard et al. (89) 2011 USA 56 (28/28) 100 10 20
Roh et al. (90) 2015 Republic of Korea 36 (16/20) 100 12 25
Rozental et al. (91) 2009 USA 21 (15/6) 57 12 25
Rozental et al. (92) 2006 USA 41 (15/26) 46 17 16
Safi et al. (93) 2013 Czech Republic 31 (6/25) 0 12 19
Sammer et al. (94) 2008 USA 85 (30/55) 46 12 16
Satake et al. (95) 2016 Japan 694 (165/529) 44.9 12 16
Saving et al. (96) 2018 Sweden 62 (17/55) 61 37 26
Selles et al. (97) 2018 Netherlands 323 (68/255) 55 12 17
Selles et al. (98) 2021 Netherlands 44 (8/36) 100 12 25
Soong et al. (99) 2010 USA 594 (244/350) 53 12 20
Souer et al. (100) 2011 Switzerland 111 (18/93) 33 24 22
Spiteri et al. (101) 2017 UK 20 (N/A) N/A 12 14
Subramanyam et al. (102) 2022 India 42 (30/12) 100 12 21
Sudow et al. (103) 2022 Sweden 33 (1/32) 33 36 19
Sugun et al. (104) 2012 Turkey 46 (24/22) 100 19 17
Tan et al. (105) 2016 Singapore 165 (121/44) 57 12 17
Tarallo et al. (106) 2011 Italy 40 (18/22) 100 17 16
Tarallo et al. (107) 2014 Italy 40 (16/24) 80 12 14
Thorninger et al. (108) 2017 Denmark 576 (N/A) 29 38 17
Thorninger et al. (109) 2022 Denmark 43 (6/37) N/A 12 21
Tosti et al. (110) 2013 USA 57 (15/32) 80 12 21
Tronci et al. (111) 2013 Italy 38 (8/30) 51 24 19
Wei et al. (112) 2009 USA 12 (3/9) 75 12 27
Weil et al. (113) 2014 Israel 75 (35/40) 83 12 21
Wichlas et al. (114) 2014 Germany 225 (89/134) 56 33 18
Wilcke et al. (115) 2011 Sweden 33 (N/A) 55 12 36
Williksen et al. (116) 2015 Norway 46 (N/A) 74 66 27
Williksen et al. (117) 2013 Norway 50 (N/A) 71 12 29
Wilson et al. (118) 2018 UK 616 (N/A) 26 17.5 17
Wright et al. (119) 2004 USA 21 (11/10) 90 17 20
Yu et al. (120) 2011 USA 47 (N/A) 68 49 19
Yasuda et al. (121) 2009 Japan 25 (6/19) 48 12 17
Yin et al. (122) 2022 China 34 (10/24) 0 36 20
Zenke et al. (123) 2011 Japan 66 (19/47) 36 22.7 19
Zyluk et al. (124) 2018 Poland 30 (12/18) 83 12 19

M/F, male/female; C type, C type according to AO classification; FU, follow-up; RoB, risk of bias; N/A, not assessed.

Complications and reinterventions

All the retrieved studies reported the number of complications, being 2434 out of 2335 patients. The complication rate was 13.5% (95% CI: 12.0–15.0%). The most frequent complication was carpal tunnel syndrome (CTS) with a rate of 2.0%, representing 14.5% of all complications (310 patients), followed by tendinopathy with a rate of 1.4%, representing 10.1% of all complications (234 patients), and pain with a rate of 1.3% (220 patients). The fourth most common complication was complex regional pain syndrome (CRPS) with a rate of 1.1%, accounting for 8.0% of all complications (186 patients) (Table 2 for further details).

Table 2

Type of complications, rate of complications, and % of all complications.

Type of complication Number of complications Rate of complications % of all complications
Carpal tunnel syndrome 329 2.00% 14.26%
Tendinopathy 234 1.42% 10.14%
Pain 220 1.34% 9.54%
CRPS 186 1.13% 8.06%
Other 204 1.24% 8.84%
Infection
 Superficial 162 0.98% 7.02%
 Deep 38 0.23% 1.65%
Nerve injury 168 1.02% 7.28%
Screw problem 144 0.87% 6.24%
Neuropathy 133 0.81% 5.77%
Tendon rupture
 Extensor 79 0.48% 3.42%
 Flexor 40 0.24% 1.73%
Lost fixation 93 0.56% 4.03%
Stiffness 83 0.50% 3.60%
Plate problem 83 0.50% 3.60%
Malunion 40 0.24% 1.73%
Non-union 27 0.16% 1.17%
Osteoarthritis 17 0.10% 0.74%
DRUJ 15 0.09% 0.65%
DeQuervain 12 0.07% 0.52%

CTS, carpal tunnel syndrome; CRPS, complex regional pain syndrome; DRUJ, distal radial ulnar joint.

A total of 104 studies (14 644 patients) reported the number of reinterventions performed after VLP for DRFs. There were a total of 1880 reinterventions out of 1861 patients, for a reintervention rate of 8.5% (95% CI: 6.9–10.0%). Eighty-two studies (11 470 patients) reported the reason for the reintervention, with the most common being patients’ willingness with a rate of 3.0%, representing 31.8% of the total reasons for reintervention (351 patients). The second reason was pain, with a rate of 1.1%, representing 12.0% of the total reasons for reintervention (132 patients), followed by CTS and hardware issues (Table 3).

Table 3

Reason for reintervention, number, rate of reinterventions, and percentage of all reinterventions.

Reason for reintervention Number of reinterventions Rate of reintervention % of all reinterventions
Patients’ will 351 3.02% 31.76%
Pain 132 1.14% 11.95%
CTS 134 1.15% 12.13%
Hardware issues 129 1.11% 11.67%
Tendinopathy 96 0.83% 8.69%
Other 81 0.70% 7.33%
Tendon rupture
 Extensor 23 0.20% 2.08%
 Flexor 17 0.15% 1.54%
Lost fixation 40 0.34% 3.62%
Stiffness 25 0.22% 2.26%
Nerve injury 23 0.20% 2.08%
Infections 23 0.20% 2.08%
DRUJ 9 0.08% 0.81%
CRPS 9 0.08% 0.81%
Non-union 5 0.04% 0.45%
Osteoarthritis 4 0.03% 0.36%
Malunion 4 0.03% 0.36%

CTS, carpal tunnel syndrome; CRPS, complex regional pain syndrome; DRUJ, distal radial ulnar joint.

A total of 70 studies (8825 patients) reported the reasons for plate removal: 713 patients had plate removal (8.1%), out of 829 patients who had undergone a reintervention. The patient’s will was the main cause of reoperation, and in all these cases, the plate was removed. All patients operated for device issues, loss of fixation, DRUJ, CRPS, osteoarthritis, and malunion underwent plate removal (Table 4).

Table 4

Reason for plate removal, number of reinterventions, number of plate removals, percentage of the reinterventions with plate removal.

Reason for plate removal Number of reinterventions Number of plate removals Reinterventions with plate removal, %
Patients’ will 159 159 100.00%
Pain 108 85 78.70%
Device failure 124 119 95.97%
CTS 116 105 90.52%
Tendinopathy 89 70 78.65%
Other 59 22 37.29%
Lost fixation 38 35 92.11%
Stiffness 24 15 62.50%
Nerve injury 23 20 86.96%
Infections 23 21 91.30%
Tendon rupture
 Extensor 21 19 90.48%
 Flexor 13 12 92.31%
DRUJ 9 9 100.00%
CRPS 9 9 100.00%
Non-union 7 6 85.71%
Osteoarthritis 4 4 100.00%
Malunion 3 3 100.00%

CTS, carpal tunnel syndrome; CRPS, complex regional pain syndrome; DRUJ, distal radial ulnar joint.

Risk of bias

The Downs and Black’s tool for assessing the risk of bias gives each study an excellent ranking for scores ≥ 26, good for scores from 20 to 25, fair for scores between 15 and 19, and poor for scores ≤ 14 points. According to these criteria, 16 of the included studies were classified as poor, 57 as fair, 31 as good, and 8 as excellent (Fig. 2). Mostly, the factors reducing the quality of the studies were the absence of confounders and blinding attempts, and the low statistical power of some studies. Based on the GRADE tool, the quality of evidence for both primary outcomes (complications, reinterventions) was judged to range from ‘moderate’  to ‘low’.

Figure 2
Figure 2

Downs and Black’s tool for assessing the risk of bias (15124). For the explanation of each column question, see Appendix 1.

Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-23-0188

Discussion

The main finding of this systematic review is that the complication rate after DRFs is 13.5%, with the most common complication being CTS, followed by pain and tendinopathy. The reintervention rate is also high, reaching 8.5% of patients treated with a volar locking plate.

DRF treatment-related complications vary largely in the literature reports on this common fracture type, ranging from 0% to 60%. Overall, the current systematic review quantifies an overall complication rate of 13.5% associated with volar locking plate fixation of DRFs. The complexity in studying the complication rate is explained by the fact that up to now there is no uniform definition of ‘complication’, and each author classifies different complications differently. For example, some authors do not mention CTS but report some form of nerve dysfunction without better specifying it (125, 126). Nonetheless, this study was able to summarize the literature evidence and identify the main complication patterns.

Regarding the complication types, this review demonstrates that CTS is the most common complication after volar locking plate fixation, with a rate of 2.0%, thus accounting for 14.3% of all complications. CTS is quite frequent in the general population, especially in middle-aged women and manual workers (127), but it is also known to occur as a product of distal radius fractures in 7–15% of cases, regardless of the treatment strategy (128). Generally, it is believed that CTS following distal radius fracture is not directly related to the hardware, but rather to the trauma suffered by the nerve due to the fracture and/or subsequent healing with thickening of the bony anatomy, residual malunion, and traction of the median nerve by the flexor pollicis longus (FPL) tendon. The rate retrieved in the present systematic review confirms the findings of a previous search in 2016 by Alter et al. (7), which reported a rate of 2.05%; contrarily to Zhang et al., who found 7.08% of complications (129). However, this higher rate could be explained by the low number of studies analyzed and the low number of patients (463 patients), with an inherently higher risk of bias.

This systematic review included a higher number of patients and complications than previous literature investigations, which allowed us to deepen the analysis of this important outcome of volar locking plate fixation. In this study, while belonging to the same family of complications, pain and CRPS were reported separately. Pain in patients undergoing volar locking plate fixation for DRFs was 1.3%, while the rate of CRPS, frequently undiagnosed or underestimated (130), was 1.1%, accounting together for 2.4% of patients and representing 18.4% of all complications. Bentham et al. in their review associated pain with CRPS and showed a rate of 1.6%, which was also confirmed by our systematic review. However, they do not report pain as a complication, resulting in an underestimated value of this family of complications. (131)

Finally, the third most frequent complication is flexor and extensor tendinopathy, which affects 1.5% of the operated patients. The incidence of tendon complications following volar locking plate fixation of DRFs has been reported over the years but with heterogeneous findings. Mellstrand et al. in their review reported a tendinopathy rate of 7.5% (125), whereas Azzi et al. reported a lower incidence of tendon complications, with a rate of 1.5% (132), and Wichlas et al. (114) surprisingly found no tendon complications at all. Such different complication rates may be explained by the fact that tendon injuries are underestimated (133), often have different origins, and each author interprets them differently: tendon injury may result from the initial traumatic event, intraoperative burn or screw penetration, postoperative screw prominence, profound scars, etc. Because of the anatomy of the distal radius, detection of screw prominence with traditional AP and lateral views is often unclear; thus, postoperative screw prominence is more common than it may appear (133, 134). A possible solution to this problem is the use of downsized unicortical screws since recent evidence suggests that they may produce equal biomechanical properties but provide a lower risk of dorsal prominence (135, 136) or using different intra-operative views (20, 137).

Another important result of this systematic review derives from the focus on the hardware removal rate. Almost one patient out of every ten required hardware removal, with most of the complications being caused by screw loosening or protruding screws. It is likely that hardware complications are underestimated in the literature, as they can often be accounted for as nerve and tendon complications, which, however, could be the consequence and not the cause of the complication itself. Arora et al. (138) found a 27% complication rate following volar locking plates, where tendon complications accounted for more than half of the complications; moreover, all patients with tenosynovitis underwent early hardware removal. Although all cases of tendinopathy and pain might not be associated with hardware prominence, the two phenomena are probably related (131, 138, 139) and may explain the lower-than-expected rate of hardware complications found in our systematic review where the different complication types were reported separately.

This systematic review shows that 8.1% of the patients required plate removal. The need for plate removal is due to different factors. A common reason for removal is the patient’s will, accounting for one-third of the total reinterventions. This probably depends on numerous factors that may influence the patient. First, a fundamental factor influencing the decision is the information that the surgeon reports to the patient at the time of the surgery proposal, which is often that the plate then can be removed at a later time if it bothers (139). Pain or hardware discomfort is not always experienced by the patient, who nevertheless wants to proceed with plate removal because of the belief that they have ‘foreign’ material in the body. In addition, sometimes the patient’s request for plate removal may be due to the fact that the clinical result is inferior to what was hoped for, with the patient willing to remove the plate in the hope of gaining functional improvement (126, 128).

Two-thirds of plate removals are caused instead by more objective reasons, with the most frequent causes being pain (12.5%), failure of synthetic means (11.2%), CTS (10.1%), and tendinopathy (8.6%). Recent studies suggest that plate irritation causing the latter complications leading to its removal can be diagnosed by tendon irritation tests, volar wrist crepitus, lateral radiography, and ultrasonography (128, 140, 141, 142). If there are positive results on plate irritation tests (e.g. incorrect volar tilts), early removal of the hardware is recommended to avoid further complications. In addition, most tendinopathies occurred within 6–25 months after surgery (143). This meta-analysis may have underestimated these complications because it has a mean follow-up time of 18.6 months. While the indications for VLP removal for patients without signs of plate irritation remain controversial since the rate of hardware removal did not have a positive correlation with improved clinical outcomes (140, 141, 144, 145), surgical removal of hardware in symptomatic patients reduced postoperative pain, discomfort, or stiffness (131, 139). Accordingly, this prompts attention toward preventing plate-related complications.

As stated in the study by Ward et al. (146) the complication rate is also associated with the surgeon’s experience. As such, in their analysis, the complication rate decreased with increasing surgeon’s experience, suggesting that many of these complications can be avoided. In particular, avoiding prolonged or aggressive traction on the median nerve may reduce postoperative nerve dysfunction. Moreover, plate coverage with pronator quadratus muscle or other vascularized gliding tissues may represent another advantage in reducing tendon irritation (147). Furthermore, prophylactic carpal tunnel release in patients at risk may represent a helpful tool to prevent secondary procedures (148).

Another interesting finding they pointed out is that a trend toward increased complications can be found in cases where more than 10 days elapsed between the injury and surgery (146). Unfortunately, this analysis could not be performed in the present systematic review and meta-analysis due to the lack of specific data, and future studies should take into account and report this aspect since it could influence the surgeon's strategy.

This systematic review has some limitations. First of all, the quality of the included studies reflects the quality of the literature regarding this topic, with 73 studies rated poor or fair, which could seem to impair the quality of the present analysis. However, the poor scoring was mainly due to a lack of comparative design and lack of blinding, both factors that, for the purpose of our analysis, are not important since the present paper is not a meta-analysis comparing two groups. The gray literature was not included in the search, which could cause some information to be lost. However, three databases were used, with PubMed and Web of Science being the largest medical databases used for searching medical information. In addition, in this study, complications were not divided into major or minor because these cannot be precisely defined since there is a lack of a universally shared classification. Thus, reporting each complication separately gives the reader the possibility to decide which ones are relevant to their evaluation. Furthermore, from the studies reviewed, it is not possible to stratify patients by age, sex, or comorbidities; it may be important to understand whether there are certain risk factors that lead to more complications, to provide clearer information to patients before distal radius osteosynthesis surgery.

Despite these limitations, this systematic review and meta-analysis provides the most updated and comprehensive evidence on this topic, which could be of value to surgeons and patients. This study presents the largest number of studies and patients analyzed regarding complications of surgically treated DRFs, thus providing the most reliable available data. Accordingly, this study investigates and details an important aspect related to the surgical approach, which helps give physicians and patients clear and comprehensive information about the possible risks and expectations of undergoing volar locking plate implantation for the treatment of DRFs.

Conclusion

The main result of this systematic review is that the complication rate after DRFs is 13.5%, with the main complication being CTS followed by pain and tendinopathy. The reintervention rate is 8.5%, mostly due to plate removal, with one-third of these cases being due to the patient’s willingness to remove the hardware. These aspects should be considered when choosing the treatment strategy to address DRFs.

ICMJE Conflict of Interest Statement

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the study reported.

Funding Statement

This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Author contribution statement

Material preparation, data collection, and analysis were performed by LP, LMO, and PF. The first draft of the manuscript was written by LP and all authors commented on previous versions of the manuscript. All authors read and approved the final version of the manuscript.

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