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KSR Number: KSRA14955

Comparison of effects of seven treatment methods for distal radius fracture on minimizing complex regional pain syndrome

Risk of Bias Assessment

Overall summary: High risk of bias in the review

Bottom Line

The current evidence indicates that bridging external fixation, K-wire fixation, dorsal plating, volar plating, dorsal and volar plating, plaster fixation and non-bridging external fixation can have no marked difference in risk of complex regional pain syndrome in distal radius fracture patients. A restriction to the Chinese and English language means that some relevant studies may have been missed. The search terms were reported, but full details of the search strategy were not reported. No information was provided regarding the number of authors involved in the study selection process.

Risk of Bias Assessment

Overall summary High risk of bias in the review

High

A restriction to the Chinese and English language means that some relevant studies may have been missed. The search terms were reported, but full details of the search strategy were not reported. No information was provided regarding the number of authors involved in the study selection process.

A. Did the interpretation of findings address all of the concerns identified in Domains 1 to 4? Probably no
B. Was the relevance of identified studies to the review's research question appropriately considered? Probably yes
C. Did the reviewers avoid emphasizing results on the basis of their statistical significance? Probably yes
Risk of bias in the review High

Details of Review

Number of studies 17
Number of participants 1,658
Last search date October 2014
Review type Intervention
Objective To evaluate adverse effects of the seven most common treatment methods, i.e. bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating, by their associated risk of developing complex regional pain syndrome in distal radius fracture patients.
Population Distal radius fracture patients (confirmed clinically and by imaging).
Interventions Bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating.

Combined use of interventions was not considered.
Comparator Bridging external fixation, non-bridging external fixation, K-wire fixation, plaster fixation, dorsal plating, volar plating, and dorsal and volar plating.
Outcome Incidence of complex regional pain syndrome.
Study design Randomised controlled trials (RCTs).

Non-RCTs were excluded.

Results

The pooled analysis of four studies showed no significant difference in risk of complex regional pain syndrome (CRPS) between the distal radius fracture (DRF) patients who received bridging external fixation and patients receiving non-bridging external fixation (odds ratio (OR) = 0.762, 95% confidential interval (CI) 0.420 to 1.383).

Similarly, no significant difference was shown in the risk of CRPS in DRF patients receiving bridging external fixation when compared to patients receiving K-wire fixation (OR = 2.097, 95% CI = 0.299 to 14.689, n=223, three studies), plaster fixation (OR = 0.609, 95% CI = 0.178 to 2.082, n=106, two studies), dorsal plating (OR = 1.143, 95% CI = 0.258 to 5.060, n=50, one study), volar plating (OR = 1.209, 95% CI = 0.327 to 4.469, n=95, two studies), and dorsal and volar plating (OR = 1.631, 95% CI = 0.327 to 8.138, n=53, one study).

Full Risk of Bias Assessment

The research objective was clearly stated and appropriate inclusion criteria were defined. No restrictions were reported based on study characteristics. Only Chinese and English language studies were included in the review.

1.1 Did the review adhere to pre-defined objectives and eligibility criteria? Yes
1.2 Were the eligibility criteria appropriate for the review question? Probably yes
1.3 Were eligibility criteria unambiguous? Probably yes
1.4 Were all restrictions in eligibility criteria based on study characteristics appropriate (e.g. date, sample size, study quality, outcomes measured)? Probably yes
1.5 Were any restrictions in eligibility criteria based on sources of information appropriate (e.g. publication status or format, language, availability of data)? Probably no
Concerns regarding specification of study eligibility criteria High

A search was conducted in PubMed, EBSCO, Ovid, SpringerLink, Wiley, Web of Science and Cochrane Library. In addition, bibliographies of relevant literature were searched manually for relevant studies. The search terms were provided, but a full search strategy was not reported. The searches were restricted to Chinese and English language studies. No information was provided regarding the number of authors involved in the study selection process.

2.1 Did the search include an appropriate range of databases/electronic sources for published and unpublished reports? Probably yes
2.2 Were methods additional to database searching used to identify relevant reports? Probably yes
2.3 Were the terms and structure of the search strategy likely to retrieve as many eligible studies as possible? No information
2.4 Were restrictions based on date, publication format, or language appropriate? Probably no
2.5 Were efforts made to minimise error in selection of studies? No information
Concerns regarding methods used to identify and/or select studies High

Data were extracted independently by two investigators and disagreements were resolved by discussion. Sufficient study characteristics were extracted to allow interpretation of the results. The study results were appropriately collected for the synthesis. Two or more reviewers independently assessed the risk of bias using the Cochrane risk of bias assessment tool.

3.1 Were efforts made to minimise error in data collection? Yes
3.2 Were sufficient study characteristics considered for both review authors and readers to be able to interpret the results? Probably yes
3.3 Were all relevant study results collected for use in the synthesis? Probably yes
3.4 Was risk of bias (or methodological quality) formally assessed using appropriate criteria? Yes
3.5 Were efforts made to minimise error in risk of bias assessment? Yes
Concerns regarding methods used to collect data and appraise studies Low

The synthesis included all eligible studies. Network meta-analyses were used to compare all treatments and rank them in order of effectiveness. The analysis methods appeared to be appropriate. There was no evidence of significant heterogeneity among the studies. No evidence of significant publication bias was found using a funnel plot as the included studies were symmetrically distributed around the vertical line. Quality of the individual studies was taken into account for the synthesis of findings.

4.1 Did the synthesis include all studies that it should? Yes
4.2 Were all pre-defined analyses reported or departures explained? Probably yes
4.3 Was the synthesis appropriate given the degree of similarity in the research questions, study designs and outcomes across included studies? Probably yes
4.4 Was between-study variation minimal or addressed in the synthesis? Probably yes
4.5 Were the findings robust, e.g. as demonstrated through funnel plot or sensitivity analyses? Probably yes
4.6 Were biases in primary studies minimal or addressed in the synthesis? Yes
Concerns regarding synthesis and findings Low

Keywords

  • complex regional pain syndrome
  • distal radius fracture