Comparison of Intramedullary Screw Fixation,Plating,and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis

Abstract

Background:

Metacarpal fractures are common injuries with multiple options for fixation. Our purpose was to compare outcomes in metacarpal fractures treated with intramedullary screw fixation (IMF), Kirschner wires (K-wires), or plating.

Methods:

A systematic literature review using the MEDLINE database was performed for studies investigating metacarpal fractures treated with IMF, plating, or K-wires. We identified 34 studies (9 IMF, 8 plating, 17 K-wires). A meta-analysis using both mixed and fixed effects models was performed. Outcome measures included mean Disabilities of the Arm, Shoulder, and Hand (DASH) scores, total active motion (TAM), grip strength, time to radiographic healing, and rates of infection and reoperation.

Results:

Patients with IMF had significantly lower DASH scores (0.6 [95% confidence interval [CI], 0.2-1.0]) compared with K-wires (7.4 [4.8-9.9]) and plating (9.8 [5.3-14.3]). Intramedullary screw fixation also had significantly lower rates of reoperation (4%, [2%-7%]), compared with K-wires (11% [7%-16%]) and plating (11% [0.07-0.17]). Grip strength was significantly higher in IMF (104.4% [97.0-111.8]) compared with K-wires (88.5%, [88.3-88.7]) and plating (90.3%, [85.4-95.2]). Mean odds ratio time was similar between IMF (21.0 minutes [10.4-31.6]) and K-wires (20.8 minutes [14.0-27.6]), but both were shorter compared with plating (52.6 minutes [33.1-72.1]). There were no statistically significant differences in time to radiographic healing, TAM, or rates of reoperation or infection.

Conclusions:

This meta-analysis compared the outcomes of metacarpal fixation with IMF, K-wires, or plating. Intramedullary screw fixation provided statistically significant lower DASH scores, higher grip strength, and lower rates of reoperation, suggesting that it is a comparable method of fixation to K-wires and plating for metacarpal fractures.

Keywords

hand anatomy fracture/dislocation diagnosis outcomes research and health outcomes disability surgery specialty

Introduction

Metacarpal fractures constitute one of the most common upper extremity injuries seen in emergency departments.¹ A 5-year epidemiological study from 2012 that analyzed the National Electronic Injury Surveillance System database found the incidence of metacarpal fractures in the United States to be 13.6 per 100 000 persons, with fractures of the second through fifth metacarpals being the most common, predominantly amongst men ages 18 to 40 years.^2,3 Management of metacarpal fractures is guided by the degree of angular deformity, shortening, and functional status of the patient. Surgical management is reserved for those who present with unstable fractures, fractures with associated soft tissue compromise or bone loss, metacarpal length shortening, rotational deformity, and multiple fractures.^4,5

Various surgical treatment options are available to treat metacarpal fractures. Percutaneous pinning with Kirschner wires (K-wires), using techniques such as cross-pinning, bouquet pinning, and transverse pinning, has been a common and relatively inexpensive method to fixing metacarpal fractures. This method of fixation requires a longer period of immobilization before the wires can be removed and may lead to stiffness and loss of motion.⁶ Internal fixation with plating is another option, which requires greater soft tissue dissection and a potential higher risk of complications such as tendon adhesions.^7-9 This risk may be outweighed by the benefits of increased stability and early range of motion offered by plating.

Intramedullary screw fixation (IMF) has emerged as a newer technique for treating metacarpal fractures. Initial studies have claimed early improvement in functional outcomes comparing plating and IMF. However, there is still a paucity of literature demonstrating a clear advantage over traditional fixation methods.^10-12 In addition, choices between these methods of surgical fixation may be influenced by the characteristics of the fracture to achieve optimal stability and healing.

The purpose of this meta-analysis was to compare clinical and functional outcomes between IMF, plate fixation, and K-wire fixation for the surgical treatment of metacarpal fractures.

Methods

A literature search was performed through the MEDLINE database of literature from 2000 to 2022 using the following search terms: “intramedullary screws metacarpal fractures,” “IM screws metacarpal fractures,” “IM nails metacarpal fractures,” “intramedullary nails metacarpal fractures,” “metacarpal AND ((plating) OR (“plate and screw”) OR (orif)),” “k wires OR Kirschner wires metacarpal fractures,” “k wire OR Kirschner wires reconstruction for metacarpal fractures,” “metacarpal fracture reconstruction k wires OR Kirschner wires,” and “metacarpal fracture k wires OR Kirschner wires.” Outcomes of interest included operating room (OR) time, time to follow up, time to healing, Disabilities of the Arm, Shoulder, and Hand (DASH) score, total active motion (TAM), grip strength (as compared with the contralateral hand), rates of infection, and rates of reoperation. Three independent reviewers (C.R.D., B.B.V., and J.C.) screened the records and selected articles. Studies that reported outcomes for K-wires, plates, and/or IMF for metacarpal fractures were included, and those not pertaining to metacarpal fractures (including the thumb), did not report outcomes of interest or outcomes pertaining to K-wires, plates, or IMF, were radiographic or biomechanical studies, or were not cohort studies, were excluded.

Statistical Analysis

Meta-analyses were then performed to compare these study measures between treatment modality groups (K-wires, plates, IMF) using both fixed effects (Mantel-Haenszel approach) and mixed effects (DerSimonian and Laird approach) models, with Cochran’s Q and Higgins’ I² used to assess heterogeneity. Similar to Hurley et al,¹³ heterogeneity between studies was primarily quantified using the I² statistic, where an I² value of less than 25% indicated low study heterogeneity and an I² value of greater than 75% indicated high study heterogeneity; this value was then used to determine whether fixed effects or mixed effects results were more appropriate to report. Mixed effects results were used when high heterogeneity was detected. Results for continuous study measures are presented as pooled means with 95% confidence intervals (CIs), while log-transformed count-based outcomes are presented as pooled proportions with 95% CIs. Any 2-sided value of P < .05 was considered statistically significant.

Results

Study selection is demonstrated via the Preferred Report-ing Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (Figure 1); 1374 studies were initially identified. Exclusion criteria included study duplication; nonhuman or in vitro design; study not pertaining to metacarpal fractures; intervention not including K-wires, IMF, or plating; inclusion of thumb fractures; radiographic or biomechanical studies; low levels of evidence; or not reporting outcomes of interest.

Figure 1.

PRISMA diagram indicating study selection process.

A total of 26 studies (13 retrospective reviews, 13 prospective studies) describing the fixation of metacarpalfractures were identified (Table 1). All studies were nonrandomized cohort studies. The studies were classified by intervention for fracture fixation, producing 34 groups: 17 using K-wires (n = 762 patients), 8 using plating (n = 195 patients), and 8 using IMF (n = 304 patients). Each fracture was considered individually, even if within the same patient. Fractures with neurovascular injuries were excluded from the analysis.

Table 1.

Characteristics of the Included Studies.

Study	Year	Method	No. of patients	Intervention	Level of evidence	Outcomes	Duration of follow-up (maximum)
Abulsoud	2021	Prospective	23	K-wires	IV	Time to radiographic union DASH score Grip strength Complications	24 mo
Assi	2019	Retrospective	30	K-wires	IV	Operative time DASH score	72 mo
Aykut	2015	Retrospective	29	Plate/Screws	III	Operative time DASH score Grip strength	39 mo
Baydar	2021	Retrospective	37 38	K-wires Plate/Screws	III	Operative time Total active motion DASH scores Grip strength Complications	56 mo
Couceiro	2018	Retrospective	11 19	K-wires IMF	III	Total active motion DASH score Grip strength Complications	Not reported
Del Pinal	2015	Retrospective	59	IMF	IV	Time to radiographic union Total active motion Complications	54 mo
Doarn	2014	Retrospective	9	IMF	III	Time to radiographic union Total active motion DASH scores Grip strength Complications	57 wk
Dreyfuss	2019	Retrospective	29 30	K-wires Plate/Screws	III	Operative time Time to radiographic union Total active motion DASH score Grip strength	>1 y >1 y
Eisenberg	2020	Retrospective	91	IMF	III	Time to radiographic union Total active motion Grip strength Complications	>1 y
Facca	2010	Prospective	18 20	Plate/Screws K-wires	II	Total active motion DASH score Grip strength Complications	14 mo
Fujitani	2012	Prospective	15 15	Plate/Screws IMF	II	Time to radiographic union Total active motion Grip strength Complications	12 mo
Han	2012	Retrospective	40	K-wires	IV	Time to radiographic union Total active motion DASH score Complications	36 mo
Jann	2017	Prospective	15	IMF	IV	Operative time Time to radiographic union Grip strength Complications	17 mo
Lee	2013	Prospective	56	K-wires	IV	Operative time Time to radiographic union Total active motion Grip strength	29 mo
Ozer	2008	Prospective	14 30	Plate/Screws K-wires	III	Operative time Time to radiographic union Total active motion DASH score	29 wk
Pasquino	2020	Prospective	26 26	Plate/Screws K-wires	II	Operative time Time to radiographic healing DASH score Total active motion Grip strength Complications	56 mo 57 mo
Poggetti	2018	Prospective	25	IMF	IV	Total active motion DASH score Grip strength Complications	24 wk
Poumellec	2017	Prospective	32	K-wires	IV	Time to radiographic union Total active motion DASH score Grip strength Complications	3 mo
Rhee	2012	Prospective	105	K-wires	IV	Time to radiographic union Total active motion DASH score Complications	31 mo
Rocchi	2018	Prospective	150	K-wires	IV	Operative time Time to radiographic union Total active motion DASH score	10 wk
Ruchelsman	2020	Retrospective	39	IMF	IV	Time to radiographic union Total active motion Grip strength Complications	33 mo
Siddiqui	2019	Prospective	32	IMF	IV	Grip strength Total active motion Complications	3 mo
Van Bussel	2017	Retrospective	27	K-wires	III	Operative time DASH score Complications	62 mo
Vasilakis	2019	Retrospective	44 26	K-wires Plate/Screws	III	Total active motion DASH score Complications	15 mo
Wu	2021	Retrospective	25	K-wires	IV	Time to radiographic union Total active motion Grip strength Complications	32 mo
Zhang	2015	Prospective	76	K-wires	IV	Total active motion Grip strength Complications	27 mo

Note. IMF = intramedullary screw fixation; DASH = Disabilities of the Arm, Shoulder, and Hand; K-wires = Kirschner wires.

Participant and Fracture Characteristics

Mean age was similar between groups, with an average of 31.4 years (29.2-33.6), 32.2 years (30.0-34.3), and 31.1 years (28.9-33.3) for K-wires, plating, and IMF, respectively. Studies included both single fracture and multifracture patient cases, with fracture types including transverse, short, long, and unspecified oblique, and comminuted fractures (Table 2). Patients with multiple fractures were counted as separate, individual injuries.

Table 2.

Summary Statistics.

Study measures	Treatment method
Study measures	K-wires (n = 17 studies)	Plating (n = 8 studies)	IMF (n = 9 studies)
Summary statistics
	No. of patients
Patient sex	n = 762 patients	n = 195 patients	n = 304 patients
Females	99 (13.0%)	24 (12.3%)	30 (9.9%)
Males	631 (82.8%)	171 (87.7%)	215 (70.7%)
Unknown/NR	32 (4.2%)	0 (0.0%)	59 (19.4%)
	No. of studies
Multifracture patients
No (0)	10 (58.8%)	5 (62.5%)	7 (77.8%)
Yes (1)	7 (41.2%)	3 (37.5%)	2 (22.2%)
Fracture types
Transverse (1)	6 (35.3%)	4 (50.0%)	3 (33.3%)
Short oblique (2)	3 (17.6%)	0 (0.0%)	2 (22.2%)
Long oblique (3)	2 (11.8%)	0 (0.0%)	0 (0.0%)
Unspecified oblique (4)	2 (11.8%)	3 (37.5)	1 (11.1%)
Comminuted (5)	2 (11.8%)	3 (37.5)	2 (22.2%)
Other (6)	0 (0.0%)	0 (0.0%)	0 (0.0%)
NR	11 (64.7%)	4 (50.0%)	6 (66.7%)

Note. IMF = intramedullary screw fixation; NR = not reported; K-wires = Kirschner wires.

Outcome Measures

Mean OR time was similar between IMF (21.0 minutes [10.4-31.6]) and K-wires (20.8 minutes [14.0-27.6]), but both were shorter compared with plate fixation (52.6 minutes [33.1-72.1]). Owing to a limited number of studies reporting on operative time, a statistically significant comparison was only found between K-wires and plating (P < .05).

Functional outcomes were recorded at the final follow-up for each study. Mean time to follow-up was similar between K-wires at 18.4 months (12.3-24.6) and plating at 18.7 months (9.7-27.8), but was significantly more than the follow-up for IMF at 12.0 months (5.0-19.0) (P < .05). Patients with IMF of metacarpal fractures had significantly lower mean DASH scores of 0.6 (95% CI, 0.2-1.0) compared with both K-wire (7.4 [4.8-9.9]) and plating (9.8 [5.3-14.3]) (both P < .05) (Supplemental Figure S1). No statistically significant differences existed in TAM score, with K-wires at 240.7° (210.4°-271.0°), plating at 253.7° (240.2°-267.1°), and IMF at 248.4° (244.4°-252.4°) (Supplemental Figure S2). Grip strength was significantly higher in patients in the IMF studies, at 104.4% (97.0%-111.8%), compared with K-wires (88.5%, [88.3%-88.7%]) and plate/screws (90.3% [85.4%-95.2%]) (both P < .05) (Supplemental Figure S3).

There was no statistically significant difference when comparing the average time to radiographic healing between IMF (5.9 weeks, [4.7-7.1]) and K-wires (6.5 weeks [5.2-7.8]) or plating (8.2 weeks [5.2-11.0]). The difference in time to radiographic healing between K-wires and plating was statistically significant (P < .05), but not clinically significant as both methods reported healing within 12 weeks.

The proportion of patients with a resulting infection did not differ significantly across all groups, with 5% (3%-6%) for K-wires, 3% (1%-8%) for plating, and 2% (1%-5%) for IMF. There were significantly lower rates of reoperation for IMF at 4% (2%-7%), in comparison with K-wires at 11% (7%-16%) (P < .05) and plating fixation at 0.11 (0.07-0.17) (P < .05) (Supplemental Figure S4). Further results of outcome measures are described in Table 3.

Table 3.

Outcome Measures.

Study measures	Treatment method
Study measures	K-wires (n = 17 studies)	Plating (n = 8 studies)	IMF (n = 9 studies)
	No. of studies
	n = 17 studies	n = 8 studies	n = 7 studies
Mean age (95% CI)—Fixed effects	31.2 (30.3-32.0)	32.0 (30.5-33.5)	30.6 (29.0-32.3)
Mean age (95% CI)—Mixed effects	31.4 (29.2-33.6)	32.2 (30.0-34.3)	31.1 (28.9-33.3)
I² (95% CI)	85.0% (77.3%-90.0%)	52.7% (0.0%-78.7%)	39.1% (0.0%-74.4%)
	n = 11 studies	n = 4 studies	n = 1 study
Mean OR time (95% CI) (minutes)—Fixed effects	14.1 (12.9-15.4)	48.8 (39.1-58.6)	21.0 (10.4-31.6)
Mean OR time (95% CI) (minutes)—Mixed effects	20.8 (14.0-27.6)	52.6 (33.1-72.1)	21.0 (10.4-31.6)
I² (95% CI)	84.2% (73.4%-90.7%)	70.7% (16.3%-89.8%)	NA
	n = 9 studies	n = 4 studies	n = 2 studies
Mean DASH score (95% CI)—Fixed effects	3.8 (3.4-4.1)	9.3 (7.6-11.0)	0.6 (0.2-1.0)
Mean DASH score (95% CI)—Mixed effects	7.4 (4.8-9.9)	9.8 (5.3-14.3)	0.6 (0.2-1.0)
I² (95% CI)	96.0% (94.0%-97.3%)	86.5% (67.2%-94.4%)	0.0% (0.0%-0.0%)
	n = 10 studies	n = 6 studies	n = 4 studies
Mean TAM score (95% CI)—Fixed effects	247.0 (246.3-247.7)	259.2 (258.3-260.1)	248.5 (246.1-250.8)
Mean TAM score (95% CI)—Mixed effects	240.7 (210.4-271.0)	253.7 (240.2-267.1)	248.4 (244.4-252.4)
I² (95% CI)	99.9%*	97.1% (95.5%-98.1%)	57.2% (0.0%-85.8%)
	n = 6 studies	n = 2 studies	n = 2 studies
Mean grip strength % (95% CI)—Fixed effects	88.5 (88.3-88.7)	90.3 (85.4-95.2)	104.4 (97.0-111.8)
Mean grip strength % (95% CI)—Mixed effects	92.0 (87.7-96.3)	90.3 (85.4-95.2)	104.4 (97.0-111.8)
I² (95% CI)	99.4% (99.2%-99.5%)	0.0% (0.0%-0.0%)	0.0% (0.0%-0.0%)
	n = 14 studies	n = 6 studies	n = 4 studies
Mean time to follow-up (95% CI) (mo)—Fixed effects	21.3 (21.1-21.4)	24.1 (24.0-24.3)	11.9 (10.9-12.9)
Mean time to follow-up (95% CI) (mo)—Mixed effects	18.4 (12.3-24.6)	18.7 (9.7-27.8)	12.0 (5.0-19.0)
I² (95% CI)	99.9%*	99.9%*	97.7% (96.1%-98.7%)
	n = 13 studies	n = 5 studies	n = 6 studies
Mean time to radiographic healing (95% CI) (wk)—Fixed effects	5.6 (5.5-5.6)	6.8 (6.6-7.1)	4.8 (4.7-5.0)
Mean time to radiographic healing (95% CI) (wk)—Mixed effects	6.5 (5.2-7.8)	8.2 (5.3-11.0)	5.9 (4.7-7.1)
I² (95% CI)	99.4% (99.4%-99.5%)	99.1% (98.8%-99.4%)	97.8% (96.7%-98.6%)
	n = 17 studies	n = 6 studies	n = 7 studies
Proportion of patients with infection (95% CI) (log trans)—Fixed effects	0.05 (0.03-0.06)	0.03 (0.01-0.08)	0.02 (0.01-0.05)
Proportion of patients with infection (95% CI) (log trans)—Mixed effects	0.04 (0.02-0.06)	0.03 (0.01-0.08)	0.02 (0.01-0.05)
I² (95% CI)	15.0% (0.0%-17.5%)	0.0% (0.0%-13.5%)	0.0% (0.0%-20.1%)
	n = 17 studies	n = 8 studies	n = 8 studies
Proportion of patients with reoperation (95% CI) (log trans)—Fixed effects	0.11 (0.07-0.16)	0.11 (0.07-0.17)	0.04 (0.02-0.07)
Proportion of patients with reoperation (95% CI) (log trans)—Mixed effects	0.03 (0.01-0.07)	0.11 (0.07-0.17)	0.04 (0.02-0.07)
I² (95% CI)	65.0% (31.9%-77.6%)	0.0% (0.0%-84.0%)	0.0% (0.0%-0.4%)

Note. IMF = intramedullary screw fixation; CI = confidence interval; OR = operating room; TAM = total active motion; K-wires = Kirschner wires; DASH = Disabilities of the Arm, Shoulder, and Hand.

CI’s were not able to be calculated for these measure.

In the K-wire studies, the most common cause for reoperation was tenosynovitis (90.9%). In the plating and IMG groups, tenosynovitis accounted for only 33.3% and 14.3% of reoperations, respectively. Repeat trauma was the most common cause for reoperation (71.4%) in studies using IMF (Table 4).

Table 4.

Causes of Reoperation.

Reoperation causes	No. of patients
Reoperation causes	K-wires, n = 22 patients	Plating, n = 17 patients	IMF, n = 5 patients
Tenosynovitis	20 (90.9%)	5 (33.3%)	1 (14.3%)
Bone not healing	1 (4.5%)	1 (6.7%)	0 (0.0%)
Infection	0 (0.0%)	0 (0.0%)	0 (0.0%)
Other
Repeat trauma	0 (0.0%)	0 (0.0%)	5 (71.4%)
Required tenolysis	1 (4.5%)	6 (40.0%)	0 (0.0%)
Screw migration	0 (0.0%)	0 (0.0%)	1 (14.3%)
Stiffness	0 (0.0%)	1 (6.7%)	0 (0.0%)
Not reported	0 (0.0%)	2 (13.3%)	0 (0.0%)

Note. IMF = intramedullary screw fixation; K-wires = Kirschner wires.

Discussion

In comparing methods for metacarpal fixation, this meta-analysis identified statistically significant lower DASH scores, higher grip strength, and lower rates of reoperation with IMF in comparison with K-wires and plating. No statistically significant differences were found in mean TAM or rates of reoperation between the 3 groups. All groups achieved healing by 12 weeks.

As a newer method for treating metacarpal fractures, previous literature has demonstrated that IMF has advantages over other techniques such as plating and K-wires, including a minimally invasive approach, limited soft tissue dissection, avoidance of periosteal stripping, and shorter duration of surgery as compared with plating.^14,15 The technique also provides stable fixation with an early range of motion, without reliance on patient compliance for follow-up as K-wires do for removal.¹⁶ Our study demonstrated that outcomes of metacarpal fractures treated with IMF are comparable to K-wires and plating.

A major advantage of both IMF and plating is allowing an early range of motion and stable fixation when compared with K-wires, which require immobilization.¹⁷ However, our study found no statistically significant difference in TAM across groups at the final follow-up, reflecting that all three methods ultimately provide adequate recovery of TAM. This is consistent with prior studies comparing plating and K-wires, which demonstrate that despite shorter immobilization, there was no advantage of plating over K-wire fixation for TAM.^18-20 The relationship of TAM at the final follow-up and outcomes such as return to work was also not reported in the data used for analysis of this study. The average age of patients in our study was 31 years, which correlates with working age and is likely a motivation to return to activities or work as soon as feasible.^2,3 When comparing return to work for plating versus K-wires, results from prior studies are mixed.^18,19 Kirschner wires are also less expensive than IMF and plating as they are associated with shorter operative times and less expensive equipment, but there is not yet literature evaluating the costs associated with longer recovery times for the patient.¹⁶ Future studies would ideally compare across methods how quickly TAM is regained, prior to final follow-up, which could elucidate whether there is a benefit of early recovery of function. There was insufficient data for our study to analyze return to work as an outcome.

Our meta-analysis demonstrates lower DASH scores with IMF as compared with plating and K-wire fixation methods. The normative values for DASH score for the age group 30 to 49 years have been reported by Klum et al as 8.4 ± 12.9 for manual working men, and 6.7 ± 10.4 for nonmanual working men.²¹ Therefore, while the average DASH score for IMF was found to be significantly lower in our study, both plating and K-wires DASH scores were within this normative range, demonstrating that all methods provide low levels of self-reported disability.

Hug et al²² conducted a systematic review that associated IMF with low DASH scores, which is comparable to our study’s findings of a mean DASH score for IMF of less than 1. As this is lower than the normative values for a comparable population, these findings must be called into scrutiny for their validity of methodology in the measurement of DASH scoring. In addition, our findings are limited by the heterogeneity of fracture types included, and the analysis of multifracture patients as individual fractures, as both fixation choice and disability outcomes are influenced by these factors.

Grip strength was also found to be significantly higher in the IMF group when compared with K-wires and platting. Beck et al performed a meta-analysis of nine articles and 169 metacarpal neck and shaft fractures treated with IMF with excellent clinical outcomes, including 96% average grip strength compared with the contralateral side, 100% radiographic union at or before the latest follow-up, and average TAM of 251°.²³ Our study had comparable results, with 104% average grip strength and 248° TAM for IMF. The studies included in this meta-analysis measured grip strength in the injured hand, in comparison with the uninjured hand, without reporting or correcting for hand dominance. Values above 100% reflect comparison to the contralateral, nonfractured hand, which may have a lower absolute grip strength than the injured hand at baseline.

Both IMF and plating provide an early range of motion and stable fixation when compared with K-wires, but plating requires longer operative times and higher costs.¹⁷ Our study found that plating had significantly longer OR times when compared with IMF and K-wires. It must be considered that the longer operative times may be related to the complexity of the case, which may influence the surgeon to choose plating as a fixation method. Previous studies have also reported higher rates of complications of plating, such as stiffness, delayed healing, tendon rupture, or plate prominence.^24,25 Daher noted that the higher rates of complications may be attributed to the use of plating in open fractures, although each of the fixation methods can be used in the treatment of open fractures.²⁶ Our study was unable to analyze outcomes based on the fracture pattern due to a lack of reported data and heterogeneity across studies.

Our study found that the rates of reoperation of both plating and K-wires were significantly higher in comparison with IMF, with reoperation due to tenosynovitis highest in the K-wire group, followed by plating and IMF. Tenosynovitis is a highly subjective complication, as there are no objective methods for grading the degree of tenosynovitis or indications for reoperation. There is also a concern for increased risk of infection with the exposure of hardware in fixation K-wires. Multiple studies have demonstrated decreased infection rates with buried versus exposed K-wires, but only one study reported results that were statistically significant.^27-29 Our study did not find a statistically significant difference in the proportion of patients with infection between fixation methods.

There is theoretical concern for damage to cartilage and extensor tendons with IMF. Urbanscitz et al described placing retrograde 3.0-mm screws with a 5% to 6% total joint surface defect.²⁴ They also described less than 25% of extensor tendon damage when a mini-open approach is used to visualize the extensor tendon. In the percutaneous group, there were no cases of damage greater than 50%, which has been traditionally the lower limit to repair tendon injuries.²⁵ In vitro studies have shown that extensor tendon rupture after drill injury is rare and even lacerations of up to 75% may not fail under physiological load.³⁰ Ten Berg et al analyzed the articular surface area violation in a flexion to hyperextension arc to be 4% and 5% for 2.4- and 3.0-mm screw head diameter, respectively. Articular surface area violation was least during the more clinically relevant maximal sagittal plane arc of active motion.³¹ Long-term studies are needed to evaluate whether there are higher rates of osteoarthritis at the metacarpal in patients with IMF of metacarpal fractures.

Metacarpal shaft fractures can be treated successfully with conservative methods of immobilization if the fracture is extra-articular, stable, and does not have significant shortening, angulation, or rotational deformity.⁵ Our meta-analysis included studies that investigated the treatment of both intra-articular and extra-articular fractures that were chosen to be treated with operative management to avoid malunion, malrotation, or metacarpal shortening. Daher et al compared the conservative and operative management of displaced metacarpal shaft fractures. While operative intervention had decreased postoperative shortening, this did not correlate to better functional outcomes as the conservative management group had lower DASH scores.²⁶ Their analysis only included three studies, so future research should continue to investigate whether operative intervention provides clinically meaningful benefits over conservative management.

Comparison across studies was limited by the number of available studies using IMF for metacarpal fixation. As this is a newer technique, more literature exists on the outcomes of plating and K-wire fixation. Given the time span of this literature, the long term complications of IMF may not be fully known yet. Warrender et al performed a retrospective review of metacarpal fractures treated with IMF over the span of nine years, and found a 2.5% complication rate, with no cases of infection or extensor tendon disruption.³²

Additional limitations of this investigation include the high heterogeneity across studies when assessing functional outcomes such as DASH scores; some studies used qDASH or modified DASH score and were excluded from comparison. Despite having a greater number of studies for comparison for K-wires, there was high heterogeneity (I² > 75%) for the outcomes of DASH score, TAM score, and grip strength. Plating also had high heterogeneity for studies used in the comparison of DASH and TAM scores (Table 3). The mixed effects model was used when high heterogeneity was found, but differences across studies limit the findings.

Future prospective research should continue to gather data on IMF with outcomes of interest such as OR time, DASH score, grip strength, time to radiographic healing, and rates of reoperation. Attention should be given to classifying metacarpal shaft versus neck fractures, and identifying the type of fractures, instead of using a heterogeneous group. There should be additional cost analysis between the three fixation methods considering cost due to time of disability from work/activity, operating room duration, implant, and need for therapy.

Conclusions

Supplemental Material

sj-png-1-han-10.1177_15589447241232094 – Supplemental material for Comparison of Intramedullary Screw Fixation, Plating, and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis

Supplemental material, sj-png-1-han-10.1177_15589447241232094 for Comparison of Intramedullary Screw Fixation, Plating, and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis by Cristina R. DelPrete, John Chao, Bobby B. Varghese, Patricia Greenberg, Hari Iyer and Ajul Shah in HAND

Supplemental Material

sj-png-2-han-10.1177_15589447241232094 – Supplemental material for Comparison of Intramedullary Screw Fixation, Plating, and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis

Supplemental material, sj-png-2-han-10.1177_15589447241232094 for Comparison of Intramedullary Screw Fixation, Plating, and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis by Cristina R. DelPrete, John Chao, Bobby B. Varghese, Patricia Greenberg, Hari Iyer and Ajul Shah in HAND

Supplemental Material

sj-png-3-han-10.1177_15589447241232094 – Supplemental material for Comparison of Intramedullary Screw Fixation, Plating, and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis

Supplemental material, sj-png-3-han-10.1177_15589447241232094 for Comparison of Intramedullary Screw Fixation, Plating, and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis by Cristina R. DelPrete, John Chao, Bobby B. Varghese, Patricia Greenberg, Hari Iyer and Ajul Shah in HAND

Supplemental Material

sj-png-4-han-10.1177_15589447241232094 – Supplemental material for Comparison of Intramedullary Screw Fixation, Plating, and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis

Supplemental material, sj-png-4-han-10.1177_15589447241232094 for Comparison of Intramedullary Screw Fixation, Plating, and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis by Cristina R. DelPrete, John Chao, Bobby B. Varghese, Patricia Greenberg, Hari Iyer and Ajul Shah in HAND

Footnotes

Supplemental material is available in the online version of the article.

Ethical Approval

This study was approved by our institutional review board.

Statement of Human and Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5).

Statement of Informed Consent

Informed consent was obtained from all individual participants included in this meta-analysis by the original study authors.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported (in part) by the National Center for Advancing Translational Sciences, a component of the National Institutes of Health under award number UL1TR003017. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iDs

Cristina R. DelPrete

Bobby B. Varghese

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Supplementary Material

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