Surgical Management of Distal Radius Malunion: An Exploratory Network Meta-Analysis of Surgical Approaches.

Background: Symptomatic malunion following distal radius fracture can adversely impact wrist function. Corrective osteotomy, utilising volar, dorsal or dual approaches, is a common treatment option. This study aimed to review the literature and compare the outcomes of these different surgical approaches. Methods: A systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was conducted, including studies comparing volar, dorsal or dual approaches in patients aged ≥16 years. Data on patient-reported outcome measures (PROMs), pain scores, grip strength, range of motion (ROM), radiographic alignment, graft use, union rates and complications were extracted and analysed via an exploratory network meta-analysis. Results: A total of 20 studies encompassing 517 wrists were included. All approaches demonstrated improvements in PROMs, functional outcomes and radiographic alignment. Analysis suggested comparable effectiveness of dorsal and volar approaches in improving ROM and pain. Dual approaches showed similar Disabilities of the Arm, Shoulder and Hand (DASH) scores to volar. No statistically significant differences were observed between approaches in improving radiographic alignment. Subgroup analysis revealed potential benefits of the dual approach over the volar for intra-articular malunions, particularly correction of radial inclination and ulnar variance. Conversely, the volar approach may be more effective than the dorsal in correcting ulnar variance in extra-articular malunions. Graft utilisation did not significantly impact union rates across any approach. Overall complication rates were low, but the dorsal approach exhibited a higher rate of hardware removal. Conclusions: This exploratory analysis found no definitive evidence to favour one surgical approach over another, though methodological limitations preclude firm comparative conclusions. Current evidence supports individualised approach selection based upon malunion configuration, patient factors and surgeon experience. Prospective comparative studies are needed to establish definitive comparative effectiveness. Level of Evidence: Level III (Therapeutic).