Comparison of Closed and Open Surgical Technique for Second to Fifth Metacarpal Shaft Fractures: A Multicenter, Retrospective Study in a Dutch City Population

Round 1

Reviewer 1 Report

The authors present the results of a multicentric retrospective study on the surgical treatment of metacarpal shaft fractures, comparing open reduction and internal fixation (ORIF) techniques versus closed reduction and internal fixation (CRIF). Overall, the authors report that although there do not appear to be significant differences in long-term clinical functional outcomes, ORIF is associated with longer surgical times and a significantly higher rate of complications and reinterventions. The only advantage of ORIF may lie in shorter immobilization times. I find the work to be very well done, with the methodology clearly explained, the results well presented, and the discussion in line with the findings obtained.

I have some observations and comments to make:

1)      It would be useful to know if there are also cases treated non-surgically in the various centers and what the percentage of surgically treated cases is compared to those treated non-surgically.

2)      Please briefly mention the AO-Müller classification in the Materials and Methods section to aid readers unfamiliar with this system. Moreove, including commonly accepted radiological cut-offs for angulation, translation shortening, and malrotation would aid in determining conservative versus surgical treatment options.

3)      Patient age and the duration of follow-up should be included in the report.

4)      At what point after the trauma were QuickDASH and EuroQol administered? Were they administered at a predetermined time or at the last available follow-up? In the latter scenario, the duration of the follow-up could be a discriminating factor.

5)      What does the power analysis refer to, and what is the 15% difference between the two groups? Why is it considered significant?

6)      The statement made at line 198, "Fracture type could be a reason to choose for open or closed technique," appears to contradict the differences in fracture type between the two groups as presented in table 1. Please clarify this comment based on your observations.

7)      The sentence "No significant differences in complications were found between the fracture types" (line 201) should be included in the results section. Are there statistically significant differences in the incidence of complications and/or reinterventions between patients with isolated fractures and those with multiple fractures?

Author Response

• It would be useful to know if there are also cases treated non-surgically in the various centers and what the percentage of surgically treated cases is compared to those treated non-surgically.

Thank you for this feedback. We agree with the reviewer that it would have been nice to compare our findings with non-surgical treatments exp. regarding complications, however this study focusses only on the surgical interventions, who were collected over a period of 13 years in both centers in The Hague. Unfortunately, no data is present for non-surgically treated patients.

Most of the metacarpal fractures are treated non-surgically in our hospitals. For the reviewers information, only <5% is treated surgically. We have added additional explanation in line 31-38.

• Please briefly mention the AO-Müller classification in the Materials and Methods section to aid readers unfamiliar with this system. Moreove, including commonly accepted radiological cut-offs for angulation, translation shortening, and malrotation would aid in determining conservative versus surgical treatment options.

Thank you for the feedback. We have added the explanation on AO muller classification in the Methods section in lines 80-89..

• Patient age and the duration of follow-up should be included in the report.

Thank you for the feedback, mean age was 33 years is described in table 1 and first alinea of the results section.  We have added follow up time in the materials section.

• At what point after the trauma were QuickDASH and EuroQol administered? Were they administered at a predetermined time or at the last available follow-up? In the latter scenario, the duration of the follow-up could be a discriminating factor.

Thank you, the functional scores were taken at one year follow up. We have added this in the materials and methods section, line 94-98.

• What does the power analysis refer to, and what is the 15% difference between the two groups? Why is it considered significant

In the power analysis we defined a difference of 15% between the two group as relevant and thus significant, and included this the formula for calculating the power.

• The statement made at line 198, "Fracture type could be a reason to choose for open or closed technique," appears to contradict the differences in fracture type between the two groups as presented in table 1. Please clarify this comment based on your observations.

Thank you for the feedback. What we can see in clinical practice, is that surgeons choose ORIF in multifragmentary fractures and more complex fractures (e.g. open fractures). This is expert based, and our study shows that in the objective analysis of the outcome data, CRIF is as safe as ORIF. We have added this in the discussion section.

In clinical practice, surgeons choose ORIF more often  in multifragmentary fractures and more complex fractures (e.g. open fractures). This is expert based, and our study shows that in the objective analysis of the outcome data, CRIF is as safe as ORIF. This study analyzes CRIF versus ORIF in the fracture groups, where specific fracture types and trauma mechanisms need specific analysis. The current study is underpowered to do this subgroup analysis. In this subgroup analysis, trauma mechanism, multiple fractures and specific fracture patterns could be analyzed properly.

• The sentence "No significant differences in complications were found between the fracture types" (line 201) should be included in the results section. Are there statistically significant differences in the incidence of complications and/or reinterventions between patients with isolated fractures and those with multiple fractures?

See above.

Reviewer 2 Report

Subject: Feedback on "Comparison of Closed and Open Surgical Technique for Second to Fifth Metacarpal Shaft Fractures; a Multicenter, Retrospective Study in a Dutch City Population" 

Dear Authors,

I have reviewed the manuscript titled "Comparison of Closed and Open Surgical Technique for Second to Fifth Metacarpal Shaft Fractures; a Multicenter, Retrospective Study in a Dutch City Population" and have the following comments for your consideration:

The authors conducted a retrospective analysis on a total of 231 cases, which is considered sufficient. However, given the retrospective nature of the study, there are concerns regarding the methodology. The study aims to compare ORIF and CRIF. While the conclusion suggests no significant difference in functional outcomes between ORIF and CRIF, it reports a lower complication rate with CRIF (17% vs. 29% with ORIF). However, it is worth noting that the ORIF group likely included more severe, multifragmented, and open fracture cases, which are challenging to treat with CRIF. The authors briefly mentioned in the discussion that there was no difference in fracture patterns between the ORIF and CRIF groups. However, a more detailed discussion on the differences in fracture patterns between the two groups is necessary to dispel any misconceptions that may lead readers to prefer CRIF over ORIF. According to the authors, even in cases of single or multiple metacarpal shaft fractures, ORIF is perceived unfavorably. Additionally, the re-operation rate is higher with ORIF compared to CRIF.

In the discussion section, the authors mention cast immobilization but do not provide a detailed explanation of the characteristics of cases treated with cast immobilization. According to the authors, functional impairment is more common in cases treated with cast immobilization. However, there is a lack of explanation regarding the specific characteristics of cases that required cast immobilization despite undergoing ORIF. Further clarification on these cases is needed to address the perception that cast immobilization may lead to unfavorable outcomes.

Overall, I recommend revisions to clarify the points mentioned above and improve the discussion section for a more comprehensive understanding of the study findings.

Author Response

The authors conducted a retrospective analysis on a total of 231 cases, which is considered sufficient. However, given the retrospective nature of the study, there are concerns regarding the methodology. The study aims to compare ORIF and CRIF. While the conclusion suggests no significant difference in functional outcomes between ORIF and CRIF, it reports a lower complication rate with CRIF (17% vs. 29% with ORIF). However, it is worth noting that the ORIF group likely included more severe, multifragmented, and open fracture cases, which are challenging to treat with CRIF. The authors briefly mentioned in the discussion that there was no difference in fracture patterns between the ORIF and CRIF groups. However, a more detailed discussion on the differences in fracture patterns between the two groups is necessary to dispel any misconceptions that may lead readers to prefer CRIF over ORIF. According to the authors, even in cases of single or multiple metacarpal shaft fractures, ORIF is perceived unfavorably. Additionally, the re-operation rate is higher with ORIF compared to CRIF.

Thank you for the feedback. We have added additional information and interpretation of the results in the discussion section.

In the discussion section, the authors mention cast immobilization but do not provide a detailed explanation of the characteristics of cases treated with cast immobilization. According to the authors, functional impairment is more common in cases treated with cast immobilization. However, there is a lack of explanation regarding the specific characteristics of cases that required cast immobilization despite undergoing ORIF. Further clarification on these cases is needed to address the perception that cast immobilization may lead to unfavorable outcomes.

Thank you for the feedback. We have added an explanation in the discussion section to address the point you raised.

The decision to employ cast immobilization post-ORIF hinges upon several factors. Firstly, concerns regarding the stability of the osteosynthesis may prompt clinicians to opt for this conservative approach to ensure optimal healing conditions. Furthermore, in cases characterized by multiple fractures where not all segments are rigidly fixated, cast immobilization serves as an additional safeguard against displacement or misalignment. Additionally, the application of casts post-ORIF may be motivated by the imperative to shield delicate soft tissues or wounds from potential complications such as infections.

Overall, I recommend revisions to clarify the points mentioned above and improve the discussion section for a more comprehensive understanding of the study findings.

Thank you, we have improved our discussion section on several points, according the suggestions by the reviewers.

Reviewer 3 Report

All data introduced was known before as evidence based inforMation.

No new information gained.

Also, the method of diagnosis was not mentioned. the follow up period was not defined in order to compare between two methods as regard outcome.

Your title was assigned to dutch city. Socio-demographic   data has to be emphasized.

Please in the discussion section mention the benefits of your study in favor of other previously published studies.

Author Response

All data introduced was known before as evidence based inforMation.No new information gained.

We respectfully disagree with this reviewer, since all previous studies were based on relatively small study groups , and we here now present the data of 231 pts, collected over a period of 13 years, in the two level 1 trauma centra in The Hague, together amongst the biggest trauma centra in the Netherlands. Based on the analyses performed in this large cohort, the data from previous studies in smaller charts can be put in the proper perspectives.

Also, the method of diagnosis was not mentioned. the follow up period was not defined in order to compare between two methods as regard outcome.

We thank the reviewer for this comment and now corrected this omission in the methods section in lines 74-78

Your title was assigned to dutch city. Socio-demographic   data has to be emphasized.

This study is performed in the two level 1 trauma centra in The Hague, a city with a mixed socio-economic and demographic population.

Please in the discussion section mention the benefits of your study in favor of other previously published studies

Thank you for this opportunity. We have added the following text in our discussion In our study we describe the outcomes of surgical treatment in the largest cohort studied thusfar of metacarpal shaft fractures. With 231 patients with only metacarpal shaft fractures, the comparison of the outcome and complications of the two treatment options, ORIF and CRIF could be performed with high fidelity. That makes our comparative study of  this specific type of fractures and treatment option unique in its kind and may be helpful in  defining treatment strategies.

Round 2

Reviewer 3 Report

please, mention what are the new information added in this manuscript or any proposed recommendations .

Author Response

The present study corroborates the findings of previous research, affirming the safety of both Closed Reduction Internal Fixation (CRIF) and Open Reduction Internal Fixation (ORIF) as viable surgical approaches for treating metacarpal fractures. Previous studies, characterized by small cohort sizes, yielded limited evidential weight and exhibited uncertainty regarding treatment preference. In contrast, our study, encompassing the largest available cohort, definitively asserts the safety of both surgical techniques in managing metacarpal fractures.

This is added in the text in line 308-311

Author Response File: Author Response.docx