Complications after volar locking plate fixation of distal radius fractures

Impact of Socioeconomic Factors on Time to Surgery for Distal Radius Fractures

Background

Delay in care secondary to socioeconomic status (SES) and demographic factors represents an area for potential improvement. Reducing time to surgery in distal radius fracture (DRF) fixation may improve outcomes while reducing cost. The purpose of this study is to investigate the effect of SES on time to surgery in our study population.

Methods

Patients undergoing outpatient DRF surgery within an academic healthcare system during a 4-year period were reviewed. Time to surgery and demographic factors were analyzed. The US Census Bureau was used to determine median household income (MHI) for a patient's ZIP code; patients were stratified into three groups based on MHI.

Results

A total of 413 patients met inclusion criteria. SES (14.7 d in the low-SES group, 14.0 d in the mid-SES group, and 11.1 d in the high-SES group, P = 0.00063), insurance (11.7 d for insured versus 16.3 d for Medicaid/uninsured, P < 0.0001), race (non-White group: 15.2 d versus White group: 10.9 d, P < 0.0001), and treatment facility (16.2 d at county hospital versus 10.9 d at university hospital, P < 0.0001) were associated with time to surgery in univariate analysis. Multivariate analysis found that only treatment facility was associated with time to surgery.

Conclusions

Non-White, uninsured/Medicaid individuals residing in low-SES areas may be more likely to receive care at a safety-net facility and are at greatest risk for delay in time to surgery. Measures aimed to reduce barriers to care, increase healthcare coverage, and improve patient education should be initiated to mitigate these disparities.

Complications of operatively treated distal radial fractures

Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications.Level of evidence: V.

Avoiding screw overlength using dorsal horizon view in palmar plate osteosynthesis of distal radius fractures: a prospective randomized trial

INTRODUCTION

Distal radius fractures are the most commonly reported fractures in adults. Treatment has changed in recent years to open reduction and palmar plate fixation. Penetration of the dorsal screw, however, is a well-known complication. Intraoperative anteroposterior and lateral radiographs lack the exact assessment of dorsal screw length and intraoperative measurement is therefore very likely to be inaccurate in a comminuted dorsal radial cortex. Secondary extensor tendon ruptures are reported in up to 6% following palmar plate fixation of distal radius fracture.

MATERIALS AND METHODS

A prospective randomized trial was performed to assess the value of the dorsal horizon view. The hypothesis was that the traditional anteroposterior and lateral fluoroscopic views aided by an axial view of the dorsal part of the radius, named dorsal horizon view, could prevent dorsal screw penetration. A total of 40 patients, 6 male and 34 female, were included in the study. Standardized anteroposterior and lateral radiographs were performed intraoperatively in 18 patients (standard group = control group). In 22 patients, intraoperative axial fluoroscopic views (dorsal horizon view) were added to anteroposterior and lateral images (horizon group). Numbers of intraoperative screw changes due to the two different radiological examinations were analyzed as well as exact postoperative CT guided measurement of screw length.

RESULTS

The total numbers of intraoperative screw changes were significantly higher in the horizon group. Forty-two screws were changed in 15 patients in the horizon group while only 8 screws were changed in 3 patients in the standard group. Postoperative computed tomography scans showed significantly lower total numbers of perforating screws in the horizon group with 11 screws in 22 patients compared to 20 screws in 18 patients in the standard group (p = 0.02).

CONCLUSIONS

Based on the results of this study, the dorsal horizon view improves the assessment of the correct screw length and should routinely be used in palmar plate osteosynthesis of distal radius fractures. Since screw protrusion cannot be absolutely ruled out using the dorsal horizon view, monocortical drilling or screw downsizing is still mandatory.

TRIAL REGISTRATION

This clinical trial was not registered because it was a clinical examination without any experimental techniques.

LEVEL OF EVIDENCE: 2

The Safety of the Volar Intraarticular Extended Window (VIEW) Approach for Intra-articular Distal Radius Fractures

BACKGROUND

A novel volar approach to intra-articular distal radius fractures has been introduced for treatment of intra-articular distal radius fractures, in which volar extrinsic ligaments are released to create a volar window into the radiocarpal joint (Volar Intraarticular Extended Window [VIEW] approach). Our purpose was to evaluate the safety of VIEW approach for treatment of intra-articular distal radius fractures.

METHODS

A retrospective chart review was performed for 13 patients with intra-articular distal radius fractures treated operatively with the VIEW surgical technique using an intra-articular window in the volar capsule to aid in reduction and fixation. Postoperative radiographs were reviewed to assess for ulnocarpal translocation by assessing lunate uncovering and radial-carpal distance.

RESULTS

Thirteen patients were treated with the VIEW approach with mean follow-up of 28 weeks (range, 7-67 weeks; SD, 18 weeks). The mean postoperative lunate uncovering was 34.6% (SD, 7.7%) and mean radial-carpal distance was 4.6 mm (SD, 1.5 mm). Postoperatively, mean intra-articular step-off was 0.9 mm (SD, 1.2 mm) and mean intra-articular gap was 1.2 mm (SD, 1.0 mm). No patients reported clinical symptoms of wrist instability.

CONCLUSIONS

Using the VIEW approach during a volar approach to intra-articular distal radius fractures is safe and does not lead to carpal instability. Surgeons can consider using the approach when direct visualization of the articular surface may be beneficial for reduction or fixation.

LEVEL OF EVIDENCE

Therapeutic IV.

Comparison of the cast and volar locking plate in the treatment of intra-articular distal radius fractures in elderly patients over 75 years of age

Background

We aimed to compare radiologically and clinically closed reduction circular casting (CRCC) and volar locking plate (VLP) treatment options in elderly patients over 75 years with intraarticular distal radius fracture (DRF).

Material and method

Elderly patients aged ≥75 years with at least one year of follow-up from the clinic archive who underwent conservative (CRCC) and surgical (VLP) treatment for AO type C DRF were retrospectively included in the study. Thirty-seven patients treated conservatively with CRCC and 31 treated surgically with VLP were compared as two groups. Quick Disability of the Arm, Shoulder, and Hand (QDASH) and Visual Analog scores (VAS) were evaluated functionally. In addition, a rapid assessment of physical activity (RAPA) score evaluation was performed since these patients were elderly. In addition, radiologic findings, wrist range of motion, and complications were evaluated.

Results

There was no difference between the CRCC and VLP groups regarding QDASH, VAS, and RAPA scores at the last follow up. Radiologically, there were significant differences between the groups regarding radial height, volar tilt, radial inclination and joint stepping. (respectively p= <0.001, p= <0.001, p= <0.001, p= <0.001).

Conclusion

In elderly patients over 75 years of age with intra-articular DRF, surgical treatment with VLP results in better radiologic results compared to conservative treatment with CRCC, although both treatment options lead to similar results in terms of functional outcomes.

Ultrasonography-assisted assessment of the influence of the volar prominence of the plate on the median nerve in distal radius fractures

OBJECTIVE

The study aimed to explore the effect of differing volar locking plate (VLP) prominence on the median nerve (MN) in distal radius fracture (DRF) with ultrasound assistance to guide clinical treatment.

METHODS

Forty-four patients who received VLP for DRF at our department were admitted and followed-up between January 2019 and May 2021. Different plate positions were graded using Soong classification; 13 were Grade 0, 18 were Grade 1, and 13 were Grade 2. The MN parameters at different wrist positions in patients with different Soong grades were measured with ultrasound assistance, including the median nerve cross-sectional area (MNCSA), diameter in the radial-ulnar direction (D1), and diameter in the dorsal-palmar direction (D2). The sensation in the affected finger and grip strength were collected at follow-up, scored using the Disabilities of the Arm, Shoulder, and Hand (DASH) scale to determine function, and statistically analysed.

RESULTS

The MNCSA differed significantly across Soong grades. The MNCSA at the flexed, neutral, and extended wrist positions was smallest at Grade 0 and largest at Grade 2 (P < 0.05), and that at the neutral position was not significantly different between Grades 1 and 2 (P > 0.05). There was no significant interaction between the wrist positions and Soong grade (P > 0.05). The differences in D1 and D2 among different Soong grades were not statistically significant (P > 0.05). There were no statistical differences in grip strength, DASH, and sensation among different Soong grades (P > 0.05).

CONCLUSIONS

Differing plate protrusions in DRF treatment did not cause clinical symptoms during follow-up; however, excessive plate protrusion (Soong Grade 2) increased the cross-sectional area of the MN. We recommend placing the plate as proximal as possible during VLP treatment of DRFs to avoid excessive bulges affecting the MN.

Using MaxDiff Analysis to Elicit Patients' Treatment Preferences for Distal Radius Fractures in Patients Aged 60 Years and Older

PURPOSE

The objective of our study was to determine how the attributes of surgical and nonsurgical distal radius fracture (DRF) treatments affect patient treatment preferences.

METHODS

Two hundred fifty patients aged 60 years and older were contacted from a single-hand surgeon's practice, and 172 chose to participate. We built a series of best-worst scaling experiments for the MaxDiff analysis to determine the relative importance of treatment attributes. Hierarchical Bayes analysis was used to generate individual-level item scores (ISs) for each attribute that together have a total sum of 100.

RESULTS

One hundred general hand clinic patients without a history of a DRF and 43 patients with a history of a DRF completed the survey. For the general hand clinic patients, the most important attributes to avoid when choosing a DRF treatment (in descending order) were the longer time to full recovery (IS, 24.9; 95% confidence interval [CI]: 23.4-26.3), longer time spent in a cast (IS, 22.8; 95% CI, 21.5-24.2), and higher complication rates (IS, 18.4; 95% CI, 16.9-19.8). Meanwhile, for patients with a history of a DRF, the most important attributes to avoid (in descending order) were a longer time to full recovery (IS, 25.6; 95% CI, 23.3-27.9), longer time spent in a cast (IS, 22.8; 95% CI, 19.9-25.7), and abnormal alignment of the radius on x-ray (IS, 18.3; 95% CI, 15.4-21.3). For both the groups, the least concerning attributes based on the IS were appearance-scar, appearance-bump, and the need for anesthesia.

CONCLUSIONS

Eliciting patient preferences is a vital component of shared decision-making and advancing patient-centered care. As conceptualized in this MaxDiff analysis, when choosing a DRF treatment, patients mostly want to avoid a longer time to full recovery and a longer time in a cast, whereas patients have the least concern about appearance and need for anesthesia.

CLINICAL RELEVANCE

Eliciting patient preferences is a vital component of shared decision-making. Our results may provide guidance to surgeons in discussions on the relative benefits of surgical and nonsurgical DRF treatments, by quantifying the most and least important factors to patients.

Complications After Volar Locking Plate Fixation of Distal Radius Fractures: A Retrospective Study of 822 Patients

PURPOSE

With the current routine use of volar locking plates as the preferred surgical treatment option for distal radius fractures, the purpose of this study was to investigate the incidence of postoperative complications following surgery and, second, investigate the correlation between demographic factors and the risk of complications.

METHODS

We retrospectively reviewed all patients who had been surgically treated for a distal radius fracture with open reduction and internal fixation using volar plating and screws during a 3-year period. Relevant demographic information and all postoperative complications of the 822 patients eligible for inclusion were recorded, with a mean follow-up time of 2.8 years.

RESULTS

We identified an overall complication rate of 12.3% (101 of the 822 patients), with 4.8% defined as experiencing major complications and 7.5% defined as experiencing minor complications. The most frequent were complications that led to hardware removal, observed in 2.7% (n = 22) of the patients; wound-related problems that did not require surgical revision, observed in 2.2% (n = 18) of the patients; and carpal tunnel syndrome, observed in 1.9% (n = 16) of the patients. Binary logistic regression modeling showed no correlation between demographic factors and the risk of complications.

CONCLUSIONS

In conclusion, a low overall complication rate of 12.3% was found. Further, 4.8% of the patients experienced a major complication and 7.5% of the patients experienced a minor complication following open reduction and internal fixation using volar plating of distal radius fractures. Age, sex, fracture type, and time from trauma to surgery were not found to be associated with an increased risk of postoperative complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

A Cost-Effectiveness Analysis of the Various Treatment Options for Distal Radius Fractures

Purpose

To conduct a cost-effectiveness study of nonsurgical and surgical treatment options for distal radius fractures using distinct posttreatment outcome patterns.

Methods

We created a decision tree to model the following treatment modalities for distal radius fractures: nonsurgical management, external fixation, percutaneous pinning, and plate fixation. Each node of the model was associated with specific costs in dollars, a utility adjustment (quality-adjusted life year [QALY]), and a percent likelihood. The nodes of the decision tree included uneventful healing, eventful healing and no further intervention, carpal tunnel syndrome, trigger finger, and tendon rupture as well as associated treatments for each event. The percent probabilities of each transition state, QALY values, and costs of intervention were gleaned from a systematic review. Rollback and incremental cost-effectiveness ratio analyses were conducted to identify optimal treatment strategies. Threshold values of $50,000/QALY and $100,000/QALY were used to distinguish the modalities in the incremental cost-effectiveness ratio analysis.

Results

Both the rollback analysis and the incremental cost-effectiveness ratio analysis revealed nonsurgical management as the predominant strategy when compared with the other operative modalities. Nonsurgical management dominated external fixation and plate fixation, although it was comparable with percutaneous fixation, yielding a $2,242 lesser cost and 0.017 lesser effectiveness.

Conclusions

The cost effectiveness of nonsurgical management is driven by its decreased cost to the health care system. Plate and external fixation have been shown to be both more expensive and less effective than other proposed treatments. Percutaneous pinning has demonstrated more favorable effectiveness in the literature than plate and external fixation and, thus, may be more cost effective in certain circumstances. Future studies may find value in investigating further clinical aspects of distal radius fractures and their association with nonsurgical management versus that with plate fixation.

Type of study/level of evidence

Economic/decision analysis II.

Does Time to Operative Intervention of Distal Radius Fractures Influence Outcomes?

BACKGROUND

No investigation has analyzed the time from injury to operative intervention and its effect on complications and functional outcomes in distal radius fractures. This investigation aimed to establish whether the time to surgical intervention from injury was associated with the observed rate of complications in distal radius fractures.

METHODS

A retrospective review of all orthopedic trauma patients who came to our center was conducted from 2008 through 2014. Patients who sustained closed distal radius fractures were included. A postoperative complication following distal radius fracture was defined as reoperation, superficial or deep infection, complex regional pain syndrome, new-onset carpal tunnel syndrome, tendon irritation, and symptomatic hardware.

RESULTS

In all, 190 patients were included in the study with a mean age of 48 years (SD ±14.7). According to the AO-Müller/Orthopaedic Trauma Association classification, radiographs revealed 80 A fractures, 15 B fractures, and 95 C fractures. Thirty distal radii were fixed within 0 to 3 days after injury, 91 patients within 4 to 10 days, and 69 patients after 10 days. Overall, 28 complications (14.7%) were identified. There was no statistical difference in the rate of complications between the time interval groups (P = .17).

CONCLUSIONS

Despite the increased popularity of surgical intervention for distal radius fractures, the optimal parameters to maximize patient outcomes have yet to be clearly defined. Time to intervention did not affect the rate of postoperative complication and range of motion.

Complications associated with anterior plate fixation of distal radial fractures: a retrospective study of 599 patients

We evaluated the incidence of postoperative complications following anterior locking plate fixation of distal radial fractures. We investigated whether there is an association with the patient's age, severity of the fracture or surgeon's experience. The medical records of all patients treated with anterior locking plate for a distal radial fracture between 2016 and 2018 were retrospectively reviewed. Radiographs were evaluated regarding Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification, Soong grade and dorsal screw prominence. Six-hundred and three distal radial fractures treated with anterior locking plate fixation in 599 patients were included. The overall postoperative complication incidence was 11%. Secondary surgery was performed in 9%. No statistical significance in the incidence of complications was found regarding age, AO/OTA type or surgeon experience.Level of evidence: IV.

User satisfaction with single-use instruments versus reusable instruments for treating distal radius fractures with locking volar plates

INTRODUCTION

The adoption of single-use instruments (SUI) in orthopedic and trauma surgery continues at a rapid pace. Economics studies on this topic have come to contradictory conclusions about whether these SUI have a cost advantage. The aims of our study were to (1) compare the satisfaction of operating room staff between SUI and reusable instruments (RUI) in the context of distal radius fracture fixation with locking volar plates; (2) compare the immediate postoperative and medium-term radiological outcomes of patients operated these two types of instrument sets. We hypothesized that users will be more satisfied with SUI in the context of distal radius fracture fixation with locking volar plates.

MATERIALS AND METHODS

This was a prospective, single-center study performed between April 2019 and July 2020. The inclusion criteria were patients more than 18 years of age who had a distal radius fracture with indication for fixation with volar locking plate, and whose initial treatment and follow-up were completed in our surgery department. Two groups of patients were created: SUI and RUI. The satisfaction of the surgeons and scrub nurses was determined using a 10-item questionnaire.

RESULTS

The analysis was done on 91 procedures for which a satisfaction questionnaire was completed by the primary surgeon and the scrub nurse. The satisfaction scores were always significantly better in the RUI group than in the SUI group (p<0.05).

DISCUSSION

This study found that surgeons and scrub nurses in our surgery department liked the RUI better than the SUI. At a time when SUI kits become more popular in orthopedic and trauma surgery, based on cost arguments that still need to be confirmed, taking into account the operating room staff's opinion is an important criterion for improving RUI kits.

LEVEL OF EVIDENCE

II.

Are external fixators as effective as volar plates in multi-fragmented radius distal intra-articular fractures (AO type C)?

INTRODUCTION

This study aimed to compare the radiological and clinical results of VP and EF applications in multi-fragmented radius distal intra-articular fractures (AO type C) in our clinic.

METHODS

We retrospectively analysed 80 patients who underwent surgery for radius distal fracture (AO type C) between 2014 and 2020. Group 1 comprised patients who were treated with VP, and Group 2 comprised patients who were treated with EF. Radiological evaluation was performed by measuring radial inclination, radial length, volar tilt, intra-articular step-off and ulnar variance by two-way radiography. The clinical findings were evaluated using the Gartland and Werley scoring system, and complications were noted.

RESULTS

There were no statistically significant differences between the two groups in terms of age, gender, side, fracture subtypes and follow-up time (p > 0.05). There were no statistically significant differences between the two groups in radiological parameters (based on cut-off values) (p > 0.05). The clinical evaluation did not reveal a statistically significant difference between the two groups (p = 0.613).

CONCLUSION

EF is as successful as VP in providing radiological cut-off values. EF treatment can be used as an effective and safe alternative method for multi-fragmented radius distal intra-articular fractures.

Prolonged Operative Time Associated with Increased Healthcare Utilization after Open Reduction and Internal Fixation of Intra-Articular and Extra-Articular Distal Radial Fractures: An Analysis of 17,482 Cases

Background  The current literature does not contain a quantitative description of the associations between operative time and adverse outcomes after open reduction and internal fixation (ORIF) of distal radial fractures (DRF). Questions/Purpose  We aimed to quantify associations between DRF ORIF operative time and 1) 30-day postoperative health care utilization and 2) the incidence of local wound complications. Methods  The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for DRF ORIF cases (January 2012-December 2018). A total of 17,482 cases were identified. Primary outcomes included health care utilization (length of stay [LOS], discharge dispositions, 30-day readmissions, and reoperations) per operative-time category. Secondary outcome was incidence of wound complications per operative-time category. Multivariate regression was conducted to determine operative-time categories associated with increased risk while adjusting for demographics, comorbidities, and fracture type. Spline regression models were constructed to visualize associations. Results  The 121 to 140-minute category was associated with significantly higher risk of a LOS > 2 days (odds ration [OR]: 1.64; 95% confidence interval [CI]:1.1-2.45; p  = 0.014) and nonhome discharge (OR: 1.72; 95% CI:1.09-2.72; p  = 0.02) versus 41 to 60-minute category. The ≥ 180-minute category exhibited highest odds of LOS > 2 days (OR: 2.08; 95%CI: 1.33-3.26; p  = 0.001), nonhome discharge disposition (OR: 1.87; 95% CI: 1.05-3.33; p  = 0.035), and 30-day reoperation occurrence (OR: 3.52; 95% CI: 1.59-7.79; p  = 0.002). There was no association between operative time and 30-day readmission ( p  > 0.05 each). Higher odds of any-wound complication was first detected at 81 to 100-minute category (OR: 3.02; 95% CI: 1.08-8.4; p  = 0.035) and peaked ≥ 181 minutes (OR: 9.62; 95% CI: 2.57-36.0; p  = 0.001). Spline regression demonstrated no increase in risk of adverse outcomes if operative times were 50 minutes or less. Conclusion  Our findings demonstrate that prolonged operative time is correlated with increased odds of health care utilization and wound complications after DRF ORIF. Operative times greater than 60 minutes seem to carry higher odds of postoperative complications.

Results of a Retrospective Fracture Register of Distal Radius Fractures Built Up Using PROM

Introduction

Although distal radius fractures (DRFs) are the most common fractures of the human body, the best treatment for every fracture type is still debatable. However, randomized controlled trials are difficult to perform. The quality of care can be determined primarily in the context of health care research using register studies. Registers enable standardized documentation of clinical observations over time. So far, no German register studies concerning DRFs exist, and therefore, the aim of this study was to develop a register with the help of patient-reported outcome measurements (PROM).

Patients and Methods

All patients treated surgically at our hospital with a DRF between 2006 and 2016 were enrolled. Patient data such as epidemiological data, treatment, complications, insurance status, etc. were collected and the register was built up as an in-house fracture register with the help of PROM. The Munich Wrist Questionnaire (MWQ) was used as a PROM tool.

Results

Of all 1,796 patients, 339 (19%) with a complete data set could be enrolled, 96 of the patients were male (28%), 243 were female (72%). Thirty-two percent were type A (n = 110), 9% (n = 31) were type B, and 58% (n = 198) were type C fractures. The average follow-up was 66 ± 31 months. Complications occurred in 25 cases (7%). The average postoperative function measured with the MWQ was 91 ± 11%. Patients suffering from a DRF type A had the best outcome. It was significantly better than the outcome of patients with a DRF type C (95 ± 7 vs. 89 ± 13%, p < 0.05 MWUT) and significantly better compared to the results from the whole fracture register (95 ± 7 vs. 91 ± 11%, p < 0.05 MWUT). Type B fractures had a better outcome than type C fractures (92 ± 11%).

Conclusions

Retrospective register studies created with the help of PROM have numerous advantages. Data collection is fast, easy and cost-effective and a huge amount of data can be achieved from numerous patients and the observation period after surgery is quite long. The drop-out rate might be high, but patients enrolled are a representative sample compared to the current literature. This is a valuable tool for monitoring of clinical treatment quality.

Tronco-conical locking plate in distal radius fractures

INTRODUCTION

Volar locked plates represent the most popular fixation technique for distal radius fracture (DRF). However, threaded screw-hole angular stability mechanism has some issues. The purpose of our study is to evaluate clinical and radiological outcome of a tronco-conical locking mechanism for volar plating of DRF.

MATERIALS AND METHODS

Eighty patients with DRF treated with tronco-conical locking volar plates between May 2013 to December 2017 in two institutions were collected. We analysed clinical and radiological outcomes and peri-operative complications, like loss of reduction, fragment displacement, deformation or implant-related problems and surgical and other general complications.

RESULTS

78 patients were available for at final follow-up. The average follow-up period was 11.4 months (range, 6-18 months). All fractures healed within three months. Five cases of final reductions were defined unsatisfying. According to Gartland and Werley's scoring system at final follow up, 36 patients had excellent results, 40 patients had good results, one patient had fair and one patient had poor results. Five complications were observed. No complications were observed during surgical plate removal.

CONCLUSION

Complications found in our study are not related to tronco-conical locking mechanism and are like those found in the literature. Further studies are needed to evaluate functional results or radiographic parameters of this new type of angular stability mechanism. Tronco-conical locking plate is an attractive alternative threaded screw-hole angular stability mechanism.

Analysis of Our Open Reduction and Internal Fixation of Distal Radius Fractures in Adults: Are We Over Operating?

Background  Fractures of the distal radius are a common injury. The British Orthopaedic Association (BOA) and The British Society for Surgery of the Hand (BSSH) have released new guidelines outlining the management of these fractures, specifically identifying "thresholds for intervention," based on radiological parameters for management with open reduction and internal fixation (ORIF). Questions/Purposes  Have our distal radius fractures (DRFs), previously managed with ORIF, met the new guidelines' thresholds for intervention, based on radiological parameters? Patients and Methods  A retrospective assessment of DRFs treated with ORIF was performed between January 2017 and August 2018. Patients were categorized into three cohorts based on their age. The five radiological parameters of ulnar variance, dorsal tilt, radial inclination, radial height, and intra-articular step were measured on the initial plain radiograph, "pre-manipulation film," postplaster application radiograph, and "post-manipulation film." These were compared with the "thresholds for intervention" outlined in the BOA/BSSH guidelines. Results  A total of 94 patients underwent an ORIF with a mean age of 56 years (range 17-86 years). As many as 75.74% of patients on the "pre-manipulation film" met the "threshold for intervention" on at least one radiological parameter, while 53.57% of patients on the "post-manipulation" met at least one "threshold for intervention." Dorsal tilt was the parameter that most often met the threshold in both films at 53.37% and 40.11%, respectively. Conclusion  Within our trust, there is a tendency to over manage the distal radius fracture with ORIF, potentially resulting in unnecessary operations. Education surrounding the new guidelines will better serve our decision-making. Level of Evidence  This is a level III study.

Volar versus combined dorsal and volar plate fixation of complex intraarticular distal radius fractures with small dorsoulnar fragment - a biomechanical study

Complex intraarticular distal radius fractures (DRFs), commonly managed with volar locking plates, are challenging. Combined volar and dorsal plating is frequently applied for treatment, however, biomechanical investigations are scant. The aim of this biomechanical study was to investigate volar plating versus double plating in DRFs with different degrees of lunate facet comminution.Thirty artificial radii with simulated AO/OTA 23-C2.1 and C3.1 DRFs, including dorsal defect and lunate facet comminution, were assigned to 3 groups: Group 1 with two equally-sized lunate facet fragments; Group 2 with small dorsal and large volar fragment; Group 3 with three equally-sized fragments. The specimens underwent volar and double locked plating and non-destructive ramped loading in 0° neutral position, 40° flexion and 40° extension.In each tested position, stiffness: (1) did not significantly differ among groups with same fixation method (p ≥ 0.15); (2) increased significantly after supplemental dorsal plating in Group 2 and Group 3 (p ≤ 0.02).Interfragmentary displacements between styloid process and lunate facet in neutral position were below 0.5 mm, being not significantly different among groups and plating techniques (p ≥ 0.63).Following volar plating, angular displacement of the lunate facet to radius shaft was significantly lower in Group 1 versus both Group 2 and Group 3 (p < 0.01). It decreased significantly after supplemental dorsal plating in Group 2 and Group 3 (p < 0.01), but not in Group 1 (p ≥ 0.13), and did not differ significantly among the three groups after double plating (p ≥ 0.74).Comminution of the lunate facet within its dorsal third significantly affected the biomechanical outcomes related to complex intraarticular DRFs treated with volar and double locked plates.Double plating demonstrates superior stability versus volar plating only for lunate facet comminution within its dorsal third. In contrast, volar plating could achieve stability comparable with double plating when the dorsal third of the lunate facet is not separated by the fracture pattern. Both fixation methods indicated achievable absolute stability between the articular fragments.

Cost-Effectiveness of Treatments after Closed Extraarticular Distal Radius Fractures in Older Adults from the WRIST Clinical Trial

BACKGROUND

This study performs an economic analysis of volar locking plate, external fixation, percutaneous pinning, or casting in elderly patients with closed distal radius fractures.

METHODS

This is a secondary analysis of the Wrist and Radius Injury Surgical Trial, a randomized, multicenter, international clinical trial with a parallel nonoperative casted group of patients older than 60 years with surgically indicated, extraarticular closed distal radius fractures. Thirty-Six-Item Short-Form Health Survey-converted utilities and total costs from Medicare were used to calculate quality-adjusted life-years and incremental cost-effectiveness ratio.

RESULTS

Casted patients were self-selected and older (p < 0.001) than the randomized surgical cohorts, but otherwise similar in sociodemographic characteristics. Quality-adjusted life-years for percutaneous pinning were highest at 9.17 and external fixation lowest at 8.81. Total costs expended were $16,354 for volar locking plates, $16,012 for external fixation, $11,329 for percutaneous pinning, and $6837 for casting. The incremental cost-effectiveness ratios for volar locking plates and external fixation were dominated by percutaneous pinning and casting. The ratio for percutaneous pinning compared to casting was $28,717. Probabilistic sensitivity analysis revealed a 10, 5, 53, and 32 percent chance of volar locking plate, external fixation, percutaneous pinning, and casting, respectively, being cost-effective at the willingness-to-pay threshold of $100,000 per quality-adjusted life-year.

CONCLUSIONS

Casting is the most cost-effective treatment modality in the elderly with closed extraarticular distal radius fractures and should be considered before surgery. In unstable closed fractures, percutaneous pinning, which is the most cost-effective surgical intervention, may be considered before volar locking plates or external fixation.

Minimally Invasive Surgery: Is There a Role in Distal Radius Fracture Management?

PURPOSE OF REVIEW

This review explores minimally invasive surgical techniques for distal radius fractures and guides their use in conjunction with, or as an alternative to, volar locked plating.

RECENT FINDINGS

Fractures of the lunate facet, die-punch fractures, and marginal articular shear injuries present challenges that cannot be easily addressed with volar plating. The use of external fixation, Kirschner wires, and dorsal bridge plating should all be considered. These techniques, in combination and in addition to volar locked plating, continue to play an important role in fracture management. Arthroscopically assisted surgery with minimally invasive fixation allows for detailed inspection of the radiocarpal joint. Closed treatment and casting continue to play an important role in distal radius fracture care. The role of minimally invasive surgery for distal radius fractures is still being defined. While fixation using a volar locking plate is by far the most common treatment method, other techniques should be considered to improve outcomes and decrease complications.

Complications of Volar Locked Plating of Distal Radius Fractures: A Prospective Investigation of Modern Techniques

Although volar locked plating (VLP) of distal radius fractures is common, complications remain a considerable concern for upper extremity specialists using modern techniques. Complications following VLP of DR fractures were recorded prospectively from January 2005 to January 2017. Fractures were characterized using the AO classification, and complications were described by severity. Severe complications required operative treatment and/or resulted in permanent impairment, moderate complications required nonoperative treatment, and mild complications resolved without intervention. The available Current Procedural Terminology data for uncomplicated VLP were used to calculate the complication rate. Statistical analysis compared severe and nonsevere complications. Thirty-seven patients (27 women; 39 radii) experienced complications following VLP of DR fractures, resulting in a complication rate of 13.2%. For those with complications, the mean age was 48.5 ± 13.5 years (range: 19-78 years) and the mean follow-up was 13.7 ± 9.0 months (range: 3-36 months). A majority (28/39: 71.8%) had type C fractures. The most common complications were hardware complication requiring removal (18) and malunion (6). There were only 3 tendon ruptures. There were 25 unplanned returns to the operating room in 24 radii (22 patients). The most common reason was removal of hardware (18). Patients with severe complications more commonly had AO type C fractures and required longer follow-up. Modern VLP of DR fractures has a complication rate of 13.2%. Hardware complication requiring removal was the most notable complication of VLP. Tendon rupture has become rare with modern techniques. AO type C fractures were associated with more severe complications.

Incidence of Flexor Pollicis Longus Complications Following Volar Locking Plate Fixation of Distal Radius Fractures

Background: Distal radius fractures are among the most common orthopedic injuries presenting to emergency departments. The complications of distal radius open reduction and internal fixation (ORIF) range from paresthesia to tendon ruptures. The Soong grading system was designed to evaluate volar plate position to predict postoperative flexor pollicis longus (FPL) ruptures. This study evaluates post-distal radius volar fixation FPL ruptures and other postoperative complication rates relative to Soong grade, surgical training, and plate design. Methods: A retrospective chart review was conducted to assess recorded complications after distal radius ORIF. Soong grade was determined on postoperative radiographs. Other demographic features, along with the surgeon fellowship training and plate design, were noted. Analysis was performed via t test, χ² test, rank sum test, and Fisher exact test. Results: A total of 522 patients met inclusion criteria. Flexor tenosynovitis was the most commonly recorded complication (21% of total complications). No FPL ruptures were recorded. Soong grades between patients with and without complications were not significantly different. Soong grades between patients with flexor tenosynovitis and other complications were not significantly different. Flexor tenosynovitis had higher odds of occurring compared with other complications when the surgeon was hand-trained or when the plate type was designed by Acumed. These higher odds were not maintained under multivariate regression analysis. Conclusion: Lack of FPL ruptures in this large series may reflect improved plate technology and increased awareness. The association between flexor tenosynovitis and hand fellowship-trained surgeons may be associated with more complex cases being referred to specialists.

A Survey of the Median Nerve Elasticity after Volar Locking Plate Fixation Using Ultrasound Elastography

Introduction Median nerve disorder is one of the complications after surgery using volar locking plate (VLP) for distal radius fracture (DRF). In this study, elasticity of the median nerve was quantified using ultrasound elastography (EG) (real-time tissue EG) and compared between the operation and healthy sides in patients after surgery for DRF using VLP. Materials and Methods The subjects of this study were 28 patients (4 males and 24 females; mean age: 58.5 years) who could be followed up for more than 6 months after surgery for DRF and were able to be examined by EG. We evaluated median nerve elasticities on the operation and healthy sides using EG on the final follow-up. Results The median nerve strain ratios were 3.97 ± 2.99 on the operation side and 3.91 ± 1.51 on the healthy side, showing no significant difference in elasticity of the median nerve between the operation and healthy sides. Conclusion Median nerve disorder, which is a complication after surgery with VLP, can be objectively detected using EG capable of evaluating median nerve elasticity externally to detect medial nerve degeneration while degeneration of the median nerve. Thus, EG may be used as a useful diagnostic tool to prevent complications and decide on appropriate timing of VLP extraction.

Volar PEEK plate for distal radius fracture: analysis of adverse events

BACKGROUND

The aim of the present retrospective study was to evaluate complications following carbon-fiber-reinforced polyetheretherketon (CFR-PEEK) volar plating in distal radius fracture in a large cohort of patients. As an alternative to conventional metallic devices, CFR-PEEK plates have been introduced over the last few years.

METHODS

We performed a retrospective study including all patients who were treated for distal radius fracture using a volar fixed-angle plate DiPHOS-RM (Lima Corporate, Udine, Italy). All CFR-PEEK plates implanted were reviewed between May 2012 and December 2017. Plate removal, second surgery and adverse events were collected by reviewing medical records. A total of 110 patients were included with a mean follow-up of 4 years.

RESULTS

Adverse side effects were observed in 9 cases (8%), developed during or after treatment. The most frequent complication was represented by intraoperative plate rupture (4%). Infection was reported in one case.

DISCUSSION

The rate of complications of PEEK volar plates seems to be similar to those occurring with plates of different materials. Advantages of PEEK plates are the absence of the cold-welding phenomenon and the absence of exuberant bone callus on the plate, ensuring an easy hardware removal. Intraoperative rupture remains the main complication correlated with PEEK material. These complications can be reduced with an accurate surgical technique, especially at the beginning of the learning curve.

LEVEL OF EVIDENCE

Therapeutic IV.

Predicting epiphyseal screw length in anterior plating of distal radial fractures

The purpose of this study was to determine whether optimal epiphyseal screw length could be predicted with reference to a given diaphyseal screw length when fixating a plate to the anterior surface of the distal radius. Computerized tomography scans of 40 wrists of 28 men and 12 women were semi-automatically segmented. A virtual anterior plate model was fixed to the distal radius. The mean maximal appropriate length of one diaphyseal screw and of the four distal epiphyseal screws were measured and linear regression analyses were performed. We found that the epiphyseal screw lengths were highly correlated to the diaphyseal screw length. Based on the data derived from measurements, we recommend epiphyseal screw lengths from ulnar to radial of 18, 18, 20 and 16 mm, respectively, if the diaphyseal screw is 14 mm or less. For diaphyseal screws longer than 14 mm we recommend epiphyseal screws of 20, 20, 22 and 18 mm. Using these recommended screw lengths as general guidelines may reduce the risk of intra-operative and postoperative extensor tendon injury.

Complications after operatively treated distal radius fractures

In the recent years, treatment of distal radius fractures (DRF) has advanced considerably. Surgical fixation with palmar angular stable plate has gained popularity, due to a reported lower complication rate when compared to dorsal fixation. The type of trauma or injury, surgical procedure and impaired bone quality are all contributors to complications in DRF. The main aim of this review is to summarize the most common complications and possible therapeutic solutions. In addition, strategies for minimizing these complications will be discussed.

Efficacy of non-bridging external fixation in treating distal radius fractures

Objective

To investigate the efficacy of non‐bridging external fixation in treating distal radius fractures (DRF) and its effect on wrist joint function.

Methods

The medical records of 207 patients who were treated for DRF between May 2008 and April 2017 in our hospital (age, 18.0–70.0 years; 99 males and 108 females) were retrospectively analyzed. All patients had evident wrist trauma and the diagnosis of DRF was confirmed by imaging tests. A total of 101 patients received bridging external fixation (control group), whereas another 106 received non‐bridging external fixation (study group). At 12 weeks after the procedure, the treatment effect was measured using the Dienst scoring system (rating scale: ≤3 points, excellent; 4–7 points, good; 8–11 points, fair; >12 points, poor), and the wrist joint function was evaluated by Gartland and Werley classification (rating scale: 0–2 points, excellent; 3–8 points, good; 9–20 points, fair; >21 points, poor); meanwhile, the radial length, radial inclination, and palmar tilt were examined by X‐ray. Follow‐up visits were conducted once every 2 weeks for 6 months, and the incidences of complications in the two groups within 6 months after operation were recorded, including incision infection, Kirschner wire loosening, delayed fracture healing, and arthritis.

Results

There were no differences in the sex ratio, mean age, mean injury period, Arbeitsgemeinschaft fur osteosynthesefragen classification, and cause of fracture between the two groups (all P > 0.05). In terms of the treatment effects, the study group had a higher percentage of excellent results (P < 0.001) and lower percentages of fair and poor results (P = 0.002, P = 0.001) than the control group 12 weeks after treatment, while both groups had similar percentages of good results (P = 0.109). In terms of the score of the wrist joint function, the study group had a higher proportion of excellent result than the control group 12 weeks after treatment (P = 0.029), whereas no intergroup differences in the proportion of good, fair, and poor results were observed (all P > 0.05). After follow‐up for 6 months, the incidences of incision infection, Kirschner wire loosening, delayed fracture healing, and arthritis, as well as the total complication rate were found to be similar between the two groups (all P > 0.05).

Conclusions

Using non‐bridging external fixation for treating DRF allows some level of wrist movement during the early stage of fixation, effectively maintains the radial length, radial inclination, and palmar tilt, and achieves better outcomes than bridging external fixation.

Radiological results of surgical management of fracture of the distal radius treated with volar locking plates

OBJECTIVES

Distal radius fracture (DRF) is the most common upper extremity fracture. The incidence of complications after surgical treatment still remains high. The objective of our study was to assess functional and radiological results of DRF treated with volar locking plate.

METHODS

We conducted a retrospective study including DRF treated by open reduction and internal fixation with a volar locking plate during a period of 8 years (2010-2018). Data were collected from clinical records and included patient demographics, fracture characteristics, radiological parameters (radial inclination, palmar tilt, ulnar variance, articular step-off), range of motion (ROM), complications and reinterventions.

RESULTS

A total of 170 patients (63.5% female) met the inclusion criteria with a mean age of 55.9 years [24.1-83.7; 13.76]. High energy injuries were more frequent in younger patients (25.56% vs 3.95%; p < 0.0001). AO classification was: 2R3A: 23.5%, 2R3B: 24.1% and 2R3C: 52.4%. Time until surgery was 8.5 days, longer in extraarticular fractures (AO-2R3A: 12.22 days, AO-2R3B: 7.97 days, AO-2R3C: 7.04 days, p = 0.018). Younger patients had better radial inclination (excellent in 85.1% vs 59.21%, p = 0.001) and radial shortening (excellent in 100% vs 88.15%, p = 0.001). ROM was: flexion 63° [0-90°; 19.73], extension 57.67° [5-90°; 21.61], pronation 78.94° [40-90°] and supination 81.76° [38-90°; 8.87]. We found a weak correlation between ROM in flexion-extension and radial shortening (r = 0.218; p = 0.001) and articular step-off (r = -0.269; p = 0.002). We had 39 complications (21.18% of patients). 10.6% of patients needed a re-operation, being the most frequent hardware removal (6.5%) and tendinous disruptions repairs (2.4%). Reintervention rate was higher in younger patients (14.9% vs 5.3%; p = 0.042), complete articular fractures (AO-2R3A: 2.5%; AO-2R3B: 7.3%; AO-2R3C: 15.7%; p = 0.037) and high energy injuries (8.4% vs 22.2%; p = 0.044). Patients undergoing reintervention had a decreased flexion-extension (94.44° vs 123.83°, p = 0.007).

CONCLUSION

Radial shortening and articular step-off seem the most important predictors for postoperative range of motion. Worse radiological outcomes are observed in complete articular fractures and those affecting elder population. Although radiological and functional results are good or excellent in most of cases, the incidence of complications and need for reintervention still remains noticeable. Re-operations were more frequent in younger patients, complete articular fractures and high energy injuries, and it worsened functional outcomes.

MRI Study on the Distance between the Distal Radius and the Flexor and Extensor Tendons: Is There Any Room for Error/Hardware?

Purpose  This study aims to quantify the distances between the cortex of the distal radius and flexor and extensor tendons. Methods  We analyzed 50 magnetic resonance images (MRI) of intact wrist without pathology. The distances between the volar cortex and the flexor pollicis longs (FPL), index flexor digitorum profunduns (FDPi), flexor digitorum profundus (FDP), and flexor digitorum superficialis (FDS) were measured at the level of the watershed line and 3- and 6-mm proximal to this level. The distances between the dorsal cortex and the extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), extensor pollicis longus (EPL), extensor indicis proprius (EIP), and the extensor digitorum communis (EDC) were measured at the level of Lister's tubercle and 5-mm distal to this level. Analysis was descriptive. Results  At the watershed line, the FPL, FDPi, FDP, and FDS were located at an average of 3.1, 2.4, 3.6, and 5.1 mm, respectively, volar to the volar cortex. The distances of the FDP and FDS increased at 3-mm proximal to the watershed line and increased for all four tendons at 6-mm proximal to the watershed line. Dorsally, at Listers' tubercle the ECRL, ECRB, EPL, EIP, and EDC were identified at an average of 0.7, 0.5, 0.5, 2.6, and 3.2 mm, respectively, dorsal to the dorsal cortex of the distal radius. At 5-mm more distal, these tendons were located on average 1.2, 1.0, 0.7, 1.9, and 1.8 mm, respectively, dorsal to the dorsal cortex. Conclusion  On the volar side, on average there is enough room for a volar plate when staying proximal to the watershed line. On the dorsal side, there is virtually no room for protruding screws as physical anatomical space is limited to a maximum of 0.7 mm from cortex to the closest tendon (the FDP), with screw increments being 2 mm. Level of Evidence  This is a Level II Study.

Comparison of radiographic and functional results of die-punch fracture of distal radius between volar locking plating (VLP) and external fixation (EF)

Purpose

The aim of this study is to investigate the radiographic and functional results of die-punch fracture of distal radius treated by volar locking plate (VLP) or external fixation (EF).

Methods

Between January 2015 and June 2018, 87 patients who were treated with EF or VLP were included in this study. At postoperative 6 months and at least 12 months, radiographic and functional outcomes were evaluated, and compared between two groups using SPSS 21.0.

Results

The follow-up period was 15.6 months in average, and at the mean 8.5 weeks bony union was achieved in all patients. At 6-month visit, patients in VLP group had significantly better wrist flexion (79.2° vs. 71.8°) and pronation (79.5° vs. 75.2°) than those in EF group, but the difference was non-significant at the last visit (> 12 months); as for other parameters, no significant differences were observed. No significant difference was found between both groups in term of volar tilt, radial inclination, radial height, ulnar variance, or Gartland–Werley score and DASH. The articular step-off was significantly greater in EF than VLP group (0.6 mm vs. 0.3 mm, p < 0.001). The overall incidence of complications seemed higher in EF group (25% vs. 14%), but not approaching to the statistical significance level.

Conclusions

Patients with VLP fixation of die-punch fractures had better wrist flexion and pronation at 6-month visit and more favorable wrist joint congruence at the last visit, but ultimately their outcome was comparable with those treated by EF.

Incidence of complications and secondary procedure following distal radius fractures treated by volar locking plate (VLP)

Objective

To investigate the incidence of postoperative overall complications or secondary procedures following distal radius fractures treated by volar locking plate (VLP)

Methods

Electronic medical records (EMR) of 1152 patients with 1175 distal radius fractures treated by volar locking plate between January 2013 and September 2018 were retrospectively reviewed and the data were extracted. The picture archiving and communication system (PACS) was inquired to assess the fracture severity and to determine the fracture type. Univariate and multivariate logistic regression analyses were used to identify the associated risk factors.

Results

During the median follow-up period of 6 months, a total of 138 complications in 131 patients were determined, indicating the accumulated rate of 11.7%; there were 68 cases of secondary procedures, with the rate of 5.8%. The independent associated factors for postoperative overall complications were AO type C fracture (OR, 2.6; 95%CI, 1.2 to 4.0), open fracture (OR, 4.2; 95%CI, 1.9 to 6.5), and significant collapse of the lunate fossa (OR, 2.9; 95%CI, 13 to 4.3), and for secondary procedures were significant collapse of the lunate fossa (OR, 3.7; 95%CI, 1.7 to 6.4) and the low-volume of surgeons (OR, 95%CI, 1.2 to 3.6)

Conclusions

Identification of these factors is of importance for the risk assessment of postoperative complications and the additional need of surgery. For patients with the above factors, especially those with combined risk factors, optimized operation scheme and high-volume surgeon should be considered to prevent or reduce the complications.

Risk factors for complications after volar plate fixation of distal radial fractures

This study assessed risk factors for complications after volar plate fixation of distal radial fractures. An assessment of electronic patient records from 2008 to 2016 identified 867 patients with a total of 881 distal radial fractures who underwent volar plating in our hospital. A total of 132 complications after volar plate fixation of distal radial fractures were observed (complication rate 15%). Surgery performed by a low-volume surgeon and patient age less than 40 years were the most important risk factors for plate-related complications. In logistic regression analysis, operation performed by a low-volume surgeon and patient age less than 40 years were independent predictors of plate-related complications. Patient age less than 40 years and low-volume surgeon were also found to be independent risk factors for plate-related secondary operations. Surgical delay had no effect on the complication rate. Level of evidence: IV.

The current evidence-based management of distal radial fractures: UK perspectives

Distal radial fractures are extremely common injuries, yet many basic questions remain unanswered about their optimum management. Recently in the United Kingdom several guideline development groups have produced national standards and best-practice guidelines based on review of the best available evidence and expert knowledge. All guideline groups agree that when surgery is needed for dorsally displaced distal radial fractures, that can be reduced closed, K-wire fixation and cast immobilization, should be offered. Further research questions have been identified. The important findings and recommendations are summarized in this article.

The efficacy of using 3D printing models in the treatment of fractures: a randomised clinical trial

Background

The aim of this study was to evaluate the efficacy of the use of three-dimensional (3D) printing models for preoperative planning in cases of complex fracture.

Methods

In total, 48 patients with AO type C fractures of the distal radius were enrolled in the study between January 2014 and January 2015. They were divided randomly into 3D model (n = 23) and routine treatment (n = 25) groups. A 3D digital model of each distal radius fracture in the former group was constructed. The model was exported to a 3D printer for construction of a full solid model. During each operation, the operative time, amount of blood loss, and frequency of intraoperative fluoroscopy were recorded, which were regarded as primary outcome measures. Patients were followed to evaluate surgical outcomes by Gartland–Werley scores, radiological evaluation, and range of motion of wrist, and these were regarded as the secondary outcome measures. In addition, we invited surgeons and patients to complete questionnaires.

Results

The treatment of complex fractures using the 3D printing approach reduced the frequency of intraoperative fluoroscopy, blood loss volume, and operative time, but did not improve postoperative function compared with routine treatment. The patients wanted the doctor to use the 3D model to describe the condition and introduce the operative plan because it facilitated their understanding. The orthopaedic surgeons thought that the 3D model was useful for communication with patients, but were much less satisfied with its use in preoperative planning.

Conclusion

Our study revealed that 3D printing models effectively help the doctors plan and perform the operation and provide more effective communication between doctors and patients, but can not improve postoperative function compared with routine treatment.

Trial Registration

This trial was registered at the Chinese Clinical Trial Registry on May 9, 2017 (ChiCTR-IRP-17011343, http://www.chictr.org.cn/showproj.aspx?proj=19264).

Intramedullary Fixation of Distal Radius Fractures Using CAGE-DR Implant

Purpose  CAGE-DR implant is a novel Food and Drug Administration approved intramedullary fracture fixation device used for distal radius fractures. We examine a series of 22 patients and report the outcomes with this device. Materials and Methods  A total of 24 patients with distal radius fractures (8 articular AO type C1/C2; 16 extra-articular AO type A2/A3) underwent open reduction and internal fixation (ORIF) using CAGE-DR implant by a single surgeon. Data including fracture type, angle of displacement, radiographic consolidation, grip strength, wrist range of motion (ROM), patient-rated wrist evaluation (PRWE), and Visual Analog Scale (VAS) pain scores were recorded at time of surgery and at standard follow-up. Results  All 24 patients underwent uneventful ORIF. At first follow-up visit (9 days), all patients had full digital ROM (measured as 0 cm tip-to-palm distance). Two patients were lost to follow-up. Eighteen of the remaining 22 patients had sufficient radiographic follow-up and all 18 demonstrated healing. At latest follow-up (mean 9.7 months, range, 3-20), VAS pain scores averaged 0.6 (range, 0-8) and PRWE averaged 12.1 (range, 0-53.5). Grip strength of the operated hand averaged 58 lbs (range, 20-130). ROM included: wrist flexion 73° (50-95), wrist extension 78° (60-110), pronation 77° (60-90), supination 79° (60-90), ulnar deviation 31° (5-45), and radial deviation 17° (10-30). Three patients underwent screw removal to prevent tendon irritation. One patient underwent hardware removal due to prominence on imaging but was asymptomatic. There were otherwise no major complications, including complex regional pain syndrome, in the series to date. Conclusion  The CAGE-DR fracture fixation system is a promising alternative to established methods of distal radius internal fixation. This series has a low reported pain score starting immediately postoperatively and a low complication rate. This novel device is a promising option for internal fixation of displaced distal radius fractures with a low complication profile. Level of Evidence  This is a level IV, therapeutic study.

Comparison of Locking and Frag-Loc Screws for Fixation of Die-Punch Fragments

Background  The Frag-Loc (FL) compression screw system was designed to stabilize dorsally displaced intra-articular dorsoulnar (die-punch) fragments in distal radius fractures. Purpose  Comparison of the biomechanical properties of fixation of the die-punch fragment (stiffness, ultimate strength, and displacement ratio of the fragment), using the FL and traditional locking screw (LS), and using simulated distal radial fractures in cadaveric specimens under axial compressive loading. Both screws were used with a volar locking plate (VLP). Materials and Methods  Eight matched pairs of formalin-fixed cadaveric specimens of the radius were used to simulate distal radius fractures with die-punch fragments. The die-punch fragment was fixed using VLP with either FL group or LS group. Biomechanical properties for the two fixation systems were evaluated under axial compression loading, applied at a constant rate of 0.5 mm/min until failure. Load data were recorded and the ultimate strength and change in the gap between the die-punch and proximal fragments measured, with the displacement ratio calculated by dividing the value of the gap before loading by the gap after loading. Failure was defined as 10 mm or more of fragment displacement, or screw failure. Results  There were no differences in ultimate strength ( p  = 0.47) or stiffness ( p  = 0.061) between the two fragment fixation systems. However, the displacement ratio was lower for the FL than for the LS system ( p  = 0.049). Conclusion  Compared with LS, the FL system lowers the displacement of die-punch fragments under compressive loading. Clinical Relevance  The FL system is effective for the treatment of distal radius fractures with die-punch fragments.

Hairline fractures following volar plating of the distal radius: a recently recognized hardware-related complication

OBJECTIVES

Intraoperative hairline longitudinal fractures were recently reported in association with distal radius volar plating. Our aim was to further analyze this newly described complication.

METHODS

A retrospective radiographic and chart review was performed on 225 patients who underwent distal radius plating between June 2013 and June 2015. The Acu-Loc/Acu-Loc2© plating system (Acumed, Hillsboro, OR, USA) was used in 208 cases, and the VariAx© plating system (Stryker, Kalamazoo, MI, USA) was used in 17 cases. Three independent reviewers performed a blind evaluation of all relevant radiographs for the occurrence of longitudinal fractures around the plate, and validity was considered only when there was agreement among all three of them.

RESULTS

Hairline longitudinal fractures were identified in 57 cases (25%), 55 with the Acu-Loc/Acu-Loc2© system and 2 with the VariAx© system. All fractures occurred with volar plating. Fracture occurrence was associated with age over 59 years, female gender, extra-articular fractures, and the use of Hexalobe screws (Acu-Loc/Acu-Loc2© system).

CONCLUSIONS

We believe that the source of fracture occurrence lies within the screw design and that better screw design and possibly tapping in patients at risk may reduce the occurrence of intraoperative hairline longitudinal fractures. Further clinical and biomechanical research is needed to better understand this newly reported complication.

A Prospective Observational Assessment of Unicortical Distal Screw Placement During Volar Plate Fixation of Distal Radius Fractures

PURPOSE

Although volar plating of the distal radius is performed frequently, the necessity of distal bicortical fixation in the metaphyseal and epiphyseal areas of the distal radius has not been proven. This study aimed primarily to quantify the ability of unicortical distal screws to maintain operative reduction of adult distal radius fractures and secondarily to determine if unicortical screw lengths could be predicted based on anatomical measurements.

METHODS

This prospective trial enrolled 75 adult patients undergoing volar locking plate fixation of a unilateral distal radius fracture at a tertiary center. Study inclusion required screw fixation in the distal rows of the plate performed with unicortical screw placement. The primary outcome was maintenance of operative reduction, according to predefined parameters, quantified by comparing initial operative reduction to final reduction after fracture healing. Repeated measures analysis of variance analyzed for systematic change in radiographic parameters between injury, operative, and healed images. Correlation coefficients quantified the relationship of screw lengths with lunate width and other anatomical measurements.

RESULTS

Seventy-five patients (mean age, 54 years ± 15 years; 79% women) were enrolled and followed to fracture union. Fracture severity varied and included AO type A (40%), B (12%), and C (48%) fractures. There was no significant change in mean lateral translation, intra-articular gap, intra-articular stepoff, radial inclination, or lateral tilt of the radius between the time of fixation and union for the cohort. Two patients lost reduction (increased dorsal tilt, 10°, 20°, respectively), potentially attributable to provision of unicortical fixation (3%; 95% confidence interval [95% CI], 0%-9%). No extensor tenosynovitis or extensor tendon ruptures occurred. Eighty percent of screws were 18 mm or less and screw lengths were not correlated with lunate width or any other anatomical measurements.

CONCLUSIONS

Unicortical distal fixation during volar locking plate fixation effectively maintains operative reductions of distal radius fractures while potentially minimizing the incidence of extensor tendon ruptures.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Complications following open reduction and internal fixation versus external fixation in treating unstable distal radius fractures: Grading the evidence through a meta-analysis

BACKGROUND

The common fixation techniques for unstable distal radius fractures include open reduction and internal fixation (ORIF) with plates and closed reduction and external fixation (EF). There is controversy over the choice of surgical approach in treating unstable distal radius fractures.

HYPOTHESIS

This meta-analysis was performed to compare complication rates in patients treated with ORIF or EF for unstable distal radius fractures and to develop GRADE (grading of recommendations, assessment, development, and evaluation)-based recommendations for using the procedures to treat unstable distal radius fractures.

MATERIALS AND METHODS

A systematic search of all the studies published was conducted using the Pubmed, ScienceDirect, Embase, BIOSIS, Springer, Cochrane Library databases. The randomized controlled trials (RCTs) that compared ORIF with EF in treating adult patients with unstable distal radius fractures and provided data regarding the complication were identified. The demographic characteristics and adverse events were manually extracted from all of the included studies. RevMan 5.1 was used for data analysis. PRISMA guidelines were followed.

RESULTS

Sixteen studies that included a total of 1280 patients met the inclusion criteria. Compared with ORIF, EF results in higher incidence of total complications, infection and malunion. The overall GRADE system evidence quality was very low, which reduces our confidence in the recommendations of this system.

DISCUSSION

This meta-analysis indicates that ORIF and EF are both effective procedures for treating unstable distal radius fractures. ORIF may be superior to EF in the treatment of unstable distal radius fractures. Because of the low quality evidence currently available, high-quality RCTs are required.

LEVEL OF EVIDENCE

Level II: low-powered prospective randomized trial meta-analysis.

Intra-articular distal radius fractures in elderly patients: a randomized prospective study of casting versus volar plating

We compared outcomes in elderly patients with intra-articular distal radius fractures treated by closed reduction and plaster immobilization or open reduction and internal fixation with a volar plate. Ninety-seven patients older than 60 years were randomly allocated to conservative (47 patients) or surgical (50 patients) treatment. Over a 2-year period, we assessed patient-rated wrist evaluation score, DASH (disability arm, shoulder and hand) questionnaire, pain, wrist range of motion, grip strength, and radiological parameters. The functional outcomes and quality of life were significantly better after volar plating fixation compared with conservative treatment. We found that restoration of the articular surface, radial inclination, and ulnar variance affected the outcomes, but the articular step-off did not. Twenty-five per cent of the patients with conservative treatment had secondary loss of reduction. We conclude that surgical plating leads to better outcomes than conservative treatment for elderly patients with intra-articular distal radius fractures.

LEVEL OF EVIDENCE

I.

Volar Capsular Release After Distal Radius Fractures

PURPOSE

Loss of full wrist range of motion is common after treatment of distal radius fractures. Loss of wrist extension limiting functional activities, although uncommon, can occur after volar plating of distal radius fractures. Unlike other joints in which capsular release is a common form of treatment for stiffness, this has been approached with caution in the wrist owing to concerns for carpal instability. We tested the null hypothesis that hardware removal and open volar capsular release would not lead to improved upper extremity-specific patient-reported outcome (Disabilities of the Arm, Shoulder, and Hand [DASH] questionnaire).

METHODS

We conducted a retrospective chart review of patients who underwent a tenolysis of the flexor carpi radialis tendon, removal of hardware, and subperiosteal release of the volar capsule (extrinsic ligaments). The primary outcome measure was patient-reported outcome on the DASH. Secondary outcomes included wrist flexion, extension, pronation, and supination, visual analog scale for pain, and radiographs/fluoroscopy for ulnocarpal translocation.

RESULTS

Eleven patients were treated with a mean follow-up of 4.5 years. Mean DASH scores improved after surgery. Mean wrist flexion, wrist extension, pronation, and supination improved after surgery. Mean visual analog scale scores did not change. The radiocarpal relationship on radiographs/fluoroscopy was normal.

CONCLUSIONS

Open volar capsular release to regain wrist extension after treatment of distal radius fractures with volar locking plates is safe and effective. Patients regain wrist extension in addition to improved DASH scores. There were no radiographic/fluoroscopic or clinical signs of ulnocarpal translocation after release of the volar extrinsic ligaments.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A systematic review of volar locking plate removal after distal radius fracture

BACKGROUND

Indication of volar locking plate (VLP) removal after bony healing of distal radius fracture (DRF) is controversial. Studies with various range of removal rate were reported. The purpose of this systematic review was to investigate the frequency and the reasons of hardware removal over the world. We hypothesized that more frequent VLP removal contribute to better clinical outcomes.

METHODS

The authors searched all available literature in the PubMed and EMBASE databases for articles reporting on outcomes of treatment using VLP for DRF. Data collection included hardware removal rate, complication rate, clinical and radiological outcomes. We analyzed correlation between hardware removal rate with clinical and radiological outcomes.

RESULTS

A total of 3472 articles were screened, yielding 52 studies for final review. The mean hardware removal rate was 9%, ranging from 0 to 100%. The mean removal rate in studies from France, Norway, Japan, and Belgium was as high as 19%. The mean removal rate in studies from the US was low (3%). The most frequent reasons for extraction were routine removal (22%), tendon irritation or tenosynovitis (14%), hardware problem (14%), and patient' request (13%). Although routine removal and patient' request were not counted as complication, correlation between removal rate with complication rate was strong (rho=0.64, p<0.001). Correlations between clinical and radiological outcomes were week except for volar tilt (rho=-0.42, p=0.009).

CONCLUSIONS

There was a diversity of removal rate and reasons in the studies over the world. High frequent VLP removal did not contribute to better clinical outcomes.

Comparison of lateral and skyline fluoroscopic views for detection of prominent screws in distal radius fractures plating: results of an ultrasonographic study

INTRODUCTION

Extensor tendon rupture is a recognized complication of volar plate fixation of distal radius fractures due to screws protruding past the dorsal cortex. The aim of this study was to compare the Skyline view with traditional lateral fluoroscopic views using ultrasonography as a reference standard in the postoperative assessment.

MATERIALS AND METHODS

A monocentric prospective study was conducted to identify screws penetrating the dorsal cortex after volar plating of distal radius fractures.

PATIENTS AND INTERVENTION

Intraoperative anteroposterior (AP) and lateral views were used for group A (28 patients). AP, lateral and skyline fluoroscopic views were used for Group B (40 patients). Prominent screws were changed.

MAIN OUTCOME MEASUREMENTS

Ultrasound was done 6 months postoperatively to evaluate the number and length of prominent dorsal screws and any signs of extensor tenosynovitis.

RESULTS

The number of prominent dorsal screws exceeding 1 mm was 14 in group A (14.9%), and 16 screws (11.8%) in group B (p = 0.487). Average length of prominent dorsal screw was 1.9 mm (range 1-2.1 mm) for group A and 2.4 mm (range 1.1-4.8 mm) for group B (p = 0.534). The number of patients with extensor tenosynovitis was 11 for group A and 12 for group B (p = 0.66).

CONCLUSIONS

The Skyline view does not provide sensitive and reliable detection of the dorsal screw penetration. Intraoperative ultrasound might be a better tool to detect screw prominence.

LEVEL OF EVIDENCE

III, case-control study.

[Design of distal radius volar locking plates : Anatomical, surgical and biomechanical aspects]

The operative treatment of unstable distal radius fractures primarily aims for the anatomical reduction of the joint while addressing accompanying injuries. Anatomical reduction, stable fixation and early functional movement of the joint are the three cornerstones of modern treatment concepts of distal radius fractures. Distal radius volar locking plates play a major role in the treatment and rehabilitation of the most commonly occurring fracture in humans. This article outlines the different principles in the current design of available distal radius volar locking plates. The biomechanical aspects, anatomical findings and clinical evaluation that have influenced current design features and trends in new developments of the latest plates are emphasized. This is an ongoing process that is supported through the investigation and feedback of clinical science.

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

INTRODUCTION

Using network meta-analysis, we evaluated the 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 (CRPS) in distal radius fracture (DRF) patients.

MATERIAL AND METHODS

Following an exhaustive search of scientific literature databases for high quality studies, randomized controlled trials (RCTs) related to our study topic were screened and selected based on stringent predefined inclusion and exclusion criteria. Data extracted from the selected studies were used for statistical analyses using Stata 12.0 software.

RESULTS

A total of 17 RCTs, including 1658 DRF patients, were enrolled in this network meta-analysis. Among the 1658 DRF patients, 452 received bridging external fixation, 525 received non-bridging external fixation, 154 received K-wire fixation, 84 received plaster fixation, 132 received dorsal plating, 123 received volar plating, and 188 received dorsal and volar plating. When compared to bridging external fixation patients, there was no marked difference in the CRPS risk in DRF patients receiving different treatments (all p > 0.05). However, the surface under the cumulative ranking curves (SUCRA) for plaster fixation (77.0%) and non-bridging external fixation (71.3%) were significantly higher compared with the other five methods.

CONCLUSIONS

Our findings suggest that compared with bridging external fixation, K-wire fixation, dorsal plating, volar plating, dorsal and volar plating, plaster fixation and non-bridging external fixation might be the better treatment methods to reduce the risk of CRPS in DRF patients.

Unstable Distal Radius Fractures Treated by Volar Locking Anatomical Plates

INTRODUCTION

Fracture of the distal end of radius represents the most common fracture of the upper extremity accounting for 16-20% of all fractures. Plating is now emerging as the gold standard for management of distal radius fractures due to increased rate of complications such as malunion, subluxation/dislocation of distal radio-ulnar joint or late collapse of fracture. Procedures such as closed reduction and cast immobilization, ligamentotaxis with external fixator and percutaneous pin fixation are no longer acceptable.

AIM

The purpose of the study was to evaluate the functional and radiological outcome of unstable distal radius fractures treated with the volar locking plate.

MATERIALS AND METHODS

We reviewed 53 patients from January 2011 to December 2015, treated for unstable distal radius fractures using a volar locking compression plate. Standard radiographic and clinical assessment after 12 months (range 12-16 months) were measured and final functional and radiological outcome were assessed using the Modified Mayo wrist scoring system and Sarmiento's modification of Lindstorm criteria respectively.

RESULTS

There were 42 males and 11 females with an average age of 39.12±31.78 years (18-71 years). At the end of 12 months, 36 patients had an excellent radiological outcome and 10 patients had good radiological outcome as per Sarmiento's modification of Lindstorm criteria. Eleven patients had an excellent functional outcome and 26 patients had a good functional outcome as per modified Mayo wrist scoring system. There was one case of superficial wound infection which subsided with intravenous antibiotics.

CONCLUSION

The volar locking plate fixation helps in early mobilization of the wrist, restores anatomy, allows early return to function, prevents secondary loss of reduction and hence is an effective treatment for unstable fractures of the distal radius.