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

Osteosynthesis of an extra-articular distal radius fracture using a palmar locking plate with 4 epiphyseal screws (Gold Standard) versus 2 epiphyseal screws: Finite element analysis

Distal radius fractures are common injuries often requiring surgical intervention for effective management. This study compares the biomechanical stability of two osteosynthesis configurations using a palmar locking plate with either four or two epiphyseal screws for extra-articular distal radius fractures. Finite element analysis (FEA) was performed on nine antomical radius models to evaluate displacement, axial stiffness, peri‑implant stresses, and fracture risk using the Mohr-Coulomb criterion. Results demonstrated minimal differences in displacement between the two groups, with both configurations maintaining acceptable levels of stability under a 250 N load. Assemblies with four screws exhibited slightly higher axial stiffness (average 4362 N/mm) compared to two screws (average 3080 N/mm). Peri-implant stresses were generally higher in the two-screw models, yet remained within tolerable ranges. This study is the first to analyze a two-epiphyseal screw configuration, offering insight into the feasibility of reducing screw count without compromising stability. Potential benefits include fewer surgical complications, reduced material use, and lower costs. However, limitations such as the small sample size, simplified loading conditions, and absence of osteodensitometry warrant further experimental validation. The findings suggest that a two-epiphyseal screw assembly could serve as an effective alternative for distal radius fracture management, supporting its potential integration into clinical practice following experimental corroboration.

Soong Classification Using Radiographs Only Moderately Correlates With Distal Radius Plate Position on Computed Tomography

BACKGROUND

The Soong classification grades the prominence of volar locking plates used to treat distal radius fractures in relation to the volar rim. The basis of the classification scheme is that increasing plate prominence over the volar rim and distal radius watershed zone is associated with increased likelihood of flexor tendon irritation and need for plate removal. However, recent studies report mixed results on the predictive value of the Soong classification for these outcomes. We hypothesized that the decreased predictive accuracy of Soong classification is due to misclassification between Soong grades secondary to a suboptimal correlation between the Soong classification on radiographs (XRs) and computed tomography (CT).

METHODS

Fifty volarly displaced distal radius fractures treated with a volar locking plate in the international and publicly available ICUC database were reviewed. All cases with a postoperative XR and CT were included. Soong classification of the volar locking plate in relation to the volar ulnar rim was determined on both XR and CT by 2 independent, fellowship-trained hand surgeons using CT imaging as the gold standard. The distribution of Soong grades on XR and CT was compared using Pearson's χ2 test, and correlation was calculated using the Matthews correlation coefficient (MCC). A multi-class confusion matrix was used to calculate each grade's positive predictive value (PPV).

RESULTS

We found an MCC of 0.65, indicating only moderate correlation between the 2 modalities. Per individual Soong grade, the PPV was the highest for grade 2 (0.96), with lower PPVs for grade 0 (0.63) and grade 1 (0.60).

CONCLUSIONS

The distribution of Soong grades was significantly different when using XR versus CT (P < .001).

LEVEL OF EVIDENCE

Oxford Centre for Evidence-Based Medicine, diagnostic, level 2b.

Outcomes of Distal Radius Fractures in Solid Organ Transplant Recipients

PURPOSE

Distal radius fractures (DRFs) are one of the most common conditions that musculoskeletal providers treat. As the frequency of solid organ transplants (SOT) increases, these providers are often called upon to manage DRFs in these patients. These patients are at increased risk for osteopenia and osteoporosis, given the altered bone metabolism after SOT and frequent use of glucocorticoid and immunosuppressive medications. This study aimed to examine both surgical and nonsurgical treatment outcomes of DRFs in the SOT population and the prevalence of decreased bone mineral density.

METHODS

A retrospective review of patients treated at a single institution who had previously undergone SOT and subsequently sustained DRF between 2013 and 2022 was completed. Patients were excluded for incomplete documentation and treatment initiation at an outside institution. Demographic variables, clinical outcomes, organ transplant, steroid use, and second metacarpal cortical percentage were collected for both groups. A telephone survey with the QuickDASH questionnaire was conducted for all available patients.

RESULTS

A total of 34 DRFs in 33 patients were included in the analysis. Of these, 15 fractures in 14 patients underwent surgical intervention, and 19 fractures in 19 patients were managed nonsurgically. The following three adverse events were observed in the patients managed operatively: hardware failure, postoperative carpal tunnel syndrome, and tendon irritation. No reported treatment complications were recorded in the patients managed nonsurgically. Of the 33 included patients, 32 had radiographic evidence of decreased bone mineral density and five were receiving treatment for osteoporosis.

CONCLUSIONS

Management of DRFs in SOT patients is challenging, given their increased medical complexity. Decreased bone mineral density was nearly universal and undertreated in this patient population. Most of these patients in both groups had good or excellent functional outcomes with both surgical and nonsurgical management. Additionally, surgery was well tolerated with no reported anesthesia complications, wound-healing issues, or infections.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Impact of surgeon volume on the risk of complications following volar locking plating of unstable distal radius fracture

Complications following volar locking plating (VLP) of distal radius fracture (DRF) are frequent. Increasing evidence has shown an inverse relationship between increased surgeon experience and fewer complications in a variety of surgeries, and this study aimed to verify whether this relationship existed when specified in the DRF surgically treated with VLP. Patients with an unstable DRF surgically treated by VLP in our institution between January 2016 and December 2021 were included. Data on complication were obtained by inquiring the medical charts and the follow-up register, also the covariables for adjustment. Surgeon volume was defined by the number of VLP procedures within 12 months preceding index surgery, and its optimal cutoff was determined by constructing the receiver operator characteristic, in which high- or low-volume was dichotomized. The relationship between surgeon volume and risk of complications was investigated using a univariate and multivariate logistic regression model. Five hundred sixty-one patients were enrolled and operated on by 21 surgeons, with a median of 14 for each surgeon. The 1-year complication rate was 13.5%, with tenosynovitis (4.1%), carpal tunnel syndrome (2.7%), and complex regional pain syndrome type 1 (2.3%) being the most common. The optimal cutoff was 8, and 69.2% of patients were operated by high-volume surgeons, with a 7.5% incidence; 30.8% of the patients were operated by low-volume surgeons, with a 27.2% incidence. Low-volume was associated with an increase in the risk of general complications by 4.8 times (95% confidential interval, 2.9-8.2). Subgroup analyses showed that this trend was intensified for AO type C fracture (odds ratio, 5.9), slightly mitigated for type B (odds ratio, 3.7), but not significant for type A. The finding highlighted the need to maintain 8 cases/year to improve the complications of DRFs, and for severe cases, centralized treatment is recommended.

A meta-analysis comparing volar locking plates and cast immobilization for distal radius fractures in the elderly

BACKGROUND

The long-term outcomes (≥ 2 years of follow-up) of volar locked plate (VLP) fixation versus closed reduction and casting (CRC) for the treatment of displaced distal radial fractures (DRFs) remain unclear. This study aimed to conduct a meta-analysis comparing the long-term clinical outcomes of VLP and CRC in elderly patients (aged ≥ 60 years).

METHODS

A comprehensive search of PubMed, Web of Science, and Cochrane Library was performed to identify studies comparing the long-term outcomes of VLP and CRC for DRFs. Only randomized controlled trials (RCTs) with a mean follow-up duration of at least 2 years and participants aged 60 years or older were included. The risk of bias in the included studies was assessed. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE). Secondary outcomes included the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, EuroQol 5 Dimension 5-level score (EQ-5D-5 L), grip strength, and incidence of reoperation.

RESULTS

Four RCTs, comprising 423 patients, were included. The meta-analysis revealed that VLP fixation was associated with significantly improved outcomes compared to CRC in terms of PRWE score (pooled mean difference: -6.21; 95% CI: -10.28 to -2.15; p = 0.003), DASH score (pooled mean difference: -8.18; 95% CI: -13.35 to -3.01; p = 0.002), and grip strength (pooled mean difference: -6.63; 95% CI: 0.25 to 13.01; p = 0.04). There were no significant differences in EQ-5D-5 L score (95% CI: -0.08 to 0.05; p = 0.74) or incidence of reoperation (RR = 0.56; 95% CI: 0.22 to 1.42; p = 0.22).

CONCLUSIONS

A two-year follow-up of displaced DRFs in elderly patients showed no significant long-term clinical advantage of VLP fixation over CRC.

Incidence and risk factors of adverse events after distal radius fracture fixation with volar locking plates: retrospective analysis of 2,790 cases

BACKGROUND AND PURPOSE

 12-18% of patients encounter adverse events after distal radius fracture (DRF) surgery with volar locking plates (VLPs). Risk factors for which preventive measures could be administered are currently scarce. We aimed to examine the incidence of postoperative adverse events and assess the causes and risk factors for the adverse events after VLP fixation of DRFs.

METHODS

 We performed a single-center retrospective cohort study evaluating all adult DRF patients treated with VLP fixation between 2009 and 2019 at Helsinki University Hospital. Patients with previous disabilities or ulnar fractures, other than styloid process fractures, in the affected extremity were excluded. We examined each patient's treatment using the electronic medical records system and identified postoperative adverse events defined as any deviation from the ordinary postoperative course, showcasing clinical symptoms. We used multivariable binary logistic regression to assess the risk for adverse events.

RESULTS

 2,790 cases of DRF were included. The incidence of adverse events was 16%. Hardware complications (8.3%), predominantly intra-articular screws (4.9%), were the most commonly encountered adverse events. Other frequent adverse events included carpal tunnel syndrome (2.8%), tendon complications (2.8%), and surgical site infections (1.5%). In the multivariable analysis, smoking, higher body mass index (BMI), alcohol abuse, C-type fractures, residual intra-articular displacement, and dorsal tilt were found as risk factors for adverse events.

CONCLUSION

 The incidence of adverse events was 16% after VLP fixation of DRFs. We identified several new risk factors for adverse events, which included residual dorsal tilt, intra-articular dislocation, insufficiently corrected inclination, smoking, alcohol abuse, and higher BMI.

Do Social Deprivation and Surgical Volume Influence Outcomes Following Distal Radius Fracture Fixation?

BACKGROUND

Distal radius fractures account for nearly 25% of fractures in adults, with a trend toward operative fixation. The objective of this study was to assess the relationship between surgeon and hospital volume with complications following distal radius fixation.

METHODS

A retrospective study was performed using the New York Statewide Planning and Research Cooperative System database from 2009 to 2015. Outpatient claims were identified for distal radius fractures and surgery. The facility and surgeon's identifier were used to calculate annual procedure volume. The risk for infection, carpal tunnel surgery, and revision/hardware removal was analyzed, and Social Deprivation Index (SDI) was linked to each patient. Patient demographics and rate of complications were compared across hospital and physician volume.

RESULTS

A total of 14 748 patients were included, finding Federal and self-pay insurance associated with low-volume (LV) facility care and private insurance with high-volume (HV) facilities. The SDI for patients treated by LV surgeons and hospitals was significantly higher compared with HV providers. Low-volume facilities and surgeons had a higher 3-month risk of infection requiring reoperation. High-volume facilities were less likely to treat Hispanic patients, those with comorbidities, higher SDI, and with Federal or self-pay insurance.

CONCLUSIONS

Patients treated by LV surgeons and facilities had a higher risk of infection requiring surgery within 3 months than those treated by HV providers. Low-volume facilities were more likely to treat patients who were Hispanic, Federally insured, and with comorbidities and higher SDI than HV facilities, increasing their risk for disadvantaged care.

LEVEL OF EVIDENCE

Level III.

Time to surgical management of distal radius fractures: effects on health care utilization and functional outcomes

BACKGROUND

Distal radius fractures are common injuries. Open reduction and internal fixation with volar locking plates is the most common approach for surgical fixation. This study investigated the association between time to surgery and health care utilization, income, and functional outcomes among patients undergoing open reduction and internal fixation for distal radius fracture.

METHODS

We conducted a retrospective review of patients who underwent open reduction and internal fixation for isolated acute distal radius fracture between 2009 and 2019. Time to surgery was grouped as early (≤ 14 d) and delayed (> 14 d). We performed χ2 (or Fisher exact) and Wilcoxon rank sum (or Kruskal-Wallis) tests to provide statistical comparison of time to surgery by health care utilization and functional outcomes. Univariable and multivariable logistic regression analyses were performed to identify factors significantly associated with time to surgery. We included all significant univariables in the multivariable logistic regression model, which identified factors based on significant adjusted odds ratios (95% confidence intervals excluding the null) after we adjusted for confounding variables.

RESULTS

We included 106 patients, with 36 (34.0%) in the group receiving early treatment and 70 (66.0%) in the group receiving delayed treatment. Patients in the delayed-treatment group attended significantly more clinic visits and postoperative hand therapy sessions. The group with delayed treatment demonstrated significantly lower degrees of wrist flexion at the first follow-up, but this difference did not persist. Patients with higher estimated income (> $39 405 per annum) had lower odds of delayed surgery than those with lower estimated income (≤ $39 405).

CONCLUSION

Delayed time to surgery was associated with greater health care utilization and lower degrees of early wrist flexion. Access to care for lower-income patients warrants further evaluation.

Complications after volar plate synthesis for distal radius fractures

Purpose

Distal radius fractures (DRFs) represent up to 18% of all fractures in the elderly population, yet studies on the rate of complications following surgery are lacking in the literature. This systematic review aimed to quantify the rate of complications and reinterventions in patients treated with volar plate for distal radius fractures, and analyze if there was any predisposing factor.

Methods

A comprehensive literature search was performed on three databases up to January 2023, following PRISMA guidelines. Studies describing volar plate complications and hardware removal were included. A systematic review was performed on complications and rate of reintervention. Assessment of risk of bias and quality of evidence was performed with the 'Down and Black's Checklist for measuring quality'.

Results

About112 studies including 17 288 patients were included. The number of complications was 2434 in 2335 patients; the most frequent was carpal tunnel syndrome (CTS), representing 14.3% of all complications. About 104 studies reported the number of reinterventions, being 1880 with a reintervention rate of 8.5%. About 84 studies reported the reason of reintervention; the most common were patient's will (3.0%), pain (1.1%), CTS (1.2%), and device failure (1.1%).

Conclusion

The complication rate after DRFs is 13.5%, with the main complication being CTS (14.3%), followed by pain and tendinopathy. The reintervention rate is 8.5%, mainly due to the patient's willingness, and all these patients had plate removal. Correct positioning of the plate and correct information to the patient before surgery can reduce the number of hardware removal, thereby reducing costs and the risk of complications associated with VLP for distal radius fractures.

Infection Rate in Type I Open Distal Radius Fractures Surgically Treated >24 Hours Post-Injury: A Comparison Study

PURPOSE

To determine how time to surgical debridement and fixation affects infection and complication rate in type I open distal radius fractures by comparing patients treated within 24 hours with those treated >24 hours post-injury.

METHODS

A retrospective review identified 62 patients who sustained a type I open distal radius fracture that was treated surgically. Patients were stratified into groups based on time to surgical intervention. An additional analysis was performed on patients with an isolated type I open distal radius fracture treated as an inpatient or outpatient. The primary outcome measure was infection rate. Secondary outcome measures were complications, reoperations, and readmissions.

RESULTS

Thirty-eight patients underwent surgery ≤24 hours post-injury at an average of 14 hours. Twenty-four patients underwent surgery >24 hours post-injury at an average of 72 hours. There were a total of 9 complications in 8 patients (14.5%). The overall infection rate was 1.6%, with only 1 deep infection occurring in the group treated ≤24 hours post-injury. There were 7 reoperations (11.3%) and 1 readmission (1.6%). No differences were found between groups in any outcome measure. In the 27 patients with an isolated fracture, there were no differences in any outcome measure when treated as an inpatient or outpatient.

CONCLUSIONS

We suggest that type I open distal radius fractures could be safely treated surgically >24 hours post-injury without increased risk of infection.

Factors predicting complications following open reduction and internal fixation of intra-articular distal radius fracture

Objective

This study aimed to determine the incidence and predictors of the complications after open reduction and internal fixation (ORIF) of intra-articular distal radius fracture (IADRF) with a minimum follow-up of 12 months.

Methods

Medical records and outpatient follow-up records were retrospectively reviewed to collect medical, surgical, and complication data on consecutive patients who had undergone an ORIF procedure for an IADRF between January 2019 and June 2022. Data included demographics, comorbidities, injury, surgical characteristics, and laboratory findings on admission. A multivariate logistic regression model was constructed to identify the significant predictors, with a composite of any complications occurring within 12 months after the operation as the outcome variable and potentially a range of clinical data as the independent variables. The magnitude of the relationship was indicated by the odds ratio (OR) and the 95% confidence interval (CI).

Results

During the study period, 474 patients were included, and 64 had documented complications (n = 73), representing an accumulated rate of 13.5%. Among them, carpal tunnel syndrome was the most common, followed by tenosynovitis caused by tendon irritation/rupture, superficial or deep wound infection, complex regional pain syndrome (CRPS) type 1, radial shortening (≥4 mm), plate/screw problems, and others. The multivariate results showed the following factors significantly associated with increased risk of complications: experience of DRF surgery with <30 cases (OR: 2.2, 95% CI: 1.6-3.5), AO type C fracture (OR: 1.7, 95% CI: 1.2-2.9), initial lunate facet collapse of ≥5 mm (OR: 4.2, 95% CI: 1.4-8.9), and use of temporary external fixation before index surgery (OR: 2.4, 95% CI: 1.5-4.3).

Conclusions

These findings may aid in patient counseling and quality improvement initiatives, and IADRF should be directed by an experienced surgeon.

Risk Factors and Outcomes in Carpal Tunnel Syndrome Following Distal Radius Open Reduction Internal Fixation

PURPOSE

Carpal tunnel syndrome (CTS) is a common complication following the operative repair of distal radius fractures. It is unclear who is at risk of developing this complication in the postoperative period. This study sought to identify risk factors for developing CTS and to evaluate patient-reported outcomes in patients who develop postoperative CTS.

METHODS

A retrospective review of all distal radius fractures treated surgically at a single private academic center was performed from January 2007 to October 2019. Of the 4,487 patients, 68 were identified to have an ipsilateral carpal tunnel release within 6 months of the distal radius injury. Collected data comprised patient demographics, medical history, and functional outcome scores.

RESULTS

Carpal tunnel syndrome was more likely to develop in older patients (62.9 years vs 57.4 years). Sex, body mass index, smoking history, and the type of insurance were not found to be significantly different between the groups. Medical history of kidney disease, psychiatric conditions, and peripheral vascular disease were found to be associated with developing CTS. Patients who developed CTS had higher average Disabilities of the Arm, Shoulder, and Hand scores than patients without CTS (28.1 vs 20.0) at the final follow-up. In a multivariable analysis, patients who developed CTS were found to be older (Odds ratio, 1.03) and less likely to be smokers (Odds ratio, 0.46).

CONCLUSIONS

In our cohort, we observed that older patients were more likely to require carpal tunnel release following distal radius fracture. In addition, nonsmokers were more likely to require subsequent carpal tunnel release, probably as a result of confounding effects. Special care should be taken to monitor these patients for CTS in the postoperative period following a distal radius open reduction and internal fixation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

[Our preferred Approaches to the distal Radius]

This article describes our preferred approaches to the distal radius treating acute fractures and malunion by plating.

Short-term results and complications of the operative treatment of the distal radius fracture AO2R3 C type, planned by using 3D-printed models. Prospective randomized control study

PURPOSE

3D-printed models rapidly evolving in orthopaedic. Studies show that 3D-printed models used for preoperative planning improve a better understanding of fracture morphology and reduce operative time, blood loss and frequency of fluoroscopy, but there are no studies that investigated possible advantages in the outcomes and complications for the treatment of distal radius fracture (DRF). Our study aims to evaluate short-term functional results and complications between two groups treated DRF using 3D-printed models for preoperative planning and without. We hypothesize that the addition of 3D-printed models would improve functional outcomes and reduce complication rates.

METHODS

66 randomized cases of DRF AO/OTA C type were enrolled and divided into "Control group" (n = 33) and "3D-printed model group" (n = 33). Personalized 3D-printed models were created. The primary outcomes were: Patient-Rated Wrist Evaluation questionnaire, Quick Disabilities of the Arm, Shoulder and Hand Score questionnaire, and complications. The secondary outcomes were: measurement of the range of motions, grip strength, radiological evaluation, and the visual analogue scale. Assessments were measured at 6 weeks, 3 months, and 6 months intervals.

RESULTS

We found that the integration of the 3D-printed model in preoperative planning decreased complication incidence significantly - from 30.3% in the "Control group" to 6.1% in the "3D-printed model group", p = .022. But we did not find a difference in functional and radiological outcomes.

CONCLUSION

The 3D-printed models for preoperative planning surgically treating DRF AO/OTA C type can help minimize the complication rate, however, they can't improve functional outcomes in the short-term results.

LEVEL OF EVIDENCE

Level I randomized controlled study.

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.

Accuracy of osseointegrated screw-bone construct stiffness and peri-implant loading predicted by homogenized FE models relative to micro-FE models

Computational predictions of stiffness and peri-implant loading of screw-bone constructs are highly relevant to investigate and improve bone fracture fixations. Homogenized finite element (hFE) models have been used for this purpose in the past, but their accuracy has been questioned given the numerous simplifications, such as neglecting screw threads and modelling the trabecular bone structure as a continuum. This study aimed to investigate the accuracy of hFE models of an osseointegrated screw-bone construct when compared to micro-FE models considering the simplified screw geometry and different trabecular bone material models. Micro-FE and hFE models were created from 15 cylindrical bone samples with a virtually inserted, osseointegrated screw (fully bonded interface). Micro-FE models were created including the screw with threads (=reference models) and without threads to quantify the error due to screw geometry simplification. In the hFE models, the screws were modelled without threads and four different trabecular bone material models were used, including orthotropic and isotropic material derived from homogenization with kinematic uniform boundary conditions (KUBC), as well as from periodicity-compatible mixed uniform boundary conditions (PMUBC). Three load cases were simulated (pullout, shear in two directions) and errors in the construct stiffness and the volume average strain energy density (SED) in the peri-implant region were evaluated relative to the micro-FE model with a threaded screw. The pooled error caused by only omitting screw threads was low (max: 8.0%) compared to the pooled error additionally including homogenized trabecular bone material (max: 92.2%). Stiffness was predicted most accurately using PMUBC-derived orthotropic material (error: -0.7 ± 8.0%) and least accurately using KUBC-derived isotropic material (error: +23.1 ± 24.4%). Peri-implant SED averages were generally well correlated (R² ≥ 0.76), but slightly over- or underestimated by the hFE models and SED distributions were qualitatively different between hFE and micro-FE models. This study suggests that osseointegrated screw-bone construct stiffness can be predicted accurately using hFE models when compared to micro-FE models and that volume average peri-implant SEDs are well correlated. However, the hFE models are highly sensitive to the choice of trabecular bone material properties. PMUBC-derived isotropic material properties represented the best trade-off between model accuracy and complexity in this study.

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.

Risk Factors for Complications following Volar Locking Plate (VLP) Fixation of Unstable Distal Radius Fracture (DRF)

Objective

To evaluate the incidence and risk factors for complications following volar locking plate (VLP) fixation of unstable distal radius fracture (DRF).

Methods

This retrospective study identified patients who underwent VLP fixation of unstable DRF between 2017 and 2020 with a minimum 12-month follow-up assessments. By reviewing electronic medical records and follow-up notes, patients were categorized complication or noncomplication group. Differences in variables were detected by using univariate analyses, and independent factors were identified using multivariate logistic regression analysis.

Results

During this study period, 423 patients were included, and 63 (rate, 14.9%) complications in 58 patients were documented. Wound infection (17, 4.0%) was most common, followed in decreasing frequency by carpal tunnel syndrome (13, 3.1%), tendon rupture/irritation (10, 2.4%), complex regional pain syndrome (8, 1.9%), and plate/screw-related complications (5, 1.7%). In the univariate analyses, 18 variables were found to be significantly different (p < 0.05). Logistic regression analysis identified 5 independent factors, including being male (OR, 3.5; p = 0.014), type C fracture (vs. type A, OR: 2.7, and p = 0.035), general anesthesia (vs. regional, OR: 2.4, and p = 0.045), bone grafting (OR, 6.3; p < 0.001), and surgery performed by less experienced surgeons (OR, 3.1; p = 0.003). The goodness-of-fit of the final model was acceptable.

Conclusions

These factors will help surgeons individualize and stratify the risk of complications and help patients for risk counselling; especially, an informed clinical decision targeting those modifiable factors (anesthesia mode, bone grafting, and surgeon experience) can be considered, when indicated.

Outcomes of Type I Open Distal Radius Fractures: A Comparison of Delayed and Urgent Open Reduction Internal Fixation

BACKGROUND

Type I open distal radius fractures treated with open reduction internal fixation (ORIF) have demonstrated minimal risk of infection. For this reason, they may not require urgent surgical treatment. The purpose of this study was to evaluate the outcomes of patients with type I open distal radius fractures treated with delayed ORIF compared with urgent ORIF.

METHODS

We identified all Gustilo-Anderson type I open distal radius fractures that had undergone ORIF using volar plating over a 5-year period. Patients were stratified into those treated urgently within 24 hours and those scheduled for delayed surgery. Outcomes including functional scores, complications, reoperations, and radiographic measures were compared.

RESULTS

Twenty-four patients (17 treated urgently and 7 treated delayed) had open type I distal radius fractures. All patients were started on empiric antibiotics at initial presentation-patients in the delayed treatment group were prescribed oral antibiotics, whereas those admitted for urgent treatment received intravenous antibiotics. There were no infections in either group and a single reoperation in each group. The mean postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 29 (range = 0-77) and did not differ significantly between delayed (mean = 19) and urgent (mean = 38) treatment. Rate of complications and radiographic measures did not differ significantly between the groups.

CONCLUSIONS

Type I open distal radius fractures appear amenable to delayed outpatient ORIF provided that the wound is clean at the time of initial presentation and that antibiotics are initiated appropriately. Further prospective studies comparing delayed and urgent treatment strategies are warranted.

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.

Evaluation of the Incidence and Etiology of Unplanned Return to Operating Room Following Open Reduction Internal Fixation of Distal Radius Fractures

BACKGROUND

Distal radius fractures (DRF) are the most common upper extremity fractures in adults. The purpose of this study was to determine the incidence, causes, and independent predictors for unplanned return to the operating room (URTO) in a single institution within 90 days following distal radius open reduction internal fixation (ORIF).

METHODS

A retrospective study of 2933 consecutive patients from January 2015 to December 2019 who underwent distal radius ORIF was undertaken. Patients who returned to the operating room within 90 days of the index procedure were identified. Patients with planned return to the operating room for staged procedures were excluded, yielding a patient cohort of those with URTO. Demographic data, causes for reoperation, and final Quick Disabilities of the Arm, Shoulder and Hand DASH (QuickDASH) scores were collected.

RESULTS

Overall, 45 patients had URTO (1.5%) occurring a mean of 44 (6-89) days from the index procedure. Reasons for reoperation included nerve complications (n = 14), loss of fixation (n = 11), hardware complications (n = 9), wound complications (n = 7), and tendon complications (n = 4). Neurologic reasons for return included carpal tunnel release (n = 13) and ulnar nerve decompression (n = 1). QuickDASH scores were higher for URTO compared with control cohort at the final follow-up (33 [range: 0-91] vs 14 [range: 0-100], P < .01).

CONCLUSIONS

Mechanical hardware failure and neurologic symptoms were the most common reasons for URTO after distal fracture ORIF.

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.

Preoperative Predictions of Distal Screw Length for the Osteosynthesis of Distal Radius Fractures

Background: The objective of this study was to clarify whether anteroposterior dimension of the radius along the screw axis of a fixed angle volar locking plate (VLP) can be predicted from the width of the radius on the VLP. Methods: Sixty-nine wrists in 68 patients with distal radius fractures that underwent fixation with a fixed angle VLPs were evaluated. All patients underwent pre- and postoperative computed tomographic scans of the distal radius. The transverse width of the radius was measured at the position of the third screw hole from the proximal edge. The anteroposterior dimension of the radius (R) was measured along the axes of the distal screws. The distal row screw holes were defined as R1, R2, R3, and R4 from the radial to the ulnar side. Correlation analysis between the width and the anteroposterior dimension, and single regression analysis were performed for each screw hole. The correlations amongst the R values for the different distal row screws were also assessed. Results: The correlation coefficients between the transverse width and anteroposterior dimensions were 0.54, 0.58, 0.55, and 0.42 for R1, R2, R3, and R4 respectively (p < 0.05). The regression equations were R1 = 0.49W + 7.99, R2 = 0.47W + 11.8, R3 = 0.52W + 10.8, and R4 = 0.41W + 11.5 respectively. The correlation coefficients among anteroposterior dimensions were 0.85, 0.64, 0.59, 0.70, 0.61, and 0.80 for R1/R2, R1/R3, R1/R4, R2/R3, R2/R4, and R3/R4 respectively (p < 0.01). Conclusions: There were significant correlations in the anteroposterior dimensions amongst the distal row screw lengths. The regression equations used in this study may be helpful to predict the length of distal row screw and prevent complications due to inappropriate screw choices. Level of Evidence: Level III (Therapeutic).

Distal Radial Fracture Fixation in Adults using Intramedullary Elastic Wires Augmented with either Cast Immobilisation or External Fixation

Introduction:

The aim of this study was to evaluate the clinical outcomes following treatment of distal radial fractures using intramedullary elastic wires with a combination of either cast immobilisation or external fixation.

Materials and methods:

A total of 42 patients (24 females and 18 males) aged 40 to 78 years who presented with displaced and unstable, closed or grade I open, extra- and/or intra-articular fractures of the distal radius were included in the study. Twenty-seven fractures were AO/OTA Type A2-A3 and 15 Type C1-C2. Twenty-four patients were treated with antegrade intramedullary (IM) fixation with elastic wires followed by cast immobilisation and 18 required an external fixator in lieu of casting.

Results:

Final follow-up evaluation was conducted 12 months post-surgery using Sarmiento's modification of Lindstrom criteria and the demerit point system of Gartland and Werley. Successful fracture union was observed in all patients between eight to 14 weeks. Using Sarmiento's modification of Lindstrom criteria, 12 patients (28.6%) had excellent, 23 (54.8%) had good and 7 (16.6 %) had fair results. Based on the functional evaluation using the demerit point system of Gartland and Werley, 13 patients (31%) had excellent, 25 (59.5%) had good and four (9.5%) had fair results. None of the patients had a poor outcome using either of these criteria. Although a fracture union rate of 100% was confirmed clinically and radiographically, eight out of the 42 patients had minor complications in our study. One patient had uneventful IM migration of the wires, one patient reported a feeling of wire loosening, three patients complained of joint stiffness and soft tissue irritation, and three others reported on-going pain. The total cost of all implants used per case was less than INR 1,000.

Conclusions:

Good to excellent functional and radiographic outcomes with easy to manage complications are achieved with the techniques described. Patient selection is key to determining which particular method should be prescribed in a given case.

Analysis of Postoperative Complications and Related Factors Affecting Prognosis in 50 Patients with Distal Radius Fractures

Objective

To explore the postoperative complications of distal radius fractures and analyze the related factors that affect its prognosis.

Methods

The clinical data of 50 patients with distal radius fractures admitted to our hospital from October 2016 to September 2019 were retrospectively analyzed. All patients were followed up for 6–12 months, and their postoperative complications were recorded. Collect general patient information and related clinical data. During the follow-up process, Gartland and Werley wrist function scoring system was used to evaluate the prognosis of patients' joint function. Univariate analysis and multiple logistic regression models were used to analyze the related factors that affected the prognosis of patients.

Results

15 patients with postoperative complications were found during the follow-up period, with an incidence rate of 30.00%. Univariate analysis showed that the patient's age, cause of injury, AO classification, shortened deformity, whether it was osteoporosis, surgical method, whether it was combined with other fractures on the same side, whether it was comminuted fracture, and the time to start postoperative exercise were all related to the distal radius. The prognosis of fractures is related (P < 0.05). Multivariate logistic analysis showed that age, AO classification, surgical method, whether it was combined with other fractures on the same side, whether it was comminuted fracture, and the time to start postoperative exercise were the independent factors affecting the prognosis of distal radius fractures (P < 0.05).

Conclusion

The postoperative complications of distal radius fractures are higher. The prognosis is related to the patient's age, AO classification, surgical method, whether it is combined with other fractures on the same side, whether it is comminuted fracture, and the time to start postoperative exercise. Therefore, choosing an appropriate surgical method and starting exercise in time can effectively improve the recovery of the patient's wrist function and reduce the occurrence of complications.

Successful Closed Reduction of Distal Radius Volar Locking Plate Plastic Deformation with Associated Fracture: A Case Report

CASE

Distal radius fractures are among the most common orthopaedic injuries. The volar locking plate is now the most utilized internal fixation method for these fractures. There are few reports of mechanical failure of volar locking plates within the literature. In this case report, we describe successful closed reduction of traumatic volar locking plate plastic deformation with associated fracture. In addition, we discuss existing literature regarding plastic deformation of distal radius plates.

CONCLUSION

Traumatic, plastic deformation of distal radius volar locking plates with associated fracture may be managed nonoperatively with closed reduction.

Unplanned Return to the Operating Room in Upper-Extremity Surgery: Incidence and Reason for Return

PURPOSE

Complications after upper-extremity surgery are generally infrequent. The purpose of this study was to assess the rate of early unplanned return to the operating room (URTO) within 3 months after surgery) in upper-extremity surgical procedures. Our hypotheses were that the rate of URTO in upper-extremity surgery would be low and that surgically treated fractures would be at greatest risk for complications.

METHODS

We performed a retrospective review of all upper-extremity surgical procedures performed at a large academic practice of fellowship-trained hand surgeons over a 5-year period. A chart review was conducted of all patients who underwent a second surgery within 3 months of the initial surgery. The surgical billing database was queried to determine the incidence of URTO per Current Procedural Terminology code.

RESULTS

There were 422 Current Procedural Terminology codes with URTO out of a total of 62,608, for an incidence of 0.6%. The most frequently performed procedures were carpal tunnel release (10,674; 0.1% URTO), trigger finger release (4,549; 0.5% URTO), and open reduction internal fixation (ORIF) for distal radius fracture (2,728; 1.2% URTO). Procedures with the highest incidences of URTO were open reduction and internal fixation of the ulna (4.9%) and excision of the olecranon bursa (4.1%). Traumatic injuries were more commonly associated with URTO compared with elective procedures. Bony trauma and soft tissue trauma had URTO incidences of 1.4% and 1.1%, respectively, whereas bony elective and soft tissue elective cases were 0.6% and 0.4%, respectively.

CONCLUSIONS

The 90-day URTO rate after upper-extremity surgery was low but higher than previously reported 30-day reoperation rates. Elbow procedures were most likely to result in URTO, as were procedures relating to bony and soft tissue trauma. Based on these results, we are able to counsel patients that the most common procedures we perform have low URTO rates, but surgically treated fractures are at greatest risk.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Complications of Volar Plating of Distal Radial Fractures: A Review

Although the overall complication rate of volar plating approaches 15%, less than 5% require reoperation. Certain factors involving the patient, the fracture, and/or the surgeon may affect the overall complication risk. Patient factors, including body mass index greater than 35 and diabetes mellitus, may increase complication risk with volar plating, but older patient age does not seem to significantly alter risk.

Outcomes and complications of operative versus non-operative management of distal radius fractures in adults under 65 years of age

To compare the outcomes of non-operative versus operative treatment for distal radius fractures in patients aged from 18 to 64 years, we performed a retrospective analysis using the OptumLabs® Data Warehouse using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes of distal radius fracture. Of the 34,184 distal radius fractures analysed, 11,731 (34%) underwent operative management. Short-term complications within 90 days of fracture identified an overall complication rate of 16.6 per 1000 fractures and the 1-year upper extremity-specific complication rate was 287 per 1000 fractures. Overall, post-injury stiffness was the most common 1-year upper extremity-specific complication and was associated with operative management (202.8 vs. 123.4 per 1000 fractures, operative vs. non-operative, p < 0.01). Secondary procedures were significantly more common following non-operative management (8.7% vs. 43%, operative vs. non-operative, p < 0.01) with carpal tunnel release representing the most common secondary procedure. Operative management of distal radius fractures resulted in significantly fewer secondary procedures at the expense of increased overall 1-year complication rates, specifically stiffness.Level of evidence: III.

Towards optimization of volar plate fixations of distal radius fractures: Using finite element analyses to reduce the number of screws

BACKGROUND

Using fewer distal screws in volar plate fixation of distal radius fractures could reduce treatment costs and complications. However, there is currently no consensus on the ideal screw configuration, likely due to experimental limitations and its subject-specific nature. In this study, finite element analysis was used to investigate (1) if reducing the number of screws is biomechanically feasible and (2) if an optimal screw configuration is subject-specific.

METHODS

Validated subject-specific finite element models of 16 human radii with extra articular distal radius fractures and volar plate fixation with six distal screws were used as a baseline. 41 additional configurations with three to six distal screws were simulated for each subject. Axial stiffness and peri-implant strains around the distal screws were evaluated. Subject-specific optimum configurations were determined using a lower bound for the axial stiffness and minimizing peri-implant strains.

FINDINGS

Even using three distal screws led to only minor deterioration of the biomechanical properties in the best configuration (axial stiffness: -11.2%, peri-implant strains: -35.0%), but a considerable deterioration in the worst configuration (axial stiffness: -46.2%, peri-implant strains: +112.4%). The optimization showed that the ideal screw configuration is subject-specific and on average 1.9 screws could be saved based on the herein used optimization criterion.

INTERPRETATION

This study highlights that not only how many, but which screws are used in volar plate fixation of distal radius fractures is critical. Using a patient-specific selection of distal screws bears potential to save costs and reduce complications.

Practice Variation Among Hispanic American Orthopedic Surgeons in the Management of Geriatric Distal Radius Fracture

Introduction

There is a controversy in the management of distal radius fractures (DRF) and its criteria for surgical intervention on geriatric patients. The American Academy of Orthopedic Surgeons (AAOS) developed evidence-based guidelines for treatment of DRF. The aim of this study was to evaluate the current practice of Hispanic orthopedic surgeons in the management of geriatric DRF and examine their adherence to AAOS guidelines based on years of surgical experience.

Material & Methods

A survey was emailed to all orthopedic surgeons who live in Puerto Rico and treated DRF in their daily practice. Responses concerning demographic, management and clinical scenarios were evaluated. For each clinical scenario, treatment of choice was selected with the same fracture in a geriatric and young adult patient. Comparison between years of surgical experience and adherence to the AAOS guidelines was performed.

Results

A total of 65 surgeons responded the survey with 65% having >15 years in practice. A high consensus with AAOS guidelines for DRF was found. Use of preoperative radiographs was reported in all respondents, with an additional 12% routine use of preoperative computed tomography scans. Seventy-seven percent of respondents did not allow any range of motion (ROM) at immediate postoperative period, while 23% allowed active or passive ROM. Use of postoperative therapy was reported in 72.3%. Correlation between years of surgical experience showed a higher use of Vitamin C postoperatively for prophylaxis of Complex Regional Pain Syndrome among surgeons <15 years (P = 0.01). A general consensus trend toward operative fixation was noted among geriatric and young adult patients with the same fracture type in all clinical scenarios.

Discussion and Conclusions

This survey demonstrates a practice variation toward surgical management of geriatric DRF among Hispanic orthopedic surgeons; despite their compliance with the AAOS AUC guidelines. The geriatric DRF management does not vary significantly among years of surgical experience.

Management of Distal Radius Fractures: Comparison of Three Methods

Introduction

Distal radius fractures are the most common type of all extremity fractures. It is generally accepted that fractures with more than 2 mm step-off in the radiocarpal joint and greater than 10 degrees dorsal tilt should be treated surgically. However, the ideal technique for surgical management is still a point of debate. We performed cross-sectional data analysis to compare the results of three treatments methods - volar locking plate (VLP), external fixation (EF), Kirschner wire (K-wire) - in patients with distal radius fractures, and compared the clinical, functional, and radiological results

Materials and methods

Forty-four patients with distal radius fractures who underwent fixation with VLP, K-wire or EF between 2011 and 2013 were included in the study. All fractures were classified according to the Müller’s Arbeitsgemeinschaft für Osteosynthesefragen (AO) and Frykman's classifications. Routine radiographs were taken at the postoperative three weeks, six weeks, and three months. Radial inclination, volar tilt, radial length and ulnar variance were assessed on the follow-up visits and additionally at the follow -up for the study. The patient-based Disabilities of the Arm, Shoulder and Hand (DASH) score system and the physician-based MAYO scale were used to evaluate functional outcomes. Radiological and functional outcomes between three surgical modalities were compared and statistically analyzed.

Results

The average age at the time of surgery was 52 years (range = 35-69 years). Of a total of 44 patients, 28 were operated with VLP, 11 were with K-wire and five with EF. Satisfactory reduction was achieved in all fractures, and all of the fractures healed. DASH and MAYO scores were similar in all groups. Regarding radiographic parameters, there was no significant difference in radial inclination, volar tilt, radial length and ulnar variance between the treatment modality groups. When evaluated based on fracture geometry, the DASH score was significantly higher in the patients with AO23A type fracture compared to the patients with AO23B and AO23C type fractures. As for MAYO score, all AO23 groups had similar outcomes.

Conclusions

Surgical treatment options VLP, EF, and K-wire provide adequate fixation, satisfactory radiological, and functional results for the management of distal radius fractures of various severities. The optimal treatment approach depends on individual features, and the choice for an internal fixation or closed reduction method for the restoration of wrist function should be evaluated thoroughly by the operating surgeon considering the patient-related variations.

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.