Distal radius fractures and titanium volar plates: should we take the plates out?

Ultrasonographic evaluation of contact configuration between flexor pollicis longus tendon and the volar prominence of volar plate in patients with distal radius fracture

INTRODUCTION

We classified the contact configuration between the volar prominence of volar locking plate (VLP) and flexor pollicis longus (FPL) tendon using ultrasound (US) into indentation contact and smooth contact, and investigated whether the contact configuration is associated with the flexor tendon attrition.

MATERIALS AND METHODS

Ninety-four patients who underwent VLP removal were included in this study. We assessed pain using visual analogue scale, grip strength, and Disabilities of the Arm, Shoulder and Hand score for clinical evaluations, radial inclination, palmar tilt, ulnar variance, and Soong classification for radiological evaluations, and contact configuration using US at 1 year after VLP fixation. After these evaluations, we removed the VLP with observation for the presence of fibrillation or wear of FPL tendon substance. Subsequently, we classified the patients into either of FPL attrition and FPL intact group.

RESULTS

Twenty-eight patients had indentation contact configuration and 66 patients had smooth contact configuration. The kappa value for inter-observer reliability for the contact configuration was 0.78. Twelve patients were included in the FPL attrition group and 82 in the FPL intact group. There was no significant difference in clinical outcomes and Soong classification between the groups. However, palmar tilt of the flexor tendon attrition group was significantly lower than that of the flexor tendon intact group and the FPL attrition group showed significantly higher indentation contact configuration rate than the FPL intact group. FPL tendon attrition was diagnosed using the contact configuration on US with a sensitivity of 100% and specificity of 80%.

CONCLUSION

This study demonstrated that FPL tendon attrition was significantly associated with indentation contact on US with high sensitivity. Therefore, we recommend selective implant removal in patients with indentation contact configuration.

Volar locking plate removal after distal radius fracture: a 10-year retrospective study

INTRODUCTION

Distal radius fracture (DRF) is the most common upper extremity fracture. After the introduction of volar locking plate (VLP) fixation, treatment has shifted from conservative management to more operative management. The implant removal rate after VLP fixation in patients with DRF varies and the reasons for removal and associated patient characteristics have not been clearly defined. This study aimed to compare the characteristics of patients who underwent VLP with and without subsequent implant removal. Second, the rate of implant removal according to the implant position and type was investigated. Finally, we summarized clinical outcome with implant removal, the reasons for, and complications associated with implant removal.

METHODS

In this retrospective study, patient data were collected between January 1, 2008, and December 31, 2017. The study population was divided into two groups based on subsequent implant removal. Data on patient characteristics, such as age, sex, comorbidities, side of the fractured arm, the AO Foundation and Orthopaedic Trauma Association classification of the DRF, plate position grade based on the Soong classification type, type of inserted plate, insurance coverage, and treatment costs were collected. Furthermore, we investigated the reason for implant removal, clinical outcomes, and post-removal complications.

RESULTS

After applying the exclusion criteria, 806 patients with a total of 814 DRFs were included in the study. Among the 806 patients who underwent VLP fixation for DRF, 252 (31.3%) patients underwent implant removal. Among the patients undergoing implant removal, the mean age was 50.8 ± 14.0 years, 94 (37.3%) were male. The average time to implant removal from the fracture fixation was 12.1 ± 9.2 months (range 1-170 months). When comparing groups, patients who underwent implant removal were significantly younger and had fewer cases of diabetes, hypertension, and cancer history. According to the Soong plate position grade, the most common position was G1 in both groups. Although there was no significant difference (p = 0.075), more G2 cases were found in the removal group (15.0%) than in the retention group (10.2%). About 66.5% of the patients with implant removal had other health insurance as well as the national service, compared with 47% of the patients with implant retention. In total, 186 patients (73.8%) underwent implant removal despite being asymptomatic after the bony union. The patient satisfaction scores improved from 4.1 to 4.4 after implant removal, and 93% of the patients answered that they would choose implant removal again. Only 10% of the patients who underwent removal reported minor complications. No major complications were reported.

CONCLUSION

Although the implant removal was conducted without clinical symptoms in the majority of patients, overall patients presented improved functional outcomes with implant removal. The evidence is inconclusive regarding its necessity, however, implant removal after VLP fixation for DRF is not a challenging procedure and is not associated with major complications.

LEVEL OF EVIDENCE

Level IV.

Do mandibular miniplates increase the risk of complex fracture in facial trauma recurrence? Case series

Whether to conserve or remove miniplates, widely used in oral and maxillofacial surgery, has not been agreed on in the literature. Complications such as pain, infection, and screw exposure or loosening have already been largely described. We present the consequences of a trauma recurrence on a mandible with miniplates. The data of 13 patients who had a mandibular fracture previously surgically treated with miniplates (ten mandibular fractures and three mandibular osteotomies) were analysed. All the patients were male; the average age was 32 years (range, 20-64 years). The mechanism of the second trauma was assault in most of the cases. The average time between the first osteosynthesis and the new fracture was 35 months (range, 6-128 months). The fractures occurred at a distance from the miniplates in all the cases except two. No plate fracture was reported. We hypothesised that miniplates reinforced the underlying bone, protecting it from fractures, and transmitted the forces to areas anterior or posterior to the miniplates or to the condyle. Thus, the risk of mandible trauma recurrence should be taken into account in the indication of plate removal, and the biomechanical consequences of the conservation of the miniplates should be studied.

Flexor tendon repair after rupture caused by volar plate fixation of the distal radius

Volar plate fixation of unstable fractures of the distal radius is preferred by a majority of surgeons today. One known complication is the rupture of flexor tendons. The aim of this paper is to present flexor tendon ruptures after volar plate fixation analysing the clinical outcome after tendon surgery, aetiology, and methods of prevention. Seventeen consecutive ruptures in 14 patients were included. The incidence was 1.4%. Three patients declined tendon surgery. Eleven patients were treated with a free tendon graft. Only two patients showed excellent results regarding mobility in the thumb and/or fingers. Analysis of radiographs demonstrated sub-optimal placement of plate or screws in all cases. Rupture of a flexor tendon is a serious complication where the functional outcome after surgical reconstruction is uncertain. Early removal of the plate when the placement is sub-optimal or when local volar tenderness appears would probably prevent many ruptures.

The evolution of distal radius fracture management: a historical treatise

Distal radius fractures (DRFs) have been a common affliction for millennia, but their treatment is a more recent development resulting from human erudition. Although immobilization has served as the only available treatment for most of our history, many advances have been made in the management of DRFs over the last century as orthopedics has grown. Yet the topic remains hotly contested in the literature and, given the frequency of the injury, research continues to focus on it. This article traces the evolution of DRF treatment to provide a context for the future.