Treatment of comminuted distal radius fractures by resurfacing prosthesis in elderly patients

Role for Wrist Hemiarthroplasty in Acute Irreparable Distal Radius Fracture in the Elderly

Volar locking plates for distal radius fracture (DRF) in the elderly may show complications in the most comminuted osteoporotic cases. The authors provide criteria for DRF in elderly that may not be amenable to volar plating ("irreparable DRF") and review the current results of a preliminary series of wrist hemiarthroplasty for these injuries. Between 2011 and 2019, 28 wrists with acute irreparable intra-articular DRF were treated with wrist hemiarthroplasty (96% female, mean age 79 years). A total of 17 wrists with a mean follow-up of 32 months were reviewed. At follow-up, mean visual analog scale (VAS) pain was 1/10, mean forearm rotation arc was 148°.

Isoelastic resurfacing prosthesis for distal radius fractures: Outcomes in 24 cases with at least 2 years' follow-up

BACKGROUND

Unicompartmental resurfacing prostheses have been reported to be useful for treating comminuted fractures involving the distal radial joint surface in elderly patients with osteoporosis. However, the data on this method remain scarce and further evaluations are needed. The objective of this study was to evaluate the clinical and radiological outcomes after unicompartmental resurfacing prosthesis implantation in patients with distal radius fractures and at least 2 years' follow-up.

HYPOTHESIS

Outcomes with Prosthelast® are as good in the mid-term as in the short term.

MATERIALS AND METHODS

We studied 24 patients with type C fractures in the AO classification. The Prosthelast® prosthesis was implanted in each. Mean age was 78 years (60 to 91). There were 22 females. Three of the fractures were open. The patients were evaluated clinically using a visual analogue scale (VAS) for pain, ranges of motion at the wrist, and grip strength. In addition, functional scores were determined, and radiographs obtained.

RESULTS

Mean follow-up was 55.2 months (24-97). Mean tourniquet time was 61.9minutes (37-126). Mean motion ranges were 39° in flexion, 49° in extension, 74° in pronation, and 68° in supination. The mean VAS pain score was 2.1 (0-7). The mean Quick DASH was 39.8 (9.09-77), the mean PRWE was 42.7 (5-95), and mean grip strength was 38 (25-150). Painful motion limitation of the elbow was noted in a patient treated with total elbow prosthesis. Complex regional pain syndrome developed in 6 patients, and 5 patients required revision surgery. Asymptomatic perforation of the radial head occurred in 8 patients. No cases of peri-prosthetic osteolysis or osteoarthritis were noted. The prosthesis impinged on the lunate bone in 2 patients and on the scaphoid bone in one patient. Mean ulnar variance was +0.17mm (-1 to 7.5). Bone remodelling about the prosthesis was noted in all the patients, but 2.

DISCUSSION

Our data obtained after a mean follow-up of 55 months indicate that resurfacing prostheses have a role to play in the treatment of comminuted articular fractures in patients with osteoporosis. A long-term study is needed to further evaluate these results.

LEVEL OF EVIDENCE

IV; therapeutic.

[An Experience of Using a Distraction Plate for an Elderly Patient with a Highly Communited Intraarticular Distal Radius Fracture]

We performed open reduction and internal fixation using a distraction plate in two cases of elderly patients with highly communited intraarticular open distal radius fractures. There was no corrective loss of intraarticular fracture fragment in either case. The implant was removed in one case because bone union was achieved. The plate was retained in the other case, without the hope of implant removal. Neither case complained of any marked disturbance of activities of daily living (ADL), and there was no pain at the time of the final follow up period. However, there is a high possibility of limitation of the range of motion (ROM) of the wrist after implant removal, therefore we need to judge the indications carefully.

Wrist hemiarthroplasty for irreparable DRF in the elderly

INTRODUCTION

The authors update their results of wrist hemiarthroplasty for irreparable distal radius fracture in the elderly, at a minimum of 2-year follow-up.

MATERIALS AND METHODS

Between 2011 and 2018, 25 consecutive independent elderly patients (24 female, 27 wrists) were treated with wrist hemiarthroplasty for distal radius fracture at a single institution. The average age was 77 years (range 65-88). They all were independent at home. A total of 19 wrists were treated at the acute stage, and 8 secondary procedures. The average follow-up was 32 months (range 24-44).

RESULTS

There was no dislocation, loosening, infection nor removal of the implants. We observed 3 CRPS. At final follow-up, the average VAS pain was 1/10, mean forearm pronation/supination arc was 150°, and mean active flexion-extension arc was 60°. Average wrist extension was 36°. Mean grip strength was 68% of contralateral side. Mean Lyon wrist score was 74%. Mean Quick DASH score was 26%, and mean PRWE score was 25%.

DISCUSSION

Our data suggest that treatment of acute irreparable distal radius fracture in the independent elderly patient with a bone-preserving primary wrist hemiarthroplasty may be a viable option. Longer-term follow-up are needed to confirm these preliminary data.

Patient-accident-fracture (PAF) classification of acute distal radius fractures in adults

There is not enough evidence in the literature to support the use of any classification system for distal radius fractures (DRF) in adults. However, there is a need for identification of more homogeneous groups of patients with DRF so that the extent of preoperative workup and sophistication of treatment would best match the needs of the patient. The authors propose an innovative method to analyse and stratify acute DRF in adults. A one-page chart includes criteria related to the patient (P), the energy of the accident (A) and the pathology of the fracture (F). Analysis of the pathology includes not only the distal radius itself but also the associated ulnar and carpal lesions. Radiological suspicion of associated carpal of distal radio-ulnar joint ligamentous injuries is included in the analysis. The preliminary results of the use of this chart in 1610 consecutive adult patients (16-102 years) with unilateral acute DRF are presented. A total of six homogeneous groups of patients are described, and the relevance of this classification regarding the therapeutic options is discussed.

Hemi-arthroplasty for distal radius fracture in the independent elderly

INTRODUCTION

The authors report their experience with hemi-arthroplasty in irreparable fresh distal radius fracture in independent elderly patients as first-line treatment (12 fractures in 11 women; mean age, 74 years) or in second line after clinically disabling primary failure (4 fractures in 4 women; mean age, 78 years).

RESULTS

In the 12 primary surgeries, at a mean 32 months' follow-up, there were no complications requiring implant ablation; mean pain score was 1/10, flexion-extension 62°, Lyon Wrist score 75%, and Patient-Related Wrist Evaluation (PRWE) 22 points. In 2 of the 4 secondary surgeries, at a mean 24 months' follow-up, there were no complications requiring implant ablation; mean pain score was 2.5/10, flexion-extension 62°, Lyon Wrist score 58%, and PRWE 50 points: i.e., slightly poorer results than in primary surgery.

CONCLUSION

Salvage of complex fracture in independent elderly patients by hemi-arthroplasty, whether primary or secondary to failure, seems to be a considerable progress, to be confirmed in larger series.

Unicompartmental isoelastic resurfacing prosthesis for malignant tumor of the distal radius: A case report with a 3-year follow-up

We report a case of 74-year-old man in whom a unicompartmental isoelastic resurfacing prosthesis was used to reconstruct the distal radius after en-bloc resection of a malignant tumor. Thirty-nine months after the operation, on a visual analogic scale, pain score was 0/10 and range of motion was 25° of flexion, 5° of extension, 70° of pronation, 45° of supination, 20° of radial deviation, and 30° of ulnar deviation. The Quick DASH functional score was 72.72/100. With radiographic finding, the prosthesis was well-aligned, with no evidence of loosening but with slightly implant conflict with the lunate. This case report indicates that unicompartmental isoelastic resurfacing prosthesis seems a simple and reliable technique for distal radius reconstruction after en-bloc resection of malignant tumor.

Can Total Wrist Arthroplasty Be an Option for Treatment of Highly Comminuted Distal Radius Fracture in Selected Patients? Preliminary Experience with Two Cases

We present two case reports of successful primary shortening of the forearm and total wrist arthroplasty (TWA) using the new angle-stable Maestro Wrist Reconstructive System (WRS) for treatment of highly comminuted distal radius fracture in selected autonomous patients. In a 56-year-old male patient with adequate bone stock, insertion of the noncemented Maestro WRS was combined with ulnar shortening osteotomy. In an 84-year-old female patient with poor osteoporotic bone stock, insertion of the radial cemented Maestro WRS was combined with ulnar head resection. Both patients could resume their work without additional surgery after TWA. At the 1-year follow-up, there were no changes in position of either implant without signs of loosening, no impingement, and no instability of the distal radioulnar joint or the distal ulna stump. All clinical parameters (DASH score, pain through VAS, and grip strength) were satisfactory. Both patients reported that they would have the same procedure again. Further experience is needed to validate this concept.

Distal Radius Isoelastic Resurfacing Prosthesis: A Preliminary Report

Background Here we present a preliminary case series of unicompartmental isoelastic resurfacing prosthesis of the distal radius to treat comminuted articular fractures of osteoporotic elderly patients. Materials and Methods Our study included 12 patients, mean age 76 years, who presented with comminuted osteoporotic distal radius fracture. Because of the severity of injury and poor bone quality; osteosynthesis was not deemed to be a good option. Description of Technique The surgery was performed through a dorsal approach. The subchondral bone of the entire distal radial articular was excised and a unicompartmental prosthesis was applied. Results At an average follow-up of 32 months, the pain was 2.8/10, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) 37.4/100, grip strength in neutral 49.9%, in supination 59.0%, and in pronation 56.2% of the contralateral normal side. The wrist ranges of motion in flexion and extension were 56.1% and 79.3%, in supination and pronation 87.7% and 91.0% of the contralateral normal side. Two patients experienced a complex regional pain syndrome (CRPS) type II; these resolved spontaneously. One patient experienced distal radioulnar joint (DRUJ) stiffness, which improved after an ulna head resection. Finally, one patient required revision surgery after a secondary traumatic fracture. Radiographically; the average volar tilt was 9.8°; the average of radial inclination was 11.6°. Conclusion The concept of a unicompartmental isoelastic resurfacing prosthesis offers a promising option for the treatment of comminuted, osteoporotic distal radius articular fractures of elderly patients. Level of Evidence IV.

Primary Wrist Hemiarthroplasty for Irreparable Distal Radius Fracture in the Independent Elderly

Background Volar plating for acute distal radius fractures (DRF) in the elderly has been recommended. Some studies have suggested that open reduction with internal fixation (ORIF) in this situation results in frequent complications. Our purposes were to provide a definition of irreparable DRF in independent elderly patients and to review the results of a preliminary retrospective series of wrist hemiarthroplasty (WHA) in this patient population. Materials Between 2011 and 2014, 11 consecutive independent elderly patients (12 wrists) with irreparable intra-articular DRF were treated with primary WHA at the acute stage. A resection of the ulnar head was associated in nine wrists. A total of 11 wrists with more than 2 years of follow-up form the basis of this paper. Description of Technique The approach was dorsal longitudinal. An osteotome longitudinally entered the dorsal aspect of the fracture medial to the Lister tubercle. Two thick osteoperiosteal flaps were elevated radially and ulnarly in a fashion similar to opening a book. The distal radius articular surface was excised. The implant was pressed into the radial canal with attention to restoring distal radius length. The two osteoperiosteal flaps were brought back together and sutured so as to close, again like a book, the osseous and soft tissues around the implant. Results At mean follow-up of 30 months, average visual analog scale (VAS) pain was 1/10. Mean QuickDASH (Disabilities of the Arm, Shoulder and Hand) score was 32, and mean Patient-Rated Wrist Evaluation (PRWE) score was 24. Mean forearm rotation arc was 151°. Mean active flexion-extension arc was 60°. Mean active extension was 34°. Mean grip strength was 14 kg (64% of contralateral wrist). Mean Lyon wrist score was 73%. Bone healing around the implants was satisfactory in all but one case. Conclusions Out data suggest that treatment of irreparable DRF in the independent elderly patient with a bone-preserving WHA may be a viable option. Longer-term follow-up and comparative studies are needed to confirm the validity of this concept.