Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients

Patients Aged 80 or More With Distal Radius Fractures Have a Lower One-Year Mortality Rate Than Age- and Gender-Matched Controls: A Register-Based Study

Introduction

With a rapidly ageing population, the number of distal radius fractures (DRFs) in the elderly will increase dramatically. The aim of this retrospective register study was to examine the 1- and 5-year mortality in DRF patients aged 80 years or more and correlate the overall survival to factors not related to the fracture itself.

Material and Methods

Patients aged ≥80 diagnosed with DRFs in Lund University Hospital in Sweden in the period 2010-2012 were extracted from the prospective Lund Distal Radius Fracture register. One- and 5-year standardised mortality rates (SMRs) were calculated using the Swedish standard population as a reference. Medical records were searched for non-fracture-related factors including comorbidity, medications, cognitive impairment and type of living. Cox proportional hazard regression models were used to identify prognostic factors for all-cause mortality.

Results

The study cohort included 240 patients, with a mean age of 86. The overall 1-year mortality was 5% (n = 11/240) and the 5-year mortality was 44% (n = 105/240). The 1-year SMR was .44 (CI .18-.69, P < .01) when indirectly adjusted for age and gender and compared to the Swedish standard population. The 5-year SMR was .96 (CI .78-1.14). The patients' ability to live independently in their own home had the highest impact on survival.

Discussion

The 1-year mortality rate among the super-elderly DRF patients was only 44% of that expected. Possibly, a DRF at this age could be a sign of a healthier and more active patient.

Conclusions

The DRF patients aged 80 or more had a substantially lower mortality rate 1 year after fracture compared to the age- and gender-matched standard population. Patients living independently in their own homes had the longest life expectancy. Treatment should not be limited solely because of old age, but individualised according to the patient's ability and activity level.

Flexor pollicis longus tendon rupture: a case series on palmaris longus tendon graft reconstruction after volar plate fixation

Flexor pollicis longus (FPL) tendon rupture is a debilitating condition that can impair hand function. This case series study aimed to evaluate the outcomes of FPL tendon rupture and subsequent palmaris longus (PL) tendon graft reconstruction. Three cases of FPL tendon rupture in patients who had previously undergone open reduction and internal fixation with a volar plate were included. The surgical intervention involved volar plate removal, tenolysis and PL tendon graft reconstruction. Follow-up assessments showed gradual improvement in wrist function, with no post-operative complications or infections observed. These findings suggest that PL tendon grafting can be an effective surgical technique for FPL tendon rupture. Further research is needed to determine optimal surgical approaches and post-operative rehabilitation protocols for this condition.

Perioperative Morbidities in Distal Radius Fractures Treated Using Locking Plates in the Super-Elderly Population: A Retrospective Study

Purpose

Currently, there is no consensus on the treatment of distal radius fractures in the super-elderly population. The aim of this study was to evaluate the perioperative morbidities and the need for rehabilitation care after a distal radius fracture treated with locking plates among patients aged 85 years or older.

Methods

A retrospective study was conducted in all patients aged 85 years or older who underwent open surgical treatment using a locking plate for an isolated distal radius fracture from January 2013 to December 2018 at a level 1 trauma center. The occurrence of minor complications (tendinopathy, neuropathy, carpal tunnel syndrome, and infection), major complications (complex regional pain syndrome, nonunion, loss of reduction, intra-articular screw, and hardware failure), and the need for revision surgery were recorded. The need and timing of rehabilitation were also documented. A nested case-control study was performed to evaluate predictive factors associated with the need for inpatient rehabilitation.

Results

The majority of fractures were AO type A, numbering 88 (55.7%), followed by 64 type C (40.5%), and then 6 type B (3.8%). The overall complication rate among the 158 included patients was 17% (n = 26), with 12 (7.6%) having minor complications and 14 (8.9%) having major complications. Inpatient rehabilitation was required for one-third of the patients (n = 59), and 11 (7%) were definitively discharged to a nursing home. The place of residence before the fracture, American Society of Anesthesiologist score, and the type of anesthesia were associated with a need for inpatient rehabilitation.

Conclusions

Overall, this study suggests that perioperative morbidity of distal radius fractures treated using a locking plate is acceptable even in the super-elderly population. Nevertheless, given the frequent requirement for rehabilitation, the impact of age cannot be ignored.

Type of Study/level of evidence

Therapeutic IV.

Posttraumatic Arthritis After Combined Plating of Distal Radius Fractures AO Type C: A 7-Year Follow-up of 97 Cases

BACKGROUND

Volar locking plate fixation is the most common method of operative fixation of distal radius fractures (DRFs). For more complex cases, combined plating is an option for stabilizing intra-articular fragments. The prevalence of posttraumatic arthritis (PA) after an intra-articular DRF, and its relation to patient-reported outcome measures (PROMs), remains unclear. The purpose of this study was to study the prevalence of PA and its correlation to clinical outcome measures.

METHODS

We evaluated 97 consecutive patients with intra-articular DRF, operated with combined plating, 7 years postoperatively. The primary outcome measure was the prevalence of radiographic PA. Secondary outcome measures included visual analog scale (VAS) pain score, hand grip strength, wrist range of motion (ROM), Patient-Rated Wrist Evaluation (PRWE) score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Radiographic examination was performed between 1 and 7 years postoperatively.

RESULTS

The prevalence of PA was 29% at the 7-year follow-up. No correlation was found between PA and ROM, hand grip strength, PRWE, QuickDASH, VAS pain scores, or radiographic reduction. Median wrist ROM and grip strength were significantly inferior compared with the uninjured side. Hardware removal was performed in 51.5% of cases. There were 2 cases of tendon ruptures.

CONCLUSIONS

Combined plating can yield a good clinical outcome 7 years postoperatively and a low prevalence of PA. The presence of PA did not correlate to clinical outcome measures or to the accuracy of anatomical reduction 1 year postoperatively. The frequency of tendon ruptures was acceptable, but the high frequency of hardware removal is a concern.

Predictors for nonunion of unrepaired ulnar styloid fracture associated with distal radius fractures in patients treated with volar locking plate fixation and their effect on functional outcomes

INTRODUCTION

Nonunion of ulnar styloid fractures after radius stabilisation by volar locking plate (VLP) fixation without surgical fixation on ulnar styloid fractures is quite common. However, the factors affecting the nonunion of ulnar styloid fractures and their effect on functional outcomes in patients with distal radius fractures (DRFs) treated with VLP fixation are unclear.

HYPOTHESIS

The purpose of this study was to investigate the predictors affecting nonunion of unrepaired ulnar styloid fractures in patients with DRFs and the effect of nonunion and its predictors on functional outcomes.

MATERIALS AND METHODS

We retrospectively reviewed data from 84 patients with DRF who underwent VLP fixation. None of the accompanying ulnar styloid fractures were manipulated during the surgery. Postoperative evaluation included the measurement of the grip strength, wrist range of motion, and Disabilities of the Arm, Shoulder, and Hand score at a minimum of one year postoperatively. Patients were divided into the nonunion and union groups according to the presence of union of ulnar styloid fracture. Demographic and radiologic parameters, including age, sex, bone mineral density, location and displacement distance of ulnar styloid fracture, and fracture pattern of DRFs, were analysed to identify predictors of nonunion. Functional outcomes were compared between the two groups and were compared according to the presence of predictors of nonunion.

RESULTS

Univariate analysis revealed that the nonunion rate was higher in ulnar styloid non-base fractures, substantial displacement (≥1.9mm) of ulnar styloid fracture, and AO/OTA C-type DRF. However, multivariate logistic regression analysis showed that non-base fractures and substantial displacement were significant predictors. Accompanying ulnar styloid fracture nonunion and its predictors were found not to influence functional outcomes.

DISCUSSION

Substantial displacement and non-base fracture are predictive factors for nonunion of unrepaired ulnar styloid fractures after DRF treatment with VLP fixation. However, nonunion and its predictors do not influence the overall wrist function. These findings suggest that the ulnar styloid fracture accompanying DRF should not be considered a fracture affecting the wrist function when treating with VLP fixation.

LEVEL OF EVIDENCE

III, Retrospective, Case Control study.

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.

Lessons learned with the Cobra prosthesis in elderly patients with complex distal radius fractures-a retrospective follow-up study

INTRODUCTION

Recently, the Cobra prostheses were introduced in the treatment of distal radius fractures (DRF) of elderly patients. Fracture prostheses provide an alternative treatment option for complex fractures where conservative therapy seems not acceptable and osteosynthesis seems not possible. Data reporting the feasibility of the Cobra prosthesis are sparse. Therefore, this retrospective follow-up study investigated the clinical and radiological mid-term outcome of the Cobra implant in complex DRFs of elderly patients.

MATERIALS AND METHODS

Thirteen patients (mean age 73.5 years, range 65-87 years) were retrospectively evaluated with at least a 1-year follow-up after surgery. Objective and subjective clinical parameters as well as the radiological outcome and complications were analyzed.

RESULTS

The mean follow-up period was 31.2 months. Seven cases required a cemented prosthesis. The mean relative range-of-motion compared to the healthy side was 72.3% and 51.8% for extension and flexion, respectively, and 87.9% and 85.7% for pronation and supination, respectively. The mean grip strength was 78.3% compared to the non-operated side. Eight patients were very satisfied, five patients were partly satisfied with the result. The DASH, PRWE, MHQ and Lyon-Scores averaged 39.1, 36.2, 64.9 and 63.3 points, respectively. The mean VAS-Score for pain was 1.1 at rest and 3.2 during activities. Perioperative complications included one dissection of the extensor pollicis longus tendon, one heterotopic ossification, one radiocarpal dislocation and two cases of an ulnar impaction syndrome due to implant subsidence.

CONCLUSION

The prosthetic treatment of complex DRFs in elderly patients with the Cobra implant led to clinically and radiologically satisfactory mid-term results. The Cobra prosthesis still does not represent a gold standard but can be regarded as a feasible salvage option for complex DRFs when osteosyntheses may not be possible and non-operative treatment will lead to further functional restrictions and wrist pain during performing activities of daily life in high functional demand patients.

Do Better Postoperative Radiological Findings Predict Better Long-Term Functional Outcomes in Adults with a Displaced Distal Radius Fracture?

Purpose: The purpose of this study was to analyze the relationship of early radiological outcomes and longterm function in postoperative distal radius fracture patients. Methods: This was prospective cohort research, with information including sex, age, patient satisfaction, Gartland and Werley Score, and radiographic score. The statistics, including correlation analysis, ROC Curve, and multivariable binary Logistic Regression, were analyzed in SPSS. Results: In the entire 135 patients, 48 were male, 87 were female. ROC curve showed longterm Gartland and Werley Score, and early radiographic scores have an association to a certain extent with a Spearman correlation coefficient of 0.196 (p = 0.023) and an AUC of 0.639 (ROC Curve, p = 0.017). Patient satisfaction was mainly determined by the statistical modeling of 4.096×(palmar flexion−dorsiflexion)−4.378× (pronation−supination)−5.754 (Multivariable Binary Logistic Regression). Conclusion: Long-terms functional outcomes of postoperative distal radius fracture patients are not only influenced by radiographic score. Patient satisfaction is mainly concerning palmar flexion and pronation–supination of the wrist.

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.

Combined Plating of Intra-Articular Distal Radius Fractures, a Consecutive Series of 74 Cases

Background  The distal radius fracture (DRF) is the most common fracture in adults. For unstable intra-articular fractures, the choice of treatment is often operative. The optimal choice of fixation remains a matter of discussion. Question/Purpose  Can combined volar and dorsal plating, using a dorsal frame plate, achieve a good functional and radiographic 1-year outcome in intra-articular DRFs? Methods  In a retrospective cohort study, we evaluated 74 consecutive patients operated with combined plating using a volar plate and a dorsal frame plate. The DRFs were operated between 2016 and 2017 and all cases were AO type C intra-articular fractures. The primary outcome was patient-reported outcome measures including radiographic examination 1 year postoperatively. Secondary outcome measures included wrist range of motion, visual analog scale (VAS) pain scores, and hand grip strength. Results  The median patient-rated wrist evaluation score was 18 points; the quick disabilities of the arm, shoulder, and hand score was 14.8 points. The median Batra radiographic score was 88. Wrist extension was 76% of the uninjured side, flexion was 74%, pronation was 94%, and supination was 94%. VAS pain scores were 0 at rest and 2 during activity. Hand grip strength was 82% compared with the uninjured side. The radiographic outcome according to Batra did not correspond to the patient-reported outcome. Patients older than 60 years had significantly better QuickDASH (quick disabilities of the arm, shoulder, and hand) and PRWE scores (patient-rated wrist evaluation scores) and less pain during activity compared with younger patients despite similar radiographic outcome. There were no tendon ruptures; hardware removal was performed in 21 of the 74 patients. Conclusion  The radiographic outcome did not correspond to the functional outcome 1 year postoperatively. Older patients report less pain and better functional outcome compared with younger patients. There were no tendon ruptures and the frequency of hardware removal was acceptable. Complex intra-articular DRFs AO type C can be managed with volar and dorsal frame-plate fixation to restore distal radius anatomy and achieve a good functional outcome.

Volar locking plate: Age related outcomes and complications

BACKGROUND

There is no unanimity for the treatment of distal radius fractures in older people. The purpose of our study is to assess the efficacy of volar locking plate for the treatment of unstable distal radius fractures in older independent individuals.

METHODS

A retrospective comparative study of 105 patients. 58 patients were below the age of 55 years and 47 above the age of 55 years. Mean follow-up was 18.4 months in patients below the age of 55 years and 18.1 months above the age of 55 years. Wrist movements, complications, reoperations, grip strength, Visual Analogue Score (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (DASH) score, and Mayo wrist score were analysed.

RESULTS

There was no statistical difference in the wrist movements, grip strength, complications, reoperations, VAS, QuickDASH and Mayo scores. Mean grip strength under 55 was 84.1 and above 55 was 84.5 (p = 0.87). The complication rate was 19.1% above 55 years of age and 17.2% below the age of 55years (p = 0.79). The reoperation rate above 55 years was 8.5% and below 55 years was 8.6% (p = 0.50). Mean VAS under 55 years of age was 1.6 and above 55 years was 1.7 (p = 0.58). Mean Mayo score in under 55 was 80.7 and 80.1 in above 55 (p = 0.78). Mean Quick DASH score under 55 was 20.9 and above 55 was 21.0 (p = 0.97).

CONCLUSION

Our results indicate that outcomes in older independent patients are satisfactory with a comparable complication and reoperation rate with younger individuals. We conclude that a volar locking plate is a favourable modality for the treatment of unstable distal radius fractures in older patients.