Treatment of unstable distal radius fractures: non-invasive dynamic external fixator versus volar locking plate - functional and radiological outcome in a prospective case-controlled series

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.

Experience of Kapandji technique in treating Colles' fracture in central region of Vietnam

Introduction: Extra-articular fractures of the distal radius, known as Colles’ fractures, are very common. The optimal management of Colles’ fracture is still controversial. The Kapandji technique is one option for orthopedic surgeons to maintain reduced fractures, however, the effectiveness of this method is no clear consensus. This study aims to access Colles’ fracture treatment by the Kapandji technique with our experiences. Methods: This prospective study of 33 patients treated with three K-wires intra-focal fractures by the Kapandji procedure for Colles’ fractures at Hue University of Medicine and Pharmacy Hospital in Vietnam between February 2017 and May 2019. The functional outcome of the patients was assessed by the demerit score system of Gartland and Werley, and the quality of reduction was elevated on radiographic as well at 3, 6, 12, and 24 weeks postoperative. Results: 33 patients’ mean age is 54.64 ± 18.00; After 24 weeks of postoperative follow-up, 78.79% presented excellent, 21.21% good, and there are not any fair or poor cases on the functional outcome. All patients achieved complete fracture union at 12 weeks postoperative. The average immediate postoperative radial length was 9.85 mm, the radial inclination was 20.64°, and the volar tilt was 9.2°. Conclusion: The study emphasizes that the Kapandji technique in Colles’ fracture treatment is simple and possible to bring a satisfactory outcome and fast recovery.

Comparison of 24-Month Outcomes After Treatment for Distal Radius Fracture: The WRIST Randomized Clinical Trial

IMPORTANCE

Distal radius fractures (DRFs) are common injuries among older adults and can result in substantial disability. Current evidence regarding long-term outcomes in older adults is scarce.

OBJECTIVE

To compare outcomes across treatment groups at 24 months among adults with DRFs who participated in the WRIST trial.

DESIGN, SETTING, AND PARTICIPANTS

The Wrist and Radius Injury Surgical Trial (WRIST) randomized, international, multicenter trial was conducted from April 1, 2012, through December 31, 2016. Participants were adults aged 60 years or older with isolated, unstable DRFs at 24 health systems in the US, Canada, and Singapore. Data analysis was performed from March 2019 to March 2021.

INTERVENTIONS

Participants were randomized to open reduction and volar locking plate system (VLPS), external fixation with or without supplementary pinning (EFP), and percutaneous pinning (CRPP). The remaining participants chose closed reduction and casting.

MAIN OUTCOMES AND MEASURES

The primary outcome was the 24-month Michigan Hand Outcomes Questionnaire (MHQ) summary score. Secondary outcomes were scores on the MHQ subdomains hand strength and wrist motion.

RESULTS

A total of 304 adults were recruited for the study, and 187 were randomized to undergo surgery, 65 to VLPS, 64 to EFP, and 58 to CRPP; 117 participants opted for closed reduction and casting. Assessments were completed at 24 months for 182 participants (160 women [87.9%]; mean [SD] age, 70.1 [8.5] years). Mean MHQ summary scores at 24 months were 88 (95% CI, 83-92) for VLPS, 83 (95% CI, 78-88) for EFP, 85 (95% CI, 79-90) for CRPP, and 85 (95% CI, 79-90) for casting, with no clinically meaningful difference across groups after adjusting for covariates (χ23 = 1.44; P = .70). Pain scores also did not differ across groups at 24 months (χ23 = 2.64; P = .45). MHQ summary scores changed from 82 (95% CI, 80-85) to 85 (95% CI, 83-88) (P = .12) between 12 and 24 months across groups. The rate of malunion was higher in the casting group (26 participants [59.1%]) than in the other groups (4 participants [8.0%] for VLPS, 8 participants [17.0%] for EFP, and 4 participants [9.8%] for CRPP; χ23 = 43.6; P < .001), but malunion was not associated with the 24-month outcome difference across groups.

CONCLUSIONS AND RELEVANCE

The study did not find clinically meaningful patient-reported outcome differences 24 months after injury across treatment groups, with little change between 12 and 24 months. These findings suggest that long-term outcomes need not necessarily be considered in deciding between treatment options. Patient needs and recovery goals that fit to relative risks and benefits of each treatment type will be more valuable in treatment decision-making.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01589692.

Management of Acute Distal Radioulnar Joint Instability Following a Distal Radius Fracture: A Systematic Review and Meta-Analysis

Purpose

We sought to review the clinical outcomes of conservative and operative treatment options for acute distal radioulnar joint (DRUJ) instability associated with distal radius fractures in adult patients.

Methods

A systematic search of PubMed, MEDLINE, and EMBASE for articles published between 1990 and 2020 involving DRUJ instability associated with distal radius fractures was performed. The primary outcomes analyzed included clinical grip strength; range of motion; the disability of the arm, shoulder and hand (DASH) score; and the modified Mayo wrist score (MMWS).

Results

Of the 531 articles identified in the literature search, 8 met our defined criteria and were included in the final analysis. The cumulative sample size was 258 patients at a mean follow-up of 11.1 months (range, 3–16.9 months). Treatment groups included cast immobilization in supination, K-wire stabilization, and triangular fibrocartilage complex (TFCC) repair. Statistical analysis revealed no difference across groups in active flexion-extension or DASH scores. A significant decrease in grip strength was found in patients who underwent TFCC repair compared with that in those who underwent both cast immobilization (P = .04) and K-wire stabilization (P = .02). Furthermore, we found a significant decrease in active pronation-supination between patients who underwent TFCC repair and those who underwent cast immobilization (P = .03). Patients who underwent TFCC repair were also found to exhibit decreased MMWS as compared with those who underwent K-wire stabilization (P = .05). Overall, persistent DRUJ instability was only found in 4 patients (1.5%), without a significant difference between treatment groups.

Conclusions

This study suggests functional advantages of certain treatment modalities over others, with the range of motion being highest in patients who underwent cast immobilization and grip strength being highest in patients who underwent K-wire stabilization. However, the mean DASH scores showed no difference across all groups, calling into question the clinical need to pursue operative treatment via K-wire stabilization or TFCC repair over conservative treatment via cast immobilization. This study will hopefully serve as a foundation for future prospective studies to help improve and standardize treatment algorithms in patients with DRUJ instability and distal radius fractures.

Type of study/level of evidence: Therapeutic II.

Is volar locking plate superior to external fixation for distal radius fractures? A comprehensive meta-analysis

Objective

The aim of this meta-analysis of randomized controlled trials (RCT) and retrospective cohort studies (CS) regarding the use of volar locking plate (VLP) and external fixation (EF) in distal radius fractures was to determine whether there was any evidence that one treatment was superior to the other.

Methods

The meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Electrical databases (PubMed, EMBASE and the Cochrane library) were retrieved to find RCTs and CSs met the eligibility criteria. Two reviewers screened the studies, extracted the data and evaluated the methodological quality, and performed data analysis with RevMan 5.1. The publication bias was test by Stata 14.0. The Begg's and Egger's test were performed by Stata 14.0. The quality of evidence was graded according to the criteria of GRADE. We ultimately included ten RCTs and eleven CSs.

Results

A total of 1590 subjects were reported. Publication bias was detected by funnel plot in RCTs. VLP could provide better results such as DASH scores (RCT: MD = −6.12, 95%CI = −12.07–0.17; CS: MD = −6.43, 95%CI = −12.53–0.3), ulnar variance (RCT: MD = −0.81, 95%CI = −1.25–0.37) and infection rate (RCT: RR = 0.25, 95%CI = 0.10–0.65; CS: RR = 0.15, 95%CI = 0.06–0.40). There were no significant differences for G-W scores, VAS and grip strength between the VLP group and EF group. There was significantly greater loss of volar tilt (P = 0.01) and radial inclination (P = 0.02) in patients receiving EF, basing on the CSs.

Conclusions

VLP could provide better results, such as DASH scores, ulnar variance, volar tilt, radial inclination and infection rate. The use of VLP appear to be associated with better results of ROM (flexion, pronation, supination and radial deviation), radiographic parameters (volar tilt and radial inclination) and lower total complication rate and CRPS rate in CSs.

Level of evidence

Level 1, Therapeutic study.

Locking plate versus external fixation for type C distal radius fractures: A meta-analysis of randomized controlled trials

PURPOSE

Distal radial fracture is one of the most common fractures. Up to now, locking plates (LP) and external fixation (EF) are two conventional surgical approaches to type C radius fracture. Which method is superior has not yet reached a consensus. We try to assess the clinical effectiveness of the two interventions by this meta-analysis.

METHODS

We used network to search the PubMed, Embase, and Cochrane Medical Library of randomized controlled clinical trials about the type C distal radius fractures performed according to the search strategy mentioned in Cochrane Handbook 5.1.0 from Jan. 2005 to Jan. 2016. Patients in the experimental group were used LP, in the control group were included EF and other surgical approaches. Publication language was restricted to English. Studies that patient population and surgical indication did not define had been excluded. Studies must report at least one of the outcomes as follow: radial inclination, palmar tilt, ulnar variance, range of wrist flexion and extension, and range of wrist supination and pronation. The trials in which participants included children were excluded. We used Jadad study scores to appraise the study.

RESULTS

Seven studies included 162 patients (LP group) and 190 patients (EF group). We compared the radial inclination, palmar tilt, ulnar variance, range of wrist flexion and extension, and range of wrist supination and pronation. The radial inclination were revealed a difference favoring LP over EF [WMD = 1.84, 95% CI (0.17, 3.50), p = 0.03] and the palmar tilt and ulnar variance was no significant difference between the two groups [(WMD = 3.61, 95% CI (0.00, 7.23), p = 0.05; WMD = 0.05, 95% CI (-0.99, 1.09), p = 0.93]. The functional activities of range of flexion and extension and range of supination and pronation between the two groups was no difference [WMD = 10.04, 95% CI (-6.88, 26.96), p = 0.24; WMD = 12.53, 95% CI (-9.99, 35.06), p = 0.28].

CONCLUSION

Locking plate and external fixation is feasible to heal radius type C fracture. We found the small difference between the two groups on imaging examination. The locking plate has the advantage on maintaining reduction, however no significant difference regarding outcomes has been found between the two groups.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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