Volar Locking Plate Fixations for Displaced Distal Radius Fractures: An Evaluation of Complications and Radiographic Outcomes

Comparison between Volar Locking Plate and Kirschner Wire Fixation for Unstable Distal Radius Fracture: A Meta-Analysis of Randomized Controlled Trials

Objective  This study aims to compare the outcomes of volar locking plating (VLP) versus percutaneous Kirschner wires (K-wire) fixation for surgical management of unstable distal radius fractures. Methods  We systematically searched multiple databases, including MEDLINE, EMBASE, Cochrane Central till January 2022 for randomized controlled trials (RCTs) that met eligibility criteria. Following outcomes were evaluated at 6-week, 3-, 6-, and 12-month follow-up period: Disabilities of the Arm, Shoulder, and Hand (DASH) score, Patient Rated Wrist Evaluation (PRWE) score, grip strength, range of motion, and complication incidence. Meta-analysis was performed using random effects models and results presented as risk ratios (RRs) or mean differences (MDs) with 95% confidence interval. Results  Fourteen RCTs with 1,450 participants met the inclusion criteria. DASH scores were significantly better for VLP fixation at 6th week (MD = 19.02; p  < 0.001), 3rd (MD = 10.79; p  < 0.001), 6th (MD= 7.78; p  < 0.001), and 12th month (MD = 2.94; p  < 0.001) postoperation. At 3-month follow-up period, VLP treatment exhibited better grip strength (MD = - 10.32; p  < 0.001) and PRWE scores (MD = 8.78; p  < 0.001). There was a statistically significant early advantage in flexion, extension, pronation, supination, radial deviation, and ulnar deviation in the VLP group at 6-week follow-up, but at 1-year follow-up only significantly better extension was observed. At 1 year, radiographic outcomes were similar except for volar tilt favoring VLP fixation ( p  < 0.001). Superficial infections were more common in patients treated with K-wire (RR = 2.89; p  = 0.001), but there was no difference in total complications or reoperation rates ( p  > 0.05). Conclusion  This meta-analysis suggests that VLP fixation and K-wire fixation are both effective procedures, but existing literature does not provide sufficient evidence to demonstrate the superiority of either method. Although VLP fixation improves DASH score, extension and volar tilt at 12-month follow-up, the difference is small and unlikely to be noticeable to the patients.

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.

Osteocutaneous Radial Forearm Flap: Harvest Technique and Prophylactic Volar Locked Plating

Background

The osteocutaneous radial forearm (OCRF) flap is a variation of the traditional radial forearm flap with incorporation of an anterolateral segment of corticocancellous bone of the radius, periosteum, and overlying skin. The OCRF flap is indicated in traumatic injuries or extirpation defects with segmental bone loss and is well suited to foot and ankle reconstruction due to its thin pliable skin.

Methods

In this single-center case series, a retrospective review was conducted to identify patients who underwent OCRF free flap for foot and ankle reconstruction that required harvest of more than 50% of the cross-sectional area of the radius with prophylactic volar locked plating of the donor site. Outcome measures included flap failure rates, postoperative fracture, thrombotic events, time to follow-up, and time to full weightbearing. Flap harvest technique is extensively discussed.

Results

Six cases were included in this series. There were no flap failures or thrombotic events. Recipient site healing was confirmed in all patients, with partial distal skin paddle loss in one patient requiring operative debridement. No patients sustained donor site complications or functional impairment. Full lower extremity weightbearing was achieved at 12.4 ± 3.3 weeks after surgery.

Conclusions

The OCRF free flap transfer provides a reliable means of obtaining thin, supple soft tissue coverage with a large, vascularized segment of bone for reconstruction in the foot and ankle. Here, we describe use of more than 50% of the cross-sectional area of the radius with volar locked prophylactic plating. These updates expand use of this reconstructive technique.

Assessment of Technical Competence in Distal Radius Fracture Fixation by a Volar Locking Plate: A Global Delphi Consensus Study

PURPOSE

Volar locking plate fixation of distal radius fractures is a common orthopedic procedure and should be mastered by graduating orthopedic residents. Surgical education is transitioning from a traditional time-based approach to competency-based medical education. Valid and objective assessment is essential for successful transition. The purpose of this study was to develop a comprehensive, procedure-specific assessment tool to evaluate technical competence in volar locking plate osteosynthesis of a distal radius fracture.

METHODS

International orthopedic/trauma experts involved in resident education participated as panelists in a four-round online Delphi process to reach consensus on the content of the assessment tool. Round 1 was an item-generating round, in which the panelists identified potential assessment parameters. In round 2, the panelists rated the importance of each suggested assessment parameter and reached consensus on which to include in the assessment tool. Round 3 yielded specific assessment score intervals for specific bone and fracture models and is not reported in this study. In round 4, the panelists assigned weights to the assessment parameters on a 1-10 scale to determine how each parameter should have an impact on the overall results.

RESULTS

Eighty-seven surgeons, representing 42 countries, participated in the study. Round 1 resulted in 45 assessment parameters, grouped into five procedural steps. After round 2, the number of parameters was reduced to 39. After the final round, an additional parameter was removed and weights were assigned to the remaining parameters.

CONCLUSIONS

Using a systematic methodology, a preliminary assessment tool to evaluate technical competence in distal radius fracture fixation was developed. A consensus of international experts supports the content validity of the assessment tool.

CLINICAL RELEVANCE

This assessment tool represents the first step in the evidence-based assessment essential for competency-based medical education. Before implementation, further studies exploring validity of variations of the assessment tool in different educational contexts are required.

Outcomes of Flexor Pollicis Longus Reconstruction for Volar Plate Related Ruptures

Aim  A rare complication following volar plate fixation of a distal radius fracture is flexor pollicis longus (FPL) rupture. This study aims primarily to analyze the radiographic features and secondly to report the patient-reported outcomes of FPL reconstruction after volar plate fixation. Methods  Ten patients were retrospectively identified and contacted for follow-up. Seven patients participated in the study and completed the numeric rating scale (NRS) for pain, patient-reported outcome measurement information system-upper extremity (PROMIS-UE), and quick disability of arm, shoulder, and hand (QuickDASH) questionnaires at a median of 3.4 years following FPL reconstruction. Soong grade was determined on preoperative radiographs. Results  Six patients were classified as Soong grade 1 and two patients had a screw or wire protruding volarly. The median time to tendon rupture was 21.6 months. At final follow-up, the median NRS pain score was 0 (range: 0-7); the median PROMIS-UE score was 47.1 (range: 25.9-61); and the median QuickDASH-score was 12.5 (range: 4.5-75). Conclusions  The outcome of FPL reconstruction after volar plate fixation is highly variable. All ruptures in our cohort occurred in patients with plate positioning classified as Soong grade 1 and occurred at up to 3 years following distal radius fixation.

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.

Treatment Patterns for Distal Radius Fractures Before and After Appropriate Use Criteria Adoption

BACKGROUND

The purpose of this study was to determine agreement with the American Academy of Orthopaedic Surgery Appropriate Use Criteria (AUC) for distal radius fractures (DRFs), before and after their adoption, and secondarily determine predictors of operative management.

METHODS

A single-institution retrospective cohort study comparing patients treated either nonoperatively (115 patients) or operatively (767 patients) for DRFs between May 1, 2008, and May 1, 2018, by 8 hand surgeons was performed. Data included demographics, injury characteristics, DRF radiographic measurements, treatment rendered, and their appropriateness according to the AUC. Statistical testing used the Fisher and χ2 tests, t test, and multiple variable logistic regression, with a significance level of .05.

RESULTS

Overall, there was a significant increase in AUC agreement for operatively treated DRFs (82.7%-89.3%, P = .01), but no difference in agreement for nonoperatively treated DRFs (12.5%-10.7%, P = .77). Age <80 years, AO classes other than B, intra-articular displacement >1 mm, radial inclination <18°, high-energy mechanism of injury, and greater than 1 week to treatment were independent predictors of operative treatment. The area under the curve for the validated regression model using the aforementioned predictors was 0.82.

CONCLUSION

Agreement with AUC for DRFs increased after its adoption for operatively treated, but not for nonoperatively treated, fractures. In addition, a predictive model for operative treatment was developed and validated. Future studies may benefit from further model refinement and testing in other patient cohorts.

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.

The Impact of the Soong Index on Hardware Removal and Overall Reoperation Rates After Volar Locking Plate Fixation of Distal Radius Fractures

PURPOSE

This study sought to determine the impact of volar plate prominence on reoperation rates after open reduction and internal fixation of distal radius fractures with volar locking plates and to identify other factors associated with removal of hardware (ROH) or a reoperation.

METHODS

A retrospective study of patients who underwent distal radius open reduction and internal fixation between 2012 and 2016 at 2 level I trauma centers was conducted. Plate prominence was evaluated using the Soong index at the first postoperative visit. The details of patient demographics, fracture and plate characteristics, complications, and reoperations were recorded. Bivariate and multivariable regression analyses were used to identify factors associated with increased rates of ROH and overall reoperation.

RESULTS

A total of 732 (70.2%) of 1,042 patients completed follow-up at an average of 38.2 months, including 34 patients with bilateral operations, yielding 766 distal radius fractures. One hundred sixteen (15.1%) patients underwent reoperation at an average of 12.1 ± 13.6 months after the index surgery. Removal of hardware was the most commonly performed reoperation (77 patients, 10%). The multivariable regression analysis revealed significantly higher rates of ROH in Soong grade 1 or 2 patients (odds ratio 16, 95% CI 5.8-47; odds ratio 44, 95% CI 14-140, respectively) than in Soong grade 0 patients. Plate type, younger age, bilateral injuries, and concomitant procedures at the time of the index operation were all associated with increased risk of ROH. There were significant differences between individual surgeons the in rates of ROH (range 2.1%-22%) and overall reoperation (range 5.2%-36%). Compared with other hand surgeons, fellowship-trained hand surgeons had lower rates of ROH (8% vs 14%, respectively) and overall reoperation (12% vs 22%, respectively).

CONCLUSIONS

The rates of ROH and overall reoperation increase with increasing Soong grade. Plate type is independently predictive of future ROH. Older patients and those undergoing open reduction and internal fixation experience lower rates of subsequent reoperation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Peri-Implant Distal Radius Fracture: Proposal of a New Classification

A peri-implant fracture near the volar plate of the distal radius represents a rarity and can be associated with a mechanical failure of the devices. A literature review was conducted including all fractures that occurred around a volar wrist plate, which could be associated with an ulna fracture. All articles published until December 2021 were considered according to the guidelines presented in the PRISMA Statement. The search was conducted with the PubMed electronic database, Cochrane Database of Systematic Reviews, Medline, Embase, and Google Scholar. Only nine cases of these fractures were reported in the literature. The causes could be due to delayed union/non-union of the old fracture after low energy traumas, high energy trauma in patients with poor bone quality, or hardware mechanical failure. Furthermore, the literature review of peri-implant radius fracture shows different level of radius fracture and types of implant failure. In accordance with these different cases, a new classification of peri-implant fracture of the distal radius is proposed.

Surgical Outcomes Following Fixation of Peri-Implant Distal Radius Fractures: A Case Series

PURPOSE

The purpose of this study was to evaluate surgical outcomes following fixation of peri-implant distal radius fractures.

METHODS

A retrospective chart review was conducted of peri-implant distal radius fractures treated surgically at a large academic practice over 18 years. Patients were included if they had previously undergone open reduction and internal fixation of a distal radius fracture; subsequently sustained a fracture at, or adjacent to, the existing hardware; and then undergone revision fixation with the removal of hardware. Fractures were categorized into 3 groups: type A (distal to the implant), type B (at the level of the implant), and type C (proximal to the implant). Outcomes, including range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores, and radiographic alignment, were recorded at the latest follow-up visit.

RESULTS

Twelve peri-implant distal radius fractures that had undergone revision surgical fixation were identified. At the time of injury, the average patient age was 63 years. Ten occurred around a volar plate, 1 occurred around an intramedullary device, and 1 occurred around a dorsal plate. One fracture occurred proximal to previous hardware (type C), 9 fractures occurred at the level of previous hardware (type B), and 2 fractures occurred distal to previous hardware (type A). The median time from initial fixation to peri-implant fracture was 2.7 years. At a mean follow-up of 6 months after the removal of the hardware and revision fixation, radiographic alignment was within acceptable parameters for all injuries. At the final follow-up, the average wrist motion for flexion, extension, supination, and pronation were 66°, 66°, 83°, and 86°, respectively. The average DASH score was 6.7. Three patients experienced complications.

CONCLUSIONS

Although peri-implant fractures are infrequent complications following distal radius fracture internal fixation, outcomes of surgically treated peri-implant distal radius fractures are satisfactory with respect to radiographic alignment, range of motion, and function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Palmar plating of distal radius fractures : 3-year follow-up with titanium and PEEK plates give similar outcomes

A variety of different plate designs and materials are available to treat distal radius fractures. This study evaluates clinical results with a carbon fibre- reinforced (CFR)-polyether ether ketone (PEEK) plate in comparison to a standard titanium plate. Thirty-one distal radius fractures were included in this randomised controlled trial. Five fractures were classified as type A, 6 as type B and 20 as type C, in accordance with the AO classification. Patients were randomly allocated into two groups : 15 patients for titanium palmar plating (TPP) and 16 patients for PEEK palmar plating (PPP). Follow-up examinations were set at 2 weeks, 6 weeks, 3 months, 6 months and 3 years postop. In terms of wrist range of motion, radiological evaluation (alignment and fracture healing), DASH score (Disabilities of Arm, Shoulder and Hand), and VAS (visual analogue scale), no statistically significant differences were detected between the two groups, at all follow-up intervals. PEEK palmar plating and titanium plates give equivalent clinical and radiological outcomes up to 3 years follow-up.

SAFETY AND RELIABILITY OF CARBON-PEEK PLATE FOR THE TREATMENT OF DISTAL RADIUS FRACTURES: A REVIEW OF THE LITERATURE

INTRODUCTION

Distal radius fractures are one of the most common injuries. Open reduction and internal fixation (ORIF) are the most diffused between surgical treatments. Carbon-fiber reinforced (CFR) polyetheretherketone (PEEK) plates have been proposed to prevent effects linked to stainless steel or titanium alloy traditional plates, such as radio-opacity, mismatch of bone-plate elasticity modulus, corrosion, limited fatigue life, osseointegration.

OBJECTIVE

This review aims to evaluate the actual safety and reliability of CFR- PEEK plates to treat distal radius fractures.

METHODS

Electronic databases PubMed, Google Scholars, and Cochrane Library were searched in December 2020. Eligible studies were published in peer-reviewed journals. Three authors independently selected relevant articles and discussed those. Searching identified 13 titles and abstracts, 11 manuscripts were considered eligible for the full-text analysis. Of these 11 papers, 7 studies were included in our review.

RESULTS

215 patients were analyzed in this systematic review. The mean age of enrolled patients was 52,8 years. 34% were males and 66% were females. Fractures were classified according to AO/ASIF classification system. We reported 12 cases of complications specific to this device, such as intraoperative plate and screws rupture, erosive flexor tendons synovitis, and loosening.

CONCLUSION

CFR-PEEK distal radius plates are potentially an alternative to traditional ones. But we believe that the use of this device does not entail a significant advantage in the treatment of distal radius fractures, as safe and low-cost traditional devices are available. Further comparative studies are needed to demonstrate the superiority of carbon devices.

Outcomes following Distal Radius Fractures with Preexisting Ulnocarpal Abutment

Background  Due to the commonality of distal radius fractures (DRFs), the potential impact of ulnocarpal abutment (UA) on patient outcomes is significant, whether it developed after or prior to injury. It is, therefore, important to consider whether preexisting UA has any impact on outcomes after an acute DRF. Questions/Purpose  The aims of this study were to determine if differences were present in (1) pain at final follow-up, (2) complications, and (3) unintended operations in patients with DRFs and either without or with preexisting radiographic UA. Methods  A single institution retrospective cohort study comparing patients treated either nonoperatively (43 patients) or operatively (473 patients) for DRFs between 5/1/2008 to 5/1/2018 was performed. Data included demographics, prior wrist pain or surgery, ulnar variance, select treatment data, and presence of pain, complication, or unintended operation by final follow-up. Statistical testing used Fisher's exact test and chi-squared test, with a significance level of 0.05. Results  The prevalence of preexisting UA was 14.0 and 15.6% in the nonoperatively- and operatively treated groups, respectively. In nonoperatively treated patients without or with UA, no differences in pain (37.8 vs. 33.3%, p  = 1.00) or complications were seen (13.5 vs. 50.0%, p  = 0.07). A higher unintended operation rate for nonoperatively treated DRFs with UA, compared with those without, UA was seen (5.4 vs. 50.0%, p  = 0.01). No differences in pain, complications, or unintended operations were seen between those without and with UA in the operatively treated group. Conclusion  Preexisting UA is not associated with pain, complications, or unintended operations after operative treatment of DRFs. Prospective studies further evaluating outcomes in nonoperatively treated DRFs with UA may be beneficial.

Plate Fixation of Distal Radius Fractures: What Type of Plate to Use and When?

There are several options for plate fixation of distal radius fractures. Volar plating has broad applicability and consistent outcomes, and thus is the most commonly used plate type. Dorsal plates are advantageous for specific fracture patterns, and can provide direct fracture reduction and buttressing, but may be prominent and can cause tendon irritation. Bridge plates offer an alternative to external fixation while avoiding the complications with prominent hardware, because they span highly comminuted fractures and can be used for immediate weight bearing; however, they require plate removal. Choice of plate fixation should depend on fracture type, patient factors, and surgeon experience.

Interpretations of the Term "Watershed Line" Used as Reference for Volar Plating

Objective  The objective of this systematic review is to provide an overview of all interpretations of the definition of the watershed line used in literature. Methods  The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed for this review. A comprehensive search was performed for definitions of the watershed line given in literature. A total of 32 studies giving an explicit interpretation of the definition of the watershed line or anatomical reference for plate positioning in writing and/or imaging were included. Results  In 32 studies, we found eight different landmarks used to refer to the watershed line or correct plate positioning. Five studies used two different soft tissue landmarks. Six different bony landmarks were described in 24 studies. These could further be subdivided into three anatomical interpretations, described in seven studies, in which the term "watershed line" is explained as a distinguishable anatomical line, and two surgical interpretations, described in 15 studies, which are purely reflecting the optimal location of the volar plate. One interpretation of the watershed line described in two studies combined both anatomical and surgical landmarks. Conclusion  The (mis)interpretation of the definition of the term "watershed line" as described by Orbay is subject to the type of landmarks and purpose used: soft tissue or bony landmarks and an anatomical or a surgical purpose. A clear distinction can be made between interpretations using bony landmarks, as the true watershed line is defined and definitions using soft tissue landmarks, which might represent the reference points surgeons use in clinical practice.

Risk Factors for Hardware-Related Complications After Olecranon Fracture Fixation

The aim of this study was to evaluate risk factors for symptomatic hardware and removal of hardware (ROH) after olecranon open reduction and internal fixation (ORIF) and to assess differences between olecranon locking plate and screws (P&S) or tension band (TB) wire cohorts. The medical records of 331 patients with olecranon fractures treated at two academic level I trauma centers with ORIF from 2012 to 2016 were reviewed. A total of 189 patients were included in the study. Complications, ROH, and subsequent surgery were assessed and compared between cohorts. There were 124 cases in the P&S cohort and 65 in the TB cohort. The overall reoperation rate was 31.2% (59 of 189). The overall incidence of ROH for all cases was 29.1% (55 of 189). Patients who required ROH or developed symptomatic hardware were significantly younger than those who did not (P&S, P<.003; TB, P<.004). Age and body mass index (BMI) were associated with ROH plus symptomatic hardware after P&S. Age (but not BMI) was associated with ROH/symptomatic hardware after TB. Measured hardware prominence was not associated with ROH or ROH plus symptomatic hardware for either the P&S or the TB cohort. Risk factors including patient age and BMI were found to be significantly associated with hardware-related complications. [Orthopedics. 2020;43(3):141-146.].

The Watershed Line of the Distal Radius: Cadaveric and Imaging Study of Anatomical Landmarks

Background  Placement of volar plates remains a challenge as the watershed line may not be an easy-identifiable distinct line intraoperatively. Objectives  The main objective of this article is to define how anatomical landmarks identifiable upon the volar surgical approach to the distal radius relate to the watershed line. Methods  We identified anatomical landmarks macroscopically upon standard volar approach to the distal radius in 10 cadaveric forearms and marked these with radiostereometric analysis (RSA) beads in cadaveric wrists. The RSA beads were then referenced against the volar osseous structures using quantification of three-dimensional computed tomography and advanced imaging software. Results  The mean measurements were the radial and ulnar prominences 11.1 mm and 2.1 mm proximal to the joint line of the distal radius, respectively. The interfossa sulcus was 0.3 mm proximal and 3 mm dorsal to the ulnar prominence. The watershed line was between 3.5 (minimal) and 7.6 (maximal) mm distal to the distal line of insertion of the pronator quadratus. Conclusion  The watershed line is situated distal to the pronator quadratus, but with a wide variability making it an impractical landmark for plate position. The osseous ulnar prominence is a good anatomical reference for safe plate positioning, as it is located on the watershed line and easily palpated at surgery. One should keep in mind the sulcus-the point on the watershed line where the flexor pollicis longus runs-can be situated just proximal to the ulnar prominence. Clinical Relevance  To provide anatomical landmarks that are easy to identify upon surgical approach without the direct need for intraoperative imaging.

Distal Radius Volar Plate Design and Volar Prominence to the Watershed Line in Clinical Practice: Comparison of Soong Grading of 2 Common Plates in 400 Patients

PURPOSE

To compare plate positioning in clinical practice of 2 commonly used volar locking plate designs with respect to the watershed line as classified by the Soong grading system.

METHODS

For this retrospective study, we included a total of 400 patients who underwent open reduction and internal fixation between May 2013 and February 2018. Cohort 1 was defined as patients treated with distal volar radius (DVR) plates during this period. Cohort 2 comprised 200 patients who had volar plate fixation with variable angle locking compression plates (LCP) during the same period. Standardized lateral wrist radiographs were categorized into Soong grade 0, 1, or 2.

RESULTS

In cohort 1, 87 plates (43.5%) were not prominent volar to the watershed line, grade 0; 95 plates (47.5%) demonstrated grade 1 prominence; and 18 plates (9.0%) demonstrated grade 2 prominence. In cohort 2, 63 plates (31.5%) were grade 0; 103 plates (51.5%) were grade 1; and 34 plates (17%) had grade 2 prominence on, and volar to, the watershed line. These radiographic results show a greater incidence of volar plate prominence with respect to the watershed line, as defined as Soong grading, in cohort 2.

CONCLUSION

This study shows that the use of the variable angle LCP plate is associated with more prominent volar positioning with respect to the watershed line compared with the DVR plate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Older Patient Preferences for Internal Fixation after a Distal Radius Fracture: A Qualitative Study from the Wrist and Radius Injury Surgical Trial

BACKGROUND

Distal radius fracture treatments provide similar functional outcomes. It has been hypothesized that the use of internal fixation is increasing because of physician preferences. The multisite randomized Wrist and Radius Injury Surgical Trial provides a unique opportunity to examine patient preferences in the absence of surgeon influence. The authors' objective was to investigate patient preference for internal fixation even after being informed of the equipoise among treatments.

METHODS

The authors performed 30 semistructured interviews with older individuals, all older than 60 years, approached at their institution for the Wrist and Radius Injury Surgical Trial. The authors' sample included three groups: those with a preference for internal fixation (n = 11), those with preference for nonsurgical treatment (n = 6), and those without a preference who consented to surgical randomization (n = 13). We used grounded theory for data collection and analysis.

RESULTS

All participants indicated their chief concern was regaining full function. Patients based their preferences for internal fixation on multiple values, including obstacles to recovery, autonomy, aesthetics, and pain relief. Some patients who did not select internal fixation reflected on their experiences, questioning whether they would have had a potentially different outcome with internal fixation treatment.

CONCLUSIONS

Without evidence for a superior treatment, patients focus on factors that pertain to recovery rather than outcomes, with most preferring the volar locking plating system. To best align with patient values, physicians should focus their discussion with patients on aspects of the recovery period rather than functional outcomes. Evidence from the Wrist and Radius Injury Surgical Trial will provide high-level information about patient-reported, functional, and radiographic outcomes.