Incidence of Flexor Pollicis Longus Complications Following Volar Locking Plate Fixation of Distal Radius Fractures

Flexor Pollicis Longus Reconstruction After Rupture Following Distal Radius Fixation With Volar Locking Plate: A Technique Guide

Flexor pollicis longus rupture is an uncommon but potentially debilitating complication after volar locking plate fixation of distal radius fractures, occurring secondary to tendon attrition against the implant. This nature of tendon injury typically precludes primary repair. This paper will illustrate 2 reconstruction techniques, an interpositional tendon graft and a tendon transfer, that have been utilized successfully by the authors.

Study of the position of six volar locking plates for distal radius fracture relative to the watershed line

INTRODUCTION

Volar plate malpositioning in the treatment of distal radial fracture can lead to tendinitis or even tendon tear, especially when the plate position is very distal. We studied the impact of design on plate position in the distal radius. The primary aim was to compare the position of six volar wrist plates relative to the watershed line using the Soong classification. The secondary objectives were to assess the epidemiology of volar locking plate fixation within the administrative Département of Finistère (northwestern France) and to study whether the type of fracture played a role in plate position.

HYPOTHESIS

The plate design itself influences positioning relative to the watershed line on the Soong classification.

MATERIALS AND METHODS

A total of 2723 volar locking plate fixation cases were analyzed and categorized according to the Soong classification. Plates used were divided into six groups based on design: Zimmer Biomet®, Newclip Technics®, Stryker®, Synthes®, Medartis® and Medartis® Footprint. The number of Soong 0 + 1 plates (i.e., plates graded 0 and 1 taken together) was determined for each design, then compared using the Marascuilo procedure with a significance level of α = 0.05.

RESULTS

On the Marascuilo procedure, we found significant differences in the number of Soong grade 0 + 1 plates. The Zimmer Biomet and Newclip Technics® plates were significantly more often proximal to the watershed line than the Synthes and Medartis Footprint plates. Plate position with the Medartis® design was significantly more proximal to the watershed line than for its companion design, the Medartis® Footprint plate. The rate of volar locking plate fixation of distal radial fractures over the past 10 years increased in Finistère. Also, the type of fracture affected the choice of plate when different designs were available within a hospital center (Medartis® Footprint plate used in 2R3A fractures).

CONCLUSION

Our study highlights a significant difference in volar locking plate position relative to the watershed line between the various models available. Plate design is a deciding factor when treating distal radial fracture, to avoid impingement when implant removal is not routinely planned.

LEVEL OF EVIDENCE: 3

3D printing assisted MIPO for treatment of complex middle-proximal humeral shaft fractures

BACKGROUND

This study was designed to explore the clinical efficacy of 3-dimensional (3D) printing assisted minimally invasive percutaneous plate osteosynthesis (MIPO) technique by comparing the clinical outcomes with traditional open reduction and internal plating fixation (ORIF) for treating complex middle-proximal humerus fractures (AO 12C fracture type).

MATERIALS AND METHODS

The data of 42 participants who received a complicated middle-proximal humerus fracture from the beginning of 2018 to the end of 2022 were retrospectively analyzed. All patients were assigned to two groups: MIPO with detailed preoperative planning assisted by 3D printing technique (MIPO group), and traditional ORIF (ORIF group).

RESULTS

This study included 21 patients in the ORIF group and 21 patients in the MIPO group. All patients were followed-up for at least one year (mean: 16.12 ± 4.13 months), and no difference was observed in the range of shoulder joint motion (ROM), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores and Constant scores between the two groups. However, the occurrence of complications (surgical incision site infection, implant loosening, bone nonunion and radial nerve palsy) in ORIF group was remarkably higher compared to the MIPO group. All the cases achieved bone union within the MIPO group. Significant differences were found in surgical time, intraoperative blood loss and fracture healing time between the two groups.

CONCLUSION

Preoperative 3D printing assisted MIPO technique exhibits obvious advantages in high operational efficiency and low occurrence of complications, which is worthy of clinical application for treating complex middle-proximal humeral shaft fractures.

Optimizing Volar Tilt Restoration and Plate Position in Distal Radius Fractures

PURPOSE

Distal radius fractures are common and often treated surgically with a volar plate. A complication of volar plating includes tendonitis or rupture of the flexor pollicis longus (FPL) tendon. We hypothesize that failure to restore the volar tilt of the distal radius results in increased pressure on the FPL tendon.

METHODS

Ten fresh-frozen cadaveric wrists were assessed for this study. During testing, weights were suspended from the FPL tendon to stimulate muscle contraction. Reproducible fractures were created and fixed via volar plating. The contact force between FPL and the bone or plate edge was measured with a force transducer in 5 surgical conditions. These were assessed to evaluate whether failure to restore the volar tilt increases the pressure with a plate proximal or distal to the watershed line.

RESULTS

Significant increases in contact forces were observed between the control and both conditions in which volar tilt was not restored, with mean increases of 1.9 N and 3.0 N. A significant increase in the contact force was found when placing the plate distal to the watershed line with a mean increase of 2.03 N comparing the failure to restore volar tilt and after restoring the volar tilt. Significant increases in contact force were also observed between the dorsal plate condition, which failed to restore the volar tilt, and both plate conditions with placement distal to the watershed line, with mean differences of 0.94 N and 1.09 N, respectively.

CONCLUSIONS

Failure to restore the volar tilt in surgically treated distal radius fractures causes increased pressure on the FPL tendon. Plate placement distal to the watershed line also causes increased FPL tendon pressure over the plate edge.

CLINICAL RELEVANCE

This study demonstrates the importance of restoring the volar tilt of the distal radius in surgically treated distal radius fractures and confirms that plate placement distal to the watershed line will increase pressure on the FPL tendon.

Risk of Volar Locking Plate Removal After Distal Radius Fractures: Time-to-Event Analysis

PURPOSE

The primary purpose of this study was to describe the rate of volar locking plate (VLP) removal after distal radius fracture and how long it takes for the risk of VLP removal to stabilize. The secondary purpose was to describe the reasons for VLP removal and analyze the relationship between it and the Soong index.

METHODS

This was a single-center retrospective cohort study. Patients aged >18 years with distal radius fracture who underwent VLP fixation were included. Hardware removal, time until VLP removal, and the primary reason for removal were recorded. The implant prominence was measured as described by Soong. We used Kaplan-Meier curves and risk tables to describe the risk of VLP removal and variation over time. Multivariable logistic regression was used to assess the relationship between Soong grade and VLP removal.

RESULTS

A total of 313 wrists were included. There were 35 cases of VLP removal, with an overall incidence of 11.2% at 15 years of follow-up. The incidence rate was 1.2 per 100 individuals per year for the entire cohort. The risk of VLP removal decreased from 6.2% in the first postoperative year to 1.7% in the second year and 1.4% in the third year. Beyond that, the rate remained <1% per year throughout the follow-up period. The median hardware removal time was 11 months. The main reasons for VLP removal were tenosynovitis, implant-associated pain, and screw protrusion. We found no association between Soong grade and VLP removal.

CONCLUSIONS

Volar locking plate removal after distal radius fracture was more common in the first year after surgery and remained notable until the third year. Regular monitoring and patient education to assess possible complications related to hardware are important during this period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Higher Soong grade predicts flexor tendon issues after volar plating of distal radius fractures - a retrospective cohort study

BACKGROUND AND PURPOSE

Soong classification is used to estimate volar locking plate prominence and evaluate the risk for flexor tendon ruptures after surgical treatment of distal radius fractures (DRFs). However, the scientific community has questioned the Soong classification due to lacking evidence. Therefore, this study aimed to evaluate the accuracy of Soong grading as a predictor for flexor tendon issues and plate removal.

PATIENTS AND METHODS

We performed a retrospective single-center review of adult distal radius fracture patients treated with a volar locking plate between 2009 and 2019. In total, 2779 patients were included in the study. The primary outcome was a flexor tendon issue (flexor tendon rupture, tendinitis, or flexor irritation), whereas plate removal was a secondary outcome. Using Soong grade 0 as a reference, we used univariable and multivariable logistic regression to calculate odds ratios (OR) with 95% confidence intervals (CI) for flexor tendon issues and plate removal.

RESULTS

In total, 756 (27%) patients were graded as Soong 0, 1679 (60%) Soong 1, and 344 (12%) Soong 2, respectively. There were 32 (1.2%) patients with flexor tendon issues, of which 4 were flexor tendon ruptures, 8 tendinitises, and 20 flexor irritations. The adjusted OR for flexor tendon issues was 4.4 (CI 1.1-39.7) for Soong grade 1 and 9.7 (CI 2.2-91.1) for Soong grade 2. The plate was removed from 167 (6.0%) patients. Soong grade 1 had a univariable OR of 1.8 (CI 1.2-2.8) for plate removal, and Soong grade 2 had an OR of 3.5. (CI 2.1-5.8), respectively.

CONCLUSION

Flexor tendon ruptures are rare complications after the volar plating of DRFs. A higher Soong grade is a risk factor for flexor tendon issues and plate removal.

TRIAL REGISTRATION

The trial was retrospectively registered.

Using Trident distal radial locking plate to fix the fracture of distal radius volar rim

BACKGROUND

The volar locking plates have been widely used in a variety of distal radius fractures, but they still have several limitations when dealing with small fragments located around the watershed line with widely reported complications. The volar rim fragments play a critical role in radiocarpal joint stability and failing to secure the volar rim fragment usually results in carpal instability, subluxation, or even dislocation. This study investigates clinical outcomes in the use of a novel implant, the Trident distal radial (TDR) locking plate to treat distal radius fracture with the intermedium column edge (lunate fossa volar rim) fragment involvement.

METHODS

A retrospective study of 25 patients was conducted, all patients had intermedium column fractures with lunate fossa volar rim involvement and treat with the TDR between January 2016 and December 2019. The clinical assessment outcomes included VAS Pain, PRWE, and DASH scores. Objective measurements included ROM of the injured wrist and grip strength. Final radiographs were used to evaluate radial inclination, volar tilt, ulnar variance, and distal radioulnar joint instability. Secondary operations related to hardware complications were also recorded.

RESULTS

The outcome revealed that the mean VAS Pain Score was 1.3, mean DASH score was 10.5, and mean PRWE score was 9.3. Objective measurements revealed good ROM recovery and an 89% gripping strength recovery compared with contralateral hand. Radiographic measurements revealed good maintenance of volar tilt, radial inclination, and mean ulnar variance. There were no complications related to the implant and all fracture sites were union.

CONCLUSION

We believe that the TDR provided more stable fixation among distal radial fractures that predominantly involved the intermedial column and volar rim fragment, and allowing early rehabilitation. We could obtain excellent results in the wrist ROM, gripping power, and Pain Score (VAS).

3D printing-assisted surgery for proximal humerus fractures: a systematic review and meta-analysis

AIM

This study aimed to assess the efficacy of three-dimensional (3D) printing to conventional surgeries in proximal humerus fractures (PHFs).

METHODS

Eight databases were comprehensively searched for data on clinical characteristics and outcomes, including operation time, time to bone healing, blood loss volume, number of intraoperative fluoroscopies, the reduction rate of anatomic proximal humeri, Constant scores, Neer rating, loss of humeral head height, and complications. These data were compared between 3D printing-assisted versus conventional surgeries to learn the efficacy of 3D printing-assisted surgery.

RESULTS

3D printing-assisted surgery outperformed conventional procedures in operation time, blood loss volume, time to the union of PHFs, number of fluoroscopies, the reduction rate of anatomic proximal humeri, Constant scores, Neer rating, and complications.

CONCLUSION

3D printing-assisted surgery improves operation time, anatomic healing, pain, and motion, with less harm to patients.

Functional outcomes following fixation of a marginal distal radius fracture with two commonly used volar locking plates: a retrospective cohort study

Introduction

The volar locking plate has been widely used for unstable distal radius fractures to provide early recovery of wrist function. Volar plate prominence to the watershed line has been reported to be related to flexor tendon irritation, and avoid implant prominence in this area was suggested. On the other hand, marginal distal radius fracture patterns required the plate to cross the watershed line, making conflict over plate positioning on marginal distal radius fractures. This study compared functional outcomes in patients with marginal distal radius fractures treated with two different implants.

Materials and methods

A retrospective study was conducted, all patients who received a Synthes 2.4 mm LCP or an Acumed Acu-Loc VLP between January 2015 and December 2018 were reviewed. The marginal distal radius fracture pattern was the most distal horizontal fracture line within 10 mm of the lunate fossa’s joint line. The primary outcomes including patient-reported pain scores, range of motion, and grip strength were assessed. Secondary outcomes included patient-based subjective satisfaction scores of the injured wrist and hand function. The Mayo Wrist Score and the requirement for a secondary procedure related to hardware complications were also recorded.

Results

Forty-two patients met our inclusion criteria. Twenty-one patients were treated with the Synthes 2.4 mm LCP, and 21 patients with the Acumed Acu-Loc VLP. The primary outcome revealed that post-operative range of motion (P = 0.016) and grip strengths (P = 0.014) were significantly improved in the Acu-Loc VLP group. The MAYO wrist score in the Acu-Loc VLP group was also significantly better (P = 0.006).

Conclusions

Despite advances in implant designs, flexor tendon irritation or rupture is still a complication following distal radius’s volar plating. We believe the Acumed Acu-Loc VLP design provided better functional outcomes than the Synthes 2.4 mm LCP if appropriately and carefully placed into its designed-for position. This positioning results in promising patient satisfaction when treating marginal distal radius fractures.

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.

Analysis of Postoperative Complications and Related Factors Affecting Prognosis in 50 Patients with Distal Radius Fractures

Objective

To explore the postoperative complications of distal radius fractures and analyze the related factors that affect its prognosis.

Methods

The clinical data of 50 patients with distal radius fractures admitted to our hospital from October 2016 to September 2019 were retrospectively analyzed. All patients were followed up for 6–12 months, and their postoperative complications were recorded. Collect general patient information and related clinical data. During the follow-up process, Gartland and Werley wrist function scoring system was used to evaluate the prognosis of patients' joint function. Univariate analysis and multiple logistic regression models were used to analyze the related factors that affected the prognosis of patients.

Results

15 patients with postoperative complications were found during the follow-up period, with an incidence rate of 30.00%. Univariate analysis showed that the patient's age, cause of injury, AO classification, shortened deformity, whether it was osteoporosis, surgical method, whether it was combined with other fractures on the same side, whether it was comminuted fracture, and the time to start postoperative exercise were all related to the distal radius. The prognosis of fractures is related (P < 0.05). Multivariate logistic analysis showed that age, AO classification, surgical method, whether it was combined with other fractures on the same side, whether it was comminuted fracture, and the time to start postoperative exercise were the independent factors affecting the prognosis of distal radius fractures (P < 0.05).

Conclusion

The postoperative complications of distal radius fractures are higher. The prognosis is related to the patient's age, AO classification, surgical method, whether it is combined with other fractures on the same side, whether it is comminuted fracture, and the time to start postoperative exercise. Therefore, choosing an appropriate surgical method and starting exercise in time can effectively improve the recovery of the patient's wrist function and reduce the occurrence of complications.

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.

The efficacy of 3D printing-assisted surgery in treating distal radius fractures: systematic review and meta-analysis

Aim: To compare the efficacy of 3D printing-assisted surgery with routine surgery in the treatment of distal radius fractures to evaluate whether 3D printing technology has more advantages. Materials & methods: To retrieve all published studies that compared the efficacy of 3D printing-assisted surgery with routine surgery for distal radius fractures. Operation time, frequency of intraoperative fluoroscopy, blood loss and other outcomes were assessed. Results: The results suggested that 3D printing-assisted surgery was better than routine surgery in the fields of operation time, frequency of intraoperative fluoroscopy, and blood loss. Conclusion: In the treatment of distal radius fractures, 3D printing-assisted surgery may be superior to routine surgery.

Impact of Soong grading on flexor tendon ruptures following palmar plating for distal radial fractures

The purpose of this study was to evaluate flexor tendon injuries following palmar plating of distal radial fractures relative to the Soong grade. This retrospective cohort study included 113 patients who underwent palmar plate removal after a distal radial fracture between 2010 and 2016. In 13 patients, a greater than 50% injury of the flexor pollicis longus tendon was observed. Of these, nine patients were classified as Soong grade 2, four as Soong grade 1 and none as grade 0. The difference between the Soong groups was statistically significant (p = 0.006). Flexor tenosynovitis was present in eight patients (7%) and more likely in patients with a higher Soong grade (p = 0.026). We conclude that higher Soong grades are associated with significantly more flexor tendon complications. Therefore, elective removal of the palmar plate after union of the fracture should be considered in patients with Soong grades 1 and 2. Level of evidence: IV.