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Surgical Treatment of Distal Radial Fractures with a Volar Locking Plate Versus Conventional Percutaneous MethodsA Randomized Controlled Trial
Alexia Karantana, FRCS(Orth)1; Nicholas D. Downing, FRCS(Orth)2; Daren P. Forward, FRCS(Orth), DM2; Mark Hatton, FRCS(Orth)2; Andrew M. Taylor, FRCS(Orth), DM2; Brigitte E. Scammell, FRCS(Orth), DM1; Chris G. Moran, FRCS(Ed), DM2; Tim R.C. Davis, FRCS2
1 Division of Orthopaedic and Accident Surgery, Queen’s Medical Centre, Derby Road, Nottingham NG7 2UH, United Kingdom. E-mail address for A. Karantana: alexiak41@hotmail.com
2 Department of Orthopaedic and Trauma Surgery, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Derby Road, Nottingham NG7 2UH, United Kingdom
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Investigation performed at the Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom

A commentary by Charles S. Day, MD, MBA, et al. is linked to the online version of this article at jbjs.org.



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Oct 02;95(19):1737-1744. doi: 10.2106/JBJS.L.00232
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Abstract

Background: 

The aim of this study was to compare the outcomes of displaced distal radial fractures treated with a volar locking plate with the results of such fractures treated with a conventional method of closed reduction and percutaneous wire fixation with supplemental bridging external fixation when required. Our aim was to ascertain whether the use of a volar locking plate improves functional outcomes.

Methods: 

A single-center, pragmatic, randomized controlled trial was conducted in a tertiary care institution. One hundred and thirty patients (eighteen to seventy-three years of age) who had a displaced distal radial fracture were randomized to treatment with either a volar locking plate (n = 66) or a conventional percutaneous fixation method (n = 64). Outcome assessments were conducted at six weeks, twelve weeks, and one year. Outcomes were measured on the basis of scores on the Patient Evaluation Measure (PEM) and QuickDASH questionnaire (a shortened version of the Disabilities of the Arm, Shoulder and Hand, or DASH, Outcome Measure), EuroQol-5D (EQ-5D) scores, wrist range of motion, grip strength, and radiographic parameters.

Results: 

The rate of follow-up at one year was 95%. Patients in the volar locking-plate group had significantly better PEM and QuickDASH scores and range of motion at six weeks compared with patients in the conventional-treatment group, but there were no significant differences between the two groups at twelve weeks or one year. Grip strength was better in the plate group at all time points. The volar locking plate was better at restoring palmar tilt and radial height. Significantly more patients in the plate group were driving at the end of six weeks, but this did not translate to a significant difference between groups in terms of those returning to work by that time.

Conclusions: 

Use of a volar locking plate resulted in a faster early recovery of function compared with use of conventional methods. However, no functional advantage was demonstrated at or beyond twelve weeks. Use of the volar locking plate resulted in better anatomical reduction and grip strength, but there was no significant difference in function between the groups at twelve weeks or one year. The earlier recovery of function may be of advantage to some patients.

Level of Evidence: 

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Mohammed Tahir Ansari and Prakash P. Kotwal
    Posted on October 30, 2013
    Rationalised Treatment of Fracture Distal End of Radius
    All India Institute of Medical Sciences, New Delhi, India

    The treatment options for fracture of distal end of radius have always been debatable. The current study showing certain early advantages of volar locking plate fixation (VLP fixation) over the percutaneous method is a well written article and has definitely substantiated further knowledge in the literature. It is a well known fact that the two modalities of treatment are based on two different principles. The VLP fixation relies on anatomical reduction of the articular surface that is maintained by fixed angle plate. On the other hand percutaneous fixation with external fixator relies mainly on the principle of ligamentotaxis. Hence the indications of use will be different depending upon the fracture geometry.

    For example, the ligamentotaxis principle can`t be used in AO type B fractures and the surgeons will not be able to achieve reduction every time in all cases of AO type C3 fractures with percutaneous method. The authors have excluded an AO type B fracture which is given in the appendix. It would have been appreciated that the issue be discussed in the main manuscript. Although AO type C3 fractures are included in the study, there are very few cases in both the groups (2 cases in the VLP group and 6 cases in the control group). Considering the very small number of cases in this subgroup, the results may not be comparable because of the small sample size. Virtually this study deals mainly with AO type A3 and C2 fractures of distal radius. Considering the rarity of C3 fractures, a different multicenter study may be needed to compare the different treatment modalities.

    Another issue is the maintenance of the ulnar variance after use of both the methods. Radiological parameter of ulnar variance has not been measured in this study. Clinically the patients may present with ulnar sided wrist pain if ulnar variance is not maintained. Another randomised control trial found that ulnar variance is maintained better with the VLP method than with the percutaneous method[1]. Although ulnar variance was not evaluated in this study, it shows an equal incidence of ulnar sided wrist pain. This aspect needs to be evaluated further.

    The finding of higher grip strength with use of VLP fixation is an important outcome of this study as it may be more useful in manual workers for whom lifting of heavy weight is a basic requirement of the job, especially in developing countries where fracture of the distal radius is very common in labourers.


    REFERENCE
    1. Williksen JH, Frihagen F, Hellund JC, Kvernmo HD, Torstein H. Volar Locking Plates Versus External Fixation and Adjuvant Pin Fixation in Unstable Distal Radius Fractures: A Randomized, Controlled Study. J Hand Surg Am. 2013; 38:1469–1476

    Alexia Karantana, Tim RC Davis
    Posted on October 16, 2013
    Response to comment entitled 'The effect of postoperative immobilisation' by Page et al.
    Division of Orthopaedic and Accident Surgery, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK

    We thank Dr. Page for his comments.  As stated in the Materials and Methods, patients who underwent Kirschner wire fixation were immobilized in a plaster splint for six weeks. In contrast, patients who underwent volar locking plate fixation were fitted with either a plaster or a removable Velcro splint for comfort, which was removed two weeks after surgery. No patients treated by plating were immobilized for six weeks.

    We did not find that patients who underwent percutaneous fixation experienced fewer complications, though many of the complications in this group were self-limiting (see Complication section of paper). Many parameters have to be considered for an accurate economic evaluation, including the cost of implants, health resource usage and the benefits to participants. However, the lack of a lasting functional advantage and the significant cost of implants, weighs against volar locking plate fixation.

    Piers Page MRCSEd, Benedict Rogers FRCS(Tr & Orth) and David Ricketts FRCS(Tr & Orth)
    Posted on October 07, 2013
    The effect of postoperative immobilisation
    Brighton and Sussex University Hospitals

    This study provides a valuable addition to the current evidence base to guide treatment of a common fracture. We were interested to know if the authors felt that the use of a plaster cast in only some patients was an interfering variable.

    The authors found a significant difference in function (at 6 weeks) between the percutaneous wiring group and the ORIF group. All of the K-wire group and some of the ORIF group were treated with a cast after operation There was no subgroup analysis to determine the effect of additional treatment in plaster after 6 weeks. Without such a subgroup analysis the effect of the plaster remains unknown. Early mobilisation of some patients after ORIF may have accounted for the early improvement noted in the ORIF group.

    If this were to be the case, one could argue that any fracture to be managed by ORIF but requiring a plaster may equally be managed by percutaneous wiring – a quicker operation with a lower complication rate and less economic cost to the health service.

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