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Comparison of External and Percutaneous Pin Fixation with Plate Fixation for Intra-articular Distal Radial FracturesA Randomized Study
Frankie Leung, FRCS1; Yuan-kun Tu, MD2; Winston Y.C. Chew, FRCS3; Shew-Ping Chow, MS, FRCS1
1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, the University of Hong Kong, Pokfulam, Hong Kong. E-mail address for F. Leung: klleunga@hkucc.hku.hk. E-mail address for S.-P. Chow: spchow@hkucc.hku.hk
2 E-Da Hospital, 1 E-Da Road, Jiau-shu Tsuen, Yan-chau Shiang, Kaohsiung County, Taiwan, 824, Republic of China. E-mail address: ed100130@edah.org.tw
3 Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433. E-mail address: Winston_Chew_YC@ttsh.com.sg
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the AO Research Institute. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at Queen Mary Hospital, Pokfulam, Hong Kong, Tan Tock Seng Hospital, Jalan Tan Tock Seng, Singapore, and Chang Gung Memorial Hospital, Keelung, Taiwan

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jan 01;90(1):16-22. doi: 10.2106/JBJS.F.01581
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Abstract

Background: The most effective method for the fixation of an intra-articular distal radial fracture has not been established. Two commonly used treatment methods are external fixation combined with percutaneous pin fixation and plate fixation. We performed a prospective multicenter randomized trial to compare these two treatment strategies.

Methods: A total of 137 patients with 144 intra-articular distal radial fractures were recruited into the study. The average age of the patients was forty-two years, and all patients were sixty years old or less. The patients were randomized to fracture fixation with one of the two methods. At six, twelve, and twenty-four months postoperatively, the patients were assessed with use of the Gartland and Werley point system and the modified Green and O'Brien scoring system. Arthritis was graded on radiographs according to a modification of the Knirk and Jupiter criteria.

Results: Seventy-four (51%) of the fractures were treated with external fixation and percutaneous pin fixation, and seventy were treated with dorsal, volar, or combined plate fixation. At the time of the twenty-four-month follow-up, the results for the plate fixation group were significantly better than those for the external fixation and percutaneous pin fixation group according to the Gartland and Werley point system (p = 0.04) and the radiographic arthritis grading system (p = 0.01). The difference was especially notable among patients with AO group-C2 fractures.

Conclusions: Plate fixation is better than external fixation combined with percutaneous pin fixation for the treatment of intra-articular fractures of the distal part of the radius.

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

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    References

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    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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    Frankie Leung, FRCS
    Posted on February 25, 2008
    Dr. Leung et al. respond to Dr. Handoll
    Department of Orthopaedics & Traumatology, Queen Mary Hospital, University of Hong Kong

    We thank Dr. Handoll for her query and comments regarding our recent article(1).

    We would agree that theoretically patients with bilateral fractures or any other substantial injuries involving either upper limb should be excluded. However, this was not done in our study after considering the availability of suitable subjects to be recruited. Three plate fixations were excluded from the study, including two partial articular fractures (AO type B) and one plate fixation that was not done according to the protocol.

    In our study, patients with bilateral fractures were allocated to the same treatment group. Sixty patients in the external fixation group were available for follow-up at twelve months, and forty-seven at twenty-four months. Fifty-seven patients in the plate fixation group were available for follow-up at twelve months, and fifty-one at twenty-four months. Regarding the number of patients and the full results of the questionnaire on general health and function, we would agree that supplementing this information would help the readers to get the most from the article.

    Presented below are the requested tables:

    Table 1
    Table 2
    Table 3
    Table 4

    Reference:

    1. Frankie Leung, Yuan-kun Tu, Winston Y.C. Chew, and Shew-Ping Chow. Comparison of External and Percutaneous Pin Fixation with Plate Fixation for Intra-articular Distal Radial Fractures. A Randomized Study. J Bone Joint Surg Am. 2008;90:16-22.

    Frankie Leung, FRCS
    Posted on January 31, 2008
    Dr. Leung et al. respond to Dr. Macnair.
    Queen Mary Hospital, the University of Hong Kong, Pokfulam, Hong Kong

    We thank Dr. Macnair and colleagues for their interest in our recent article(1) and we would like to make the following comments.

    Dr. Macnair et al. have concerns regarding our conclusion that open reduction and plate fixation is a better way to treat intra-articular distal radial fractures based on the differences in the Gartland and Werley clinical grading system(2) and the modified criteria of Knirk and Jupiter(3). In fact, our conclusion was based on the comparison of the two groups as a whole and not just based on the AO C2 sub-group, as suggested by Dr. Macnair et al.

    Although the modified clinical scoring system of Green and O'Brien is more contemporary than the Gartland and Werley system(4), both of these measures are not validated outcome measures such as the DASH(5). This point was addressed in the Discussion section of our paper(1).

    We do not believe that the evidence we provided is conflicting. In addition, we do not think it necessary to show a difference in the modified clinical scoring system of Green and O'Brien in order to draw any conclusion. The Gartland and Werley system is still widely used(6-14). Hence, we believe that it is still a valuable tool in assessing our patients with distal radial fractures.

    References:

    1. Frankie Leung, Yuan-kun Tu, Winston Y.C. Chew, and Shew-Ping Chow. Comparison of External and Percutaneous Pin Fixation with Plate Fixation for Intra-articular Distal Radial Fractures. A Randomized Study. J Bone Joint Surg Am. 2008;90:16-22.

    2. Gartland JJ, Wertley CW. Evaluation of healed Colles' fractures. J Bone Joint Surg [Am] 1951;33A:895-907

    3. Knirk JL, Jupiter JB. Intraarticular fractures of the distal end of the radius in young adults. J Bone Joint Surg [Am] 1986; 68: 647-59

    4. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res. 1987;214:136-47.

    5. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29:602-8. Erratum in: Am J Ind Med. 1996;30:372.

    6. Rogachefsky RA, Lipson SR, Applegate B, Ouellette EA, Savenor AM, McAuliffe JA. Treatment of severely comminuted intra-articular fractures of the distal end of the radius by open reduction and combined internal and external fixation. J Bone Joint Surg Am 2001; 83A No.4:509-19

    7. Doi K, Hattori Y, Otsuka K, Abe Y, Yamamoto H. Intra-articular fractures of the distal aspect of the radius: arthroscopically assisted reduction compared with open reduction and internal fixation. J Bone Joint Surg Am. 1999 Aug;81(8):1093-110.

    8. Kamath AF, Zurakowski D, Day CS. Low-profile dorsal plating for dorsally angulated distal radius fractures: an outcomes study. J Hand Surg [Am]. 2006 Sep;31(7):1061-7.

    9. Ruch DS, Papadonikolakis A. Volar versus dorsal plating in the management of intra-articular distal radius fractures. J Hand Surg [Am]. 2006 Jan;31(1):9-16.

    10. Rogachefsky RA, Ouellette EA, Sun S, Applegate B. The use of tricorticocancellous bone graft in severely comminuted intra-articular fractures of the distal radius. J Hand Surg [Am]. 2006 Apr;31(4):623-32.

    11. Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation of complex fractures of the distal part of the radius. J Bone Joint Surg Am. 2004 Aug;86-A(8):1646-52.

    12. Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am. 2003 Oct;85-A(10):1956-60.

    13. Rein S, Schikore H, Schneiders W, Amlang M, Zwipp H. Results of dorsal or volar plate fixation of AO type C3 distal radius fractures: a retrospective study. J Hand Surg [Am]. 2007 Sep;32(7):954-61.

    14. Ruch DS, Ginn TA, Yang CC, Smith BP, Rushing J, Hanel DP. Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution. J Bone Joint Surg Am. 2005 May;87(5):945-54.

    Rory D Macnair
    Posted on January 28, 2008
    Misleading Conclusions
    Norfolk & Norwich University Hospital, Colney Lane, Norwich, England, NR4 7UY

    To The Editor:

    We read the paper, “Comparison of External and Percutaneous Pin Fixation with Plate Fixation for Intra-Articular Distal Radial Fractures”(1), with interest and congratulate the authors for tackling the enigma of these fractures and their various treatments. However, we have some concern about their conclusions.

    They state ‘we have demonstrated that open reduction and plate fixation is a better way to treat intra-articular distal radial fractures’, yet the evidence provided from the paper is conflicting and unsupportive of this conclusion. In fact, the evidence suggested only a marginal benefit, of doubtful clinical significance, using a scoring system not validated for these fractures(2), and a radiographic outcome score(3) in the AO C2 sub-group.

    Of interest, the authors note that the reason the modified Green and O’Brien evaluation(4) showed no difference between treatments is because it is clinically based and more stringent with regard to range of motion and strength. Are these not appropriate factors that support the use of the system?

    We would be grateful if the authors would comment on these issues. The conclusion that we would draw is that there is no difference in the outcomes between the two treatment methods studied.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Frankie Leung, Yuan-kun Tu, Winston Y.C. Chew, Shew-Ping Chow. Comparison of External and Percutaneous Pin Fixation with Plate Fixation for Intra-Articular Distal Radial Fractures. J Bone Joint Surg Am. 2008;90:16-22.

    2. Gartland JJ Jr, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg Am. 1951;33:895-907.

    3. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68:647-59.

    4. Cooney WP, Bussey R, Dobyns JH, Linscheid RL. Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin Orthop Relat Res. 1987;214:136-47.

    Helen H Handoll, DPhil
    Posted on January 11, 2008
    Inadequate reporting of results
    School of Health and Social Care, University of Teesside, Middlesbrough, UK

    To The Editor:

    I congratulate the authors for the publication of their multi-centre international trial. My comments are on aspects of trial analysis and reporting.

    Leung et al.(1) state that "Each clinic could only recruit patient numbers in multiples of four". It would, thus, be helpful if the authors explain how there ended up being 137 patients. Additionally, could Leung et al.(1) please clarify whether patients with bilateral fractures were allocated the same treatment for both wrists. Additionally, could they please provide the numbers of patients followed up at one and two years in each treatment group.

    I am not certain about the best approach for data analysis where the problem of dependent observations(2) for the seven people with bilateral fractures is probably quite small. However, I suggest it would be useful if the authors seek statistical advice on additional analysis to check this assumption.

    In general, the presentation of results of trials without exact numbers (both numerators and denominators) is unsatisfactory. It can be a source of frustration for the reader, obscure the trial results and it may perpetuate errors(3). Even when the denominators are known, rounding and other errors can also mean that numbers can not be calculated with certainty. This is the case in Leung et al.(1), where, in addition, an imperative for the percentages of individual categories to total 100% appears to have overridden the rounding rules for individual percentages. Fortunately, the facility of supplementary material can remedy this for this article. I would like to suggest that the numbers forming the basis of the percentages in the tables (II to IV) and the full results for questionnaire on general health and function are provided as supplementary material.

    The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of her immediate family, is affiliated or associated.

    References:

    1. Leung F, Tu YK, chew WYC, Chow SP. Comparison of external and percutaneous pin fixation with plate fixation for intra-articular distal radial fractures. A randomized study. J Bone Joint Surg Am. 2008;90:16-22.

    2. Sauerland S, Lefering R, Bayer-Sandow T, Bruser P, Neugebauer EA. Fingers, hands or patients? The concept of independent observations. J Hand Surg Br. 2003;28:102-5.

    3. Colwell HR. The use of numbers and percentages in scientific writing. J Bone Joint Surg Am. 1998;80:1095-6.

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