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Commentary and Perspective   |    
More Evidence That Volar Locked Plating for Distal Radial Fractures Does Not Offer a Functional Advantage Over Traditional Treatment OptionsCommentary on an article by Alexia Karantana, FRCS(Orth), et al.: “Surgical Treatment of Distal Radial Fractures with a Volar Locking Plate Versus Conventional Percutaneous Methods. A Randomized Controlled Trial”
Charles S. Day, MD, MBA1; Keiichiro Maniwa, MD1; Wei Kang Wu, BA1
1 Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Massachusetts
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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):e147 1-2. doi: 10.2106/JBJS.M.01064
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Distal radial fracture is one of the most frequent fractures in the upper extremity, with a multitude of treatment options. Despite the lack of evidence to justify the trend, there is a noticeable shift away from percutaneous fixation in favor of treatment with a volar locking plate1. While volar plates were designed to minimize complications such as tendon irritation2, their theoretical superiority over other treatment methods has yet to be demonstrated scientifically.
In this prospective randomized study, Karantana et al. compared two techniques of fixation for distal radial fractures: open reduction and internal fixation (ORIF) with use of a volar locking plate and closed reduction and percutaneous pinning with or without external fixation. Functional outcome assessments were conducted at six weeks, twelve weeks, and one year. The authors found that scores of the Patient Evaluation Measure (PEM) and QuickDASH (a shortened version of the Disabilities of the Arm, Shoulder and Hand Outcome Measure) were significantly better for patients in the volar locking-plate group at six weeks, but these scores were similar between the groups by twelve weeks and at one year. In 2009, a similar study performed at two hospitals in our academic medical system also compared the results of ORIF with those of closed reduction and percutaneous pinning in a prospective randomized fashion. We found similar outcomes comparing the two treatment groups at one year3. However, the difference in DASH scores in our study remained significant at twelve weeks, with no other measurement intervals until one year. That means that the difference in functional outcomes between groups in our study could potentially have been present up to one year after surgery. These two studies demonstrated that there was no difference in functional outcomes beyond the short term despite the technical differences between volar plating and pinning. However, there was a difference in short-term functional recovery. While our study suggested that the functional difference might have been present for as long as a year, Karantana et al. demonstrated that the functional difference between the two treatment groups might not have been present after six weeks.
Additionally, in both studies, the postoperative immobilization period differed between the two surgical techniques. Patients in the ORIF group started moving their wrist one to two weeks after surgery, whereas patients in the group treated with closed reduction and percutaneous pinning had the wrist immobilized for six weeks3. When the first functional outcome scores were determined at six weeks in both studies, the ORIF group demonstrated better results. This difference at six weeks may be due to the longer immobilization period following closed reduction and percutaneous pinning, rather than the result of a difference in initial fixation techniques.
In examining the correlation between anatomical alignment and functional outcomes, Karantana et al. found that the volar locking-plate group had significantly better radiographic palmar-tilt measurements at six weeks and at one year than those of the group treated with closed reduction and percutaneous pinning. Despite this radiographic difference, there was no functional difference after six weeks. This demonstrates a lack of association between radiographic alignment and functional outcomes beyond the short term. This was also suggested by numerous other studies comparing nonsurgical treatment with surgical treatment techniques in an older population4-6. These studies have demonstrated uniformly that there is no significant difference in functional outcomes beyond the short term, whereas radiographic outcomes are significantly different. However, one important feature of the study by Karantana et al. is that it included patients of all ages, which implies that the lack of correlation between functional and radiographic outcomes may, in fact, extend beyond just the older population.
Karantana et al. reported that, while the plating group had a lower complication rate than the pinning group (24% compared with 42%), this difference was not significant. The complication rate for volar plating is quite consistent with previous studies. In 2007, Arora et al. retrospectively evaluated 114 patients for complications after fixed-angle volar plating and reported thirty-one cases (27%) with complications7. The current study strengthens the validity of those findings. In another one of our studies, published in 2011, we retrospectively compared complications of dorsal plating with those of volar locking-plate fixation and found a 21% complication rate for volar plating8. Both the current study and our study demonstrated similar types of complications from volar plating, with neuropathy and discomfort from the implant being the most common. In our 2009 study, we did find a significantly higher rate of minor complications, but not of major complications, in the percutaneous pinning group compared with the group treated with ORIF3.
In summary, this is a well-designed prospective randomized study in which functional outcomes up to one year following volar plating were compared with those after percutaneous pinning for distal radial fractures. The results of this study add to the mounting evidence that there is no direct correlation between anatomic reduction and functional outcomes in older patients beyond the short term. In fact, this study further suggests that there may not be a correlation between radiographic and functional outcomes for younger patients. The benefit of volar plating in terms of functional outcomes in the short term has been challenged by this study. Previously, it was suggested that the functional benefit of volar plating may last from twelve weeks up to a year. However, Karantana et al. suggest that this short-term benefit may last only between six and twelve weeks after surgery. As such, given the prevalence of distal radial fractures9, the results of this study may have a substantial impact on the future utilization of health-care resources. If indeed patients are experiencing only six to twelve weeks of functional advantage from the use of volar plating, as well as a 21% to 27% complication rate, then we must consider if these outcomes justify the potential added costs of treatment with a volar plate over treatment with Kirschner wires. Whether in terms of patient outcomes, management, or cost effectiveness, Karantana et al. bring us one step closer to making more informed decisions about the treatment of distal radial fractures.
Koval  KJ;  Harrast  JJ;  Anglen  JO;  Weinstein  JN. Fractures of the distal part of the radius. The evolution of practice over time. Where’s the evidence?J Bone Joint Surg Am.  2008 Sep;90(  9):1855-61.[CrossRef]
 
Orbay  JL;  Fernandez  DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am.  2002 Mar;27(  2):205-15.[CrossRef]
 
Rozental  TD;  Blazar  PE;  Franko  OI;  Chacko  AT;  Earp  BE;  Day  CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am.  2009 Aug;91(  8):1837-46.[CrossRef]
 
Arora  R;  Lutz  M;  Deml  C;  Krappinger  D;  Haug  L;  Gabl  M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am.  2011 Dec 7;93(  23):2146-53.[CrossRef]
 
Synn  AJ;  Makhni  EC;  Makhni  MC;  Rozental  TD;  Day  CS. Distal radius fractures in older patients: is anatomic reduction necessary?Clin Orthop Relat Res.  2009 Jun;467(  6):1612-20.  Epub 2008 Dec 12.[CrossRef]
 
Egol  KA;  Walsh  M;  Romo-Cardoso  S;  Dorsky  S;  Paksima  N. Distal radial fractures in the elderly: operative compared with nonoperative treatment. J Bone Joint Surg Am.  2010 Aug 4;92(  9):1851-7.[CrossRef]
 
Arora  R;  Lutz  M;  Hennerbichler  A;  Krappinger  D;  Espen  D;  Gabl  M. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma.  2007 May;21(  5):316-22.[CrossRef]
 
Yu  YR;  Makhni  MC;  Tabrizi  S;  Rozental  TD;  Mundanthanam  G;  Day  CS. Complications of low-profile dorsal versus volar locking plates in the distal radius: a comparative study. J Hand Surg Am.  2011 Jul;36(  7):1135-41.[CrossRef]
 
Alffram  PA;  Bauer  GCH. Epidemiology of fractures of the forearm. A biomechanical investigation of bone strength. J Bone Joint Surg Am.  1962 Jan;44-A:105-14.
 

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References

Koval  KJ;  Harrast  JJ;  Anglen  JO;  Weinstein  JN. Fractures of the distal part of the radius. The evolution of practice over time. Where’s the evidence?J Bone Joint Surg Am.  2008 Sep;90(  9):1855-61.[CrossRef]
 
Orbay  JL;  Fernandez  DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am.  2002 Mar;27(  2):205-15.[CrossRef]
 
Rozental  TD;  Blazar  PE;  Franko  OI;  Chacko  AT;  Earp  BE;  Day  CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am.  2009 Aug;91(  8):1837-46.[CrossRef]
 
Arora  R;  Lutz  M;  Deml  C;  Krappinger  D;  Haug  L;  Gabl  M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am.  2011 Dec 7;93(  23):2146-53.[CrossRef]
 
Synn  AJ;  Makhni  EC;  Makhni  MC;  Rozental  TD;  Day  CS. Distal radius fractures in older patients: is anatomic reduction necessary?Clin Orthop Relat Res.  2009 Jun;467(  6):1612-20.  Epub 2008 Dec 12.[CrossRef]
 
Egol  KA;  Walsh  M;  Romo-Cardoso  S;  Dorsky  S;  Paksima  N. Distal radial fractures in the elderly: operative compared with nonoperative treatment. J Bone Joint Surg Am.  2010 Aug 4;92(  9):1851-7.[CrossRef]
 
Arora  R;  Lutz  M;  Hennerbichler  A;  Krappinger  D;  Espen  D;  Gabl  M. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma.  2007 May;21(  5):316-22.[CrossRef]
 
Yu  YR;  Makhni  MC;  Tabrizi  S;  Rozental  TD;  Mundanthanam  G;  Day  CS. Complications of low-profile dorsal versus volar locking plates in the distal radius: a comparative study. J Hand Surg Am.  2011 Jul;36(  7):1135-41.[CrossRef]
 
Alffram  PA;  Bauer  GCH. Epidemiology of fractures of the forearm. A biomechanical investigation of bone strength. J Bone Joint Surg Am.  1962 Jan;44-A:105-14.
 
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