We read with interest "A Prospective, Randomized Trial Comparing the
Limited Contact Dynamic Compression Plate with the Point Contact Fixator for
Forearm Fractures"
(2003;85:2343-8), by Leung and
Chow, a well-executed study with good numbers and adequate follow-up.
It was not clear to us why the decision was made to remove the devices
(twenty-two PC-Fix devices and twenty-nine LC-DCP devices, totaling 40.8% of
the devices). It is very unlikely that there was a definite clinical
indication for removing the implants. It is well established in the literature
that removing the implants not only subjects the patients to an unnecessary
second surgery but also exposes them to a substantial risk of complications,
including infection and nerve injury. If looking at the refracture rate was
the only reason for removing the devices, we believe that it was unnecessary.
A valid and reliable comparison between the two groups could have been
achieved by assessment of bone healing, patient function, and complications
with radiographs and clinical examination alone.
The advent of the locking compression plate system (LCP) ensures more
biological fracture healing with plate devices. The LCP, which has a
combination hole, gives the surgeon the choice to use conventional screws,
locking screws, or a combination of both. This, we feel, will reduce the use
of the PC-Fix device for fixation of forearm fractures in the near future.
It is true that there is still no well-established indication for implant
removal. We explained the pros and cons and gave the option of implant removal
to the patients when they were recruited for the study, and the decision for
removal was made entirely by the patient. Moreover, the 40% rate of implant
removal was similar to the rates for other kinds of fixation in our
institution (e.g., intramedullary nailing and plate fixation of ankle
fractures), and most of those removals are the patient's request. We strongly
believe that there is a cultural reason behind such requests.
There is of course a newer implant, the locking compression plate (LCP),
that uses the locking screw principle. While we are currently using this new
implant, we are not aware of any randomized controlled trial showing an
advantage over either LC-DCP or PC-Fix. Hence, we feel that the advent of LCP
does not decrease the value of our study, in which we compared two schools of
philosophy regarding plate fixation—namely, interfragmentary fixation
and bridging plate fixation. The use of mixed conventional and locking head
screws in LCP would not allow such a comparison.