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Locking Versus Nonlocking Palmar Plate Fixation of Distal Radius Fractures

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Locking Versus Nonlocking Palmar Plate Fixation of Distal Radius Fractures n Feature Article SPOTLIGHT ON upper extremity Locking Versus Nonlocking Palmar Plate Fixation of Distal Radius Fractures MICHAEL OSTI, MD; CHRISTOPH MITTLER, MD; RICHARD ZINNECKER, MD; CHRISTOPH WESTREICHER, MD; CLEMENS ALLHOFF, MD; KARL PETER BENEDETTO, MD abstract Full article available online at Healio.com/Orthopedics. Search: 20121023-18 This study compared functional and radiological outcomes after treatment of extension- type distal radius fractures with conventional titanium nonlocking T-plates or titanium 1.5-mm locking plates. A total of 60 patients were included and followed for 4 to 7 years after receiving nonlocking T-plates (group A; n530) or locking plates (group B; n530) with and without dorsal bone grafting. Bone grafting was significantly more of- ten performed in the nonlocking group to increase dorsal fracture fixation and stability (P,.003). Pre- and postoperative and follow-up values for palmar tilt, radial inclination, radial shortening, and ulnar variance were recorded. Age, sex, and fracture type were similarly distributed between the 2 groups. Postoperative and follow-up evaluation re- vealed equal allocation of intra-articular step formation and osteoarthritic changes to both groups. The overall complication rate was 25%. Compared with the nonlocking system, patients undergoing locking plate fixation presented with statistically signifi- cantly better values for postoperative palmar tilt (5.53° vs 8.15°; P,.02) and radial incli- nation (22.13° vs 25.03°; P,.02). However, forearm pronation was significantly better in group A (P,.005). At follow-up, radial inclination tended to approach a statistically significant difference in favor of group B. All clinical assessment, including Mayo wrist score, Disabilities of the Arm, Shoulder, and Hand score, Green and O’Brien score, Gartland and Werley score, visual analog scale score, and grip strength, yielded no statistically significant difference between the 2 groups. Locking plates seem to provide benefits regarding surgical technique and comfort, improvement in implant anchorage (especially in osteoporotic bone), and reduce the necessity of additional bone grafting. Drs Osti, Mittler, Zinnecker, Westreicher, Allhoff, and Benedetto are from the Department of Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Feldkirch, Austria. Drs Osti, Mittler, Zinnecker, Westreicher, Allhoff, and Benedetto have no relevant financial relation- ships to disclose. Correspondence should be addressed to: Michael Osti, MD, Department of Trauma Surgery and Sports Traumatology, Academic Hospital Feldkirch, Carinagasse 47, 6800 Feldkirch, Austria (michael. [email protected]). doi: 10.3928/01477447-20121023-18 NOVEMBER 2012 | Volume 35 • Number 11 e1613 n Feature Article he purposes of surgical treatment radial shortening, ulnar variance, intra- to AO/ASIF classification, 12 fractures of displaced distal radius fractures articular step formation, and development were type A3, 6 were type C2, and 12 Tare restoration of anatomic align- of osteoarthritic transformation, were per- were type C3. Five patients presented ment and articular congruity, preservation formed postoperatively and at follow-up. with an average 2.8061.24-mm intra- of reduction, and achievement of the best For clinical wrist function assessment, articular step formation. Surgery was per- possible wrist. Many studies have report- the Mayo wrist score, Disability of the formed an average of 6.465.6 days after ed that palmar plate fixation is an effec- Arm, Shoulder, and Hand (DASH) score, trauma. Additional dorsal cancellous bone tive option for most types of distal radius Green and O’Brien score, and Gartland grafting was performed in 13 cases, which fractures.1-8 Using an interlocking fixation and Werley score were used. Follow-up is statistically significantly less frequent system results in good patient satisfac- examination also included an evaluation compared with group A (P,.003). Mean tion and wrist function and restoration of active range of motion, wrist pain ac- time of postoperative immobilization in a of physiological radius length and axis cording to the visual analog scale (VAS) splint cast was 31.969.2 days. Complete function.1-4,9-12 Several analyses could not 0-100), and grip power measurement us- osseous fracture consolidation was docu- reveal that locking compression plates ing a hydraulic dynamometer (Jamar, mented on plain radiographs an average of providing angular stability are superior Clifton, New Jersey). Mean follow-up 52.7625.8 days postoperatively. in terms of biomechanical performance time was 6.3760.62 years for group A The overall complication rate for both when compared with conventional non- and 4.8560.80 years for group B. groups was 25%. Impairment of the su- locking fixation systems.5,13 The clinical Demographical data and pre- and post- perficial branch of the radial nerve, which significance of these findings is unknown, operative variables were compared be- was caused by irritation by dorsal ap- and it remains unclear whether the favor- tween the 2 groups. Unpaired t test was proach for bone grafting or intraoperative able results of surgical treatment with used to compare quantitative data, and temporary fracture fixation with K-wires, palmar locking plates are implant related. 2-tailed Fisher’s exact test was used for resulted in dysesthesia, preferential at the The objective of this study was to evaluate categorical data. Statistical significance extensor side of the thumb, in 6 patients. and compare the functional and radiologi- was defined as a P value less than .05. Implant malposition compelled early cal results of both fixation strategies to as- implant removal in 4 patients, 3 patients sess differences in the outcomes of wrist RESULTS developed complex regional pain syn- function and fracture reduction. Group A comprised 21 women and 9 drome, and 2 patients developed carpal men (18 right and 12 left wrists) with a canal syndrome. MATERIALS AND METHODS mean age of 52.6617.3 years. According Functional results for both groups are The records of 60 patients undergo- to AO/ASIF classification, 2 fractures shown in Table 1. ing surgery for displaced, extension-type were type A2, 11 were type A3, 1 was In group A, 23 patients specified no distal radius fractures at the authors’ in- type B1, 3 were type C1, 4 were type C2, residual wrist pain. Average grip strength stitution between 2001 and 2004 were and 9 were type C3. Four patients pre- was 23.7610.9 kg, which is 87% of the retrospectively reviewed. Thirty patients sented with an average 1.8660.66-mm noninvolved side. Mayo wrist score was received a conventional palmar titanium intra-articular step formation. Surgery excellent in 10 (33%) patients, good in nonlocking T-plate (group A). After the was performed an average of 6.364.9 14 (47%), fair in 5 (17%), and poor in institution converted to using modern an- days after trauma. To support the un- 1 (3%). According to the Gartland and gular stable fixation systems, 30 patients stable metaphyseal area of comminu- Werley score, 13 (43%) patients achieved were treated with a 1.5-mm palmar tita- tion, additional cancellous bone grafting an excellent result, 16 (53%) a good re- nium locking plate from the first genera- was performed in 25 patients, which was sult, and 1 (3%) a fair result. tion of locking compression plates for the statistically significantly more frequent In group B, 22 patients specified no distal radius (group B). The mechanism of compared with group B (P,.003). Mean residual wrist pain. Average grip strength injury was a fall on a hyperextended palm time of postoperative immobilization in a was 23.6610.0 kg, which is 92% of the in all cases. All fractures were classified splint cast was 30.469.7 days. Complete noninvolved side. Mayo wrist score was by computed tomography scans and plain osseous fracture consolidation was docu- excellent in 13 (43%) patients, good in 9 radiographs according to Association for mented on plain radiographs an average of (30%), fair in 6 (20%), and poor in 2 (7%). Osteosynthesis/Association for the Study 58.2628.5 days postoperatively. According to the Gartland and Werley of Internal Fixation (AO/ASIF) clas- Group B comprised 21 women and 9 score, 17 (57%) patients achieved an ex- sification. Radiological measurements, men (16 right and 14 left wrists) with a cellent result, 9 (30%) a good result, 1 including palmar tilt, radial inclination, mean age of 52.0612.0 years. According (3%) a fair result, and 1 (3%) a poor result. e1614 ORTHOPEDICS | Healio.com/Orthopedics DISTAL RADIUS FRACTURES | OSTI ET AL tients and averaged radial and ulnar abduction, and supination Table 1 1.260.76 mm. Mild on follow-up examination. Comparison of Functional Results preexisting osteo- VAS scores, grip strength, and all scoring arthritic changes systems showed no statistically signifi- Result Group A Group B were found in 2 pa- cant difference. Follow-up radiological ROM, % of contralateral side tients. On follow-up assessment revealed a similar distribution radiographs, intra- of palmar tilt, radial inclination, radial Wrist extension 89 88 articular steps av- shortening, and ulnar variance between Wrist flexion 87 89 eraged 2.0261.23 the groups. Pre- and postoperative and Radial abduction 89 83 mm in 5 patients. follow-up intra-articular step formation Ulnar abduction 85 90 Osteoarthritic and development of osteoarthritic changes Forearm rotation 97 95 changes were grad- were equally allocated to both groups. Mean scores ed mild in 7 patients Compared with patients receiving VAS 7.6616.0 5.2611.8 and moderate in 3 the nonlocking system, patients receiv- DASH 14.9617.6 9.9610.4 patients. ing locking plate fixation of the distal Green and O’Brien 87.7613.9 85.2620.1 In group B, radius presented with superior values postoperative intra- for postoperative palmar tilt and radial Mean grip strength, kg 23.7610.9 23.6610.0 articular step for- inclination that reached statistical sig- Abbreviations: DASH, Disabilities of the Arm, Shoulder, and Hand; ROM, range of motion; VAS, visual analog scale.
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