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Biomechanical considerations for strategies to improve outcomes following volar plating of distal radius fractures.

ABSTRACT: This article is a systematic review of the recent published literature on the biomechanics of volar locking plate fixation of distal radius fractures. PUBMED/MEDLINE and EMBASE databases were searched on 13th Sep 2018. Biomechanical papers on volar locking plate fixation of distal radius fractures since 2010 were included. Papers were analysed and included studies were appraised by the author using the validated quality assessment GRADE tool. The search revealed 456 papers between January 2010 and the present day whose abstracts were reviewed for relevance and 21 papers were included for full paper review. The aim of this systematic review was to evaluate the evidence to determine the surgical techniques and strategies that are associated with the best biomechanical outcomes of volar plating for distal radius fractures. Review of the literature revealed that it was not necessary to fill all available distal locking screws, there was little evidence to support the use of 2 rows of screws distally over 1 row. Screws of 75% length of the distal cortex are sufficient to withstand standard postoperative regimes in extrarticular fractures. The was a paucity of evidence to conclude multidirectional locking plates were superior to fixed angle plates or that one brand of plate was superior to another.

SUBMITTER: Ramavath A

PROVIDER: S-EPMC6739430 | biostudies-literature | 2019 Sep-Oct

REPOSITORIES: biostudies-literature

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Biomechanical considerations for strategies to improve outcomes following volar plating of distal radius fractures.

Ramavath A A Howard N N Lipscombe S S

Journal of orthopaedics 20190511 5

This article is a systematic review of the recent published literature on the biomechanics of volar locking plate fixation of distal radius fractures. PUBMED/MEDLINE and EMBASE databases were searched on 13th Sep 2018. Biomechanical papers on volar locking plate fixation of distal radius fractures since 2010 were included. Papers were analysed and included studies were appraised by the author using the validated quality assessment GRADE tool. The search revealed 456 papers between January 2010 a ...[more]

PMID: 31528050

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Project description:BACKGROUND:Distal radius fracture (DRF) is the most common upper extremity fracture that requires surgery. Operative treatment with a volar locking plate has proved to be the treatment of choice for unstable fractures. However, no consensus has been reached about the benefits of pronator quadratus (PQ) repair after volar plate fixation of DRF in terms of patient-reported outcome measures, pronation strength, and wrist mobility. METHODS:We searched the PubMed, Embase, Cochrane Central, and China National Knowledge Infrastructure (CNKI) databases up to March 13, 2020, and included randomized-controlled, non-randomized controlled, or case-control cohort studies that compared cases with and without PQ repair after volar plate fixation of DRF. We used a random-effects model to pool effect sizes, which were expressed as standardized mean differences (SMDs) and 95% confidence intervals. The primary outcomes included Disabilities of the Arm, Shoulder, and Hand scores and pronation strength. The secondary outcomes included the SMDs in pain scale score, wrist mobility, and grip strength. The outcomes measured were assessed for publication bias by using a funnel plot and the Egger regression test. RESULTS:Five randomized controlled studies and six retrospective case-control studies were included in the meta-analysis. We found no significant difference in primary and secondary outcomes at a minimum of 6-month follow-up. In a subgroup analysis, the pronation strength in the PQ repair group for AO type B DRFs (SMD = - 0.94; 95% CI, - 1.54 to - 0.34; p < 0.01) favored PQ repair, whereas that in the PQ repair group for non-AO type B DRFs (SMD = 0.39; 95% CI, 0.07-0.70; p = 0.02) favored no PQ repair. DISCUSSION:We found no functional benefit of PQ repair after volar plate fixation of DRF on the basis of the present evidence. However, PQ muscle repair showed different effects on pronation strength in different groups of DRFs. Future studies are needed to confirm the relationship between PQ repair and pronation strength among different patterns of DRF. REGISTRATION:This study was registered in the PROSPERO registry under registration ID No. CRD42020188343 . LEVEL OF EVIDENCE:Therapeutic III.

Project description:BackgroundThe surgical technique of radius distraction for stabilization of distal radioulnar joint (DRUJ) if intraoperative DRUJ instability was found after the fixation of distal radius fracture has been previously described, but this surgical technique lacks clinical and radiographic effect in minimal 3 years follow-up. We therefore evaluated the clinical outcome and radiographic results of radius distraction in minimal 3 years follow-up as long-term evaluation.MethodsWe reviewed the case series of distal radius fracture with concomitant DRUJ instability receiving radius distraction from the senior author over a 5-year period (January 1st, 2013, to June 30th, 2017) retrospectively. Radius distraction during volar plating was performed by moving the volar plate distally via compression screw loosening/fastening to achieve firm endpoint on the dorsopalmar stress test. The evaluations of radiographic, including bone union time and ulnar variance, and clinical outcomes, including grading of DRUJ instability, NRS of wrist pain, DASH score, MMWS score, and range of motion of operated wrist at final follow-up, were performed at clinic as minimum 3-year follow-up; a total 34 patients had been evaluated.ResultsAt minimal post-operative 36 months follow-up, all cases demonstrated acceptable wrist range of motion with stable DRUJs, low NRS of wrist pain (0.6, SD 0.7), and satisfactory DASH score (mean 9.1, SD 6.2) and MMWS score (mean 87, SD 10). There were no cases suffering from nonunion of distal radius. The mean ulnar variance of injured wrist and uninjured wrist were -1.2 mm and 0.2 mm, respectively (SD 1.0 and 0.6) with significant statistical difference.ConclusionsRadius distraction during volar fixation of distal radius fracture should be considered if DRUJ instability was found by the dorsopalmar stress test intraoperatively, and the long-term DRUJ stability could be achieved by maintenance of normal-to-negative ulnar variance, with decreased wrist pain and satisfactory function outcome.Level of evidenceTherapeutic Level IV.

Project description:PURPOSE: Fixed-angle devices have been a major advancement in orthopedic fracture care and have become an attractive option for fixation of distal radius fractures. Several volar locking plates exist, but there is insufficient literature comparing the strengths of these plates. This study compares the biomechanical strength of two popular volar locking plate systems (Synthes LCP and Hand Innovations DVR-A) along with a nonlocking volar T-plate (Synthes). METHODS: Twenty-three formalin-fixed cadaveric forearms were divided into three groups with similar ages and bone densities. An unstable extra-articular fracture was created using a standardized osteotomy. Each group was fixed with one of the three plates. Each specimen was loaded in axial compression for 2000 cycles at a force of 400 N. Each specimen that completed cyclic testing was loaded to failure. Stiffness, yield point, and ultimate strength were recorded for each construct. RESULTS: Each fixed-angle construct completed all 2000 cycles. The nonlocking plates failed at an average of 560 cycles. The mean stiffness of the DVR-A, LCP, and the volar T-plates were 277.00, 343.17, and 175.67 N/mm, respectively. There was a statistically significant difference between both fixed-angle plates and the nonlocking plate (p < 0.05). The difference between each fixed-angle construct did not reach significance. Yield point and ultimate strength could only be determined for the two fixed-angle devices. There was no statistically significant difference between the constructs for both yield point (DVR-A = 855.56 N, LCP = 894.15 N) and ultimate strength (DVR-A = 1,021.97 N, LCP = 1,114.87 N). CONCLUSIONS: Given our data, fixed-angle constructs withstand cyclical loading representing normal physiologic forces encountered during post-operative rehabilitation. There was no significant biomechanical difference between the two fixed-angle constructs. Our results support that volar fixed-angle locking plates are an effective treatment for unstable extra-articular distal radius fractures, allowing early postoperative rehabilitation to safely be initiated.

Project description:BackgroundThis study aimed to compare functional outcomes of a volar plate osteosynthesis for distal radius fractures (DRF) performed with either a standard volar approach (SVA), which required detachment of the pronator quadratus muscle, or a pronator-sparing approach (PqSA).Materials and methodsThis prospective randomized controlled study included 106 patients scheduled for volar plate osteosyntheses. Patients were allocated to either the SVA group (n = 53) or the PqSA group (n = 53). Patients were blinded to treatment until completion of the study. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE). Secondary outcome parameters were the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Modified Mayo Wrist Score (MMWS). Follow-up examinations were performed at 8 weeks and 3, 6, and 12 months postoperatively.ResultsOverall, 91 patients were included in the final analysis: 48 in the SVA group and 43 in the PqSA group. The two cohorts were not significantly different in demographic characteristics, including age, sex, injuries on the dominant side, type of injury, and fracture classification. We found significant differences between groups at 6 months in the mean PRWE (SVA: 12.3 ± 10.4, PqSA: 18.9 ± 14.11 points) and in the mean DASH score (SVA: 12.3 ± 11.9, PqSA: 19.3 ± 16.7 points), which favoured the SVA. We found no significant differences between groups in the MMWS or in the PRWE and DASH scores at any other time points.ConclusionsThis randomized comparative clinical trial failed to demonstrate that a volar plate osteosynthesis performed with a PqSA could improve the outcome, compared to the SVA, in patients with DRF.Level of evidenceII Trial registration Comparison of Two Volar Plating Systems for Distal Radius Fractures, ClinicalTrials.gov (NCT03474445), registered 22 March 2018, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03474445?cond=radius&cntry=AT&draw=2&rank=1.

Project description:BackgroundThe most commonly used approach for distal radius fractures is the traditional Henry approach. However, it requires an intraoperative incision of the pronator quadratus (PQ) muscle, which results in a series of complications if the repair of the PQ fails.AimThe objective of this study was to investigate the efficacy of sparing the pronator quadratus for volar plating of the distal radius fractures.MethodsSeventy-six patients who suffered from distal radius fractures of types 23-B, 23-C1, and 23-C2 as per the AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification were treated with volar locking plate fixation using either the PQ muscle incision and repair (group A, n = 39) or the PQ muscle preservation approach (group B, n = 37). Intraoperative index, postoperative efficacy and complications of patients were recorded and evaluated.ResultsAll patients were followed up for more than one year after surgery. All fractures achieved union. There were significant differences in mean operative time, mean intraoperative blood loss, and mean fracture healing time between the two groups. Still, there were no significant differences in limb function scores between the two groups at the 12-month postoperative follow-up. Outcomes assessed at 1 week, 1 month, and 3 months after surgery demonstrated significant differences in the mean range of motion and pain-related visual analog scale (VAS) between the two groups. As the range of motion and grip strength increased, the VAS scores decreased, and there was no significant difference between the two groups at 12 months postoperatively. Although tendon irritation and delayed carpal tunnel syndrome were more common in group A than in group B (7.6% vs. 0% and 5.1% vs. 0%, respectively), the differences were not statistically significant.ConclusionThe modified Henry approach with sparing pronator quadratus muscle has no significant advantage in the range of wrist motion and upper limb function in the late stage. Nevertheless, the intraoperative placement of the plate under the pronator quadratus muscle can shorten the operation time, reduce intraoperative bleeding, reduce early postoperative pain, promote early activity, and improve the patient's quality of life. It is recommended that the pronator be preserved at the time of surgery.

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Biomechanical considerations for strategies to improve outcomes following volar plating of distal radius fractures.

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Biomechanical considerations for strategies to improve outcomes following volar plating of distal radius fractures.

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