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Results of geriatric distal radius fractures treated by intramedullary fixation
Injury, Int. J. Care Injured 47S7 (2016) S31–S35
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Injury j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c at e / I n j u r y
Results of geriatric distal radius fractures treated by intramedullary fixation Steffi S.I. Falka,*, Thomas Mittlmeiera, Georg Gradlb a
Department of Trauma, Hand and Reconstructive Surgery, Rostock University Medical Center, Rostock, Germany Department of Trauma, Orthopedic and Reconstructive Surgery, Munich Municipal Hospital Group, Harlaching Clinic, Munich, Germany
b
K E Y W O R D S
A B S T R A C T
intramedullary interlocking
Introduction: Distal radius fracture are common injuries but no gold standard for their therapy exists. The aim of this study was to evaluate the quality of fracture care in distal radius fractures using an intramedullary implant (Targon DR interlocking nail). The nail had been developed to minimize the surgical exposure, increase fixation strength, to prevent tendon irritations and to allow for a fast return to activity. Patients and Methods: This prospective study reports the result of 43 patients with an age over 70 years (range 70– 91 years) treated by closed reduction and intramedullary fixation. Inclusion criteria were displaced unilateral isolated AO A or C type fractures. The Targon DR interlocking nail was used for all patients. The minimum follow up was 12 months. Results: All fractures united within 2 months. At one-year follow-up the patients had a mean extension of 96.1 ± 1.5%, flexion of 91.6 ± 3.3%, pronation of 99.4 ± 0.7%, supination of 94.0 ± 2.0%, radial abduction of 98.1 ± 1.3%, ulnar deviation of 91.4 ± 3.0% and a grip strength of 91.5 ± 4.3% compared to the contralateral wrist. Pain score measured by a Visual Analogue Scale scored 0.0 ± 0.0 at rest and in activity 0.3 ± 0.3. The mean Castaing Score was good (1.06 ± 0.30) and the Gartland & Werley Score was excellent (1.50 ± 0.57). The mean radial shortening was 0.2 ± 0.1 mm and radial inclination was 3.1 ± 1.1° (range +15° to 0°). No deep soft-tissue or chronic osseous infections were observed. One patient developed a carpal tunnel syndrome. Paraesthesia or dysaesthesia of the superficial radial nerve was registered in seven patients and fully recovered in four patients. There were two cases of single screw loosening. We also found two cases of screw overlength and consecutive contact with the ulnar head, one patient underwent implant removal. Another patient developed CRPS (2.3%). We did not observe any case of hardware failure, tendon irritation or tendon rupture. Conclusion: In geriatric patients intramedullary interlocking nailing of displaced extraarticular or intraarticular distal radius fracture with the Targon DR nail represents a viable treatment option and alternative to the use of volar interlocking plating in terms of fracture reduction, maintenance of reduction and functional outcome. © 2016 Elsevier Ltd. All rights reserved.
radius fractures osteoporotic fractures Colles’ fractures functional assessment geriatric fracture geriatric patients
Introduction In adults fractures of the distal radius are quite common [1–4]. These fractures are even more frequent in elderly patients. The peak of age is around 85 years [5]. With an average age over 70 years most of these patients are geriatric [6]. Especially, in these geriatric patients the functional result decides about an ongoing independent life or the need of permanent nursing. The aims of treatment are restoration of a full pain-free functional capacity of the wrist and lower arm and of course the prevention of complications. Good functional outcome after such fractures is the result of the suitable surgical treatment which
* Corresponding author at: Steffi Falk, Department of Trauma, Hand and Reconstructive Surgery, Rostock University Medical Center, Schillingallee 35, D-18055 Rostock, Germany. Tel: +49 381 494 6051; fax: +49 381 494 6052. E-mail address: [email protected] (S.S.I. Falk).
0020-1383 / © 2016 Elsevier Ltd. All rights reserved.
endeavors for an accurate anatomical reconstruction as well as a timely rehabilitation [7–9]. With increased age of patients and the percentage of unstable fractures in mechanically compromised bones due to osteoporosis the rate of conservative treatment had substantially decreased during the last 2 decades in favour of surgical treatment [10]. Metaanalyses of clinical studies do not attribute superiority to any choice of treatment, until now [11,12]. The clinical results published by Lindemann-Sperfeld highlight the need and usefulness of an appropriate selection of operative treatment according to the AO/ASIF fracture type classification [13]. The best operative treatment would offer stable fragment-specific support with minimal soft tissue damage and exact anatomical restoration and tolerance of safe and early active wrist rehabilitation [10]. Today, surgical treatment strategies available for unstable distal radius fractures include percutaneous pinning, external fixation, dorsal plating and volar and dorsal angular stable plating. External fixation might be better in maintaining the reduction compared with percutaneous pinning but not in terms of functional
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outcome [14,15]. Angular stable locking plates are nowadays widely used for the management of any type of distal radius fracture and appear to have become an accepted standard of modern treatment [16,17]. Numerous studies reported good and excellent clinical outcomes [18,19]. Nevertheless, volar and dorsal locking plate fixation is associated with a surprisingly high rate of complications such as tendon irritations or ruptures [19,20]. The implantation of locking plate can also end in breakage of the plate or screw loosening or may be associated with carpal tunnel syndrome (CTS) or complex regional pain syndrome (CRPS) [21–24]. Additionally, the loss of radial inclination of the distal radius is an infrequent but serious complication of volar angular stable plating fixation [18,19,25,26]. Intramedullary nailing is the most recent technique to treat distal radius fractures. It combines the soft-tissue protection of a less invasive surgical method with the biomechanical advantages of intramedullary nailing and locking screw technology [27]. There are only a few intramedullary implant types available for clinical application at the distal radius [28]. This study analyses the clinical course and outcome of interlocking nailing in unstable distal radial fractures using a specific intramedullary nail type which in essence represents a hybrid between locking plate and nail, the Targon DR nail (B.Braun-Aesculap AG, Am Aesculap Platz, 78532 Tuttlingen, Germany) [27]. The implant was developed to minimize the surgical insult to the soft tissues, to avoid tendon irritations, and to allow the patient for an early return to activity. Currently, only preliminary clinical data for alternative intramedullary implants is emerging in the form of short-term follow-up studies with small groups of patients [29]. The aim of this study is to evaluate the outcome of closed intramedullary interlocking nailing of distal radius fractures in elderly patients treated with the Targon DR nail. Patients and methods Patients In this prospective study patients with distal radius fractures were invited to participate from September 2005 to May 2008. The inclusion criteria were displaced isolated unilateral distal radius fractures and an age over 70 years at the time of the accident. Patients who sustained a dorsal or volar shear type fracture or presented with a history of previous wrist trauma were excluded from the study. All participants were treated by closed reduction and intramedullary interlocking nailing using the Targon DR nail (Aesculap AG, Am Aesculap Platz, 78532 Tuttlingen, Germany). All patients gave their consent. Our study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki. Surgical technique The operation was performed under general or regional anesthesia. All patients were placed in a supine position and the affected arm lay abducted in 90° on an arm-table. Next a 4-cm skin incision was made with proximal extension from the tip of the radial styloid. Afterwards the superficial branch of the radial nerve was identified and protected until the operation was finished. The incision was deepened to the radius between the first and second extensor compartment. The fracture was reduced by manual traction. For preliminary fixation a Kirschner wire (K-wire) (diameter 1.7 mm) was placed bicortically from the tip of the styloid across the fracture line. The insertion of the K-wire should preferably be done with a direction of 30–40° to the longitudinal axis of the radius. Afterwards, the correct location of the K-wire was controlled by fluoroscopy. Now, the K-wire was used as guide for the cannulated drill needed to open the intramedullary canal. Then, the intramedullary canal was stepwise widened with three different profilers of increasing size positioning the forearm in flexion and ulnar deviation.
A minimal cortical flake formation during widening of the intramedullary canal could be accepted. The fragment might be secured in its anatomical position by the interlocking screws of the nail. The implant was then inserted via the aiming jig. Afterwards, four K-wires were inserted through the guide sleeves into the distal fragment and controlled under fluoroscopy. The ideal position for the first wire was the subchondral bone area. No K-wire was positioned bicortically to avoid any interference with the distal radio-ulnar joint. In case of need of further restoration of the radial length this was accomplished by pulling at the aiming device. After the correct radial length was achieved two wires were inserted into the left proximal guide sleeves. Already, at this phase of the operation a fixed angle construct was attained. The operation was finished by exchanging the threaded K-wires by interlocking screws, removal of the aiming device and wound closure. Further volar splinting was provided for up to three days to allow wound protection prior to mobilization. Implant removal was not intended.
Follow-up assessment All patients were invited to follow-up examinations at eight weeks, six months and one year after surgery. This analysis included range of wrist motion measurements (extension, palmar flexion, pronation, supination, radial deviation, ulnar deviation) and grip strength using an angulometer and a grip dynamometer (Saehan SH5001, Saehan Corporation, South Korea) respectively. Values were expressed as percentage of the non-injured side [30]. Pain was measured by a visual analog scale (VAS, range 0–10) in rest and motion. Besides the utilized radiological, functional and subjective results, the Castaing Score [31] and the Gartland and Werley Score [32] were obtained at all timepoints. Both scores are comprehensive scores where more points correspond to a poor outcome. The Castaing score has a range of 0 for perfect up to 25 for very poor outcome. The Gartland & Werley score counts 0 for excellent and over 20 for poor outcome. Standard posterior-anterior and lateral radiographs of the wrist were taken one day after surgery and at all follow-up examinations. All radiographs were digitally recorded and palmar inclination, radial length and radial shortening were measured. The analyses were performed relative to a central axis that was constructed on the lateral and posteroanterior films [33] and included the assignment of the AO/ASIF-classification [34]. Radial length was measured as the distance between the ulnar border of the distal radius and the distal articular surface of the ulna. In comparison to the uninjured side the difference in length of both sides was reported [35]. Therefore, we took an x-ray of the uninjured side at the 8-weeks-follow-up examination. All data were analysed using a Microsoft® Access Database and SPSS Version 20. Mean values are given ± the standard error of mean (SEM). Results In total 43 patients (38 women) were recruited and treated with a Targon DR nail with a mean age of 78 ± 0.8 years (range 70–91). With respect to the AO/ASIF-classification 36 patients had an extraarticular fracture and seven a type C fracture. 40 patients completed each followup. The loss to follow-up was due to death unrelated to surgery (n = 1) or to a non-response after the invitation (n = 2). The mean time for surgery was 45 ± 1 min with a mean fluoroscopy time of 2.3 seconds. All fractures united with 8 weeks from the time of surgery (Figure 1). Radiologic analysis revealed a mean palmar inclination of 3.1 ± 1.1°. As soon as 8 weeks after surgery the arc of active extension/flexion reached 83/83% of the uninjured side and 96/92% one year after. Mean Gartland-Werley Score one year after surgery corresponded to an excellent outcome (1.5 ± 0.6 points). Radial shortening, which means shortening greater 2 mm was not seen.
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Fig. 1. x-rays of a 78 year old woman with a type A3.2 fracture of the right distal radius fracture. (a) right after the accident (b) intraoperative fluoroscopy (c) at 8-week follow-up (d) at one year follow-up.
The analysis using the Mann-Withney-U-test showed no differences between the fracture types so we did not allocate the patients to the groups regarding the AO-ASIF A or C fracture type.
Radiological findings demonstrated mean radial shortening of 0.0 ± 0.1 mm. The mean palmar inclination was 2.1 ± 0.9°. Follow-up at 1 year
Follow-up at 8 weeks 40 patients out of 43 (93%) participated in the first follow-up. The mean follow-up period was 54 ± 1 days. At this time point patients had a mean extension of 82.8 ± 3.1%, flexion of 83.3 ± 2.9%, pronation of 99.6 ± 0.4%, supination of 92.2 ± 1.9%, radial deviation of 92.0 ± 2.8%, ulnar deviation of 88.3 ± 2.9% and grip strength of 49.8 ± 6.2%. The VAS was 0.0 ± 0.0 at rest and during activity 1.8 ± 0.4. The mean of the Castaing Score was 4.2 ± 0.4 which means 69% of our patients had perfect or good results. In the scoring system of Gartland & Werley 65% had excellent or good results with a mean Score of 5.7 ± 0.5. Radiological examination showed that mean radial shortening was 0.0 ± 0.1 mm compared to the uninjured side which meant that 2 patients had a shortening of 1 mm. The mean palmar inclination was 2.3 ± 0.8°. Follow-up at 6 months Forty patients completed the follow-up. The average follow-up period was 177 ± 4 days. Average active motion was: extension 91.1 ± 2.7%, flexion 84.8 ± 3.1%, pronation 100.0 ± 0.0%, supination 95.3 ± 1.5%, radial deviation 93.7 ± 2.6%, ulnar deviation 90.4 ± 2.6% and grip strength 81.9 ± 5.3%. For the VAS the patients scored 0.0 ± 0.0 at rest and during activity 0.3 ± 0.2. According to the Castaing Score 90% achieved a perfect or good results the mean Score was 1.7 ± 0.5. The mean of the Gartland & Werley Score was 1.9 ± 0.5 points which means that 90% of the patients had excellent or good results.
Forty patients out of 43 (93.0%) completed the one year follow-up. The mean follow-up period was 363 ± 4 days. At follow-up the patients had a mean extension of 96.1 ± 1.5%, flexion of 91.6 ± 3.3%, pronation of 99.4 ± 0.7%, supination of 94.0 ± 2.0%, radial deviation of 98.1 ± 1.3%, ulnar deviation of 91.4 ± 3.0% and grip strength of 91.5 ± 4.3%. Table 1 illustrates results on the range of motion of the injured and the uninjured side. Regarding the VAS the patients scored 0.0 ± 0.0 at rest and during activity 0.3 ± 0.3. In the scoring system of Castaing the mean Score was 1.1 ± 0.3 which means that all of our patients had perfect or good results. The mean of the Gartland & Werley Score was 1.5 ± 0.6 points which correlates to 95% of excellent results. Radiological findings showed that the mean radial shortening was 0.2 ± 0.1 mm. The mean radial inclinationwas 3.1 ± 1.1° (range +15° to 0°).
Table 1. Range of motion in degrees for both examined wrists (injured and uninjured) and the wrist strength in kilogram at one-year-follow-up examination
Extension Flexion Pronation Supination Ulnar deviation Radial abduction Grip strength
Injured wrist
Non injured wrist
54.6 ± 2.3 56.2 ± 2.2 89.5 ± 0.6 81.8 ± 1.9 38.0 ± 1.6 23.9 ± 1.0 14.3 ± 1.9
56.8 ± 2.8 61.4 ± 2.0 90.0 ± 0.0 87.1 ± 1.1 41.6 ± 1.8 24.4 ± 1.1 15.6 ± 1.6
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All patients had a well-functioning joint and resumed their previous activities. Complications We found no case of chronic or deep soft-tissue infection. One patient developed a carpal tunnel syndrome and was treated by surgical release. Paraesthesia or dysaesthesia of the superficial radial nerve was observed in seven cases. Full nerve recovery occurred in four cases by the 1-year-follow up examination. There were two cases of screw loosening after fracture healing; in one case the implant was completely removed, in the second patient the screw was removed as an outpatient treatment. We also saw two cases of screw penetration: one into the ulna and one into the DRUJ, both patients received recommendation to have implant removal. We had one request for implant removal after one year due to discomfort at the wrist region. One patient (2.3%) developed a chronic regional pain syndrome (CRPS) according to IASP criteria (mechanical allodynia, temperature asymmetry and edema on examination) which recovered within one year after surgery. Implant breakage, tendon irritation or tendon rupture were not observed. Discussion Distal radius fractures are the most common fractures in humans and still there is some controversy upon the most favourable treatment strategy [11,12,36,37]. Intramedullary interlocking nailing of the distal radius as reported here is one of the most recent techniques introduced into clinical practice. There are very limited data available in regards to intramedullary nailing procedures for the distal radius. Ilyas et al. and Tan et al. reported a good functional outcome after intramedullary nailing [38,39]. This single-center study was implemented to assess the quality of fracture care using the Targon DR interlocking nail. The average operation time was below the time usually required for volar plating. We registered good or excellent results for early wrist motion and grip strength. Direct postoperative functional after treatment resulted in restoration of 83–99% wrist function when compared to the uninjured side after 8 weeks. Even our geriatric patients returned quickly to their pre-injury level of wrist motion and tolerated the minimal invasive surgical procedure very well. At 1 year follow-up all patients reached a functional restoration of at least 91% compared to the uninjured side and resumed their previous activities. With these results all patients had a functioning joint. As such, our results are comparable with those of other intramedullary nailing procedures which achieved also levels of recovery around 91% [40,41]. In the field of open reduction and volar plating Ateschrang et al. reported about a recovery of 82% after 3.5 years [16]. The outcomes reported by Lee et al. with 94% after one year and Matschke et al. with 90% of recovery after two years are more close to our results [42]. Thus our outcome after one year matches the results published for locking plates at the distal radius. Equally to an excellent range of motion patients were noted to have a painless wrist function. At the 8 weeks follow up our patients already scored 0 at the VAS without movement and only 2 points while using the wrist. After one year we could observe a reduction of the residual score by more than half for pain during movement of the wrist. These outstanding findings correspond to results with other intramedullary implants as well as to treatment outcome with volar plating [40,43]. Our clinical and radiological results were excellent for 95% of our patients according to the Gartland & Werley Score. Compared to the treatment with the interlocking plate these results match each other after one and also two years within the literature where the outcome level vary from 89% to 100% [19]. The results for the Castaing Score published for palmar interlocking plating vary widely from 50% to 93% of perfect and good results [44–46]. Therefore, our results with the Castaing Score are at least as competitive as the results in the scoring system of Gartland & Werley.
X-ray analysis revealed bone healing in all cases without secondary loss of reduction. In contrast, after intramedullary nailing with a different intramedullary nail implant a secondary loss of reduction was seen in 13% of the cases, which required reoperation [28,38]. Radiographic healing without secondary loss of reduction appears to be closely related to the particular design of the used implant with its proven high primary stability and fixation strength compared with volar angular stable plating [27]. The reported radial shortening in two patients of 1 mm was very near to the measurement error and did not go along with functional limitations for both patients. So the surgical technique using the Targon DR allows for an anatomical restoration, in particular with respect to radial length. We experienced no such complications like tendon irritation or tendon rupture. Volar interlocking plating has been associated with up to 17% tendon affections that displays 57% of the overall complication rate [20]. In our study tendon affections were not faced because of the intramedullary location of the nail and the fact, that all screws were inserted in the frontal level of the radius. Nevertheless, the incision at the radial styloid holds a certain risk to damage the superficial radial nerve. In our patients a transitory paraesthesia or dysaesthesia of the superficial radial nerve was detected in seven cases. Full remission occurred in four cases until the one year-follow-up. We expect further recovery within the next 12 months. Loosening of interlocking screws in the distal part of the nail was registered in 2 cases, only (4.7%) whereas Espen et al. experienced that in 1 of 32 patients (3.1%) [47]. We did not see any screw loosening in the proximal fracture segment. Screw penetration into the distal radioulnar joint was seen due to primary selection of an interlocking screw with incorrect length. In contrast to Ilyas et al. who found a screw penetration into the DRUJ with a rate of 30%, we registered this complication in only two patients (4.7%) [39]. In conclusion, distal radius fractures continue to be of great clinical and research interest to the clinicians [48–53]. In the herein study, we found that the main advantage of intramedullary fixation was the fast functional recovery attributed to the limited surgical approach at the radial styloid. Consequently, the intramedullary fixation with a novel hybrid implant between a plate and a nail comes along with an excellent functional outcome and very low pain levels even at the earlier stages after surgical treatment. Thus, our geriatric patients benefitted from an early functional recovery and an early return to their daily routine. Therefore, the internal fixation with the Targon DR is a viable option for surgical treatment and at least equivalent to open reduction and volar plating in terms of fracture reduction, maintenance of reduction and functional outcome especially in geriatric patients in the type of fractures presented in this cohort of patients. Further prospective randomized studies are welcome to provide more evidence of the effectiveness of the Targon DR nail for stabilization of distal radial fractures. Conflict of interest None of the authors received grants, honorarias or consulting fees from B. Braun Aesculap. Funding/Support The study was funded by B. Braun Aesculap. The funding organisation had no role in the design and conduct of the study; collection, management and analysis of the data; or preparation, review and approval of the manuscript. Acknowledgements We are thankful to Martina Wendt, MD, and Nadja Mielsch who helped for data acquisition and examining the patients.
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Injury j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c at e / I n j u r y
Results of geriatric distal radius fractures treated by intramedullary fixation Steffi S.I. Falka,*, Thomas Mittlmeiera, Georg Gradlb a
Department of Trauma, Hand and Reconstructive Surgery, Rostock University Medical Center, Rostock, Germany Department of Trauma, Orthopedic and Reconstructive Surgery, Munich Municipal Hospital Group, Harlaching Clinic, Munich, Germany
b
K E Y W O R D S
A B S T R A C T
intramedullary interlocking
Introduction: Distal radius fracture are common injuries but no gold standard for their therapy exists. The aim of this study was to evaluate the quality of fracture care in distal radius fractures using an intramedullary implant (Targon DR interlocking nail). The nail had been developed to minimize the surgical exposure, increase fixation strength, to prevent tendon irritations and to allow for a fast return to activity. Patients and Methods: This prospective study reports the result of 43 patients with an age over 70 years (range 70– 91 years) treated by closed reduction and intramedullary fixation. Inclusion criteria were displaced unilateral isolated AO A or C type fractures. The Targon DR interlocking nail was used for all patients. The minimum follow up was 12 months. Results: All fractures united within 2 months. At one-year follow-up the patients had a mean extension of 96.1 ± 1.5%, flexion of 91.6 ± 3.3%, pronation of 99.4 ± 0.7%, supination of 94.0 ± 2.0%, radial abduction of 98.1 ± 1.3%, ulnar deviation of 91.4 ± 3.0% and a grip strength of 91.5 ± 4.3% compared to the contralateral wrist. Pain score measured by a Visual Analogue Scale scored 0.0 ± 0.0 at rest and in activity 0.3 ± 0.3. The mean Castaing Score was good (1.06 ± 0.30) and the Gartland & Werley Score was excellent (1.50 ± 0.57). The mean radial shortening was 0.2 ± 0.1 mm and radial inclination was 3.1 ± 1.1° (range +15° to 0°). No deep soft-tissue or chronic osseous infections were observed. One patient developed a carpal tunnel syndrome. Paraesthesia or dysaesthesia of the superficial radial nerve was registered in seven patients and fully recovered in four patients. There were two cases of single screw loosening. We also found two cases of screw overlength and consecutive contact with the ulnar head, one patient underwent implant removal. Another patient developed CRPS (2.3%). We did not observe any case of hardware failure, tendon irritation or tendon rupture. Conclusion: In geriatric patients intramedullary interlocking nailing of displaced extraarticular or intraarticular distal radius fracture with the Targon DR nail represents a viable treatment option and alternative to the use of volar interlocking plating in terms of fracture reduction, maintenance of reduction and functional outcome. © 2016 Elsevier Ltd. All rights reserved.
radius fractures osteoporotic fractures Colles’ fractures functional assessment geriatric fracture geriatric patients
Introduction In adults fractures of the distal radius are quite common [1–4]. These fractures are even more frequent in elderly patients. The peak of age is around 85 years [5]. With an average age over 70 years most of these patients are geriatric [6]. Especially, in these geriatric patients the functional result decides about an ongoing independent life or the need of permanent nursing. The aims of treatment are restoration of a full pain-free functional capacity of the wrist and lower arm and of course the prevention of complications. Good functional outcome after such fractures is the result of the suitable surgical treatment which
* Corresponding author at: Steffi Falk, Department of Trauma, Hand and Reconstructive Surgery, Rostock University Medical Center, Schillingallee 35, D-18055 Rostock, Germany. Tel: +49 381 494 6051; fax: +49 381 494 6052. E-mail address: [email protected] (S.S.I. Falk).
0020-1383 / © 2016 Elsevier Ltd. All rights reserved.
endeavors for an accurate anatomical reconstruction as well as a timely rehabilitation [7–9]. With increased age of patients and the percentage of unstable fractures in mechanically compromised bones due to osteoporosis the rate of conservative treatment had substantially decreased during the last 2 decades in favour of surgical treatment [10]. Metaanalyses of clinical studies do not attribute superiority to any choice of treatment, until now [11,12]. The clinical results published by Lindemann-Sperfeld highlight the need and usefulness of an appropriate selection of operative treatment according to the AO/ASIF fracture type classification [13]. The best operative treatment would offer stable fragment-specific support with minimal soft tissue damage and exact anatomical restoration and tolerance of safe and early active wrist rehabilitation [10]. Today, surgical treatment strategies available for unstable distal radius fractures include percutaneous pinning, external fixation, dorsal plating and volar and dorsal angular stable plating. External fixation might be better in maintaining the reduction compared with percutaneous pinning but not in terms of functional
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outcome [14,15]. Angular stable locking plates are nowadays widely used for the management of any type of distal radius fracture and appear to have become an accepted standard of modern treatment [16,17]. Numerous studies reported good and excellent clinical outcomes [18,19]. Nevertheless, volar and dorsal locking plate fixation is associated with a surprisingly high rate of complications such as tendon irritations or ruptures [19,20]. The implantation of locking plate can also end in breakage of the plate or screw loosening or may be associated with carpal tunnel syndrome (CTS) or complex regional pain syndrome (CRPS) [21–24]. Additionally, the loss of radial inclination of the distal radius is an infrequent but serious complication of volar angular stable plating fixation [18,19,25,26]. Intramedullary nailing is the most recent technique to treat distal radius fractures. It combines the soft-tissue protection of a less invasive surgical method with the biomechanical advantages of intramedullary nailing and locking screw technology [27]. There are only a few intramedullary implant types available for clinical application at the distal radius [28]. This study analyses the clinical course and outcome of interlocking nailing in unstable distal radial fractures using a specific intramedullary nail type which in essence represents a hybrid between locking plate and nail, the Targon DR nail (B.Braun-Aesculap AG, Am Aesculap Platz, 78532 Tuttlingen, Germany) [27]. The implant was developed to minimize the surgical insult to the soft tissues, to avoid tendon irritations, and to allow the patient for an early return to activity. Currently, only preliminary clinical data for alternative intramedullary implants is emerging in the form of short-term follow-up studies with small groups of patients [29]. The aim of this study is to evaluate the outcome of closed intramedullary interlocking nailing of distal radius fractures in elderly patients treated with the Targon DR nail. Patients and methods Patients In this prospective study patients with distal radius fractures were invited to participate from September 2005 to May 2008. The inclusion criteria were displaced isolated unilateral distal radius fractures and an age over 70 years at the time of the accident. Patients who sustained a dorsal or volar shear type fracture or presented with a history of previous wrist trauma were excluded from the study. All participants were treated by closed reduction and intramedullary interlocking nailing using the Targon DR nail (Aesculap AG, Am Aesculap Platz, 78532 Tuttlingen, Germany). All patients gave their consent. Our study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki. Surgical technique The operation was performed under general or regional anesthesia. All patients were placed in a supine position and the affected arm lay abducted in 90° on an arm-table. Next a 4-cm skin incision was made with proximal extension from the tip of the radial styloid. Afterwards the superficial branch of the radial nerve was identified and protected until the operation was finished. The incision was deepened to the radius between the first and second extensor compartment. The fracture was reduced by manual traction. For preliminary fixation a Kirschner wire (K-wire) (diameter 1.7 mm) was placed bicortically from the tip of the styloid across the fracture line. The insertion of the K-wire should preferably be done with a direction of 30–40° to the longitudinal axis of the radius. Afterwards, the correct location of the K-wire was controlled by fluoroscopy. Now, the K-wire was used as guide for the cannulated drill needed to open the intramedullary canal. Then, the intramedullary canal was stepwise widened with three different profilers of increasing size positioning the forearm in flexion and ulnar deviation.
A minimal cortical flake formation during widening of the intramedullary canal could be accepted. The fragment might be secured in its anatomical position by the interlocking screws of the nail. The implant was then inserted via the aiming jig. Afterwards, four K-wires were inserted through the guide sleeves into the distal fragment and controlled under fluoroscopy. The ideal position for the first wire was the subchondral bone area. No K-wire was positioned bicortically to avoid any interference with the distal radio-ulnar joint. In case of need of further restoration of the radial length this was accomplished by pulling at the aiming device. After the correct radial length was achieved two wires were inserted into the left proximal guide sleeves. Already, at this phase of the operation a fixed angle construct was attained. The operation was finished by exchanging the threaded K-wires by interlocking screws, removal of the aiming device and wound closure. Further volar splinting was provided for up to three days to allow wound protection prior to mobilization. Implant removal was not intended.
Follow-up assessment All patients were invited to follow-up examinations at eight weeks, six months and one year after surgery. This analysis included range of wrist motion measurements (extension, palmar flexion, pronation, supination, radial deviation, ulnar deviation) and grip strength using an angulometer and a grip dynamometer (Saehan SH5001, Saehan Corporation, South Korea) respectively. Values were expressed as percentage of the non-injured side [30]. Pain was measured by a visual analog scale (VAS, range 0–10) in rest and motion. Besides the utilized radiological, functional and subjective results, the Castaing Score [31] and the Gartland and Werley Score [32] were obtained at all timepoints. Both scores are comprehensive scores where more points correspond to a poor outcome. The Castaing score has a range of 0 for perfect up to 25 for very poor outcome. The Gartland & Werley score counts 0 for excellent and over 20 for poor outcome. Standard posterior-anterior and lateral radiographs of the wrist were taken one day after surgery and at all follow-up examinations. All radiographs were digitally recorded and palmar inclination, radial length and radial shortening were measured. The analyses were performed relative to a central axis that was constructed on the lateral and posteroanterior films [33] and included the assignment of the AO/ASIF-classification [34]. Radial length was measured as the distance between the ulnar border of the distal radius and the distal articular surface of the ulna. In comparison to the uninjured side the difference in length of both sides was reported [35]. Therefore, we took an x-ray of the uninjured side at the 8-weeks-follow-up examination. All data were analysed using a Microsoft® Access Database and SPSS Version 20. Mean values are given ± the standard error of mean (SEM). Results In total 43 patients (38 women) were recruited and treated with a Targon DR nail with a mean age of 78 ± 0.8 years (range 70–91). With respect to the AO/ASIF-classification 36 patients had an extraarticular fracture and seven a type C fracture. 40 patients completed each followup. The loss to follow-up was due to death unrelated to surgery (n = 1) or to a non-response after the invitation (n = 2). The mean time for surgery was 45 ± 1 min with a mean fluoroscopy time of 2.3 seconds. All fractures united with 8 weeks from the time of surgery (Figure 1). Radiologic analysis revealed a mean palmar inclination of 3.1 ± 1.1°. As soon as 8 weeks after surgery the arc of active extension/flexion reached 83/83% of the uninjured side and 96/92% one year after. Mean Gartland-Werley Score one year after surgery corresponded to an excellent outcome (1.5 ± 0.6 points). Radial shortening, which means shortening greater 2 mm was not seen.
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Fig. 1. x-rays of a 78 year old woman with a type A3.2 fracture of the right distal radius fracture. (a) right after the accident (b) intraoperative fluoroscopy (c) at 8-week follow-up (d) at one year follow-up.
The analysis using the Mann-Withney-U-test showed no differences between the fracture types so we did not allocate the patients to the groups regarding the AO-ASIF A or C fracture type.
Radiological findings demonstrated mean radial shortening of 0.0 ± 0.1 mm. The mean palmar inclination was 2.1 ± 0.9°. Follow-up at 1 year
Follow-up at 8 weeks 40 patients out of 43 (93%) participated in the first follow-up. The mean follow-up period was 54 ± 1 days. At this time point patients had a mean extension of 82.8 ± 3.1%, flexion of 83.3 ± 2.9%, pronation of 99.6 ± 0.4%, supination of 92.2 ± 1.9%, radial deviation of 92.0 ± 2.8%, ulnar deviation of 88.3 ± 2.9% and grip strength of 49.8 ± 6.2%. The VAS was 0.0 ± 0.0 at rest and during activity 1.8 ± 0.4. The mean of the Castaing Score was 4.2 ± 0.4 which means 69% of our patients had perfect or good results. In the scoring system of Gartland & Werley 65% had excellent or good results with a mean Score of 5.7 ± 0.5. Radiological examination showed that mean radial shortening was 0.0 ± 0.1 mm compared to the uninjured side which meant that 2 patients had a shortening of 1 mm. The mean palmar inclination was 2.3 ± 0.8°. Follow-up at 6 months Forty patients completed the follow-up. The average follow-up period was 177 ± 4 days. Average active motion was: extension 91.1 ± 2.7%, flexion 84.8 ± 3.1%, pronation 100.0 ± 0.0%, supination 95.3 ± 1.5%, radial deviation 93.7 ± 2.6%, ulnar deviation 90.4 ± 2.6% and grip strength 81.9 ± 5.3%. For the VAS the patients scored 0.0 ± 0.0 at rest and during activity 0.3 ± 0.2. According to the Castaing Score 90% achieved a perfect or good results the mean Score was 1.7 ± 0.5. The mean of the Gartland & Werley Score was 1.9 ± 0.5 points which means that 90% of the patients had excellent or good results.
Forty patients out of 43 (93.0%) completed the one year follow-up. The mean follow-up period was 363 ± 4 days. At follow-up the patients had a mean extension of 96.1 ± 1.5%, flexion of 91.6 ± 3.3%, pronation of 99.4 ± 0.7%, supination of 94.0 ± 2.0%, radial deviation of 98.1 ± 1.3%, ulnar deviation of 91.4 ± 3.0% and grip strength of 91.5 ± 4.3%. Table 1 illustrates results on the range of motion of the injured and the uninjured side. Regarding the VAS the patients scored 0.0 ± 0.0 at rest and during activity 0.3 ± 0.3. In the scoring system of Castaing the mean Score was 1.1 ± 0.3 which means that all of our patients had perfect or good results. The mean of the Gartland & Werley Score was 1.5 ± 0.6 points which correlates to 95% of excellent results. Radiological findings showed that the mean radial shortening was 0.2 ± 0.1 mm. The mean radial inclinationwas 3.1 ± 1.1° (range +15° to 0°).
Table 1. Range of motion in degrees for both examined wrists (injured and uninjured) and the wrist strength in kilogram at one-year-follow-up examination
Extension Flexion Pronation Supination Ulnar deviation Radial abduction Grip strength
Injured wrist
Non injured wrist
54.6 ± 2.3 56.2 ± 2.2 89.5 ± 0.6 81.8 ± 1.9 38.0 ± 1.6 23.9 ± 1.0 14.3 ± 1.9
56.8 ± 2.8 61.4 ± 2.0 90.0 ± 0.0 87.1 ± 1.1 41.6 ± 1.8 24.4 ± 1.1 15.6 ± 1.6
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All patients had a well-functioning joint and resumed their previous activities. Complications We found no case of chronic or deep soft-tissue infection. One patient developed a carpal tunnel syndrome and was treated by surgical release. Paraesthesia or dysaesthesia of the superficial radial nerve was observed in seven cases. Full nerve recovery occurred in four cases by the 1-year-follow up examination. There were two cases of screw loosening after fracture healing; in one case the implant was completely removed, in the second patient the screw was removed as an outpatient treatment. We also saw two cases of screw penetration: one into the ulna and one into the DRUJ, both patients received recommendation to have implant removal. We had one request for implant removal after one year due to discomfort at the wrist region. One patient (2.3%) developed a chronic regional pain syndrome (CRPS) according to IASP criteria (mechanical allodynia, temperature asymmetry and edema on examination) which recovered within one year after surgery. Implant breakage, tendon irritation or tendon rupture were not observed. Discussion Distal radius fractures are the most common fractures in humans and still there is some controversy upon the most favourable treatment strategy [11,12,36,37]. Intramedullary interlocking nailing of the distal radius as reported here is one of the most recent techniques introduced into clinical practice. There are very limited data available in regards to intramedullary nailing procedures for the distal radius. Ilyas et al. and Tan et al. reported a good functional outcome after intramedullary nailing [38,39]. This single-center study was implemented to assess the quality of fracture care using the Targon DR interlocking nail. The average operation time was below the time usually required for volar plating. We registered good or excellent results for early wrist motion and grip strength. Direct postoperative functional after treatment resulted in restoration of 83–99% wrist function when compared to the uninjured side after 8 weeks. Even our geriatric patients returned quickly to their pre-injury level of wrist motion and tolerated the minimal invasive surgical procedure very well. At 1 year follow-up all patients reached a functional restoration of at least 91% compared to the uninjured side and resumed their previous activities. With these results all patients had a functioning joint. As such, our results are comparable with those of other intramedullary nailing procedures which achieved also levels of recovery around 91% [40,41]. In the field of open reduction and volar plating Ateschrang et al. reported about a recovery of 82% after 3.5 years [16]. The outcomes reported by Lee et al. with 94% after one year and Matschke et al. with 90% of recovery after two years are more close to our results [42]. Thus our outcome after one year matches the results published for locking plates at the distal radius. Equally to an excellent range of motion patients were noted to have a painless wrist function. At the 8 weeks follow up our patients already scored 0 at the VAS without movement and only 2 points while using the wrist. After one year we could observe a reduction of the residual score by more than half for pain during movement of the wrist. These outstanding findings correspond to results with other intramedullary implants as well as to treatment outcome with volar plating [40,43]. Our clinical and radiological results were excellent for 95% of our patients according to the Gartland & Werley Score. Compared to the treatment with the interlocking plate these results match each other after one and also two years within the literature where the outcome level vary from 89% to 100% [19]. The results for the Castaing Score published for palmar interlocking plating vary widely from 50% to 93% of perfect and good results [44–46]. Therefore, our results with the Castaing Score are at least as competitive as the results in the scoring system of Gartland & Werley.
X-ray analysis revealed bone healing in all cases without secondary loss of reduction. In contrast, after intramedullary nailing with a different intramedullary nail implant a secondary loss of reduction was seen in 13% of the cases, which required reoperation [28,38]. Radiographic healing without secondary loss of reduction appears to be closely related to the particular design of the used implant with its proven high primary stability and fixation strength compared with volar angular stable plating [27]. The reported radial shortening in two patients of 1 mm was very near to the measurement error and did not go along with functional limitations for both patients. So the surgical technique using the Targon DR allows for an anatomical restoration, in particular with respect to radial length. We experienced no such complications like tendon irritation or tendon rupture. Volar interlocking plating has been associated with up to 17% tendon affections that displays 57% of the overall complication rate [20]. In our study tendon affections were not faced because of the intramedullary location of the nail and the fact, that all screws were inserted in the frontal level of the radius. Nevertheless, the incision at the radial styloid holds a certain risk to damage the superficial radial nerve. In our patients a transitory paraesthesia or dysaesthesia of the superficial radial nerve was detected in seven cases. Full remission occurred in four cases until the one year-follow-up. We expect further recovery within the next 12 months. Loosening of interlocking screws in the distal part of the nail was registered in 2 cases, only (4.7%) whereas Espen et al. experienced that in 1 of 32 patients (3.1%) [47]. We did not see any screw loosening in the proximal fracture segment. Screw penetration into the distal radioulnar joint was seen due to primary selection of an interlocking screw with incorrect length. In contrast to Ilyas et al. who found a screw penetration into the DRUJ with a rate of 30%, we registered this complication in only two patients (4.7%) [39]. In conclusion, distal radius fractures continue to be of great clinical and research interest to the clinicians [48–53]. In the herein study, we found that the main advantage of intramedullary fixation was the fast functional recovery attributed to the limited surgical approach at the radial styloid. Consequently, the intramedullary fixation with a novel hybrid implant between a plate and a nail comes along with an excellent functional outcome and very low pain levels even at the earlier stages after surgical treatment. Thus, our geriatric patients benefitted from an early functional recovery and an early return to their daily routine. Therefore, the internal fixation with the Targon DR is a viable option for surgical treatment and at least equivalent to open reduction and volar plating in terms of fracture reduction, maintenance of reduction and functional outcome especially in geriatric patients in the type of fractures presented in this cohort of patients. Further prospective randomized studies are welcome to provide more evidence of the effectiveness of the Targon DR nail for stabilization of distal radial fractures. Conflict of interest None of the authors received grants, honorarias or consulting fees from B. Braun Aesculap. Funding/Support The study was funded by B. Braun Aesculap. The funding organisation had no role in the design and conduct of the study; collection, management and analysis of the data; or preparation, review and approval of the manuscript. Acknowledgements We are thankful to Martina Wendt, MD, and Nadja Mielsch who helped for data acquisition and examining the patients.
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