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Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients
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Orthopaedics & Traumatology: Surgery & Research xxx (2020) xxx–xxx
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Original article
Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients Alejandro Lizaur-Utrilla a,∗ , Daniel Martinez-Mendez a , Maria F. Vizcaya-Moreno b , Fernando A. Lopez-Prats c a
Servicio de cirugía ortopédica, hospital universitario de Elda, Ctra Elda-Sax s/n, 03600 Elda, Alicante, Espa˜ na Grupo de investigación clínica, facultad de ciencias de la salud, universidad de Alicante, Ctra San Vicente Raspeig s/n, 03690 San Vicente Raspeig, Alicante, Espa˜ na c Departamento de traumatología y ortopedia, universidad Miguel-Hernández, Ctra Nacional 340, Km 87, 03550 San Juan de Alicante, Espa˜ na b
a r t i c l e
i n f o
Article history: Received 8 February 2019 Accepted 29 December 2019 Available online xxx Keywords: Elderly Intra-articular distal radius fracture Outcome Volar locking plate Young patient
a b s t r a c t Introduction: Treatment of the distal radius fracture in elderly remains controversial. The objective was to assess the outcomes of volar locking plate for displaced complete intra-articular distal radius fractures in elderly as compared to younger patients. Hypothesis: The outcomes in elderly patients would be comparable with those in younger patients with a low rate of complications. Material and methods: Non-randomised prospective comparative study between 70 patients older than 65 years and 46 younger patients with AO type-C fractures. The main outcome was Disabilities Arm, Shoulder and Hand (DASH) score. Secondary variables were Patient-Rated Wrist Evaluation (PRWE) score, range of motion, Visual Analogue Scale (VAS) for pain, and grip strength. Radiological measurements were also performed. Results: The mean follow-up was 30.9 (range, 24–53) months. There were no significant differences in mean DASH, PRWE, VAS-pain, wrist motion or radiological parameters at final follow-up. Multivariate analysis showed that the functional outcomes were significantly influenced by baseline ulnar positivity greater than 3 mm at baseline but not by age. Discussion: The study hypothesis was confirmed. Surgical treatment with volar locking plate for displaced complete intra-articular fractures of the distal radius in elderly patients represents a safe and effective treatment alternative with similar early complication rate than in younger. Level of evidence: III, cohort study. © 2020 Elsevier Masson SAS. All rights reserved.
1. Introduction While the open reduction and internal fixation (ORIF) has been considered the treatment of choice for intra-articular fractures of the distal radius in young patients [1], a great controversy has emerged in the literature for the treatment of these fractures in elderly patients. Some authors referred better functional outcomes with volar plating than non-operative treatment in the elderly [2,3], while others have reported no significant superiority of volar plate fixation over closed reduction and casting [4–7]. In addition, some studies found that an unsatisfactory radiological outcome in
∗ Corresponding author. E-mail address: [email protected] (A. Lizaur-Utrilla).
elderly patients does not necessarily translate into unsatisfactory functional outcome [8,9]. However, most of the published studies were about displaced extra-articular fractures or included a mixture of extra- and intraarticular fractures. Likewise, most of those studies focused on intraarticular fractures included varied types of fractures and did not differentiate between displaced and undisplaced fractures. Thus, there is no clear consensus about the best treatment for elderly patients with displaced intra-articular distal radius fractures [4,10]. The purpose of this study was to assess the functional outcomes of volar locking plate for displaced complete intra-articular distal radius fractures in elderly as compared to younger patients. The hypothesis was that the functional outcomes in elderly patients would be comparable with those in younger patients with a low rate of complications.
https://doi.org/10.1016/j.otsr.2019.12.008 1877-0568/© 2020 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Lizaur-Utrilla A, et al. Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.008
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2. Patients and methods A prospective study of consecutive patients with intra-articular distal radius fractures treated with volar locking plate between 2011 and 2016 was performed. The study protocol was approved by our institutional ethics committee, and informed consent was obtained from each patient. The inclusion criteria were displaced complete intra-articular fracture (AO type-C) [11], and age over 18 years. Type-C fracture was defined as that with fracture lines in both distal metaphysis and epiphysis. The displaced fracture was defined as a displacement of at least 2 mm in the articular surface or a gap of 2 mm. Metaphyseal fractures with articular extension but without articular displacement were excluded. Partial articular fractures (AO type-B) were also excluded. Other exclusion criteria were open fracture or concomitant bone injury to the ipsilateral upper extremity. A minimum 2-year follow-up was required for the result analysis. For the objective of this study, the patients were divided according to age into two groups: young group (under 65 years) and elderly group (age 65 years or older).
2.1. Surgery All surgeries were performed under brachial plexus anesthesia. All fractures were treated by the same team of 3 experienced surgeons in upper limb surgery. Through a standard Henry volar approach, open reduction and locking plate fixation was performed. According to Loisel et al. [12], a fourth generation plate was used (Acu-Loc, Acumed, Hillsboro, USA). Combined percutaneous pinning was not used in any patient. Bone substitute was used in 3 patients. Postoperatively, the wrists were immobilised using a plaster splint for rest for one week, followed by rehabilitation. All patients in both groups received supervised active physiotherapy at the outpatient clinic of our hospital with a frequency of about 3 weekly sessions. They were also instructed for exercises at home. This physiotherapy was discontinued when the patient achieved an adequate pain-free range of wrist motion or when further improvement was not possible.
2.2. Evaluations Patients were prospectively evaluated pre- and postoperatively at 6 weeks, 3, 6 and 12 months, and then annually with a minimum of 2 years. Clinical assessment was performed with the Disabilities Arm, Shoulder and Hand (DASH) score [13] (primary outcome), Patient-Rated Wrist Evaluation (PRWE) score [14], range of motion, grip strength, and 0-10 Visual Analogue Scale (VAS) for pain. Motion was measured with a clinic goniometer. Grip strength was measured with a Jamar dynamometer and compared to the unaffected hand. The test was repeated 3 times in each hand with intervals of approximately one minute. In each test, the patient exerted maximum pressure for 4 seconds. The highest value was selected as outcome. Grip strength was not corrected for hand dominance. Anteroposterior and lateral wrist radiographs were obtained preoperatively and at each postoperative visit. Fractures were classified using the AO system [11]. Fracture type and displacement were evaluated by software on digitised radiographs. Computed tomography was made when necessary to ensure fracture type or quality of postoperative reduction. The Medoff radiological system [15] was used for measurements on digitised radiographs. Measurements included volar tilt, radial inclination, radial height and ulnar variance. Ulnar variance greater than 3 mm was considered relevant [5].
Table 1 Baseline patient characteristics.
Age (years) Gender (F/M) Side (R/L) Dominant hand AO type (C1/C2/C3) Follow-up (months)
Elderly group n = 70
Young group n = 46
p
68.7 (66–81) 50/20 54/16 60 30/29/11 31.7 (24–53)
41.9 (19–63) 28/18 32/14 41 20/19/7 30.9 (24–49)
0.001 0.162 0.242 0.405 0.549 0.516
Continuous variables: mean (range).
2.3. Statistical analysis Power analysis was calculated to determine the needed sample size. The calculation was based on the primary outcome (DASH). In order to detect a minimal clinically important difference (MCID) [16] of 10 points between groups, with standard deviation of 7, alpha error of 5% and power of 80%, 34 patients were needed in each group. Assuming a drop-out rate of 10%, at least 38 patients were required per group. Normal distribution was assessed by the Kolmogorov–Smirnov test. The unpaired Student t-test or non-parametric Mann–Whitney U-test was used for continuous variables, and the chi-square test or Mantel–Haenszel test for categorical variables. The paired Student t-test or Wilcoxon signed-rank test were used for comparison of the outcomes over the time. Logistic regression analysis was performed to analyse influence of the age (dependent variable) on the functional outcomes (independent variables). Statistical significance was set at p < 0.05. 3. Results Among patients who met the criteria, 6 refused to participate. Thus, the initial study cohort was 127 patients. Of these, 11 were excluded (2 elderly patients died within the 2 postoperative years from reasons unrelated to the fracture, and 5 other elderly patients and 4 young patients did not complete the minimum 2-year followup). Thus, the study cohort consisted of 116 patients; 70 elderly patients (mean age 68.7 years, range 66–81) and 46 young patients (mean age 41.9 years, range 19–63). Baseline characteristics of both groups are shown in Table 1. The mean follow-up was 30.9 (range, 24–53) months. At the final follow-up (Table 2), there were no significant differences between groups in mean DASH (p = 0.547), PRWE (p = 0.433) or VAS-pain (p = 0.129). Regarding the wrist motion, there were no significant differences in any movements (p < 0.05). However, grip strength as compared to unaffected hand was significantly better in the young group (p = 0.002). Regarding the functional outcomes (DASH and PRWE), postoperative recovery at 6 weeks and 6 months were significantly better in the young group, but there were no significant differences at 12 months or final follow-up (Table 3). In the multivariate analysis, age as a continuous variable had no significant influence on the final DASH (OR: 0.4: 95% CI: 0.01–3.3; p = 0.439) or PRWE score (OR: 0.1; 95% CI: 0.02–2.8; p = 0.351), while ulnar variance positive greater than 3 mm at baseline had significantly negative influence on the final DASH (OR: 2.1; 95% CI: 1.6–4.5; p = 0.038) and PRWE scores (OR: 1.8; 95% CI: 1.2–3.1; p = 0.024). All fractures were healed on the radiological evaluation at the visit about 3 (range, 3–4) months after surgery. At the final follow-up, there were no significant differences between groups in radiological parameters (Table 4). In the elderly group, one patient had a transient median nerve compression that resolved without any specific intervention, and another presented flexor tendinitis that required plate removal at
Please cite this article in press as: Lizaur-Utrilla A, et al. Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.008
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DASH Baseline Final PRWE Baseline Final Flexion (◦ ) Baseline Final Extension (◦ ) Baseline Final Supination (◦ ) Baseline Final Pronation (◦ ) Baseline Final Final VAS-pain Grip strength (kg) Non-injured hand Final injured hand % final
Elderly group
Young group
p
16.0 (9.6) 17.3 (11.3)
15.7 (6.4) 16.1 (9.9)
0.840 0.547
15.8 (7.1) 17.2 (11.2)
16.8 (6.1) 15.7 (8.0)
0.434 0.433
59.3 (9.5) 52.9 (12.6)
61.4 (7.3) 57.0 (11.2)
0.206 0.069
61.3 (9.4) 53.9 (9.9)
62.8 (9.1) 56.3 (10.4)
0.396 0.213
84.1 (10.5) 81.7 (9.9)
86.0 (11.7) 84.8 (9.6)
0.364 0.097
84.8 (10.4) 82.8 (11.6) 3.1 (4.6)
86.3 (11.1) 83.7 (9.4) 2.2 (1.4)
0.467 0.661 0.129
27.3 (10.2) 22.4 (8.7) 76.4 (14.3)
34.2 (8.6) 28.7 (5.6) 83.8 (10.0)
0.002 0.001 0.002
Data as mean (standard deviation). Baseline data for motion and pain were measured in the unaffected hand. % final grip strength: with respect to non-injured side.
Table 3 Changes in functional outcomes over time. 6 week
6 months
12 months
Final
DASH Elderly Young p
27.4 (12.1) 22.2 (9.7) 0.016
24.3 (11.8) 20.1 (9.4) 0.035
22.7 (11.6) 19.3 (10.1) 0.107
17.3 (11.3) 16.1 (9.9) 0.547
PRWE Elderly Young p
28.3 (12.8) 23.4 (9.7) 0.029
24.9 (12.1) 20.6 (9.8) 0.046
19.3 (12.3) 18.6 (9.2) 0.742
17.2 (11.2) 15.7 (8.0) 0.433
Data as mean (standard deviation).
Table 4 Radiological results.
Volar tilt (◦ ) After surgery Final p Radial inclination (◦ ) After surgery Final p Radial height (mm) After surgery Final p Ulnar variance (mm) After surgery Final p
Elderly group
Young group
p
11.7 (4.2) 9.7 (6.6) 0.034
11.9 (3.4) 10.2 (5.7) 0.085
0.787 0.665
19.9 (3.7) 17.4 (6.8) 0.007
21.1 (3.6) 19.3 (3.7) 0.020
0.086 0.085
10.1 (2.7) 9.9 (2.9) 0.673
10.9 (2.9) 10.6 (3.5) 0.655
0.132 0.244
2.5 (2.1) 2.0 (2.4) 0.191
1.9 (2.0) 1.7 (1.9) 0.624
0.127 0.477
Data as mean (standard deviation).
13 months. There were no cases of infection or plate failure. In the young group, there were no complications. 4. Discussion Currently, there is no clear consensus about the best treatment for elderly patients with displaced intra-articular distal radius fractures [4,10]. Arora et al. [4] found no differences in
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functional outcomes between the elderly patients treated with volar plate and those with non-operative treatment. Mulders et al. [17] reported that non-operative treatment of displaced distal radius fractures leads to acceptable functional outcomes. However, they also reported that 40% of the patients underwent subsequent surgery due to a secondary displacement or symptomatic malunion. For intra-articular fractures treated conservatively, Leung et al. [18] reported a rate of re-displacement of 28%, 65% of which underwent subsequent surgical fixation. The main findings of the present study were no significant differences between older and younger patients in the final functional outcomes, and no difference in early complications. The mean difference at final follow-up in DASH score was 1.2. The MCID for DASH and quick-DASH of 10 and 14, respectively, have been reported [16]. On the other hand, the young group of the present study had a significantly better grip strength than the elderly group with a mean difference at the final follow-up of 6.3 kg. MCID has been calculated in 5 kg [19]. However, this difference may be due to the age itself and not due to the surgery. In a comparative study of elderly patients treated with volar plate and non-operative treatment, the operative group had better grip strength through the entire period of 12 months [4]. Lameijer et al. [20], in a study of post-traumatic arthritis following distal radius fractures, reported that grip strength was not statistically significantly different between patients with and without post-traumatic arthritis. The comparison with the literature is difficult because, to our knowledge, no studies have compared volar plating for complete displaced intra-articular fractures between older and younger patients. In a multicentre study, Fok et al. [21] found that most intraarticular distal radius fractures can be managed with volar plating irrespective of age. These authors reported that 95% of patients who were employed at the time of injury were able to return to work, and the majority of retired patients were able to return to their preinjury daily activities. Ruch et al. [22] reported better functional outcomes in patients with intra-articular fractures treated by volar plate than those treated with dorsal plate. A recent meta-analysis [23] showed that volar plate was more effective and had lower complications rate than external fixator for treatment of unstable distal radius fractures. On the contrary, Arora et al. [4] and Bartl et al. [7] reported no significant functional superiority of volar plate fixation over closed reduction and casting in the treatment of intra-articular distal radius fractures in the elderly, although the follow-up was of 12 months. In the present study, ulnar variance positive greater than 3 mm at baseline had significantly negative influence on the final DASH. This risk factor was also found in the study by Larouche et al. [5]. Mignemi et al. [24] reported that the ability of volar plating to restore and maintain the radiological parameters, particularly volar tilt and ulnar variance, decreased with more complex intra-articular fractures. Other factors influencing the functional outcomes have been described. Trumble et al. [25], in a study of displaced intra-articular distal radius fractures treated with ORIF, found that the restoration of the articular congruency and radial length surgically obtained was strongly correlated with improved outcome, but correction of radial tilt or dorsal tilt did not correlate with improved outcome. Johnson et al. [10] investigated the accuracy and maintenance of reduction in intra-articular fractures treated with volar plate fixation or closed reduction and percutaneous K wires. They found no difference between the two techniques for quality of initial reduction or persisting step on the last available radiographs, and only the initial displacement and increased age-influenced initial reduction. In a study of elderly patients treated conservatively, radius height and volar tilt were significantly correlated with the clinical outcomes [26]. In the present study, there were no significant differences to restore the anatomy in terms of radiological parameters between
Please cite this article in press as: Lizaur-Utrilla A, et al. Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.008
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older and younger patients. However, small but significant loss of the reduction initially obtained after surgery was observed at the final follow-up, such as volar tilt and radial inclination in the elderly group, and volar tilt in the young group. This loss of reduction did not affect the final functional outcomes. Other studies have also reported a small loss of reduction in elderly patients with complex intra-articular fractures [2,27]. Several authors have studied the ability of the volar plate fixation to stabilise complex intraarticular fractures. Using volar plating, Bini et al. [28] reported that the restoration of the radiological parameters was achieved in only 70% of the elderly patients. In contrast, Figl et al. [29] reported that volar plating allows exact anatomic reduction of the fracture without a late loss of reduction in 95% of the elderly patients with unstable distal radius fractures. Sharma et al. [3] found that volar plating for intra-articular fractures provided anatomical stable fixation and early mobilisation with better clinical and radiological outcomes as compared to conservative treatment. Unfortunately, functional outcomes were not reported in those studies. A recent study found a better reduction of the radio-carpal reduction in the fractures treated with arthroscopy assistance than those under fluoroscopic control [30]. However, another study reported that intra-articular distal radius fractures can be treated successfully with a fragment specific fixation under fluoroscopy, and the outcomes were similar than those under arthroscopy assistance [31]. In the present study, there was no incremented risk of complications in elderly patients. Quadlbauer et al. [32] reported 13% early complications including carpal tunnel syndrome, complex regional pain syndrome and loss of reduction. Likewise, 73% of these complications occurred in AO type-C fractures. Another large review [33] of distal radius fractures treated with volar plate found 11% complications and 10% revision surgery. The main reason for revision was median nerve compression. A study reported that a volar plate could mechanically affect the flexor pollicis longus tendon [34]. Using dorsal plating for intra-articular fractures, a revision rate as high as 50% for removal of the plate, due to discomfort has been reported [35]. The present study had several limitations. Both study groups had relatively small sizes but these intra-articular fractures are not frequent, and our study was similar in size to those previously published. The minimum follow-up in the present study was 2 years. However, previous studies have shown that outcomes do not vary greatly after two postoperative years and the long-term occurrence of post-traumatic arthritis is not related to functional outcomes [36]. In a meta-analysis, Margaliot et al. [37] reported rapid functional recovery after volar plating within one year after surgery. Another weakness was that those carrying out radiological measurements were not blinded to the functional outcomes. In conclusion, the study hypothesis was confirmed. The age of the patients has no influence on patient-rated, functional or radiological outcomes. Ulnar variance positive greater than 3 mm at baseline had significantly negative influence on the final DASH. The treatment in elderly patients by volar plate does not result in a significant higher early complication rate than in the younger ones. Our findings suggest that open reduction and internal fixation with volar plating in elderly patients with displaced intra-articular fractures of the distal radius represents a safe and effective treatment alternative.
Disclosure of interest The authors declare that they have no competing interest.
Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contribution A Lizaur-Utrilla did the study, analysed the data, and wrote the manuscript. A Lizaur-Utrilla, Daniel Martinez-Mendez, Maria F. Vizcaya-Moreno, Fernando A. Lopez-Prats were involved in the design, and data management. A Lizaur-Utrilla, Daniel MartinezMendez, Maria F. Vizcaya-Moreno, Fernando A. Lopez-Prats contributed to the study analysis. All authors read and approved the final manuscript. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.otsr.2019.05.010. References [1] Bolmers A, Luiten WE, Doornberg JN, Brouwer KM, Goslings JC, Ring D, et al. A comparison of the long-term outcome of partial articular (AO Type B) and complete articular (AO Type C) distal radius fractures. J Hand Surg Am 2013;38:753–9. [2] Earp BE, Foster B, Blazar PE. The use of a single volar locking plate for AO C3-type distal radius fractures. Hand 2015;10:649–53. [3] Sharma H, Khare GN, Singh S, Ramaswamy AG, Kumaraswamy V, Singh AK. Outcomes and complications of fractures of distal radius (AO type B and C): volar plating versus non-operative treatment. J Orthop Sci 2014;19:537–44. [4] Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomised trial comparing non-operative 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;93:2146–53. [5] Larouche J, Pike J, Slobogean G, Guy P, Broekhuyse H, O’Brien P, et al. Determinants of functional outcome in distal radius fractures in high-functioning patients over the age of 55. J Orthop Trauma 2016;30:445–9. [6] Toon DH, Premchand RA, Sim J, Vaikunthan R. Outcomes and financial implications of intra-articular distal radius fractures: a comparative study of open reduction internal fixation (ORIF) with volar locking plates versus nonoperative management. J Orthop Traumatol 2017;18:229–34. [7] Bartl C, Stengel D, Bruckner T, Gebhard F, ORCHID Study Group. The treatment of displaced intra-articular distal radius fractures in elderly patients: a randomised multi-centre study (ORCHID) of open reduction and volar locking plate fixation versus closed reduction and cast immobilisation. Dtsch Arztebl Int 2014;111:779–87. [8] Dario P, Matteo G, Carolina C, Marco G, Cristina D, Daniele F, et al. Is it really necessary to restore radial anatomic parameters after distal radius fractures? Injury 2014;45:21–6. [9] Brennan SA, Kiernan C, Beecher S, O’Reilly RT, Devitt BM, Kearns SR, et al. Volar plate versus k-wire fixation of distal radius fractures. Injury 2016;47:372–6. [10] Johnson NA, Dias JJ, Wildin CJ, Cutler L, Bhowal B, Ullah AS. Comparison of distal radius fracture intra-articular step reduction with volar locking plates and K wires: a retrospective review of quality and maintenance of fracture reduction. J Hand Surg Eur 2017;42:144–50. [11] Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin: Springer-Verlag; 1990. [12] Loisel F, Kielwasser H, Faivre G, Rondot T, Rochet S, Adam A, et al. Treatment of distal radius fractures with locking plates: an update. Eur J Orthop Surg Traumatol 2018;28:1537–42. [13] Beaton DE, Wright JG, Katz JN. Development of the Quick-DASH: comparison of three item-reduction approaches. J Bone Joint Surg Am 2005;87:1038–46. [14] MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma 1998;12:577–86. [15] Medoff RJ. Essential radiographic evaluation for distal radius fractures. Hand Clin 2005;21:279–88. [16] Sorensen AA, Howard D, Tan WH, Ketchersid J, Calfee RP. Minimal clinically important differences of 3 patient-rated outcomes instruments. J Hand Surg Am 2013;38:641–9. [17] Mulders MAM, van Eerten PV, Goslings JC, Schep NWL. Non-operative treatment of displaced distal radius fractures leads to acceptable functional outcomes, however at the expense of 40% subsequent surgeries. Orthop Traumatol Surg Res 2017;10:905–9. [18] Leung F, Ozkan M, Chow SP. Conservative treatment of intra-articular fractures of the distal radius – factors affecting functional outcome. Hand Surg 2000;5:145–53.
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Original article
Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients Alejandro Lizaur-Utrilla a,∗ , Daniel Martinez-Mendez a , Maria F. Vizcaya-Moreno b , Fernando A. Lopez-Prats c a
Servicio de cirugía ortopédica, hospital universitario de Elda, Ctra Elda-Sax s/n, 03600 Elda, Alicante, Espa˜ na Grupo de investigación clínica, facultad de ciencias de la salud, universidad de Alicante, Ctra San Vicente Raspeig s/n, 03690 San Vicente Raspeig, Alicante, Espa˜ na c Departamento de traumatología y ortopedia, universidad Miguel-Hernández, Ctra Nacional 340, Km 87, 03550 San Juan de Alicante, Espa˜ na b
a r t i c l e
i n f o
Article history: Received 8 February 2019 Accepted 29 December 2019 Available online xxx Keywords: Elderly Intra-articular distal radius fracture Outcome Volar locking plate Young patient
a b s t r a c t Introduction: Treatment of the distal radius fracture in elderly remains controversial. The objective was to assess the outcomes of volar locking plate for displaced complete intra-articular distal radius fractures in elderly as compared to younger patients. Hypothesis: The outcomes in elderly patients would be comparable with those in younger patients with a low rate of complications. Material and methods: Non-randomised prospective comparative study between 70 patients older than 65 years and 46 younger patients with AO type-C fractures. The main outcome was Disabilities Arm, Shoulder and Hand (DASH) score. Secondary variables were Patient-Rated Wrist Evaluation (PRWE) score, range of motion, Visual Analogue Scale (VAS) for pain, and grip strength. Radiological measurements were also performed. Results: The mean follow-up was 30.9 (range, 24–53) months. There were no significant differences in mean DASH, PRWE, VAS-pain, wrist motion or radiological parameters at final follow-up. Multivariate analysis showed that the functional outcomes were significantly influenced by baseline ulnar positivity greater than 3 mm at baseline but not by age. Discussion: The study hypothesis was confirmed. Surgical treatment with volar locking plate for displaced complete intra-articular fractures of the distal radius in elderly patients represents a safe and effective treatment alternative with similar early complication rate than in younger. Level of evidence: III, cohort study. © 2020 Elsevier Masson SAS. All rights reserved.
1. Introduction While the open reduction and internal fixation (ORIF) has been considered the treatment of choice for intra-articular fractures of the distal radius in young patients [1], a great controversy has emerged in the literature for the treatment of these fractures in elderly patients. Some authors referred better functional outcomes with volar plating than non-operative treatment in the elderly [2,3], while others have reported no significant superiority of volar plate fixation over closed reduction and casting [4–7]. In addition, some studies found that an unsatisfactory radiological outcome in
∗ Corresponding author. E-mail address: [email protected] (A. Lizaur-Utrilla).
elderly patients does not necessarily translate into unsatisfactory functional outcome [8,9]. However, most of the published studies were about displaced extra-articular fractures or included a mixture of extra- and intraarticular fractures. Likewise, most of those studies focused on intraarticular fractures included varied types of fractures and did not differentiate between displaced and undisplaced fractures. Thus, there is no clear consensus about the best treatment for elderly patients with displaced intra-articular distal radius fractures [4,10]. The purpose of this study was to assess the functional outcomes of volar locking plate for displaced complete intra-articular distal radius fractures in elderly as compared to younger patients. The hypothesis was that the functional outcomes in elderly patients would be comparable with those in younger patients with a low rate of complications.
https://doi.org/10.1016/j.otsr.2019.12.008 1877-0568/© 2020 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Lizaur-Utrilla A, et al. Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.008
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2. Patients and methods A prospective study of consecutive patients with intra-articular distal radius fractures treated with volar locking plate between 2011 and 2016 was performed. The study protocol was approved by our institutional ethics committee, and informed consent was obtained from each patient. The inclusion criteria were displaced complete intra-articular fracture (AO type-C) [11], and age over 18 years. Type-C fracture was defined as that with fracture lines in both distal metaphysis and epiphysis. The displaced fracture was defined as a displacement of at least 2 mm in the articular surface or a gap of 2 mm. Metaphyseal fractures with articular extension but without articular displacement were excluded. Partial articular fractures (AO type-B) were also excluded. Other exclusion criteria were open fracture or concomitant bone injury to the ipsilateral upper extremity. A minimum 2-year follow-up was required for the result analysis. For the objective of this study, the patients were divided according to age into two groups: young group (under 65 years) and elderly group (age 65 years or older).
2.1. Surgery All surgeries were performed under brachial plexus anesthesia. All fractures were treated by the same team of 3 experienced surgeons in upper limb surgery. Through a standard Henry volar approach, open reduction and locking plate fixation was performed. According to Loisel et al. [12], a fourth generation plate was used (Acu-Loc, Acumed, Hillsboro, USA). Combined percutaneous pinning was not used in any patient. Bone substitute was used in 3 patients. Postoperatively, the wrists were immobilised using a plaster splint for rest for one week, followed by rehabilitation. All patients in both groups received supervised active physiotherapy at the outpatient clinic of our hospital with a frequency of about 3 weekly sessions. They were also instructed for exercises at home. This physiotherapy was discontinued when the patient achieved an adequate pain-free range of wrist motion or when further improvement was not possible.
2.2. Evaluations Patients were prospectively evaluated pre- and postoperatively at 6 weeks, 3, 6 and 12 months, and then annually with a minimum of 2 years. Clinical assessment was performed with the Disabilities Arm, Shoulder and Hand (DASH) score [13] (primary outcome), Patient-Rated Wrist Evaluation (PRWE) score [14], range of motion, grip strength, and 0-10 Visual Analogue Scale (VAS) for pain. Motion was measured with a clinic goniometer. Grip strength was measured with a Jamar dynamometer and compared to the unaffected hand. The test was repeated 3 times in each hand with intervals of approximately one minute. In each test, the patient exerted maximum pressure for 4 seconds. The highest value was selected as outcome. Grip strength was not corrected for hand dominance. Anteroposterior and lateral wrist radiographs were obtained preoperatively and at each postoperative visit. Fractures were classified using the AO system [11]. Fracture type and displacement were evaluated by software on digitised radiographs. Computed tomography was made when necessary to ensure fracture type or quality of postoperative reduction. The Medoff radiological system [15] was used for measurements on digitised radiographs. Measurements included volar tilt, radial inclination, radial height and ulnar variance. Ulnar variance greater than 3 mm was considered relevant [5].
Table 1 Baseline patient characteristics.
Age (years) Gender (F/M) Side (R/L) Dominant hand AO type (C1/C2/C3) Follow-up (months)
Elderly group n = 70
Young group n = 46
p
68.7 (66–81) 50/20 54/16 60 30/29/11 31.7 (24–53)
41.9 (19–63) 28/18 32/14 41 20/19/7 30.9 (24–49)
0.001 0.162 0.242 0.405 0.549 0.516
Continuous variables: mean (range).
2.3. Statistical analysis Power analysis was calculated to determine the needed sample size. The calculation was based on the primary outcome (DASH). In order to detect a minimal clinically important difference (MCID) [16] of 10 points between groups, with standard deviation of 7, alpha error of 5% and power of 80%, 34 patients were needed in each group. Assuming a drop-out rate of 10%, at least 38 patients were required per group. Normal distribution was assessed by the Kolmogorov–Smirnov test. The unpaired Student t-test or non-parametric Mann–Whitney U-test was used for continuous variables, and the chi-square test or Mantel–Haenszel test for categorical variables. The paired Student t-test or Wilcoxon signed-rank test were used for comparison of the outcomes over the time. Logistic regression analysis was performed to analyse influence of the age (dependent variable) on the functional outcomes (independent variables). Statistical significance was set at p < 0.05. 3. Results Among patients who met the criteria, 6 refused to participate. Thus, the initial study cohort was 127 patients. Of these, 11 were excluded (2 elderly patients died within the 2 postoperative years from reasons unrelated to the fracture, and 5 other elderly patients and 4 young patients did not complete the minimum 2-year followup). Thus, the study cohort consisted of 116 patients; 70 elderly patients (mean age 68.7 years, range 66–81) and 46 young patients (mean age 41.9 years, range 19–63). Baseline characteristics of both groups are shown in Table 1. The mean follow-up was 30.9 (range, 24–53) months. At the final follow-up (Table 2), there were no significant differences between groups in mean DASH (p = 0.547), PRWE (p = 0.433) or VAS-pain (p = 0.129). Regarding the wrist motion, there were no significant differences in any movements (p < 0.05). However, grip strength as compared to unaffected hand was significantly better in the young group (p = 0.002). Regarding the functional outcomes (DASH and PRWE), postoperative recovery at 6 weeks and 6 months were significantly better in the young group, but there were no significant differences at 12 months or final follow-up (Table 3). In the multivariate analysis, age as a continuous variable had no significant influence on the final DASH (OR: 0.4: 95% CI: 0.01–3.3; p = 0.439) or PRWE score (OR: 0.1; 95% CI: 0.02–2.8; p = 0.351), while ulnar variance positive greater than 3 mm at baseline had significantly negative influence on the final DASH (OR: 2.1; 95% CI: 1.6–4.5; p = 0.038) and PRWE scores (OR: 1.8; 95% CI: 1.2–3.1; p = 0.024). All fractures were healed on the radiological evaluation at the visit about 3 (range, 3–4) months after surgery. At the final follow-up, there were no significant differences between groups in radiological parameters (Table 4). In the elderly group, one patient had a transient median nerve compression that resolved without any specific intervention, and another presented flexor tendinitis that required plate removal at
Please cite this article in press as: Lizaur-Utrilla A, et al. Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.008
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DASH Baseline Final PRWE Baseline Final Flexion (◦ ) Baseline Final Extension (◦ ) Baseline Final Supination (◦ ) Baseline Final Pronation (◦ ) Baseline Final Final VAS-pain Grip strength (kg) Non-injured hand Final injured hand % final
Elderly group
Young group
p
16.0 (9.6) 17.3 (11.3)
15.7 (6.4) 16.1 (9.9)
0.840 0.547
15.8 (7.1) 17.2 (11.2)
16.8 (6.1) 15.7 (8.0)
0.434 0.433
59.3 (9.5) 52.9 (12.6)
61.4 (7.3) 57.0 (11.2)
0.206 0.069
61.3 (9.4) 53.9 (9.9)
62.8 (9.1) 56.3 (10.4)
0.396 0.213
84.1 (10.5) 81.7 (9.9)
86.0 (11.7) 84.8 (9.6)
0.364 0.097
84.8 (10.4) 82.8 (11.6) 3.1 (4.6)
86.3 (11.1) 83.7 (9.4) 2.2 (1.4)
0.467 0.661 0.129
27.3 (10.2) 22.4 (8.7) 76.4 (14.3)
34.2 (8.6) 28.7 (5.6) 83.8 (10.0)
0.002 0.001 0.002
Data as mean (standard deviation). Baseline data for motion and pain were measured in the unaffected hand. % final grip strength: with respect to non-injured side.
Table 3 Changes in functional outcomes over time. 6 week
6 months
12 months
Final
DASH Elderly Young p
27.4 (12.1) 22.2 (9.7) 0.016
24.3 (11.8) 20.1 (9.4) 0.035
22.7 (11.6) 19.3 (10.1) 0.107
17.3 (11.3) 16.1 (9.9) 0.547
PRWE Elderly Young p
28.3 (12.8) 23.4 (9.7) 0.029
24.9 (12.1) 20.6 (9.8) 0.046
19.3 (12.3) 18.6 (9.2) 0.742
17.2 (11.2) 15.7 (8.0) 0.433
Data as mean (standard deviation).
Table 4 Radiological results.
Volar tilt (◦ ) After surgery Final p Radial inclination (◦ ) After surgery Final p Radial height (mm) After surgery Final p Ulnar variance (mm) After surgery Final p
Elderly group
Young group
p
11.7 (4.2) 9.7 (6.6) 0.034
11.9 (3.4) 10.2 (5.7) 0.085
0.787 0.665
19.9 (3.7) 17.4 (6.8) 0.007
21.1 (3.6) 19.3 (3.7) 0.020
0.086 0.085
10.1 (2.7) 9.9 (2.9) 0.673
10.9 (2.9) 10.6 (3.5) 0.655
0.132 0.244
2.5 (2.1) 2.0 (2.4) 0.191
1.9 (2.0) 1.7 (1.9) 0.624
0.127 0.477
Data as mean (standard deviation).
13 months. There were no cases of infection or plate failure. In the young group, there were no complications. 4. Discussion Currently, there is no clear consensus about the best treatment for elderly patients with displaced intra-articular distal radius fractures [4,10]. Arora et al. [4] found no differences in
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functional outcomes between the elderly patients treated with volar plate and those with non-operative treatment. Mulders et al. [17] reported that non-operative treatment of displaced distal radius fractures leads to acceptable functional outcomes. However, they also reported that 40% of the patients underwent subsequent surgery due to a secondary displacement or symptomatic malunion. For intra-articular fractures treated conservatively, Leung et al. [18] reported a rate of re-displacement of 28%, 65% of which underwent subsequent surgical fixation. The main findings of the present study were no significant differences between older and younger patients in the final functional outcomes, and no difference in early complications. The mean difference at final follow-up in DASH score was 1.2. The MCID for DASH and quick-DASH of 10 and 14, respectively, have been reported [16]. On the other hand, the young group of the present study had a significantly better grip strength than the elderly group with a mean difference at the final follow-up of 6.3 kg. MCID has been calculated in 5 kg [19]. However, this difference may be due to the age itself and not due to the surgery. In a comparative study of elderly patients treated with volar plate and non-operative treatment, the operative group had better grip strength through the entire period of 12 months [4]. Lameijer et al. [20], in a study of post-traumatic arthritis following distal radius fractures, reported that grip strength was not statistically significantly different between patients with and without post-traumatic arthritis. The comparison with the literature is difficult because, to our knowledge, no studies have compared volar plating for complete displaced intra-articular fractures between older and younger patients. In a multicentre study, Fok et al. [21] found that most intraarticular distal radius fractures can be managed with volar plating irrespective of age. These authors reported that 95% of patients who were employed at the time of injury were able to return to work, and the majority of retired patients were able to return to their preinjury daily activities. Ruch et al. [22] reported better functional outcomes in patients with intra-articular fractures treated by volar plate than those treated with dorsal plate. A recent meta-analysis [23] showed that volar plate was more effective and had lower complications rate than external fixator for treatment of unstable distal radius fractures. On the contrary, Arora et al. [4] and Bartl et al. [7] reported no significant functional superiority of volar plate fixation over closed reduction and casting in the treatment of intra-articular distal radius fractures in the elderly, although the follow-up was of 12 months. In the present study, ulnar variance positive greater than 3 mm at baseline had significantly negative influence on the final DASH. This risk factor was also found in the study by Larouche et al. [5]. Mignemi et al. [24] reported that the ability of volar plating to restore and maintain the radiological parameters, particularly volar tilt and ulnar variance, decreased with more complex intra-articular fractures. Other factors influencing the functional outcomes have been described. Trumble et al. [25], in a study of displaced intra-articular distal radius fractures treated with ORIF, found that the restoration of the articular congruency and radial length surgically obtained was strongly correlated with improved outcome, but correction of radial tilt or dorsal tilt did not correlate with improved outcome. Johnson et al. [10] investigated the accuracy and maintenance of reduction in intra-articular fractures treated with volar plate fixation or closed reduction and percutaneous K wires. They found no difference between the two techniques for quality of initial reduction or persisting step on the last available radiographs, and only the initial displacement and increased age-influenced initial reduction. In a study of elderly patients treated conservatively, radius height and volar tilt were significantly correlated with the clinical outcomes [26]. In the present study, there were no significant differences to restore the anatomy in terms of radiological parameters between
Please cite this article in press as: Lizaur-Utrilla A, et al. Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.008
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older and younger patients. However, small but significant loss of the reduction initially obtained after surgery was observed at the final follow-up, such as volar tilt and radial inclination in the elderly group, and volar tilt in the young group. This loss of reduction did not affect the final functional outcomes. Other studies have also reported a small loss of reduction in elderly patients with complex intra-articular fractures [2,27]. Several authors have studied the ability of the volar plate fixation to stabilise complex intraarticular fractures. Using volar plating, Bini et al. [28] reported that the restoration of the radiological parameters was achieved in only 70% of the elderly patients. In contrast, Figl et al. [29] reported that volar plating allows exact anatomic reduction of the fracture without a late loss of reduction in 95% of the elderly patients with unstable distal radius fractures. Sharma et al. [3] found that volar plating for intra-articular fractures provided anatomical stable fixation and early mobilisation with better clinical and radiological outcomes as compared to conservative treatment. Unfortunately, functional outcomes were not reported in those studies. A recent study found a better reduction of the radio-carpal reduction in the fractures treated with arthroscopy assistance than those under fluoroscopic control [30]. However, another study reported that intra-articular distal radius fractures can be treated successfully with a fragment specific fixation under fluoroscopy, and the outcomes were similar than those under arthroscopy assistance [31]. In the present study, there was no incremented risk of complications in elderly patients. Quadlbauer et al. [32] reported 13% early complications including carpal tunnel syndrome, complex regional pain syndrome and loss of reduction. Likewise, 73% of these complications occurred in AO type-C fractures. Another large review [33] of distal radius fractures treated with volar plate found 11% complications and 10% revision surgery. The main reason for revision was median nerve compression. A study reported that a volar plate could mechanically affect the flexor pollicis longus tendon [34]. Using dorsal plating for intra-articular fractures, a revision rate as high as 50% for removal of the plate, due to discomfort has been reported [35]. The present study had several limitations. Both study groups had relatively small sizes but these intra-articular fractures are not frequent, and our study was similar in size to those previously published. The minimum follow-up in the present study was 2 years. However, previous studies have shown that outcomes do not vary greatly after two postoperative years and the long-term occurrence of post-traumatic arthritis is not related to functional outcomes [36]. In a meta-analysis, Margaliot et al. [37] reported rapid functional recovery after volar plating within one year after surgery. Another weakness was that those carrying out radiological measurements were not blinded to the functional outcomes. In conclusion, the study hypothesis was confirmed. The age of the patients has no influence on patient-rated, functional or radiological outcomes. Ulnar variance positive greater than 3 mm at baseline had significantly negative influence on the final DASH. The treatment in elderly patients by volar plate does not result in a significant higher early complication rate than in the younger ones. Our findings suggest that open reduction and internal fixation with volar plating in elderly patients with displaced intra-articular fractures of the distal radius represents a safe and effective treatment alternative.
Disclosure of interest The authors declare that they have no competing interest.
Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contribution A Lizaur-Utrilla did the study, analysed the data, and wrote the manuscript. A Lizaur-Utrilla, Daniel Martinez-Mendez, Maria F. Vizcaya-Moreno, Fernando A. Lopez-Prats were involved in the design, and data management. A Lizaur-Utrilla, Daniel MartinezMendez, Maria F. Vizcaya-Moreno, Fernando A. Lopez-Prats contributed to the study analysis. All authors read and approved the final manuscript. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.otsr.2019.05.010. References [1] Bolmers A, Luiten WE, Doornberg JN, Brouwer KM, Goslings JC, Ring D, et al. A comparison of the long-term outcome of partial articular (AO Type B) and complete articular (AO Type C) distal radius fractures. J Hand Surg Am 2013;38:753–9. [2] Earp BE, Foster B, Blazar PE. The use of a single volar locking plate for AO C3-type distal radius fractures. Hand 2015;10:649–53. [3] Sharma H, Khare GN, Singh S, Ramaswamy AG, Kumaraswamy V, Singh AK. Outcomes and complications of fractures of distal radius (AO type B and C): volar plating versus non-operative treatment. J Orthop Sci 2014;19:537–44. [4] Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomised trial comparing non-operative 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;93:2146–53. [5] Larouche J, Pike J, Slobogean G, Guy P, Broekhuyse H, O’Brien P, et al. Determinants of functional outcome in distal radius fractures in high-functioning patients over the age of 55. J Orthop Trauma 2016;30:445–9. [6] Toon DH, Premchand RA, Sim J, Vaikunthan R. Outcomes and financial implications of intra-articular distal radius fractures: a comparative study of open reduction internal fixation (ORIF) with volar locking plates versus nonoperative management. J Orthop Traumatol 2017;18:229–34. [7] Bartl C, Stengel D, Bruckner T, Gebhard F, ORCHID Study Group. The treatment of displaced intra-articular distal radius fractures in elderly patients: a randomised multi-centre study (ORCHID) of open reduction and volar locking plate fixation versus closed reduction and cast immobilisation. Dtsch Arztebl Int 2014;111:779–87. [8] Dario P, Matteo G, Carolina C, Marco G, Cristina D, Daniele F, et al. Is it really necessary to restore radial anatomic parameters after distal radius fractures? Injury 2014;45:21–6. [9] Brennan SA, Kiernan C, Beecher S, O’Reilly RT, Devitt BM, Kearns SR, et al. Volar plate versus k-wire fixation of distal radius fractures. Injury 2016;47:372–6. [10] Johnson NA, Dias JJ, Wildin CJ, Cutler L, Bhowal B, Ullah AS. Comparison of distal radius fracture intra-articular step reduction with volar locking plates and K wires: a retrospective review of quality and maintenance of fracture reduction. J Hand Surg Eur 2017;42:144–50. [11] Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin: Springer-Verlag; 1990. [12] Loisel F, Kielwasser H, Faivre G, Rondot T, Rochet S, Adam A, et al. Treatment of distal radius fractures with locking plates: an update. Eur J Orthop Surg Traumatol 2018;28:1537–42. [13] Beaton DE, Wright JG, Katz JN. Development of the Quick-DASH: comparison of three item-reduction approaches. J Bone Joint Surg Am 2005;87:1038–46. [14] MacDermid JC, Turgeon T, Richards RS, Beadle M, Roth JH. Patient rating of wrist pain and disability: a reliable and valid measurement tool. J Orthop Trauma 1998;12:577–86. [15] Medoff RJ. Essential radiographic evaluation for distal radius fractures. Hand Clin 2005;21:279–88. [16] Sorensen AA, Howard D, Tan WH, Ketchersid J, Calfee RP. Minimal clinically important differences of 3 patient-rated outcomes instruments. J Hand Surg Am 2013;38:641–9. [17] Mulders MAM, van Eerten PV, Goslings JC, Schep NWL. Non-operative treatment of displaced distal radius fractures leads to acceptable functional outcomes, however at the expense of 40% subsequent surgeries. Orthop Traumatol Surg Res 2017;10:905–9. [18] Leung F, Ozkan M, Chow SP. Conservative treatment of intra-articular fractures of the distal radius – factors affecting functional outcome. Hand Surg 2000;5:145–53.
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Please cite this article in press as: Lizaur-Utrilla A, et al. Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.12.008