Boyer, Martin

Martin Boyer

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The Journal of Bone and Joint Surgery (American)

Volar Locking-Plate and Kirschner-Wire Fixation Did Not Differ in Terms of Functional Outcomes After Dorsally Displaced Distal Radial Fracture

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Washington University School of MedicineDigital Commons@BeckerOpen Access Publications2015Volar locking-plate and kirschner-wire fixation didnot differ in terms of functional outcomes afterdorsally displaced distal radial fractureMartin BoyerWashington University School of Medicine in St LouisFollow this and additional works at: http://digitalcommons.wustl.edu/open_access_pubsThis Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in OpenAccess Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact engeszer@wustl.edu.Recommended CitationBoyer, Martin, ,"Volar locking-plate and kirschner-wire fixation did not differ in terms of functional outcomes after dorsally displaceddistal radial fracture." The Journal of Bone and Joint Surgery.97,10. 859. (2015).http://digitalcommons.wustl.edu/open_access_pubs/4493Evidence-Based OrthopaedicsVolar Locking-Plate and Kirschner-Wire Fixation Did Not Differ inTerms of Functional Outcomes After Dorsally Displaced DistalRadial FractureCostaML, Achten J, ParsonsNR, RanganA,GrifﬁnD, Tubeuf S, Lamb SE; DRAFFT StudyGroup. Percutaneous Fixationwith KirschnerWires VersusVolar Locking Plate Fixation in Adults with Dorsally Displaced Fracture of Distal Radius: Randomised Controlled Trial. BMJ. 2014 Aug 5;349:g4807.Question: In patients with a dorsally displaced fracture of thedistal part of the radius, how does volar locking-plate ﬁxationcompare with Kirschner-wire ﬁxation?Design: Randomized (allocation concealed), blinded (datacollectors and outcome assessors), controlled trial with twelvemonths of follow-up (Distal Radius Acute Fracture FixationTrial [DRAFFT]).Setting: 18 centers in the United Kingdom.Patients: 461 patients ‡18 years of age (mean age, 59 years;84% women) who had a dorsally displaced fracture of thedistal part of the radius within 3 cm of the radiocarpal joint inthe past 2 weeks. Exclusion criteria were a fracture extending.3 cm from the radiocarpal joint, open fracture, inabilityof the fracture to be reduced with indirect techniques, orcontraindication to anesthesia. 416 patients (90%) completedfollow-up.Intervention: Patients were allocated to volar locking-plateﬁxation (n= 231) or Kirschner-wire ﬁxation (n= 230). Locking-plate ﬁxation involved an incision over the volar aspect of thewrist. The screws in the distal portion of the bone were screwedinto the plate at a ﬁxed angle. The surgical approach, type of plate,and number and conﬁguration of screws were decided by thesurgeon. During Kirschner-wire ﬁxation, the wires were passedthrough the skin over the dorsal aspect of the distal part of theradius and into the bone. The size, number, and conﬁguration ofwires and the insertion technique were decided by the surgeon.All patients received the same postoperative advice.Main outcome measures: The primary outcome measurewas the Patient Rated Wrist Evaluation (PRWE) (100 points,with higher scores indicating worse outcome). Secondaryoutcomes were the Disabilities of the Arm, Shoulder andHand(DASH) score (100 points, with higher scores indicating moredisability) and health-related quality of life measured with theEuroQol questionnaire (EQ-5D) (ranging from 1 [perfecthealth] to 0 [death]). Complications included refracture,neurological injury, vascular injury, tendon injury, superﬁcialwound infection, and deep wound infection.Main results: The study had ‡80% power to detect a 6-pointdifference between groups. Analysis was by intention to treat.No difference was seen between the groups in terms of thePRWE score at twelve months (Table). A borderline differencebetween groups was seen for the DASH score, favoring thelocking-plate group; no differences were seen for the EQ-5D(Table). The locking-plate and Kirschner-wire groups hadsimilar rates of complications, including refracture (1% vs.1%), neurological injury (6% vs. 9%), vascular injury (0% vs.0%), tendon injury (2% vs. 3%), superﬁcial infection (8%vs. 5%), and deep infection (,1% vs. ,1%).Conclusion: In patients with a dorsally displaced fractureof the distal part of the radius, no differences were seen infunctional outcomes between treatment with volar locking-plate and Kirschner-wire ﬁxation.Source of funding: Health Technology Assessment scheme of theNational Institute for Health Research.For correspondence: Professor M.L. Costa, Warwick Clinical Trials Unit,University of Warwick, Coventry CV4 7AL, U.K. E-mail address:matthew.costa@warwick.ac.ukCommentaryMany questions remain unanswered by this randomized, blinded, controlled trial byCosta and colleagues. Most notably, why were the postoperative results in the ﬁrst sixweeks, when the beneﬁts of internal plate ﬁxation might reasonably be expected to bemost obvious, not reported? In addition, the absence of any sort of radiographic follow-up or estimation of articular or extra-articular reduction in the two groups leaves thefollowing question unanswered: Given that the two groups were not statistically differentat one year, is there a reasonable expectation of either equality or non-difference afteradditional follow-up? If one recalls the data of Goldfarb et al. demonstrating the totalabsence of a correlation between radiocarpal osteoarthritis and disability at ﬁfteen yearsof follow-up1, this may not matter; however, the data gathered during this study could beuseful in this regard.Other difﬁculties with the study are that a substantial number of the operativeprocedures were done by “trainees” and that some of the complications and neurologicalinjuries were reported in a selective manner. Because of this, questions remain. How does onerefracture a distal part of the radius that was treated operatively with internal ﬁxation? Wereplates removed? Were these pin injuries to the lateral antebrachial cutaneous nerve andinternal ﬁxation injuries to the median and ulnar nerves?These concerns notwithstanding, the authors showed that if the surgeon is facile ateither percutaneous pinning or internal ﬁxation of these fractures, similar functionalresults might be reasonably expected at one year of follow-up. What this study does not tellus is whether early postoperative function is improved in either group or whether eithermethod is better in terms of obtaining and maintaining operative reduction. The long-term functional sequelae of these issues remain unknown.Martin Boyer, MD, MSc, FRCSCWashington University School of Medicine,St. Louis, MOReference1. Goldfarb CA, Rudzki JR, Catalano LW, Hughes M, Borrelli J Jr. Fifteen-year outcome of displaced intra-articular fractures of the distal radius. J Hand Surg Am. 2006 Apr;31(4):633-9.Volar locking plate vs. Kirschner wires for dorsally displaced distal radial fracture at twelve months*Outcomes Volar locking plate Kirschner wire Treatment effect (95% CI)†PRWE 13.9 15.3 21.3 (24.5 to 1.8)DASH 13.0 16.2 23.2 (26.5 to 0.0)EQ-5D 0.85 0.83 0.02 (20.02 to 0.06)*PRWE = Patient Rated Wrist Evaluation (100 points, with higher scores indicating worse outcome); DASH = Disabilities ofthe Arm, Shoulder and Hand (100 points, with higher scores indicating more disability); EQ-5D = EuroQol questionnaire(ranging from 1 [perfect health] to 0 [death]); CI = conﬁdence interval.†Adjusted for treatment group, age, sex, intra-articularextension, and recruiting center.Disclosure: The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. He, or his institution, has had a ﬁnancialrelationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to inﬂuence or have the potential to inﬂuence what is written in this work.The author has not had any other relationships, or engaged in any other activities, that could be perceived to inﬂuence or have the potential to inﬂuence what is written in this work. The completeDisclosuresof Potential Conﬂicts of Interest submitted by authors are always provided with the online version of the article.J Bone Joint Surg Am. 2015;97:859 d http://dx.doi.org/10.2106/JBJS.9710.ebo101859THE JOURNAL OF BONE & JOINT SURGERY d J B J S .ORGVOLUME 97-A d NUMBER 10 d MAY 20, 2015EVIDENCE-BASED ORTHOPAEDICS

Volar locking-plate and kirschner-wire fixation did not differ in terms of functional outcomes after dorsally displaced distal radial fracture

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Volar locking-plate and kirschner-wire fixation did not differ in terms of functional outcomes after dorsally displaced distal radial fracture

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