More Evidence That Volar Locked Plating for Distal Radial Fractures Does Not Offer a Functional Advantage Over Traditional Treatment Options: Commentary on an article by Alexia Karantana, FRCS(Orth), et al.: “Surgical Treatment of ...
第一作者：Charles S. Day
2013-11-20 我要说
More Evidence That Volar Locked Plating for Distal Radial Fractures Does Not Offer a Functional Advantage Over Traditional Treatment Options: Commentary on an article by Alexia Karantana, FRCS(Orth), et al.: “Surgical Treatment of Distal Radial Fractures with a Volar Locking Plate Versus Conventional Percutaneous Methods. A Randomized Controlled Trial”
Charles S. Day,Keiichiro Maniwa, Wei Kang Wu
Distal radial fracture is one of the most frequent fractures in the upper extremity, with a multitude of treatment options. Despite the lack of evidence to justify the trend, there is a noticeable shift away from percutaneous fixation in favor of treatment with a volar locking plate1. While volar plates were designed to minimize complications such as tendon irritation2, their theoretical superiority over other treatment methods has yet to be demonstrated scientifically.
In this prospective randomized study, Karantana et al. compared two techniques of fixation for distal radial fractures: open reduction and internal fixation (ORIF) with use of a volar locking plate and closed reduction and percutaneous pinning with or without external fixation. Functional outcome assessments were conducted at six weeks, twelve weeks, and one year. The authors found that scores of the Patient Evaluation Measure (PEM) and QuickDASH (a shortened version of the Disabilities of the Arm, Shoulder and Hand Outcome Measure) were significantly better for patients in the volar locking-plate group at six weeks, but these scores were similar between the groups by twelve weeks and at one year. In 2009, a similar study performed at two hospitals in our academic medical system also compared the results of ORIF with those of closed reduction and percutaneous pinning in a prospective randomized fashion. We found similar outcomes comparing the two treatment groups at one year3. However, the difference in DASH scores in our study remained significant at twelve weeks, with no other measurement intervals until one year. That means that the difference in functional outcomes between groups in our study could potentially have been present up to one year after surgery. These two studies demonstrated that there was no difference in functional outcomes beyond the short term despite the technical differences between volar plating and pinning. However, there was a difference in short-term functional recovery. While our study suggested that the functional difference might have been present for as long as a year, Karantana et al. demonstrated that the functional difference between the two treatment groups might not have been present after six weeks.
Additionally, in both studies, the postoperative immobilization period differed between the two surgical techniques. Patients in the ORIF group started moving their wrist one to two weeks after surgery, whereas patients in the group treated with closed reduction and percutaneous pinning had the wrist immobilized for six weeks3. When the first functional outcome scores were determined at six weeks in both studies, the ORIF group demonstrated better results. This difference at six weeks may be due to the longer immobilization period following closed reduction and percutaneous pinning, rather than the result of a difference in initial fixation techniques.
In examining the correlation between anatomical alignment and functional outcomes, Karantana et al. found that the volar locking-plate group had significantly better radiographic palmar-tilt measurements at six weeks and at one year than those of the group treated with closed reduction and percutaneous pinning. Despite this radiographic difference, there was no functional difference after six weeks. This demonstrates a lack of association between radiographic alignment and functional outcomes beyond the short term. This was also suggested by numerous other studies comparing nonsurgical treatment with surgical treatment techniques in an older population4-6.
These studies have demonstrated uniformly that there is no significant difference in functional outcomes beyond the short term, whereas radiographic outcomes are significantly different. However, one important feature of the study by Karantana et al. is that it included patients of all ages, which implies that the lack of correlation between functional and radiographic outcomes may, in fact, extend beyond just the older population.
京公网安备11010502051256号