Restoration Of Volar Tilt Research Articles

A Novel Trigonometry Equation; Precisely Restoring Distal Radius Volar Tilt

Introduction: Displaced distal radius fractures are often associated with loss of normal volar tilt. Restoration of volar tilt is critical for preservation of normal wrist biomechanics. There is no standardized way to reliably and predictably restore the volar tilt. We introduce a technique of using a locking screw in the most proximal hole of a locking plate to provide a predictable restoration of volar tilt in dorsally displaced distal radius fractures. The desired correction is dictated by the locking screw length to be used which can be calculated by the following equation: tan(θ) x d=b. In this equation, θ is the desired correction angle to restore the volar tilt, d is the distance from the locking screw to the volar bend of the plate, and b is the length of the locking screw. Methods: We performed a retrospective review of 20 patients who sustained distal radius fractures. The volar tilt status post closed reduction of the distal radius fracture was recorded for each patient. Additionally, the volar tilt status post open reduction internal fixation with our novel technique using a synthes 2.4mm volar plate was recorded for each patient. The length of the locking screw was documented and correction angle was calculated for each case. Results: The average volar tilt status post closed reduction of the distal radius fracture was -3.3 degrees. The average volar tilt status post open reduction internal fixation with our novel technique was 6.55 degrees. The resultant correction angle post-operatively was 10.75 degrees. The average length of the locking screw was 6.7 mm and the distance from the locking screw to the volar bend of the plate was 25 mm in all cases. Conclusion: Restoration of volar tilt is one of the most critical steps in the treatment of distal radius fractures. An accurate and highly reproducible technique is required to consistently achieve this goal. A simple technique using a locking screw in the most proximal hole of a locking plate can be utilized to restore the volar tilt accurately and reliably in dorsally displaced distal radius fractures.

Volar Locking Plate Versus Dorsal Locking Nail-Plate Fixation for Dorsally Displaced Unstable Extra-Articular Distal Radial Fractures: Functional and Radiographic Results from a Randomized Controlled Trial.

Background:The use of low-profile dorsal and volar locking plates for distal radial fracture surgery has improved results and lowered the complication rate compared with older plate designs. The purpose of the present randomized controlled trial was to compare patient-reported outcomes as well as radiographic and functional results between patients who underwent stabilization with a volar locking plate or a dorsal locking nail-plate for the treatment of dorsally displaced unstable extra-articular distal radial fractures.Methods:One hundred and twenty patients ≥55 years of age were randomized to surgery with either a volar locking plate or a dorsal locking nail-plate and were assessed at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year. The primary outcome was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Secondary outcomes were the Patient-Rated Wrist Evaluation (PRWE), EuroQol 5 Dimensions (EQ-5D) index and visual analog scale (VAS), range of motion, grip strength, radiographic measurements, and complication rate.Results:The median age was 66 years (range, 55 to 88 years). The rate of follow-up was 97%. There was no clinically important difference between the groups at any point during follow-up. Patients in the volar locking plate group had better mean QuickDASH scores at 6 weeks, 6 months, and 1 year. However, the differences were small (5.8 vs. 11.3 points at 1 year; mean difference, −5.5 points [95% confidence interval (CI), −9.9 to 1.2]; p = 0.014), which is lower than any proposed minimum clinically important difference (MCID). The difference in PRWE scores was also lower than the MCID (1.0 vs. 3.5 at 1 year; mean difference, −2.5 [95% CI, −4.4 to 0.6]; p = 0.012). The dorsal locking nail-plate group had slightly better restoration of volar tilt (p = 0.011). EQ-5D index, EQ-5D VAS, range of motion, grip strength, and complication rates were similar.Conclusions:We found no clinically relevant difference between the volar locking plate and dorsal locking nail-plate groups after 1 year or in the time period up to 1 year. A dorsal locking nail-plate can therefore be an alternative method for the treatment of these unstable fractures or in cases in which a dorsal approach is preferable over a volar approach.Level of Evidence:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Trigonometry-Integrated 'Lift' Technique (TILT) for Restoring Volar Tilt in Distal Radius Fractures: Description of Technique and Preliminary Results.

Restoration of extra-articular and intra-articular parameters are important considerations during operative fixation of distal radius fractures. Restoration of volar tilt by using visual estimation and the 'lift' technique has previously been described. The aim of our study was to describe a mathematical technique for accurately restoring the volar tilt of the distal radius to acceptable anatomic values. A retrospective review of cases performed using the trigonometry-integrated ' lift' technique (TILT) was performed. This technique uses the pre-operative volar tilt angle as well as the dimensions of the implant to calculate the 'lift' required to restore volar tilt. Intra-operative angles were measured using a marked transparency overlay on fluoroscopic images. Pre-operative and post-operative volar tilt were measured and analysed. Twenty-seven fractures were included in the study, with 20 being classified as Arbeitsgemeinschaft für Osteosynthesefragen (AO) C-type. Pre-'lift' volar tilt ranged from 0° to -20°. Post-'lift' volar tilt ranged from 2° to 16°, with all but three cases ranging from 5° to 15°. The mean volar tilt achieved was 10.2°. The trigonometry-integrated 'lift' technique resulted in reliable intra-operative restoration of anatomic volar tilt in distal radius fractures.

Leveraging the Plate: Reliably Restoring Volar Tilt of Distal Radius Fractures

Restoration of volar tilt is critical when performing open reduction and internal fixation of distal radius fractures. A reproducible technique is required to consistently achieve this goal. A simple technique using the locking plate and an electrocautery scratch pad as reduction tools can reliably generate volar tilt. This technique can be performed with minimal aid from surgical assistants.

Comparison of internal and external fixation of distal radius fractures

Background and purpose There is no consensus on the difference in effects of internal fixation (IF) and external fixation (EF) on outcomes for the treatment of distal radius fractures. We performed a meta-analysis of randomized clinical studies.Methods We searched the literature and included studies that compared the effects of IF and EF on the treatment of distal radius fractures. Statistically, we pooled patient data using standard meta-analytic methods. For the continuous variables, the weighted mean difference (WMD) was used. For dichotomous data, the relative risk (RR) was calculated.Results 10 studies were eligible for data extraction. The pooled data showed that compared with EF, IF led to statistically significantly better Disabilities of the Arm, Shoulder, and Hand (DASH) scores at 12 months postoperatively, recovery of forearm supination at 3 months, and restoration of volar tilt and radial inclination. IF using volar locking plates resulted in better DASH scores than EF at 3 and 6 months, but the trend diminished over time; at 12 months postoperatively, the scores were not statistically significant. Compared with EF, IF led to fewer minor surgical complications.Interpretation For surgical treatment of distal radius fractures, IF yields better functional outcomes, forearm supination, restoration of anatomic volar tilt and radial inclination, and fewer minor complications. The patients who received IF using volar locking plates for the treatment of distal radius recovered more quickly than did patients who received EF.

External Fixation Versus Internal Fixation for Unstable Distal Radius Fractures

There is no consensus on the surgical management of unstable distal radius fractures. In this systematic review and meta-analysis, we pool data from trials comparing external fixation and open reduction and internal fixation (ORIF) for this injury. We searched electronic databases (including MEDLINE, EMBASE, and SCOPUS) and conference proceedings from 1950 to 2009 in the English literature. We pooled data from 12 trials totaling 1011 patients (491 fractures treated with external fixation and 520 with ORIF). All randomized studies of external fixation to ORIF for unstable distal radius fractures were considered, and nonrandomized trials were included if and only if they directly compared external fixation with ORIF. Two authors independently extracted data from all eligible studies, including patient characteristics, sample size, fracture type, length of follow-up, intervention, and outcomes. Continuous variables were pooled across studies using the method of standard mean differences (SMD) or effect size. ORIF demonstrated significantly better Disabilities of the Arm, Shoulder, and Hand scores (SMD, 0.28; 95% confidence interval, 0.03-0.53; P = 0.03), recovery of forearm supination (SMD, 0.23; 95% CI, 0.08-0.38; P = 0.003), and restoration of volar tilt (SMD, 0.53; 95% CI, 0.34-0.72; P < 0.00001). However, external fixation resulted in significantly better grip strength (SMD, -10.32; 95% CI, -16.36 to -4.28; P = 0.0008), and subgroup analyses of randomized studies showed external fixation yielded better wrist flexion (SMD, -0.38; 95% CI, -0.58 to -0.17; P = 0.0004). For surgical fixation of unstable distal radius fractures, ORIF yields significantly better functional outcomes, forearm supination, and restoration of anatomic volar tilt. However, external fixation results in better grip strength, wrist flexion, and remains a viable surgical alternative. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.