The aim of this study was to test the hypothesis that precise restoration of distal radius fractures is correlated to better patient-reported outcome.The correlation between radiographic results and functional outcome was explored in 156 patients with extra-articular distal radius fractures included in a multicenter, randomized controlled trial comparing 2 surgical interventions, Volar Locking Plate or External Fixator. The primary functional outcome was the Patient Rated Wrist and Hand Evaluation score (PRWHE). Radiographically we assessed volar tilt, radial inclination, radial height, ulnar variance, and the presence of ulnar styloid fracture. The Pearson correlation analysis was used to estimate correlations between parameters.At 1-year follow-up the mean difference in radiographic findings compared with the uninjured side (min, max) was: reduced volar tilt 5.3° (-15°, 25°), reduced radial inclination 2.3° (-6°, 12°), radial height 1.3 mm (-4 mm, 7 mm), and ulnar variance -0.5 mm (-6 mm, 3 mm). Overall, we found no correlation between radiographic parameters and the PRWHE at 1-year follow-up within the whole group, regardless of which treatment was chosen. At the time of injury 53% (N = 80) had sustained an additional ulnar styloid fracture. After 1 year this fracture was still radiographically present in 31% (N = 43) of the patients. No correlation between PRWHE score and the presence of an ulnar styloid fracture at 1-year follow-up was found.We found no correlation between functional outcome (PRWHE) and radiographic findings after 1 year in patients operated on with a Volar Locking Plate or External Fixator. Patient-specific factors were more important than radiographic measurements in this study group.Level of evidence: Therapeutic Level 2Trial registration: Norway: National Committee for Medical and Health Research Ethics 213/555ClinicalTrials.gov ID: NCT01904084Randomization of first patient: 02.09.2013.
Acute traumatic dislocation of the proximal fibula occurs in an anterolateral, posteromedial, or superior direction. The dislocation is seen both isolated and in combination with other injuries of the leg. A dislocation is an uncommon injury. We have recently treated three patients with this injury which we believe will illustrate some treatment aspects.Case 1: A 25-year-old man fell in a football match. He had pain in his leg especially proximally. There was a prominent fibular head on inspection. X-rays showed an anterolateral dislocation in the proximal tibiofibular joint. The dislocation was treated by closed reduction under spinal anesthesia. The joint was stable when tested subsequently. He avoided weight bearing for 2 weeks. At 6 months follow-up, the patient played football at the same level. Case 2: A 63-year-old man caught his right foot in a net and fell immediate pain and minimal swelling proximally on the leg. It was diagnosed as a tibiofibular dislocation. A computed tomography (CT) scan was conducted to confirm a dislocation in an anterolateral direction while waiting for surgery, the dislocation spontaneously reduced. The patient was treated with a cast, with non-weight bearing for 2 weeks. Six months after injury, the patient was without symptoms. Case 3: A 45-year-old woman got a large object on the proximal part of her right leg. She had an open wound over her proximal fibula. We found a posteromedial dislocation. Through the wound, the fibular head dislocation was reduced and temporarily (for 6 weeks) fixated with a screw. At 6 months follow-up, there was no restriction of movement in the knee and the proximal tibiofibular joint was stable. She still had occasional pain with full weight bearing.Anamnesis and clinical examination usually provide the diagnosis of proximal tibiofibular dislocation. X-ray (and CT scans) examination may be helpful. The treatment of acute traumatic dislocation is closed reduction. Open reposition and temporary fixation are required if closed reduction fails or if the joint is unstable (after reduction) and in the case of posteromedial dislocation. The prognosis is good if the joint is stable after closed reduction.
In this study we report the results of thumb carpometacarpal (CMC) joint replacements in the Norwegian population over a 17-year period. In total, 479 primary replacements performed from 1994 to 2011 were identified in the Norwegian Arthroplasty Register. Implant survival and risk of revision were analyzed using Cox regression analyses. Four different implant designs were compared and time trends were analyzed. The overall 5 and 10 year survivals were 91% and 90%, respectively. The newer metal total arthroplasties did not outperform the older silicone and mono-block implants. At 5 years, the implant survival ranged from 90% to 94% for the different implant brands. Gender, age, and diagnosis did not influence the risk of revision. The incidence of thumb CMC joint replacement did not change during the study period. Despite relatively satisfactory implant survivorship in our register study, current evidence does not support widespread implementation of thumb CMC replacements.
Background: The use of volar locking plate fixation (VLP) for unstable extra-articular distal radial fractures has increased in the last decades. External fixation (EF) is less frequently used. This change of surgical approach has only to some extent been evidence-based. Methods: In this multicenter, randomized controlled trial, we compared VLP and EF in patients between 18 and 70 years of age who had a displaced extra-articular distal radial fracture (OTA/AO type A3). The patients were examined at 6 weeks, 3 months, and 1 year postoperatively. The primary outcome measure was the Patient-Rated Wrist/Hand Evaluation score (PRWHE). Secondary outcomes were the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), pain score on a visual analog scale (VAS), and radiographic measurements. Range of motion, grip strength, finger stiffness, complications, and reoperations were also recorded. Results: One hundred and fifty-six patients were included. One hundred and forty-two (91%)—127 women (89%) and 15 men (11%)—completed 1 year of follow-up. Sixty-nine patients were treated with VLP and 73, with EF. The mean age was 56 years. At 6 weeks, the median PRWHE score was significantly higher in the EF group (44) compared with the VLP group (27) (p < 0.001). At 3 months and 1 year, the difference between groups was not significant. The median QuickDASH score was 27 in the VLP group and 43 in the EF group at 6 weeks (p < 0.001), and a significant difference persisted at 3 months (p = 0.023). The VLP group had superior results in terms pain during activity, wrist extension, and ulnar and radial deviation at 1 year, whereas the number of major complications was similar in the 2 groups. Conclusions: Patients treated with VLP had earlier recovery of function compared with patients treated with EF. One year postoperatively, we found no significant functional difference. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
AbstractWe have used open reduction and internal fixation (ORIF) with the AO π-plate in 32 displaced, intra-articular fractures of the distal radius. The indication was a displaced intra-articular fracture with a step-off of more than 1 mm and a gap between fragments of more than 3 mm, judged from the primary computed tomograms (CT). All fractures were classified as AO type C3. Twenty-nine patients were followed-up after a mean of 23 (9-46) months. The dorsal tilt, the radial length, the radial inclination, the articular step-off, and the intra-articular gap between fragments were substantially improved postoperatively. All the patients had excellent or good extra-articular and intra-articular alignment. Two patients had reduced extension power of the first finger. Seventeen patients had Disability of the arm, shoulder, and hand (DASH) scores of less than 10 points, five had scores between 11 and 20, three between 21 and 30, three between 31 and 40, and one patient had a score of 65 points. Complications occurred in two patients: one had a painful amputation neuroma of the superficial radial nerve, and one developed adhesions of the flexor tendons of the second and third fingers because the screws were too long and had penetrated the tendon sheaths. We conclude that the AO π-plate is an excellent option for the most comminuted fractures of the distal radius.KeywordsFractureDistal RadiusOpen ReductionAo π-plate
Background: External fixation is an established method of treating certain types of distal radial fractures. We have designed a dynamic external fixator to treat these fractures. The purpose of the present study was to compare this device with current static bridging external fixators in terms of anatomical and functional results. Methods: We conducted a prospective randomized study to compare the radiographic and clinical results of dynamic external fixation with those of static external fixation for the treatment of seventy unstable distal radial fractures. Mobilization of the wrist was begun in the dynamic fixator group on the day after surgery. The external fixation frames were kept in place for a mean of six weeks. The patients were assessed clinically and radiographically at the time of removal of the fixator and at three, six, and twelve months. Results: Dynamic fixation resulted in a significantly better restoration of radial length at all follow-up visits in comparison with static fixation. There were no significant differences in radial tilt or radial inclination between the two groups. Wrist flexion, radial deviation, and pronation-supination were regained significantly faster in the dynamic fixator group. Wrist extension was significantly better in the dynamic fixator group in comparison with the static fixator group at all follow-up times. Self-evaluation with use of the Disabilities of the Arm, Shoulder and Hand score and a visual analog pain score demonstrated no significant differences between the two groups at the time of the latest follow-up. Superficial pin-track infections were significantly more common in the dynamic external fixator group than in the static fixator group. Conclusions: Continuous dynamic traction with a dynamic external fixator compares favorably with the use of static external fixators for the treatment of unstable fractures of the distal part of the radius. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.
There is very little literature on the long-term outcome of wrist replacements. The Norwegian Arthroplasty Register has registered wrist replacements since 1994. We report on the total wrist replacements and their revision rates over a 16-year period. 189 patients with 189 primary wrist replacements (90 Biax prostheses (80 of which were cementless), 23 cementless Elos prostheses, and 76 cementless Gibbon prostheses), operated during the period 1994-2009 were identified in the Norwegian Arthroplasty Register. Prosthesis survival was analyzed using Cox regression analyses. The 3 implant designs were compared and time trends were analyzed. The 5-year survival was 78% (95% CI: 70-85) and the 10-year survival was 71% (CI: 59-80). Prosthesis survival was 85% (CI: 78-93) at 5 years for the Biax prosthesis, 77% (CI: 30-90) at 4 years for the Gibbon prosthesis, and 57% (CI: 33-81) at 5 years for the Elos prosthesis. There was no statistically significant influence of age, diagnosis, or year of operation on the risk of revision, but females had a higher revision rate than males (RR = 3, CI: 1-7). The number of wrist replacements performed due to osteoarthritis increased with time, but no such change was apparent for inflammatory arthritis. The survival of the total wrist arthroplasties studied was similar to that in other studies of wrist arthroplasties, but it was still not as good as that for most total knee and hip arthroplasties. However, a failed wrist arthroplasty still leaves the option of a well-functioning arthrodesis.
