Our study has certain limitations. Certainly, the sam- ple size was limited and the overall follow-up was around 1 year. However, we feel that despite the limited number, our study is valuable for the following reasons: 1. It represents a single-surgeon experience for surgery and two experienced surgeons for follow-up. 2. In all pa- tients, we waited to submit the clinical result after com- pletion of physical functioning and return to work. In distalradiusfractures, this is achievable within 3 months after injury. 3. We were pleased with the radiolucency of the implant, allowing for proper assessment of healing in every X-ray on follow-up. In this respect, radius frac- tures differ from other injuries, such as tibial or femur shaft fractures.
A number of studies have analysed the functional out- come after locking plateosteosynthesis for displaced fractures of the proximal humerus [3, 4]. Clinical func- tion i.e. Constant Score improved after six to twelve months to 91 % of the contra-lateral uninjured side . After this period, the Constant Score doesn’t further improve significantly as reported by Hirschmann et al. . In several outcome studies, proximal humerus frac- tures treated with plateosteosynthesis achieved a Con- stant score from 61 to 75. This value correlates to about 80–90 % of the Constant score of the uninjured shoulder with a score around 80 [3, 4, 10, 11]. We recorded a Constant score in our population of 71 before implant removal. Therefore, a large improvement with continu- ing conservative and physiotherapy would not have been expected. Meteorosensitivity and impingement might be a reason for the persisting functional impairment and discomfort. It is therefore not surprising, that implant removal is an offered solution to potentially improve function. Lovald et al. assessed the incidence of implant removal after humerus (proximal, shaft and distal) . They found that implant removal was performed in about 10 % of all cases But it seemed, that many of these procedures were associated with the type of health care insurance in the US and age of the patients. Richards et al. confirmed age as a major influential factor for implant removal [9, 12].
The traditional method of open reduction and plate fixation for distalradius requires wide exposure of the fracture site with stripping of the soft tissues which may devascularize the fracture fragments . This will contribute to the necrosis caused by trauma itself or operation and, consequently, increase the risks of delayed healing and infection. Minimally invasive plateosteosynthesis (MIPO) was developed to avoid wide exposures of the fracture site and minimize soft tissue damage . It has been used most frequently for fixation of lower extremity fractures [3,4]. More recently, its use
outcomes in the treatment of distalradiusfractures using plateosteosynthesis are achieved in spite of a high incidence of complications . Based on the criteria for success- ful treatment , our results are excellent and are similar to those described by other authors for the treatment of distalradiusfractures with volar locking plates [, ]. In one APTUS patient, injury to the extensor pollicis longus tendon was caused by a screw penetrating through the dorsal corticalis. It was managed by implant removal and repair of the rupture with tendon transfer. Th is damage can be avoid- ed by a careful operative technique with use of ﬂ uoroscopic guidance during screw insertion to prevent penetration of a screw through the dorsal corticalis of the distalradius. The loss of correction was the most serious complication. Two APTUS patients (. ), women with osteopenia aged and years, experienced secondary displacement of type A3 and type C3 fractures, respectively. Revision sur- gery was not indicated; no patient wanted to have the im- plant removed. Koenig et al. performed a study to evaluate whether early internal ﬁ xation or non-operative treatment is preferred for displaced, potentially unstable distal radial fractures with initial adequate reduction. They found that internal ﬁ xation with a volar plate provided a higher prob- ability of painless union for potentially unstable distalradiusfractures. However, patients older than years, who had lower risk of symptomatic malunion seemed to prefer non- operative treatment . Our results of the APTUS group confirm this statement. Because due to poor bone quality even angle-stable plate does not suﬃ ciently guarantees good stability for all bone fragments. On the other hand, the risk of fracture re-displacement in a plaster cast is higher in os- teoporotic bone compared to healthy bone. Clayton et al.  identiﬁ ed a high correlation between bone mineral density
Rohit Arora, et al.(2007): In Austria, 114 patients who had displaced, unstable fractures involving the distalradius were treated with ORIF using palmar LCP of 2.4mm size and followed up over a minimum time frame of 12 months. All the data based on the clinical and radiological findings were analyzed at the end of the research period and it was found that fixation with fixed angled plates allowed only a minimal loss of reduction and thereby provided stability to formerly unstable dorsally displaced fractures involving the distalradius (18) .
ments, the bone shape was checked 3D. Reduction of the fragment was performed to regain the volar tilt and radial inclination, with a less than 2 mm step-off for the intra-articular displacement referring to a healthy side wrist X-ray. If there was fracture comminution, the frag- ments were separated based on up to 5 mm bone frag- ments. In the second step, simulations of the volar locking plate implantation with various sizes of plates and screws were performed. Stellar II locking plates (HOYA Technosurgical, Inc., Tokyo, Japan) were used in this study. This plate system has small, medium, and large sizes for the width, and short and long sizes for the plate length. Screw lengths from 10 to 24 mm for the distal (2.4 mm diameter) and 10 to 20 mm for the prox- imal (2.6 mm diameter) are available. Computer-aided design models of different-sized implants were installed in the software. The plate size was chosen to cover the distal fragment maximally and not exceed the width of the distalradius. The screw lengths for each screw hole were determined. All patients had pre- and postoperative CT scans in order to compare the planned and postop- erative reduction shape and placement of the implant.
S.G Pneumatocos studied 25 consecutive patients with volar plating of which 13 patients with intra- articular fracture distalradius shows good results while 9 patients with extra-articular fractures show excellent results . Above mention author’s studies had comparable or in positive association with our study as we noticed satisfactory outcome (DASH <50) was observed in 60(69.77%) cases while 26(30.23%) were unsatisfactory, and concluded that palmer T-plate could be the favorable method for fixing unstable distalradius fracture. In our study with respect to age, satisfactory outcome was observed in 70% of age group 22 to 30 years of age patients, 60% satisfactory result noted in 31 to 40 years of age patients while 72.2 % satisfactory outcomes noted in 40 to 50 years of age group patients. Significant difference was not observed among the age (p=0.87). Dumont C et al in their study compared group 1 (younger than 60 years, n=88) vs. group 2 (older than 60 years, n=78). The patients’ evaluation of the usability of the hand was normal in 56% and in 26.5% slightly reduced. 12.5% felt handicapped and 5% felt severely handicapped. Function according to Lidström: 23% excellent, 58% good, 15% fair and 4% poor results. Radiological results according to Lidström were excellent and good in 88.3% and fair in 11.7%. Gartland and Werley score was excellent in 66%, good in 24%, fair in 6% and poor in 4%. They also noted no significant difference between group 1 and group 2 in the age-depending results.
The patients were randomized into two groups using random number tables generated online (http://www. graphpad.com/quickcalcs/randomize1/). The external fixa- tion technique was chosen for group 1 and volar locking plates were chosen for group 2. All surgical procedures were performed by a single author (RS) at a single institute using standard protocols under general or regional anes- thesia.The general external fixation technique used two 2.5-mm Schanz pins in the second metacarpal and two 3.5- mm pins in the radius proximal to the fracture. The pins were interconnected and tightened with solid connecting rod and link joints. After application of a frame, reduction
Fixed-angle volar plates can adequately stabilize artic- ular fragments and both volar and dorsal comminution, even in osteoporotic bone [8, 9]. Optimal positioning of the plate, with screws and pins placed in the subchondral position, restores radial length and radial and palmar tilt, acting as an internal fixator; indirect reduction of the dorsal aspect of the radius avoids damaging bone vascularity in comminuted fractures, reducing or avoiding the need for bone grafting. Using long plates, the metaphyseal and distal diaphyseal fracture is bypassed and the plate fixed proximally with at least three screws in the healthy diaphyseal bone. In multifragmented and highly commi- nuted fractures, multiple wire loops or single cortical screws can be used to improve stability and the reduction of the metadiaphyseal part of the radius. The rationale behind this technique is to obtain optimal stability of the fracture, restoring radial length and correct radioulnar and radiocarpal relationships, avoiding interference with soft tissues, and allowing an early functional recovery. As the plate is positioned deep and covered by muscles, interfer- ence with tendons is rare; elsewhere, there is no need to remove the hardware. Associated ulnar head fractures are treated with percutaneous pin fixation or ORIF depending on the stability of the fracture [10, 11]. In our cases, this technique led to the consolidation of all fractures except one that needed a secondary bone grafting. Optimal reduction was achieved in most cases (16 out of 21); in particular, restoration of radial length was obtained in all cases with average ulnar variance of 0°. Two patients healed with an articular step; clinical results were graded as good and fair. No case showed loss of reduction during the treatment. Imperfect reduction was found to be associated with higher DASH scores (P = 0.0006). A clinical evalu- ation revealed satisfactory results in 19 cases out of 21. Two cases had poor results—one associated with articular incongruity and one due to radioulnar synosthosis. The latter case was operated on 12 months from the first intervention with almost complete recovery of forearm rotation. Extra-articular A3 fractures showed better results than articular C2 and C3 fractures, but no significant dif- ferences were noted among these two groups (P = 0.2). Associated ulnar fractures are generally the consequence of a high-energy trauma; despite that, they did not produce significant effects on the outcome (P = 0.4). Even though the fractures appeared extremely comminuted in some cases, bone grafts or substitutes were never used. In C3 fractures with multiple small articular fragments, adequate fixation with periarticular plates may be difficult and, in
outcomes reported that nonoperative treat- ment might be the preferred method of treat- ment in elderly population, in spite of better radiographic results (dorsal tilt, radial inclina- tion, and radial shortening) in patients treated by volar fixed-angle plate fixation than those by cast immobilization , because unsatisfac- tory radiographic outcome in older patients did not necessarily translate into unsatisfactory functional outcome. Considering the shorter following-up in our study, a further prospective study with a long follow-up time was needed. As most of elderly unstable DRF patients were usually associated with hypertension, diabe- tes, chronic bronchitis and other internal dis- eases, preoperative assessments of operative and anesthesia risks were necessary. Except for preoperative preparations, some details of operative procedure should be also noted: 1) For elderly unstable DRF patients with osteopo- rosis, especially female patients, Kirschner wire will be needed for temporary fixation after the completion of the reduction; the plate should be placed 2-3 mm under the articular surface. If it was too low below the articular sur- face, fixation would not be solid, as evidenced Table 4. Preoperative and postoperative radiological measurements
Donor site morbidity, especially at the iliac crest, has been well described and minor complications such as persistent pain at the harvest site, superficial sensory nerve injury, superficial hematoma or seroma and superficial infection have been reported . Moreover, a volar approach is easier than a dorsal approach and the reduction of the volar cortex is simple because of less comminution and the advantage of direct vision . The present study showed that a corrective osteotomy using a volar locking plate without the use of bone grafting could effectively produce a significant improvement in wrist function in patients treated for extra-articular distalradius malunion. We obtained an excellent correction of deformity based on radiographic parameters, with low morbidity and no non- unions, hardware failure or need for hardware removal. Our results are in line with those reported by Mahmoud et al. , who treated 30 malunited dorsally-angulated radii using fixed-angle volar locking plates without bone graft- ing, obtaining at a mean 18-month follow-up radiological evidence of union, correction of the deformity, and clinical and functional improvement in all cases. In particular, the improvement in the DASH and Mayo scores obtained in the present study was 28.5 and 42.8 points, respectively, compared with the 21.6 and 22.7 points reported by Mahmoud et al. . These differences in functional out- come can probably be explained by the longer follow-up period of the present research. Favorable results have also been reported in numerous studies following volar locking plates with additional bone graft [18, 19]. The volar approach and the use of locking plates is an extremely effective and safe technique; in fact, the use of fixed-angle locking plates reduces the risk of postoperative bone dis- placement, and requires a shorter immobilization time [20, 21]. Moreover, the mechanical strength provided by this construct does not necessarily require the use of bone grafting. We therefore believe that the volar approach and locking plate, without necessarily the use of bone grafting, is an effective technique for addressing symptomatic and even severe deformities of the distalradius, and should be preferred especially in elderly patients with poor bone
Locking volar plates mechanically bridge the bone and bear the load through the locking construct, resulting in a lower incidence of failure. The subchondral placement of distal screws is essential to prevent a loss of correction and to achieve good functional results (5). Comminuted distal end radiusfractures may require the use of additional fixa- tion methods such as Kirschner wire and dorsal plate in ad- dition to volar fixed-angle plates. This is because the volar fixed-angle locking plates allow the screws to be inserted in a predefined direction, and they do not take into account the personality of the fracture and any variability in the po- sitioning of the plate. This type of fracture can be better managed with the use of a variable-angle plate as it allows greater flexibility in terms of screw angle insertion and the engagement of periarticular fragments (7).
fractures only; however, this could be attributed to the more demanding surgical technique of dorsal plating with possible devascularization of soft tissues and bony struc- tures, as well as the iatrogenic tendon injury with the addition of longer operative time. Additionally, the posi- tioning of dorsal plates right under the tendon sheaths can further irritate the tendons postoperatively and lead to implant-associated pain. While implant removal rates in the dorsal group were also significantly higher, it was interesting that in almost half of the cases, implant removal was initiated by the patients themselves, even in the absence of objective impairment. The problem of foreign body feeling has not yet been overcome, even afterplate design optimization . We generally do not advocate an implant removal unless hardware-associated tendon pathology or functional impairment is present.
In conclusion, our meta-analysis compared IMN versus MIPPO for the treatment of tibial fractures. The results demonstrated high rate of wound complications, longer operation time, and a longer time to union with MIPPO when compared to IMN. Regarding the functional out- comes, IMN and MIPPO demonstrated similar findings using AOFAS and FFI. Based on DRI, patients might have slightly better outcomes when using IMN. In total, IMN demonstrated had more advantages than MIPPO and was preferred for patients with distal tibial fractures. In future, larger RCTs and RCTs by matching age, sex, and severity degrees of the patients should be conducted for detecting important differences.
There was a significant difference in the final outcome in both the study groups, assessed using The Modified Green O‟Brien System. However, we preferred using the external fixator application in the treatment of intra-articular fractures of the distalradius (Frykman Type VII and VIII). Although open reduction and internal fixation has advantages such as direct visualization and manipulation of the fracture segments, stable fixation and the possibility of immediate postoperative motion but we preferred the use of external fixator since it provides continuity of reduction under fluoroscopic control, improved reduction by ligamentotaxis, 15 and the ability to protect the reduction until
Mean age in our study was 38.5 years with maximum patients in age group of 18-50 years (80%) which comparable with other studies (21) . Males predominated our study with 27 male patients and 13 female patients .The increased incidence of male sex in distal end radius can be attributed to an over whelming large proportion of male patients and high outdoor activities and the female population largely work indoors (21). Right hand was slightly more involved than left hand. RTA and fall from height was mode of trauma in 85% cases. Around 62.5 % of the study population had type III or type IV fracture according to Frykman’s classification. Similar results
period, clinical and radiographic results were evaluated and the complications were assessed. Intraoperative complica- tions were excluded. Late complications, including implant cutout, Z-effect, reverse Z-effect, calcification of the tip of the greater trochanter, femoral neck shortening, nonunion, malunion, cortical thickening at the distal locking region, broken locking screw, broken PFN, and diaphyseal femoral fractures, were considered during radiographic assessment. The relationship between the complications and SWS
perforations with rates between 8 %–20 %, avascular necrosis between 10 %–33 %, loss of fixation up to 16 %, impingement up to 6 %–11 % and infection between 4 %–19 % [10, 21]. In this study, we found complication and reoperation rates of 30 % for patients treated with the PHILOS plate and 23 % for the Humerusblock. Radiologic signs of AVN were found in 4 patients in the PHILOS group and in 2 in the Humerusblock group. Oc- currence of AVN is influenced not only by surgical factors but also by nonsurgical factors, such as fracture type, medial hinge, short calcar fragment or head split fracture, as well as the comorbidities of the patient . However, nonanatomical reduction and extended soft tissue dissec- tion are suggested to promote AVN development [22, 23]. The Humerusblock is removed from the fracture zone without harming soft tissue in the injured area. Reduction is performed in a closed or percutaneous manner, thus preserving remaining periosteal bridges between fracture fragments and reducing the risk of AVN [8, 12, 13]. Unlike pin perforation after treatment using the Humerusblock, screw cut-out after angular stable plating is a serious com- plication . In the literature, screw perforations seem to be one of the most frequent complications after plating, with reported rates up to 20 % [11, 24]. In a study by Jost et al. , 57 % of patients with screw perforations showed glenoid destruction, and this represents a devas- tating complication. In our study, 5 patients with screw perforations needed reosteosynthesis. In contrast to screw perforation, in angular stable plating, pin perforation after treatment using the Humerusblock, as long as the tips of the k-wires do not aim at the glenoid surface, is consid- ered a minor complication. Quite to the contrary, the Humerusblock allows for the dynamic stabilization and controlled sintering and fracture consolidation of the head fragment. In this study, pin perforation occurred in 2 pa- tients (7 %), but rates up to 41 % are reported in the litera- ture . In the studies by Brunner et al.  and Bogner et al. , secondary impaction of the head leads to k-wire perforation in 22 % and 10 % of patients, respectively. Pin perforation can be easily detected in standard x-rays. Treatment is simple and doesn’t influence final outcome or bony healing . If pin perforation occurs before bony healing and the k-wires aim at the glenoid surface, re- trieval at the subcortical level is performed under local anesthesia. If the k-wires don’t aim at the glenoid sur- face, immediate k-wire removal after bony healing and before sling removal is performed. In general, the Humerusblock is not required to be removed. As men- tioned, such as in angular stable plates, only in cases of k-wire perforation or due to the wish of the patient should the Humerusblock be removed.
The failure of the procedure in the presented osteotomy case is after a delayed union. Hardware failure during fracture healing has generally occurred after either a delayed union  or nonunion, although delayed union/nonunion of these osteotomies is very uncommon [5–7]. The possible causes of the delayed union in our case include biological factors (no bone graft on the osteotomy site) and mechanical factors (unfilled screw holes, large corrective lengthening osteotomy, and insufficient immobilization). We had not used bone graft according to some authors [5–7], who recommend that the volar cortex can be fixed directly with a VLP without structural bone grafting, even in severe deformities and osteoporotic bone. A segmental bone defect of 6 mm, where
In a diagonally opposite prospective randomized study of 85 distal tibia fractures managed with either IM nailing or minimally invasive plateosteosynthesis (44 nailed, 41 plated), Guo et al (64) found that all fractures united with no statistically significant difference in pain, function, or alignment based on American Orthopaedic Foot and Ankle Society scores. Their study had stricter inclusion criteria (purely extra articular and closed fractures).Co morbid conditions of patients relevant to fracture healing were excluded. Patients were also excluded if they required fibular plating. They found a wound complication rate of 14.6% in MIPO as compared to 6.8% in the IM nailing group.