Is VLP better than K-wiring for Colles Fractures?

Abbas Rashid FRCS (Tr&Orth) Wrightington Upper Limb Fellow

Changes in Practice

Koval et al. JBJS (Am) 2008

VLP: 42% in 1999 81% in 2007

no perceived improvement in outcomes

Hull et al. Hand Surg. 2010

50 surgeons

5 clinical scenarios

preferred management

52%: VLP for ALL cases 21%: K-wiring for all cases

little consensus

no high level evidence to guide surgeons

Cost differential

Shyamalan et al. Injury 2009

no prospective data on clinical effectiveness ? cost of technique

June 2007 to June 2008 Colles fracture N=20, (ORIF 10, K wiring 10)

difference of 1549 pounds and 65 min

K wiring VLP

Mean age 34 years 54 years

Mean time for op

56 mins 121 mins

cost 662 2212

VLP vs. K-wiring

Meier et al. Unfallchirurg. 2012

systematic review - 2002-2012

6 studies - 1: K-wiring superior - 2: VLP superior - 3: no difference

VLP restores radiographic parameters Complications: VLP 7.3% vs. k-wiring 20% - VLP complications more severe

VLP earlier functional recovery - disappears in long-term

Costa et al. BMJ. 2014

Prospective multicenter RCT [DRAAFT] 18 trauma centers N=461

PRWE, DASH, EQ-5D and complications

No difference at 3, 6, or 12 months No difference in health related quality of

life No difference in complications

no difference in functional outcome K-wiring cheaper and quicker

outcome after 2 years

Hull et al. J Trauma. 2011

retrospective comparative study

long-term functional outcomes VLP vs. K-wiring

N=71, VLP 36, K-wiring 35 2 independent hospitals measured from 15 to 27 months DASH & PRWE

No difference at 2 years

Fragment specific vs. VLP

Sammer et al. Plast Reconstr Surg. 2008

prospective cohort study N=99 [FS 14 vs. VLP 85]

XR, function, complications at 0,6 &12 months

VLP: more stable fixation better objective and subjective early outcomes fewer complications requiring reoperation

VLP FSF

Radial inclination No difference

No difference

Volar tilt

Radial length

Grip & Pinch Same at 1 year

Michigan hand outcome score

Same at 1 year

ROM Same at 1 year

Complications requiring surgery

!

Optimal screw length

Liu et al. PLoS One. 2014 18 specimens Randomized: - A=50% length, B=75% length, C=bicortical Force applied before and after cycling load to clinical and catastrophic failure

unicortical locking screws with 75% length early stability avoided extensor tendon complications

Mehling et al. J Hand Surg. 2010

16 pairs of fresh-frozen cadavers

randomized into 4 groups. - A: 4 screws in distal row ONLY - B: 4 screws (alternate rows) - C: 3 screws in proximal row ONLY - D: 7 screws in all holes

load to failure tests performed

Configuration D offered highest stability

min 4 screws in the distal fragment at least 2 in distal row

A B C

Stiffness to bending - - -

Stiffness to axial loading "

Load to clinical failure "

Load to catastrophic failure - - -

Complications

Bentohami et al. J Hand Surg. 2014

systematic review - prospective - comparative and cohort studies

complications with VLP

33 studies

overall complication rate 16.5% - Mostly minor

low rates of nonunion and malunion

safe treatment option

Infection Tendon complications DRUJ penetration Radiocarpal

penetration De-vascularisation Nerve injury CRPS stiffness

Conclusion

VLP biomechanically equivalent to DLP

Fewer complications than FSP

Apply proximal to watershed line

Fill distal holes

Screws should be 75% length

Conclusion

VLP biomechanically equivalent to DLP

Fewer complications than FSP

Apply proximal to watershed line

Fill distal holes

Screws should be 75% length

VLP

Superior DASH & PRWE scores < 3 months

x Not evident at 1 year x Grip strength NO better No long term differences

References Koval KJ1, Harrast JJ, Anglen JO, Weinstein JN. Fractures of the distal part of the radius. The evolution of practice over time. Where's the evidence? J Bone Joint Surg Am. 2008 Sep;90(9):1855-61. doi: 10.2106/JBJS.G.01569.

Hull P1, Baraza N, Whalley H, Brewster M, Costa M. Dorsally displaced fractures of the distal radius - a study of preferred treatment options among UK trauma and orthopaedic surgeons. Hand Surg. 2010;15(3):185-91.

Shyamalan G1, Theokli C, Pearse Y, Tennent D. Volar locking plates versus Kirschner wires for distal radial fractures--a cost analysis study. Injury. 2009 Dec;40(12):1279-81. doi: 10.1016/j.injury.2009.02.018. Epub 2009 Jun 13.

Meier R1, Krettek C, Probst C. Treatment of distal radius fractures. Percutaneous Kirschner-wires or palmar locking plates? Unfallchirurg. 2012 Jul;115(7):598-605. doi: 10.1007/s00113-012-2180-5.

Costa ML1, Achten J2, Parsons NR3, Rangan A4, Griffin D2, Tubeuf S5, Lamb SE6; DRAFFT Study Group. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial. BMJ. 2014 Aug 5;349:g4807. doi: 10.1136/bmj.g4807.

Hull P1, Baraza N, Gohil M, Whalley H, Mauffrey C, Brewster M, Costa ML. Volar locking plates versus K-wire fixation of dorsally displaced distal radius fractures--a functional outcome study. J Trauma. 2011 Jun;70(6):E125-8. doi: 10.1097/TA.0b013e3181e32714.

Sammer DM1, Fuller DS, Kim HM, Chung KC. A comparative study of fragment-specific versus volar plate fixation of distal radius fractures. Plast Reconstr Surg. 2008 Nov;122(5):1441-50. doi: 10.1097/PRS.0b013e3181891677.

Liu X1, Wu WD2, Fang YF3, Zhang MC3, Huang WH3. Biomechanical comparison of osteoporotic distal radius fractures fixed by distal locking screws with different length. PLoS One. 2014 Jul 31;9(7):e103371. doi: 10.1371/journal.pone.0103371. eCollection 2014.

Mehling I1, Mller LP, Delinsky K, Mehler D, Burkhart KJ, Rommens PM. Number and locations of screw fixation for volar fixed-angle plating of distal radius fractures: biomechanical study. J Hand Surg Am. 2010 Jun;35(6):885-91. doi: 10.1016/j.jhsa.2010.03.027.

Bentohami A1, de Burlet K2, de Korte N2, van den Bekerom MP3, Goslings JC4, Schep NW4. Complications following volar locking plate fixation for distal radial fractures: a systematic review. J Hand Surg Eur Vol. 2014 Sep;39(7):745-54. doi: 10.1177/1753193413511936. Epub 2013 Nov 21.