Distal Radius Fractures- Volar Plating for All Frontiers in Upper Extremity Surgery 2017 Francisco Rubio, M.D. Miami Hand and Upper Extremity Institute Miami, FL Disclosure Skeletal Dynamics- Consultant 85% Dorsal 15% Volar 1
1970 - AO Anatomical Reduction Stable Fixation Early Function Dorsal Plate Fixation Extensor Tendon Disturbance Limited Motion Plate Removal 2
1994 Fragment Specific Fixation 1995 - Distal Radius Locking Plate Fixation π-plate - Distal fragment does not toggle - Provides stable distal fixation in comminuted or osteoporotic bone Extensor Tendon Ruptures 3
- Plate redesign The Dogma Dorsal Fracture Dorsal Plate Palmar Fracture Palmar Plate 4
PQ PQ The volar approach seldom presents flexor tendon problems Operative Treatment of Volar Intra-Articular Fractures of the Distal End of the Radius. - Jupiter JB, Fernandez DL, Toh CL, Fellmann T, Ring D. J Bone and Joint Surg. 78A: 1817-1828 1996 5
A new method of treatment Volar management of the dorsal fracture 1997 Ineffective for Dorsal Fractures 6
1998 H-Plate First Plate Designed for Volar Fixation of Dorsal Fractures 2002 Volar Fixation for Dorsally Displaced Fractures of the Distal Radius: A Preliminary Report. JL Orbay, DL Fernandez; J Hand Surg 2002;27A:205 215 7
4-6 weeks post-op 1998-2013 Volar Plate Evolution Strongest Fixed Angle Possible Fixation Interface 8
Plate acts as template and drill guide Subchondral Support Scaffold Ligament Contribution to Patterns of Articular Fractures of the Distal Radius Daniel G. Mandziak, MBBS, Adam C. Watts, MBBS, Gregory I. Bain, PhD, MBBS Journal of Hand Surgery. 2011.07.014 9
DRC DRU PMF LF VRU AMF SRL LRL RSC Load Transmission Through the Wrist in the Extended Position Masataka Majima, MD, Emiko Horii, MD, Hiroshi Matsuki, MD, Hitoshi Hirata, MD, Eiichi Genda, MD ( J Hand Surg 2008;33A:182 188.) Pins/wires Fracture fixation methods 10
Hand (NY). 2014 Jun; 9(2) 230-236 Fracture fixation methods Pins/plates Fracture fixation methods Plates and extenders 11
Scaphoid Fossa Fixation Lunate Fossa Fixation 12
Lunate Fossa Watershed Line Watershed Line 13
Watershed Line 3 mm Watershed Line 2 mm Watershed Line to Plate Distance Volar Lunate Fragment Volar Marginal 5 mmfragment 14
Plate extenders 15
Plate extenders Radiographic Evaluation of Dorsal Screw Penetration After Volar Fixed-Angle Plating of the Distal Radius: A Cadaveric Study Steven D. Maschke & Peter J. Evans & David Schub & Richard Drake & Jeffrey N. Lawton Hand. 2007 Sep; 2(3): 144 150 16
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Extended Tangential View Carpal shoot through Marsland et al. Hand ( 2014) 9: 516-521 Extended Tangential View MW Flexor Tendon Injury 18
Most Frequently Ruptured Tendons #1 #2 FPL FDP II 19
Volar Radial ------- Tubercle --------Volar Rim Lunate Fossa Inter Fossa Sulcus FPL Tendon Center to Bone Plate to Tendon Surface 4.5mm 0mm 20
Volar Locking Plate Implant Prominence and Flexor Tendon Rupture By Maximillian Soong, MD, Brandon E. Earp, MD, Gavin Bishop, MD, Albert Leung, BS, and Philip Blazar, MD Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic, Burlington, and the Department of Orthopaedic Surgery, Brigham and Women s Hospital, Boston, Massachusetts The Critical Line 0 1 2 Volar Locking Plate Implant Prominence and Flexor Tendon Rupture By Maximillian Soong, MD, Brandon E. Earp, MD, Gavin Bishop, MD, Albert Leung, BS, and Philip Blazar, MD Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic, Burlington, and the Department of Orthopaedic Surgery, Brigham and Women s Hospital, Boston, Massachusetts 168 DRFs treated with volar plating Grade 0 Grade 1 Grade 2 0 Ruptures 1 Rupture 2 Ruptures Volar Locking Plate Implant Prominence and Flexor Tendon Rupture By Maximillian Soong, MD, Brandon E. Earp, MD, Gavin Bishop, MD, Albert Leung, BS, and Philip Blazar, MD Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic, Burlington, and the Department of Orthopaedic Surgery, Brigham and Women s Hospital, Boston, Massachusetts Group 1 (Acu-Loc) Group 2 (DVR) P Value No. of patients 72 93 21
Volar Locking Plate Implant Prominence and Flexor Tendon Rupture By Maximillian Soong, MD, Brandon E. Earp, MD, Gavin Bishop, MD, Albert Leung, BS, and Philip Blazar, MD Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic, Burlington, and the Department of Orthopaedic Surgery, Brigham and Women s Hospital, Boston, Massachusetts Group 1 (Acu-Loc) Group 2 (DVR) P Value No. of patients 72 93 No. of prominent plates, volar Grade 0 19% 49% <0.0001 Grade 1 18% 51% <0.0001 Grade 2 63% 0% <0.0001 Volar Locking Plate Implant Prominence and Flexor Tendon Rupture By Maximillian Soong, MD, Brandon E. Earp, MD, Gavin Bishop, MD, Albert Leung, BS, and Philip Blazar, MD Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic, Burlington, and the Department of Orthopaedic Surgery, Brigham and Women s Hospital, Boston, Massachusetts Group 1 (Acu-Loc) Group 2 (DVR) P Value No. of patients 72 93 No. of prominent plates, volar Grade 0 19% 49% <0.0001 Grade 1 18% 51% <0.0001 Grade 2 63% 0% <0.0001 No. of cases with flexor tendon rupture(s) 4% 4 4 4 4 0% 0.08 Prospective Randomized Trial Comparing Nonoperative Treatment with Volar Locking Plate Fixation for Displaced and Unstable Distal Radial Fractures in Patients Sixty-five Years of Age and Older Rohit Arora,MD,Martin Lutz, MD, Christian Deml,MD, Dietmar Krappinger, MD, PhD, Luzian Haug, MD, and Markus Gabl,MD J Bone Joint Surg Am. 2011;93:32146-93 22
Randomized: VLP vs Casting. Simple volar approach @ 1-2 weeks Operative group did better first 6 months. At one year both groups were almost equal. 36% vs 14% complication rate Operative Non Operative Total: 13 5 Flexor 4 (plate prom) 0 Extensor 6 (long screws) 0 CTS 1 0 CRPS 2 5 Operative Non Operative Total: 3 5 CTS 1 0 CRPS 2 5 23
Standard Fixation Technique Complication rate and patient satisfaction after volar plating of distal radius fractures J. L. Orbay, F. Rubio, E. J. Balaguer, L. Vernon Unpublished data - 808 consecutive patients - 443 evaluated thus far (54.8%) - 9.2% overall complication rate - 4.3% required a second operation - <0.5% infection rate Complication rate and patient satisfaction after volar plating of distal radius fractures J. L. Orbay, F. Rubio, E. J. Balaguer, L. Vernon Unpublished data - Overall satisfaction 91.4% - 90.1% would have the same procedure again - 92.6% would recommend their surgeon 24
Volar Approach Not Trivial for Dorsal Fracture Anatomical Plates Require Anatomical Reduction 25
Using the Extended FCR Approach Release FCR tendon sheath Release the radial septum Pronate the proximal fragment Intrafocal Exposure Standard Fixation Technique Standard Fixation Technique Removing dorsal hematoma allows reduction 26
Dorsal rim fracture 27
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Bone Graft Support 2 mm 2 mm 2 mm Rule 30
1- Reduce and Pin Lunate Fossa 2- Reduce and Pin the Scaphoid Fossa 31
Volar rim fracture 32
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Prevent Collapse and Salvage Failures of the Volar Rim of the Distal Radius J. L. Orbay, F. Rubio, L. Vernon Journal of Wrist Surgery 2016;00:1 5. 21 patients - 17 had volar marginal fixation at primary surgery - 4 had volar marginal fixation as a revision - No failures in primary VMF fixation group - 2/4 had failure after revision - 91% successful overall VMF fixation - failure associated with revision fixation Prevent Collapse and Salvage Failures of the Volar Rim of the Distal Radius J. L. Orbay, F. Rubio, L. Vernon Journal of Wrist Surgery 2016;00:1 5. - For failed VMF fixation, opening wedge osteotomy - Correct volar tilt to 5 degrees dorsal - Restores supination loss seen after failed VMF fixation 34
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A combination 37
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Is there any role for a dorsal approach? 40
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Thank You! 43