Is it possible to avoid intra-articular screw penetration with minimal use of fluoroscopy in the application of distal radius volar plate?

Abstract

ÖZAmaç: Bu çalışmada distal radius volar plak uygulamasında minimum floroskopi kullanılarak eklem içi vida penetrasyonundan kaçınmanın ve böylece cerrahi ekibin radyasyona maruz kalma riskinin minimuma indirilmesinin mümkün olup olmadığı araştırıldı. Hastalar ve yöntemler: Haziran 2014 -Mayıs 2016 tarihleri arasında instabil distal radius kırığı olan 50 hastada (22 erkek, 28 kadın; ort. yaş 43.52 yıl; dağılım 18-76 yıl) kırık redüksiyonunu takiben distal vida ile volar plak uygulaması minimum floroskopi kullanımı ile gerçekleştirildi. Özel tasarlanmış volar anatomik plak lunat fossanın fasetinin ucundan proksimale doğru 3 mm mesafe oluşturularak uygulandı. Bulgular: Vida yataklarına özel açı verilerek tasarlanmış plak ile tarif edilen cerrahi tekniğe dikkat ederek ve minimum düzeyde floroskopi kullanarak yaptığımız plakvida uygulamalarında eklem içi vida komplikasyonu ile karşılaşılmadı. Ameliyat sırasında floroskopi minimum düzeyde uygulandı ve eklem içi vida kullanımını düşündürecek herhangi bir bulguya rastlanmadı. Ameliyat sırasında ve sonrasında el bileği hareketlerinde kısıtlılık, takılma ya da sürtünme bulgularına rastlanmadı. Sonuç: Volar plak ve distal kilit vida yatağı tasarımındaki iyileştirmeler ile eklem içi vida komplikasyonları olasılığını ve erken dönem tekrar cerrahi düzeltme ihtiyacını ortadan kaldırmak ve cerrahi ekibin radyasyona maruz kalma riskini minimuma indirmek mümkündür.Anahtar sözcükler: Distal radius kırığı; floroskopi, volar anatomik plak. ABSTRACTObjectives: This study aims to investigate whether or not it is possible to avoid intra-articular screw penetration in the application of distal radius volar plate with minimal use of fluoroscopy and thereby reduce to a minimum the risk of exposure of the surgical team to radiation. Patients and methods: Volar plate with distal screw application with minimal use of fluoroscopy was performed in a total of 50 patients (22 males, 28 females; mean age 43.52 years; range 18 to 76 years) with unstable distal radius fracture following reduction of fracture between June 2014 and May 2016. A specially designed volar anatomic plate was applied by creating a 3 mm gap proximal from the tip of the facet of the lunate fossa. Results: No intra-articular screw complication was observed during plate-screw applications that we performed by using fluoroscopy at a minimum level and paying attention to the surgical technique described with the plate designed by giving a specific angle to screw beds. During the operation, fluoroscopy was performed at a minimum level and no finding was observed which could suggest use of intra-articular screw. No findings of restriction in wrist movements, locking or friction were observed intra-or postoperatively. Conclusion: With improvements in the design of the volar plate and the distal locking screw bed, it is possible to rule out the possibility of intra-articular screw complications and the need for surgical re-correction in the early-term, and to reduce to a minimum the risk of exposure of the surgical team to radiation.

Three-Dimensional Analysis of Polyaxial Volar Locking Plate Position for Distal Radius Fracture

“…Factors contributing to screw penetration into the joint include a mismatch in the shape of the distal radius and plate design, the misperception of the shape of the lunate fossa, and inadequate reduction. 16 The use of intraoperative techniques to confirm screw penetration into the joint, such as imaging by slightly elevating the forearm in the anteroposterior and lateral views to depict the joint plane on fluoroscopy and the use of 3D reconstructed images, are recommended. 16 Soong et al reported that radiographic images from multiple directions are needed to accurately evaluate the placement of all screws in VLP fixation of the distal radius.…”

Comparison of a ceiling-mounted 3D flat panel detector vs. conventional intraoperative 2D fluoroscopy in plate osteosynthesis of distal radius fractures with volar locking plate systems

“…The volar locking plate system was established in 2000 and has rapidly become gold standard in treatment of distal radius fractures [ 7 – 10 ]. It is a safe procedure, offering biomechanically stable fixation and allowing early rehabilitation [ 6 , 11 ].…”

“…The former derives from insufficient fracture reduction [ 12 , 13 ] and intraarticular positioned screws [ 8 , 14 ], the latter from plate misplacement (especially ruptures of the flexor pollicis longus tendon) [ 15 , 16 ] or dorsally protruding screws (especially ruptures of the extensor pollicis longus tendon) [ 8 , 14 , 17 ]. To correct these mistakes intraoperatively and avoid postoperative CT and revision surgery, the surgeon needs competent knowledge of the complex distal radius anatomy [ 7 , 18 ] and high-quality imaging [ 1 , 8 ].…”

“…Thus, additional imaging modalities were used lately [ 14 , 22 ]. Intraoperative computed tomography is a conceivable option [ 7 , 23 ], but not yet widely available. Intraoperative 3D fluoroscopy however can be performed with almost every up-to-date mobile image intensifier and has proven its benefits in various anatomical regions allowing the surgeon prompt correction of insufficient fracture reductions or plate/screw misplacements [ 18 , 24 – 28 ].…”

Comparison of three surgical methods in the treatment of intraarticular comminuted distal radius fractures: Volar locking plate, non-bridging external fixator, and bridging external fixator

“…[3] The main goals of treatment are maintaining normal anatomy and obtaining a functional joint. [4] The most complicated fractures of the distal radius are highenergy, comminuted, intraarticular, and unstable fractures.…”