This page of eRadius is devoted to listing research presentations from meetings around the world. We have Corresponding Editors for North America (AAOS, ORS), Japan, India,and Australia. If you are interested in volunteering or if you know of proceedings that are not listed, please contact the Webmaster.

Note: All comments are by David Nelson, MD, unless otherwise indicated.

American Society for Surgery of the Hand
56th Annual Meeting, October 4-6, 2001, Baltimore, MD

ORIF OF UNUNITED FRACTURES OF THE DISTAL RADIUS: DOES THE SIZE OF THE DISTAL FRAGMENT AFFECT THE RESULT?
Karl-Josef Prommersberger, MD, Bad Neustadt, Bayern Germany
Diego L. Fernandez, Berne Switzerland
Jesse B. Jupiter, MD, Boston, MA
Ulrich Lanz, MD, Bad Neustadt, Bayern Germany

Introduction: Ununited fractures of the distal radius, once thought to be exceedingly rare, are now frequently discussed. Most authors advise against attempts to gain healing when the distal fragment is less than 6 millimeters in size, suggesting total wrist fusion instead.
Method: Twenty-three patients with ununited fractures of the distal radius had plate fixation and autogeneous bone grafting in an attempt to heal the fracture. The 10 patients in whom the distal fragment had less than 6 millimeters of subchondral bone at the lunate facet were compared with the 13 patients with a larger distal fragment. Age, gender, side, dominance, fracture types, and initial treatment were comparable between the two groups. Pre-operative radiographic deformity was slightly greater in the small fragment cohort and pre-operative motion was slightly less.
Results: Postoperative radiographs showed no significant difference in regard to palmar tilt, ulnar inclination and ulnar variance between the two groups. Postoperatively an average of 43° of wrist flexion and 34° wrist of extension was preserved in the small fragment cohort compared with 41° wrist flexion and 44° wrist extension in the large fragment cohort. Forearm pronation averaged 76° and supination 64° in the small fragment group compared with 73° pronation and 59° supination in the large fragment group. In the large fragment cohort one patient failed to heal the fracture and had wrist fusion and another patient had radioulnar symptoms treated with Bower’s arthroplasty. In the small fragment cohort, two patients developed advanced radiocarpal arthritis and one patient had loss of alignment. According to the rating of Fernandez, 4 patients in the small fragment cohort had good or excellent results, 3 had fair and 3 poor results. While in the large fragment cohort 3 patients had good and excellent results, 7 had fair and 3 poor results. At an average follow-up of 30 months only one patient has been converted to a wrist fusion.
Conclusion: These data suggest that operative attempts to gain union of an ununited fracture of the distal radius are worthwhile even when the distal fragment is small. Although there may be minimal subchondral bone beneath the lunate facet, the radial styloid offers sufficient bone for the application of one or more internal fixation devices. Surgeons should try to preserve even a small amount of wrist flexion and reserve wrist fusion as a final resort.

ULNAR FRACTURES ASSOCIATED WITH DISTAL RADIUS FRACTURES: INCIDENCE AND IMPLICATIONS FOR INSTABILITY
Megan May, BS, Lexington, KY
Jeffrey Lawton, MD, Lexington, KY
Philip Blazar, MD, Lexington, KY

Introduction: Ulnar-sided injuries are receiving increased recognition for their contribution to poor outcomes following distal radius fractures.
Method: We retrospectively evaluated the radiographs and charts of all patients with distal radius fracture identified by ICD-9 code treated at a university-based Level I trauma center over a 12 month period. Each distal radius fracture was classified according to the AO system, the presence of an ulnar fracture, and evidence of acute or chronic distal radioulnar joint (DRUJ) instability. Ulnar fractures were further evaluated for size and degree of displacement. Ninety-seven of the 166 distal radius fractures identified (58.4%) had a concomitant ulnar fracture (86 ulnar styloid fractures, 9 ulnar head fractures, 2 ulnar shaft fractures). Complete radiographic and clinical evaluation was available for 143 of these fractures. For each ulnar styloid fracture, the fractured fragment was measured on an injury film and reported as a percentage of the intact styloid process. A Chi-Square Test for Equal Proportions indicated that the size of the ulnar styloid fracture was not random (p=0.0001); fractures clustered at intervals representing fractures of 25-50% and 100% of the intact styloid process.
Results: Thirteen of 143 distal radius fractures were excluded from the evaluation of DRUJ instability due to the presence of an associated forearm injury. Each distal radius fracture complicated by DRUJ instability was found to have an associated ulnar fracture. The incidence of DRUJ instability was found to increase with a fracture of the ulnar styloid at its base (odds ratio=3.6, p=0.04) and with significant displacement of the distal ulna fracture (odds ratio=11.6, p=0.0052). The combination of a fracture of the ulnar styloid, at its base, with significant displacement yielded a p=0.0007 and an odds ratio=8.3. Previous clinical research has not consistently found fractures of the distal ulna to contribute to poor outcome following distal radius fracture.
Conclusion: This study suggested that characteristics of the distal ulna fracture, such as size and displacement, should be considered rather than merely the presence of a distal ulna fracture alone. In this study a large, significantly displaced ulnar fracture was eight times more likely to result in DRUJ instability than a smaller fracture and/or one that was nondisplaced. Moreover, the nonrandom distribution of ulnar styloid fractures based on size may contribute to a better understanding of the soft tissue anatomy, injury patterns, and mechanisms of distal radius fractures.

ANALYSIS OF DYNAMIC DISTAL RADIOULNAR CONVERGENCE AFTER DISTAL ULNAR RESECTION, SOFT TISSUE STABILIZATION PROCEDURES AND ENDOPROSTHESIS IMPLANTATION
Michael Sauerbier, MD, Ludwigshafen Germany
Masaki Fujita, MD, Rochester, MN
Michael Hahn, MD, Rochester, MN
Richard A. Berger, MD, Rochester, MN

Introduction: The most common method of treating the arthrotic DRUJ is resection of the distal ulna (Darrach procedure). Although technical modifications and soft tissue stabilization techniques for the distal ulna have evolved, complications related to instability of the distal forearm resulting from loss of the ulnar head followed by pain and weak grip strength have remained the drawbacks of this procedure. To this end, an endoprosthesis was developed to replace the ulnar head after Darrach resection. The purpose of this study was to: 1) evaluate the dynamic effects of the Darrach resection on radioulnar convergence; and 2) evaluate the mechanical efficacy of two soft tissue stabilizing techniques (Pronator quadratus interpostion and ECU/FCU tenodesis) for the unstable distal ulnar stump vs. the implantation of an ulnar head endoprosthesis following a Darrach resection.
Method: With a dynamic PC-controlled forearm simulator cadaveric forearm rotation was actively and passively performed while simultaneously loading relevant muscles. Torque along the forearm axis was generated by simulated muscle action through
pneumoactuators connected to relevant tendons while the wrist was constrained to rotate at prescribed endpoints. Seven fresh-frozen cadaver upper extremities were used to evaluate the instability after Darrach resection, subsequent stabilization procedures for the ulnar stump and implantation of the prosthetic device. Using nylon posts fixed to the radius, third metacarpal and ulna, electromagnetic sensors were fixed to the specimen. The instability of the radius relative to the ulna was evaluated using displacement data of digitized landmarks in an ulnar coordinate system.
Result: The kinematic data showed a significant translation of the radius towards the ulna through the entire pro- and supination arc after resection of the distal ulna and the two soft tissue stabilization techniques. Anteroposterior translation in each loading condition could be detected as well but the magnitude of displacement was less predictable. The implantation of the prosthetic device significantly restored the stability of the DRUJ by simulating the geometry of the ulnar head, further stabilized by attaching the TFCC.
Conclusion: The Darrach resection creates an extreme instability of the forearm with movement of the radius ulnarly and anteroposterior translation in each particular loading condition as well. The implantation of the ulnar head endoprosthesis effectively restores the stability of the DRUJ. This study provides laboratory validity to the option of implanting an ulnar head endoprosthesis for patients who suffer from painful forearm instability after Darrach resection in lieu of performing muscle-interposition or tendon-stabilization procedures.

OUTCOME STUDY OF UNSTABLE DISTAL RADIUS FRACTURES: ORIF WITH A VOLAR FIXED ANGLED TINE PLATE VS EXTERNAL FIXATION
Dean Smith, MD, Gainesville, FL
Thomas Wright, MD, Gainesville, FL

Introduction: The purpose of this study is to compare the outcome of unstable distal radius fractures that were treated with open reduction internal fixation through a volar approach with a fixed angled tine plate versus a standard external fixation method.
Method: The preliminary study reports on 31 patients (age 19-74) with similar distribution of comminuted unstable intra-articular and extra-articular distal radius fractures who were treated with an external fixation device or internal fixation using a fixed angled volar tine plate. 18 patients treated with volar plating and 13 with external fixation were compared for final results in patient satisfaction, range of motion, pain, complications, and radiographic reduction. Final follow-up averaged 12 months for the volar plate group and 47 months for external fixation and included radiographic evaluation for distal radius alignment and an assessment of wrist pain, ROM, and functional outcome using the Patient Rated Wrist Evaluation (PRWE) and DASH outcome measurements.
Results: The average wrist extension at final f/u in patients treated with external fixation was 49 degrees of extension and 51 degrees of flexion, compared to 54 degrees of extension and 59 degrees of flexion in patients treated with volar plating. The pronation/supination arc of motion was 150 degrees in the external fixation group and 140 degrees in the volar plating group at final follow-up. 7 of the 13 patients treated with external fixation were complicated by RSD, pin site infection, or loss of reduction. There were 3 complications in the volar plate group. At final follow-up, the average volar tilt was 3 degrees of volar angulation in the external fixation group and 5 degrees volar angulation in patients treated with volar plating. ORIF with the volar fixed angled tine plate allowed for reduction of the articular surface and provided for fracture stability, resulting in earlier range of motion of the wrist. Despite the short follow-up, the PRWE and DASH outcome measures, as well as the final ROM measurements, were equivalent.
Comment for eRadius: This is a very interesting and exciting study, by authors who are developers of a volar, fixed angle plate (see Ferenandez and Orbay ). Their group with internal fixation should improve over time, and therefore may be better than the external fixation group. Both Fernandez and Orbay are speaking at the October 18-20, 2002, International Distal Radius Fracture course, which is run by eRadius, so we should see what the latest developments are. - David Nelson, MD

THE INFLAMMATORY EFFECT OF TITANIUM DISTAL RADIUS PLATES ON TENDONS: A HISTOLOGIC STUDY IN THE BEAGLE DOG
Brian Su, BSE, New York, NY
Frank J. Raia, MD, New York, NY
Robert J. Strauch, MD, New York, NY
Melvin P. Rosenwasser, MD, New York, NY

Introduction: Several case reports have described extensor tenosynovitis or extensor tendon rupture associated with the AO titanium distal radius pi plate. There is a notable disparity in reported complications between dorsal radial titanium implants and stainless steel implants, suggesting that titanium may contribute significantly to the development of synovitis and resulting tendon rupture. Previous studies in the orthopedic literature have found inflammatory reactions in the soft tissue surrounding titanium implants. The purpose of this study is to examine the direct effects of titanium on adjacent tissue by implanting titanium plates in a beagle fracture model and performing histologic analysis on the overlying tendons.
Method: An osteotomy was created in the distal radius of skeletally mature female beagles and fixed with either a stainless steel plate (control), a pure titanium plate, or a titanium alloy plate. Eighteen dogs were studied: 6 stainless, 7 titanium, and 5 titanium alloy plates were implanted. The animals were followed for four months. At sacrifice, the mobility of the tendons overlying the plates was assessed. The extensor tendons and their surrounding sheaths were removed en-bloc and stained with hematoxylin and eosin. The slides were read by two blinded observers and graded for inflammation on a scale from 0 (none) to 5 (severe). The specimens were also examined grossly for inflammation and graded from 0 to 5.
Results: The tissue surrounding the stainless steel implants had an average grade of 1.5 grossly and 1.5 microscopically. All six tendon specimens in the stainless steel group glided freely over the plate on post-sacrifice examination. In the titanium group, the average inflammation score was 3.7 grossly and 3.1 microscopically. Four of 7 specimens glided freely. In the titanium alloy group, the average score was 3.2 grossly and 3.8 microscopically. 4 of 5 specimens glided freely over the plate. Metallic particles were not found in the soft tissues histologically.
Discussion:There has been no study to date that has examined the direct effects of titanium implants on surrounding tissue. This study using an in vivo dog model demonstrated that plates of titanium and titanium alloy caused significantly more inflammation in the surrounding tendon and connective tissue when compared to control stainless steel plates. These results demonstrate a potential inflammatory effect of titanium implants on surrounding soft tissue, and may help to explain complications involving tendons seen with the use of titanium on the dorsal aspect of the radius.
Comment for eRadius: I think we all have seen inflammation of extensor tendons after dorsal titanium plates, so this paper is quite timely. It would be good to know what titanium alloy was used, since there are several available. Synthes is moving to a titanium alloy, and Hand Innovations uses an alloy (although their design is for volar use and should not see this problem.) - David Nelson, MD

ARTHROSCOPICALLY ASSISTED VERSUS FLUOROSCOPICALLY ASSISTED REDUCTION AND EXTERNAL FIXATION OF DISTAL RADIUS FRACTURES
David S. Ruch, MD, Winston-Salem, NC
Jeffrey A. Vallee, MA, Winston-Salem, NC

Introduction: While arthroscopy offers an unparalleled view of intra-articular pathology, its uses and indications in the management of intra-articular distal radius fractures remain controversial. The specific aim of this study was to compare functional and radiological outcomes of arthroscopically assisted (AA) versus fluoroscopically assisted (FA) reduction and external fixation of distal radius fractures.
Method: A retrospective chart review was completed to identify patients with intra-articular distal radius fractures who underwent external fixation and percutaneous pinning using arthroscopic guidance by one surgeon between January 1, 1995 and December 1, 1999 (N=15). Controls (N=15) were patients who underwent external fixation and fluoroscopically-assisted reduction and pinning by the same surgeon during the same time period. The groups were matched for fracture pattern (AO C2 or C3) and age (mean=40.5 years). Follow-up at a minimum of 12 months (range of 12 - 71 months), consisted of an evaluation of: 1) grip strength and 2) range of motion parameters as well as radiographic evaluation of: 1) palmar tilt, 2) radial shortening, 3) step off, and 4) degenerative changes. Health-related quality of life outcomes were assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire at follow-up.
Results: Patients who underwent AA surgery exhibited significantly improved supination as compared to FA (88E vs 73E; P=0.04). Patients who underwent AA reduction also exhibited improved wrist extension (mean=77E vs. 69E; P=0.01), and wrist flexion, (means=78E vs. 59E; P=0.05). Palmar inclination was -2.12E for the AA group and -0.32E for the FA group (P=0.92). Additionally, radial shortening (mean=0.74 mm) and Knirk and Jupiter congruity grades (mean=0.06) were similar for both groups. With respect to health-related quality of life measures, the mean DASH score for patients in the AA group was 10.7 while for the FA group the mean was 19.2. Due to the small sample size and wide variability within groups, there was no statistically significant difference between the scores of the two patient groups (P=0.58).
Conclusion: Arthroscopic assistance may permit greater inspection of ulnar-sided injury thereby resulting in a greater degree of supination following wrist fracture.
Comment for eRadius: I am not sure that range of motion is the main outcome that we are looking for with AA, but better long-term results, primarily less arthritis. However, we will not see these results for a long time and will need large numbers of patients, most likely, to see any differences. Nonetheless, AA is probably an important technique. In 2002, we just lack proof of its effectiveness. We also have to bear in mind the fact that there is no clear relationship between stepoff and outcome, and this position has been taken by Jesse Jupiter.
I object to the authors stating that there was no statistical difference due to the small sample size and the large variability; logically, another explanation is that there was no difference. It begs the question to lay the blame on small sample size and large variability. - David Nelson, MD

1999 SICOT Meeting

Arthroscopy and Distal Radius Fractures

Greg Bain, JA Mehta
Modbury Hospital, Adelaide, Australia

Purpose: To assess the value of arthroscopy in the management of intra articular distal radial fractures.
Method: Operative information was collected prospectively and in independent observer performed the clinical and radiological reviews 30 complex intra articular distal radial fractures - Frykman 7 & 8 were treated with arthroscopically assisted reduction and fixation. 26 wrists (25 patients) were reviewed at an average of 19-month follow-ups. The fractures were fixed using percutaneous pinning techniques with or without external fixateurs. Associated procedures include scapholunate (19) and lunotriquetral (10) percutaneous K-wire fixation, TFC debridement (14) and sutures (1), and debridement of osteochondral defects (5).
Results: Average pain score (0-10) was 1.3. 24 patients were satisfied. Grip strength was 75% and range of motion 81% of the contralateral side. 17 patients had no articular step. Only 1 patient had a step greater than 1mm on follow-up radiographs. Twenty-three (88%) had an excellent or good results with the New York Hospital score. Complications included infection of the proximal pin sites of the external fixateurs, paraesthesia of the superficial cutaneous branch of the radial nerve and one acute median nerve compression.
Conclusion: Wrist arthroscopy provides a magnified view of the articular surface to allow accurate reduction with minimally invasive techniques. Associated ligamentous injuries are common and can also identified and treated arthroscopically.

THE ROLE OF OSTEOPOROSIS IN THE OUTCOME OF DISTAL RADIUS FRACTURES IN POSTMENOPAUSAL WOMEN
N. HOLLEVOET,
S. Goemaere, F. Mortier. R. Verdonk
Dept. orthopaedic Surgery, University Hospital Gent, Belgium

We examined 22 postmenopausal women who had sustained a distal radius fracture in a simple fall. TNO mean age was 67 years and the mean follow-up 17 months. All fractures required reduction. 14 patients were treated with percutaneous pinning. 5 patients with a volar plate and 3 patients with closed reduction and plaster cast. The patients had a clinical and X-ray examination of both wrists. The AO classification was used to classify the fractures and the Gartland and Werly scoring system to evaluate the final outcome. Bone mineral density (BMD) of the non-fractured contralateral wrist was measured with dual energy X-ray absorptiometry. We looked for a correlation between the clinical and radiological parameters and BMD. The Gartland and Werly scoring system correlated with the loss of wrist extension and the increase of ulnar variance compared with the normal wrist. DMD correlated with the AO-classification, but not with the radiological or clinical parameters
Additional Author: Van Bouchaute

Comment for eRadius: The orthopedist may be the first contact with the medical profession for a patient who has osteoporosis. This topic will be covered at the 2002 International Distal Radius Fracture course, to be held Oct 18-20, 2002, in San Francisco, sponsored by eRadius. Watch for a posting. - David Nelson, MD

MANAGEMENT OF UNSTABLE DISTAL RADIUS FRACTURES USING THE ULSON DEVICE

A. GUPTA, T. WoIff, L. Scheker. D. Cautilli

Christine M. Kleinert Institute for Hand and Micro Surgery, Inc.. Louisville, KY, USA

We reported the use of the Ulson device for management of unstable distal radius fractures. Two specifically designed, eccentrically tipped K-wires are introduced percutaneously into the intramedullary radius canal. Via the use of the unique external coupling device. the fractured radius is distracted and bony collapse is prevented. At our institution, 97 distal radius fractures in 96 patients have been treated with the Ulson device. The distal radius fractures were classified according to Frykman types: I (12), II (20), II (8), IV (19), V (4), VI (4). VII (11), VIII 11 (16), and unknow type (2). The clinical records, physical therapy notes, preoperative and postoperative radiographs, range of motion and grip strength were analyzed All fractures united with excellent maintenance of joint angles and radius height. The Ulson device has many advantages, (1) the volar angle is maintained, (2) collapse of the radius is not allowed, (3) early range of motion and grip strength are maintained, (4) it is simple to perform, (5) inexpensive, and (6) good, reproducible clinical results are achieved.

T. MURASE, Y. Kishida, K. Hiroshima
Kansai Rosai Hospital and Osaka National Hospital, Japan

Intrafocal pinning combined with external fixation was employed in 13 recent cases of distal radial fracture including those with articular involvement and/or dorsal or volar comminution. There were 12 females and one male, whose ages ranged from 19 to 81 years old. After 2 or 3 intrafocal pins were used to reduce and fixate the fragment, an external fixator was applied under manual traction on the wrist joint. Kirschner wires were removed 4 weeks post-operation and the external fixator 2 weeks afterward. Follow-up term ranged from 6 to 18 months with an average of 11 months. Clinical results were excellent in 6, good in 6 and fair in one. In the latest radiographic evaluation, averaged volar tilt, radial inclination and ulnar variance were11 degrees, 21 degrees and 1.5mm respectively. This procedure is an useful alternative to restore anatomical reduction and will get successful results for distal radial fractures.

COMPARISON OF DIRECT CORONAL AND AXIAL COMPUTED TOMOGRAPY IN THE ASSESSEMENT OF POST-TRAUMATIC WRIST DEFORMITIES

W.Y. IP, L.L.S. Wong, W.C.G. Peh, A. Mak

University of Hong Kong, Hong Kong, China

Purpose: This study aims to compare direct coronal and axial computed tomography (CT) scans in the assessment of distal radius deformities following open reduction and internal fixation (ORIF) for complex intra-articular fractures.
Materials and methods: 15 adults patients (12 men, 3 women, age range 21-64 years) with 16 type C3 intra-articular fractures of the distal radius who had been treated by ORIF were recalled for CT assessment. Using a spiral CT scanner, 5mm thick axial slices, with 2.5 mm overlapping reconstructions, and 3mm thick direct coronal slices, with 1.5mm overlapping reconstructions, were obtained for each wrist. CT images were reviewed for scan quality, articular step and gap, intra and para-articular bony fragments, fracture healing, malunion, osteoporosis and osteoarthritis.
Results: CT images were of good quality except for mild streak artifacts in 3 direct coronal images. Articular step was seen in 7/16 cases on direct coronal but not on axial images. No articular gap was detected. One intra-articular fragment was seen only on direct coronal CT. Para-articular fragments were seen on 12/16 direct coronal scans and on only 7/16 axial scans. Direct coronal scans better showed osteoporosis (4) and osteoarthritis (5). Axial scans were superior in depicting dorsal radius malunion and DRUJ incongruity.
Conclusions: Direct coronal CT are superior to conventional axial CT scans in showing articular irregularities, bony fragments and osteoarthritis, and are recommended in the assessment of post-traumatic distal radius deformities.

THE USE OF BIODEGRADABLE PINS IN THE OPERATIVE TREATMENT OF DISTAL RADIAL FRACTURES

J. KORNER, P. Verlheyden, K. Nocker, C. Josten
University of Leipzig, Germany

Introduction:Clinical and radiological results following distal radial fractures treated with biodegradable pins are presented in comparison with a control group receiving Kirschner-wires.
Methods: Between January 1995 and July 1996 19 patients with distal radial fractures have been included in a prospective randomized study and were treated with biodegradable pins. According to the AO-classification 9 fractures (47%) were classified as A2, 8 (42%) as A3 and 2 (11%) as Bl fractures. For comparison purposes a control group (n=21) were treated with conventional Kirschner-wires. The insertion of the pins and K-wires has been performed according to Willenegger in a modified manner. 17 patients with biodegradable pins and 19 patients with K-wires were followed-up clinically and radiologically (median follow up 25,4 months).
Results: In the group receiving biodegradable wires difficulties during insertion of the pins were documented in 8 patients (42%). In the clinical and radiological follow-up one patient was found to have had a secondary displacement of the fracture necessitating revision. Compared to the contralateral wrist the loss of range of motion was in average 30º for extension/flexion and 35º for Pronation/Supination. The average duration for the operations was 40.5 min. 9 patients (47%) had radiological signs of arthrosis. In the group receiving K-wires no complications were documented perioperatively. In one case a superficial wound infection occurred. The loss of range of motion was 20º for extension)/flexion and 30º for pronation/supination. The average duration for the operation was 23,5 min. Radiological signs of arthrosis were, found in 7 patients (33%).
Discussion and Conclusion: The high rate, of perioperative complications and the longer duration of the operational procedure in the group with biodegradable pins does not justify this procedure for the operative treatment of distal radial fractures. There is it higher incidence of arthrotic findings following treatment with biodegradable pins.

Lower end radius fractures- Pins and plaster: The middle path regime?
GD Salunkhe

ABSTRACT
An old and innocuous method for treatment of fractures of the lower end of the radius using plaster casts and transfixing pins has been described but not commonly used. A series of 50 cases treated by this method is presented with a three year follow up.

K wires are placed in the metacarpals and shafts of the radius and ulna. Reduction is achieved by suspension and traction. After confirming reduction, a plaster cast is applied incorporatinmg the pins. The assembly is removed after 8 to 10 weeks.

Assessment of post reduction and post union x-rays has been done measuring radial length, angle and dorsal tilt. Clinical assessment has been done after six months of the injury. Patients have been examined yearly for three years for early arthritic changes on the x-rays.Excellent and good results have been found in 84% of cases. Consistent results could be obtained in complex fracture patterns.

Complications of malunion due to radial collapse have been noted, related directly to inadequate reduction or early removal of pins.

The advantages are simplicity of instruments and technique, application in a variety of fractuers and flexibility for further augmentation, if required. This simple method prevents uncontrolled collapse of fracture fragments, which is the main cause of unacceptable results.


My comments: Very simplistic approach to the vexed problem. Probably a paper presented more out of his own conviction that the method is good and that it is applicable to all fractures of the distal radius. While a classification was presented, the results achieved in different groups were not compared. Few unclear slides of function and union were presented. Unconvincing.

Sudhir Warrier
Corresponding Editor, India.

Tel: 91-22-6286142
Tel/Fax: 91-22-6200637
Mobile: 9821139151
E-Mail: swarrier@vsnl.com

Prediction of Instability of Fractures of the Distal Radius
Paul J. MacKenney, FRCS; Margaret M. McQueen, MD; Rob Elton, PhD

Edinburgh Orthopaedic Trauma Unit, Edinburgh, Scotland

Purpose: To produce a method of accurately predicting instability of distal radius fractures on the day of injury which is easily applicable in the clinical situation.

Methods: During a five-and-one-half year period, data were recorded prospectively on 4025 patients with distal radial fracture. The items of information included demographic data, mode of injury, the patient's level of function, and radiological data. The latter included: fracture classification (AO and Frykman); the degree of fracture comminution; measurement of dorsal angulation, radial shift and ulnar variance at presentation, post manipulation, one week, and six weeks after injury; carpal alignment at union. Using the position of the fracture at one and six weeks and the alignment of the carpus as outcome measures, statistical analysis of the data was performed to identify factors of independent significance in the prediction of early instability, late instability, and carpal malalignment respectively. Each factor was analysed using the Mann-Whitney or chi- squared test, and significant factors used in multiple logistic regression analysis. Predictive equations were then derived from the multiple logistic regression.

Results: Factors predictive of fracture instability were seen to vary depending on the position of the fracture at presentation (displaced with more than 10 degrees of dorsal angulation or minimally displaced with less than 10 degrees of dorsal angulation). There were also differences between factors predictive of early and late instability. The most highly significant prognostic factor was the age of the patient (p<0.001), and this applied to all sets of data analysed. Comminution was also important, though to a lesser degree. The dorsal angulation of the fracture at presentation was only of prognostic significance in fractures with minimal displacement at presentation, whereas the ulnar variance was significant in all fractures. Surprisingly, independence in the activities of daily living was of value in predicting late instability in displaced fractures. The sex of the patient, mode of injury, the radial shift at presentation, and Frykman classification was of no prognostic value following multiple logistic regression. In the prediction of carpal malalignment the patient's age and level of function, fracture comminution, AO and Frykman classifications, and the dorsal angulation of the fracture at presentation were all of significance. From the data analysed it was possible to construct an equation to predict the percentage chance of instability after distal radius fracture. The following example is for the probability of early instability in a displaced fracture at presentation:

An example can be given as follows. A 75-year-old lady sustains a distal radial fracture after slipping on ice. She is normally independent and active. Initial dorsal angle is 17 degrees and ulnar variance is 3 mm with dorsal comminution. This patient therefore has a fracture which is displaced at presentation. To calculate the probability of displacement at one week, the formula is used as above. The score is -0.14. Using the probability formula, this patient has an 82% chance of the fracture being unstable at one week.

Discussion and conclusions: Previously it has been demonstrated that the ulnar variance, dorsal angulation, and age of the patient were all factors related to the anatomical outcome following distal radial fracture. We have shown that the significance of these factors depends on the position of the fracture at presentation, and whether one is trying to predict early or late instability. We have shown that the age of the patient is by far the most important factor in assessing the instability of a fracture. It is hoped that refinement of the predictive equations will produce a user-friendly and reliable method of assessing the distal radial fracture at presentation. The value of such a system cannot be underestimated: unnecessary manipulations can be avoided in patients with fractures that require operative fixation, and these patients will be able to have definitive treatment at presentation. In addition, this rationalisation of the treatment protocol is likely to be of economic benefit.

Webmaster's Comments: This is a very important paper and I think that this work will get a lot of attention once it is published. In some ways, it represents a Holy Grail of distal radius fracture management: predicting in the ER which patients will collapse and therefore may need prophylactic fixation of some type, rather than waiting until the collapse happens and then playing catchup, or worse, an osteotomy. (As Jesse Jupiter has phrased it once to me, a Darrach procedure is not fracture aftercare; the implication is that proper fracture care will avoid the salvage procedures down the line.)

The paper only presented one equation, which was the probability of early instability, although that was not clear from the abstract in the program. This was clearer after I talked to the authors after the presentation. During the presentation, they gave a different equation, the probability of late instability:

Dr. McQueen told me that they have four equations based on their dataset. The third one predicts carpal malalignment. She did not mention what the fourth equation represented.

Before you complain, "But I don't have time to do an exponential calculation at 2 am in the ER!", the authors have worked out tables that do all the calculations for you. These could be posted in the ER or reduced and carried in a pocket. Other more convenient means are also underway.

There are a number of surprises in the results of the study. One: the best predictor of late instability is age. I believe that we all have felt that this was a factor, but this is the first study to document (rather than just opine) that this is the most important factor. Two: dorsal angle is not a good predictor. I discussed this with Dr. McQueen (who incidentally is on the Board of Editors of eRadius), who clairfied that, although it was a predictor, it was not an independant predictor and therefore did not make it into the equation. I asked if angle was not more readily measured than degree of comminution (a problem with other attempts at prediction), and learned that communution was rated as either present or absent, not graded, which simplified the matter. Three: mode of injury was not of prognostic significance. I usually feel that high velocity injuries are more unstable; it could be that the dataset did not have enough of these injuries to reflect this contribution. (I await the manuscript, or possibly the authors will respond.) Four: dorsal angulation was of value only with minimally displaced fractures. I would like to know if this means that minimally displaced fractures were predictive of stability, but more displaced fractures were not predictive. This was not clear either from the abstract or presentation.

Criticisms aside, this is a very important work and one that will be a benchmark for future studies. Most questions will probably be answered in the manuscript. Congratulations to the authors (and apologies if I have misunderstood or misrepresented any of your work. I was writing madly in the dark during the presentation, and only remembered a limited number of questions when we spoke.)

Comparison of Structural and Nonstructural Bone Graft for Distal Radius Osteotomy

Celine Roberge, MD, David Ring, MD, and Jesse Jupiter, MD; Boston, MA

This was an excellent clinical study comparing the standard, Fernandez osteotomy with iliac crest corticocancellous graft with a new approach, using only cancellous graft. This technique is only possible due to the stability allowed by the new Synthes' Pi plate. Nine consecutive patients had the traditional osteotomy and grafting (Group I) and eight had the new technique (Group II). The average ages were similar (50 and 46, respectively), the delay from the time of injury was similar (62 weeks and 67 weeks, respectively), the degrees of deformity were similar (but the data was not given), and the followup was similar (14 months and 22 months, respectively). All osteotomies healed. The average ulnar variance improved from 2.6 mm to 1.3 mm in Group I, and from 5.6 mm to 1.5 mm in Group II. The average volar tilt improved from -20 degrees to +1 degree in Group I, and from -10 degrees to +3 degrees in Group II. The results were Group I: 3 excellent, 4 good, 1 fair, and 1 poor; compared to Group II: 4 excellent, 3 good, and 1 poor. Both the poor outcomes were in Workers' Compensation cases, and one had severe intracarpal trauma. The paper was reviewed by Thomas Trumble, who noted that the groups were not entirely comparable, and questioned if there was a selection bias. However, my feeling from hearing both the paper and the review, was that this was a very exciting technique that had been adequately tested to suggest it to the surgical community. We all know how difficult it can be to contour the corticocancellous graft properly and how nearly impossible it is to get it into the osteotomy site. I ususally need to employ a few choice swear words to get it to fit. I would note that the only complication was that five patients in each group required plate removal. This is not a criticism of the technique, since they both use it. However, I have found that if you enter through the third compartment (a bit radial on the superficial layer and a bit ulnar on the deep layer), you have enough soft tissue to cover the plate. I have not had to remove any plates since using this technique. An obvious question arises: if the osteotomy can be done with cancellous bone, and Collagraft has been shown to be equivalent to cancellous bone [J Bone Joint Surg Am 1997 Apr;79(4):495-502, Treatment of acute fractures with a collagen-calcium phosphate graft material. A randomized clinical trial.Chapman MW, Bucholz R, Cornell C], could this not be done without any iliac crest harvest at all? If the criteria of excellence include changing clinical practice and stimulating further research, this paper rates excellent on all grounds.

A Prospective, Randomized Comparison of Corraline Hydroxyapitite and Autogenous Bone Graft in the Treatment of Distal Radius Fractures

John Wyrick, MD, Christopher Spieles, MD, and Irfan Ansari, MD

This was a prospective, randomized clinical study of 36 comminuted distal radius fractures in 35 patients, all treated with external fixation and supplementaly K-wire fixation. Group I consisted of 16 patients treated with iliac crest bone grafting and Group II had "coralline hydroxyapetite", which presumeably was Interpore's Prosteon. [Although the authors did not say if it was the newer 500R, I suspect it was the earlier version of the product that had less of the calcium carbonate changed into calcium phosphate, which makes the product much slower to incorporate, and in my opinion, too slow to incorporate. Interpore apparently agrees, since they came up with the 500 R (for resorbable). For further discussion and histology, see the navigation button Basic Science (to the left on your screen), and choose the paper Types of Bone Graft Substitute.] The fixators were removed at six weeks in both groups. The average range of motion, grip strength, and outcome were not statistically different for the two groups. The cost of the product was equal to the surgeon's fee, but Group II did not require an overnight stay in the hospital. There was no comment about the rate of incorporation, which to me is a very important consideration, and there were 10 patients lost to followup (29%). I have not had to admit any of my patients who have had an iliac crest bone graft since I have started to place a Marcaine block prior to closing the hip incision, so there would not be that benefit in my patients. The area of bone graft substitutes is a very important one for the surgeon to stay abreast of, and this paper demonstrates the advantages of avoiding iliac crest complications by using "bone in a bottle." The question is, which bone in a bottle? Prospective, double blind studies are needed, and the one cited above by Chapman, from the J Bone Joint Surg Am 1997, is the only one of which I am aware.

Norian SRS vs. Conventional Therapy in Distal Radius Fractures: Minimum One-year Follow-up in 323 Patients

Charles Cassidy, MD (Boston, MA), Jesse Jupiter, MD (Boston, MA), Michelle Delli-Santi, BS (Norian, Cupertino, CA), Jeffrey Husband, MD, Charles Leinberry, MD, and Brent Constantz, PhD (Norian, Cupertino, CA)

This was the data upon which Norian Corporation had their carbonated hyproxyapetite cement, SRS (for Skeletal Reconstruction System), approved by the FDA. It was a very complex undertaking, with vast amounts of data collected, and the authors are to be congratulated. The study was run by Dr. Amy Ladd of Stanford. The study was a prospective, randomized, culticenter clinical study of distal radius fractures. The patients were stratified by fracture type, bone density as measured by DXA scanning, and type of treatment chosen by the patient and surgeon (either cast or ex fix), and randomized to either the control group (conventional treatment) or treatment with SRS. With this many treatment arms, a large number of patients were required, and there were 162 in the conventional treatment group and 161 in the SRS group. The conventional treatment (cast of ex fix) group was immobilized for 6-8 weeks, and the SRS group immoblized in a cast for 2 weeks and a splint for 4 weeks. The large amount of data collected allowed many different comparisons to be made, more than could be presented at the ASSH or presented here. To summarize: although there were many early differences between the groups, they usually did not persist beyond 3 months. The authors claim that the loss of reduction was similar between the two groups, but others looking at the same data have felt that the loss of reduction in the SRS patients that did not have supplemental K-wire fixation was greater, and the FDA has suggested that "use of the cement does not eliminate the need for other stabilizing devices, such as hardware and pins, in patients who would normally need them. This is espeically true for patients with very complex fractures." (http://www.fda.gov/bbs/topics/ANSWERS/ANS00931.html) The infection rate was significantly higher in the control group, due to the use of external fixation, but this should not be clinically relevant, given the FDA's suggestion that SRS not be used without external fixation, if the surgeon felt that normally ex fix was indicated. The authors concluded that "Norian SRS appears to be safe and effective in the management of distal radius fractures." I would agree, with several caveats: the surgeon needs to be sure to take Norian surgeon's training course and closely follow the company's recommendations. Although we all expect to see a large amount of off-label use of this product, the surgeon is strongly advised to speak to the experienced surgeons who have used SRS in the study and learned a great deal about its strengths and weaknesses. There is no need to repeat the lessons already learned by these excellent surgeons.

Arthroscopic Assisted Reduction of Distal Radius Fractures

William Geissler, MD Jackson, Mississippi

This was an excellent clinical study of 33 patients who had an intraarticular distal radius fracture with > 2mm of articular displacement after attempted closed reduction. There were 7 Type B1, 1 Type B2, 3 Type B3, 9 Type C1, 3 Type C2, and 10 Type C3 fractures (AO Classification). There were, in addition to the bony injury, TFCC tears in 13 (40%), with 8 peripheral tears, 4 radial avulsions, and 1 central tear. A complete or partial SL tear was found in 12 (36%) and a complete or partial LT tear in 4 (12%). All patients had an arthroscopically-assisted reduction, plus percutaneous pin fixation alone in 18, plates and K-wires in 11, and cannulated screws in 4. The general procedure was to reduce the radial styloid first, then elevate the depressed fragments, and then the volar medial complex. SL tears of Geissler Grade II were pinned for 6 weeks, Grade III and IV had an open "reconstruction". [Will did not discuss the type of "reconstruction", but I believe he meant "repair." Due to the various types of repair (Taleisnik), substitution (Blatt or Linscheid), or true reconstruction (Weiss {bone-ligament-bone}or Nelson {using the transverse carpal ligament, which was presented at the previous year's IWIW meeting}), I think it is important to be clear which surgery is done.] The articular reduction was anatomic (< 1 mm) in 25 and nearly anatomic (1 mm) in 8. There were twenty excellent, 10 good, and 3 fair results (Gartland and Werley). Simple articular fractures (Type B) had 82% (9/11) excellent results compared with 50% (11/22) complex articular fractures (Type C). Partial tears of the SL ligament did not adversely affect results (6/8 excellent results). However, the higher grade (III and IV) tears occurred more frequently in the Type C fractures, and did have an effect: Type C without Type III or IV tears had an excellent result, while those with this level of tear had only good or fair results. Additionally, none of the LT ligament tears had an excellent result, but the low number (4) made generalizations difficult. Interestingly, the presence of a TFC tear did not adversely affect the results. Will concluded that arthroscopy was a valuable aid in treating these fractures, somewhat like a mini-c-arm. Someone from the audience called it the "gold standard", but this view was not supported byothers, who took a more limited view, and Will reiterated his opinion that it was a "valuable aid." His circumspect attitude was appreciated by many. This is a very important paper, by a thoughtful and reliable investigator. The role of arthroscopy has not yet been established, but some role can no longer be denied. One observation: there has been a controversy in the literture regarding whether the initial displacement or the final reduction affects outcome most. This study would posit a third possibility: it is the soft tissue injury that best predicts outcome. Other researchers (Bain in Australia and Lindau in Sweden, to mention two) are also working in this area.

Correction of Distal Radius Malunion Fractures Using the Norian SRS

Riccardo Luchetti, MD

The complete manuscript and xrays are available here. This is an interesting, preliminary study of three patients who had an osteotomy performed for malunion. Instead of inserting tricortical bone graft (the standard method) or cancellous graft (see Jupiter's paper, above), the author stabilized the osteotomy with K-wires and inserted Norian SRS. This has the advantages of not requiring iliac crest bone or a dorsal plate. Norian has been shown to have a large amount of settling in distal radius fractures (see the FDA report , page 10, Table 8). Norian SRS had loss of radial length of 4.7 + 4.3 mm at 3 months compared to a control of 4.0 + 4.3, and a loss of 4.5 + 4.3 compared to a control of 3.7 + 4.0 at 12 months. However, settling does not seem to be the problem with osteotomy as it is with fractures, at least as seen by these three cases. Norian is remodeled fairly slowly, but that may not be a problem in this application.

This is an interesting approach and should be investigated further.

As a member of the FDA Panel that approved Norian SRS for use in unstable distal radius fractures, I feel it is important to urge readers not to attempt to use Norian SRS off-label. We have seen many examples of how these new materials do not behave as one might think, and all new indications should be evaluated carefully as part of a controlled study, with the results (either positive or negative) shared with the rest of the surgical community. Personally, I do not feel we will know the exact indications for the in-situ hardening cements (there are at least three on the market in Europe; for a listing, see the paper under Basic Knowledge, Types of Bone Graft Substitutes, and scroll down to Mineral Cements) for at least a decade. However, we will never reach that point if surgeons use them outside of controlled studies. (See also my comments under Norian SRS vs. Conventional Therapy in Distal Radius Fractures, reviewed above.) -reviewed by David Nelson, MD

All of the abstracts as well as some of the Instructional Course Lectures are on-line. Some papers you might like to look at include:

Pin Site Care During External Fixation in Children: Results of a Nihilistic Approach

This contribution to the ongoing controversy regarding pin site care suggests that daily showering without specific pin site care can result in only a 4% complication rate. No pins needed removal.

A Randomized Controlled Trial of Indirect Reduction and Percutaneous Fixation Versus ORIF for Displaced Intra-Articular Distal Radius Fractures

An excellent paper by a well-known group of investigators, including one of our own Editors. This paper will put the pressure on the ORIF guys to show a better outcome compared to percutaneous methods.

Do Fractures Heal by the Reinduction of Genes Expressed During Bone Development?

An interesting basic science paper in mice that documents what we have guessed: fracture healing utilizes a similar pathway to skeletogenesis.

Delayed Postoperative Injection of Osteogenic Protein-1 (OP-1) in the Canine Noncritical-Sized Defect Model

Allthough the cytokines are not curently (Feb 24, 1999) available for use in humans in the US, they are a hotbed of research. Indeed, the ORS used to be a biomechanics meeting, and now it is a cytokine, tissue engineering, and gene therapy meeting! This paper lets you see what will be coming down the pike in the future.

Synergism of Bone Marrow and rhBMP-2 in Segmental Bone Repair

Another cytokine paper that shows what will be possible in the future.

Instructional Course Lecture: Advances in Distal Radius Fracture Management

An excellent symposium with William Geissler, Jesse Jupiter, Matthew Putnam, and William Sieitz; moderated by Scott Wolfe.

The use of BMP-2 in Interbody Fusion Cages: Definitive Evidence of Osteoinduction in Humans

You may wonder why I include a paper on lumbar fusions on this site. The reason is that this technology will be applied to distal radius fractures in the future, and was so important that Scott D. Boden, MD, was given the Kappa Delta/Young Investigator Award for this work. The paper is worth review if you have an interest in bone grafting alternatives. Also, be sure to visit the paper on this site on bone graft alternatives, available through the Basic Knowledge navigation button (on the left of your screen), under Types of Bone Graft Substitutes.

The abstracts for the ORS are on a protected site and I cannot directly link to them. I have asked the authors of all papers relating to distal radius fractures and bone grafting for permission to post their work. I will post them as I get permission and have time to format them. Stay tuned.

THE SIGNIFICANCE OF THE IMMUNE RESPONSE IN THE FATE OF BONE ALLOGRAFTS
Wooley, P.H., Nadim, Y, Schaefer, C.J., and Ryan, J.R. Department of Orthopaedic Surgery, Wayne State University, Hutzel Hospital 1S, 4707 St Antoine Blvd,
Detroit, MI48201. (313)745-6828 FAX (313) 993-0857, p_wooley@wayne.edu

Research

Updated: November 28, 1999

This page of eRadius is devoted to listing research presentations from meetings around the world. We are looking for Corresponding Editors for North America (AAOS, ORS), Japan, India, and Australia. We need one for SICOT. If you are interested in volunteering or if you know of proceedings that are not listed, please contact the Webmaster.

Note: All comments are by David Nelson, MD, unless otherwise indicated.

Prediction of Instability of Fractures of the Distal Radius
Paul J. MacKenney, FRCS; Margaret M. McQueen, MD; Rob Elton, PhD

Edinburgh Orthopaedic Trauma Unit, Edinburgh, Scotland

Purpose: To produce a method of accurately predicting instability of distal radius fractures on the day of injury which is easily applicable in the clinical situation.

Methods: During a five-and-one-half year period, data were recorded prospectively on 4025 patients with distal radial fracture. The items of information included demographic data, mode of injury, the patient's level of function, and radiological data. The latter included: fracture classification (AO and Frykman); the degree of fracture comminution; measurement of dorsal angulation, radial shift and ulnar variance at presentation, post manipulation, one week, and six weeks after injury; carpal alignment at union. Using the position of the fracture at one and six weeks and the alignment of the carpus as outcome measures, statistical analysis of the data was performed to identify factors of independent significance in the prediction of early instability, late instability, and carpal malalignment respectively. Each factor was analysed using the Mann-Whitney or chi- squared test, and significant factors used in multiple logistic regression analysis. Predictive equations were then derived from the multiple logistic regression.

Results: Factors predictive of fracture instability were seen to vary depending on the position of the fracture at presentation (displaced with more than 10 degrees of dorsal angulation or minimally displaced with less than 10 degrees of dorsal angulation). There were also differences between factors predictive of early and late instability. The most highly significant prognostic factor was the age of the patient (p<0.001), and this applied to all sets of data analysed. Comminution was also important, though to a lesser degree. The dorsal angulation of the fracture at presentation was only of prognostic significance in fractures with minimal displacement at presentation, whereas the ulnar variance was significant in all fractures. Surprisingly, independence in the activities of daily living was of value in predicting late instability in displaced fractures. The sex of the patient, mode of injury, the radial shift at presentation, and Frykman classification was of no prognostic value following multiple logistic regression. In the prediction of carpal malalignment the patient's age and level of function, fracture comminution, AO and Frykman classifications, and the dorsal angulation of the fracture at presentation were all of significance. From the data analysed it was possible to construct an equation to predict the percentage chance of instability after distal radius fracture. The following example is for the probability of early instability in a displaced fracture at presentation:

An example can be given as follows. A 75-year-old lady sustains a distal radial fracture after slipping on ice. She is normally independent and active. Initial dorsal angle is 17 degrees and ulnar variance is 3 mm with dorsal comminution. This patient therefore has a fracture which is displaced at presentation. To calculate the probability of displacement at one week, the formula is used as above. The score is -0.14. Using the probability formula, this patient has an 82% chance of the fracture being unstable at one week.

Discussion and conclusions: Previously it has been demonstrated that the ulnar variance, dorsal angulation, and age of the patient were all factors related to the anatomical outcome following distal radial fracture. We have shown that the significance of these factors depends on the position of the fracture at presentation, and whether one is trying to predict early or late instability. We have shown that the age of the patient is by far the most important factor in assessing the instability of a fracture. It is hoped that refinement of the predictive equations will produce a user-friendly and reliable method of assessing the distal radial fracture at presentation. The value of such a system cannot be underestimated: unnecessary manipulations can be avoided in patients with fractures that require operative fixation, and these patients will be able to have definitive treatment at presentation. In addition, this rationalisation of the treatment protocol is likely to be of economic benefit.

Webmaster's Comments: This is a very important paper and I think that this work will get a lot of attention once it is published. In some ways, it represents a Holy Grail of distal radius fracture management: predicting in the ER which patients will collapse and therefore may need prophylactic fixation of some type, rather than waiting until the collapse happens and then playing catchup, or worse, an osteotomy. (As Jesse Jupiter has phrased it once to me, a Darrach procedure is not fracture aftercare; the implication is that proper fracture care will avoid the salvage procedures down the line.)

The paper only presented one equation, which was the probability of early instability, although that was not clear from the abstract in the program. This was clearer after I talked to the authors after the presentation. During the presentation, they gave a different equation, the probability of late instability:

Dr. McQueen told me that they have four equations based on their dataset. The third one predicts carpal malalignment. She did not mention what the fourth equation represented.

Before you complain, "But I don't have time to do an exponential calculation at 2 am in the ER!", the authors have worked out tables that do all the calculations for you. These could be posted in the ER or reduced and carried in a pocket. Other more convenient means are also underway.

There are a number of surprises in the results of the study. One: the best predictor of late instability is age. I believe that we all have felt that this was a factor, but this is the first study to document (rather than just opine) that this is the most important factor. Two: dorsal angle is not a good predictor. I discussed this with Dr. McQueen (who incidentally is on the Board of Editors of eRadius), who clairfied that, although it was a predictor, it was not an independant predictor and therefore did not make it into the equation. I asked if angle was not more readily measured than degree of comminution (a problem with other attempts at prediction), and learned that communution was rated as either present or absent, not graded, which simplified the matter. Three: mode of injury was not of prognostic significance. I usually feel that high velocity injuries are more unstable; it could be that the dataset did not have enough of these injuries to reflect this contribution. (I await the manuscript, or possibly the authors will respond.) Four: dorsal angulation was of value only with minimally displaced fractures. I would like to know if this means that minimally displaced fractures were predictive of stability, but more displaced fractures were not predictive. This was not clear either from the abstract or presentation.

Criticisms aside, this is a very important work and one that will be a benchmark for future studies. Most questions will probably be answered in the manuscript. Congratulations to the authors (and apologies if I have misunderstood or misrepresented any of your work. I was writing madly in the dark during the presentation, and only remembered a limited number of questions when we spoke.)

There were other good presentations at the OTA, which will be posted as time permits.

Comparison of Structural and Nonstructural Bone Graft for Distal Radius Osteotomy

Celine Roberge, MD, David Ring, MD, and Jesse Jupiter, MD; Boston, MA

This was an excellent clinical study comparing the standard, Fernandez osteotomy with iliac crest corticocancellous graft with a new approach, using only cancellous graft. This technique is only possible due to the stability allowed by the new Synthes' Pi plate. Nine consecutive patients had the traditional osteotomy and grafting (Group I) and eight had the new technique (Group II). The average ages were similar (50 and 46, respectively), the delay from the time of injury was similar (62 weeks and 67 weeks, respectively), the degrees of deformity were similar (but the data was not given), and the followup was similar (14 months and 22 months, respectively). All osteotomies healed. The average ulnar variance improved from 2.6 mm to 1.3 mm in Group I, and from 5.6 mm to 1.5 mm in Group II. The average volar tilt improved from -20 degrees to +1 degree in Group I, and from -10 degrees to +3 degrees in Group II. The results were Group I: 3 excellent, 4 good, 1 fair, and 1 poor; compared to Group II: 4 excellent, 3 good, and 1 poor. Both the poor outcomes were in Workers' Compensation cases, and one had severe intracarpal trauma. The paper was reviewed by Thomas Trumble, who noted that the groups were not entirely comparable, and questioned if there was a selection bias. However, my feeling from hearing both the paper and the review, was that this was a very exciting technique that had been adequately tested to suggest it to the surgical community. We all know how difficult it can be to contour the corticocancellous graft properly and how nearly impossible it is to get it into the osteotomy site. I ususally need to employ a few choice swear words to get it to fit. I would note that the only complication was that five patients in each group required plate removal. This is not a criticism of the technique, since they both use it. However, I have found that if you enter through the third compartment (a bit radial on the superficial layer and a bit ulnar on the deep layer), you have enough soft tissue to cover the plate. I have not had to remove any plates since using this technique. An obvious question arises: if the osteotomy can be done with cancellous bone, and Collagraft has been shown to be equivalent to cancellous bone [J Bone Joint Surg Am 1997 Apr;79(4):495-502, Treatment of acute fractures with a collagen-calcium phosphate graft material. A randomized clinical trial.Chapman MW, Bucholz R, Cornell C], could this not be done without any iliac crest harvest at all? If the criteria of excellence include changing clinical practice and stimulating further research, this paper rates excellent on all grounds.

A Prospective, Randomized Comparison of Corraline Hydroxyapitite and Autogenous Bone Graft in the Treatment of Distal Radius Fractures

John Wyrick, MD, Christopher Spieles, MD, and Irfan Ansari, MD

This was a prospective, randomized clinical study of 36 comminuted distal radius fractures in 35 patients, all treated with external fixation and supplementaly K-wire fixation. Group I consisted of 16 patients treated with iliac crest bone grafting and Group II had "coralline hydroxyapetite", which presumeably was Interpore's Prosteon. [Although the authors did not say if it was the newer 500R, I suspect it was the earlier version of the product that had less of the calcium carbonate changed into calcium phosphate, which makes the product much slower to incorporate, and in my opinion, too slow to incorporate. Interpore apparently agrees, since they came up with the 500 R (for resorbable). For further discussion and histology, see the navigation button Basic Science (to the left on your screen), and choose the paper Types of Bone Graft Substitute.] The fixators were removed at six weeks in both groups. The average range of motion, grip strength, and outcome were not statistically different for the two groups. The cost of the product was equal to the surgeon's fee, but Group II did not require an overnight stay in the hospital. There was no comment about the rate of incorporation, which to me is a very important consideration, and there were 10 patients lost to followup (29%). I have not had to admit any of my patients who have had an iliac crest bone graft since I have started to place a Marcaine block prior to closing the hip incision, so there would not be that benefit in my patients. The area of bone graft substitutes is a very important one for the surgeon to stay abreast of, and this paper demonstrates the advantages of avoiding iliac crest complications by using "bone in a bottle." The question is, which bone in a bottle? Prospective, double blind studies are needed, and the one cited above by Chapman, from the J Bone Joint Surg Am 1997, is the only one of which I am aware.

Norian SRS vs. Conventional Therapy in Distal Radius Fractures: Minimum One-year Follow-up in 323 Patients

Charles Cassidy, MD (Boston, MA), Jesse Jupiter, MD (Boston, MA), Michelle Delli-Santi, BS (Norian, Cupertino, CA), Jeffrey Husband, MD, Charles Leinberry, MD, and Brent Constantz, PhD (Norian, Cupertino, CA)

This was the data upon which Norian Corporation had their carbonated hyproxyapetite cement, SRS (for Skeletal Reconstruction System), approved by the FDA. It was a very complex undertaking, with vast amounts of data collected, and the authors are to be congratulated. The study was run by Dr. Amy Ladd of Stanford. The study was a prospective, randomized, culticenter clinical study of distal radius fractures. The patients were stratified by fracture type, bone density as measured by DXA scanning, and type of treatment chosen by the patient and surgeon (either cast or ex fix), and randomized to either the control group (conventional treatment) or treatment with SRS. With this many treatment arms, a large number of patients were required, and there were 162 in the conventional treatment group and 161 in the SRS group. The conventional treatment (cast of ex fix) group was immobilized for 6-8 weeks, and the SRS group immoblized in a cast for 2 weeks and a splint for 4 weeks. The large amount of data collected allowed many different comparisons to be made, more than could be presented at the ASSH or presented here. To summarize: although there were many early differences between the groups, they usually did not persist beyond 3 months. The authors claim that the loss of reduction was similar between the two groups, but others looking at the same data have felt that the loss of reduction in the SRS patients that did not have supplemental K-wire fixation was greater, and the FDA has suggested that "use of the cement does not eliminate the need for other stabilizing devices, such as hardware and pins, in patients who would normally need them. This is espeically true for patients with very complex fractures." (http://www.fda.gov/bbs/topics/ANSWERS/ANS00931.html) The infection rate was significantly higher in the control group, due to the use of external fixation, but this should not be clinically relevant, given the FDA's suggestion that SRS not be used without external fixation, if the surgeon felt that normally ex fix was indicated. The authors concluded that "Norian SRS appears to be safe and effective in the management of distal radius fractures." I would agree, with several caveats: the surgeon needs to be sure to take Norian surgeon's training course and closely follow the company's recommendations. Although we all expect to see a large amount of off-label use of this product, the surgeon is strongly advised to speak to the experienced surgeons who have used SRS in the study and learned a great deal about its strengths and weaknesses. There is no need to repeat the lessons already learned by these excellent surgeons.

Arthroscopic Assisted Reduction of Distal Radius Fractures

William Geissler, MD Jackson, Mississippi

This was an excellent clinical study of 33 patients who had an intraarticular distal radius fracture with > 2mm of articular displacement after attempted closed reduction. There were 7 Type B1, 1 Type B2, 3 Type B3, 9 Type C1, 3 Type C2, and 10 Type C3 fractures (AO Classification). There were, in addition to the bony injury, TFCC tears in 13 (40%), with 8 peripheral tears, 4 radial avulsions, and 1 central tear. A complete or partial SL tear was found in 12 (36%) and a complete or partial LT tear in 4 (12%). All patients had an arthroscopically-assisted reduction, plus percutaneous pin fixation alone in 18, plates and K-wires in 11, and cannulated screws in 4. The general procedure was to reduce the radial styloid first, then elevate the depressed fragments, and then the volar medial complex. SL tears of Geissler Grade II were pinned for 6 weeks, Grade III and IV had an open "reconstruction". [Will did not discuss the type of "reconstruction", but I believe he meant "repair." Due to the various types of repair (Taleisnik), substitution (Blatt or Linscheid), or true reconstruction (Weiss {bone-ligament-bone}or Nelson {using the transverse carpal ligament, which was presented at the previous year's IWIW meeting}), I think it is important to be clear which surgery is done.] The articular reduction was anatomic (< 1 mm) in 25 and nearly anatomic (1 mm) in 8. There were twenty excellent, 10 good, and 3 fair results (Gartland and Werley). Simple articular fractures (Type B) had 82% (9/11) excellent results compared with 50% (11/22) complex articular fractures (Type C). Partial tears of the SL ligament did not adversely affect results (6/8 excellent results). However, the higher grade (III and IV) tears occurred more frequently in the Type C fractures, and did have an effect: Type C without Type III or IV tears had an excellent result, while those with this level of tear had only good or fair results. Additionally, none of the LT ligament tears had an excellent result, but the low number (4) made generalizations difficult. Interestingly, the presence of a TFC tear did not adversely affect the results. Will concluded that arthroscopy was a valuable aid in treating these fractures, somewhat like a mini-c-arm. Someone from the audience called it the "gold standard", but this view was not supported byothers, who took a more limited view, and Will reiterated his opinion that it was a "valuable aid." His circumspect attitude was appreciated by many. This is a very important paper, by a thoughtful and reliable investigator. The role of arthroscopy has not yet been established, but some role can no longer be denied. One observation: there has been a controversy in the literture regarding whether the initial displacement or the final reduction affects outcome most. This study would posit a third possibility: it is the soft tissue injury that best predicts outcome. Other researchers (Bain in Australia and Lindau in Sweden, to mention two) are also working in this area.

Correction of Distal Radius Malunion Fractures Using the Norian SRS

Riccardo Luchetti, MD

The complete manuscript and xrays are available here. This is an interesting, preliminary study of three patients who had an osteotomy performed for malunion. Instead of inserting tricortical bone graft (the standard method) or cancellous graft (see Jupiter's paper, above), the author stabilized the osteotomy with K-wires and inserted Norian SRS. This has the advantages of not requiring iliac crest bone or a dorsal plate. Norian has been shown to have a large amount of settling in distal radius fractures (see the FDA report , page 10, Table 8). Norian SRS had loss of radial length of 4.7 + 4.3 mm at 3 months compared to a control of 4.0 + 4.3, and a loss of 4.5 + 4.3 compared to a control of 3.7 + 4.0 at 12 months. However, settling does not seem to be the problem with osteotomy as it is with fractures, at least as seen by these three cases. Norian is remodeled fairly slowly, but that may not be a problem in this application.

This is an interesting approach and should be investigated further.

As a member of the FDA Panel that approved Norian SRS for use in unstable distal radius fractures, I feel it is important to urge readers not to attempt to use Norian SRS off-label. We have seen many examples of how these new materials do not behave as one might think, and all new indications should be evaluated carefully as part of a controlled study, with the results (either positive or negative) shared with the rest of the surgical community. Personally, I do not feel we will know the exact indications for the in-situ hardening cements (there are at least three on the market in Europe; for a listing, see the paper under Basic Knowledge, Types of Bone Graft Substitutes, and scroll down to Mineral Cements) for at least a decade. However, we will never reach that point if surgeons use them outside of controlled studies. (See also my comments under Norian SRS vs. Conventional Therapy in Distal Radius Fractures, reviewed above.) -reviewed by David Nelson, MD

All of the abstracts as well as some of the Instructional Course Lectures are on-line. Some papers you might like to look at include:

Pin Site Care During External Fixation in Children: Results of a Nihilistic Approach

This contribution to the ongoing controversy regarding pin site care suggests that daily showering without specific pin site care can result in only a 4% complication rate. No pins needed removal.

A Randomized Controlled Trial of Indirect Reduction and Percutaneous Fixation Versus ORIF for Displaced Intra-Articular Distal Radius Fractures

An excellent paper by a well-known group of investigators, including one of our own Editors. This paper will put the pressure on the ORIF guys to show a better outcome compared to percutaneous methods.

Do Fractures Heal by the Reinduction of Genes Expressed During Bone Development?

An interesting basic science paper in mice that documents what we have guessed: fracture healing utilizes a similar pathway to skeletogenesis.

Delayed Postoperative Injection of Osteogenic Protein-1 (OP-1) in the Canine Noncritical-Sized Defect Model

Allthough the cytokines are not curently (Feb 24, 1999) available for use in humans in the US, they are a hotbed of research. Indeed, the ORS used to be a biomechanics meeting, and now it is a cytokine, tissue engineering, and gene therapy meeting! This paper lets you see what will be coming down the pike in the future.

Synergism of Bone Marrow and rhBMP-2 in Segmental Bone Repair

Another cytokine paper that shows what will be possible in the future.

Instructional Course Lecture: Advances in Distal Radius Fracture Management

An excellent symposium with William Geissler, Jesse Jupiter, Matthew Putnam, and William Sieitz; moderated by Scott Wolfe.

The use of BMP-2 in Interbody Fusion Cages: Definitive Evidence of Osteoinduction in Humans

You may wonder why I include a paper on lumbar fusions on this site. The reason is that this technology will be applied to distal radius fractures in the future, and was so important that Scott D. Boden, MD, was given the Kappa Delta/Young Investigator Award for this work. The paper is worth review if you have an interest in bone grafting alternatives. Also, be sure to visit the paper on this site on bone graft alternatives, available through the Basic Knowledge navigation button (on the left of your screen), under Types of Bone Graft Substitutes.

The abstracts for the ORS are on a protected site and I cannot directly link to them. I have asked the authors of all papers relating to distal radius fractures and bone grafting for permission to post their work. I will post them as I get permission and have time to format them. Stay tuned.

THE SIGNIFICANCE OF THE IMMUNE RESPONSE IN THE FATE OF BONE ALLOGRAFTS
Wooley, P.H., Nadim, Y, Schaefer, C.J., and Ryan, J.R. Department of Orthopaedic Surgery, Wayne State University, Hutzel Hospital 1S, 4707 St Antoine Blvd,
Detroit, MI48201. (313)745-6828 FAX (313) 993-0857, p_wooley@wayne.edu