Key Points
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The minimally invasive approach of the flexor carpi radialis can be used for volar plate fixation of distal radius fractures.
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The upsides of this technique are the preservation of the ligamentotaxis to facilitate the reduction of the fracture and the small size of the incision to improve the cosmetic results of the procedure.
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The incision can always be extended in case of difficulties of reduction.
Acknowledgment
Pr François Severac, Marie Mielcarek, Public Health Department and Statistics, Strasbourg University Hospitals, France.
Conflicts of Interest
Philippe Liverneaux has conflicts of interest with Argomedical, Newclip Technics. None of the other authors have conflicts of interest.
A 49-year-old, left-handed female director of a cosmetic enterprise sustained a dorsally displaced extraarticular distal radius fracture when walking her dog. Radiographs show 25 degrees of dorsal angulation and dorsal metaphyseal comminution. In your office she immediately states that she refuses surgery as she does not accept any large scar on her wrist. You esteem that casting nor K-wire fixation will yield sufficient stability in her mild osteoporotic bone and comminutive fracture, for which you recommend plate fixation. What are the advantages and drawbacks for minimal invasive plate fixation?
Importance of the Problem
Since the year 2000, the fixation of distal radius fractures by volar locking plate has become the gold standard. Three surgical approaches have been described: conventional, extended, and minimally invasive.
The conventional approach of the flexor carpi radialis (FCR) ( Fig. 1 A ) has been developed to treat volar tilt fractures. It corresponds to the distal part of the Henry Approach and is less aggressive for the extensor tendons than dorsal approaches. It also enables the fixation of dorsal tilt fractures where the reduction is facilitated by ligamentotaxis.
The extended approach of the FCR ( Fig. 1 B) is used for dorsal tilt fractures. The incision is 8–10 cm long. The distal edge of the pronator quadratus (PQ) forms a transverse line on the surface of the radius called the watershed line beyond which the plate should not be positioned to avoid conflicts with the flexor tendons. The PQ is elevated to expose the fracture site without risk of necrosis for some authors, and with a risk of necrosis for others. MIPO enables the mobilization of the proximal end of the radius in pronation through the fracture site giving a large exposure. Ligamentotaxis is limited with this technique.
Minimally invasive plate osteosynthesis (MIPO) techniques were developed for hip, knee, ankle, shoulder, and elbow surgeries. They aim at preserving bone vascularization, improve bone healing, reduce the rate of infections, ease the reduction of the fracture using ligamentotaxis, and meet the cosmetic expectations of the patients.
For the wrist, the concept is raised in 2000. It has been reported to improve bone healing because of the preservation of the periosteum and PQ at the fracture site unlike in the traditional approach. The cosmetic benefit is notable.
Main Question
What is the additional value of a Minimal Invasive Approach for plate fixation of simple distal radius fractures?
Current Opinion
Minimal invasive plate fixation is a cosmetically attractive treatment option with the potential drawback of adding intraoperative difficulty due to lesser visualization of the fracture. Being considered in developmental phase, its superiority remains to be proven.
Finding the Evidence
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Cochrane search: Distal Radius Fracture
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Pubmed (Medline): (“Radius Fractures” [Mesh] OR distal radius fracture*[tiab]) AND (minim* invasive plate OR MIPO)
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Bibliography of eligible articles
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Articles that were not in the English, French or German language were excluded.
Quality of the Evidence
Level II:
Systematic Reviews/Metaanalyses: 1
Randomized trials with methodological limitations: 1
Level III:
Retrospective comparative studies: 3
Level IV:
Case series: 12
Findings
Minimally invasive techniques are growing stronger in all surgical specialties. They are not only justified for cosmetic reasons, but also for technical and physiological reasons.
From a technical point of view, it has been proven that an approach of a limited size preserved ligament and muscle insertions of the distal radius and carpus thus facilitating the reduction of the fracture and contributing to its stability thanks to ligamentotaxis. The concept is opposed to the concept of the extended approach of the FCR that requires to almost “strip” the distal radius. From a physiological point of view, a limited approach should, theoretically, limit bone ischemia, source of necrosis of small articular fragment or nonunion, sometimes observed in extensive approaches with extensive deperiosting in patients with comorbidities. Finally, a limited approach preserves the hematoma of the fracture site leading to faster bone healing.
Lee et al. recently performed a systematic review and metaanalysis of four studies comparing conventional distal radius plating to MIPO. They included one randomized controlled trial with methodological limitations and three retrospective comparative series. All studies reported patient-reported outcome scores (PROMs) at the final follow-up of 139 patients in the conventional group and 149 patients in the MIPO group. There were no significant differences in PROMS, grip strength or range of motion between the conventional and MIPO groups. However, there was a significant higher patient satisfaction in the MIPO group compared to the conventional plating group at final follow-up reported in three studies (123 patients in the conventional group and 134 patients in the MIPO group) (standard mean difference − 0.54; 95% confidence interval − 0.79 to − 0.29). It should be acknowledged that this difference being inferior to 1 out of 10 points is likely nonclinically relevant.
With almost 500 cases published to date ( Table 1 ), indications of MIPO techniques in distal radius fractures are growing. Some consider they can only be used for simple extraarticular fractures. While others extend their indications to articular fractures and diaphysiometaphyseal fractures. Others recommend arthroscopy for articular fractures with fragments that are not spontaneously reduced when the plate is put in place. A double approach, proximal and distal, is recommended for fractures with a diaphyseal extension.
| Authors | Date | Incision | Respect PQ | Patients | Result | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Number (N) | Size (mm) | Orientation (T/L) | Arthroscopy (Y/N) | (Y/N) | Number (N) | Clinical | Complications | Radiological | ||
| Geissler et Fernandes | 2000 | 2 | ? | L (Pl) L (Dl) | N | N | ? | ? | ? | ? |
| Imatani et al. | 2005 | 2 | 50 (20 + 30) | L (Ds) L (Pr) | N | Y | 5 | F59° E55° P85° S82° Grip 88% | N | Volar tilt 13° Radial inclination 24° Ulnar variance 0.6 mm |
| Yoshikawa et al. | 2008 | 2 | 40 (25 + 15) | T (Ds) L (Pr) | N | Y | 13 | Cooney score 92.7 F + E = 122° P + S = 157° Grip 86% | N | Volar tilt 8.6° Radial inclination 22.5° Ulnar variance 0.4 mm |
| Sen et al. | 2008 | 2 | 50 (20 + 30) | L (Ds) L (Pr) | N | Y | ? | ? | ? | ? |
| Zenke et al. | 2011 | 2 | 40 (30 + 10) | T (Ds) L (Pr) | N | Y | 30 | F86° E67° P89° S89° Grip 94% | Intraarticular screw (1) | Volar tilt 9.4° Radial inclination 24° Ulnar variance 1.1 mm |
| Abe et al. | 2013 | 1 | 30 (25 − 30) | L | Y | Y | 153 | Score Mayo 89.5% DASH 4.1 F60° E63° P83° S86° Grip 88% | Secondary displacement (3) EPL rupture (2) CPRS type I (1) | Volar tilt 5.6° Radial inclination 26.1° Ulnar variance 0.1 mm |
| Zemirline et al. | 2014 | 1 | 15 | L | Y | Y | 20 | Pain 1.9/10 DASH 24.6 F71° E72° P86° S86° Grip 67% | CPRS type I (3) | Volar tilt 8.8° Radial inclination 20.7° Ulnar variance − 1 mm |
| Rey et al. | 2014 | 1 | 26 | L | N | Y | 31 | DASH 10 Grip 80% | Secondary displacement (1) | Volar tilt 4.8° Ulnar variance 0.3 mm |
| Lebailly et al. | 2014 | 1 | 15 | L | Y | Y | 144 | DASH 25 F86° E86° P96° S91° Grip 67% | CPRS type I (9) Secondary displacement (2) tenosynovitis (9) Intraarticular screw (2) Distal screw displacement (1) | Volar tilt 8.3 Radial inclination 22° Ulnar variance 0.4 mm |
| Wei et al. | 2014 | 2 | 40 (20 + 20) | T (Ds) L (Pr) | N | Y | 22 | ? | Anesthesia of thenar eminence (1) Delayed healing (1) Pain of ulnar aspect of wrist (2) Limited function (2) | ? |
| Chmielnicki et Prokop | 2015 | 2 | 30 (25 + 5) | T (Ds) L (Pr) | N | Y | 11 | F45° E45° P85° S85° Grip 96% | ? | ? |
| Chen et al. | 2015 | 2 | 30 (20 + 10) | T (Ds) L (Pr) | N | Y | 21 | Mayo wrist score 95.0 | N | Volar tilt 9.86° Radial inclination 22.43° Ulnar variance 0.29 mm |
| Naito et al. | 2016 | 1 | 10 | L | N | Y | 18 | F67° F67° P88° S88° DASH 0.7 Mayo wrist score 93.3 | CPRS type I (1) | Complete union |
| Wei et al. | 2016 | 2 | 40 (20 + 20) | T (Ds) L (Pr) | N | N | 9 | DASH 5.8 F76° E77° P79° S81° Grip 89% | Delayed healing (1) | Volar tilt 10.7° Radial inclination 18.2° Ulnar variance 2.3 mm |
| Zhang X et al. | 2017 | 1 | 18 | L | N | Y | 182 | F75° E65° P80° S85° Grip 94% DASH 3.5 Mayo wrist Score 81% | ? | Volar tilt 12° Radial inclination 22° Ulnar variance 1 mm |
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