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October 2022, Volume 72, Issue 10

Research Article

Application of Rikkli and Regazzoni three-column theory in distal radius intraarticular fractures and its functional and radiological assessment

Muhammad Asad Iqbal Khan  ( Department of Orthopedic Surgery, Indus Hospital, Lahore, )
Syed Faraz Ul Hassan Shah Gillani  ( Department of Orthopedic Surgery, King Edward Medical University, Mayo Hospital, Lahore. )
Ahmed Humayoun Sarfraz  ( King Edward Medical University, Mayo Hospital, Lahore, )
Umar Hayat  ( Mian Munshi Hospital, Lahore,Pakistan. )
Hafiz Ahmed Fayyaz Bajwa  ( King Edward Medical University, Mayo Hospital, Lahore, )

Abstract

Objective: To determent the effectiveness of Rikli and Regazzoni three-column theory in treating intra-articular fractures of the distal radius with T-plate and K-wire in terms of functional outcome and fracture union.

Method: The cross-sectional study was conducted at the Department of Orthopaedic Surgery and Traumatology, King Edward University, Mayo Hospital, Lahore, Pakistan, from June 2013 to March 2017, and comprised patients aged 15-60 years having closed intraarticular fracture of the distal radius <1 month older. The subjects were divided into two group A, managed by percutaneous K-wire fixation, and group B, managed with open reduction and internal fixation using T-plates. Wound infection, supination and pronation, flexion and extension at the wrist joint, bone union and functionality were observed. All patients were followed up with intervals for 12 months in the out-patient department, and wound infection and supination and pronation of the forearm were observed clinically. Union was observed using the standard criterion, and function was evaluated using the Disabilities of Arm, Shoulder and Hand score. Data was analysed using SPSS 20.

Results: Of the 60 patients, there were 30(50%) with mean age 48.83±11.11 years in group A, and 30(50%) with mean age 49.87±13.45 years in group B. Overall, there were 49(81.7%) males and 11(18.3%) females. There were 33(55%) cases with right side involvement, and 27(45%) had the left side involved. Functionality imprived significantly in both groups (p<0.05). Union was observed in all cases in both groups, while the mean duration in group A was 9.21±1.74 weeks, and in group B it was 9.87±2.14 weeks.

 

Introduction

 

The specific treatment of distal radius fractures has transformed entirely from nearly extensive use of the plaster of Paris (POP) application to a multitude of vastly sophisticated surgical interventions.1,2 Emergency visits comprise 2.5% of distal radius injuries.1,3,4 Distal radius fractures were present in 17% of adults in a bimodal scattering of distal radial fractures comprising a set of young people who endured high-strength injury to the upper limbs and an elder cluster which suffered traumatic and osteoporotic fractures equally.5  The majority of fractures in the elder group are extraarticular, but intraarticular fractures are more prevalent in young patients.6   There is also dissimilarity in the mode of trauma in the elderly who undergo fall, and the young with road traffic accidents (RTAs) and sports injuries.7,8 

In the elderly, causative elements for distal radius are extensively examined. Diminished bone mineral density (BMD), female gender, ethnicity, genetics, and untimely menopause have been shown as causative features for wrist fractures, and at any stage of the treatment, complications related to the fracture of distal radius can take place, and the incidence is up to 27% of all such fractures.9   An orthopaedic surgeon must be attentive to the likely problems, which include nerve damage, stiffness, infection arthrosis, malunion, non-union, pain, soft-tissue, neuro-vascular, and bony complications, comprising extensor tendon or flexor tendon damage, carpal tunnel syndrome, complex-local pain-syndrome, and implant failure.

The three-column principle using Rikkli and Reggazzoni10   for distal radial intraarticular fractures explains the wrist as a biomechanical construct. It splits the wrist joint into three distinct columns, including radial, ulnar and intermediate parts. According to the principle, the treatment goal should be the anatomical reduction of the fracture, which will align the wrist, giving the patient an improved wrist strength for daily activities. To permit structural alignment of the radiocarpal and the radioulnar joint and to achieve normal function, displaced articular fractures necessitate sound reduction and fixation.11   Several treatment procedures comprised closed manipulation and POP, percutaneous K-wire insertion, and open reduction and internal fixation (ORIF_ with T-plates.12-18 

For fractures of the distal radius, intraarticular treatment principles must be the same as any other joint injury. All displaced joint fractures require manipulation for functional restoration of radiocarpal and the radioulnar joints alike.

The current study was planned to evaluate the effectiveness of Rikli and Regazzoni10 three-column theory in treating intra-articular fracture of the distal radius with T-plate and K-wire in terms of the functional outcome and fracture union.

 

Patients and Methods

 

The cross-sectional study was conducted at the Department of Orthopaedic Surgery and Traumatology, King Edward Medical University (KEMU), Mayo Hospital, Lahore, Pakistan, from June 2013 to March 2017. After approval from the institutional review board of KEMU, The sample size of 60 patients, was estimated by using 1% level of significance, 95% power of test with expected percentage of k wires as 19%19   and t plates as 70%.20   The sample was raised using consecutive sampling technique. Those included were patients of either gender aged 15-60 years having closed intraarticular fracture of the distal radius <1 month old diagnosed on the basis of history and clinical examination. Patients presenting with pathological fracture, both bone fracture with compartment syndrome needing fasciotomy, recognised hereditary bone disorder, associated injury, like vascular injury, head trauma and infection, were excluded.

After taking informed written consent from all the patients, they were divided into two groups. All patients were assessed for treatment options by a hand surgeon with >10 years of experience. All cases were operated either by the hand surgeon or by researchers under the supervision of the hand surgeon. Group A was managed by percutaneous K-wire fixation, while group B was given ORIF using T-plates. Pre-operative third-generation cephalosporin (ceftriaxone) 1gm was given half-an-hour before the surgery and two doses were administered postoperatively. The postoperative above-elbow POP cast was given in both groups for two weeks. Radius was operated through a volar Henry incision. The primary surgeon and another consultant with >5 years of experience assessed the wound infection, supination and pronation, flexion, and extension at the wrist joint, union, and upper limb function. The surgical wound was inspected on the second postop day, and the patient discharge status was contingent on the wound status. All patients were followed up in the outpatient department (OPD) at 2nd, 6th, and 12th weeks and then at 6, 9 and 12 months. Wound infection and supination and pronation of the forearm were observed clinically. Union was observed using Hammer et al. criteria,21   and upper-limb function was evaluated using the Disabilities of Arm, Shoulder and Hand (DASH) score.22 

Data was analysed using SPSS 20. Quantitative variables, like age, were presented as mean and standard deviation. Qualitative variables, like gender, appearance and outcome, were expressed as frequencies and percentages. The Kolmogorov-Smirnov Z test was applied to the ages and DASH score to test the normality of data distribution. The sample t-test was applied for normally distributed data, and the Mann-Whitney U test was applied for non-normally distributed data. The Chi-square test and odds ratio (OR) with 95% confidence interval (CI) was calculated to see the effectiveness of the two modalities of treatment. P<0.05 was taken as significant.

Results

Of the 60 patients, there were 30(50%) with mean age 48.83±11.11 years in group A, and 30(50%) with mean age 49.87±13.45 years in group B. Overall, there were 49(81.7%) males and 11(18.3%) females. There were 33(55%) cases with right side involvement, and 27(45%) had the left side involved (Table-1).

Data related to age and DASH scores at 6 and 12 weeks was normally distributed, while the rest of the variables were not normally distributed.

Functionality imprived significantly in both groups (p<0.05). After 12 months, no restriction in supination and pronation was seen in 29(96.67%) patients in group A, and 24(80%) patients in group B. Mild restriction in supination and pronation was observed in 1(3.33%) patient in group A and 6(20.0%) patients in group B. There was no significant difference in supination and pronation in both groups during the follow-up except after 12 months when higher effects were noted in group A (p=0.044) (Table-2).

The mean duration of the union in group A was 9.21±1.74 weeks and in the group, B was 9.87±2.14 weeks (p-value >0.05). Functional outcome improved significantly at 24th week (p<0.008), but there was no significant inter-group difference at other follow-up points (Table-3).

Discussion

There was no difference in terms of the union in both groups until the last follow-up in the current study. The mean duration of union in group A was 9.21±1.74 weeks and in group B it was 9.87±2.14 weeks (Figure-1 & 2). Phadnis et al.23   reported overall mean time to fracture union was 8.4 weeks (range: 6-28 weeks). Khan et. al.24   reported mean DSH score in distal radius fracture at 6-months to be 17.2±8.8 (range: 4-40). Quadlbauer et al.25   reported mean quick DASH score in distal radius fracture at last follow-up to be 11.1±13.8. In the current study, the mean DASH score till the last follow-up was 16.33±5.59 in patients treated with T-plate. Jacob et al.26   treated distal radius fracture with percutaneous K-wire and reported mean Mayo's score of 85.66±7.07 (range: 75-100). In the current study, the mean DASH score in K-wire fixation was 14.26±5.51.

In the upper extremity, fractures of the distal radius are the most commonly seen injuries. In contrast to the more prevalent, lower energy, extraarticular fractures, intraarticular distal radius fractures signify a problematic injury that is linked with significant morbidity. Generally displaced, comminuted, intraarticular fractures have a poor prognosis. Difficulties in reinstating the wrist joint are the prime reason for poor results.27 

Distal radius fractures are managed in considerable numbers.28   Although distal radius fractures are seen most frequently in females aged >40 years, young adults make a substantial portion of the cases. In females, the frequency rises sharply after the age of 40 from approximately 36.8/10000 to 115/10000 at the age of 70. The sharpest increase in incidence arises in elderly females. It has been related to oestrogen withdrawal and reduced bone density.29 

A study reported mean age of patients as 58.3 years (range 20-80 years), with 20(23.5%) males and 65(76.5%) females.30   One more study described a higher female ratio of 5:1.31   A recent study mean age of 43 years (range: 23-53 years).32   A study reported equal gender distribution with mean age 51 years.31   In the current study, the overall mean age was 49.35 years, with a higher male-to-female ratio. The gender distribution is comparable, while mean age is lower compared to earlier studies,30,32  but age distribution waas reported in a study.33 

More aggressive treatment regimens are usually required to reestablish the wrist joint anatomically. When applicable reduction is attained, renovation of discount with fixation via pins and plaster or outside fixation is challenging because of the innate unpredictability of the wrist damage and the propensity for articular fragments to settle after stress relaxation of the tension soft tissue casing. Also, it is not unusual for cases with displaced, intraarticular distal radius fractures to have associated, identical side, higher extremity injuries, which makes their management difficult.34 

ORIF techniques have been set up to treat the comminuted intraarticular distal radius fractures that can not be anatomically reestablished and sustained through external manipulation and ligamentotaxis.35   Open techniques restore widespread joint composition and wrist joint congruency by means of permitting direct reduction and rigid inner fixation of intraarticular parts. Early convalescence can be commenced with the goal of higher functional outcome by means of making a more regular construct through internal fixation.36   Anatomic discount, stable fixation, and early rehabilitation of the hand and wrist are the top goals for managing complicated intraarticular distal radius fractures. The mainstay of remedy for these intricate accidents is external fixation augmented with the aid of K-wires to boom fracture fragment stability.37 

ORIF outcomes after fracture displacement in 20 patients aged >60 years were studied. Volar and dorsal procedures were both used with outstanding functional outcomes in 18 and superb radiographic results in 19 patients; the complication rate was 15%, containing a tendon rupture. ORIF was considered an expected intervention after unsuccessful closed management of distal radius fractures.38   In another trial, functional results of 166 patients managed with non-locking volar plates had 81% good or very good, with equally promising radiological outcomes. Initially, wrist range of motion (ROM) was permitted, and the use of a POP was advised. Patients in each set younger and those aged >60 did equally fine. The incidence of complications for each group was18%, and the complications were predominantly median nerve irritation.39   The current study did not find such a complication rate as it focussed on DASH score, union, flexion/extension, and supination, etc., and both groups improved equally.

Both dorsal plates and K-wire and volar plate fixation procedures were studied in patients with a mean age of 71 years in whom initial closed reduction and cast immobilisation attempts were unsuccessful. Overall, 78% subjects were satisfied, and 22% were moderately happy. No fractures were displaced, and the Gartland score displayed 83% excellent and 17% good outcomes. There was 16% incidence of complications in plate fixation, and a supplementary 5% was credited to associated K-wire insertion. The study recommended both volar and dorsal ORIF as excellent stabilisation systems with a higher incidence of good and excellent results.38   The current study also found significant results in terms of lesser DASH scores in both the groups at the last follow-up. The mean DSH score was significant till the last follow-up.

By bone grafting, radial shortening was avoided and it supported the reduced articular surface, which revealed better practical results.40   ORIF produces a more stiff mechanical construct that allows initial mobilisation, but due to extensive soft tissue dissection, they have been linked with higher complication rates than the closed techniques.41 

In 199610 it was proposed that fractures of the distal end of the radius should be treated on the same principles as other joint fractures. To permit anatomical restoration of both the radiocarpal and the radioulnar joints of the wrist, displaced articular fractures necessitate open reduction. Stable internal fixation can be achieved with two 2.0 Arbeitsgemeinschaft für Osteosynthesefragen (AO) titanium plates positioned on each of the 'lateral' and the 'intermediate' columns of the wrist at an angle of 50-70 degrees. This offers good stability regardless of the small dimensions of the plates and permits early function.39   A series of 20 fractures managed by this technique of internal fixation reported acceptable results in all cases.39 The current study extended this idea and applied the concept to compare the efficacy of the Rikkli and Reggazzoni three-column concept10 in the treatment of distal radius intraarticular fractures by applying T-plates and K-wires for fixation. Both surgical options were equally effective and could be utilised to achieve the maximum clinical and functional outcome.

Wire irritation was reported in patients with K-wire fixation, and implant removal was done in T-plate, which the current study did not consider a variable at the start.

The current study had a small sample size and it did not use other radiographic parameters, including volar tilt, radial height and inclination, which are study limitations. Further studies are needed to gather more evidence for the application of Rikli and Regazzoni's three-column theory10 in the treatment of distal radius intraarticular fractures.

 

Conclusion

 

Good to excellent functional and satisfactory union results were found in both treatment groups for the management of distal radius fracture in maintaining the Rikli and Regazonni three-column approach without wound infection and acceptable flexion and extension as well as supination and pronation of the wrist joint.

 

Disclaimer: None.

 

Conflict of Interest: None.

 

Source of Funding: None.

 

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