Plates not better than K-wires in distal radius fractures?

 Kirschner wire fixation is a longstanding technique in which smooth metal wires with a sharp point are passed across the fracture site through the skin. This technique is rapidly being superseded by locking plate fixation, in which a plate is attached to the bone with fixed angle screws. Locking plates are widely considered to provide stronger fixation, which facilitates earlier return to normal activities. This potential benefit is said to justify the greater cost of the plates.To date, studies comparing the two methods have indicated that locking plates provide improved radiological and/or functional outcomes, particularly in the early stages of rehabilitation; though these studies were smaller single centre trials.

In this multicentre randomised trial, the distal radius acute fracture fixation trial (DRAFFT), the authors examined Kirschner wire fixation compared with volar locking plate fixation for patients with a dorsally displaced fracture of the distal radius. The hypothesis was that locking plates would provide improvements in the patient rated wrist evaluation (PRWE) score in the 12 months after surgery.

Objectives To compare the clinical effectiveness of Kirschner wire fixation with locking plate fixation for patients with a dorsally displaced fracture of the distal radius.

Design A multicentre two arm parallel group assessor blind randomised controlled trial with 1:1 treatment allocation.

Setting 18 trauma centres in the United Kingdom.

Participants 461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation. Patients were excluded if the surgeon thought that the surface of the wrist joint was so badly displaced it required open reduction.

Interventions Kirschner wire fixation: wires are passed through the skin over the dorsal aspect of the distal radius and into the bone to hold the fracture in the correct anatomical position. Locking plate fixation: a locking plate is applied through an incision over the volar (palm) aspect of the wrist and secured to the bone with fixed angle locking screws.

Main outcome measures Primary outcome measure: validated patient rated wrist evaluation (PRWE). This rates wrist function in two (equally weighted) sections concerning the patient’s experience of pain and disability to give a score out of 100. Secondary outcomes: disabilities of arm, shoulder, and hand (DASH) score, the EuroQol (EQ-5D), and complications related to the surgery.

Results The baseline characteristics of the two groups were well balanced, and over 90% of patients completed follow-up. The wrist function of both groups of patients improved by 12 months. There was no clinically relevant difference in the patient rated wrist score at three, six, or 12 months (difference in favour of the plate group was −1.3, 95% confidence interval −4.5 to 1.8; P=0.40). Nor was there a clinically relevant difference in health related quality of life or the number of complications in each group.

Conclusions Contrary to the existing literature, and against the rapidly increasing use of locking plate fixation, this trial found no difference in functional outcome in patients with dorsally displaced fractures of the distal radius treated with Kirschner wires or volar locking plates. Kirschner wire fixation, however, is cheaper and quicker to perform.

 Dr Pietsch, distal radius fractures, treatment of radius fractures, K-wires in radius fractures, theexpertwitnessreference.blogspot.com

 Literature:

 BMJ 2014;349:g4807

Smoking kills, but how quick?

Cigarette smoking, adiposity, unhealthy diet, heavy alcohol drinking and physical inactivity together are associated with about half of premature deaths in Western populations. The aim of this study was to estimate their individual and combined impacts on residual life expectancy (RLE).

Lifestyle and mortality data from the EPIC-Heidelberg cohort, comprising 22,469 German adults ≥40 years and free of diabetes, cardiovascular disease and cancer at recruitment (1994–1998), were analyzed with multivariable Gompertz proportional hazards models to predict lifetime survival probabilities given specific baseline status of lifestyle risk factors. The life table method was then used to estimate the RLEs.

For 40-year-old adults, the most significant loss of RLE was associated with smoking (9.4 [95% confidence interval: 8.3, 10.6] years for male and 7.3 [6.0, 8.9] years for female heavy smokers [>10 cigarettes/day]; 5.3 [3.6, 7.1] years for men and 5.0 [3.2, 6.6] years for women smoking ≤10 cigarettes/day). 

Other lifestyle risk factors associated with major losses of RLE were 

1. low body mass index (BMI <22.5 kg/m², 3.5 [1.8, 5.1] years for men; 2.1 [0.5, 3.6] years for women), obesity (BMI ≥30, 3.1 [1.9, 4.4] years for men; 3.2 [1.8, 5.1] years for women).The obesity-associated loss of RLE was stronger in male never smokers, while the loss of RLE associated with low BMI was stronger in current smokers.
2. heavy alcohol drinking (>4 drinks/day, 3.1 [1.9, 4.0] years for men), and 
3. high processed/red meat consumption (≥120 g/day, 2.4 [1.0, 3.9] years for women).  
4. The loss of RLE associated with low leisure time physical activity was moderate for women (1.1 [0.05, 2.1] years) and negligible for men (0.4 [−0.3, 1.2] years). 

And even worse:

The combined loss of RLE for heavy smoking, obesity, heavy alcohol drinking and high processed/red meat consumption, versus never smoking, optimal BMI (22.5 to 24.9), no/light alcohol drinking and low processed/red meat consumption, was 17.0 years for men and 13.9 years for women.

Conclusions

Promoting healthy lifestyles, particularly no cigarette smoking and maintaining healthy body weight, should be the core component of public health approaches to reducing premature deaths in Germany and similar affluent societies.

5 Minutes For A Longer Life

Although running is a popular leisure-time physical activity, little is known about the long-term effects of running on mortality. The dose-response relations between running, as well as the change in running behaviors over time, and mortality remain uncertain.

Objectives

We examined the associations of running with all-cause and cardiovascular mortality risks in 55,137 adults, 18 to 100 years of age (mean age 44 years).

Methods

Running was assessed on a medical history questionnaire by leisure-time activity.

Results

During a mean follow-up of 15 years, 3,413 all-cause and 1,217 cardiovascular deaths occurred. Approximately 24% of adults participated in running in this population. Compared with nonrunners, runners had 30% and 45% lower adjusted risks of all-cause and cardiovascular mortality, respectively, with a 3-year life expectancy benefit. In dose-response analyses, the mortality benefits in runners were similar across quintiles of running time, distance, frequency, amount, and speed, compared with nonrunners. Weekly running even <51 min, <6 miles, 1 to 2 times, <506 metabolic equivalent-minutes, or <6 miles/h was sufficient to reduce risk of mortality, compared with not running. In the analyses of change in running behaviors and mortality, persistent runners had the most significant benefits, with 29% and 50% lower risks of all-cause and cardiovascular mortality, respectively, compared with never-runners.

Conclusions

Running, even 5 to 10 min/day and at slow speeds <6 miles/h, is associated with markedly reduced risks of death from all causes and cardiovascular disease. This study may motivate healthy but sedentary individuals to begin and continue running for substantial and attainable mortality benefits.

Comments:

If you transfer these results into the treatment of patients, it may well be questioned if the patient's contiuned and regular imput into physical work-outs can result in a quicker healing time.

Lee DC et al. Leisure-Time Running Reduces All-Cause and CV Mortality Risk. J Am Coll Cardiol 2014; 64: 472–81

Instability of the distal radioulnar joint: Have your say!

Dear Colleagues,

instability of the distal radioulnar joint can occur after trauma of the wrist. As Expert Witness, I have tie impression that the prevalence of this pathology is more common than we think. And it appearss to be easily missed. It presents with ongoing symptoms that occur with manual ADL, e.g. lifting and carrying. If it remains untreated, it can result in disability of the wrist.

Considering the severity of this pathology, I would like to ask for opinion. Please find the minute to complete a short survey. It is anonymous and does not ask for any personal details.

Thank you

Click here for the Survey

Degenerative Meniscus tears: You better leave it

Background: Arthroscopic surgery for degenerative meniscal tears is a commonly performed procedure, yet the role of conservative treatment for these patients is unclear. This systematic review and meta-analysis evaluates the efficacy of arthroscopic meniscal debridement in patients with knee pain in the setting of mild or no concurrent osteoarthritis of the knee in comparison with nonoperative or sham treatments.

                   

Methods: We searched MEDLINE, Embase and the Cochrane databases for randomized controlled trials (RCTs) published from 1946 to Jan. 20, 2014. Two reviewers independently screened all titles and abstracts for eligibility. We assessed risk of bias for all included studies and pooled outcomes using a random-effects model. Outcomes (i.e., function and pain relief) were dichotomized to short-term (< 6 mo) and long-term (< 2 yr) data.

                   

Results: Seven RCTs (n = 805 patients) were included in this review. The pooled treatment effect of arthroscopic surgery did not show a significant or minimally important difference (MID) between treatment arms for long-term functional outcomes (standardized mean difference [SMD] 0.07, 95% confidence interval [CI]–0.10 to 0.23). Short-term functional outcomes between groups were significant but did not exceed the threshold for MID (SMD 0.25, 95% CI 0.02 to 0.48). Arthroscopic surgery did not result in a significant improvement in pain scores in the short term (mean difference [MD] 0.20, 95% CI –0.67 to 0.26) or in the long term (MD –0.06, 95% CI –0.28 to 0.15). Statistical heterogeneity was low to moderate for the outcomes.

                   

Interpretation: There is moderate evidence to suggest that there is no benefit to arthroscopic meniscal debridement for degenerative meniscal tears in comparison with nonoperative or sham treatments in middle-aged patients with mild or no concomitant osteoarthritis. A trial of nonoperative management should be the firstline treatment for such patients.

         

M Khan. N Evaniew, A Bedi, OR Ayeni, M Bhandari: Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ August 25, 2014 First published August 25, 2014, doi: 10.1503/cmaj.140433 

Meniscus tears, degenerative meniscus tears, outcome after meniscus debridement, Dr Pietsch, the-expert-witness.de