Commentary & Perspective

Commentary & Perspective on
"A Prospective, Randomized Trial Comparing the Limited Contact Dynamic Compression Plate with the Point Contact Fixator for Forearm Fractures"
by Frankie Leung, FRCS, and Shew-Ping Chow, MS, FRCS

Commentary & Perspective by
R. Malcolm Smith, MD, FRCS*,
Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts

The last few years have seen a revolution in the philosophy of fracture fixation, with the emphasis changing from techniques designed to restore perfect anatomy and absolute stability to those aimed at maintaining local tissue viability while providing relative stability to the fracture site. Although many of the changes have been in surgical technique, parallel changes in plate design have also occurred. Following Perren's¹ concept of the adverse effect of plates on underlying bone vascularity, a progressive change in plate design occurred to limit this effect. Theoretically, bone vascularity is damaged by the footprint of the plate. As the size of the footprint is reduced, healing is improved and complications are reduced.

The initial reduction in plate footprint came with the introduction of the limited contact dynamic compression plate (LC-DCP). The next step was the Point Contact Fixator (PC-Fix), wherein small pins on the inferior surface of the plate minimized the footprint. The PC-Fix also had threaded holes and monocortical locking screws. However, the advent of the Less Invasive Stabilization System (LISS), which leaves no footprint at all, has left the PC-Fix with few users and few reports to assess its utility^2,3.

This paper is a report of a prospective randomized trial that compares the PC-Fix and the LC-DCP in their most optimal applications: forearm fractures. As a randomized study, it seems well planned to compare the two plates. The patient groups, fractures, and surgical techniques seem comparable, allowing for a fair analysis of the results.

With regard to the results presented, however, there is no clinical difference between the plates and no evidence of an improvement in results or a decrease in complications associated with the use of the PC-Fix. While the discussion appropriately comments on the difficulties that are inherent in the assessment of fracture-healing in clinical trials, it also illustrates a weakness of this study. The fractures are not stratified by AO/OTA classification. Theoretically, the advantages conveyed by the PC-Fix are most likely to be seen in multifragmentary, higher-energy "C"-type fractures in which biological relative-stability techniques have advantages. However, it is likely that this study will not have the power to show a difference in this smaller group and that any difference in results would be small. In clinical practice, both plating systems seem to function well.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002;84:1093-110.
2. Haas N, Hauke C, Schutz M, Kaab M, Perren SM. Treatment of diaphyseal fractures of the forearm using the Point Contact Fixator (PC-Fix): results of 387 fractures of a prospective multicentric study (PC-Fix II). Injury. 2001;32(Suppl 2):S-B51-62.
3. Fernandez Dell'Oca AA, Tepic S, Frigg R, Meisser A, Haas N, Perren SM. Treating forearm fractures using an internal fixator: a prospective study. Clin Orthop. 2001;389:196-205.

Copyright © 2004 by the The Journal of Bone and Joint Surgery, Inc.