Bone Graft (Substitutes) in Distal Radius Fractures

Importance of the Problem

Principles of treatment of distal radius fractures have changed in the last decades. While in the past, alignment of the bony fragments and maintenance of radial length were considered to be most important, nowadays meticulous reduction of the articular surface and adequate reconstruction of metaphyseal comminution along with reliable stabilization are key principles in most surgically treated distal radius fractures.

As more patients presenting with distal radius fractures are of older age, many clinicians are confronted with problems of osteoporosis when treating distal radius fractures. Osteoporotic fractures have an impaired ability to heal and often require more time to heal. The degree of comminution is generally high and alignment is often lost, despite of some remaining healing potential of osteoporotic bone. As a result, metaphyseal comminution and impaction, especially in patients with osteoporotic bone, may result in a metaphyseal bony void with subsequent instability, loss of reduction, and malunion. This may lead to serious functional impairment on short and long term.

Although healing of metaphyseal defects in distal radius fractures can be a slow process, the risk of nonunion in distal radius fractures is minimal. As a consequence, bone grafts or bone graft substitutes are primarily used to provide structural stability and thereby support early return to function. By using bone grafts or bone graft substitutes for treatment of bony defects in the distal radius, the construct can be stabilized by providing mechanical support for the radiocarpal joint surface and a scaffold for ingrowth of new bone is provided. The ideal implanted material is biocompatible, bio-resorbable and will lead to optimal structural stability by providing substantial initial compression strength while allowing rapid ingrowth of new bone with preservation of anatomical reduction of the joint surface.

Addressing bone defects as part of primary treatment of distal radius fractures is a challenge for the treating surgeon, since outcome of the fracture is dependent on how successful the defect is treated. Remodeling of metaphyseal defects in distal radius fractures that are fixated without additional bone graft or bone graft substitute does not lead to optimal bone quality after trabecular modeling. Additionally, clinical evidence supports the hypothesis that the use of bone graft substitutes for treatment of metaphyseal defects may lead to faster healing. On the other hand, structural stability is also directly influenced by the method of fixation. As advances in plate design have led to the applicability of anatomically shaped and variable angle locking plates in recent years, perhaps bone graft substitutes are not essential in most situations.

Main Question

• What is the role and additional value of bone graft substitutes in comminuted distal radius fractures?

• Which type of bone graft is most effective for treatment of bone defects in comminuted distal radius fractures? (autograft, allograft, or bone substitutes)

Current Opinion

There are many surgical options for treatment of metaphyseal bone defects in distal radius fractures including autografts, allografts and bone substitutes, both biological and synthetic. However, the use of bone grafts or bone graft substitutes for treatment of comminuted distal radius fractures is dictated by tradition, training, and personal experience. In highly exceptional cases of bone defects larger than 6–8 cm, vascularized bone grafts are recommended. Strategies based on potential robust scientific evidence are very limited for treatment of bone defects in comminuted distal radius fractures.

Finding the Evidence

We provide below a list of search algorithms used to retrieve evidence for the main question:

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  Cochrane search: “distal radius fracture” OR “distal radial fracture” AND “bone substitutes”

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  Pubmed (Medline): “Radius Fractures” [Mesh] OR “radius fracture” [tiab] OR “radial fracture” [tiab] OR “distal radius fracture” [tiab] OR “distal radial fracture” [tiab] AND “Bone Substitutes” [Mesh] OR “bone substitutes” [tiab]

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  Only articles written in English, French or German were included.

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  Study protocols or abstracts of oral or poster presentations at congresses were excluded.