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Letters to the Editor to:

Scientific Articles:
David S. Ruch, T. Adam Ginn, Charles C. Yang, Beth P. Smith, Julia Rushing, and Douglas P. Hanel
Use of a Distraction Plate for Distal Radial Fractures with Metaphyseal and Diaphyseal Comminution
J Bone Joint Surg Am 2005; 87: 945-954 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] INFECTIONS AFTER DISTRACTION PLATING
MANOJ S TODKAR   (8 June 2005)
[Read Letter to the Editor] Dr. Ginn et al respond to Dr. Todkar
T. Adam Ginn, M.D., David S. Ruch, M.D., Charles C. Yang, M.D., Beth P. Smith, Ph.D., Julia Rushig, MStat., Douglas P. Hanel, M.D.   (8 June 2005)

INFECTIONS AFTER DISTRACTION PLATING 8 June 2005
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MANOJ S TODKAR,
ORTHOPAEDIC SURGEON
NUFFIELD ORTHOPAEDIC CENTRE, OXFORD

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Re: INFECTIONS AFTER DISTRACTION PLATING

mtodkar{at}hotmail.com MANOJ S TODKAR

To the Editor:

I read the article "Use of a Distraction Plate for Distal Radial Fractures with Metaphyseal and Diaphyseal Comminution" with great interest. The authors report that three wounds became infected after plating; the infection was controlled with debridement and antibiotics; and the plates were retained.

I would ask the authors whether bone grafts were used in these patients? Was there a significant defect after debridement, and if there was, how did they manage the defect with the plate in situ? Also, did these infections lead to delayed union and stiffness of wrist and did they require secondary procedures.

They also mention that bone grafts were used in only half of the patients with comminuted distal radius fractures.It would be interesting to know how they managed bone defects or comminution in patients in whom they did not use bone graft.
Dr. Ginn et al respond to Dr. Todkar 8 June 2005
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T. Adam Ginn, M.D.
Wake Forest University School of Medicine, Dept. Orthopaedic Surgery, Winston-Salem, NC 27157,
David S. Ruch, M.D., Charles C. Yang, M.D., Beth P. Smith, Ph.D., Julia Rushig, MStat., Douglas P. Hanel, M.D.

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Re: Dr. Ginn et al respond to Dr. Todkar

tginn{at}wfubmc.edu T. Adam Ginn, M.D., et al.

Dear Sir:

Thank you for your input and your interest in our paper. We would like to respond to your letter at a point by point fashion. First, the technique has been applied in cases of infected nonunions of the radius. In the three cases which we treated in this cohort of patients, these were infections following management with more conventional techniques. These cases were managed with the basic principle of resection of the infected bone, placement of an antibiotic impregnated cement spacer when necessary and antibiotic beads when a smaller defect was present. The DCP plate was applied after debridement to maintain the radius at the appropriate length. The patient's received an eight week course of IV antibiotics. At approximately three months following placement of the spacer, the spacers were removed and either cancellous graft (one case) or tricortical graft (two cases) was placed. The plate was maintained in its position until the defect was felt to be consolidated and the plate was removed. In none of these cases did the plate continue to harbor the infected organism and all 3 healed uneventfully. It is difficult to assess whether the infection resulted in additional stiffness in the wrist as all of these cases were considered to be "salvage" cases and difficult to compare one to the other.

In response to the question regarding bone grafting, there is some variation in the way in which these patients were managed. We feel that there are essentially two patient populations in which the technique is useful. One are those patients with extensive metaphyseal and diaphyseal involvement and the second are those in which there is extensive comminution of the articular surface and metaphyses where conventional plating would require both palmar, dorsal and radial plate placement. In the first group of patients, if the metaphyseal diaphyseal junction can be reconstructed with the patient's native bone, then additional graft was not used. The plate allowed for sufficiently rigid fixation to permit healing of the cortical bone of the forearm. In patients with extensive comminution involving the metaphysis, primary grafting was performed in order to allow for early union and removal of the implant. Finally, open fractures or previously infected fractures were not primarily grafted due to concerns over secondary infection.