Gernot Schmidle

Aspects of current management of distal radius fractures in the elderly individuals.

Diatal radius fractures (DRFs) are typical fractures of relatively fit persons with osteoporotic bone who remain active into older age. Traditionally, DRFs in older patients have been treated with closed reduction and cast immobilization. Considering the increasing life expectancy of the elderly population, appropriate management of these fractures is of growing importance. Decision making for surgical or nonsurgical approach to osteoporotic DRFs is difficult. These decisions are often made based on the data from treatments of much younger patients. The current literature concerning the treatment of DRFs in the elderly individuals is more controversial. Some investigators have recommended open reduction internal fixation (ORIF) as treatment for unstable DRFs in older patients, while others have suggested that elderly patients should be treated nonsurgically even if there is an unstable fracture situation because fracture reduction is not associated with functional outcomes as in younger patients. This article reviews the different treatment options for DRFs in the elderly individuals reported in the recent literature.

Intraosseous rotation of the scaphoid: assessment by using a 3D CT model—an anatomic study

AbstractObjectivesThe purpose of this study was to assess intraosseous rotation as the third dimension of scaphoid anatomy on a 3D CT model using common volume rendering software to impact anatomical reconstruction of scaphoid fractures.MethodsCT images of 13 cadaver wrist pairs were acquired. Reference axes for the alignment of distal and proximal scaphoid poles were defined three-dimensionally. Two methods for rotation measurement—the reference axis method (RAM) and the scapho-trapezio-trapezoidal joint method (STTM)—were developed and compared by three independent observers.ResultsRotation measured by the RAM averaged 66.9° ± 7 for the right and 67.2° ± 5.8 for the left wrists. Using the STTM there was a mean rotation of 68.6° ± 6.6 for the right and 68.6° ± 6.8 for the left wrists. The overall results showed a significant variability of the measured values between different specimens (P < 0.05). There was no significant difference between left and right wrists of the same specimen, neither for the RAM (P = 0.268) nor for the STTM (P = 0.774). Repeatability coefficients between the observers were low, indicating good repeatability.ConclusionsThe presented methods are practical tools to quantify intraosseous rotation between distal and proximal scaphoid poles using common volume rendering software. For clinical application the opposite side provides the best reference values to assess malrotation in scaphoid fracture cases.Key points• Scaphoid intraosseous rotation can be measured using common volume rendering software. • The opposite uninjured side provides good reference values for rotation measurement. • Assessment of malrotation may impact anatomical reconstruction of scaphoid fractures.

Carpal tunnel syndrome assessment with diffusion tensor imaging: Value of fractional anisotropy and apparent diffusion coefficient

AbstractObjectivesTo quantitatively assess carpal tunnel syndrome (CTS) with DTI by evaluating two approaches to determine cut-off values.MethodsIn forty patients with CTS diagnosis confirmed by nerve conduction studies (NCs) and 14 healthy subjects (mean age 58.54 and 57.8 years), cross-sectional area (CSA), apparent diffusion coefficient (ADC) and fractional anisotropy (FA) at single and multiple levels with intraobserver agreement were evaluated.ResultsMaximum and mean CSA and FA showed significant differences between healthy subjects and patients (12.85 mm2 vs. 28.18 mm2, p < 0.001, and 0.613 vs. 0.524, p=0.007, respectively) (10.12 mm2 vs. 19.9 mm2, p<0.001 and 0.617 vs. 0.54, p=0.003, respectively), but not maximum and mean ADC (p > 0.05). For cut-off values, mean and maximum CSA showed the same sensitivity and specificity (93.3 %). However, mean FA showed better sensitivity than maximum FA (82.6 % vs. 73.9 %), but lower specificity (66.7 % vs. 80 %), and significant correlation for maximum CSA, 97 % (p < 0.01), with good correlation for maximum ADC and FA, 84.5 % (p < 0.01) and 62 % (p=0.056), respectively.ConclusionsCSA and FA showed significant differences between healthy subjects and patients. Single measurement at maximum CSA is suitable for FA determination. Key Points • DTI showed that FA is stronger than ADC for CTS diagnosis.• Single- and multiple-level approaches were compared to determine FA and ADC. • Single-level evaluation at the thickest MN cross-sectional area is sufficient.

Chapter 31 – Vascularized Versus Nonvascularized Bone Grafts

Scaphoid nonunions are well known to be problematic, especially in cases with humpback deformity, long-standing nonunions with cysts and bone loss and fragmented proximal pole, nonunions with several previous surgeries, and nonunions with avascular proximal pole necrosis. The aim of this systematic review is to examine the published evidence for the use of nonvascularized and vascularized bone grafts in problematic scaphoid nonunion. A systematic review was performed with the following defined search strategy on Cochrane search, Pubmed (clinical queries), and Pubmed (Medline): ([scaphoid bone, scaphoid non-union, scaphoid pseudarthrosis, bone graft]). Articles were reviewed and data compiled into tables for analysis. There is still a lack of series that are truly comparable. The main problem is that the preoperative workup varies to a great extent. Fracture characteristics are not reported consistently and are often poorly documented or not examined in the results. Especially the assessment of vascularity of the proximal pole, a supposedly relevant prognostic factor, is not standardized, making it difficult to compare similar groups and hence arrive at clear conclusions. All included studies reported higher union rates using vascularized bone grafts. Nonvascularized bone grafts are used for simple, minimally displaced nonunions as standard treatment. Vascularized bone grafts should be considered in cases of avascular necrosis, long-standing proximal pole pseudarthrosis, or failed previous surgery. In long-standing pseudarthrosis with proximal pole fragmentation and bone loss, vascularized osteochondral grafts from the medial femoral condyle are most favourable.

Time‐dependent changes in bone healing capacity of scaphoid fractures and non‐unions

The scaphoid is the most frequently fractured carpal bone and prone to non‐union due to mechanical and biological factors. Whereas the importance of stability is well documented, the evaluation of biological activity is mostly limited to the assessment of vascularity. The purpose of this study was to select histological and immunocytochemical parameters that could be used to assess healing potential after scaphoid fractures and to correlate these findings with time intervals after fracture for the three parts of the scaphoid (distal, gap and proximal). Samples were taken during operative intervention in 33 patients with delayed or non‐union of the scaphoid. Haematoxylin and Eosin (HE), Azan, Toluidine, von Kossa and Tartrate‐resistant acid phosphatase (TRAP) staining were used to characterise the samples histologically. We determined distribution of collagen 1 and 2 by immunocytochemistry, and scanning electron microscopy (SEM) was used to investigate the ultrastructure. To analyse the samples, parameters for biological healing status were defined and grouped according to healing capacity in parameters with high, partial and little biological activity. These findings allowed scoring of biological healing capacity, and the ensuing results were correlated with different time intervals after fracture. The results showed reduced healing capacity over time, but not all parts of the scaphoid were affected in the same way. For the distal fragment, regression analysis showed a statistically significant correlation between summarised healing activity scores and time from initial fracture (r = −0.427, P = 0.026) and decreasing healing activity for the gap region (r = −0.339, P = 0.090). In contrast, the analyses of the proximal parts for all patients did not show a correlation (r = 0.008, P = 0.969) or a decrease in healing capacity, with reduced healing capacity already at early stages. The histological and immunocytochemical characterisation of scaphoid non‐unions (SNUs) and the scoring of healing parameters make it possible to analyse the healing capacity of SNUs at certain time points. This information is important as it can assist the surgeon in the selection of the most appropriate SNU treatment.

Time-Dependent Recovery of Outcome Parameters in Ulnar Shortening for Positive Ulnar Variance: A Prospective Case Series

Background: This study evaluates the results of ulnar shortening using the ulna osteotomy locking plate system (UOL; I.T.S. GmbH, Graz, Austria) with special regard to the time-dependent recovery of subjective and objective outcome parameters and surgeons’ experiences. Methods: Ulnar shortening using the UOL was performed on 11 patients (3 men, 8 women) with an average age of 47 ± 19.6 years. Range of motion (ROM) and grip strength were compared with the contralateral hand. Patient-rated outcomes were measured using a visual analogue scale (VAS) for pain and the Disability of the Arm, Shoulder and Hand (DASH) and the Patient Rated Wrist Evaluation (PRWE) survey for subjective outcomes. Ulnar variance and bony union were assessed using conventional wrist radiographs. The surgeons evaluated intraoperative handling through a standardized feedback form. Results: ROM improved and grip strength increased significantly between preoperative values and final follow-up. Flexion and supination improved significantly between weeks 8 and 12 and grip strength from week 8 onward. Patient-rated outcomes changed significantly with a final DASH score of 14.2 ± 12.4 and a PRWE score of 24.3 ± 17.0. Pain levels improved significantly with no pain at rest and a mean VAS of 0.8 ± 1.2 during activity. The average amount of shortening was 4.0 ± 1.9 mm with a final ulnar variance of 0.2 ± 1.8 mm. All osteotomies healed with 2 cases of delayed union. Conclusions: In ulnar shortening with the UOL, wrist function recovered after an initial decrease from week 8 onward. Subjective outcome parameters showed early recovery and improved continuously over time.

Sesamoid bone transfer for metacarpophalangeal hyperextension instability of the thumb: A CT-osteoabsorptiometry study

BACKGROUND AND AIM Hyperextension instability of the metacarpophalangeal (MCP) joint of the thumb may result in pain, malfunction, and accelerated osteoarthritis in the carpometacarpal (CMC) joint. One method of treatment is sesamoid arthrodesis. The aim of this study is to investigate if a sesamoid transfer as a treatment of hyperextension instability of the thumb MCP joint leads to an altered distribution of the subchondral mineralisation and a negative clinical outcome. METHODS Sesamoid transfer was performed on 12 patients with hyperextension instability of the MCP joint of the thumb. The range of motion (ROM) and radiologic outcome were assessed. Pinch and power grip strength were measured and compared to the nonoperated side. To determine the areas of maximum subchondral mineralisation in the joint, computed tomography (CT)-osteoabsorptiometry was performed to determine the long-term stress distribution within the joint. RESULTS The distributions of the stress zones in the operated and nonoperated thumbs were not statistically different a median of 5 years following the sesamoid transfer procedure. There was no difference in the functional and radiological results between the operated and nonoperated thumbs. CONCLUSION If it is assumed that the nonoperated thumb represents the normal condition for each individual, then it may be deduced that the operation achieves good clinical results, and the distribution of the subchondral mineralisation does not change.

Correlation of CT imaging and histology to guide bone graft selection in scaphoid non-union surgery

IntroductionFor the treatment of scaphoid non-unions (SNU), different surgical techniques, including vascularized and non-vascularized bone grafts, are applied. Besides stability, vascularity, and the biological situation at the non-union site are important for healing and the appropriate choice of treatment. We assessed the healing potential of SNUs by histological parameters and compared it to CT parameters of bone structure and fracture location. Based on the results, we developed a CT classification and a treatment algorithm to impact graft selection in SNU surgery.Patients and methodsPreoperative 2D-CT reformations of 29 patients were analyzed for trabecular structure, sclerosis, and fragmentation of the proximal fragment. The fracture location was assessed on 3D-CT reconstructions and grouped in three zones depending on the potential blood supply. Samples were taken during surgery for histological evaluation. Histological parameters of bone healing were defined and a bone healing capacity score (BHC), reflecting histological bone viability, was calculated. CT findings were compared to BHC, age of SNU, and time to union.ResultsCases with trabecular structure and without fragmentation showed a statistically significant higher BHC. Time to union was significantly faster if trabecular structure was present and sclerosis was absent. In intraarticular proximal pole non-unions, where no blood supply is assumed, the BHC was statistically significantly lower and time to union was longer compared to SNUs of the other locations. A statistically significant correlation between BHC and time to union was found in the proximal and distal fragment with higher BHC associated with faster healing.ConclusionsCT parameters of bone structure and fracture location can reflect histological healing capacity of SNUs. This can guide bone graft selection in SNU surgery.

Ulna Rotation Osteotomy in Complete Dislocation of the Distal Radioulnar Joint

Background Complete dislocation of the distal radioulnar joint (DRUJ) is a rare injury. Dislocation can present as uni- or multidirectional, acute or chronic, reducible or irreducible. It can occur due to isolated loss of ligamentous restraints or more frequent in Galeazzi - or Essex-Lopresti-type fractures. Case Description A 28-year-old man sustained a distal radius fracture and presented after conservative treatment with blocked supination. Examination revealed a malunion of the distal radius in combination with an irreducible dorsal dislocation of the DRUJ. Corrective osteotomy of the distal radius was performed, the DRUJ was reduced, and the ulnar avulsed triangular fibrocartilage complex (TFCC) refixed with transosseous sutures. Redislocation occurred 8 weeks later. Revision surgery showed a palmar dislocated TFC fixed in a palmar scar formation along the distal interosseous membrane (DIOM). The scar was released and a rotation osteotomy of the distal ulna was performed. At follow-up, the patient was pain-free, had good range of motion, and returned to work and sport activities. Literature Review For reconstruction of chronic complete dislocations of the DRUJ, ligament plasty procedures are described. In case of additional cartilage damage, salvage procedures are recommended. Clinical Relevance We report a procedure in which the rotation of the distal ulna is corrected to restore DRUJ congruity in chronic dislocations. The rotation osteotomy described is useful in gross ligamentous instability following loss of constraint by the TFCC and the DIOM.

Reduced Risk of FPL-Tendon Rupture in Distal Radius Fracture Treated by a Palmar V-Shaped Plate

Objectives: Palmar locking plates enabling early active motion are successfully used in distal radius fracture treatment. But some fracture types can necessitate to place a plate distally to the watershed line with the risk of rupture of the flexor pollicis longus (FPL) tendon. In addition, the indication for implant removal following palmar plating is still discussed controversially. Patients and Method: In this prospective follow-up study, 18 patients with distal radial fracture (DRF) were stabilized by a new anatomical designed V-shaped palmar plate (Medartis, Basel, Switzerland). Radial inclination (RI), dorsal tilt (DT), and ulnar variance (UV) were assessed. An independent radiologist investigated the FPL tendon by ultrasound to course within the V-space of the plate at its distal end. In addition, the gliding and course of the FPL tendon was investigated during surgery. Results: In lateral projection, the plate appeared Soong type 0 (n = 3), Soong type 1 (n = 12), and Soong type 2 (n = 3). RI measured 20° (minimum 14°, maximum 27°), DT 3.8° (minimum 0°, maximum 12°), and UV 0 mm (minimum −3, maximum 2). In sonography, the FPL tendon run within the V-space in all cases. In all Soong types, there was no contact of the FPL tendon with the plate found in ultrasound. In Soong type 2, the ulnar column of the plate protruded and caused friction of the flexor digitorum profundus (FDP) tendon in 2 patients when a fit bone/implant contact was missing. Protrusion was seen in dorsal displacement of the distal fragment ad latus and soft tissue interposition. Intraoperatively, the radial column of the plate ended proximal at the watershed line without contact to the FPL tendon. Proximal to the watershed line, the course of the FPL tendon was minimally altered after release of the pronator quadratus (PQ) and mobilizing the FPL muscle for plate positioning. It remained unaltered distal to the watershed line where the FPL tendon enters the nonreleased carpal tunnel. Conclusion: The V-shaped FPL plate spared the FPL tendon in all Soong-type plate positions. Achieved reduction of RI greater 14°, DT more than 0°, and UV better than −3 mm proofed sufficient for the V-space design to avoid friction of the FPL. Restoration of DT and firm bone/plate contact of the distal fragment are important in distal plate position. Implant removal of plates positioned Soong types 1 and 2 seems to be no more imperative. In Soong type 3, the FDP tendons should be considered to be of some risk.