Marion Burnier

Primary Wrist Hemiarthroplasty for Irreparable Distal Radius Fracture in the Independent Elderly

Background Volar plating for acute distal radius fractures (DRF) in the elderly has been recommended. Some studies have suggested that open reduction with internal fixation (ORIF) in this situation results in frequent complications. Our purposes were to provide a definition of irreparable DRF in independent elderly patients and to review the results of a preliminary retrospective series of wrist hemiarthroplasty (WHA) in this patient population. Materials Between 2011 and 2014, 11 consecutive independent elderly patients (12 wrists) with irreparable intra-articular DRF were treated with primary WHA at the acute stage. A resection of the ulnar head was associated in nine wrists. A total of 11 wrists with more than 2 years of follow-up form the basis of this paper. Description of Technique The approach was dorsal longitudinal. An osteotome longitudinally entered the dorsal aspect of the fracture medial to the Lister tubercle. Two thick osteoperiosteal flaps were elevated radially and ulnarly in a fashion similar to opening a book. The distal radius articular surface was excised. The implant was pressed into the radial canal with attention to restoring distal radius length. The two osteoperiosteal flaps were brought back together and sutured so as to close, again like a book, the osseous and soft tissues around the implant. Results At mean follow-up of 30 months, average visual analog scale (VAS) pain was 1/10. Mean QuickDASH (Disabilities of the Arm, Shoulder and Hand) score was 32, and mean Patient-Rated Wrist Evaluation (PRWE) score was 24. Mean forearm rotation arc was 151°. Mean active flexion-extension arc was 60°. Mean active extension was 34°. Mean grip strength was 14 kg (64% of contralateral wrist). Mean Lyon wrist score was 73%. Bone healing around the implants was satisfactory in all but one case. Conclusions Out data suggest that treatment of irreparable DRF in the independent elderly patient with a bone-preserving WHA may be a viable option. Longer-term follow-up and comparative studies are needed to confirm the validity of this concept.

The role of arthroscopy for treatment of perilunate injuries.

Background Open reduction with internal fixation (ORIF) is currently the gold standard treatment of acute perilunate injuries (PLIs). Less invasive surgery, including arthroscopic techniques, has recently emerged in the hope that results similar to those of ORIF could be obtained with less tissue disturbance. Our purpose was to review retrospectively a series of selected PLIs treated with arthroscopic assistance over the past 10 years. Materials and Methods Between 2004 and 2014, a total of 135 acute PLIs were surgically treated in our unit. A total of 27 patients were treated with arthroscopic assistance, among whom 18 were reviewed clinically and radiologically. Description of Technique After an initial closed gross reduction, radio- and midcarpal arthroscopy were performed to clean up the debris and assess the cartilaginous, bony, and ligamentous damage. In 22 cases arthroscopy was followed by either radiolunate and lunotriquetral pinning, scapholunate ligament repair, and SL joint pinning or ORIF of a scaphoid fracture through a mini-invasive dorsal approach. In the remaining six cases, fixation of the ligamentous and/or bony injuries was done using arthroscopy alone. Results Arthroscopic findings are presented as well as the clinical results in a subgroup of patients. At final follow-up, visual analog scale (VAS) pain was rated 18/100 on average (minimum 0, maximum 50). If we consider only the patients without reflex sympathetic dystrophy (RSD; n = 14), the average active wrist flexion-extension was 87° (58% of the normal contralateral side) and the average grip strength was 30 kg (71% of the normal contralateral side). Conclusions Although no statistical comparisons were made, we found that the results were similar to those of ORIF. The results of our study suggest that the use of arthroscopy to treat selected PLIs may be a reliable adjunct either alone or in combination with a dorsal mini-open approach.

A New Wrist Clinical Evaluation Score

Background The number of available wrist scoring systems is limited; some of them do not include forearm rotation criteria. Purpose To describe a new electronic wrist clinical score and to present a new patients generated wrist evaluation criterion, the subjective wrist value (SWV). Materials and Methods A new electronic wrist clinical score, the Lyon wrist score (LWS) including wrist VAS pain and function, active range of motion and strength was built into an excel file. VAS flexion‐extension pain and function were evaluated independently from pronation‐supination pain and function. A new patients generated wrist evaluation criterion, SWV was described. Results The LWS is available in two versions, standard and full (the latter including forearm rotation strength). Both standard and full LWS are displayed into an automatically generated diamond‐shaped graph providing a comprehensive visual display of the clinical status of most osteoarticular wrist disorders. The graph also includes SWV. The LWS, combined with SWV into a graph that may be directly exported to a PowerPoint presentation, provide a new practical and comprehensive tool for following/comparing wrist osteoarticular clinical status/outcomes. Both standard and full LWS charts are available in colored versions on a related website for free download. Conclusion A comprehensive updated electronic display of osteoarticular wrist clinical status including forearm rotation criteria is provided and displayed into a graph which may be exported as such into a PowerPoint presentation for clinical analysis/comparisons. Level of Evidence Level II.

Diagnostic value of ultrasonography in elbow trauma in children: Prospective study of 34 cases

INTRODUCTION Among the various elbow injuries in children that initially have normal radiographs, a certain number of occult fractures are only diagnosed correctly after the fact, during a follow-up visit. PURPOSE This study evaluated the diagnostic contribution of ultrasonography in the treatment of acute elbow injuries in children and the strategic and economic impact of using this tool alongside radiography. MATERIALS AND METHODS During this prospective study performed between January 1 and April 1 2014, elbow ultrasonography was performed within 6 days in all children under 15 years of age with a suspected occult fracture. The ultrasonography exam looked for lipohemarthrosis, the posterior fat pad sign and cortical disruption. If no fracture was visible on ultrasonography, a removable splint was given to the patient to relieve pain, and no radiological or clinical follow-up was scheduled. The patients were contacted again at least 15 days later to determine whether an undetected fracture was present. Lastly, we evaluated the cost of treatment with and without ultrasonography in the cases where no fracture was diagnosed. RESULTS In 13 cases, ultrasonography revealed lipohemarthrosis and a fat pat sign, with cortical disruption also present in 11 of these cases. In two cases, the diagnosis was made based solely on the presence of lipohemarthrosis and a fat pat sign. There were seven lateral condyle fractures, two medial epicondyle fractures and two supracondylar fractures. Among the 21 patients with normal ultrasonography, no fracture was diagnosed later on. In patients without a fracture, using ultrasonography resulted in a cost savings of €29.10 per patient versus not using it. CONCLUSION In our study, ultrasonography is a sensitive examination for the diagnosis of occult elbow fractures in children. When the radiography and ultrasonography are both normal, the possibility of fracture can be rule out definitively, which reduces the need for immobilization, follow-up and treatment costs. The findings of this preliminary study should be validated with a larger prospective study.

Primary Wrist Hemiarthroplasty for Irreparable Distal Radius Fractures in the Independent Elderly

Objective: Despite the improvement of open reduction and internal fixation (ORIF) of distal radius fractures (DRFs) provided by locked volar plating in elderly patients, there are still complex distal DRF not amenable to any satisfactory fixation. The purpose of this article is to define irreparable acute DRF in autonomous elderly patients and to review the preliminary results of a prospective series using wrist hemiarthroplasty at the acute stage. Methods: A total of 12 wrists in 10 women were prospectively included. The average age was 74 years (range, 65-87). All patients were autonomous at home. All were intra-articular Arbeitsgemeinschaft für Osteosynthe-sefragen (AO) “C” type fractures. Circumferential comminution was present in all cases. Impaction and cartilage defect were present in all cases. All patients sustained wrist hemiarthroplasty through a single dorsal approach. The proximal part of a total wrist arthroplasty was used in 10 cases and a modified implant with a longer stem was used in 2 cases. An ulnar head resection was associated in 10/12 cases whereas the ulnar head could be kept intact in 2 wrists. Postoperative immobilization was 3 weeks followed by a splint for 3 weeks. Follow-up consisted of clinical and radiographic evaluation at 6 weeks and 2, 6, and 12 months. The average clinical and radiological follow-up was 27 months (minimum 12, maximum 41). Results: There were no dislocation, loosening, or implant removal. One wrist was reoperated on for stiffness followed by a significant improvement. Complex pain regional syndrome (CPRS) was present in 3 patients. At follow-up, Visual Analog Scale (VAS) pain was 10/100. Average Quick Disability of the Arm, Shoulder and Hand (QuickDASH) was 32 points and Patient-Rated Wrist Evaluation (PRWE) was 24.7. Mean active motion values were as follows: pronation 74°, supination 77°, extension 34°, and flexion 26°. The average grip strength was 14 kg, 67% of the contralateral side. The average wrist score was 69%. Radiologically, periprosthetic bone healing was observed in all cases. We observed 1 radial and 3 ulnar inclination of the implant. This was not observed with the longer stem implant. Discussion: Implant surgery at the acute stage for complex fractures in the elderly is an old validated concept for hip, shoulder, and elbow. Indeed some DRFs in the autonomous elderly are beyond any ORIF possibilities due to the combination of comminution and a very distal fracture line. Our results suggest that primary wrist hemiarthroplasty is a viable method to treat these difficult wrist injuries in this specific population. Further controlled prospective studies are necessary to validate this concept.