Ryotaro Fujitani

Prospective Outcomes of Comminuted Periarticular Metacarpal and Phalangeal Fractures Treated Using a Titanium Plate System

PURPOSE The purpose of this study was to prospectively evaluate clinical results for open reduction and internal fixation of unstable metaphyseal fractures of the metacarpal and phalangeal bones using a miniature titanium plate. METHODS Fifty-one consecutive patients with periarticular fractures with metaphyseal comminution and displacement were enrolled. Intra-articular involvement with a split or depression fracture was identified in 22 hands. Minimum follow-up was 1 year. There were 37 male and 14 female patients; average age was 38 years (range, 14-63). Of the 51 fractures, 15 were open; 8 of these had additional soft tissue injury, involving neurovascular injury in 4 and extensor tendon injury in 6. The average duration from injury to surgery was 6 days (range, 2-40 days). RESULTS Bone union was successfully achieved in all patients over an average period of 2.6 months. The final range of total active motion (%TAM) was excellent (>85%) for 26, good (70%-84%) for 17, fair (50%-69%) for 5, and poor (<49%) for 3. Postoperative complications occurred in 5 patients, including fracture redisplacement in 2, a collapse or absorption of the condylar head in 2, and superficial infection due to hardware exposure in one. Subsequently, 2 of these patients had malrotation deformities or osteoarthritic changes in the injured finger. Plates were removed in 30 cases, and additional surgery was required in 20 cases. Postoperative grip strength averaged 87% of the contralateral side. Statistical analysis revealed that patient age was significantly correlated with %TAM of the injured finger at 1-year follow-up (p < .01), and intra-articular (p < .05) and phalangeal bone (p < .01) involvement, as well as associated soft tissue injury (p < .05), significantly affected the range of finger motion. CONCLUSIONS Despite the technical demands of plating for comminuted metacarpal and phalangeal fractures, the low-profile titanium plate system was highly effective in maintaining anatomic reduction. The postoperative complication rate was relatively low, and the objective outcomes approached a reasonable level at 1-year follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Predictors of distal radioulnar joint instability in distal radius fractures.

PURPOSE A tear of the triangular fibrocartilage complex (TFCC) is the most frequent soft tissue injury associated with fractures of the distal radius, and repair of the deep ligamentous portion of the TFCC is considered when the tear contributes to instability of the distal radioulnar joint (DRUJ). The purpose of this prospective cohort study was to identify predictors of DRUJ instability accompanying unstable distal radius fractures. METHODS Between 2002 and 2007, we prospectively treated 163 consecutive patients with unstable distal radius fractures with the volar locking plating system. Complete radioulnar ligament tears representing DRUJ instability were present in 11 of 163 distal radius fractures. We tested univariate associations between DRUJ instability and potential predictors and conducted multivariate analysis to establish independent predictors of instability. We applied receiver operating characteristics curves within the significant risk factors to determine threshold values. RESULTS In univariate analyses, only the radial and sagittal translation ratios of the fracture site were significant predictors of DRUJ instability. Multivariate logistic regression analysis confirmed that the radial translation ratio, which corresponds to a normalized DRUJ gap, was a significant risk factor. According to the receiver operating characteristics curve for the radial translation ratio, the area under the curve was 0.89. A cutoff value of 15% for the radial translation ratio showed the highest diagnostic accuracy rate. CONCLUSIONS A radiographic finding of a normalized DRUJ gap on posteroanterior views was the most important predictor to identify DRUJ instability accompanying unstable distal radius fractures. The relative risk of instability increases by 50% when the ratio of DRUJ widening increases by 1%.

Dorsal radiocarpal ligament capsulodesis for chronic dynamic lunotriquetral instability.

PURPOSE Chronic lunotriquetral (LT) instability (persisting >3 months after injury) can be treated with a variety of surgical methods (LT fusion, ligament repair or reconstruction, or arthroscopic debridement), with varying degrees of success. We retrospectively evaluated the results of dorsal capsulodesis using the dorsal radiocarpal ligament in an attempt to reinforce the dorsal LT interosseous ligament in patients with chronic dynamic LT instability. METHODS A total of 11 patients (mean age, 37 years) with persistent posttraumatic wrist pain and weakness were diagnosed with dynamic LT instability (positive LT ballotment test, disruption of Gilulas lines or volar intercalated segment instability deformity on stress radiography, arthroscopic findings of Geissler grade 3, or 4 LT tears). They were treated consecutively with dorsal capsulodesis. We used subjective and functional outcome measures to evaluate the results. RESULTS The mean follow-up period was 31 months (range, 12-65 months). The postoperative visual analog pain score and Mayo wrist score were significantly improved compared with their preoperative values. The average grip strength increased by 5 kg, and the average range of wrist flexion was reduced by 3 degrees . CONCLUSIONS In this small series, in the short term, dorsal radiocarpal ligament capsulodesis reduced pain and instability and improved function in patients with chronic dynamic LT instability. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Distal radius fracture arthroscopic intraarticular displacement measurement after open reduction and internal fixation from a volar approach

BackgroundThe purpose of this study was to assess articular surface reduction arthroscopically after volar locked-plate fixation of distal radius fractures (DRFs) via fluoroscopyguided open reduction/internal fixation. We also aimed to develop preoperative radiographic criteria to help assist in determining which DRFs may need arthroscopic evaluation.MethodsA total of 31 consecutive patients with DRF were prospectively enrolled. Posteroanterior (PA) and lateral radiographs as well as axial, coronal, and sagittal CT scans were obtained just after attempted reduction of the DRF. The widest articular displacement at the radiocarpal joint surface of the distal radius (preopD) was then measured using a digital radiography imaging system. The DRF was reduced under fluoroscopy, and a volar locked plate was applied. The degree of residual articular displacement was then measured arthroscopically, and the maximum displacement (postopD) was measured with a calibrated probe.ResultsOf the 31 patients, 7 had an arthroscopically assessed maximum postopD of ≥2 mm after internal fixation. The correlation coefficients between each preopD and postopD of all radiographs and CTs were statistically significant. The cutoff values were 0.5 mm for PA radiographs, 2.10 mm for lateral radiographs, 2.15 mm for axial CT scans, 3.15 mm for coronal CT scans, and 1.20 mm for sagittal CT scans. All cutoff values for PA and lateral radiographs and for axial, coronal, and sagittal CT scans were unsuitable as screening criteria for arthroscopic reduction of DRF because of their low sensitivities and specificities. The cutoff value of the new preopD (the sum of the preopDs determined by lateral radiography and coronal CT scan) was 5.80 mm, and its sensitivity and specificity were 100% and 83.3%, respectively.ConclusionsBecause a new preopD cutoff value of 5.80 mm is a good indicator for residual articular displacement after internal fixation of >2 mm, it is also a good indicator for the need for arthroscopic evaluation after internal fixation.

Reverse midpalmar island flap transfer for fingertip reconstruction.

Significant soft tissue defects of the fingertip with exposure of tendon or bone represent a challenging problem when homodigital or heterodigital artery island flaps are not available. In an attempt to resolve this problem, 15 patients with fingertip injuries involving palmar skin defects or amputation were treated with a vascularized flap transfer from the midpalmar area. A 2.5 x 1.5 to 4.5 x 2 cm flap from the radial or distal aspect of the midpalm, pedicled on the terminal branch of the superficial palmar arch or common/proper palmar digital artery and vein, was transferred in a retrograde fashion to cover the skin and soft tissue defects of the finger. All the flaps survived without complications. Moving two-point discrimination in the flap averaged 6 mm in patients who underwent sensory flap transfer. We concluded that vascularized skin flaps from the radial or distal aspects of the midpalm offer a good alternative option for the reconstruction of fingertip palmar skin and soft tissue defects.

Reliability and Clinical Importance of Teardrop Angle Measurement in Intra-articular Distal Radius Fracture

PURPOSE The teardrop angle (TDA) is a newly characterized radiographic parameter that some authors propose as an indicator of articular incongruity of the lunate facet. The purposes of this study were to investigate intra-observer and interobserver reliability of the measurements of the TDA and to determine whether the TDA is a reliable indicator of articular step and gap formation after distal radius fracture. METHODS We studied radiographs of 24 uninjured wrists and 24 wrists with intra-articular distal radius fractures. On standard and 10° tilt views of lateral wrist radiographs, the teardrop represents the volar rim of the lunate facet, and the TDA is defined as the angle between the central axis of the teardrop and the radial shaft. We examined interobserver and intra-observer reliability for 3 observers using the intraclass correlation coefficient (ICC) for measurements of the uninjured and fractured wrists. For subjects with fractures, we determined correlation of the TDA-volar tilt with the articular step and gap measured by computed tomography using simple linear regression. RESULTS There was almost perfect intra-observer (ICC = 0.95) and interobserver (ICC = 0.93) reliability in the fractured wrists. We observed substantial intra-observer (ICC = 0.64) and fair interobserver (ICC = 0.28) reliability in the uninjured wrists on the standard lateral radiographs. On the 10° tilt views, intra-observer and interobserver reliability in the uninjured wrists increased to substantial levels (ICC = 0.76 and 0.61, respectively). The TDA-volar tilt was significantly associated with articular step and gap on computed tomography. CONCLUSIONS The TDA, measured on the lateral radiograph of the wrist, exhibits higher intra-observer and interobserver reliability in fractured wrists compared with uninjured wrists. On the 10° tilt views, the reliability increased in the uninjured wrists. Measurement of the TDA in plain radiographs may allow direct estimation of articular incongruity as seen on sagittal computed tomography reconstruction images.

Radiographic Predictors of DRUJ Instability with Distal Radius Fractures

Because the distal radioulnar joint (DRUJ) is an inherently unstable joint, the diagnosis and treatment of DRUJ instability is often difficult in a clinical hand surgery practice. Several soft tissue stabilizers are recognized, of which the deep limbs of the radioulnar ligament are primary stabilizers. This article discusses the predictors of DRUJ instability in distal radius fractures based on our clinical and biomechanical analyses.

Predictors of Postoperative Finger Stiffness in Unstable Proximal Phalangeal Fractures

Background: The purpose of this study was to determine the risk factors for postoperative finger stiffness after open reduction and internal fixation of unstable proximal phalangeal fractures using a low-profile plate and/or screw system. We hypothesized that dorsal plate placement is a risk factor for postoperative finger stiffness. Methods: Seventy consecutive patients (50 men, 20 women; average age, 40 years) with 75 unstable proximal phalangeal fractures were treated with titanium plates and/or screws and evaluated at a minimum follow-up of 1 year. Thirty-six comminuted fractures and 24 intra-articular fractures were included, and 16 fractures had associated soft-tissue injuries. Plate fixation was performed in 59 fractures, and the remaining 16 were fixed with screws only. The implants were placed in a dorsal location in 33 fractures and in a lateral or volar location in 42 fractures. Finger stiffness was defined as a total active range of finger motion <80% for the treated finger. Univariate and multivariate analyses were performed on 8 variables: patient characteristics (age and sex), fracture characteristics (fracture comminution, joint involvement, and associated soft-tissue injury), and surgical characteristics (type and location of implants and removal of the implants). Results: Postoperative finger stiffness occurred in 38 fractures. The multivariate analysis indicated that plate fixation (odds ratio, 5.9; 95% confidence interval, 1.5–24.0; P = 0.01) and dorsal placement (odds ratio, 3.0; 95% confidence interval, 1.1–8.3; P = 0.03) were independent risk factors for finger stiffness. Conclusion: We recommend the use of screw fixation as much as possible for unstable proximal phalangeal fractures using a midlateral approach.

Reliability of the iPad Measurement for Range of Dart-Throwing Motion

Hypothesis: The dart-throwing motion (DTM) is functionally very important movement from radial extension to ulnar flection of the wrist and the anatomical and biomechanical futures have been demonstrated experimentally. Clinically, there is the only report to be published to describe the method of goniometric measurement for DTM but the reliability of measurement has not been evaluated. We hypothesized that our DTM measurement method using a tablet device and a simple jig can be a more reliable method. Methods: Participants were 10 healthy volunteers for assessing intrarater reliability and 3 examiners for interrater reliability. Range of extension-flexion and DTM were evaluated. Participants moved their wrist in each motion plane on a flat table. During the DTM measurements, their hand was fixed to an isosceles right triangle jig and kept their wrist rotation 45° obliquely on the table, so they moved their wrist freely in a DTM plane on the table. Photo images at each maximum wrist position from right overhead were recorded using a tablet device and the angle was measured by goniometric software launched on the device. Reference points were marked on participant’s skin before recording images according to our protocol. Intraclass correlation coefficients (ICC) were compared to determine intrarater and interrater reliability, using the SPSS software package (P < .05). Results: All results are shown in Table 1. According to the guideline provided by Landis and Koch, there was substantial intraobserver (ICC = .67, .71) and interobserver (ICC = .77, .72) in flexion and extension, respectively. We observed almost perfect intraobserver (ICC = .92) and substantial interobserver (ICC = .79) in ulnar flexion and substantial intraobserver (ICC = .62) in radial extension in a DTM plane. There was moderate interobserver (ICC = .59) in radial extension in a DTM plane. Conclusion: The results of the study indicate that the measuring method of the range of motion by use of tablet device can maintain fixed reliability or more. Intrarater and interrater reliability of our method of measurement for DTM compares favorably with conventional flexion-extension motion. The recording of photo image can transform a 3-dimensional object to the plane figure and make the measurement easy.