T. Pillukat

Malunion of the distal radius

Fractures of the distal radius are extremely common injuries, which are steadily becoming a public health issue. One of the most common complications following distal radius fractures is still malunion of the distal radius. This review of the literature surrounding distal radius malunion covers the biomechanics of distal radial malunion, treatment options, indications for surgery, surgical techniques, and results.

Intra- und Interobserver-Reliabilität digital fotodokumentierter Befunde von Handgelenksspiegelungen

PURPOSE The aim of this study was to evaluate the intra- and interobserver reliability of findings in wrist arthroscopies documented by digital photography. PATIENTS AND METHODS 102 consecutive wrist arthroscopies were documented by at least 6 photographs: (1) radioscaphoidal joint with radiopalmar ligaments, (2) scapholunate ligament from radiocarpal, (3) TFCC, (4) lunotriquetral joint with ulnar recessus, (5) scapholunate, and (6) lunotriquetral joint from midcarpal. More photographs were taken of additional pathologies. Arthroscopic findings were documented in an arthroscopy form (synovitis: no/yes, articular effusion: no/yes, cartilage lesion: no/yes). Lesions of the scapholunate ligament were classified according to Geissler, scapholunate and lunotriquetral ligament lesions were graded as partial or complete, TFCC lesions were categorised according to Palmer and trampoline effects noted. Three months later the 6 standard photos and then all photos were re-evaluated by the scoping surgeon and two experienced hand surgeons. Cohens kappa was used as a measure of agreement between findings three months postoperatively and those in the operation report. Further statistical analyses were done, e. g., to compare intra- and interobserver reliability. RESULTS In general intraobserver reliability (mean kappa 0.44) was better than interobserver reliability (0.28, 0.30). Assessing all available photos (0.47) did not improve reliability compared to assessing only the six standard photos (0.44). On grading scapholunate ligament lesions as partial or complete the interobserver reliability was fair (0.37, 0.30). Using Geisslers classification the interobserver reliability was κ=0.34 and 0.23. There was substantial intra- (0.61) and interobserver reliability (0.63, 0.60) for cartilage lesions. While intraobserver reliability for TFCC lesions was substantial (0.61), interobserver reliability was only moderate (0.31, 0.48). CONCLUSION Even with wrist arthroscopy, the best diagnostic modality for scapholunate ligament, TFCC and carpal cartilage lesions, hand surgeons do not agree in diagnosis and pathology. Therefore, the documentation of arthroscopic findings has to be improved. Digital video documentation of wrist arthroscopy may illustrate wrist pathologies more adequately. However, this still has to be proven by further studies.

Long-Term Results after Midcarpal Arthrodesis

Background and Purpose Midcarpal arthrodesis is a well-accepted treatment option for advanced carpal collapse. In this study, we retrospectively assessed survival, analyzed complications and reviewed the long-term follow-up after midcarpal fusion. Materials and Methods The computerized medical records of 572 patients who had undergone 594 four-corner fusions between 1992 and 2001 were explored. Furthermore 56 patients with 60 midcarpal fusions were randomized for clinical and radiological follow-up at a mean of 14.7 years. Results Forty midcarpal fusions (6.7%) had to be converted into complete wrist arthrodesis. The reasons were ongoing pain in spite of a well-healed midcarpal fusion (31) or nonunion (9). Sixty-three patients (11%) required revision surgery because of nonunion (22), hematoma (8), wound infection (3) or persisting pain (31). In clinical follow-up the mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 20.4. Pain at rest was infrequent, a mild increase with daily activity was complained of (mean visual analog scale [VAS] 3.3). The mean active range of wrist motion for extension and flexion, ulnar and radial deviation and supination and pronation reached 62.5%, 68.4%, 94.7%, and mean grip strength 84.9% of the unaffected side. All patients had radiographic abnormalities, with frequent evidence of osteoarthritis of the lunate fossa. Patients with preserved carpal height appeared to have less pain, better DASH scores and a better range of motion. Conclusions The midcarpal arthrodesis is a long-lasting treatment option for advanced carpal collapse and has good long-term results. Level of Evidence Level IV, Therapeutic study.

Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance

IntroductionThe treatment of ulnar-sided wrist pain after malunited distal radius fractures remains controversial. Radial corrective osteotomy can restore congruity in the distal radioulnar joint (DRUJ) as well as adequate length of the radius. Ulnar shortening osteotomies leave the radius’ angular deformities unchanged, risking secondary DRUJ osteoarthritis. We supposed that, even within the widely accepted limit of 20°, a greater angulation of the radius in the sagittal plane correlates with a higher rate of DRUJ osteoarthritis. Furthermore, we suspected worse results from an ulna shortened to a negative rather than a neutral or positive ulnar variance.Materials and methodsFor this retrospective study, we reviewed 23 patients a mean 7.2 (range 5.6–8.5) years after ulnar shortening osteotomy for malunion of distal radius fractures. We compared 14 patients with up to 10° dorsal or palmar displacement from the normal palmar tilt of 10° to 9 patients with more than 10° displacement, and 15 patients whose post-operative ulnar variance was neutral or positive to 8 who had a negative one.ResultsUlnar-sided wrist pain decreased enough to satisfy 21 of the 23 patients. Clinical results tended to be better when radial displacement was minor and when post-operative ulnar variance was positive or neutral. A shorter ulna significantly increased the rate of DRUJ osteoarthritis, whereas a greater degree of radial displacement only increased the rate slightly.ConclusionsRadial corrective osteotomy should be discussed as alternative when displacement of the radius in the sagittal plane exceeds 10°. The ulna should be shortened moderately to reduce the risk of osteoarthritis in the distal radioulnar joint.

Comparison of the results between reconstruction of the extensor pollicis longus tendon using a free interposition tendon graft and extensor indicis transposition

QUESTION Is there a difference in the results of free tendon grafting or transfer of the extensor indicis tendon for the reconstruction of the extensor pollicis longus tendon? PATIENTS AND METHODS Two groups of patients, who underwent surgery between 1992 and 1998, were compared. From 58 patients with tendon grafts 48 were re-examined. For reconstruction, a graft harvested from the palmaris longus tendon was applied that was woven into the proximal and distal stump of the extensor pollicis tendon according to the technique of Pulvertaft. From 56 patients with transfer of the extensor indicis tendon, 40 were re-examined. The extensor indicis transfer was performed by the standard technique. Extension and flexion of the metacarpophalangeal and interphalangeal joints of the thumb, retroposition, abduction and opposition were examined. In addition, the span of the hand, grip strength and pinch strength were measured. A summarising assessment was performed according to the Geldmacher score, the subjective impairment was assessed by the DASH score. RESULTS Both groups were comparable according to demographic data and aetiology of the rupture. The range of motion was nearly identical after both surgical techniques. Range of motion of the joints of the thumb, abduction and opposition reached normal values but both methods restored only 60 % of the normal retroposition. According to the Geldmacher score, both methods showed good and excellent results. The DASH score resulted in low values with 10 and, respectively, 14 points. After extensor indicis transfer all patients demonstrated isolated extension of the index. CONCLUSIONS Both methods establish equally good results. Free tendon grafting is technically more demanding but preserves a more powerful isolated extension of the index finger and should, therefore, be preferred in patients with special demands on this function (e.g., musicians). The transfer of the extensor indicis tendon is technically less demanding, requires retraining and may impair the isolated function of the index finger.

Die Arthroskopie des distalen Radioulnargelenks

OBJECTIVE Insertion of a small joint arthroscope into the proximal and distal parts of the distal radioulnar joint (DRUJ) allows visualization of the proximal pouch of the DRUJ, the joint surfaces of the sigmoid notch and the ulnar head, the convexity of the ulnar head and the proximal ulnar-sided surface of the triangular fibrocartilage complex (TFCC). INDICATIONS Evaluation of joint pathologies in ulnar-sided wrist pain, especially in cases without diagnostic findings in standard X-rays and MRI, suspected cartilage lesions without osteochondral changes (signs of osteoarthritis), undefined swelling of the DRUJ in suspected synovitis, removal of loose bodies and arthroscopical synovialectomy, suspected lesions of the deep part of the TFCC, respectively foveal avulsions, wear or superficial tears of the proximal TFCC and arthroscopic-assisted ulnar shortening. CONTRAINDICATIONS Significant changes of the local topographical anatomy, extensive scar formation, ulna plus variance, local infection or open wounds, affected sensibility in the area of the dorsal branch of the ulnar nerve, fractures of the sigmoid notch or the ulnar head, capsular tears causing effusion of irrigation fluid. SURGICAL TECHNIQUE In vertical extension of the wrist, two portals are created on the dorsal side of the DRUJ between the extensor digiti minimi and extensor carpi ulnaris tendons. Partial visualization of the ulnar head, the sigmoid notch, the proximal pouch of the DRUJ, and the proximal surface of the TFCC. POSTOPERATIVE MANAGEMENT Following isolated diagnostic arthroscopies immobilization of the wrist in a semicircular ulnar-sided cast for 1 week. No extensive load to the wrist for 4 weeks. RESULTS Still rarely performed procedure for diagnosis and therapy of ulnar-sided wrist pain. Technically demanding with a flat learning curve and anatomy-related obstacles. A complete view of the joint is not always accessible. Rare complications are injuries of the extensor digiti minimi tendon as well as contusion or sectioning of the transverse branch of the dorsal branch of the ulnar nerve. In distinct cases this procedure offers valuable additional information about the distal radioulnar joint.

Die Hemiresektions-Interpositionsarthroplastik des distalen Radioulnargelenks nach Bowers

ZusammenfassungOperationszielWiederherstellung der Unterarmdrehung und Schmerzreduktion am distalen Radioulnargelenk durch Resektion der Gelenkflächen des Ulnakopfes unter Erhalt oder Refixation des ulnokarpalen Komplexes und Interposition eines Kapsel-Retinakulum-Lappens zwischen Incisura ulnaris des Radius und distaler Ulna.IndikationenSchmerzhafte Arthrosen des distalen Radioulnargelenks.KontraindikationenLongitudinale Instabilitäten des Unterarms, z.B. bei Essex- Lopresti-Läsionen oder nach Radiuskopfresektionen. Posttraumatische ulnare Translokation des Carpus.OperationstechnikEröffnung des distalen Radioulnargelenks durch den Boden des fünften Strecksehnenfachs unter Bildung eines ulnar gestielten Kapsel-Retinakulum-Lappens. Erhalt des vierten und sechsten Strecksehnenfachs. Resektion der gelenktragenden Teile des Ellenkopfes unter Erhalt des Processus styloideus ulnae und des Ansatzes des ulnokarpalen Bandkomplexes (TFCC [„triangular fibrocartilage complex“]). Gegebenenfalls Refixation oder Rekonstruktion des ulnokarpalen Bandkomplexes. Interposition des Kapsel-Retinakulum-Lappens zwischen Radius und Ulna. Stabilisation der distalen Ulna durch Naht der dorsalen Anteile des Interponats an die dorsale Lippe der Incisura ulnaris des Radius.WeiterbehandlungRuhigstellung in einer Oberarmgipsschiene in 45° Supinationsstellung des Unterarms für 4 Wochen. Anschließend werden Pronation und Supination mit einer thermoplastischen, Ulna und Radius ulnar umgreifenden Schiene unter Freilassung des Radio- und Ulnokarpalgelenks für weitere 4 Wochen begrenzt. Danach Steigerung des Bewegungsumfangs und der Belastung bis zur Vollbelastung.ErgebnisseDie Hemiresektions-Interpositionsarthroplastik des distalen Radioulnargelenks reduziert den Schmerz signifikant und erhöht die Grobkraft. Bei präoperativer Einschränkung der Umwendbewegung kann der Bewegungsumfang durch die Operation deutlich gesteigert werden. Eine Instabilität des Ulnaendes kann verbleiben bzw. resultieren, was aber nur bei einem Teil der Patienten leichte Beschwerden verursacht. Die Patientenzufriedenheit ist hoch bei gutem funktionellem Ergebnis.AbstractObjectiveRestoration of forearm rotation and pain relief at the distal radioulnar joint by resection of the joint surfaces of the ulnar head, interposition of a capsular-retinacular flap, and preservation or reconstruction of the ulnocarpal complex.IndicationsPainful osteoarthritis of the distal radioulnar joint.ContraindicationsLongitudinal instability in the forearm, e.g., Essex-Lopresti lesions or after radial head resection. Posttraumatic ulnar subluxation of the carpus.Surgical TechniqueExposition of the distal radioulnar joint via the floor of the fifth extensor compartment and preparation of an ulnarbased capsular-retinacular flap. Preservation of the fourth and sixth extensor compartment. Resection of the jointbearing areas of the ulnar head preserving the ulnar styloid and the triangular fibrocartilage complex (TFCC). If necessary, refixation or reconstruction of the TFCC. Interposition of the capsular-retinacular flap between the distal radius and ulna. Stabilization of the distal ulna by suture fixation of the dorsal part of the flap to the dorsal rim of the sigmoid notch.Postoperative ManagementImmobilization in a long arm cast with 45° forearm supination for 4 weeks. Afterwards, forearm pronation and supination are further limited for 4 weeks by a splint. Following that period, the range of motion and the load are raised to normal levels.ResultsThe hemiresection-interposition arthroplasty of the distal radioulnar joint improves the range of forearm rotation. Pain is significantly reduced and grip strength increased. Instability of the distal ulna may persist or result; however, this gives rise to moderate complaints only in some patients. Patients’ satisfaction is high and the functional results are good.

The Value of Wrist Arthroscopy in Kienböck's Disease

PURPOSE/BACKGROUND The integrity of the articular surfaces is of major importance for the prognosis and treatment of lunate necrosis (Kienböcks disease). Though arthroscopy is the most reliable method in the diagnosis of intraarticular pathology it is rarely applied in this condition. The purpose of this study was to evaluate the value of arthroscopy in Kienböcks disease. PATIENTS/MATERIAL AND METHODS 20 prospectively evaluated patients underwent arthroscopy for Kienböcks disease. Initial diagnosis was performed by enhanced magnet resonance images, standard radiographies and computed tomography. Preoperative staging was performed according to the MRI-adapted classification of Lichtman and Ross . The arthroscopical measures followed standard procedures. Cartilage lesions were rated by an own modified classification. The wrists were further staged according to an arthroscopical classification system for Kienböcks disease (Bain and Begg ). The posterior and anterior interosseus nerves were resected in all patients and, if necessary, an arthroscopical debridement of the lunate performed. RESULTS No clinical or statistical correlation was found between the Lichtman-stages and the distribution and severity of the cartilage lesions. In selected cases severe cartilage lesions (3 degrees and 4 degrees ) were already found in Lichtman-stage IIIA and IIIB, while less severe lesions than expected were observed in Lichtman-stage IV. There was no correlation between the Lichtman-stages and the classification according to Bain and Begg. In selected cases without cartilage lesions carpal collapse (Lichtman stage IIIB) was found. The individual response was unequivocal: Four patients reported minimal, five patients remarkable improvement but all did not demand further procedures. Four patients reported complete relieve. Seven patients demanded further operations (3 proximal row carpectomies, 4 STT fusions). In three of these seven cases the arthroscopical evaluation guided the further operative therapy to appropriate procedures. CONCLUSIONS In Kienböcks disease arthroscopy more precisely detected alterations of the articular surfaces than radiological diagnostics. Radiological staging over- but also underestimated the cartilage damage. Arthroscopic results strongly influenced the further surgical treatment. Therefore in Kienböcks disease arthroscopy is of high value and recommended.

Complex fragmentation of the articular surface of the distal radius: management with small Kirschner wires and bone graft.

Severe intra-articular fractures of the distal radius with comminuted, displaced, and malrotated fragments are the most challenging fracture patterns. Reconstruction faces 3 major problems: fixation of fragments that are too small for stabilization by standard plates or screws, restoration of substantial cartilage loss in the articular surfaces, and extended metaphyseal/subchondral bony defects. For addressing these problems, a strategy is reported, by applying small, subchondrally placed Kirschner wires for the realignment of the articular surfaces, temporary inlay of a silicone foil in case of lost articular cartilage, and iliac crest bone grafting for bony defects. Stability is further augmented by buttress plates. This study reviews the historical perspective, indications, technique, complications, and rehabilitation of this strategy.

Diagnosing central lesions of the triangular fibrocartilage as traumatic or degenerative: a review of clinical accuracy

This study examined the reliability of surgeons’ estimations as to whether central lesions of the triangular fibrocartilage complex were traumatic or degenerative. A total of 50 consecutive central triangular fibrocartilage complex lesions were independently rated by ten experienced wrist surgeons viewing high-quality arthroscopy videos. The videos were reassessed after intervals of 3 months; at the second assessment surgeons were given the patient’s history, radiographs and both, each in a randomized order. Finally, the surgeons assessed the histories and radiographs without the videos. Kappa statistics revealed fair interrater agreement when the histories were added to the videos. The other four modalities demonstrated moderate agreement, with lower Kappa values for the assessment without videos. Intra-rater reliability showed fair agreement for three surgeons, moderate agreement for two surgeons and substantial agreement for five surgeons. It appears that classification of central triangular fibrocartilage complex lesions depends on the information provided upon viewing the triangular fibrocartilage complex at arthroscopy. Level of evidence: II