Wim Vanhove

Proximal Row Carpectomy Versus Four-Corner Arthrodesis as a Treatment for SLAC (Scapholunate Advanced Collapse) Wrist

Four-corner arthrodesis and proximal row carpectomy are motion-preserving salvage solutions for the scapholunate advanced collapse wrist. We compared both procedures in a non-randomised, retrospective study of 30 cases with a mean follow-up of 3½ years. Pain relief and functional gain were equal in both treatment groups. However, the complication rate was higher in the four-corner arthrodesis group, partly because of the need for internal fixation. The higher incidence of carpal tunnel syndrome following four-corner arthrodesis is intriguing. We also found significant differences in the duration of hospital stay and of postoperative sick leave in favour of proximal row carpectomy. If the cartilage on the capitate head is well preserved (Stages I–II), we prefer proximal row carpectomy because of the socio-economic benefits, the lower complication rate and the ease of the procedure. Degenerative changes following proximal row carpectomy may be a concern in young manual labourers, but have not been observed.

Muscle fibres crossing the line of incision used in carpal tunnel decompression

Muscle fibres that cross the proposed line of incision of the flexor retinaculum at carpal tunnel decompression can be a source of confusion, particularly for the less experienced surgeon. We investigated how frequently muscle fibres crossed the line of incision on the palmar surface of the flexor retinaculum at carpal tunnel decompression in 143 hands, and dissected 103 cadaver hands to study the origin and insertion of these muscle fibres. The line of incision was defined as a longitudinal line between thenar and hypothenar eminences along the third web space, with the wrist in neutral radioulnar deviation and the fingers in extension. Muscle fibres crossing the line of incision were absent in 50% of the operated hands, 2–10 mm wide in 39% and more than 10 mm wide in 11%. In the cadaver hands the proportions were similar at 50%, 35% and 15%, respectively. The fibres were extensions of the thenar and hypothenar muscles and did not appear to represent a separate anomalous muscle.

Outcome of Ulnar Shorting Osteotomy

Introduction: Ulnar shortening is a treatment option for ulnar wrist pain. Most frequently, this procedure is performed for ulnocarpal impingement, but it may also be useful in patients with persistent ulnar wrist pain after a sprain. The aim of the study was to assess outcome of patients who were operated on in our hospital with a diaphysial ulnar shortening osteotomy; to look for complications; and to find out if results were influenced by factors such as age, gender, hand dominance, smoking, type of osteotomy (horizontal or oblique), and length of follow-up; and whether or not a trauma was involved. Methods: Between 2006 and 2014, 37 out of 46 patients who were operated on in our hospital were available for evaluation with a mean follow-up of 54 months (range, 7-69). Mean age at the time of surgery was 39 years (range, 15-69), 24 were women, in 19 the dominant hand was involved, 15 were smokers, and in 28 a horizontal and in 9 an oblique osteotomy was performed. In 18 a trauma was involved, and in 14 there was an associated fracture of the radius or ulna. In all patients, Disability of Arm Shoulder and Hand (DASH) questionnaire, patient rated wrist hand evaluation (PRWE), visual analogue scale (VAS) for pain, satisfaction, and complications could be assessed, and in 25 grip strength and range of motion were determined. Statistical analyses (Mann-Whitney U test, independent samples t test) were performed to find out which factors had an influence on the outcome. Multiple regression analysis was done to assess influences on the DASH score. Results: Mean DASH was 22 (range, 0-75) and mean PRWE score 33 (range, 0-90). Mean VAS for pain was 2.6 (range, 0-7.8). Thirty patients were satisfied and 7 would not undergo the same operation again. In 17 the plate and screws had to be removed. In 3 cases with a horizontal osteotomy, a second operation had to be performed for nonunion. Two of them were smokers. Mean grip strength was 84%, mean wrist flexion 84%, extension 75%, pronation 85%, and supination 86% of the contralateral side. PRWE and DASH scores were significantly better in smokers. PRWE was significantly worse in posttraumatic ulnocarpal impaction syndrome. Multiple regression analysis showed a significantly better DASH score in smokers, in patients operated on the nondominant side and with a longer follow-up. Discussion and Conclusion: Ulnar shortening may not be able to solve ulnar wrist pain in all patients as one fifth was not satisfied. Complications should not be underestimated. Reoperations were needed in half of patients. Outcomes were better in idiopathic ulnocarpal impaction. In posttraumatic cases, ligamentous lesions may also play a role in causing ulnar wrist pain. Results were better when the follow-up was longer which may indicate that recovery after ulnar shortening may take long time or that patients may have adapted their activities. In contrast to other studies, outcome scores in the present study were better in smokers, but 2 of the 3 patients with nonunion were smokers.