Results after radioscapholunate arthrodesis with or without resection of the distal scaphoid pole

Outcomes after radioscapholunate arthrodesis for intra-articular malunion of distal radius fractures

PURPOSE

To study the clinical, radiological, and functional outcomes after of radioscapholunate (RSL) fusion for intra-articular malunion of the distal radius.

METHODS

This retrospective study included 26 patients (17 males and 9 females) with intra-articular malunion of distal radius fractures who underwent RSL arthrodesis using locked miniplates (without distal scaphoid excision) between 2012 and 2020. Their mean age was 43 years (range, 32-56). Patients were assessed radiographically for union and clinically for range of motion, grip strength, and pain (assessed by Visual Analogue Scale (VAS) for pain). Functional evaluation was performed by using the Mayo modified wrist score (MMWS) and the Disabilities for the Arm, Shoulder, and Hand (DASH) questionnaire.

RESULTS

All patients showed complete healing at the fusion site after a mean of 8.7 weeks (range, 8-12). The mean follow-up period was 72 months (range, 60-84). The pinch strength improved from a mean of 6.2 kg (range, 3-12) to a mean of 9.8 kg (range, 5-18) which represents 80% of the contralateral side. The mean pinch strength was 7 kg (range, 5-18) which presents 80% of the other side. VAS for pain showed a mean improvement of 72.6%. The DASH score improved to a mean of 19.2 (range, 14-24). The MMWS improved to a mean of 68 (range, 45-86). At the final follow-up period, no degenerative changes were detected in the midcarpal joint.

CONCLUSION

RSL arthrodesis (using locked miniplates without distal scaphoid excision) is a reliable surgical procedure to manage cases of radiocarpal OA after intra-articular malunion of distal radius fractures with good clinical and radiological outcomes.

LEVEL OF EVIDENCE

Level IV- therapeutic.

Prospective analysis of grip strength and load distribution after surgical treatment of common diseases of the hand with novel's manugraphy® system

BACKGROUND

Carpal tunnel syndrome, A1 annular pulley stenosis and Dupuytren's contracture are among the most common conditions of the hand. In this study, we investigated the impact of surgical procedure on hand grip strength and high-resolution spatial load distribution in individuals suffering from those diseases over a follow-up period of one year.

MATERIALS AND METHODS

In this prospective study, data of 9 patients with carpal tunnel syndrome, 12 patients with A1 annular pulley stenosis and 7 patients with Dupuytren's contracture were evaluated. Only patients with unilateral disease were included providing the contralateral hand as an intra-individual control. Grip strength was measured with cylindrical instruments in two different sizes with respect to the hand size of the patients. Maximum and average values of grip strength as well as spatial load distribution in each finger, thenar, hypothenar and palm were analyzed. Data of the affected patients were collected preoperatively and 6 weeks, 6 months and 1 year postoperatively. Grip strength and spatial load distribution were compared preoperatively to postoperatively. In addition, DASH score, Levine score, 2-point discrimination and degree of flexion contracture were assessed.

RESULTS

The patients with A1 annular pulley stenosis showed a significant increase in grip strength 6 months and one year postoperatively. Patients with carpal tunnel syndrome and Dupuytren's contracture showed no significant difference in grip strength over the course of time. An increase in the percentual grip strength of the thenar in patients with carpal tunnel disease and within the affected finger in A1 annular pulley stenosis was observed over the course of time. The DASH score was significantly lower in all patient cohorts one year postoperatively.

CONCLUSION

Surgical procedure in carpal tunnel syndrome, A1 annular ligament stenosis and Dupuytren's contracture improves the functionality of the hand in everyday life. Some areas of the hand seem to compensate other weaker areas in grip strength.

Wrist Arthritis and Arthrodesis: Preserving Function, Minimizing Problems

Wrist arthritis is a common condition with numerous causes and presentations. Several management options exist, and treatment should be individualized based on patient age, comorbidities, occupation, duration of symptoms, and failed treatment modalities. Arthroscopy and denervation are appealing because of shorter recovery time and preservation of motion, but duration of effectiveness varies between patients. Patients who fail these smaller procedures or those with pancarpal arthrosis are treated effectively with total wrist arthrodesis or total wrist arthroplasty in lower-demand patients. This article reviews causes and patterns of wrist arthritis and discusses treatment strategies aimed at preserving function and minimizing complications.

Radiographic and Clinical Outcomes of Radioscapholunate Arthrodesis in Patients With Inflammatory and Posttraumatic Arthritis

BACKGROUND

Radioscapholunate (RSL) fusion is performed for painful radiocarpal arthritis that is typically posttraumatic or inflammatory in nature. The purpose of this study was to determine whether patients with inflammatory conditions undergoing RSL fusion had comparable outcomes as those with posttraumatic arthritis and to determine factors impacting union.

METHODS

This was a retrospective review of all RSL fusions over a 25-year period. Demographic information, wrist range of motion, postoperative complications, and surgical technique, including presence or absence of resection of distal scaphoid pole, data were collected. Radiographs were examined for evidence of healing of the RSL fusion site as well as development of midcarpal arthritis.

RESULTS

Fifty-six patients underwent RSL fusion. Eight patients required revision of radiocarpal arthrodesis for painful nonunion. The fusion rate was 85.7%, and median 25th to 75th percentile (time to healing was 4.0 3.2-5.2) months. There were no differences in time to or rate of union by inflammatory arthropathy status. Grip strength increased significantly and pain decreased significantly with surgery. Union rate was 90% with the use of K-wires, screws, or staples, which was significantly greater than plates, fusion cups, or multiple implant types. The use of autologous bone graft significantly decreased the rate of nonunion and significantly decreased time to union by 3 months compared to allograft alone. Extension was significantly improved with scaphoid distal pole resection versus without distal scaphoid pole resection.

CONCLUSIONS

Radioscapholunate (RSL) fusion is an effective treatment for radiocarpal arthritis but has high nonunion rates. Fixation with K-wires, screws, or staples and use of autograft confers improved union rate.

Radiocarpal Fusion: Indications, Technique, and Modifications

Degenerative disorders of the wrist may affect isolated joints and inhibit normal functions of the wrist secondary to pain and stiffness. These processes that affect only the radiocarpal joint may be secondary to posttraumatic osteoarthritis, primary osteoarthritis, or rheumatoid arthritis. Radiocarpal wrist arthrodesis may help preserve some of the native wrist kinematics while alleviating pain and improving the range of motion. However, the surgeon must ensure that the patient's pathologic process primarily affects the radiocarpal articulations while relatively sparing the midcarpal articulations. Depending on the location of the pathology, isolated radiolunate or radioscapholunate arthrodesis have been described to preserve some motion in the midcarpal joint. To maximize motion in the midcarpal joint after radiocarpal arthrodesis, techniques for distal scaphoid and triquetrum excision have been described. We report patient outcomes for various techniques and describe our preferred technique for radioscapholunate arthrodesis using distal scaphoid excision.

The Biomechanical Effects of Simulated Radioscapholunate Fusion With Distal Scaphoidectomy, 4-Corner Fusion With Complete Scaphoidectomy, and Proximal Row Carpectomy Compared to the Native Wrist

PURPOSE

To determine the effect of simulated radioscapholunate fusion with distal scaphoid excision (RSLF+DSE), 4-corner fusion with scaphoidectomy (4-CF), and proximal row carpectomy (PRC) on the wrist's range of motion (ROM), contact pressure, and contact force in a cadaveric model.

METHODS

Ten freshly frozen cadaveric wrists were tested under 4 sequential conditions: native wrist, RSLF+DSE, 4-CF, and PRC. The simulated fusions were performed using two 1.6-mm Kirschner wires. The ROM in the flexion-extension and radioulnar deviation planes was evaluated. Contact area, contact pressure, and contact force were measured at the scaphocapitolunate joint for the RSLF+DSE simulation and radiocarpal joint for the 4-CF and PRC simulations. Mechanical testing was performed using a 35-N uniaxial load and pressure-sensitive film.

RESULTS

The RSLF+DSE and 4-CF groups had a decreased wrist arc ROM compared with the native wrist. The PRC group had a greater wrist arc ROM compared with the RSLF+DSE and 4-CF groups, but compared to the native wrist, it demonstrated a mildly decreased wrist arc ROM. The carpal pressure and contact force were significantly increased in the RSLF+DSE, 4-CF, and PRC groups compared with those in the native wrist. The RSLF+DSE group had the smallest increase in the carpal pressure and contact force, whereas the PRC group had the greatest increase.

CONCLUSIONS

Our study validates previous findings that PRC is motion-conserving but has the greatest contact force, whereas RSLF-DSE and 4-CF may cause a decrease in the ROM but have lower contact forces.

CLINICAL RELEVANCE

Understanding the underlying native wrist biomechanics and alterations following different surgical treatments may assist hand surgeons in their clinical decision making for the treatment of stage II scapholunate advanced collapse.

Osteoarthritis of the Wrist: Pathology, Radiology, and Treatment

Osteoarthritis (OA) is a degenerative disease that can manifest in any synovial joint under certain conditions. It leads to destruction of articular cartilage and adjacent bone, as well as formation of osteophytes at the edges of afflicted joint surfaces. Regarding the wrist, typical degenerative arthritis affects particular joints at a specific patient age, due to asymmetric load distribution and repetitive microtrauma. However, in the presence of instability or systemic diseases, early-onset degeneration can also impair the range of motion and grip strength in younger patients. Although advanced stages of OA display characteristic signs in radiography, the detection of early manifestations frequently requires computed tomography or magnetic resonance imaging (in some cases with additional arthrography). If a wrist becomes unstable, timely diagnosis and precise treatment are essential to prevent rapid disease progression. Therefore, close collaboration between radiologists and hand surgeons is obligatory to preserve the carpal function of patients.

A Systematic Review of Radiolunate and Radioscapholunate Arthrodesis

Purpose

The aims of this systematic review were to examine the use of radiolunate (RL) or radioscapholunate (RSL) arthrodesis as surgical management for patients with advanced radiocarpal arthritis that failed conservative management and to assess postoperative outcomes.

Methods

We reviewed articles from PubMed, EMBASE, and Web of Science from inception through December 2019. We identified complete manuscripts written in English reporting on RL or RSL arthrodesis for treatment of wrist pathology that included the primary outcomes (pain or grip strength) and at least 2 secondary outcomes (range of motion, patient-reported outcomes, or nonunion). Data pooling was used to calculate weighted averages.

Results

We identified 2,252 articles and selected 13 for inclusion. Across all studies, RSL arthrodesis was performed for 180 patients (49% female; 45 years old) and RL for 94 (87% female; 50 years old). Both procedures exhibited improvements in pain score and grip strength. Both cohorts demonstrated postoperative changes in flexion-extension arc, flexion, extension, ulnar deviation, supination, and pronation after data pooling. The nonunion rate for RSL was 15% versus 2% for RL, whereas the rate of progression to total wrist arthrodesis for RSL and RL was 4% and 0%, respectively.

Conclusions

Both RL and RSL arthrodesis can be successfully used to manage debilitating radiocarpal arthritis by affording patients with pain reduction. Each has its own benefits, in which RSL arthrodesis provides a total arc of motion within the functional demands of most activities of daily living, and RL arthrodesis has low rates of nonunion and progression to total wrist arthrodesis. Further research is needed to compare the 2 surgeries directly and prospectively in comparable patient groups.

Type of study/level of evidence

Therapeutic III.

Dry arthroscopic 4-corner arthrodesis and other refinements to stay within a tourniquet time

4-corner arthrodesis is a widely implanted procedure to treat degenerated joints in the wrist such as SLAC and SNAC stage II and III. Arthroscopy in combination with headless cannulated screws, permits reproducing the same intervention with the advantages of a minimally invasive surgery. This technique has already been published in the past supported by the early experience in this new exciting field. The purpose of this paper is to present new technical refinements collected over the years in order to speed up the surgery while obtaining optimum results. In this paper we also present extreme scenarios solved by combining the scope with cannulated screws.

Intra-articular corrective osteotomy for intra-articular malunion of distal radius fracture using three-dimensional surgical computer simulation and patient-matched instrument

BACKGROUND

Corrective osteotomy of malunited intra-articular distal radius fracture is challenging. In this study, we investigated the results in patients with malunited intra-articular distal radius fracture who underwent intra-articular corrective osteotomy through an extra-articular approach using three-dimensional (3-D) computer simulation and a patient-matched instrument (PMI).

METHODS

We retrospectively studied five consecutive patients with symptomatic malunited intra-articular distal radius fracture who underwent corrective osteotomy using a PMI. The maximal step-off on computed tomography and the deformity angle on plain radiographs were evaluated. The clinical examination parameters included range of motion (ROM), grip strength, pain according to visual analog scale (VAS), and Patient-Rated Wrist Evaluation (PRWE) score.

RESULTS

The maximal step-off was significantly reduced from 4.9 ± 1.8 to 1.0 ± 0.2 mm (p = 0.008). The absolute differences between the affected side and the normal contralateral side in radial inclination were significantly reduced from 5.4° ± 3.4°-1.2° ± 1.1° (p = 0.043). These differences were not significantly reduced postoperatively in the volar tilt and ulnar variance. VAS was significantly reduced from 4.1 ± 1.6 to 0.9 ± 0.7 cm (p = 0.006). The PRWE score significantly improved from 41.6 ± 22.0 to 15.7 ± 19.5 (p = 0.043). Grip strength was significantly increased from 54.0% ± 14.8%-85.8% ± 18.8% (p = 0.003). The preoperative and postoperative total arc of the wrist and forearm ROM were not significantly different.

CONCLUSIONS

Intra-articular corrective osteotomy using PMI could be one of the reliable treatment options for intra-articular malunion. PMI has exceptionally high precision performance, and it is also anticipated to yield superior surgical results.

Radioscapholunate fusion for posttraumatic osteoarthritis with consecutive excision of the distal scaphoid and the triquetrum: A comparative study

The aim of this study was to assess the clinical and radiographic outcomes after radioscapholunate (RSL) fusion for posttraumatic osteoarthritis. This was a retrospective, dual-center study of all patients who underwent RSL fusion between 1995 and 2015 for posttraumatic radiocarpal osteoarthritis. Patients were assessed at the final review to determine clinical (pain, wrist range of motion and strength), self-reported (QuickDASH, PRWE and MWS scores) and radiological (degenerative osteoarthritis in the scaphotrapeziotrapezoid (STT) or midcarpal joint and radiocarpal fusion) outcomes. We analyzed three groups: RSL fusion alone, RSL fusion with distal scaphoid excision (DSE) and RSL fusion with DSE and triquetrum excision (TE). Eighty-five patients were included; 10 were lost to follow-up and 11 required conversion to total wrist fusion before the final review. Finally, 64 patients had both clinical and radiographic evaluations. The mean follow-up was 9.1 years (range 1-21.4). RSL fusion alone was performed in 29 patients, RSL fusion with DSE in 23 and RSL fusion with DSE and TE in 12. At the final follow-up, the three groups did not differ in their pain or wrist motion. Overall, 47 (73%) patients were satisfied or very satisfied with the procedure. DSE significantly decreased STT osteoarthritis and radiocarpal non-union. The total wrist osteoarthritis rate after RSL fusion was 55%. RSL fusion is an effective procedure to preserve some motion in wrists with posttraumatic radiocarpal osteoarthritis. DSE prevents STT osteoarthritis by removing bony impingement and increases the fusion rate. LEVEL OF EVIDENCE: Level IV, Case series, Therapeutic studies.

Salvage procedure after malunited distal radius fractures and management of pain and stiffness

Indications for surgical treatment of distal radius fractures (DRF) remain controversial in the literature, especially in elderly patients. Complication rates after operatively treated DRF are low and well documented. These include malunion, degenerative osteoarthritis in the radiocarpal joint and subsequently pain and impaired hand function. If conservative treatment fails then salvage procedures are necessary. This review summarizes the therapeutic options available to treat degenerative osteoarthritis after malunited distal radius fractures, regardless of the initial operative or conservative treatment.

[Palmar radioscapholunate arthrodesis with distal scaphoidectomy]

OBJECTIVE

Radioscapholunate (RSL) arthrodesis with distal scaphoidectomy using an angular stable plate and palmar access in post-traumatic or degenerative osteoarthritis limited to the radiocarpal joint.

INDICATIONS

Osteoarthritis limited to the radiocarpal joint with intact mediocarpal joint after malunited intra-articular distal radius fractures, rheumatoid osteoarthritis, scapholunate advanced collapse (SLAC) up to stage II.

CONTRAINDICATIONS

Mediocarpal osteoarthritis, poor patient compliance, SLAC from stage III, osteitis.

SURGICAL TECHNIQUE

The palmar RSL arthrodesis is performed using the palmar approach between the flexor carpi radialis tendon and the radial artery. After releasing the pronator quadratus muscle, a longitudinal capsulotomy is performed and the radiocarpal joint is inspected. After correction of a volar or dorsal intercalated segmental instability of the lunate, the lunate is temporarily fixed to the scaphoid using a K-wire. The distal quarter of the scaphoid and the palmar rim of the distal radius is resected and the cartilage between the scaphoid, lunate and distal radius is removed. The scaphoid and lunate are temporarily fixed to the distal radius using K‑wires. Under image intensifier control the angular stable low-profile plate (e.g., volar 2.5 Trilock RSL Fusion plate [Medartis® Aptus® Basel, Switzerland]) is fixed to the distal radius in the long-leg hole. The scaphoid and lunate are fixed distally with two screws each. The carpus is pushed distally using a Codeman distractor and the cancellous bone graft is impacted. Finally, the shaft is fixed with angular stable screws.

POSTOPERATIVE MANAGEMENT

Immobilization using a plaster cast or thermoplastic short-arm orthosis for 5 weeks. After 2 weeks, the orthosis can be removed during hand therapy with active wrist and finger exercises. Normal activities permitted after 12 weeks.

RESULTS

Palmar RSL arthrodesis and distal scaphoidectomy using angular stable plate fixation shows a high union rate and pain relief while maintaining good residual mobility of the wrist.

Radioscapholunate Fusion for Radiocarpal Osteoarthritis: Prognostic Factors of Clinical and Radiographic Outcomes

Background  Radioscapholunate (RSL) fusion is a surgical option to manage radiocarpal osteoarthritis. Many authors upgrade the procedure by adding distal scaphoid excision with or without excision of the triquetrum. Our objective was to identify the prognostic factors for good clinical and radiographic outcomes of RSL arthrodesis. Purpose  Distal scaphoid excision improves both scaphotrapeziotrapezoidal osteoarthritis and radiocarpal fusion, and excision of the triquetrum is not critical to achieving satisfactory outcomes. Methods  In this retrospective and bicentric investigation, all wrists were managed with RSL fusion for posttraumatic radiocarpal osteoarthritis. A total of 85 patients were included and evaluated at the revision by clinical (pain, wrist motion, and strength), functional (Disabilities of the Arm, Shoulder, and Hand questionnaire, Patient-Related Wrist Evaluation score, and Modified Mayo Wrist Score), and radiological (scaphotrapeziotrapezoidal, midcarpal osteoarthritis, and radiocarpal nonunion) examinations. We assessed prognostic factors for clinical and radiographic (osteoarthritis and nonunions) outcomes. Results  The average follow-up was 9.1 years (1-21.4). Work-related accidents adversely impacted the clinical outcomes, and distal scaphoid excision significantly improved them and decreased scaphotrapeziotrapezoidal osteoarthritis and nonunion. Neither distal scaphoid excision nor excision of the triquetrum influenced midcarpal osteoarthritis. Radiocarpal fusion was significantly promoted by memory staples and bone grafting. Discussion  Distal scaphoid excision should be preferred to improve the functional results while decreasing scaphotrapeziotrapezoidal osteoarthritis and radiocarpal nonunion rates. Excision of the triquetrum appears to be an alternative to radioulnar resection-arthroplasty to solve ulnocarpal impaction syndrome. Strict surgical procedure must be observed to promote RSL fusion combining solid bone fixation and the use of bone graft. Level of evidence  This is a level IV, case series, retrospective series.

Triquetrum Excision in Radioscapholunate Arthrodesis for Posttraumatic Radiocarpal Osteoarthritis With Ulnar Impaction Syndrome

Dependent on fracture type, concomitant carpal injuries, and operative treatment, distal radius fractures can lead to symptomatic radiocarpal osteoarthritis. In addition, radial shortening can cause ulnar impaction syndrome. Radiocarpal arthrodesis and ulnar shortening osteotomy are known and frequently applied surgical procedures for each of those pathologies. There are limited data concerning treatment options for a combined disorder. The presented technique in this article demonstrates that radioscapholunate arthrodesis with distal pole scaphoidectomy and total triquetrum excision successfully treats both symptomatic radiocarpal osteoarthritis and ulnar impaction syndrome without further surgery on the ulna.

The Effect of Radioscapholunate Fusion With and Without Distal Scaphoid and Triquetrum Excision on Capitolunate Contact Pressures

PURPOSE

To determine the effects of motion-increasing modifications to radioscapholunate (RSL) arthrodesis on capitolunate contact pressure in cadaveric wrist specimens.

METHODS

Ten fresh-frozen cadaveric wrists were dissected of all superficial soft tissue, potted in polymethyl-methacrylate, and the carpus exposed via a ligament-sparing capsulotomy. An RSL arthrodesis was simulated using 2 2.4-mm distal radius plates with locking screws. The distal scaphoid pole and triquetrum were removed with an osteotome and rongeur, respectively. Contact area, pressure, and force were measured in the capitolunate joint during the application of a 35-N uniaxial load using pressure-sensitive film. Measurements were obtained before and after simulated RSL fusion, following distal scaphoidectomy and after triquetrectomy.

RESULTS

The combination of RSL fusion with distal scaphoid excision (DSE) increased contact forces in the capitolunate joint by 50% over controls. An RSL fusion, and RSL fusion with DSE and triquetrum excision (TE), exhibited intermediate levels of contact force between controls and RSL fusion with DSE. Capitolunate contact pressures were similar between all experimental groups. Contact area in the capitolunate joint increased by 43% after RSL fusion with DSE over intact specimen controls. Lastly, contact area in wrists with RSL fusion, and RSL fusion with DSE and TE, were elevated, but not significantly different from intact controls.

CONCLUSIONS

A DSE performed at the time of RSL fusion results in increased midcarpal joint contact force and area, with resultant contact pressures unchanged. Triquetrectomy, which has been previously shown to improve range of motion, did not increase contact forces in the capitolunate joint.

CLINICAL RELEVANCE

If a surgeon is contemplating performing an RSL arthrodesis with DSE, we recommend adding a triquetrectomy to improve motion because this does not add to the potentially deleterious effects of increased midcarpal contact force.

A blinded, randomized trial comparing bicolumnar arthrodesis to radioscapholunate arthrodesis in scapholunate advanced collapse II arthritis: a pilot study

The purpose of this study was to compare the outcome of scaphoid excision with capitolunate and triquetrohamate arthrodesis (bicolumnar arthrodesis) to radioscapholunate arthrodesis in patients with scapholunate advanced collapse (SLAC) II wrist arthritis. Twelve patients with symptomatic SLAC II arthritis were recruited and randomized to receive either bicolumnar arthrodesis or radioscapholunate arthrodesis. The primary outcome was wrist function as assessed by the patient rated wrist evaluation. Secondary outcomes included range of motion, grip strength and the Mayo wrist score. A linear mixed-effects model was used to evaluate the effects of bicolumnar arthrodesis and radioscapholunate arthrodesis in treating SLAC II arthritis. Patients receiving bicolumnar arthrodesis had more improvement in their wrist function compared with patients receiving radioscapholunate arthrodesis. A high rate of re-operation was observed in patients receiving radioscapholunate arthrodesis. In SLAC II arthritis, the expected benefit of preserving the midcarpal joint was not observed. Scapholunate ligament disruption makes radioscapholunate arthrodesis a technically challenging operation.

LEVEL OF EVIDENCE

I.

Radioscapholunate fusion with triquetrum and distal pole of scaphoid excision: long-term follow-up

The purpose of this study was to assess the long-term outcomes of radioscapholunate fusion, with and without distal pole of scaphoid excision and excision of the triquetrum. These compromised three operative groups. Seventeen patients were identified with a minimum of 10 years follow-up, with a mean of 15 years (range 10-19). Fifteen of the 17 patients were satisfied with their outcome. Two were converted to total wrist fusion. The mean outcomes scores were; pain visual analogue scale score 2.1/10, Quick Disabilities of the Arm, Shoulder, and Hand 29 and Modified Mayo Wrist score 60. Patients with excision of the triquetrum had a mean radial-ulnar arc increase of 10° compared with the other two groups, but this was not statistically significant. The mean space for the scaphocapitate joint was 1.7 mm and lunocapitate joint was 1.3 mm at latest follow-up. Close adherence to the indications and surgical technique provided a sustainable good clinical outcome. Patients who obtained a good result at 2 years were likely to achieve a good long-term outcome.

LEVEL OF EVIDENCE

IV.

Clinical and radiological outcomes following radioscapholunate fusion

INTRODUCTION

Radioscapholunate (RSL) fusion is typically performed following wrist trauma. It addresses the pain caused by radiocarpal osteoarthritis but reduces the wrist's mobility. The objective of this study was to determine the long-term clinical and radiological outcomes of this procedure.

MATERIALS AND METHODS

This was a retrospective study of all wrists operated for RSL fusion in our surgery unit over a 12-year period. The clinical analysis consisted of joint amplitudes, grip strength, pain (VAS) and functional scores (PRWE, QuickDash, Mayo Wrist Score). The radiological analysis focused on bone fusion and the presence of midcarpal osteoarthritis.

RESULTS

This surgery procedure was performed on 48 wrists. Of these, 34 patients were available for review, including 6 who had subsequently undergone total wrist fusion after the RSL procedure. The average follow-up was 53 months. Flexion/extension and radioulnar deviation were 56° and 30°, respectively. Grip strength in the operated wrist was 71% of the contralateral wrist. The mean pain level was 3 out of 10. The PRWE, QuickDash and Mayo Wrist Score were 35.7, 44.5 and 57.2, respectively. Seventy-nine percent of patients were satisfied with the outcome. The fusion rate was 71%, the midcarpal osteoarthritis rate was 64% and the STT osteoarthritis rate was 46%.

DISCUSSION

Reduced wrist range of motion in patients who have undergone RSL fusion helps to preserve satisfactory function in the majority of patients; however, the functional outcome scores point to some hindrance in day-to-day activities. Nonunion occurred in nearly one-quarter of patients and appears to be preventable by excision of the distal pole of the scaphoid (DPS). Midcarpal osteoarthritis develops in most wrists over the long-term and appears to be inevitable.

CONCLUSION

RSL fusion is a palliative procedure that preserves some of the wrist's mobility. However, it is a difficult procedure that has a significant nonunion rate. Excision of the DPS may contribute to lowering the nonunion rate.

Volar Radioscapholunate Arthrodesis and Distal Scaphoidectomy After Malunited Distal Radius Fractures

PURPOSE

The purpose of this study was to assess range of motion (ROM), pain, and incidence of radiographic degenerative joint disease (DJD) after volar radioscapholunate (RSL) arthrodesis and distal scaphoidectomy (DSE) following malunited distal radius fractures (DRF).

METHODS

Fourteen patients with malunited DRF and DJD limited to the radiocarpal joint underwent RSL arthrodesis and DSE between 2006 and 2014. These were retrospectively analyzed both clinically and radiologically. Eleven patients with a mean follow-up of 63 months (range, 30-97 months) were included in the final analysis because 1 was unavailable and 2 had died. The outcome was evaluated using parameters of pain, ROM, grip strength, nonunion rate, and DJD of the adjacent joints. In addition, self-assessment by patients was registered on the Disability of the Arm, Shoulder and Hand score, Patient-Rated Wrist Evaluation score, and Michigan Hand Outcomes Questionnaire. To investigate DJD and union, a computed tomography (CT) scan at the final follow-up visit was performed.

RESULTS

All patients showed union and no midcarpal DJD in the CT scans at final follow-up. The mean ROM in extension was 53°, flexion 42°, supination 81°, pronation 85°, radial deviation 10° and ulnar deviation 25°. The ROM in extension, extension/flexion arc, and supination improved significantly after surgery. Patients achieved a mean of 80% of grip strength compared with the other hand.

CONCLUSIONS

Volar angular stable plate RSL arthrodesis with resection of the distal scaphoid pole is a safe and effective method for treating malunited DRF. This leads to an improved ROM and low pain level.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Artrodesis radio-escafo-lunar. Experiencia en el ámbito laboral

Introducción: La artrodesis radio-escafo-lunar (RSL) es un procedimiento quirúrgico paliativo utilizado para el tratamiento de artrosis radiocarpiana en pacientes con la articulación mediocarpiana preservada. Esta técnica reduce el dolor asociado a la artrosis radiocarpiana y preserva la función de la articulación mediocarpiana.

Material y método: Se realizó un estudio descriptivo retrospectivo, de una serie de 45 pacientes intervenidos en nuestro hospital desde 2005 a 2015. En todos los casos se llevó a cabo la intervención quirúrgica mediante artrodesis RSL con agujas de Kirschner (AK) e injerto autólogo de cresta ilíaca. Se evaluó la fuerza, rango de movilidad, dolor, tasas de seudoartrosis y de conversión a artrodesis total y el tipo de incapacidad que obtuvo el paciente al final del proceso.

Resultados: Se obtuvo un déficit de fuerza de puño del 49% respecto a la mano contralateral. El rango de movilidad postoperatorio fue de 20° flexión, 25° extensión, 7° desviación radial y 14° desviación ulnar. Se obtuvo un resultado favorable en cuanto a la reducción del dolor, según la escala analógica visual (EVA) posquirúrgica. La tasa de conversión a artrodesis total fue de un 15,5% y el fracaso de consolidación de un 13,3%.

El 83% de los casos obtuvo una incapacidad parcial y el 27% una incapacidad total.

Conclusión: La artrodesis RSL en una técnica quirúrgica paliativa satisfactoria para el tratamiento del dolor que obtiene una tasa de consolidación alta y que mantiene la movilidad de la articulación mediocarpiana. Sin embargo, la mayoría de los pacientes obtienen algún tipo de incapacidad laboral tras su realización.

The treatment of arthritis of the wrist

Arthritis of the wrist is a painful disabling condition that has various causes and presentations. The traditional treatment has been a total wrist fusion at a price of the elimination of movement. However, forms of treatment which allow the preservation of movement are now preferred. Modern arthroplasties of the wrist are still not sufficiently robust to meet the demands of many patients, nor do they restore normal kinematics of the wrist. A preferable compromise may be selective excision and partial fusion of the wrist using knowledge of the aetiology and pattern of degenerative change to identify which joints can be sacrificed and which can be preserved. This article provides an overview of the treatment options available for patients with arthritis of the wrist and an algorithm for selecting an appropriate surgical strategy.

RSL Fusion with Excision of Distal Scaphoid and Triquetrum: A Cadaveric Study

Radioscapholunate (RSL) fusion has been utilized for treatment of radiocarpal arthritis for patients with an intact midcarpal joint. This preserves midcarpal joint motion while alleviating pain. Dart thrower's motion (DTM), which has been emphasized recently, is mainly a midcarpal joint motion. Question A cadaveric study was designed to measure and compare the range of motion (ROM) of the human wrist before and after an RSL fusion, followed by distal scaphoid excision, and finally excision of the triquetrum. Methods Twelve embalmed adult cadaveric upper limbs were assessed. The wrist motion was measured with an electrogoniometer. Measurements of the flexion-extension plane and radial-ulnar deviation plane were obtained for baseline after capsulotomy, after simulated RSL fusion with memory staples, after distal scaphoidectomy, and after excision of the triquetrum. Results The effects of scaphoid and triquetrum excision were expressed as improvements in movement over that of the preceding step. RSL fusion alone resulted in a decrease of the flexion-extension (F-E) arc by 36% and the radioulnar deviation (R-U) arc by 30%. Excision of the distal scaphoid with RSL improved the F-E arc by 34% and the R-U arc by 34%. With excision of the triquetrum, the F-E arc improved further by 13% and the R-U arc by 21%. The ROM of the simulated RSL fusion with distal scaphoidectomy is improved with excising the triquetrum, mainly through an increase in ulnar deviation motion. RSL fusion with distal scaphoidectomy and triquetrectomy can be an alternative to total wrist arthrodesis for patients with an intact midcarpal joint.

Vascularized graft from the metatarsal base for reconstructing major osteochondral distal radius defects

PURPOSE

To present our experience of reconstructing distal radius articular defects with a vascularized osteochondral graft from the metatarsal base and to present the mid-term outcomes.

METHODS

Seven patients (average age, 36 y; range, 26-55 y) who had reconstruction of major defects of the articular surface of the radius are presented. In 5, the lunate facet and sigmoid notch were reconstructed; in 1, an isolated defect on the surface of the lunate facet was reconstructed; and in 1, the scaphoid facet was reconstructed. In 6, the base of the third metatarsal was transferred, and in 1, the base of the second was transferred.

RESULTS

All flaps survived without complications. At the latest follow-up (range, 20 mo to 8 y), the flexion-extension arc improved an average of 50°, and the pain on a visual analog scale decreased from 8 to 1 on average. Disabilities of the Arm, Shoulder, and Hand score improved from 54 to 11 on average. One patient did not improve. No major complaints related to the donor site were mentioned (average American Orthopedic Foot and Ankle Society score of 96/100).

CONCLUSIONS

Our mid-term results are promising; however, the decision-making process and the operation are complex. The operation is not indicated when the carpals are devoid of cartilage or when the defect involves the whole radius surface.