Robotic transversus abdominis release (TAR) for ventral hernia repairs is associated with low surgical site occurrence rates and length of stay despite increasing modifiable comorbidities

PURPOSE

Modifiable comorbidities (MCMs) have previously been shown to complicate postoperative wound healing occasionally leading to surgeon hesitancy to repair ventral hernias prior to preoperative optimization of comorbidities. This study describes the effects of MCMs on surgical site occurrences (SSOs) and hospital length of stay (LOS) following robotic transversus abdominis release (TAR) with poly-4-hydroxybutyrate (P4HB) resorbable biosynthetic mesh retromuscular sublay for ventral hernia repair in patients who had not undergone preoperative optimization.

METHODS

A single-surgeon retrospective review was performed for patients who underwent the robotic TAR procedure with P4HB mesh between January 2015 and May 2022. Patients were stratified by the amount of MCMs present: 0, 1, or 2 + . MCMs included obesity, diabetes, and current tobacco use. Patient data was analyzed for the first 60 days following their operation. Primary outcomes included 60-day SSO rates and hospital LOS.

RESULTS

Three hundred and thirty-four subjects met the inclusion criteria for SSO and prolonged LOS analysis. 16.8% had no MCM, 56.1% had 1 MCM, and 27% had 2 + MCMs. No significant difference in SSO was seen between the 3 groups; however, having 2 + MCMs was significantly associated with increased odds of SSO (odds ratio 3.25, P = .019). When the groups were broken down, only having a history of diabetes plus obesity was associated with significantly increased odds of SSO (odds ratio 3.54, P = .02). No group showed significantly increased odds of prolonged LOS.

CONCLUSION

2 + MCMs significantly increase the odds of SSO, specifically in patients who have a history of diabetes and obesity. However, the presence of any number of MCMs was not associated with increased odds of prolonged LOS.

Radially Displaced Perilunate Injuries: A Report of Two Cases

We present two unusual cases of radially displaced perilunate dislocations, one of which involved acute ulnar nerve compression requiring Guyon's canal release. The first case underwent closed reduction and cast immobilization but developed scapholunate instability, necessitating secondary ligament reconstruction. The second case, treated with open reduction and fixation, resulted in persistent volar intercalated segment instability of the proximal row and ulnar nerve paresthesia 1 year after surgery.

Carpal Instability Nondissociative Following Acute Wrist Fractures

PURPOSE

Carpal malalignment following intra-articular fractures has been reported in the literature, with no clear description of possible ligamentous injury leading to the radiological appearance. This study presents a series of patients that developed carpal instability nondissociative (CIND) following acute wrist fractures. The mechanism of injury is postulated by using a cadaveric laboratory investigation.

METHOD

Twelve patients with average age of 32 years were identified with CIND, between 2013 and 2018. Ten patients with a normal carpal alignment in the initial postoperative radiographs exhibited CIND-palmar radiographically at different postoperative periods, and 2 patients showed CIND-dorsal in the initial postoperative x-rays. Four cadaveric specimens were used to validate this injury pattern.

RESULTS

In cadaveric dissections, CIND-palmar could be reproduced by applying an axial loading and dorsal shearing force on a wrist with sequential sectioning of dorsal and palmar extrinsic wrist ligaments. For the intra-articular fractures with CIND-dorsal, the cause is likely a result of volar radiocarpal extrinsic ligament injury combined with intra-articular incongruity of the scaphoid fossa. Eight out of the 12 patients had severe wrist pain and underwent additional surgery. Three patients with reducible CIND-palmar had open capsular repair, and 5 patients with fixed nonreducible malalignment were treated with radioscapholunate arthrodesis. At an average follow-up of 2.3 years, pain relief was noted, together with an improvement in grip strength and range of movement. Radiographically, the wrist alignment was corrected and maintained.

CONCLUSIONS

This article highlights the existence of possible concomitant radiocarpal ligament lesions and residual articular incongruity, associated with acute intra-articular fractures and radiocarpal fracture-dislocations, that destabilize the proximal carpal row into a pattern of nondissociative carpal instability. Early detection of this condition may preserve wrist function by capsular repair, whereas cases with fixed deformity and residual joint incongruity may be best managed with a limited radiocarpal arthrodesis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Dorsal Barton fracture is a variation of dorsal radiocarpal dislocation: a clinical study

Dorsal Barton fractures may be better described as variants of dorsal radiocarpal dislocations. We aimed to better characterize these fractures by reviewing 111 patients in the ICUC® dataset who had a dorsally displaced, intra-articular distal radius fracture. We identified 13 patients with a dorsal Barton fracture on radiographs (dorsal articular margin fracture with radiocarpal subluxation and intact volar cortex). All patients with a dorsal Barton fracture had radial styloid involvement and volar cortical disruption that was subsequently identified on three-dimensional CT. Based on three-dimensional CT and intra-operative findings, none of the patients had classically described dorsal Barton fractures. All patients were treated using a volar exposure. A volar capsular tear was identified intra-operatively in three patients and the volar capsule repaired. This series supports the contention that dorsal Barton fractures are better characterized and treated as a variation of a dorsal radiocarpal dislocation. Level of evidence: IV.

Midterm Outcomes of the Use of a Spherical Ulnar Head Prosthesis for Failed Sauvé-Kapandji Procedures

PURPOSE

The use of a spherical ulnar head prosthesis (UHP) for the treatment of symptomatic radioulnar convergence after Sauvé-Kapandji (SK) procedure has shown promising results in the short term. This study aims to evaluate the midterm outcome of the original cohort of patients treated with this technique.

METHODS

Seventeen patients with unstable ulnar stumps confirmed both clinically and radiographically were studied. The etiology for the initial SK procedure included posttraumatic distal radioulnar joint (DRUJ) incongruity, primary DRUJ arthrosis, and dysplastic DRUJ. Fourteen of the 17 patients had a minimum of 2, and a maximum of 6, operations prior to having a spherical UHP. All patients suffered from severe pain with difficulty in performing work and daily activities. Ceramic UHP was used for all patients, except 2 in whom a cobalt chrome head was used.

RESULTS

The average follow-up was 6 years (range, 4-17 years). A marked reduction in pain was observed with 11 patients reporting that they remained pain free. The range of motion of the wrist and power grip was maintained and showed a statistically significant improvement at the late follow-up. The Disabilities of the Arm, Shoulder, and Hand score also significantly improved from 77 to 41. There were no signs of prosthetic loosening at the midterm follow-up. The 2 patients with cobalt chrome prostheses had pain and osteolysis requiring revision to total DRUJ prosthesis. Two patients with dorsal prosthetic subluxation were successfully treated with distal radial osteotomy.

CONCLUSIONS

The midterm results of ceramic spherical UHP for failed SK procedures in this small patient series are encouraging.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Current Perspectives on Complex Wrist Fracture-Dislocations

Although perilunate injuries represent only 5% of all carpal injuries, they compose a spectrum of devastating complex wrist injuries. Perilunate injuries result from high-energy trauma to the wrist and may be associated with multiple fractures, dislocations, and ligament injuries. Although the diagnosis of a perilunate injury is made via radiographic assessment, missed diagnosis occurs in 25% of patients with a perilunate injury. Immediate diagnosis of perilunate injuries is critical to optimize patient outcomes. Closed reduction of perilunate injuries is performed to avoid permanent damage to the median nerve and other compromised structures. As swelling subsides, open reduction is performed to restore anatomic alignment, attain stable fixation, and repair the ligaments. Despite optimal management of perilunate injuries, complications, including median nerve dysfunction, complex regional pain syndrome, carpal instability, and late posttraumatic arthritis, may occur. Satisfactory outcomes can be achieved in patients with a perilunate injury via prompt recognition and timely surgical management. Although radiographic signs of arthritis develop in many patients with a perilunate injury, these radiographic signs do not necessarily correlate with functional outcomes. Some patients with a perilunate injury require salvage procedures for the management of persistent complications. Radiocarpal fracture-dislocations are a complex wrist fracture-dislocation pattern. Radiocarpal fracture-dislocations generally result from high-energy trauma and are characterized by a carpal dislocation, which usually involves a small portion of the rim of the dorsal or volar aspect of the distal radius. Neurologic dysfunction and elevated intracompartment pressure may be present in patients with a radiocarpal fracture-dislocation. Wrist fracture-dislocations are associated with a number of complications, including intercarpal instability, later arthrosis, carpal nonunion, and loss of radiocarpal mobility.

Nonunion of greater trochanter following total hip arthroplasty: Treated by an articulated hook plate and bone grafting

BACKGROUND

Trochanteric osteotomy still has an important role in hip arthroplasty in cases of (1) preexisting developmental hip dysplasia with superior subluxation, (2) revision arthroplasty, specifically with acetabular component revision in the face of well-fixed femoral component, and (3) recurrent dislocation without component loosening or malalignment, in treatment of complicated trochanteric fixation in osteoporotic bone and nonunions may be difficult. This study reports the clinical outcomes of trochanteric fixation following total hip arthroplasty (THA) utilizing a hook plate construct in a cohort of ten patients.

MATERIALS AND METHODS

The Arbeitsgemeinschaft für Osteosynthesefragen (AO) articulated hook plate was used in nine cases of established approach related nonunion following THA and in one case of osteopenic bone during primary THA. All ten patients returned for interviews and clinical examination. The average time for clinical followup was 35 months (range 5-48 months). The mean age of the study cohort was 65 years (range 56-74 years). Time to union and incidence of postoperative complications were assessed.

RESULTS

Union occurred in all ten cases at an average of 3.3 months postoperatively. One patient developed symptomatic trochanteric bursitis and required plate removal. Another patient developed a superficial infection which was successfully treated with local wound debridement and antibiotics. A third patient developed a symptomatic neuroma at the site of the iliac crest bone harvest and was successfully treated with excision of the neuroma. No catastrophic implant failures occurred.

CONCLUSIONS

The articulated design of the plate allows for ease in application and functional construct stability. The articulated hook plate is an option for fixation of osteopenic bone fragments and established nonunions of the greater trochanter.

DVR plating of distal radius fractures

Volar plating has become the standard of care for most distal radius fractures. When done for the right indication and with adequate mastering of the technique complication ratio is low. The concept of subchondral support is key in this technique. Osteoporotic patients will especially benefit from this type of fixation which allows early immobilization, quick return to activities of daily living and early good outcome.

A less invasive distal osteotomy of the radius for malunited dorsally displaced extra-articular fractures

A less invasive corrective osteotomy for symptomatic post-traumatic deformity of the distal radius was done in 12 patients. They were followed up for an average of 3.7 years. The indications for correction were based on the patients' level of activities, pain, functional limitations, loss of grip strength or deformity occurring with an extra-articular rotational malunion of the distal end of the radius. The procedure included a dorsal open wedge osteotomy through a dorsal incision in which the fulcrum of rotation, or hinge, was located at the palmar cortex, and stabilized with an extra- and intramedullary fixed angle device. The bone defect was replaced with autologous morsellized iliac bone graft. The final outcome was graded as very good in eight patients, good in two and fair in two. Level of evidence: IV.

Chronic scapholunate instability treated with temporary screw fixation

PURPOSE

To determine the efficacy of scapholunate (SL) temporary screw fixation to maintain the reduction of SL interval after ligament debridement, repair, or reconstruction.

METHODS

A total of 36 patients who had chronic SL instability were included. Arthroscopic debridement was performed for dynamic instability, and primary repair or reconstruction of the SL ligament was performed for static instability. We then used SL screw fixation for the protection of the repair or reconstruction. Screws were removed when loosening was noted on x-ray.

RESULTS

The average patient age was 43 years. Eleven had dynamic instability, and 25 had static instability. The average follow-up was 7.9 years. Nearly 95% of the patients had no more than mild pain. The average ranges of movement of the wrist were 55° extension, 51° flexion, 26° ulnar deviation, and 15° radial deviation. Postoperative x-ray revealed an average SL angle of 56°. The average SL gap was 2.5 mm. Both of these radiographic parameters were maintained at final follow-up. Dorsal intercalated segmental instability (DISI) deformity was not corrected in 2 patients. One patient had avascular changes in the proximal scaphoid and lunate but remained asymptomatic at 7 years postoperatively. There was no further intercarpal and radiocarpal degeneration.

CONCLUSIONS

Temporary SL screw fixation together with arthroscopic debridement, ligament repair, or reconstruction provided a stable closure of the SL interval and satisfactory clinical and functional results along with a low incidence of complication.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Rupture of the flexor digitorum superficialis at the musculotendinous junction due to a forearm fracture: a case report

We present a case of a closed distal-third forearm fracture, in which the flexor digitorum superficialis was found ruptured at its musculotendinous junction. We diagnosed the ruptured tendon during the exploration of the ulnar nerve for observed preoperative palsy. Although there are numerous reports about avulsions at the bony insertions, there are very few about avulsion at the musculotendinous junction in the literature. This consideration leads to the conclusion that this kind of rupture may be more frequent than recognized.

Volar plate fixation of intra-articular distal radius fractures: a retrospective study

Background Intra-articular fractures of the distal radius represent a therapeutic challenge as compared with the unstable extra-articular fractures. With the recent development of specifically designed internal fixation materials for the distal radius, treatment of these fractures by fragment-specific implants using two or more incisions has been advocated. Purpose The purpose of this study was to investigate the efficacy of a fixed-angle locking plate applied through a single volar approach in maintaining the radiographic alignment of unstable intra-articular fractures as well as to report the clinical outcomes. We only excluded those with massive comminution, as is discussed in greater detail in the text. Patients and Methods This is a multicentered, retrospective study involving three hospitals situated in Spain, Switzerland, and the United States. In the period between January 2000 and March 2006, 97 patients with 101 intra-articular distal radius fractures, including 13 volarly displaced and 88 dorsally angulated fractures were analyzed. Over 80% were C2/C3 fractures, based on the AO classification. 16 open fractures were noted. Results With an average follow-up of 28 months (range 24-70 months), the range of movement of the wrist was very satisfactory, and the mean grip strength was 81% of the opposite wrist. The Disabilities of the Arm, Shoulder, and Hand (DASH) score was 8. The complications rate was < 5%, including loss of reduction in two patients. All fractures healed by 3 months postinjury. Conclusions Irrespective of the direction and amount of initial displacement, a great majority of intra-articular fractures of the distal radius can be managed with a fixed-angle volar plate through a single volar approach. Level IV retrospective case series.

Corrective osteotomy for combined intra- and extra-articular distal radius malunion

PURPOSE

This study evaluated the functional outcome of corrective osteotomy for combined intra- and extra-articular malunions of the distal radius using multiple outcome scores.

METHODS

We evaluated 18 skeletally mature patients at an average of 78 months after corrective osteotomy for a combined intra- and extra-articular malunion of the distal part of the radius. The indication for osteotomy in all patients was the combination of an extra-articular deformity (≥ 15° volar or ≥ 10° dorsal angulation or ≥ 3 mm radial shortening) and intra-articular incongruity of 2 mm or greater (maximum stepoff or gap), as measured on lateral and posteroanterior radiographs. The average interval from the injury to the osteotomy was 9 months. The average maximum stepoff or gap of the articular surface before surgery was 4 mm.

RESULTS

All 18 patients healed uneventfully and the final articular incongruity was reduced to 2 mm or less. Final range of motion and grip strength significantly improved, averaging 89% and 84% of the uninjured side and 185% and 241% of the preoperative measures, respectively. The rate of excellent or good results was 72% according to the validated rating system Mayo Modified Wrist Score, and 89% according to the unvalidated system of Gartland and Werley. The mean Disabilities of the Arm, Shoulder, and Hand score was 11, which corresponds to mild perceived disability. Of the 18 cases, 11 normalized upper limb function. Five patients had complications; all were successfully treated. According to the rating system of Knirk and Jupiter, 4 had grade 1 and 1 had grade 2 osteoarthritis of the radiocarpal joint on radiographs. Two of those patients reported occasional mild pain. Radiographic osteoarthritis did not correlate with strength, motion, and wrist scores.

CONCLUSIONS

Outcomes of corrective osteotomy for combined intra- and extra-articular malunions were comparable to those of osteotomy for isolated intra- and extra-articular malunions. A successful corrective osteotomy for the treatment of complex intra- and extra-articular distal radius malunions can improve wrist function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Scaphocapitolunate arthrodesis and radial styloidectomy for posttraumatic degenerative wrist disease

Long-standing scaphoid nonunion, scaphoid malunion, and chronic scapholunate dissociation result in malalignment of the carpal bones, progressive carpal collapse, instability, and osteoarthritis of the wrist. The most commonly used procedures to treat scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC) wrists are the four-corner fusion (4CF) and the proximal row carpectomy (PRC). The purpose of this study was to evaluate the clinical outcome of a different treatment modality: radial styloidectomy and scaphocapitolunate (SCL) arthrodesis. This treatment option is chosen in an effort to maintain the joint contact surface and load transmission across the radiocarpal joint. We conducted a retrospective review of 20 patients (average age 62 years, range: 27 to 75 years) treated from 1994 to 2010. Seven patients were treated for SNAC, 12 patients for SLAC wrists, and 1 for degenerative joint disease following a transscapho-transcapitate perilunar dislocation. Sixteen patients had Herbert screw fixation, and four had Spider plate fixation. All patients had autologous bone graft used for the arthrodesis. The mean follow-up was 4.6 years (range: 2 to 9.6 years). Patients were evaluated clinically and radiographically. Nineteen of 20 arthrodeses healed on an average of 9.6 weeks. One patient was reoperated 8 months after the initial operation with salvage of the SCL arthrodesis with a spider plate with an adequate result. The mean active flexion-extension arc was 70 degrees and the radioulnar deviation arc was 23 degrees. Pain decreased in all patients, 13 of whom were pain free postoperatively. The average postoperative disabilities of arm, shoulder, and hand score was 24. Radiographically, neither radiolunate nor radioscaphoid arthritis was noted on follow-up. SCL arthrodesis with radial styloidectomy resulted in an adequate residual range of motion and pain relief. This method preserves the normal ulnar sided joints of the carpus and maintains a more physiologic joint surface for radiocarpal load sharing.

Salvage of failed resection arthroplasties of the distal radioulnar joint using an ulnar head prosthesis: long-term results

PURPOSE

The aim of this prospective multicenter study was to evaluate the long-term outcome of the Herbert ulnar head prosthesis for painful instability of the distal radioulnar joint (DRUJ) following resection of the ulnar head.

METHODS

Twenty-three patients were treated with a Herbert ulnar head prosthesis in 3 international hand centers. One patient was excluded from the study because a septic prosthesis had to be removed after 3 months. Sixteen of the remaining 22 patients could be assessed at 2 follow-up times, 28 months (range, 10-43 mo) and 11 years and 2 months (range, 97-158 mo) after surgery, for DRUJ stability, forearm rotation, grip strength, pain level (0-10), and satisfaction (0-10). Standardized radiographs of the wrist were evaluated for displacement of the ulnar head and loosening or bony reactions at the sigmoid notch or the ulna shaft.

RESULTS

All patients demonstrated a clinically stable DRUJ at the latest examination, and no patient required further surgery at the DRUJ since the short-term evaluation in 1999. Average pain measured 3.7 before surgery, 1.7 at the short-term follow-up, and 1.7 at the long-term follow-up; patients' satisfaction, 2.2, 8.2, and 8.9; pronation, 73°, 86°, and 83°; supination, 52°, 77°, and 81°; and grip strength, 42%, 72%, and 81% of the unaffected side. All clinical parameters improved significantly from before surgery to the short-term follow-up, with no further statistically significant change between the short-term and long-term follow-up. Radiographs demonstrated no signs of stem loosening or incongruity of the DRUJ.

CONCLUSIONS

The previously reported short-term results with the Herbert prosthesis did not deteriorate in the long term. Reconstruction of the DRUJ with this prosthesis in painful radioulnar impingement following ulnar head resection is a reliable and reproducible procedure with lasting results.

Fractures of the base of the thumb metacarpal

The thumb trapeziometacarpal joint is a saddle joint that is subject to high compressive forces during prehensile hand function. Fractures to the base of the thumb metacarpal occur commonly following axial load to a partially flexed thumb. Although reduction is easily performed, severe deforming forces act to displace the fractures into a varus and shortened position. Most extra-articular fractures can be treated with closed reduction and cast immobilization. Angulation up to 30 degrees can be tolerated because of the substantial compensatory motion at the thumb carpometacarpal joint. In Bennett fractures, good functional results are observed even with residual deformity and articular incongruity. However, the goal of treatment for intra-articular fractures should be the anatomic reduction of the joint surface with less than 1 mm of articular step-off to minimize the long-term risk of posttraumatic arthritis. Most Bennett fractures can be treated with closed reduction with percutaneous Kirschner wire fixation. Fractures with large Bennett fragments and Rolando fractures should be treated with open reduction and internal fixation to allow anatomic reduction with rigid fixation and early range of motion. Comminuted intra-articular fractures are challenging injuries that are best treated with application of an external fixator with limited open reduction and internal fixation, followed by bone grafting of metaphyseal bone defects if necessary.

Reconstruction of posttraumatic disorders of the forearm

Forearm rotation is crucial for full upper extremity mobility. The two-bone unit with its proximal and distal radioulnar joints should be considered as a single bicondylar articulation. After a traumatic bony forearm injury, surgical treatment for complications, such as deformity, bone loss, or failed fracture healing is challenging because complete return of forearm rotation can be difficult to achieve. It is important to be aware of methods for assessing and managing posttraumatic forearm bony complications, including preoperative assessment and osteotomy techniques for malunited fractures. The vascularized fibular transplant also has been proven as an effective treatment method. Although nonunion of forearm fractures is uncommon, it can prove problematic; therefore, it is beneficial to review options for surgical management.

Bone-tissue-bone repairs for scapholunate dissociation

Scapholunate dissociation is a commonly seen and treated form of carpal instability. Several surgical options have been used for the repair of scapholunate instability over the past 50 years. These have included benign neglect, reduction and percutaneous pinning, primary repair, partial fusions, tendon weaves, and combinations of these. Recent advancements in scapholunate repair and anatomy have been aimed at a more physiologic repair. Composite replacement of the entire scapholunate interval, similar to other tendon repairs seen in orthopedic surgery, has become popular. Bone-tissue-bone (BTB) autograft replacement from the foot has been used but the problems of a secondary surgical site have resulted in other graft site selections. Currently more commonly used grafts are bone-retinaculum-bone, third or second metacarpal-carpal bone, or hamate-capitate grafts, all performed with or without screw augmentation. Vascularized autograft replacement on pedicled grafts from the hand is being explored. This review discusses the surgeons' indications and technical details of the surgery. The lack of long-term outcome measurements for these BTB surgeries makes it difficult for the hand surgeon to determine the appropriate use of these treatment modalities, but early reports have indicated that the BTB graft will be an important part of scapholunate dissociation treatment.

"Wrap around" pedicled muscle flaps for the treatment of recurrent forearm synostosis

Three proximal and 2 mid shaft recurrent radioulnar synostoses were managed with a "wrap around" vascularized muscle interposition after excision of the heterotopic bone. A proximally pedicled brachioradialis flap was used for the proximal forearm and elbow synostoses, and the flexor carpi ulnaris muscle was used for the midshaft area. Anatomy of the flaps and the technical details of each procedure are thoroughly described. After a mean follow-up period of 8 years (range 3-14 years), there were no recurrences. The functional outcome regarding forearm rotation, elbow motion, and working capacity was highly satisfactory in all 5 patients.

Treatment of failed Sauvé-Kapandji procedures with a spherical ulnar head prosthesis

Radioulnar convergence is a painful complication after a Sauvé-Kapandji procedure, with a reported incidence of 13% to 39%. We evaluated 10 patients with painful radioulnar convergence treated with a spherical ulnar head prosthesis proximal to the radioulnar fusion mass. At a mean follow-up of 2.6 years, patients were evaluated clinically and radiographically to determine whether an ulnar head replacement could restore forearm stability, prevent radioulnar convergence, and reduce pain. Postoperatively, no patient had subjective complaints of radioulnar convergence or clinical signs of distal ulnar instability. Pain had improved in all patients. Grip strength, expressed as a percentage of the uninjured hand, improved on average from 27% to 55%. Range of motion improved in seven patients, worsened in two and remained the same in one. Nine of 10 patients returned to their previous occupation with an average working capacity of 76%. The prosthesis was stable radiographically in all patients. Complications included two fractures of the radioulnar fusion mass and the development of painful periprosthetic calcifications in one patient. Placement of a spherical ulnar head prosthesis after a Sauvé-Kapandji procedure provides adequate early results for patients with painful radioulnar convergence.

LEVEL OF EVIDENCE

Therapeutic study, level IV (case series).

Closed manipulation and casting of distal radius fractures

Closed reduction and cast treatment of distal radius fractures renders satisfactory results in fractures that are reducible and stable and do not re-displace in plaster in the first 2 weeks following reduction. Intra-articular and unstable fractures have a high risk for re-displacement in plaster and therefore represent a contraindication for cast treatment. A fracture that re-displaces in plaster despite perfect casting technique is most probably an unstable type that requires skeletal fixation. A fracture that re-displaces in a non-molded, loose, or over-padded cast because of insufficient technique is, however, in the author's view, the only clinical situation in which re-manipulation is worth the effort. The tolerable amount of residual deformity has been radiographically defined by Fourrier et al in an analysis of 64 malunions of the distal radius and correlated the functional impairment with the residual deformity of the distal radius. They concluded that the lower limits of deformity, at which symptoms are likely to be present, area radial deviation of 20-30 degrees, a sagittal tilt of 10-20 degrees, and a radial shortening of 0-2 mm. In addition, experimental evidence suggests that a sagittal tilt of 20-30 degrees should be viewed as a pre-arthrotic condition. Although these figures are useful for decision making, acceptance of deformity when treating fractures conservatively varies individually according to the age, osteoporosis, and functional demands of the patient. Anatomic restoration, however, should remain the primary goal of conservative management.

Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius

BACKGROUND

The purpose of the present study is to report on a cohort of patients with a volar shearing fracture of the distal end of the radius in whom the unique anatomy of the distal cortical rim of the radius led to failure of support of a volar ulnar lunate facet fracture fragment.

METHODS

Seven patients with a volar shearing fracture of the distal part of the radius who lost fixation of a volar lunate facet fragment with subsequent carpal displacement after open reduction and internal fixation were evaluated at an average of twenty-four months after surgery. One fracture was classified as B3.2 and six were classified as B3.3 according to the AO comprehensive classification system. All seven fractures initially were deemed to have an adequate reduction and internal fixation. Four patients required repeat open reduction and internal fixation, and one underwent a radiocarpal arthrodesis. At the time of the final follow-up, all patients were assessed with regard to their self-reported level of functioning and with use of Sarmiento's modification of the system of Gartland and Werley.

RESULTS

At a mean of two years after the injury, six patients had returned to their previous level of function. The result was considered to be excellent for one patient, good for four, and fair for two. The average wrist extension was 48 degrees, or 75% of that of the uninjured extremity. The average wrist flexion was 37 degrees, or 64% of that of the uninjured extremity. The one patient who underwent radiocarpal arthrodesis had achievement of a solid union. The four patients who underwent repeat internal fixation had maintenance of reduction of the lunate facet fragment. The two patients who declined additional operative intervention had persistent dislocation of the carpus with the volar lunate facet fragment.

CONCLUSIONS

The stability of comminuted fractures of the distal part of the radius with volar fragmentation is determined not only by the reduction of the major fragments but also by the reduction of the small volar lunate fragment. The unique anatomy of this region may prevent standard fixation devices for distal radial fractures from supporting the entire volar surface effectively. It is preferable to recognize the complexity of the injury prior to the initial surgical intervention and to plan accordingly.

[Ulnar head prosthesis]

The ulnar head prosthesis has been the subject of a prospective multicenter-study since 1995. Until 2000, it has been used in 57 patients by the study group. In 35 patients, the indication was painful instability of the distal end of the ulna following previous resection arthroplasties, and in 22 patients it was painful arthritis of the distal radioulnar joint (DRUJ). The mean follow-up was 38 months. Pronation increased from a preoperative mean of 63 degrees to a postoperative value of 78 degrees, while supination increased from 43 degrees to 76 degrees. Grip strength improved from a preoperative mean of 51% to a postoperative mean of 77% of the opposite limb. Pain, measured on the verbal pain scale (1-4), was reduced remarkably from a preoperative mean level of 3.6 to a postoperative mean of 1.7. Patient' satisfaction was evaluated using the visual analog scale (0-10) and improved from a preoperative mean of 2.1 to a postoperative mean of 7.9. With one exception of loosening, we consistently found bony integration of the shaft of the prosthesis. Stability of the DRUJ was achieved in all but three patients. This method has given reliable and excellent results as a salvage procedure for failed resection arthroplasties of the DRUJ with painful instability of the distal end of the ulna. We consider the method an alternative treatment option for the arthritically destroyed DRUJ. Sufficient soft tissue to stabilise the prosthesis is needed to successfully reconstruct the DRUJ.

Nonunion of distal radius fractures

Nonunion of a distal radius fracture is extremely uncommon. Healing problems in the distal radius seem to be related to unstable situations, such as concomitant fracture of the distal radius and ulna, and to an inadequate period of immobilization. Nonunion should be suspected if there is continuing pain after remobilization of the wrist in combination with a progressing deformity. The diagnosis may be confirmed by showing movement at the fracture site on lateral radiographs of the wrist in flexion and extension. Because of the rarity of distal radius fracture nonunion, it is not surprising that there is no consensus on the optimum mode of operative treatment. Based on our experience with reconstruction surgery in 23 patients, we think that most nonunions of the distal radius are amenable to attempts to re-align and heal the fracture even when the distal fragment is small. Therefore, surgeons should try to preserve even a small amount of wrist motion and reserve wrist fusion as a final resort.

Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient

PURPOSE

Increased incidence of falls and osteoporosis combine to make distal radius fractures a major cause of morbidity for the elderly patient. This report presents our experience treating distal radius fractures in the elderly population using a volar fixed-angle internal fixation plate.

METHODS

We reviewed retrospectively all patients older than 75 years treated during a period of 4 years and 7 months at our centers for unstable distal radius fractures using a volar fixed-angle plate. Postoperative management included immediate finger motion, early functional use of the hand, and a wrist splint used for an average of 3 weeks. Standard radiographic fracture parameters were measured and final functional results where assessed by measuring finger motion, wrist motion, and grip strength.

RESULTS

Of 26 patients that fit the inclusion criteria, we were able to evaluate 23 patients with 24 unstable distal radius fractures for an average of 63 weeks. Final volar tilt averaged 6 degrees and radial tilt 20 degrees, and radial shortening averaged less than 1 mm. The average final dorsiflexion was 58 degrees, volar flexion 55 degrees, pronation 80 degrees, and supination 76 degrees. Grip strength was 77% of the contralateral side. There were no plate failures or significant loss of reduction, although there was settling of the distal fragment in 3 patients (1-3 mm).

CONCLUSIONS

The treatment of unstable distal radius fractures in the elderly patient with a volar fixed-angle plate provided stable internal fixation and allowed early function. This technique minimized morbidity in the elderly population by successfully handling osteopenic bone, allowed early return to function, provided good final results, and was associated with a low complication rate.

Melengestrol acetate blocks the preovulatory surge of luteinizing hormone, the expression of behavioral estrus, and ovulation in beef heifers

We tested the hypothesis that melengestrol acetate (MGA), an orally active progestin, blocks estrus and the preovulatory surge of luteinizing hormone (LH) in beef heifers. Cycling yearling Angus heifers were divided randomly into two groups: MGA-treated (n = 6) and control (n = 5). All heifers received injections of prostaglandin F2alpha (PGF) on d -25, -11, and 0 to synchronize estrus. Following the last PGF injection on d 0, heifers were fed either 0.5 mg MGA in a carrier or the MGA carrier each day for 8 d. At 4-h intervals on d 1 through 6, all heifers were observed for expression of estrous behavior, and blood samples were collected and assayed for LH. Daily blood samples were collected at 0800 on d 1 through 10 and assayed for circulating progesterone concentrations. All control heifers exhibited estrus and a preovulatory surge of LH. In each case, this was followed by increases in circulating concentrations of progesterone indicative of ovulation and normal luteal function. In contrast, none of the MGA-treated heifers exhibited estrus, LH surges, or evidence of ovulation. The results of this experiment show that MGA prevents ovulation in cattle by inhibiting the preovulatory surge of LH.

Open reduction and internal fixation of un-united fractures of the distal radius: does the size of the distal fragment affect the result?

Two cohort populations consisting of 13 patients with an un-united fracture of the distal radius in whom the distal fragment had more than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion and ten patients with an un-united fracture of the distal radius with a smaller distal fragment were compared. There were no preoperative differences with respect to age, gender, interval between injury and index procedure, preoperative amount of radius tilt, ulnar inclination and ulnar variance, or the preoperative function. Independent of the size of the distal fragment in all patients the distal radius was restored to gain bony union and realignment with preservation of some wrist motion. The length of the follow-up period averaged 30 months for the small fragment group compared with 22 months for the large fragment group. Bony union was achieved in 22 patients. One patient out of the large fragment group failed to heal the fracture and had wrist fusion. At the follow-up examination there were no significant differences in the radiological and clinical outcome between the two groups. No differences were seen on total range of motion of forearm supination and pronation with an average of 135 degrees in the large fragment group and 145 degrees in the small fragment group. Wrist motion revealed no significant differences in the flexion-extension arc, averaging 90 degrees in the large fragment group and 83 degrees in the small fragment group. Total range of motion of radial and ulnar deviation of the wrist was similar, averaging 39 degrees in the large fragment group and 43 degrees in the small fragment group. Grip strength averaged 59% compared with the opposite limb for the large fragment group and 67% for the small fragment group. We believe that the results of reconstruction of un-united fractures of the distal end of the radius for patients in whom the distal fragment had less than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion are comparable to the results for patients with a larger distal fragment. Therefore, we believe that surgeons should try to preserve even a small amount of wrist motion and reserve wrist fusion as a final resort.

Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report

Using a volar approach to avoid the soft tissue problems associated with dorsal plating, we treated a consecutive series of 29 patients with 31 dorsally displaced, unstable distal radial fractures with a new fixed-angle internal fixation device. At a minimal follow-up time of 12 months the fractures had healed with highly satisfactory radiographic and functional results. The final volar tilt averaged 5 degrees; radial inclination, 21 degrees; radial shortening, 1 mm; and articular incongruity, 0 mm. Wrist motion at final follow-up examination averaged 59 degrees extension, 57 degrees flexion, 27 degrees ulnar deviation, 17 degrees radial deviation, 80 degrees pronation, and 78 degrees supination. Grip strength was 79% of the contralateral side. The overall outcome according to the Gartland and Werley scales showed 19 excellent and 12 good results. Our experience indicates that most dorsally displaced distal radius fractures can be anatomically reduced and fixed through a volar approach. The combination of stable internal fixation with the preservation of the dorsal soft tissues resulted in rapid fracture healing, reduced need for bone grafting, and low incidence of tendon problems in our study.

Unstable scaphoid fracture nonunion: a medium-term study of anterior wedge grafting procedures

A retrospective review of 37 patients with scaphoid fracture nonunions treated by interpositional bone grafting and internal fixation was conducted at an average follow-up of 5.7 years. Solid radiographic union was achieved in 35 cases. Preexisting avascular necrosis was a major adverse factor for achievement of union and satisfactory outcome. Based on the modified Mayo wrist-scoring system, 15 patients had an excellent result, 11 had a good result, four had a fair result and seven had a poor result. Patients with preexisting degenerative changes had a significantly worse clinical outcome. The vast majority of the patients had satisfactory correction of scaphoid length and the associated dorsal intercalated segment instability (DISI). Although 30 patients showed radiographic evidence of mild or moderate degenerative changes at their latest follow-up, there was no significant progression of arthrosis and the scaphoid nonunion advanced carpal collapse deformity did not progress after healing of the fracture nonunion.

Distal radius fracture: the rationale of a classification

A thorough review of both historical and contemporary classifications of distal radial fractures is presented. Critical analysis of older and newer classifications clearly shows the difficulty of including all the necessary parameters associated to a distal radius fracture in order to comprehensively assess the complexity of the lesion. The author has attempted to simplify the classification of distal radial fractures into five main groups according to the mechanism of injury. It includes the children fracture equivalent, the associated distal radioulnar joint lesions, and provides management recommendations. An alpha-numerical code is also provided for computer documentation.

Scaphoid nonunion and malunion. How to correct deformity

This article reviews the historical evolution of the assessment and understanding of the deformity of the nonunited and malunited scaphoid. The preoperative assessment, planning, and surgical technique for restoration of scaphoid anatomy are described. A brief presentation of our midterm and long term results obtained with interpositional wedge grafting is also discussed.

Corrective osteotomy for symptomatic increased ulnar tilt of the distal end of the radius

Twelve wrists in 10 patients with a mean age of 23.6 years were treated for symptomatic increased ulnar inclination of the joint surface with corrective osteotomy of the radius. Diagnoses included mild ulnar dysplasia, posttraumatic deformity, Madelung's disease, and multiple hereditary exostosis. All patients had radial-sided wrist pain and an ulnarly displaced arc of radioulnar deviation. Preoperative radiographs showed excessive ulnar inclination of the distal radius, ulnar carpal translation, adaptive carpal malalignment, and frequent distal radioulnar joint incongruency. The patients had decreased pain and improved wrist function at a mean of 5.1 years (range, 2-10 years) after surgery. Average radial deviation changed from 3 degrees to 16 degrees and ulnar deviation from 48 degrees to 29 degrees; flexion/extension and pronosupination remained unchanged. Realignment of the wrist was shown radiographically by a change of ulnar inclination of the radius from 33 degrees to 21 degrees, an increase in scaphoid height from 16.4 to 20.4 mm, and reversal of ulnar carpal translation as shown by an increase in lunate-covering ratio of 64% to 77%. Reduction of the ulnar inclination to normal values by corrective radial osteotomy restores a more physiologic range of motion, decreases symptomatic wrist pain, reverts adaptive carpal changes to normal, increases lunate coverage, and may prevent abnormal cartilage overload in the ulnar compartment of the wrist.

Surgical management of delayed union and nonunion of distal radius fractures

Ten patients with malaligned fractures of the distal radius that demonstrated either delayed healing or the development of an atrophic or synovial nonunion on standard radiographs were treated with surgical realignment, stable internal fixation, and autogenous iliac crest bone grafting. All 10 fractures healed with acceptable radiologic alignment within 3 months of the index procedure. After an average follow-up period of 3 years 6 months (range, 2 years to 8 years 6 months) patients had an average of 105 degrees wrist flexion and extension, 145 degrees forearm rotation, and 73% grip strength compared with the opposite limb. In the treatment of malaligned, ununited fractures of the distal radius, specific techniques and implants must be tailored to the deformity of the distal radius and the shape of the distal fragment. A stable, well-aligned wrist with preservation of at least 50 degrees mobility in flexion and extension was achieved in every patient, but the final result was compromised by associated problems in 3 patients.

Neurobiological mechanisms of the onset of puberty in primates

An increase in pulsatile release of LHRH is essential for the onset of puberty. However, the mechanism controlling the pubertal increase in LHRH release is still unclear. In primates the LHRH neurosecretory system is already active during the neonatal period but subsequently enters a dormant state in the juvenile/prepubertal period. Neither gonadal steroid hormones nor the absence of facilitatory neuronal inputs to LHRH neurons is responsible for the low levels of LHRH release before the onset of puberty in primates. Recent studies suggest that during the prepubertal period an inhibitory neuronal system suppresses LHRH release and that during the subsequent maturation of the hypothalamus this prepubertal inhibition is removed, allowing the adult pattern of pulsatile LHRH release. In fact, y-aminobutyric acid (GABA) appears to be an inhibitory neurotransmitter responsible for restricting LHRH release before the onset of puberty in female rhesus monkeys. In addition, it appears that the reduction in tonic GABA inhibition allows an increase in the release of glutamate as well as other neurotransmitters, which contributes to the increase in pubertal LHRH release. In this review, developmental changes in several neurotransmitter systems controlling pulsatile LHRH release are extensively reviewed.

Traumatic and reconstructive problems of the scaphoid

The management of acute scaphoid fractures should be oriented on the concept of fracture stability, ease of reduction, associated ligamentous injury, and risk of impaired blood supply, rather than the direction of the fracture line or location of the fracture within the scaphoid. The lack of predictability of successful fracture union and prognostic discrepancies of historic and contemporary classifications may be related to subtle differences of the internal vascular architecture of each scaphoid. Because the possibility of impaired vascularity is greater with fractures located in the proximal third, stable internal fixation is indicated to provide mechanical stability and fracture surface contact to enhance revascularization. Improved healing rates in a shorter time and earlier rehabilitation with percutaneous techniques of internal fixation have produced a clear shift from classic conservative treatment to internal skeletal fixation. Although the rates of union of well-vascularized nonunions have not been dramatically improved with the use of internal fixation as compared with inlay bone grafting, the restoration of scaphoid anatomy and prevention of malunion and associated carpal collapse with interpositional bone grafting techniques will reduce the risk of osteoarthritis.

Should anatomic reduction be pursued in distal radial fractures?

Two articles on distal radial fractures in young adults are published in this issue of the journal. One reports the results of open reduction and internal fixation with the pi -plate in a group of patients in which the majority of fractures were complex and intraarticular. The other retrospectively assessed 169 fractures with an average follow-up of 4.9 years, based on the radiographic evaluation of the patient's X-rays until discharge and on the answers provided by a patient-based subjective outcome questionnaire. My task has been to comment, criticize and analyse the findings and results reported in both articles, in order to highlight areas of uncertainty and controversy regarding the current management of fractures of the distal radius in the younger age group.

The treatment of complex carpal dislocations by external fixation

This article presents the treatment of complex carpal dislocations and fracture dislocations by external fixation. Twenty-four patients were treated with external fixation after complex carpal trauma. Operative technique, aftertreatment, complications and long-term results are presented and discussed.

Salvage of failed resection arthroplasties of the distal radioulnar joint using a new ulnar head prosthesis

Twenty-three patients with painful instability following total or partial resection of the ulnar head were treated using a new ulnar head prosthesis combined with a simple soft tissue repair. Stability and marked symptomatic improvement were achieved in all patients. With a mean follow-up period of 27 months, this improvement has been maintained in all but 1 patient, whose prosthesis had to be removed because of a low-grade infection. These results suggest that the use of a prosthesis is a satisfactory way to restore stability and relieve secondary symptoms that may be associated with partial or total excision of the ulnar head.

Results of the modified Sauvé-Kapandji procedure in the treatment of chronic posttraumatic derangement of the distal radioulnar joint

We reviewed the results of a modified Sauvé-Kapandji procedure with tenodesis of the flexor carpi ulnaris to the carpus in eighteen patients who had chronic derangement of the distal radioulnar joint. There were fourteen men and four women. The mean supination of the forearm had improved from 16 degrees (range, 0 to 75 degrees) preoperatively to 76 degrees (range, 40 to 90 degrees) at the time of the latest follow-up, and the mean pronation had improved from 42 degrees (range, 0 to 80 degrees) preoperatively to 81 degrees (range, 60 to 90 degrees) at the time of follow-up. Pain relief was satisfactory, and the mean grip strength had improved from 36 percent of that on the unaffected side preoperatively to 73 percent at the time of follow-up. One patient had moderate pain over the ulnar stump associated with residual volar instability of the proximal ulnar segment, and he had a tenodesis of the extensor carpi ulnaris as a second procedure. Another patient had mild instability of the stump only after he had a second operation, which was an excision of a bone mass (ossification) in the resected area. The ulnar stump was stable in sixteen patients. Eight of the eleven patients who had performed heavy manual labor before the injury were able to return to work full-time without restrictions. According to a modification of the wrist-scoring system of the Mayo Clinic, at a mean of four years and two months (range, two years to eight years and four months), six patients had an excellent result; seven, a good result; four, a fair result; and one, a poor result. On the basis of our findings, we believe that the index operation is an excellent salvage procedure for the treatment of chronic posttraumatic derangement of the distal radioulnar joint, especially when nonoperative treatment has been unsuccessful and rotation of the forearm is severely limited.

Corrective osteotomy for malunited, volarly displaced fractures of the distal end of the radius

Twenty-five patients who had had an opening-wedge osteotomy for the treatment of a malunited, volarly displaced fracture of the distal end of the radius were studied retrospectively. The indications for the operation were pain and functional limitations rather than the degree of anatomical deformity. Fifteen patients were men and ten were women; their average age was forty-six years (range, twenty-one to eighty-four years). Preoperative radiographs revealed an average ulnar inclination of 14 degrees, an average ulnar variance of five millimeters, and an average volar inclination of 24 degrees. Extension of the wrist averaged 25 degrees; flexion of the wrist, 53 degrees; supination of the forearm, 41 degrees; and pronation of the forearm, 64 degrees. The average grip strength was a force of seventeen kilograms compared with a force of forty kilograms in the contralateral hand. At an average of sixty-one months (range, eighteen to 114 months) after the osteotomy, supination of the forearm had improved to an average of 69 degrees and pronation had improved to an average of 75 degrees (p < 0.05 for both). Extension of the wrist had improved to an average of 55 degrees, and grip strength had improved to a force of thirty kilograms (p < 0.05 for both). Volar inclination averaged 5 degrees; ulnar variance, zero millimeters; and ulnar inclination, 22 degrees. A reoperation was performed in eleven patients. Seven patients had removal of the hardware only, two had a procedure involving the distal radioulnar joint, one had a procedure because the site of the osteotomy had not healed, and one had a median-nerve release. The functional result was rated as very good in ten patients, good in eight, fair in three, and poor in four.

Fixation methods in contaminated wounds and massive crush injuries of the forearm

This article presents a critical review of the current literature on the stabilization methods of severe open fractures or crush injuries of the forearm. Due to the complexity of the problem, the advantages and disadvantages of the different fixation methods are presented in order to provide the reader with a combination of possibilities for timing and decision-making when confronted with such fractures in clinical practice.

Comparative classification for fractures of the distal end of the radius

As suggested by Muller, a useful classification system for distal radius fractures must consider the severity of the bone lesion and serve as a basis for treatment and for evaluation of outcome. Although these fractures have long been considered to be Colles or Smith's fractures, they have been subjected to extensive scrutiny in order to define fracture morphology and treatment considerations. This review highlights a number of contemporary classification systems for distal radius fractures, including the systems of Older et al., the Comprehensive Classification of fractures, the Melone intra-articular classification system, and that of Fernandez.

Operative treatment of volar intra-articular fractures of the distal end of the radius

We retrospectively reviewed the results of operative treatment of forty-nine volar marginal intra-articular fractures of the distal end of the radius. According to the Comprehensive Classification of Fractures, there were two B3.1 fractures (characterized by a small volar fragment, with the sigmoid notch intact), three B3.2 fractures (characterized by a large volar fragment that included the sigmoid notch), and forty-four B3.3 fractures (characterized by comminution of the volar fragment). Although all fractures healed and only nine patients had evidence of osteoarthrosis on follow-up radiographs, there were six early and fourteen late complications, some of which adversely influenced the over-all outcome. After an average of fifty-one months (range, twenty-four to 117 months), there were thirty-one excellent, ten good, and eight fair results according to the system described by Gartland and Werley, and thirty-two excellent, nine good, five fair, and three poor results according to the modified system of Green and O'Brien. Two factors were found to have a significant association with a fair or poor outcome: evidence of osteoarthrosis on the most recent follow-up radiographs and reversal of the normal volar tilt of the distal end of the radius. The age of the patient, the interval from the injury to the operation, a concomitant injury of the ipsilateral upper extremity, an associated fracture of the ulnar styloid process, the radio-ulnar index, ulnar angulation, the classification of the fracture, comminution of the volar fragment, and articular incongruity were not significantly associated with the outcome.

Distal radioulnar joint injuries associated with fractures of the distal radius

The most common cause of residual wrist disability after fractures of the distal radius is the distal radioulnar joint. The 3 basic conditions that produce radioulnar pain and limitation of forearm rotation are instability, joint incongruency, and ulnocarpal abutment. The last 2 entities initiate irreversible cartilage damage that eventually leads to degenerative joint disease. Early recognition and management in the acute stage aim at the anatomic reconstruction of the distal radioulnar joint including bone, joint surfaces, and ligaments in an effort to reduce the incidence of painful sequelae and functional deficit. This article provides a description and the treatment options of the distal radioulnar joint lesions that occur in association with fractures of the distal radius, and the results obtained with open and arthroscopic techniques. Both acute and chronic disorders are analyzed, and a prognostic and treatment oriented classification is presented Furthermore, the pathoanatomy and management of chronic distal radioulnar joint derangement after fracture of the distal radius are reviewed briefly.