Madelung Deformity: Diagnosis and Treatment Options

Madelung deformity (MD) comprises an increased volar and ulnar tilt of the joint facet of the distal radius, secondary to an idiopathic physeal dysplasia. Such change causes radial shortening and consequent distal ulnar prominence, along with wrist pain and loss of motion. Surgery becomes an option in patients with severe deformity that do not respond to conservative treatment.The classic surgical techniques are problematic for adults, as they are specific for children and adolescents, whose radial physis is still open. Very few papers discuss the treatment of adult patients; furthermore, most are focused on the distal radioulnar joint, and thus do not approach the origin of the pathology.When analyzing computed tomography scans with tridimensional reconstruction, a feature of MD, growth arrest of the volar and ulnar portions of the distal radius, is noted, causing the typical distal radius deformity that leads to lack of coverage of the lunate bone. That leads to palmar subluxation of the lunate bone and consequent radiocarpal instability.We herein describe the possibilities of treatment in different stages of evolution, summarizing the authors' view on MD.

Shelf Osteotomy for Madelung’s Deformity in Adults: A Novel Technique

Background Madelung's deformity (MD) comprises increased volar and ulnar tilt of the distal radius joint facet, secondary to an idiopathic physeal dysplasia. Such change causes radial shortening and a consequent distal ulnar prominence, along with wrist pain and loss of motion. Classic surgical techniques are problematic for adults, as they are specific for children and adolescents whose distal radial physis is still open. Description of Technique It is suggested a new treatment method for MD in skeletally mature patients: a distal radius osteotomy and joint realignment are performed through a volar approach to increase the support area of the lunate bone. The rotation and lengthening of the distal epiphysis of the radius generate support and cover to the lunate bone, with improvement of both radiocarpal and distal radioulnar joints. Patients and Methods We describe the technique in details and report the treatment of a 25-year-old female patient. Results Early clinical and radiographic outcomes are encouraging for the treatment of symptomatic patients. Conclusion There is a plethora on the literature about conflicting opinions on the best treatment options and surgical techniques are quite variable, although usually with good results. Besides, the technique here described is indicated during a specific stage of disease presentation, consisting of young adults without any wrist-degenerative changes. Having said that, it is possible to claim that MD treatment with shelf osteotomy is a concept change. Our main goal is to reconstruct the diseased segment and improve wrist stability.

Treatment of Advanced Lunate Bone Necrosis by Individualized Bone Cement Prosthetic Replacement

Objective: The aim of this study is to prospectively analyze the clinical effect of an individualized bone cement prosthetic replacement in treating advanced lunate bone necrosis. Methods: Since 2006, a total of 19 Lichtman stage III and IV aseptic lunate bone necrosis patients with a wrist height ratio ≥0.5 were included, the last visit time was three years after operation. The statistically significant differences in range of motion, (Visual Analogue Scale/Score, VAS) score, Cooney score, grasp force, wrist height ratio (to the capitate bone), and radio scaphoid angle of the affected wrist joint were observed before the operation and at the last visit (p<0.05). Results: There were no statistically significant differences in the axial line and maximum diameter of the lunate bone between the healthy side and the affected side (p>0.05). Conclusion: The surgical method can restore the original anatomic structure of wrist joint, play an important role in recovering the movement function of wrist joint, and has a significant effect on wrist pain and few complications.

Hydroxyapatite deposition disease of the wrist with intraosseous migration to the lunate bone

Hydroxyapatite deposition disease (HADD) is a mostly uniarticular, self-limiting condition caused by deposition of hydroxyapatite (HA) crystals in tendons or in the peritendinous soft tissues. Commonly, the glenohumeral joint is affected. More rarely, the HA depot can be cause of a carpal tunnel syndrome due to an acute inflammatory reaction and space-occupying soft tissue oedema. We report a case of acute HA depot located at the volar site of the right wrist with affection of the deep flexor tendons and intraosseous migration into the lunate bone in a 50-year-old female. There are two main goals of this case report: First, to remind the diagnosis of HADD as a cause of wrist pain and also of carpal tunnel syndrome, as this entity being often misdiagnosed clinically, and second, to report a rare case of intraosseous migration of HA crystals into the lunate bone.

Comparison of Biomechanical Results about the Effect of Three Surgery Methods in Decompression of Lunate Bone

Objective Kienbock's disease is an unusual disorder caused by osteonecrosis and the collapse of lunate bone which leads to pain and a chronic decrease in wrist function. The treatments in this disease aim to relieve pain and maintain wrist function and movement. Various surgical procedures have been recommended for the subjects with Kienbock's disease; however, the main question posed here is which of the selected procedures are more successful in relief of the pressure applied on lunate. Methods and Materials Computed tomography (CT) scan images of a normal subject were used to create a three-dimensional model of the wrist joint. The effects of several surgical procedures, including radial shortening, capitate shortening, and a combination of both radial and capitate shortening, on the joint contact force of the wrist bones were investigated. Results The pressure applied to the lunate bone in articulation with radius, scaphoid, capitate, hamate, and triquetrum varied between 19.7 and 45.4 MPa. The Von Mises stress, maximum principal stress, and minimum principal stress decreased in the model with a combination of radius and capitate shortening. Conclusion It can be concluded from the results of this study that the combinations of radius and capitate shortening seem to be an effective procedure to decrease joint pressure, if the combined surgery could not be done, shortening of radius or capitate would be recommended. Level of Evidence This is a Level III study.

SAT0554 SONOGRAPHIC ASSESSMENT OF CALCIUM PYROPHOSPHATE DEPOSITION DISEASE AT WRIST. A FOCUS ON THE SCAPHO-LUNATE LIGAMENT.

Background:Only few articles evaluated the wrist in calcium pyrophosphate deposition disease (CPPD), although it is the second most frequent target of CPPD. Very recently, in a computed tomography (CT) study ligamentous calcifications were reported as a highly specific feature of CPPD at wrist level (1).Objectives:i) to determine the prevalence and distribution of the ultrasound (US) findings indicative of calcium pyrophosphate (CPP) crystal deposits at the wrist, with a particular focus on the dorsal aspect of the scapho-lunate ligament (SLL); ii) to investigate the diagnostic accuracy of US and conventional radiography (CR) in the evaluation of CPP crystal deposits at wrist level, iv) to assess the agreement between the different imaging techniques.Methods:Consecutive patients with a “definite” diagnosis of CPPD according to the Ryan and McCarty criteria and disease controls were prospectively included in this cross-sectional single-centre study. Dorsal part of the SLL, triangular fibrocartilage complex (TFCC), and volar recess of the radio-lunate joint were explored using US (according to EULAR standard scans and OMERACT definitions), CR and CT.Results:Sixty-one CPPD patients and 39 disease controls were enrolled. Two-hundred wrists were evaluated using both CR and US. CT data of 26 (13.0%) wrists were available: 20 wrists in CPPD patients and 6 wrists in controls. CPP crystal deposits were found by US in at least one wrist in 95.1% of CPPD patients and in 15.4% of controls (p<0.001). SLL calcification was reported in 83.6% of CPPD patients and in 5.1% of controls (p<0.001). CPP crystal deposits were observed by US at the SLL and/or radio-lunate joint in 5.7% of wrists and 6.6% of CPPD patients, but not at the TFCC of the same wrist. On CR, calcifications were found in at least one wrist in 72.1% of CPPD patients and in 0% of controls (p<0.001). Using the Ryan-McCarty criteria as a gold standard, the sensitivity, specificity and diagnostic accuracy were 0.72 (0.59-0.83), 1.0 (0.91-1.0) and 0.83 (0.74-0.90) for CR and 0.95 (0.86-0.99), 0.85 (0.69-0.94) and 0.91 (0.84-0.96) for US. Table 1 shows the agreement between the different imaging techniques.Tabel 1.Agreement between US and the other imaging techniques in the evaluation of CPP crystal deposits at the wrist.US-CR (n=200)US-CT (n=26)TFCC0.55 (0.43-0.67)0.70 (0.43-0.97)SLL0.23 (0.07-0.39)0.69 (0.41-0.97)RLJ0.25 (0.09-0.41)0.46 (0.12-0.80)Legend.n: number of the wrists,RLJ: volar recess of the radio-lunate joint. Values in brackets are the 95% confidence intervals of the Cohen’s kappa.Figure 1provides a pictorial evidence of the appearance of CPP crystal deposits in the SLL.A: CPP crystal deposits (curved arrow) at the TFCC. The SLL is not assessable due to superimposition of other bones.B: in the same patient of figure 1A, CT scan shows the presence of a calcification of the dorsal aspect of the SLL (arrow).C: dorsal longitudinal scan of the SLL: isolated hyperechoic spot (arrowheads) inside the ligament.D: dorsal longitudinal scan of the SLL showing the presence of a large aggregate extending towards the extensor tendons and hyperechoic spots (arrowheads) within it.Legend.iii: third extensor compartment,iv: fourth extensor compartment,l: lunate bone,s:scaphoid bone.Conclusion:This study supports the diagnostic accuracy of US in evaluating wrist involvement in CPPD patients. SLL calcifications are a specific US finding of CPPD at wrist level.References:[1]Ziegeler K, Diekhoff T, Hermann S, et al. Low-dose computed tomography as diagnostic tool in calcium pyrophosphate deposition disease arthropathy: focus on ligamentous calcifications of the wrist. Clin Exp Rheumatol 2019;37:826-33.Disclosure of Interests:Edoardo Cipolletta: None declared, Gianluca Smerilli: None declared, Riccardo Mashadi Mirza: None declared, Andrea Di Matteo Grant/research support from: the publication was conducted while Dr. Di Matteo was an ARTICULUM fellow, Fausto Salaffi Speakers bureau: Dr. Salaffi reports personal fees from Bristol Myers Squibb, personal fees from Pfizer, personal fees from Novartis, personal fees from AbbVie, personal fees from Roche, personal fees from Merck Sharp & Dohme Italia, outside the submitted work., Walter Grassi Speakers bureau: Prof. Grassi reports personal fees from AbbVie, personal fees from Celgene, personal fees from Grünenthal, personal fees from Pfizer, personal fees from Union Chimique Belge Pharma, outside the submitted work., Emilio Filippucci Speakers bureau: Dr. Filippucci reports personal fees from AbbVie, personal fees from Bristol-Myers Squibb, personal fees from Celgene, personal fees from Roche, personal fees from Union Chimique Belge Pharma, personal fees from Pfizer, outside the submitted work.