Functional outcomes following fixation of a marginal distal radius fracture with two commonly used volar locking plates: a retrospective cohort study

Introduction The volar locking plate has been widely used for unstable distal radius fractures to provide early recovery of wrist function. Volar plate prominence to the watershed line has been reported to be related to flexor tendon irritation, and avoid implant prominence in this area was suggested. On the other hand, marginal distal radius fracture patterns required the plate to cross the watershed line, making conflict over plate positioning on marginal distal radius fractures. This study compared functional outcomes in patients with marginal distal radius fractures treated with two different implants. Materials and methods A retrospective study was conducted, all patients who received a Synthes 2.4 mm LCP or an Acumed Acu-Loc VLP between January 2015 and December 2018 were reviewed. The marginal distal radius fracture pattern was the most distal horizontal fracture line within 10 mm of the lunate fossa’s joint line. The primary outcomes including patient-reported pain scores, range of motion, and grip strength were assessed. Secondary outcomes included patient-based subjective satisfaction scores of the injured wrist and hand function. The Mayo Wrist Score and the requirement for a secondary procedure related to hardware complications were also recorded. Results Forty-two patients met our inclusion criteria. Twenty-one patients were treated with the Synthes 2.4 mm LCP, and 21 patients with the Acumed Acu-Loc VLP. The primary outcome revealed that post-operative range of motion (P = 0.016) and grip strengths (P = 0.014) were significantly improved in the Acu-Loc VLP group. The MAYO wrist score in the Acu-Loc VLP group was also significantly better (P = 0.006). Conclusions Despite advances in implant designs, flexor tendon irritation or rupture is still a complication following distal radius’s volar plating. We believe the Acumed Acu-Loc VLP design provided better functional outcomes than the Synthes 2.4 mm LCP if appropriately and carefully placed into its designed-for position. This positioning results in promising patient satisfaction when treating marginal distal radius fractures.

Treatment of subacute/chronic ECU tendinopathy using wrist arthroscopy and open surgical repair

Purpose To report the arthroscopic and clinical findings of patients with extensor carpi ulnaris (ECU) tendinopathy treated with wrist arthroscopy and open surgical repair. Methods We retrospectively reviewed the medical records of seven patients with chronic ECU tendinopathy who were treated with diagnostic wrist arthroscopy and open surgical repair between 2010 and 2017. Seven cases diagnosed with ECU tendinopathy had undergone open procedure for the ECU tendinopathy, as well as wrist arthroscopy in the same session. Any pathology of the triangular fibrocartilage complex (TFCC) diagnosed by wrist arthroscopy were treated simultaneously with open procedure for the ECU tendinopathy. The functional outcome was evaluated by comparing the preoperative and final follow-up values of range of motion (ROM), grip strength, visual analog scale (VAS) for pain, modified Mayo wrist score and quick disabilities of the arm, shoulder, and hand (DASH) score. Results TFCC tears were identified in four patients of which repair was performed concomitantly. The average follow-up period was 39 months (range, 25–49 months). At the final follow-up, all the outcomes including average VAS score (6.4→1), the ROM (173→192°), quick DASH score (42.5→18.2), and modified Mayo wrist score (48.6→79.3) improved significantly. Conclusion When treating patients with ECU tendinopathy, the possibility of TFCC combined injury should always be considered. If surgical treatment is planned, we suggest a wrist arthroscopy for more accurate diagnosis an intra-articular pathology, particularly for patients whose MRI findings suggest a degenerative tear or degeneration at the periphery of the TFCC. Additionally, if ECU and DRUJ stability is obtained by repair or reconstruction of the concurrent pathologies in the ECU subsheath, TFCC and other intra-articular structures, the results will be favorable.

Lateral approach for scaphoid excision and capitolunate arthrodesis in the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists

Background Four-corner arthrodesis (4-CA) is an effective treatment for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC). Capitolunate arthrodesis is an alternative option that limits intercarpal fusion. We propose a lateral approach using a small incision over the scaphoid anatomic snuffbox, which could be a straightforward method for performing scaphoid excision and capitolunate arthrodesis. This approach would be beneficial for shortening the operative time, facilitating bone healing, and improving wrist motion. Methods Between 2016 and 2020, eight patients were enrolled retrospectively and underwent the lateral approach for scaphoid excision and capitolunate arthrodesis. We presented the radiographic outcomes, including fusion status, capitolunate angle, and carpal height ratio. The functional outcomes of wrist range of motion, grip strength, pain, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and Mayo wrist score were evaluated. Results Fusion could be achieved, without complications, in all eight patients, and the mean follow-up period was 22.4 months (12–38 months). Five operations were completed within 1 h and 30 min. Postoperatively, the mean capitolunate angle and carpal height ratio improved from 19.6o to 2.4o and 0.44–0.51%, respectively. At the final follow-up, the average flexion-extension arc was 76.3o, visual analogue scale for pain was 0.9, QuickDASH score was 26.4, and Mayo wrist score was 72.5. Conclusions The lateral approach for scaphoid excision and capitoluante arthrodesis in treating SLAC and SNAC could have several advantages, including easy performance since it is similar to the open method and the lack of need for dorsal wrist opening and closure, which may preserve surrounding circulation, avoid the formation of a dorsal scar, and mimic the advantages of arthroscopic treatment.

PRIMARY BONE GRAFTING AND K-WIRE FIXATION: A PREFERABLE OPTION TO TREAT ACUTE UNSTABLE SCAPHOID FRACTURE

Objective: The Objective of this study is to analyze the radiological, clinical and functional outcome of patients with acute unstable scaphoid fracture treated with primary bone grafting and K (Kirschner)-wire fixation Methods:Based on inclusion and exclusion criteria , a prospective observational study was carried out on 21 patients with acute unstable scaphoid fracture who had been treated with primary bone grafting and K-wire fixation from November 2017 to March 2020 and were followed up for a minimum of 24 weeks. The average patient age was 26.9 years. The time from injury to treatment averaged 11days. Surgery was done under Bier’s Block using volar approach. Bone graft was harvested from distal Radius. The mean operating time was 24 minutes.Clinical parameters like tenderness, grip strength and Range of Movement (ROM) at wrist was assessed. The functional outcome was evaluated using Modified Mayo wrist score. Bone union was assessed using serial plain radiographs. Results:Union was achieved in all (100%) at 12 weeks. There was no evidence of Avascular necrosis (AVN) or arthrosis at latest follow up. As per Modified Mayo wrist score, there were 15 excellent,03 good and 03 fair results at the final follow-up. Individuals resumed their routine work at 12 weeks and all were comfortable with heavy works/ sports activity by 24 weeks. Conclusion: Primary bone grafting has a definite role in the management of acute unstable scaphoid fracture by which aquicker and higher rate of union isachieved with minimal complications. Open reduction allows thorough assessment of fracture for better anatomic reduction. Although the type of fixation device hardly contributes for quicker and higher union, but then the use of K-wire for fixation is the only viable option for smaller bony fragments and is more forgiving in terms of its positioning. It has an added advantage in terms of requirement of minimal inventory and thus is a cost-effective modality. This procedure also confirms that the patients could get back to their work earlier hence decreasing economic burden.

Modified Graner's Technique with\without Vascularized Capitate Lengthening for Kienböck Disease Stage IIIb—A Pilot Study

Background Intercarpal fusions are used to treat stage IIIb Kienböck disease. They increase force transfer across the radioscaphoid articulation with predisposition to arthritis. Description of Technique This technique is excision of lunate followed by proximal transfer of capitate, with scaphocapitate and triquetrocapitate fusion to increase area of load transfer mimicking wrist hemiarthroplasty. Our purpose is to evaluate mid-term results of this technique. Patients and Methods A prospective case series study was conducted on 11 patients with stage IIIb and IIIc. In seven cases, transfer of the capitate was performed by osteotomizing the capitate just distal to its waist, proximal migration to replace the excised lunate then bone grafting. In four cases, proximal transfer of vascularized pedicled capitate was done. Clinical outcome measures included pain (visual analog scale), grip strength, range of motion, and functional evaluation by modified Mayo wrist score and scoring system of Evans. Radiological outcome measures included healing of fusion mass, progression of the disease, and occurrence of avascular necrosis to the capitate. Results Follow-up period averaged 54 months. Scaphocapitate fusion healing averaged 11 weeks. Union of the lengthened capitate occurred in 10 patients only. There was postoperative improvement in pain scores, grip, Evans, and modified Mayo wrist score. There was postoperative decrease in wrist flexion and extension. One patient showed resorption of the capitate head with progressive radioscaphoid arthritis-necessitated wrist fusion. Conclusion The mid-term results of this technique may be satisfactory due to low incidence of degenerative arthritis in the radioscaphoid joint. However, longer follow-up with recruiting larger number of patients is needed.

Functional Outcomes Following Fixation of an Ultra-distal Radius Fracture with Two Commonly used Volar Locking Plates: A Retrospective Cohort Study

Introduction: The volar locking plate has been widely used for unstable distal radius fractures to provide early recovery of wrist function. Volar plate prominence to the watershed line has been reported to be related to flexor tendon irritation, and avoid implant prominence in this area was suggested. On the other hand, ultra-distal radius fracture patterns required the plate to cross the watershed line, making conflict over plate positioning on ultra-distal radius fractures. This study compared functional outcomes in patients with ultra-distal radius fractures treated with two different implants.Materials and Methods: A retrospective study was conducted, all patients who received a Synthes 2.4mm LCP or an Acumed Acu-Loc VLP between January 2015 and December 2018 were reviewed. The ultra-distal fracture pattern was the most distal horizontal fracture line within 10 mm of the lunate fossa's joint line. The primary outcomes including patient-reported pain scores, range of motion, and grip strength were assessed. Secondary outcomes included patient-based subjective satisfaction scores of the injured wrist and hand function. The Mayo Wrist Score and the requirement for a secondary procedure related to hardware complications were also recorded. Results: Forty-two patients met our inclusion criteria. Twenty-one patients were treated with the Synthes 2.4 mm LCP, and 21 patients with the Acumed Acu-Loc VLP. The primary outcome revealed that post-operative range of motion (P = 0.016) and gripping strengths (P = 0.014) were significantly improved in the Acu-Loc VLP group. The MAYO wrist score in the Acu-Loc VLP group was also significantly better (P = 0.006). Conclusions: Despite advances in implant designs, flexor tendon irritation or rupture is still a complication following distal radius's volar plating. We believe the Acumed Acu-Loc VLP design provided better functional outcomes than the Synthes 2.4 mm LCP if appropriately and carefully placed into its designed-for position. This positioning results in promising patient satisfaction when treating ultra-distal radius fractures.

Is Pulley Reconstruction Better Than Pulley Release for De Quervain's Tenosynovitis? A Double-Blind Randomized Controlled Trial

Purpose The aim of this study was to compare the results of surgeries of the De Quervain's disease (DQD) through a randomized control trial.Materials and Methods We treated 40 cases of De Quervain's tenosynovitis in 2 groups: 20 patients by pulley release method and another 20 patients by pulley reconstruction method. The patients were selected as per the random table number. The clinical data, numeric Visual Analogue Scale (VAS) score, Quick DASH—Disabilities of the Arm, Shoulder, and Hand—score, Mayo Wrist Score, and subluxation of the tendons in dynamic ultrasonography (USG) during wrist hyperflexion and abduction of the thumb test were noted preoperatively and 6 months after the operation. All patient charts were reviewed and data analysis was done after completion of the study.Results All patients improved after surgery. There was no difference in clinical outcome data, numeric VAS score, Quick DASH Score, and Mayo Wrist Score (p-value > 0.05). There were four patients with tendon subluxation under USG in pulley release group, out of which only one patient was clinically symptomatic. There was no tendon subluxation in pulley reconstruction group. The tendon subluxation between the two groups was not found to be statistically significant (p-value: 0.661).Conclusion Although, higher numbers of subluxation were found in release group, there was no statistically significant difference in the outcome of the two surgical procedures for DQD. This study is a pilot study, and it may act as the groundwork over which further studies may be performed.Level of Evidence This is a Level I study.

Wrist function recovery course in patients with scaphoid nonunion treated with combined volar bone grafting and a dorsal antegrade headless screw

Background Surgical treatment is necessary for scaphoid nonunion. Open surgery with a combined volar and dorsal approach is thought to have poor functional outcomes and a prolonged recovery course. However, the detailed recovery course for this approach is rarely reported. The aim of this study was to investigate the recovery course and radiographic outcome for patients with scaphoid nonunion who underwent a combined volar bone grafting and dorsal antegrade headless screw approach. Material and methods Eighteen patients with scaphoid nonunion who underwent combined volar bone grafting and dorsal antegrade headless screw fixation were enrolled in this retrospective study. Preoperative and serial postoperative wrist functional and radiographic outcomes were collected and analysed. Results All 18 patients achieved bone union at a mean time of 14.3 weeks. Compared to the preoperative status, the grip strength, wrist motion arc, and Mayo Wrist score were improved significantly 6 months after surgery, whilst the Disabilities of the Arm, Shoulder, and Hand (DASH) score did not recover until 12 months after surgery. Significant improvements were found in all scaphoid radiographic parameters. Conclusion The surgical outcomes for scaphoid nonunion treated with a combined volar bone grafting and dorsal antegrade headless screw achieved a high union rate, with great wrist functional and radiographic outcomes. The earliest recovered wrist functional parameters were grip strength, motion arc, Mayo Wrist score and finally the DASH score at postoperative 6 months and 12 months, respectively.

Wrist Function Recovery Course in Patients with Scaphoid Nonunion Treated with Combined Volar Bone Grafting and a Dorsal Antegrade Headless Screw

Objectives:Surgical treatment is necessary for scaphoid nonunion. Open surgery with a combined volar and dorsal approach is thought to have poor functional outcomes and a prolonged recovery course. However, the detailed recovery course for this approach is rarely reported. The aim of this study was to investigate the recovery course and radiographic outcome for patients with scaphoid nonunion who underwent a combined volar bone grafting and dorsal antegrade headless screw approach.Material and methods:Eighteen patients with scaphoid nonunion who underwent combined volar bone grafting and dorsal antegrade headless screw fixation were enrolled in this retrospective study. Preoperative and serial postoperative wrist functional and radiographic outcomes were collected and analysed.Results:All 18 patients achieved bone union at a mean time of 14 weeks. Compared to the preoperative status, the grip strength was significantly recovered, and the Mayo wrist score improved significantly 6 months after surgery. Wrist motion arc was significantly improved 9 months after surgery, while the Disabilities of the Arm, Shoulder, and Hand (DASH) score did not recover until 12 months after surgery. Significant improvements were found in all scaphoid radiographic parameters.Conclusion:The surgical outcomes for scaphoid nonunion treated with a combined volar bone grafting and dorsal antegrade headless screw achieved a high union rate, with great wrist functional and radiographic outcomes. The earliest recovered wrist functional parameters were grip strength and Mayo wrist score followed by the motion arc and finally the DASH score at postoperative 6, 9 months and 12 months, respectively.

Kahnbeinpseudarthrose: Erfahrungen aus mehr als 280 Rekonstruktionen mit einem vaskularisierten Knochenblock aus der medialen Femurkondyle

Zusammenfassung Hintergrund/Ziel Vaskularisierte Transplantate von der medialen Femurkondyle werden in unserer Klinik seit 2008 in großem Umfang zur Sanierung komplexer Skaphoidpseudarthrosen eingesetzt. Ziel der Arbeit ist eine Bilanz der Ergebnisse. Patienten und Methoden Bis Ende 2019 wurde bei 287 Patienten eine Skaphoidrekonstruktion unter Verwendung eines mikrovaskulär angeschlossenen Knochentransplantates, 158-mal mit einem kortikospongiösen und 129-mal mit osteochondralen Transplantat von der medialen Femurkondyle, durchgeführt. 28 von insgesamt 42 Patienten mit kortikospongiöser Rekonstruktion aus dem Zeitraum von September 2008 bis Dezember 2010 konnten durchschnittlich 6,1 Jahre postoperativ und 44 von insgesamt 76 Patienten mit osteochondralem Ersatz des proximalen Kahnbeinpoles aus den Jahren 2011 bis 2016 konnten durchschnittlich 44 Monate postoperativ nachuntersucht werden. Neben klinischen Parametern und Röntgenaufnahmen wurde der DASH-Score und der modifizierte Mayo-Wrist-Score (MMWS) erhoben. Zusätzlich werden relevante Erfahrungen der Autoren aus dem gesamten Zeitraum – notwendigerweise ohne Quantifizierung – berichtet. Ergebnisse Bei den kortikospongiösen Rekonstruktionen betrug die knöcherne Ausheilungsrate 69 %, bei 9,5 % erfolgten Rettungseingriffen. Der DASH-Score lag bei den 28 Patienten im Mittel bei 11, der MMWS bei 83 Punkten. Für Streckung/Beugung wurden durchschnittlich 86° und für die Kraft 89 % der unverletzten Gegenseite gemessen. Beim osteochondralen Polersatz betrug die vollständige knöcherne Ausheilungsrate 80 %, die partielle 5 %; bei 11 % war eine Rettungsoperation erforderlich. Der DASH-Score lag im Mittel bei 15, der MMWS bei 80 Punkten. Für Streckung/Beugung wurden im Mittel 90° und für die Kraft 81 % der Gegenseite gemessen. Neben eingriffsspezifischen Komplikationen wie Stielossifikationen erwies sich die Wiederherstellung der Form des Skaphoids und der karpalen Stabilität in Abhängigkeit von der Komplexität des Ausgangsbefundes als Kernproblem. Eine Klärung der Ursachen der persistierenden Pseudarthrosen war nicht möglich. Schlussfolgerung Großartigen Möglichkeiten stehen relevante Risiken in Abhängigkeit von der Komplexität des Ausgangsbefundes gegenüber. Eine umfassende Aufklärung ist zwingend, so dass geeignete Patienten sich mit realistischen Erwartungen für diesen Eingriff entscheiden können.