Luke P. Robinson, MD, Rashad H. Usmani, MD, Victor Fehrenbacher, MD, Lauren Protzer, MD

Journal of Wrist Surgery, March 24 2021

Background: Extra-articular fractures of the distal radius are often treated with a trial of nonoperative management if radiographic parameters are within an acceptable range, especially in the elderly population. Unfortunately, some malunions become symptomatic or become grossly misaligned during nonoperative management which require corrective surgery to restore the normal osseous anatomy and restore function.

Description of Technique: We describe correction of a distal radius malunion utilizing a distraction-type volar osteotomy, a volar plate specific distraction device, and a novel resorbable calcium phosphate bone cement (Trabexus) designed to withstand compressive loads.

Patients and Methods: Twelve patients with 13 distal radius fractures were included in this study. The average patient age was 60.9 years and average time from injury to corrective osteotomy was 96.3 days. Radiographic measures (radial inclination, volar tilt, and ulnar variance) and clinical assessment (wrist/forearm range of motion and grip strength) were done pre- and postoperatively and compared.

Results: The average time from corrective surgical osteotomy to final clinical followup was 375.8 days. After surgical intervention, there was a statistically significant improvement in mean volar tilt (19.8 vs. þ0.5 degrees) and mean ulnar variance (þ2.8 vs. 0.4 mm). Improvements were also seen in grip strength (1.7 vs. 43.6 lb), wrist flexion (30.5 vs. 48.3 degrees), wrist extension (33.3 vs. 53.8 degrees), forearm pronation (75.0 vs. 88.8 degrees), and forearm supination (53.8 vs. 81.3 degrees). On average, 56.0% of Trabexus bone substitute remained on final clinical radiographs. Conclusion This simplified technique of distraction corrective osteotomy after distal radius malunion results in improved clinical and radiographic outcomes for patients.

Wang, W.L., and Tosti, R. (2018)

Techniques in Hand and Upper Extremity Surgery, 22 (3), 116-119.

Abstract: We describe a novel technique in correcting distal radius fractures deformed with significant shortening or coronal plane translation in both the acute or chronic setting. The technique involves using a modified push-pull device to assist the surgeon in correcting length and/or translation of the articular block without the use additional hardware outside of the volar plate.

Rozental, T. D., & Blazar, P. E. (2006)

The Journal of Hand Surgery, 31(3), 359–365. https://doi.org/10.1016/j.jhsa.2005.10.010

Purpose: Despite the recent popularity of volar plating for dorsally displaced distal radius fractures there is a paucity of data documenting the results of this treatment method. The purpose of this study was to determine the functional outcome of patients treated with volar fixed-angle plating for dorsally displaced, unstable distal radius fractures.

Methods: We reviewed the records of all patients treated at our institution with internal fixation using volar plates for dorsally displaced, comminuted distal radius fractures. Patients with follow-up periods shorter than 12 months were excluded from the study.

Outcomes: were evaluated at the latest follow-up examination with the Disabilities of the Arm, Shoulder, and Hand and the Gartland and Werley scoring systems.

Results: We studied 41 patients with a mean age of 53 years. The average follow-up period was 17 months. All fractures were stabilized with volar locking plates. Radiographs in the immediate postoperative period showed a mean radial height of 11 mm, mean radial inclination of 21°, and mean volar tilt of 4°. At fracture healing the mean radial height was 11 mm, mean radial inclination was 21°, and mean volar tilt was 5°. The average score on the Disabilities of the Arm, Shoulder, and Hand questionnaire was 14 and all patients achieved excellent and good results on the Gartland and Werley scoring system, indicating minimal impairment in activities of daily living. Nine patients experienced postoperative complications. There were 4 instances of loss of reduction with fracture collapse, 3 patients required hardware removal for tendon irritation, 1 patient developed a wound dehiscence, and 1 patient had metacarpophalangeal joint stiffness.

Conclusions: Patients with unstable, dorsally displaced fractures of the distal radius treated with volar fixed-angle devices have good or excellent functional outcomes despite a high complication rate. When compared with previous reports on dorsal plating volar plates appear to have a higher incidence of fracture collapse but a lower rate of hardware-related complications. Complex fracture patterns thus mandate a careful and individualized approach.

Miller, Jonathan E., Naram, Aparajit, Qin, BaiJing, and Rothkopf, Douglas M.

Annals of Plastic Surgery, Volume 82, Number 1, January 2019

IFU – English (USA)

IFU – English (International)

Mir H Ali, MD; Marco Rizzo, MD; Alexander Y Shin, MD and Steven L Moran, MD

Hand, 7(1), 72-78

Abstract: Introduction: Proximal row carpectomy (PRC) is a popular procedure for the treatmet of wrist arthritis; however, the long-term clinical outcomes of this procedure are not well characterized. The purpose of this study was to evaluate long-term results with PRC and to identify factors that may improve clinical outcomes.

Methods: A retrospective study was performed on all patients who underwent proximal rowcarpectomy between January 1967 and January 1992. Medical records and available radiographs were reviewed. The Disabilities of the Arm, Shoulder, and Hand and Patient Rated Wrist Exam, as well as hand motion diagrams were sent to all surviving patients. The contralateral extremity was used as a control. Data was analyzed using multivariant analysis and a Student’s t test.

Results: Eight-one patients underwent PRC. Average age at the time of surgery was 41 years. Average follow-up was 19.8 years. Sixty-one patients responded to the questionnaires. On final follow-up, wrist motion and grip strength were no significantly different from preoperative values. Radiographic follow-up beyond 2 years revealed joint narrowing and arthritic changes within the radiocapitate joint. Forty-six patients (74%) were not satisfied with the results of their surgery due to persistent pain or inability to return previous occupational activities. Fifty-two patients required daily pain medication for wrist pain. Twelve patients hand undergone a wrist arthrodesis.

Conclusions: Post-operative motion and grip strenght valued following PRC appear to remain stable over time. Surgical failure rates with conversion to wrist fusion occured early within the post-operative follow-up. Many patients continued to complain of pain requiring dialy medication and were unable to return to manual labor type jobs. The results of this study suggest that long-term patient satisfaction following PRC can be poor and the surgeon may wish to consider alternative treatment options for younger patients and those with high-demand jobs.

Rudnick B, Goljan P, Pruzansky J, Bachoura A, Jacoby S, Rekant M

The Journal of Hand Surgery, 34(8), 1407-1412, October 2009

Purpose: To compare the clinical outcomes of scaphoid and triquetral excision combined with capitolunate arthrodesis versus 4-corner (capitate, hamate, lunate, triquetrum) intercarpal arthrodesis.

Methods: We retrospectively identified 50 patients with scapholunate advanced collapse wrist changes who had 4-corner arthrodesis. Thirty-four patients were able to return and complete all follow-up evaluations. Patient demographics were similar between the 2 groups. Follow-up evaluation included radiographs, wrist range of motion (flexion-extension, radial-ulnar deviation, and pronation-supination); grip strength; visual analog scale (VAS); and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Complications of nonunion, hardware migration, conversion to wrist arthrodesis or arthroplasty, and pisotriquetral arthritis were recorded.

Results: Sixteen patients had capitolunate arthrodesis, and 18 patients had a 4-corner arthrodesis. There was no statistical difference in radial-ulnar deviation, pronation-supination, grip strength, VAS, or DASH scores between groups. There was a slight increase in flexion-extension in the 4-corner group. There were 2 nonunions in the 4-corner group and none in the capitolunate group. Five patients in the capitolunate group required screw removal secondary to migration. Three patients in the 4-corner group required a subsequent pisiform excision.

Conclusions: Capitolunate arthrodesis compared favorably to 4-corner arthrodesis at an average 3-year follow-up in this series with respect to the range of motion, grip strength, DASH scores, and VAS. Advantages of capitolunate arthrodesis include a lessened need for bone graft harvesting while maintaining a similarly low nonunion rate, easier reduction of the lunate following triquetral excision, and avoiding subsequent symptomatic pisotriquetral arthritis. Screw migration, however, remains a concern with this technique.

Type of study / level of evidence: Therapeutic III.

Baker A, Ishikawa S.

Techniques in Foot & Ankle Surgery, 14(4), 171-176, December 2015

Abstract: Surgical treatment of Charcot neuroarthropathy is complicated by poor wound healing, nonunion, malunion, recurrent ulceration, and deformity recurrence. This article gives an overview of different arthrodesis techniques used in Charcot neuroarthroparthy along with a description of a modified subtalar arthrodesis technique using a PEEK (Polyether-ether-ketone) subtalar fusion cup.

Level of Evidence: Diagnositc Level 5. See instructions for Authors for a complete description of levels of evidence.

Huh J, Glisson R, Matsumoto T, Easley M

Foot and Ankle International Vol. 37, Number 4: 411-418

Background: Intramedullary screw fixation of fifth metatarsal Jones fractures often produces statisfactory results, however, nonunion and refracture rates are not negligible. The low-profile “hook” plate is an alternative fixation methods that has been promoted to offer improved rotational control at the fracture site, but this remains to be proven. The purpose of this study was to document biomechanical performance differences between this type of plate and a contemporary solid, dual-pitch intramedullary screw in cadaveric Jones fracture model.

Methods: Simulated Jones fractures were created in 8 matched pairs of fresh-frozen cadaveric fifth metatarsals. One bone from each pair was stabilized using an intramedullary TriMed Jones Screw and the other using a TriMed Jones Fracture Plate (TriMed, Inc., Santa Clarita, CA). Controlled bending and torsional loads were applied. Bending stiffness and fracture site angulations, as well as torsional stiffness, peak torque, and fracture site rotation were quantified and compared.

Results: Intramedullary screw fixation demonstrated greater bending stiffness and less fracture site angulation than plate fixation during plantar-to-dorsal and lateral-to-medial bending. Torsional stiffness of screw-fixed metatarsals exceeded that of plate-fixed bones at initial loading; however, as rotation progessed, the plate resisted torque better than the screw. No difference in peak torque was demonstrable between fixation methods, but it was reached earlier in specimens fixed with screws and later in those fixed with plates as rotation progressed.

Conclusions: In this cadaveric Jones fracture model, intramedullary screw fixation demonstrated bending stiffness and resistance to early torsional laoding that was superior to that offered by plate fixation.

Clinical Relevance: Although low-profile “hook” plates offer an alternative for fixation of fifth metatarsal Jones fracutures, intramedullary screw fixation may provide better resistance to bending and initiation of fracture site rotation. The influence of these mechanical characteristics on fracture healing is unknown, and further clinical investigation is warranted.