Outcomes using an internal osteotomy and distraction device for corrective osteotomy of distal radius malunions requiring correction in multiple planes

A Standard Set for Outcome Measurement in Patients With Hand and Wrist Conditions: Consensus by the International Consortium for Health Outcomes Measurement Hand and Wrist Working Group

PURPOSE

To describe the principles, process, and results of creating the International Consortium for Health Outcomes Measurement (ICHOM) standard set for hand and wrist conditions.

METHODS

Following the standardized methods of ICHOM, an international working group of hand surgeons, therapists, and researchers was assembled to develop an evidence-based, patient-centered, standard set of outcome measures for patients with hand and wrist conditions. Multiple systematic reviews were performed to support our choices of outcome domains and tools for hand and wrist conditions. Fourteen video conferences were held between March 2018 and March 2020, and a modified Delphi process was used.

RESULTS

A consensus was reached on 5 measurement tracks: the thumb, finger, wrist, nerve, and severe hand trauma tracks, with a distinction between regular and extended tracks for which specific allocation criteria applied. The standard set contains a selection of outcome tools and predefined time points for outcome measurement. Additionally, we developed a hierarchy for using the tracks when there are multiple conditions, and we selected risk-adjustment, case-mix variables.

CONCLUSIONS

The global implementation of the ICHOM standard set for hand and wrist conditions may facilitate value-based health care for patients with hand and wrist conditions.

CLINICAL RELEVANCE

The ICHOM standard set for hand and wrist conditions can enable clinical decision making, quality improvement, and comparisons between treatments and health care professionals.

Distal radius malunion in adults

Distal radius malunion (DRMU) consists in a non-anatomical consolidation of a distal radius fracture. The resulting alteration of the articular or extra-articular radial anatomy impairs wrist function to a greater or lesser degree: Restricted ranges of motion, loss of strength, pain. There may also be nerve or tendon involvement. Adaptive carpal malalignment and ulnar-carpal impingement are also possible. Imaging assessment should at least include X-ray and CT; CT-arthrography is essential in intra-articular DRMU, which regularly progresses toward radiocarpal osteoarthritis. Surgical indications are guided by clinical assessment. Restoring distal radial anatomy requires osteotomy, according to type of DRMU: anterior or posterior opening or closing wedge. Bone or bone-substitute graft may need to be associated. Computerisation has improved planning and should be implemented, whenever possible. Ulnar osteotomy may be performed, isolated or associated to distal radial osteotomy. Palliative partial fusion or bone resection is possible in case of joint involvement or in patients with low functional demand.

Early Correction of Distal Radius Partial Articular Malunion Leads to Good Long-term Functional Recovery at Mean Follow-up of 4 Years

Background: Distal radius articular step-off or deformity may cause posttraumatic arthritis and poor functional outcome. The purpose of this study was to evaluate pain and functional outcomes in patients with malunited partial articular distal radius fractures who underwent corrective osteotomy. We hypothesized that anatomic restoration of distal radius articular surface after a malunited partial articular distal radius fracture results in improvement in pain and functional measures and delays the development of posttraumatic arthritis. Methods: Seven consecutive patients with mean age of 38 years underwent corrective osteotomy via either a standard dorsal approach or combined dorsal and volar approach. Mean time from injury to corrective osteotomy was 10 weeks. Patients were assessed with respect to Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), forearm and wrist range of motion, pain, and grip strength. Results: At mean follow-up of 44 months, significant improvements in pain scores (7.1-0.9, P < .001), QuickDASH (38.7-11.6, P < .001), grip strength (21.4-30.0 kg, P = .01) were achieved. All range of motion measurements demonstrated significant improvements except forearm pronation. One patient demonstrated radiographic evidence of osteoarthritis but had no pain at final follow-up. No patients required secondary surgery for removal of symptomatic hardware. Conclusions: Based on these findings, we recommend that early corrective osteotomies should be considered in young patients with intra-articular distal radius malunions before considering salvage procedures such as partial or complete wrist arthrodesis.

Bifocal osteosynthesis to treat radial shortening deformity with dislocation of the inferior radioulnar joint

Background

Several methods have been reported to correct deformity and shortening of the distal radius. However, the results are not entirely satisfactory. The results of bifocal osteosynthesis were retrospectively analyzed in this study.

Methods

Eight patients treated with bifocal osteosynthesis were evaluated retrospectively. Pre-operative and post-operative clinical and radiographic examinations were performed. Subjective symptoms and objective joint function were assessed. Radiographic data of the extent of radial lengthening and distal radial articular angle were collected.

Results

The mean follow-up period was 46 months (37–68 months). Satisfactory wrist appearance and radial lengthening was achieved in all patients. All patients were satisfied with the wrist appearance and willing to undergo the same treatment again. The range of motion (ROM) of the forearm and wrist was significantly improved. Pin-track infections occurred in two patients, for which they received wound care and oral antibiotics. Complications such as fixation device failure, tendon rupture, fracture of regenerated bone or nerve impairment did not occur. The duration of lengthening depended on the shortening of the radius. Delayed union in the docking site was observed in two patients and union was achieved after bone grafting.

Conclusions

Bifocal osteosynthesis using the Ilizarov method provides a useful method for correction of radial shortening deformity with dislocation of the inferior radioulnar joint. Despite the fact that we did not validate pre-and post-operation functional outcome scores, all patients were satisfied with the wrist appearance and function.

Carpal Tunnel Syndrome Following Corrective Osteotomy for Distal Radius Malunion: A Rare Case Report and Review of the Literature

BACKGROUND

Although median nerve neuropathy and carpal tunnel syndrome (CTS) are known complications of both untreated and acutely treated distal radius fracture, median neuropathy after correction of distal radius malunion is not commonly reported in hand surgery literature. We describe a patient with severe CTS after corrective osteotomy, open reduction internal fixation (ORIF) with a volar locking plate (VLP), and bone grafting for distal radius malunion.

METHODS

We report a case of severe acute CTS as a complication of corrective osteotomy with bone grafting for distal radius malunion.

RESULTS

The patient was treated with surgical exploration of the median nerve and carpal tunnel release.

CONCLUSION

The authors report a case of acute CTS after ORIF with VLP for a distal radius malunion warranting surgical exploration and carpal tunnel release. Treatment teams must be aware of this potential complication so that the threshold for reoperation is low and irreversible damage to the median nerve is prevented.

Management of malunions of the distal radius

Despite encouraging results from small case series, correction of distal radius malunion remains a challenging procedure with uncertain outcomes. The most appropriate treatment for a distal radius malunion is prevention. If a symptomatic malunion is discovered, correction should be undertaken as early as possible. It is recommended that action be taken within six months of the primary injury to decrease the negative impact of soft-tissue contracture on the eventual reconstruction. Although some patients complain about residual problems after malunion surgery, corrective surgery has been shown to improve both radiographic and functional outcomes, and may prevent future secondary problems.

Is distal ulna resection influential on outcomes of distal radius malunion corrective osteotomies?

INTRODUCTION

The mechanical repercussions of distal radius malunion on the distal radio-ulnar (DRU) joint are common and inconsistently corrected by radius osteotomy alone. Ulnar resection has thus become a palliative solution.

HYPOTHESES

Does ulna resection influence the outcomes of distal radius malunion corrective osteotomies? What preoperative factors warrant preserving the distal radio-ulnar joint?

PATIENTS AND METHODS

Twenty-one corrective osteotomies of the radius were retrospectively reviewed. Ulna resection was performed in cases of cartilage damage, joint incongruence, or persistent stiffness in pronosupination after osteotomy of the radius. After the osteotomies, two groups were identified: 10 cases with preservation of the distal end of the ulna (DRU+) and eleven with distal resections (DRU-).

RESULTS

At review, all the osteotomies had united, with comparable anatomical restoration of the radial epiphysis for the two groups. We noted a statistically significant gain in mobility after osteotomy for both techniques (but no difference between them) and comparable grip strengths with 89.8% of the contralateral side for the DRU+ group versus 90.4% for the DRU- group. Pain (scale, 0-3) had significantly diminished for both groups decreasing from 1.9 to 0.3 for the DRU+ group and from 2.5 to 1.1 for the DRU- group, with no significant difference between them. The Mayo Clinic Wrist Score and the DASH score did not differ significantly with 73/100 and 13.5 for the DRU+ group compared with 68.2/100 and 20.2 for the DRU- group, respectively.

DISCUSSION

These results show that the impact of ulna resection after distal osteotomy of the radius is limited as reflected by radiological correction, mobility and grip strength. However, after resection pain in the ulnar tilt of the wrist due to instability of the distal ulnar stump was noted. Besides cartilage damage, ulnar deviation of over 5mm was, for this series, a constant factor in non-preservation of the DRU joint.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Outcomes of trapeziectomy with a modified abductor pollicis longus suspension arthroplasty for the treatment of thumb carpometacarpal joint osteoarthritis

PURPOSE

Various arthroplasty procedures have been described for the treatment of thumb carpometacarpal joint osteoarthritis. The purpose of this study was to determine the outcomes of patients treated with trapeziectomy and a variation of abductor pollicis longus suspension arthroplasty.

METHODS

Eighteen consecutive patients were treated by a single surgeon (K.C.C.) with trapeziectomy and abductor pollicis longus suspension arthroplasty (21 thumbs). Prospective outcomes data were collected before the operation and at 3, 6, and 12 months after surgery. Outcomes were assessed with x-rays, grip/key pinch strength, the Jebsen-Taylor test, and the Michigan Hand Outcomes Questionnaire.

RESULTS

Immediately after surgery, a 32 percent loss in carpometacarpal joint height was observed and an additional 11 percent proximal metacarpal migration was observed at 1 year. The mean grip strength was 11.1 kg preoperatively and 7.7, 14.3, and 16.7 kg at 3 months, 6 months, and 1 year postoperatively, respectively. Michigan Hand Outcomes Questionnaire results demonstrated improvements in all domains. Statistically significant improvements were noted in the domains of overall score, from 41 to 67 (p = 0.03); activities of daily living, from 43 to 66 (p = 0.01); work, from 41 to 65 (p = 0.05); patient satisfaction, from 25 to 68 (p = 0.01); and pain, which decreased from 73 to 30 (p < 0.01).

CONCLUSIONS

Abductor pollicis longus suspension arthroplasty is a faster and technically easier technique that avoids any additional deficit by using an accessory tendon. This procedure gives acceptable patient-rated outcomes, especially in pain relief and satisfaction.

Long-term outcomes of corrective osteotomy for the treatment of distal radius malunion

Corrective osteotomy is an established but challenging treatment for distal radius malunion. Short- and intermediate-term results have been previously published while long-term results have not. The long-term results of 22 patients treated with corrective osteotomy for symptomatic distal radius malunion are presented (range 6-24 years, mean 13 years). All patients completed the DASH questionnaire and the modified Gartland and Werley, and Green and O'Brien scores postoperatively. Wrist alignment was assessed through standard wrist radiographs. Average wrist flexion-extension was 72.5% of the contralateral limb. Grip strength averaged 71%. The DASH score averaged 16 points corresponding to mild perceived disability. Results were categorized as fair on both the Gartland and Werley score (average 9 points) and the modified Green and O'Brien score (average 67 points). Wrist alignment was maintained over time but 13 patients presented mild to moderate symptomatic wrist arthritis. The outcome presented may be a reflection of the use of stricter evaluation instruments or reflect the development of post-traumatic arthritis.

Clinical research in hand surgery

Clinical research designed to enhance the quality of health care has always received a great deal of national attention. Outcomes studies, clinical trials, and evidence-based research are key components of clinical research that have advanced the field of hand surgery. The purpose of the Weiland Award is to encourage innovations and progress in clinical research in hand surgery for the betterment of patients and to promote hand surgery's visibility in American medicine. This article will highlight my efforts in clinical research through 3 specific research themes: (1) outcomes research, (2) economic analysis, and (3) evidence-based research and quality assessment in health care.

The effect of ulnar styloid fractures on patient-rated outcomes after volar locking plating of distal radius fractures

PURPOSE

Ulnar styloid fractures commonly occur with distal radius fractures (DRFs). Ulnar styloid fractures that involve the insertion of the radioulnar ligaments can cause distal radioulnar joint (DRUJ) instability, and the literature suggests that these fractures should be treated with open reduction internal fixation (ORIF). However, in the absence of DRUJ instability, the effects of ulnar styloid fractures are unknown. The purpose of this study is to evaluate the outcome of ulnar styloid fractures without DRUJ instability on patient-rated outcomes after DRF ORIF.

METHODS

Between 2003 and 2008, a cohort of DRF patients treated with volar plating was enrolled. Patients with DRUJ instability treated at the time of distal radius ORIF were excluded. Radiographs were evaluated to identify and characterize ulnar styloid fractures. Patient-rated outcomes were measured at 6 weeks, 3 months, 6 months, and 12 months postoperatively using the Michigan Hand Outcomes Questionnaire (MHQ). Regression analysis was performed to determine whether the presence of an ulnar styloid fracture, the size or displacement of the fracture, or the healing status of the fracture was predictive of MHQ scores.

RESULTS

One-hundred and forty-four patients were enrolled; 88 patients had ulnar styloid fractures. During the collection period, DRUJ instability was found intraoperatively in 3 patients; these patients had ulnar styloid ORIF and were not enrolled. The 144 patients with a stable DRUJ after DRF ORIF maintained DRUJ stability after surgery. In these patients, the presence of an ulnar styloid fracture did not affect MHQ scores. Furthermore, the size of the ulnar styloid fracture, the degree of displacement, and the healing status of the ulnar styloid did not affect MHQ scores.

CONCLUSIONS

In patients with a stable DRUJ after DRF ORIF ulnar styloid fractures did not affect subjective outcomes as measured by the MHQ.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.