Volar radioscapholunate arthrodesis for malunited distal radius fracture with unsalvageable wrist articular degeneration: case report

Radiocarpal Fusion: Indications, Technique, and Modifications

Degenerative disorders of the wrist may affect isolated joints and inhibit normal functions of the wrist secondary to pain and stiffness. These processes that affect only the radiocarpal joint may be secondary to posttraumatic osteoarthritis, primary osteoarthritis, or rheumatoid arthritis. Radiocarpal wrist arthrodesis may help preserve some of the native wrist kinematics while alleviating pain and improving the range of motion. However, the surgeon must ensure that the patient's pathologic process primarily affects the radiocarpal articulations while relatively sparing the midcarpal articulations. Depending on the location of the pathology, isolated radiolunate or radioscapholunate arthrodesis have been described to preserve some motion in the midcarpal joint. To maximize motion in the midcarpal joint after radiocarpal arthrodesis, techniques for distal scaphoid and triquetrum excision have been described. We report patient outcomes for various techniques and describe our preferred technique for radioscapholunate arthrodesis using distal scaphoid excision.

Volar Radioscapholunate Arthrodesis and Distal Scaphoidectomy After Malunited Distal Radius Fractures

PURPOSE

The purpose of this study was to assess range of motion (ROM), pain, and incidence of radiographic degenerative joint disease (DJD) after volar radioscapholunate (RSL) arthrodesis and distal scaphoidectomy (DSE) following malunited distal radius fractures (DRF).

METHODS

Fourteen patients with malunited DRF and DJD limited to the radiocarpal joint underwent RSL arthrodesis and DSE between 2006 and 2014. These were retrospectively analyzed both clinically and radiologically. Eleven patients with a mean follow-up of 63 months (range, 30-97 months) were included in the final analysis because 1 was unavailable and 2 had died. The outcome was evaluated using parameters of pain, ROM, grip strength, nonunion rate, and DJD of the adjacent joints. In addition, self-assessment by patients was registered on the Disability of the Arm, Shoulder and Hand score, Patient-Rated Wrist Evaluation score, and Michigan Hand Outcomes Questionnaire. To investigate DJD and union, a computed tomography (CT) scan at the final follow-up visit was performed.

RESULTS

All patients showed union and no midcarpal DJD in the CT scans at final follow-up. The mean ROM in extension was 53°, flexion 42°, supination 81°, pronation 85°, radial deviation 10° and ulnar deviation 25°. The ROM in extension, extension/flexion arc, and supination improved significantly after surgery. Patients achieved a mean of 80% of grip strength compared with the other hand.

CONCLUSIONS

Volar angular stable plate RSL arthrodesis with resection of the distal scaphoid pole is a safe and effective method for treating malunited DRF. This leads to an improved ROM and low pain level.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[Operative options for rectification after failed osteosynthesis of the distal radius]

BACKGROUND

Even in an era of clear improvements in implants and standardized treatment procedures, abortive osteosynthesis after distal radius fractures is not an uncommon complication.

DIAGNOSTICS

Although not every malunion of the radius leads to complaints, affected patients often suffer from limitations in movement, reduction in strength, pain and aesthetic deficits. Following thorough clinical and imaging diagnostics a selection from the possible treatment options must be made taking the results obtained from the diagnostics into consideration.

THERAPY

Operative possibilities are available for reconstructing the anatomical features as accurately as possible, functional improvement without correction of the malunion, pain reduction alone and combined procedures.

CONCLUSION

Despite abortive osteosynthesis of distal radial fractures there are possibilities for anatomical reconstruction, retention of mobility and pain reduction. Taking the pathological deformities into consideration, the highest priority should be given to reconstructing the anatomical joint conditions as accurately as possible, even when the conservative treatment options were unsuccessful.