Distal Radius Nonunions: A Rare Entity?

Although distal radius fractures are common injuries, nonunion is extremely rare. Nonunion has been associated with increased metaphyseal comminution, concomitant distal ulna fracture, inadequate immobilization, and patient factors. Nonunion should be suspected in patients with persistent pain, limited range of motion, and worsening wrist deformity after wrist remobilization. Treatment selection depends on presence of infection, status of the radiocarpal and distal radioulnar joints, and type of prior surgical interventions. Multiple surgical techniques exist for managing distal radius nonunions including open reduction and internal fixation of the nonunion site with/without bone graft augmentation versus total wrist arthrodesis.

Staple Technology for Fracture Fixation and Joint Arthrodesis

The use of staple technology in the upper extremity has continued to evolve with the development of shape-memory alloys (SMAs) such as Nitinol that display superelastic properties that can be exploited for persistent compression. Clinical and biomechanical studies support the use of SMA staples for upper extremity fracture fixation and joint arthrodesis. To optimize biomechanical strength and clinical outcomes, it is recommended to place two staples, if possible, at the site of interest as well as to trough the staples to prevent hardware prominence.

Use of volar distal radius plate dorsally for wrist arthrodesis in patients with upper limb spasticity: A retrospective review

Standard wrist arthrodesis implants are generally designed for adult joints with arthritis. They are often too big for patients with limb spasticity who generally tend to have osteopenic and smaller bones for their age, resulting in high complication rates. We previously described the novel use of volar distal radius variable-angle locking plate (APTUS® Wrist distal radius system 2.5, Medartis AG, Basel, Switzerland) on the dorsum for wrist arthrodesis in patients with limb spasticity. This study aimed to further establish the use of the implant by reporting the outcomes in cohort A (nondistal radius plate) and cohort B (distal radius plate cohort). Patient-reported outcome measures were used to assess the primary outcome, whereas secondary outcomes included implant-related complications and improvement in wrist position and fusion rates. A total of 17 wrist arthrodesis procedures were performed over a period of 4 years in 15 patients for wrist deformity secondary to limb spasticity. There were no complaints of implant prominence, implant or tendon irritation, metacarpal prominence, or extension requiring further treatment in cohort B. Cohort A had a high implant removal rate that is comparable to the published literature. Both groups reported significant improvement in hygiene and wrist position but neither group had any appreciable gain in function. Volar distal radius variable-angle locking plates appear to be safe and have superior patient acceptability and low complication rates when used dorsally for wrist arthrodesis in patients with upper limb spasticity. Comparable overall satisfaction rates in cohort B were reported in relation to the literature and the cohort A in this study.

Long-term functional outcomes after total wrist arthrodesis

Current literature surrounding functional outcomes after total wrist arthrodesis is limited by short follow-up or limited use of validated patient reported outcome measures (PROMs). The primary aim of this study was to describe long-term functional outcomes following wrist arthrodesis. Secondary aims were to describe the incidence of complications and patient satisfaction. This was a retrospective single-center study. Patients with a minimum of 10-year follow-up completed a questionnaire including the Patient-Rated Wrist Evaluation (PRWE), the Quick version of the Disabilities of the Arm, Shoulder and Hand (Quick-DASH) score, the EQ-5D-5L score, and a question assessing satisfaction. Presence of a complication was also assessed. During the study period 66 patients underwent total arthrodesis. At a median follow-up of 15 years, complete patient reported outcomes were available for 34 patients. Thirty-two patients were lost to follow-up. Mean age at surgery was 49 and 16 patients were female. Mean PRWE and Quick-DASH scores were 44.8 (SD 27.7; range 0-96) and 41.9 (SD 23.6; range 2.3-97.7) respectively. Twenty-eight patients were satisfied. Nine patients reported complications. There were six cases of hardware removal and two cases of prominent metalwork. One patient underwent revision surgery for non-union. Presence of a complication did not affect the Quick-DASH or PRWE scores. Median EQ-5D-5L score was 0.7. This long-term follow-up suggests high levels of patient satisfaction and health related quality of life, despite significant functional disability. The complication rates are not insignificant, although the presence of a complication did not affect functional outcomes.

Wrist shortening arthrodesis with volar plate in a dorsal position for spastic wrist contracture

Total wrist arthrodesis in severe wrist flexion deformities (greater than 60°) due to spasticity represents a valid therapeutic option. It aims to improve the hand's appearance, hygiene, function and to prevent the deformity from getting worse. The objective of this study is to evaluate the clinical and anatomical results of wrist shortening arthrodesis using a classic volar plate in the dorsal position in functional surgery for central spastic hands. We conducted a single-center analysis of a series of patients who underwent this shortening arthrodesis. The review at a minimum 1-year follow-up included a clinical evaluation (House score, INOM score, patient satisfaction and complications), and anatomical evaluation (arthrodesis position, bone healing and carpometacarpal arthropathy). Twenty-eight patients with a mean age of 40.6 years (18-74) were included at a mean follow-up of 30.6 months (12-75). The fusion rate was 100%. No carpometacarpal arthropathy was noted. The mean position of the fused wrist was 11° extension and 15° ulnar tilt. There were two complications (7%): one postoperative hematoma and one case of discomfort due to impingement that required plate removal. The House score was significantly improved postoperatively (2.4 (0-5) versus 1.8 (0-4), p < 0.001), as was the INOM score (45 (12-64) versus 63 (36-84), p < 0.001). The patient satisfaction rate was 93%. The use of a simple and common material (volar plate in dorsal position) during this challenging surgery (spastic wrist contracture), provides good anatomical results and high patient satisfaction. LEVEL OF EVIDENCE: Level 4, case series, therapeutic study.

Wrist fusion in peripheral paralysis

In cases of paralysis of the upper limb, wrist fusion is useful in selected indications, especially when there are little to no tendon transfers available to restore finger function and wrist extension. Wrist fusion is particularly useful in the sequelae of brachial plexus lesions and in total paralysis of the radial nerve with hand drop and preserved wrist flexors. Numerous fusion techniques have been proposed. In cases of sequelae of brachial plexus lesions, locking of pronation-supination is associated with the wrist fusion. The use of anatomical plates has dropped the non-union and complication rates.

Wrist Arthrodesis in Athetoid Type Cerebral Palsy: A Case Study of 2 Patients

Wrist arthrodesis has been used successfully for the management of severe wrist flexion deformity when soft tissue procedures would not provide adequate correction. However, in athetoid type cerebral palsy which has a component of involuntary movement, the outcome of wrist arthrodesis has not been discussed much. We present our experience in 2 athetoid type cerebral palsy patients who underwent wrist arthrodesis due to severe involuntary movement of the wrist. One patient had a nonunion and both patients had unexpected aggravation of involuntary movement in the adjacent joints. Secure fixation using a pre-contoured plate is necessary and preparation for iliac bone grafting should be considered as proximal row carpectomy is usually not necessary in these patients. In addition, although single-event, multi-level surgery is advocated for patients with cerebral palsy, potential additional procedures for the adjacent joints should be discussed preoperatively because unexpected aggravation of involuntary movement of adjacent joints can occur after stabilization of the wrist.

Operative technique of distal radius resection and wrist fusion with iliac crest bone graft

Malignant lesions of distal radius and appropriately selected cases of benign aggressive lesions (giant cell tumor) of distal radius require resection for limb salvage. Post resection, reconstruction of that defect can be accomplished by either arthrodesis or arthroplasty both having their own pros and cons. In cases undergoing arthrodesis as modality of reconstruction, small defects (≤6 cm) can be reconstructed using autologous iliac crest bone graft which results in good cosmetic appearance and functional outcome. We have described in detail, the preoperative planning, surgical steps and rehabilitation of wrist fusion with iliac crest bone grafting post distal radius resection.

Chondrodesis of the wrist in children with severe paralytic hand deformities

We examined the anatomical and clinical results of a new wrist subphyseal arthrodesis method called chondrodesis, which relies on resorbable suture-bone fixation for children with severe paralytic hand deformities and does not require fixation devices or bone grafting. Four children's wrists underwent the procedure, resulting in three successful wrist bone fusions. The wrists were stabilized by joint fusion in 4-5 months in good positions, ranging from neutral to extension 15°, while still allowing the forearm to keep growing since the radial growth plate remained open as of the last follow-up. The procedure improved hand function (House score, Raimondi score) and appearance. It also increased control over gripping motions with the operated hand, and even restored key pinch ability in one of the patients. The youngest patient was not able to achieve bone fusion at the key sites and will need further corrective procedures at a later and more optimal age. This novel procedure is appealing because of its technical reproducibility, low cost, encouraging outcomes, ease of rehabilitation, and because it spares the physeal cartilage.

the conventional AO system: early comparative results in wrist arthrodesis

INTRODUCTION

Total wrist arthrodesis represents a reliable salvage procedure for severe painful conditions of the wrist. To date, wrist arthrodesis using a dorsal plate reaching from the distal radius to the third metacarpal is still recommended. A new implant (APTUS© 2.5 TriLock Wrist Fusion Plate, Medartis Suisse) that does not cross the third carpometacarpal joint (CMCJ-3) has been introduced recently. The purpose of this retrospective study was to compare both implants concerning early functional and clinical results.

MATERIALS AND METHODS

A total of 20 patients underwent total wrist arthrodesis [10, using the new APTUS© implant (APT); 10 using the Depuy-Synthes© LCP plates (AO)]. The postoperative control interval was 18.2 and 37.2 months in APT and AO, respectively. Clinical assessment included functional parameters such as active range of motion (AROM) for pronation and supination, grip strength, and passive range of motion of the CMCJ-3. Additionally the DASH score and the Krimmer wrist score as well as pain levels at rest and under stress conditions were evaluated.

RESULTS

All patients showed osseous healing without complications except one case of non-union in APT. There were no significant differences between both groups concerning grip strength, AROM of the wrist, pain levels, DASH- and Krimmer Score. APT showed a significantly increased passive range of motion of the CMCJ-3 compared to the unaffected contralateral side.

CONCLUSIONS

The new implant shows similar functional results compared to the standard procedure. The main advantage of the new implant is the fact that no implant removal is necessary due to the unaffected CMCJ-3. Furthermore the mobility of the CMCJ slightly increased and showed positive impact on hand kinematics.

Extended intralesional curettage preferred over resection-arthrodesis for giant cell tumour of the distal radius

BACKGROUND

Distal radius giant cell tumour (GCT) is known to be associated with distinct management difficulties, including high rates of local recurrence and lung metastases compared to other anatomic locations. Multiple treatment options exist, each with different outcomes and complications.

QUESTIONS/PURPOSES

To compare oncological and functional outcomes and complications following treatment of patients with distal radius GCT by extended intralesional curettage (EIC) or resection-arthrodesis.

METHODS

Patients operated on for distal radius GCT were identified from prospectively collected databases at four Canadian musculoskeletal oncology specialty centres. There were 57 patients with a mean age of 35.4 years (range 17-57). Thirteen tumours were Campanacci grade 2, and 40 were Grade 3 (4 unknown). Twenty patients presented with an associated pathologic fracture. There were 34 patients treated by EIC and 23 by en bloc resection and wrist arthrodesis. All resections were performed for grade 3 tumours. The mean follow-up was 86 months (range 1-280).

RESULTS

There were a total of 11 (19%) local recurrences: 10 of 34 (29%) in the EIC group compared to only 1 of 23 (4%) in the resection-arthrodesis group (p = 0.028). For the 10 patients with local recurrence following initial treatment by EIC, 7 underwent repeat EIC, while 3 required resection-arthrodesis. The one local recurrence following initial resection was managed with repeat resection-arthrodesis. Six of the 11 local recurrences followed treatment of Campanacci grade 3 tumours, while 4 were in grade 2 lesions and in one case of recurrence the grade was unknown. There were no post-operative complications after EIC, whereas 7 patients (30%) had post-operative complications following resection-arthrodesis including 4 infections, one malunion, one non-union and one fracture (p = 0.001). The mean post-operative Musculoskeletal Tumor Society score was 33.5 in the curettage group compared to 27 in the resection group (p = 0.001). The mean Toronto Extremity Salvage Score was 98.3% following curettage compared to 91.5% after resection (p = 0.006). No patients experienced lung metastasis or death.

CONCLUSIONS

EIC is an effective alternative to wide resection-arthrodesis following treatment of distal radius GCT, with the advantage of preserving the distal radius and wrist joint function, but with a higher risk of local recurrence. Most local recurrences following initial treatment by EIC could be managed with iterative curettage and joint preservation. Wide excision and arthrodesis were associated with a significantly lower risk of tumour recurrence but was technically challenging and associated with more frequent post-operative complications. EIC was associated with better functional scores. Resection should be reserved for the most severe grade 3 tumours and recurrent and complex cases not amenable to treatment with EIC and joint salvage.

LEVEL OF EVIDENCE

III, retrospective comparative trial.

Limited Wrist Arthrodesis for Scapholunate Advanced Collapse Wrist: Triangle Fixation for Four-Corner Fusion

BACKGROUND

Limited wrist arthrodesis with scaphoid excision is a useful treatment for scapholunate advanced collapse (SLAC) of the wrist. Multiple Kirschner wires were originally used for internal fixation of the four carpal bones, however long-term cast immobilization, pin tract infection, and hardware removal are still problematic. We introduce and evaluate the clinical outcomes of an internal fixation technique; triangle fixation for four-corner fusion, using three headless screws, as an alternative to conventional multiple Kirschner wires for the treatment of SLAC wrist.

METHODS

Five male patients with SLAC wrist secondary to three scaphoid nonunions and two scapholunate dissociations were treated with four-corner fusion using triangle fixation with three Double-threaded Japan screws. The mean age was 59.5 years (35-79 years) and the mean follow-up period was 40 months. After surgery, short arm splints were applied for 3-4 weeks, and then range of motion exercises were initiated.

RESULTS

Wrist range of motion and grip strength both improved postoperatively. At the final follow-up evaluation, bone union was completely achieved and satisfactory pain relief was observed in all patients.

CONCLUSIONS

Compared with the conventional Kirschner wire technique, the present technique shortens the period of splint immobilization due to a strong compression force in a skewed position, does not require pin removal or cause pin tract infections, and provides satisfactory results.

Ulna Autograft for Wrist Arthrodesis: A Novel Approach in Failed Wrist Arthoplasty

Rheumatoid arthritis is a polyarthropathy affecting approximately 1% of the population worldwide. Wrist involvement is observed around 75% of patients, resulting in substantial disability and morbidity. A multidisciplinary approach to management of such patients is undertaken to prevent disease progression, many go on to develop debilitating disease requiring surgical intervention. Total wrist arthroplasty and arthrodesis are the main options available for those with end-stage disease, with arthroplasty preferred due to its ability to preserve a good degree of wrist function. Where complications occur with total wrist arthroplasty, salvage surgery with arthrodesis can be considered, however this requires satisfactory bone stock to enable stable fusion of the joint following arthroplasty. We report our experience of Ulna strut allografts in wrist arthrodesis in the management of failed total wrist arthroplasty.

Skeletal Fixation in a Mutilated Hand

Hand fracture fixation in mutilating injuries is characterized by multiple challenges due to possible skeletal disorganization and concomitant severe injury of soft tissue structures. The effects of skeletal disruption are best analyzed as divided into specific locales in the hand: radial, ulnar, proximal, and distal. Functional consequences of injuries in each of these regions are discussed. Although a variety of implants are now in vogue, K-wire fixation has stood the test of time and is especially useful in multiple fracture situations. Segmental bone loss is quite common in such injuries, which can be safely reconstructed in a staged manner.

Wrist Arthrodesis for Failed Total Wrist Arthroplasty

PURPOSE

Treatment options for failed total wrist arthroplasty include implant revision, resection arthroplasty, and arthrodesis. Variable results associated with different techniques have been reported for arthrodesis and the procedure has substantial technical challenges, including restoration of wrist height, obtaining stable fixation, and achieving bony fusion. This study evaluates the radiographic results of a surgical technique for conversion of a failed arthroplasty to an arthrodesis.

METHODS

A retrospective chart and radiograph review was performed in 20 wrists in 18 patients in whom conversion to an arthrodesis was performed using a contoured cancellous femoral head structural allograft and a wrist arthrodesis plate. Supplemental demineralized bone matrix combined with corticocancellous allograft chips was also used in 15 wrists. Median age at arthrodesis was 61 years (range, 45-78 years), and median follow-up was 34 months (range, 4-71 months).

RESULTS

Nineteen of 20 wrists fused following the index procedure at a median of 4 months (range, 3-7 months). Proximal plate loosening occurred in 1 wrist but the joint still fused at 6 months; a successful osteotomy and revision of screw fixation was done 2 years later to correct the deformity and hardware irritation in this case. Complications were otherwise limited to 1 superficial infection that resolved with intravenous antibiotics.

CONCLUSIONS

This technique for conversion of a failed total wrist arthroplasty to a wrist arthrodesis is safe, effective, and versatile. Wrist deformity is corrected, wrist height can be restored, stable fixation is obtained, and a high rate of fusion is achieved despite filling large defects using structural cancellous allograft.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Four-corner arthrodesis with a radiolucent locking dorsal circular plate: technique and outcomes

BACKGROUND

Scaphoid excision and four-corner arthrodesis (FCA) is an acceptable motion sparing procedure used to treat wrist arthritis. Recently, a locking dorsal circular plate composed of polyether-ether-ketone has been introduced (Xpode®; TriMed Inc.). The purpose of this study is to assess the efficacy of this specific plate design with regard to FCA.

METHODS

A retrospective chart review of all patients who underwent FCA with an Xpode® between January 1, 2008 and December 31, 2012 was conducted. Patients were contacted and asked to return to clinic for clinical and radiographic follow-up. Patient demographics, range of motion, grip strength, and complications were collected from medical records. Patients completed a patient-rated wrist evaluation (PRWE). A paired t test was used to compare means, and p values <0.05 were considered statistically significant.

RESULTS

Twenty-six procedures (24 patients) were identified. One patient required full wrist fusion following the initial procedure. Of the 25 remaining wrists, arthrodesis was successfully achieved in 20 (80 %). Eleven patients (13 wrists, 52 %) returned to clinic for an average follow-up of 28 months. Mean wrist extension improved from 30 to 47°, and flexion decreased from 33 to 23°. Average grip strength was 77 % of the uninjured side. The mean PRWE scores for pain and function were 19.7 and 17.1, respectively. Five patients underwent additional operations (two hardware removals, two contracture releases, and one distal radial ulnar joint arthroplasty).

CONCLUSIONS

FCA with the Xpode® yielded reasonable results for pain and function and demonstrated a fusion rate of 80 %.

[Capitolunate arthrodesis: 12 patients followed-up an average of 10 years]

The aim of the study was to evaluate long-term results of capitolunate arthrodesis for the treatment of posttraumatic degenerative wrist disorders. A capitolunate arthrodesis was performed on 12 patients, three women and nine men, of 45 years on average (28-66). Ten patients were manual workers. Dominant side was involved in seven cases. Indications were nine scapholunate dissociations (SLAC) and three scaphoid non-unions (SNAC) with degenerative lesions. Fixation of the arthrodesis was performed with K-wires in seven, K-wires and staples in two, and only staples in three. Patients were reviewed at 118 months of average follow-up (72-168). One complete wrist arthrodesis was necessary one year after the capitolunate arthrodesis for an evolutive painful osteoarthritis. For the 11 remaining patients, pain on visual analogic scale (VAS) was 0.5. The flexion/extension arc was decreased of 25° and strength of 6kg compared to preoperative values. DASH score was equal to 33.7 points, Cooney score to 77.2 points and Mayo score to 82.8 points. Radiolunate and capitolunate angles were decreased of 4.9° and 6.2° respectively compared to preoperative values. Some complications occurred: evolutive osteoarthritis between triquetrum and lunate in two, non-union of the arthrodesis in one, and reflex sympathetic dystrophy in two. Nine patients were able to return to their previous professional activities. Capitolunate arthrodesis allowed restoring a pain free and functional wrist in eight out of the 11 patients reviewed. Results were maintained with follow-up. It is a satisfactory therapeutic alternative to four corners fusion for chronic instability of the wrist with osteoarthritis.

LEVEL OF EVIDENCE

IV.