Fixed Subluxation of the Distal Radioulnar Joint following Malunion of the Ulnar Styloid Process.

Purpose Recent literature on significance and treatment of ulnar styloid fractures suggest that the ulnar styloid is not the central problem but the radioulnar ligaments and their impact on joint stability. However, specifically displaced ulnar styloid process fractures that secondarily heal in an ectopic position remain a rare situation for which diagnostics and treatment options remain a topic of discussion. Methods This case series presents four patients with limited supination due to a fixed dorsal subluxation of the distal radioulnar joint (DRUJ). The reason here fore was a significant malunion of ulnar styloid fracture that was addressed by corrective ulnar styloid osteotomy. Three of these osteotomies used three-dimensional (3D) preoperative planning and patient specific guides. Results All patients presented with a significant displacement of the malunited ulnar styloid fracture (average 32-degree rotation and 5-mm translation). In all four patients, the fixed subluxation of the ulnar head was resolved clinically and radiographically, and the forearm rotation restored after corrective osteotomy of the ulnar styloid and fixation in an anatomical position. Conclusion This case series presents a very specific subset of patients with nonanatomically healed ulnar styloid fractures responsible for a chronic DRUJ dislocation and limited prosupination and its treatment. Level of evidence This is a Level IV, therapeutic study.

Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists. RESULTS: Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. CONCLUSIONS: Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. CLINICAL RELEVANCE STATEMENT: MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. KEY POINTS: • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Surgical fixation techniques in four-corner fusion of the wrist: a systematic review of 1103 cases.

BACKGROUND: Four-corner fusion (4CF) is a known treatment option for degenerative wrist conditions. Different techniques may be used and there is no general consensus on best implant. As such, it was the purpose of the current systematic review to compare fusion rates and outcomes depending on the fixation technique. METHODS: The systematic review was registered in the international prospective register of systematic reviews (PROSPERO): CRD42020164301. It followed the PRISMA guidelines. Original articles were screened using the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and Web of Science Core Collection. Studies reporting on outcome for 4CF surgery were included. Studies with a minimum Level IV of evidence were considered eligible. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: A total of 29 studies met the inclusion criteria, for a total of 1103 wrists. The mean age was 41.8 years (range 19-83). Mean follow-up overall was 43.5 months (range 24-146 months). Reported fusion weighted rates were >90% and did not differ significantly between techniques. Reoperations due to different reasons occurred in 135 (12%) of all 1103. There was significant data heterogeneity regarding fusion rates (I2 = 70%). Inconsistency and heterogeneity in data reporting did not allow meta-analysis with direct data pooling and comparison of subgroups. CONCLUSIONS: Satisfactory fusion rates (over 90%) can be achieved independent of the fixation technique used in 4-corner arthrodesis. Due to the high data heterogeneity and reporting inconsistency across studies, no statements regarding PROMs, ROM or grip strength can be made. LEVEL OF EVIDENCE: Systematic Review of Level IV Studies.

Three-Dimensional Planning and Patient-Specific Instrumentation for the Fixation of Distal Radius Fractures.

Background and Objectives: Three-dimensional planning and guided osteotomy utilizing patient-specific instrumentation (PSI) with the contralateral side used as a reference have been proven as effective in the treatment of malunions following complex fractures of the distal radius. However, this approach has not yet been described in relation to fracture reduction of the distal radius. The aim of this study was to assess the technical and logistical feasibility of computer-assisted surgery in a clinical setting using PSI for fracture reduction and fixation. Materials and Methods: Five patients with varied fracture patterns of the distal radius underwent operative treatment with using PSI. The first applied PSI guide allowed specific and accurate placement of Kirschner wires inside the multiple fragments, with subsequent concurrent reduction using a second guide. Results: Planning, printing of the guides, and operations were performed within 5.6 days on average (range of 1-10 days). All patients could be treated within a reasonable period of time, demonstrating good outcomes, and were able to return to work after a follow-up of three months. Mean wrist movements (°) were 58 (standard deviation (SD) 21) in flexion, 62 (SD 15) in extension, 73 (SD 4) in pronation and 74 (SD 10) in supination at a minimum follow-up of 6 months. Conclusions: Three-dimensional planned osteosynthesis using PSI for treatment of distal radius fractures is feasible and facilitates reduction of multiple fracture fragments. However, higher costs must be taken into consideration for this treatment.

Clinical, radiological and patient-rated outcome comparison between total and partial ulnar head implants.

This study aimed to analyse the clinical and radiological outcomes after ulnar head replacement and to compare partial and total ulnar head implants. Twenty-two patients with 23 implants were available with a mean follow-up time of 7 years (range 1.3 to 17) after distal radioulnar joint arthroplasty. At the final follow-up, patients had a low level of pain at rest and during effort, a median Disabilities of the Arm, Shoulder, and Hand (DASH) score of 12 and Patient-Rated Wrist Evaluation score of 12 with partial ulnar head implants, and scores of 20 and 22 in total ulnar head implants, respectively. While the range of motion in patients with partial ulnar head implants was slightly reduced in comparison with the preoperative condition and to the patients with total ulnar head implants, there was a tendency to a higher grip strength and rotational torque. Both types of prosthesis showed sigmoid notch resorptions and resorptions around the neck. We conclude that the results after partial ulnar head replacement do not significantly differ from the total ulnar head implants in many aspects.Level of evidence: III.

Intermediate-Term Outcome of 3-Dimensional Corrective Osteotomy for Malunited Distal Radius Fractures With a Mean Follow-Up of 6 Years.

PURPOSE: Our study aimed to analyze the functional and radiological intermediate-term outcome of 3-dimensional-guided corrective osteotomies for malunited distal radius fractures and to evaluate the progression of osteoarthritis after this intervention. METHODS: All patients with malunited distal radius fractures who underwent 3-dimensional-guided corrective osteotomies from October 2008 to January 2015 were included. Pre- and postoperative range of motion, grip strength, and postoperative patient-reported outcomes were assessed. Pre- and postoperative osteoarthritis grading was performed using conventional radiographs and the osteoarthritis grading system described by Knirk and Jupiter. Additionally, the evaluation of articular stepoff was performed using pre- and postoperative computed tomography. RESULTS: Fifteen patients, with a mean follow-up of 6 years (range, 4.1-10.4 years), were included. According to rater 1, 8 cases had no postoperative osteoarthritis progression, 6 cases had progression of 1 grade, and 1 case had progression of 2 grades. According to rater 2, there was no progression in 11 cases, and there was progression of 1 grade in 2 cases and progression of 2 grades in 2 cases. Compared with before the surgery, the patients demonstrated a mean improvement of 14.8 kg (±12.6 kg) in grip strength after the surgery. At the last follow-up, the mean Patient-Rated Wrist Evaluation score was 11.8 (±12.0), the mean Disabilities of the Arm, Shoulder and Hand score was 11.1 (±11.4), and the mean residual pain score on the visual analog scale was 0.8 (±1.0). CONCLUSIONS: The intermediate-term outcome of 3-dimensional-guided corrective osteotomies for distal radius intra-articular malunions showed excellent patient-reported outcomes and no clinically relevant progression of osteoarthritis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Long-term results of Sauvé-Kapandji procedure.

The Sauvé-Kapandji procedure is an established treatment option for distal radioulnar joint dysfunction. We retrospectively analysed 36 patients following Sauvé-Kapandji procedure between 1997 and 2013. Fifteen patients were available for a follow-up after a mean of 13 years (range 6 to 23). Six patients needed revision surgery because of ulnar stump instability. Radiographs and sonography were performed to quantify the instability of the proximal ulnar stump. These showed a radioulnar convergence of 8 mm without weight and 2 mm while lifting 1 kg. Sonographically, the proximal ulnar stump dislocated by 8 mm to the volar side while applying pressure to the palm, compared with 4 mm on the contralateral side. Sonographically measured ulnar stump instability showed a positive strong correlation with the Disabilities of the Arm, Shoulder and Hand questionnaire and Patient-Reported Wrist Evaluations and a negative strong correlation with grip strength and supination torque. Because of the high incidence of revision surgery due to instability of the proximal ulnar stump, we restrict the use of the Sauvé-Kapandji procedure only to very selected cases.Level of evidence: IV.

Inter-rater variability of three-dimensional fracture reduction planning according to the educational background.

BACKGROUND: Computer-assisted three-dimensional (3D) planning is increasingly delegated to biomedical engineers. So far, the described fracture reduction approaches rely strongly on the performance of the users. The goal of our study was to analyze the influence of the two different professional backgrounds (technical and medical) and skill levels regarding the reliability of the proposed planning method. Finally, a new fragment displacement measurement method was introduced due to the lack of consistent methods in the literature. METHODS: 3D bone models of 20 distal radius fractures were presented to nine raters with different educational backgrounds (medical and technical) and various levels of experience in 3D operation planning (0 to 10 years) and clinical experience (1.5 to 24 years). Each rater was asked to perform the fracture reduction on 3D planning software. RESULTS: No difference was demonstrated in reduction accuracy regarding rotational (p = 1.000) and translational (p = 0.263) misalignment of the fragments between biomedical engineers and senior orthopedic residents. However, a significantly more accurate planning was performed in these two groups compared with junior orthopedic residents with less clinical experience and no 3D planning experience (p < 0.05). CONCLUSION: Experience in 3D operation planning and clinical experience are relevant factors to plan an intra-articular fragment reduction of the distal radius. However, no difference was observed regarding the educational background (medical vs. technical) between biomedical engineers and senior orthopedic residents. Therefore, our results support the further development of computer-assisted surgery planning by biomedical engineers. Additionally, the introduced fragment displacement measure proves to be a feasible and reliable method. LEVEL OF EVIDENCE: Diagnostic Level II.

Accuracy and Early Clinical Outcome After 3-Dimensional Correction of Distal Radius Intra-Articular Malunions Using Patient-Specific Instruments.

PURPOSE: To investigate the residual articular incongruity on computed tomography image data and the early clinical outcome of 3-dimensional planned and navigated intra-articular osteotomies of the distal radius. METHODS: We conducted a retrospective analysis of intra-articular osteotomies executed between 2008 and 2016. We identified 37 patients (aged 26-73 years) and performed a combined intra-articular and extra-articular osteotomy on 20 patients. A preoperative 3-dimensional plan with the superimposed bone of the contralateral healthy side was performed in each case to analyze and execute the osteotomy by intraoperative navigation. The residual articular incongruity was assessed by quantification of the maximal stepoff in the coronal or sagittal computed tomography scans. Clinical outcome, including range of motion, grip strength, and return to work, was assessed after a minimum follow-up of 12 months and compared with preoperative measurements. RESULTS: On average, the preoperative intra-articular stepoff was 2.5 mm (±0.6 mm; range, 1.4-4.2 mm) and was significantly reduced to 0.8 mm (±0.2 mm) after surgery. After surgery, 30 patients had a stepoff less than 1 mm; in 7, a stepoff of 1.1 to 1.4 mm was measured. After 1 year, 22 had no pain, 9 had slight pain during heavy work, and 5 had moderate pain with no improvement compared with their preoperative status, although wrist strength and range of motion improved in all 37 patients. One patient underwent a secondary radioscapholunate arthrodeses owing to persistent pain despite a congruent joint with a small residual intra-articular stepoff (0.6 mm). CONCLUSIONS: Intra-articular osteotomies of the distal radius treated by 3-dimensional preoperative planning and patient-specific guides are an accurate technique to reduce articular incongruity to an average stepoff of 0.8 mm (range, 0.3-1.4 mm). The early clinical outcomes demonstrated overall reduction in pain and improvement of range of motion and grip strength in 36 of 37 patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Three-Dimensional Automated Assessment of the Distal Radioulnar Joint Morphology According to Sigmoid Notch Surface Orientation.

PURPOSE: To develop reproducible 3-dimensional measurements for quantification of the distal radioulnar joint (DRUJ) morphology. We hypothesized that automated 3-dimensional measurement of the ulnar variance (UV) and the sigmoid notch (SN) angle would be comparable to those of the reference standard while overcoming some drawbacks of conventional 2-dimensional measurements. METHODS: Radiological data of healthy forearm bones (radiographs and computed tomography) of 53 adult subjects were included in the study. Automated measurements were developed for assessment of the SN morphology based on 3-dimensional landmarks, incorporating subject-specific estimation of cartilage surface orientation. A common anatomical reference was defined among the different imaging modalities and a comparison of the SN angle and UV measurements was performed in radiographs, computed tomography scans, and 3-dimensional models. Finally, the 3-dimensional UV measurements were evaluated in an experimental setup using 3-dimensional printed bone models. RESULTS: The automated 3-dimensional measurements of SN subtypes showed a notably larger notch radius (18.9 mm) for negative SN angles compared with positive SN angles in subjects (16.9 mm). Similar UV measurements were obtained in healthy DRUJ morphologies, with a high correlation between radiographs and 3-dimensional measurements for the SN angle (0.77) and UV (0.85). In the experimental setup with pathological radial inclinations, UV was on average 1.13 mm larger in the radiographs compared with the 3-dimensional measurements, and 1.30 mm larger in the cases with pathological palmar tilts. Furthermore, UV radiograph measurements on the modified palmar tilt deviated from the 3-dimensional measurements. CONCLUSIONS: The developed 3-dimensional automated measurements were able to quantify morphological differences among sigmoid notch subtypes and were comparable to those of the reference standard. CLINICAL RELEVANCE: The developed methods do not depend on the forearm position or orientation of the distal radius and can be used for 3-dimensional quantification of DRUJ pathologies in 3-dimensional surgical planning.

An automatic genetic algorithm framework for the optimization of three-dimensional surgical plans of forearm corrective osteotomies.

Three-dimensional (3D) computer-assisted corrective osteotomy has become the state-of-the-art for surgical treatment of complex bone deformities. Despite available technologies, the automatic generation of clinically acceptable, ready-to-use preoperative planning solutions is currently not possible for such pathologies. Multiple contradicting and mutually dependent objectives have to be considered, as well as clinical and technical constraints, which generally require iterative manual adjustments. This leads to unnecessary surgeon efforts and unbearable clinical costs, hindering also the quality of patient treatment due to the reduced number of solutions that can be investigated in a clinically acceptable timeframe. In this paper, we propose an optimization framework for the generation of ready-to-use preoperative planning solutions in a fully automatic fashion. An automatic diagnostic assessment using patient-specific 3D models is performed for 3D malunion quantification and definition of the optimization parameters' range. Afterward, clinical objectives are translated into the optimization module, and controlled through tailored fitness functions based on a weighted and multi-staged optimization approach. The optimization is based on a genetic algorithm capable of solving multi-objective optimization problems with non-linear constraints. The framework outputs a complete preoperative planning solution including position and orientation of the osteotomy plane, transformation to achieve the bone reduction, and position and orientation of the fixation plate and screws. A qualitative validation was performed on 36 consecutive cases of radius osteotomy where solutions generated by the optimization algorithm (OA) were compared against the gold standard solutions generated by experienced surgeons (Gold Standard; GS). Solutions were blinded and presented to 6 readers (4 surgeons, 2 planning engineers), who voted OA solutions to be better in 55% of the time. The quantitative evaluation was based on different error measurements, showing average improvements with respect to the GS from 20% for the reduction alignment and up to 106% for the position of the fixation screws. Notably, our algorithm was able to generate feasible clinical solutions which were not possible to obtain with the current state-of-the-art method.

Improving accuracy of opening-wedge osteotomies of distal radius using a patient-specific ramp-guide technique.

BACKGROUND: Opening-wedge osteotomies of the distal radius, performed with three-dimensional printed patient-specific instruments, are a promising technique for accurate correction of malunions. Nevertheless, reports of residual malalignments and discrepancies in the plate and screw position from the planned fixation exist. Consequently, we developed a patient-specific ramp-guide technique, combining navigation of plate positioning, osteotomy cutting, and reduction. The aim of this study is to compare the accuracy of navigation of three-dimensional planned opening-wedge osteotomies, using a ramp-guide, over state-of-the-art guide techniques relying solely on pre-drilled holes. METHODS: A retrospective analysis was carried out on opening-wedge osteotomies of the distal radius, performed between May 2016 and April 2017, with patient-specific instruments. Eight patients were identified in which a ramp-guide for the distal plate fixation was used. We compared the reduction accuracy with a control group of seven patients, where the reduction was performed with pre-drilled screw holes placed with the patient-specific instruments. The navigation accuracy was assessed by comparing the preoperative plans with the postoperative segmented, computed tomography scans. The accuracy was expressed using a 3D angle and in measurements of all six degrees of freedom (3 translations, 3 rotations), with respect to an anatomical coordinate system. RESULTS: The duration of the surgery of the ramp-guide group was significantly shorter compared to the control group. Significantly less rotational and translational residual malalignment error was observed in the open-wedged osteotomies, where patient-specific instruments with ramp-guides were used. On average, a residual rotational malalignment error of 2.0° (± 2.2°) and a translational malalignment error of 0.6 mm (± 0.2 mm) was observed in the ramp-guide group, as compared to the 4.2° (± 15.0°) and 1.0 mm (± 0.4 mm) error in the control group. The used plate was not significantly positioned more accurately, but significantly fewer screws (15.6%) were misaligned in the distal fragment compared to the control group (51.9%). CONCLUSION: The use of the presented ramp-guide technique in opening-wedge osteotomies is improving reduction accuracy, screw position, and surgical duration, compared to the existing patient-specific instrument based navigation methods.

Corrective Osteotomies of Phalangeal and Metacarpal Malunions Using Patient-Specific Guides: CT-Based Evaluation of the Reduction Accuracy.

BACKGROUND: Surgical planning of corrective osteotomies is traditionally based on conventional radiographs and clinical findings. In the past 10 years, 3-dimensional (3D) preoperative planning approaches with patient-specific guides have been developed. However, the application of this technology to posttraumatic deformities of the metacarpals and phalangeal bones has not yet been investigated. Our goal was to evaluate the feasibility of the surgical application to the latter and to evaluate the extent and precision of correction. METHODS: We present results of 6 patients (8 osteotomies) treated with phalangeal or metacarpal corrective osteotomy. Deformities were located in the third ray in 1, fourth ray in 3, and fifth ray in 4 cases. Six malunited metacarpal bones (1 intra-articular) and 2 deformed proximal phalanges were treated. Computer-based 3D preoperative planning using the contralateral hand as a template allowed the production of 3D-printed patient-specific guides that were used intraoperatively for navigation. The precision of the reduction was assessed using pre- and postoperative computed tomography by comparing the postoperative bone model with the preoperatively simulated osteotomy. Range of motion and grip strength were documented pre- and postoperatively. RESULTS: The mean follow-up time was 6 months (range: 5-11 months). Rotational deformity was reduced from a mean of 10.0° (range: 7.2°-19.3°) preoperatively to 2.3° (range: 0.7°-3.7°) postoperatively, and translational incongruency decreased from a mean of 1.4 mm (range: 0.7-2.8 mm) to 0.4 mm (range: 0.1-0.9 mm). CONCLUSION: Preliminary results indicate that a precise reduction for corrective osteotomies of metacarpal and phalangeal bones can be achieved by using 3D planning and patient-specific guides.

Accuracy and Early Clinical Outcome of 3-Dimensional Planned and Guided Single-Cut Osteotomies of Malunited Forearm Bones.

PURPOSE: To investigate the reduction accuracy of 3-dimensional planned single-cut osteotomies (SCOTs) of the forearm that were performed using patient-specific guides. METHODS: A retrospective analysis of SCOTs performed between 2012 and 2014 was performed. Ten patients (age, 15-59 years) with 6 malunions of the ulna and 6 malunions of the radius were identified. The reduction accuracy was assessed by comparing the 3-dimensional preoperative plan of each osteotomy with the superimposed bone model extracted from postoperative computed tomography data. The difference was assessed by 3-dimensional angle and in all 6 degrees of freedom (3 translations, 3 rotations) with respect to an anatomical coordinate system. Wrist range of motion and grip strength was assessed after a mean of 16.7 months and compared with the preoperative measurements. RESULTS: On average, the 12 SCOTs demonstrated excellent accuracy of the reduction with respect to rotation (ie, pronation/supination, 4.9°; flexion/extension, 1.7°; ulnar/radial angulation, 2.0°) and translation (ie, proximal/distal, 0.8 mm; radial/ulnar, 0.8 mm; dorsal/palmar, 0.8 mm). A mean residual 3-dimensional angle of 5.8° (SD, 3.6°) was measured after surgery. All 6 patients operated on for reasons of a reduced range of motion demonstrated improved symptoms and increased movement (from 20° to 80°). In the patients with unstable/painful distal radioulnar joint, 3 were totally free of complaints and 1 patient showed residual pain during sports. CONCLUSIONS: A SCOT combined with patient-specific guides is an accurate and reliable technique to restore normal anatomy in multiplanar deformities of the forearm. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Anatomic Reconstruction of Distal Radioulnar Ligaments With Tendon Graft for Treating Distal Radioulnar Joint Instability: Surgical Technique and Outcome.

Among the various reasons for chronic posttraumatic ulnar-sided wrist pain, instability of the distal radioulnar joint (DRUJ) has recently received major attention and finally achieved fundamental progress in understanding thanks to anatomic and biomechanical studies. This has resulted in more physiological and successful treatment methods compared with the historic options. One and the most dramatic surgical technique consists in the replacement of the main ligamentous stabilizer of the DRUJ, the so-called triangular fibrocartilage, with a tendon graft. On the basis of our experience, the refined surgical technique is presented as well as the results obtained in a retrospective consecutive case series of 48 patients with 48 wrists followed-up for 16 months in average (6 to 43) clinically and radiographically. Out of 48 unstable DRUJ's stability was restored in 44 patients associated with a significant pain relief by 1.44 points (on a scale 0 to 4). There was however a loss of forearm rotation of 20 degrees in average (pronation-8 degrees; supination-12 degrees), whereas the range of motion of the wrist and grip strength remained unchanged. We did not find any influence on the result by performing simultaneous ulnar shortening osteotomy, the duration of cast immobilization or the positioning in the cast. There were no postoperative complications, 4 failed cases needed secondary procedures (2× rereconstruction, 2× Sauvé-Kapandji-operation).

Conventional Versus Computer-Assisted Corrective Osteotomy of the Forearm: a Retrospective Analysis of 56 Consecutive Cases.

PURPOSE: Accuracy and feasibility of corrective osteotomies using 3-dimensional planning tools and patient-specific instrumentation has been reported by multiple authors with promising results. However, studies describing clinical outcomes following these procedures are rare. Therefore, the purpose of this study was to compare the results of computer-assisted corrective osteotomies of the diaphyseal and distal radius with a conventional non-computer-assisted technique regarding duration of surgery, consolidation of the osteotomy, and complications. Also, subjective and objective clinical outcome parameters were assessed. METHODS: We retrospectively compared the results of 31 patients who underwent a corrective osteotomy performed conventionally with 25 patients treated with a computer-assisted method (CA) using patient-specific instrumentation. Baseline data were similar among both groups. The duration of surgery, bony consolidation, complications, gain in range of motion, and subjective outcome were recorded. RESULTS: The mean operating time was significantly shorter in the CA group compared with the conventional group. After 12 weeks, significantly more osteotomies were considered healed in the CA group compared with the conventional group. Two patients in the CA group required revision surgery to treat nonunion of the osteotomy. Otherwise clinical results were similar among both groups. CONCLUSIONS: The results demonstrate that the computer-assisted method facilitates shorter operation times while providing similar clinical results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Influence of Plate Size and Design upon Healing of Ulna-Shortening Osteotomies.

Purpose Ulna-shortening osteotomy is one of the most established and most frequent operations in hand surgery. However, bone union is not always achieved and the use of plates implies potential risks and problems. The traditional points of criticism are the duration of bone healing, the incidence of nonunion, and the necessity of hardware removal due to the soft tissue irritation by the plate or the screws. These shortcomings have been addressed by an increasing standardization of the procedure and finally specific instruments and implants. The aim of this retrospective study was to compare a new LCP (locking compression plate) Ulna Osteotomy System 2.7 mm (Synthes, Paoli, PA) with the former 3.5-mm LCDCP (limited-contact dynamic compression plate) (Synthes) regarding consolidation, complications, and rate of plate removal. Methods To investigate the effect of an implant and technique specifically designed for this purpose, we have compared the course of healing and the result in 72 patients who have undergone ulnar shortening osteotomy using general instruments and applying a standard osteosynthesis plate (Synthes, 3.5-mm LCDCP) to a consecutive cohort of 40 patients who had ulnar shortening using the new dedicated ulna-shortening osteotomy system plate (Synthes, 2.7-mm LCP). Clinical and radiologic evaluation was performed 8 weeks, 3 months, 6 months, and 1 year postoperatively in all patients. Results The latter displayed shorter bone healing time, suggesting an advantage of an oblique osteotomy. There was no significant difference in rate of plate removal. Ultimate complication and consolidation rate was not different. Conclusion Using the new LCP 2.7 implant, time to consolidation was shorter and oblique osteotomies healed faster than transverse ones. However, in spite of the smaller plate, screws, and tapered design, the plate did not cause less local problems and failed to decrease the necessity of plate removal. Furthermore, the cost of the implant is higher than the LCDPC 3.5. Type of Study Retrospective comparative study. Therapeutic evidence Level III.

Stability and Clinical Outcome after Reconstruction of Complete Triangular Fibrocartilage Disruption.

Purpose Patients with symptomatic instability of the distal radioulnar joint (DRUJ) after traumatic complete disruption of the triangular fibrocartilage complex (TFC) are best treated by anatomic reconstruction of the TFC. Postoperative clinical results from the literature are known but the improvement of DRUJ instability remains still challenging to quantify. We recently published a reliable and validated method to measure the instability of the DRUJ. This sonographic method was used to quantify the pre- and postoperative instability in correlation with clinical outcome in patients with complete TFC disruption. Methods 11 patients with complete disruption of the TFC resulting in symptomatic instability of the DRUJ underwent open reconstruction of the TFC. The instability was measured with sonography preoperatively and one year postoperatively including the Patient-Rated Wrist Evaluation score (PRWE Score). Results By subjective measurement, 9 patients showed comparable stability to the contralateral side. By objective measurements, DRUJ stability was completely restored in 6 patients. Seven patients had a very good and good clinical outcome. The dorsovolar shift (preoperative mean 5.2mm, min 2.4, max 7.1; postoperative 3.6mm, min 1.2, max 6.2) was significantly decreased (p < 0.05) and was postoperatively not different to the contralateral healthy side (p > 0.1). PRWE score in the 1 year follow up was 13.8. Three patients remained with significant pain, sonographically two of them were still more lax and one tighter compared to the contralateral side. Conclusions The sonographic measurement technique allows evaluation of the stability pre- and postoperatively and does not always correlate with the qualitative clinical assessment. The described operation technique is effective for treatment of irreplaceable TFC ruptures and significantly improves the DRUJ stability and wrist function one year after surgery, which could be quantified objectively by ultrasound.

Extensor Pollicis Longus Ruptures Following Distal Radius Osteotomy Through a Volar Approach.

PURPOSE: To investigate the cause and pathological process of extensor pollicis longus (EPL) ruptures after correction of distal radius malunion through a volar approach. METHODS: We included patients with EPL ruptures who underwent distal radius osteotomies performed through a volar approach. Data were pooled from members of the International Wrist Investigators Workshop. Patient demographics, initial injury parameters, imaging studies, preoperative and postoperative examination, intraoperative findings, surgical technique, and outcomes were compared and analyzed. Preoperative and postoperative radiographic images were evaluated and compared. RESULTS: We evaluated 6 cases from 5 surgeons in 4 institutions. Length of follow-up ranged from 1 to 5 years. On initial radiographic evaluation all malunions were healed with dorsal angulation (20° to 60°) and with positive ulnar variance. Deformity correction in the sagittal plane was 25° to 55°. Osteotomies were fixed with volar locking plates with autologous bone graft except for one patient who received calcium phosphate-based bone void filler. Postoperative x-rays suggested prominent osteotomy resection edges, osteophytes, or dorsal bony prominence resulting from healed callus. Average time from osteotomy to EPL rupture was 10 weeks (range, 2-17 weeks). Two patients initially refused to undergo tendon transfers. One was pleased with the outcome despite the ruptured EPL. The other patient ruptured 2 more tendons and chose to have tendon transfers. One patient also ruptured the transferred tendon after 2 months and underwent successful tendon grafting. CONCLUSIONS: In the absence of screw prominence and technical flaws, it is likely that dorsal callus, prominent osteotomy resection edges, and osteophytes may contribute to attritional rupture of the EPL tendon after a corrective osteotomy through a volar approach. Exposure and debridement of excessive callus, dorsal ridge, or a prominent Lister tubercle performed during the osteotomy may reduce subsequent EPL rupture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.