Capitate shortening osteotomy with or without vascularized bone grafting for the treatment of early stages of Kienböck's disease.

PURPOSE: The study evaluates the procedures of capitate shortening osteotomy with or without vascularized bone grafting (VBG) for the treatment of stage II or IIIA Kienböck's disease with neutral ulnar variance. METHOD: Forty-five patients with stage II (n = 21) and IIIA (n = 24) Kienböck's disease were included in the study. Patients were classified into two groups; isolated capitate shortening (ICS) group included 21 patients (stage II [n = 10] and stage IIIA [n = 11]) treated by capitate shortening without VBG of the lunate. Combined capitate shortening (CCS) group includes 24 patients (stage II [n = 11] and stage IIIA [n = 13]) who treated by capitate shortening combined with VBG of the lunate from the dorsal distal radius based on the fourth + fifth extensor compartment artery. All patients were evaluated pre- and post-operative for pain as measured by visual analogue scale score (VAS), range of motion (ROM), grip strength, modified Mayo wrist score (MMWS), lunate height index (LHI) ratio, and carpal height index (CHI) ratio. RESULTS: The mean operative time for CCS procedure was 85 min (76 to 120) and for ICS was 58 min (47 to 65). The mean follow-up period for all patients was 33 months (29 to 47). Patients with stage IIIA Kienböck's disease treated by CCS procedure had better post-operative VAS, ROM, grip strength, MMWS, LHI, and CHI ratio than patients treated by ICS procedure. ICS procedure reported 28% failure rate versus 8% for CCS. No differences were found between CCS and ICS procedures in patients with stage II Kienböck's disease in the term of clinical, radiographic outcomes, or failure rate. CONCLUSION: Using CCS procedure for the treatment of stage IIIA Kienböck's disease (lunate height collapse) with neutral ulnar variance can restore height and dimensions of the collapsed lunate and subsequently improve the final outcomes with lower failure rate. However, in patients with stage II Kienböck's disease (maintained lunate height), no advantages were noticed for CCS over ICS procedure. Lunate height index might be considered a prognostic factor for the treatment outcomes of Kienböck's disease.

Management of Failed External Fixation by Two-Staged Internal Osteosynthesis in the Lower Limb.

OBJECTIVE: This study aims to evaluate the result of a two-stage (delayed conversion) management of nonunion after failed external fixation of the lower limb. METHODS: A case series of 25 patients (19 males and six females) enrolled in this study between February 2008 and October 2016, mean age 33.4 years (range, 22-65 years). Eight had femoral fractures, and 17 had tibial fractures. All were due to high-energy trauma and were open fractures. All cases were presented by non-union after external fixation in the lower limb long bones. All patients were managed by two stages (delayed conversion) osteosynthesis. The patients have been assessed for rate and time for union, range of motion of adjacent joints, the Modified functional outcome score of Karlstrom-Olerud, and Trauma outcomes measure score. RESULTS: The mean follow-up was 36.5 months (range 24-54 months). Twenty-two cases (88%) were fully united on an average of 5.3 months. According to the Karlstrom-Olerud scores, the final functional outcome score was excellent 12 cases, good 9 cases, accepted 2 cases, and poor in two cases. As regards the trauma outcome measure score, the mean TOM after 3 months was 26.1 (25.3-27.3), 30.4 (29.3-32.1) after 12 months, and 33.4 (32.3-40) after 24 months. CONCLUSIONS: The technique of two-stage treatment of nonunions of long bone after external fixation is a successful tool to achieve bony union. It could be a favorable option with a low risk of complications and a high level of functional outcomes.

Kirschner wire versus Herbert screw fixation for the treatment of unstable scaphoid waist fracture nonunion using corticocancellous iliac bone graft: randomized clinical trial.

PURPOSE: The study compared the impact of the Kirschner wires versus Herbert screw fixation on the rate of union, time to union, correction of deformity, and clinical outcome in adults with unstable scaphoid waist fracture nonunions without avascular necrosis. METHODS: We prospectively randomized 122 patients to undergo corticocancellous iliac bone grafting and internal fixation either with multiple Kirschner wires or Herbert screw. Radiographs, clinical outcome measures (pain, range of motion, and grip strength), and the Quick DASH score were taken pre- and post-operatively. RESULTS: The rate of the scaphoid union in the Kirschner wire group was 91% versus 88% in the Herbert group. No difference was detected between the two groups with respect to the time to union, deformity correction, pain analysis, range of motion, grip strength, return to work, and complications. CONCLUSION: Using of multiple Kirschner wires as a fixation method for unstable scaphoid waist fracture nonunion that was treated by open reduction and corticocancellous iliac bone grafting had a shorter operative time and lower cost as compared with the Herbert screw fixation. Herbert screw fixation was technically more demanding in terms of technique than K-wires. However, because of easy application of Kirschner wires, and low cost, especially in developing countries, it may be a good alternative to Herbert screw.

Madelung's deformity: capitate-related versus ulna-related measurement methods.

Several investigators have defined measurements for Madelung's deformity based on the distal radius or on the longitudinal ulnar axis to avoid the distorted distal radius and its lunate fossa. However, errors may occur in severe cases because of ulnar deformity and displacement. We quantified seven established measurements for Madelung's deformity relying on the central axis of the capitate. The inter- and intrarater reliability of the capitate-related and the ulna-related techniques were compared. We observed a higher inter- and intrarater reliability for the capitate-related method than for the ulna-related method. Better agreement was also observed for measurements of distance than for measurements of angles. However, the palmar tilt angle measurement method was neither reliable nor reproducible. The capitate-related technique can help to accurately determine the severity of Madelung's deformity, assist in surgical planning and identify the prognosis. Level of evidence: III.