Pyrocarbon interposition arthroplasty for proximal capitate avascular necrosis.

INTRODUCTION: Avascular necrosis of the capitate head is a rare condition commonly treated with partial wrist fusion. Although good functional results are usually reported, a degree of stiffness is to be expected. We report a pyrocarbon interposition arthroplasty technique in a young sportsman with 3.5 years of follow-up. METHODS: A 15-year-old rugby player presented with a 6-month history of wrist pain and stiffness with no preceding injury. The necrotic bone was replaced with interposition of a pyrocarbon interposition implant (PI(2)) (Tournier, Grenoble, France), originally designed to replace the trapezium. A concave socket was created in the distal fragment to accommodate the implant and prevent dislocation. Regular follow-up included subjective and objective measures. RESULTS: He was pain free by 6 weeks and regained good functional range of motion and grip strength by 3 months. He returned to playing rugby at the 1-year follow-up. At 2 years, he remained asymptomatic. After 3.5 years, he had no limitations in his heavy manual work as a plant mechanic and retained a good functional range of motion including the dart-thrower's motion. CONCLUSIONS: Medium-term results appear to offer the benefits of being able to return to heavy manual labour as well as retaining a functional range of motion. It is difficult to predict long-term survival, but the outcome so far is encouraging, and conversion to midcarpal fusion remains a salvage option.

Restoration of the volar cortex: predicting instability after manipulation of distal radial fractures.

INTRODUCTION: Distal radial fractures are one of the most common fractures that are presented to the emergency department (ed). The management of non-emergent cases often involves closed reduction and immobilisation before referral to orthopaedic services. Surgical intervention is offered based on the criteria for instability. This can be predicted from the initial and post-manipulation radiographs. The purpose of this study was to assess the role of various predictors of instability in the requirement for surgery, based on specific evidence-based criteria. PATIENTS AND METHOD: We audited 87 consecutive distal radial fractures that had been manipulated by the ED and analysed what factors predicted instability. RESULTS: The most significant predictor of instability and hence further surgery was the failure to anatomically restore the volar cortex (VC) (p = 0.002) during the manipulation. Other significant factors were increasing age (p = 0.006) and fracture of the ulna styloid (p = 0.028). If the VC was restored or remained intact during the manipulation, only 38% required further surgery. If the VC was displaced or not restored, 65% required further surgery. CONCLUSION: The restoration or maintenance of volar cortical alignment during the manipulation of distal radial fractures offers patients the best chance of avoiding the need for further surgery. This factor should be taken into account in the decision-making process for these fractures.