Improving standard volar plate fixation in 3D-guided corrective osteotomy of the distal radius: evaluation of a shim instrument.

Standard volar plates often do not fit the surface of the malunited distal radius after osteotomy, necessitating an offset angle for accurate volar tilt correction. The correction can be achieved if the plate is held at the correct angle when the distal screws are locked. With the advantage of 3D surgical planning and patient-specific instruments, we developed a shim instrument to assist the surgeon in securing the plate at the intended angle when locking the distal screws, and evaluated radiological results. Five female patients aged 63-74 with dorsally angulated extra-articular malunions underwent surgery using 3D-printed guides and the shim instrument. The plate position, drilling guide alignment, screw placements, and distal radius correction on postoperative CTs were compared with the surgical plans. Errors were measured using an anatomical coordinate system, and standard 2D radiographic measures were extracted. Preoperative dorsal tilt ranged from 16° to 35°, and postoperative volar tilt from 1° to 11°. 3D analysis revealed mean absolute correction errors of 6.1° in volar tilt, 1.6° in radial inclination, and 0.6 mm in ulnar variance. The volar tilt error due to the shim instrument, indicated by the mean angle error of the distal screws to the plate, was 2.1° but varied across the five patients. Settling of the distal radius, due to tension during and after reduction, further contributed to a mean loss of 3.5° in volar tilt. The shim instrument helped with securing plates at the intended angle; however, further correction improvements should consider the tension between the fragments of osteoporotic bone.

Validity and Responsiveness of Forearm Strength Measurements in the Evaluation of Distal Radioulnar Joint Implant Arthroplasty.

PURPOSE: To assess the responsiveness of forearm strength tests and to correlate the change to grip strength and a patient-reported outcome measure used for evaluation of distal radioulnar joint (DRUJ) implant arthroplasty. METHODS: We performed a retrospective review of 18 patients treated with Herbert (n = 12) and Scheker (n = 6) DRUJ implants. Patients who had undergone the various measurements of arm and grip strength both before surgery and after a minimum follow-up of 1 year were included. Our primary aim was to compare the responsiveness of grip strength with our new methods for measuring forearm torque and lifting strength. The secondary aim was to correlate observed changes in strength measurements to change in a patient-reported outcome measure with use of the patient-reported wrist evaluation (PRWE). Measurements of grip strength, forearm torque, and lifting strength were performed with the Jamar dynamometer and the Kern and Baseline instruments. Preoperative values were compared with 1-year values. RESULTS: Standardized response mean and effect size values were higher for forearm torque than for grip strength. Change in forearm torque and lifting strength had a moderate to strong correlation with change in PRWE. The correlation between grip strength and PRWE was weak. CONCLUSIONS: Forearm torque measurements were better than grip strength in detecting changes after DRUJ arthroplasty. It also had a stronger correlation to patient-reported outcome, measured with the PRWE. CLINICAL RELEVANCE: Forearm torque testing may add further information to the evaluation of DRUJ disorders and their treatments. These tests can provide quantifiable data on the patient's ability to perform various tasks requiring physical strength.

Three-Dimensional Compared with Two-Dimensional Preoperative Planning of Corrective Osteotomy for Extra-Articular Distal Radial Malunion: A Multicenter Randomized Controlled Trial.

BACKGROUND: Malunion is the most frequent complication seen after a fracture of the distal end of the radius. The primary aim of this study was to compare patient-reported outcome measures (PROMs) after corrective osteotomy for malunited distal radial fractures with and without 3-dimensional (3D) planning and use of patient-specific surgical guides. METHODS: From September 2010 to May 2015, 40 adult patients with a symptomatic extra-articular malunited distal radial fracture were randomized to 3D computer-assisted planning or conventional 2-dimensional (2D) planning for corrective osteotomy. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score. Secondary outcomes included the Patient-Rated Wrist Evaluation (PRWE) score, pain and satisfaction scores, grip strength, and radiographic measurements at 3, 6, and 12 months postoperatively. RESULTS: From baseline to 12 months of follow-up, the reduction in the mean DASH score was -30.7 ± 18.7 points for the 3D planning group compared with -20.1 ± 17.8 points for 2D planning (p = 0.103). Secondary functional outcome by means of the PRWE resulted in a similar reduction of -34.4 ± 22.9 points for the 3D planning group compared with -26.6 ± 18.3 points for the 2D planning group (p = 0.226). There were no significant differences in pain, satisfaction, range of motion, and grip strength. Radiographic analysis showed significant differences in the mean residual volar angulation (by 3.3°; p = 0.04) and radial inclination (by 2.7°; p = 0.028) compared with the templated side, in favor of 3D planning and guidance. The duration of preoperative planning and surgery as well as complication rates were comparable. CONCLUSIONS: Although there was a trend toward a minimal clinically important difference in PROMs in favor of 3D computer-assisted guidance for corrective osteotomy of extra-articular distal radial malunion, it did not attain significance because of (post hoc) insufficient power. Despite the challenge of feasibility, a trial of large magnitude is warranted to draw definitive conclusions regarding clinical advantages of this advanced, more expensive technology. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

New Methods to Assess Forearm Torque and Lifting Strength: Reliability and Validity.

PURPOSE: To determine the repeatability and validity of new methods designed to objectively measure forearm torque and lifting strength in a clinical setting. METHODS: Twenty-eight healthy volunteers, 19 women and 9 men, were tested for lifting strength and forearm torque with the Kern and Baseline dynamometers. Two raters tested each participant on 3 occasions in the standing position. One of the raters also examined 15 subjects, 3 times, for forearm torque in the seated position and for lifting strength and forearm torque by the Work Simulator II, Baltimore Therapeutic Equipment (BTE II). Intraclass correlation coefficients (ICC) model 2,1 was used to calculate ICCs for intra- and interrater reliability. The same ICC model and Bland-Altman plots were used to analyze the validity and agreement between the new test methods and the BTE II equipment and for comparison between tests performed in the standing and seated positions. RESULTS: Intra- and interrater reliability for forearm torque measurements with both the Baseline and the BTE II demonstrated ICCs between 0.88 and 0.96. The comparison between the Baseline and the BTE equipment yielded lower ICCs of 0.74 to 0.88 but they were still substantial and in good agreement. The ICCs for torques recorded in the standing and seated position were 0.89 to 0.96. Lifting strength, measured in 3 different positions of forearm rotation, yielded ICC values between 0.84 and 0.96 for both raters and with both the Kern and the BTE II instruments. Similarly, comparisons between the Kern and the BTE II methods showed ICC values between 0.91 and 0.95. CONCLUSIONS: Both the Baseline and the Kern dynamometers demonstrated excellent intra- and interrater repeatability. Except for forearm torque test in direction of pronation, which had a slightly lower ICC of 0.74, our new methods were valid when the BTE II was used as the reference standard. Assessments in the standing or seated position for torque measurements made little difference. Thus, we found the quality of measurements performed with our new methods sufficient for future studies of forearm torque and lifting strength. CLINICAL RELEVANCE: Simple, yet reliable, methods to quantify torque and lifting strength in a clinical setting have the potential to improve evaluations of wrist and forearm disorders as well as their treatments.

Forearm Torque and Lifting Strength: Normative Data.

PURPOSE: To establish reference values for new methods designed to quantitatively measure forearm torque and lifting strength and to compare these values with grip strength. METHODS: A total of 499 volunteers, 262 males and 237 females, aged 15 to 85 (mean, 44) years, were tested for lifting strength and forearm torque with the Kern and Baseline dynamometers. These individuals were also tested for grip strength with a Jamar dynamometer. Standardized procedures were used and information about sex, height, weight, hand dominance, and whether their work involved high or low manual strain was collected. RESULTS: Men had approximately 70% higher forearm torque and lifting strength compared with females. Male subjects aged 26 to 35 years and female subjects aged 36 to 45 years showed highest strength values. In patients with dominant right side, 61% to 78% had a higher or equal strength on this side in the different tests performed. In patients with dominant left side, the corresponding proportions varied between 41% and 65%. There was a high correlation between grip strength and forearm torque and lifting strength. Sex, body height, body weight, and age showed a significant correlation to the strength measurements. In a multiple regression model sex, age (entered as linear and squared) could explain 51% to 63% of the total variances of forearm torque strength and 30% to 36% of lifting strength. CONCLUSIONS: Reference values for lifting strength and forearm torque to be used in clinical practice were acquired. Grip strength has a high correlation to forearm torque and lifting strength. Sex, age, and height can be used to predict forearm torque and lifting strength. Prediction equations using these variables were generated. CLINICAL RELEVANCE: Normative data of forearm torque and lifting strength might improve the quality of assessment of wrist and forearm disorders as well as their treatments.

The microsurgical training programme in Gothenburg, Sweden: early experiences.

OBJECTIVE: Microsurgical techniques are increasingly used in routine surgical practice as well as in biomedical research. The training opportunities at standardised training courses are limited, and no microsurgical training facility or programme existed in Scandinavia before 2013. METHODS: A microsurgery laboratory was set up and two different courses were started, aiming separately at biomedical researchers and surgeons. The course for biomedical researchers teaches basic microsurgical skills such as vessel isolation, cannulation, and arterial microvascular suture under magnification. The more advanced course for surgeons focuses on various techniques of microvascular and nerve anastomosis. Both courses use a combination of theory and practice, with emphasis on the practical part, the course for surgeons also includes clinically relevant information. RESULTS: Twelve 5-day courses using both non-living models and exercises on laboratory animals have been conducted and attended by 49 researchers and 44 surgeons. The organisation and the programme of the training courses as well as 'The 4E concept' behind the course (educational curriculum, equipment, ergonomy, and evaluation) are further detailed. CONCLUSIONS: We have successfully established the first training laboratory and series of microsurgical training courses in Scandinavia at two different levels. The experience from the first 12 courses shows the need for this type of structured training, and confirms that the microsurgical education curriculums needs to be adapted to participants' prerequisites and expectations, and various difficulty levels should be considered.

Ulnar Head Replacement: 21 Cases; Mean Follow-Up, 7.5 Years.

PURPOSE: To report clinical and radiographic outcomes for the Herbert ulnar head prosthesis after a mean of 7.5 years (range, 2.0-12.5 years). METHODS: We performed 22 Herbert ulnar head prosthesis arthroplasties between 2000 and 2011. Five were primary procedures, and the remaining 17 were done after an average of 2 (range, 1-5) previous operations. The mean age at surgery was 55 years (range, 31-74 years). Follow-up including clinical examination, standardized questionnaires, and radiographic examination was done after mean 7.5 years (range, 2.0-12.5 years) in 21 cases. We used the Disabilities of the Arm, Shoulder, and Hand questionnaire, the Patient-Rated Wrist Evaluation questionnaire, and the Mayo wrist score questionnaire. Pain and satisfaction were evaluated with a 10-cm visual analog scale (VAS). Measurements of range of motion and strength for grip were recorded. RESULTS: Wrist range of motion was not affected by the arthroplasty except for supination, which significantly improved from 55° to 70°. At follow-up, grip strength averaged 25 kg (range, 10-48 kg) in the operated wrists and 31 kg (range, 8-74 kg) on the contralateral side. Visual analog scale-pain averaged 2.9 (range, 0-8.7) during activity and 1.7 (range, 0-7) at rest. Satisfaction VAS was 8.9 (range, 4.3-10). Five patients had VAS-pain above 5 during activity, and 1 patient was dissatisfied and regretted having undergone arthroplasty. Mean outcomes were 27 (range, 5-50) for Disabilities of the Arm, Shoulder, and Hand measure, 31 (range, 0-90) for the Patient-Rated Wrist Evaluation score, and 71 (range, 30-90) for the Mayo wrist score. One patient was reoperated with capsuloplasty 9 months after the arthroplasty owing to recurrence of painful instability. Full stability was not achieved but the pain resolved. None of the implants showed any radiographic signs of loosening. CONCLUSIONS: The Herbert ulnar head prosthesis was a safe method of treatment and provided satisfactory midterm results for selected cases of distal radioulnar joint disorders. CLINICAL RELEVANCE: Increased knowledge of performance for ulnar head implant arthroplasty may aid surgical decision making for distal radioulnar joint disorders. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Constrained implant arthroplasty as a secondary procedure at the distal radioulnar joint: early outcomes.

PURPOSE: To evaluate the clinical and radiological outcomes for the Scheker total joint endoprosthesis when used for previously failed surgeries of the distal radioulnar joint (DRUJ). METHODS: Eight patients with DRUJ derangement with painful instability and 1 patient with DRUJ synostosis received a Scheker DRUJ total joint endoprosthesis between 2006 and 2010. All patients had at least 1 procedure previously performed on the distal ulna (mean, 3.6 procedures). The follow-up time was on average 3.7 years (range, 2-5 y). Standardized preoperative and postoperative assessments included radiographic examination, evaluation of pain by a visual analog scale, and measurements of range of motion and grip strength. We evaluated patient-perceived function with the Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS: There was significant improvement in pain and Disabilities of the Arm, Shoulder, and Hand scores. Grip strength was improved but not significantly. Range of motion was not impaired. We encountered no major complications. Radiographic evaluation showed bone resorption at the distal ulna for most patients and at the tip of a screw in 1 patient, but we found no evidence of implant loosening. CONCLUSIONS: Our short-term results in a limited patient series show that in selected cases, the Scheker total joint endoprosthesis is a safe and efficient treatment option for previously failed surgeries of the DRUJ. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Can total wrist arthroplasty be an option in the treatment of the severely destroyed posttraumatic wrist?

Background Severely destroyed posttraumatic wrists are usually treated by partial or total wrist fusion or proximal row carpectomy. The indications for and longevity of total wrist arthroplasty (TWA) are still unclear. Case Description The aim of this study was to analyze a series in which one last-generation total wrist arthroplasty was used as a salvage procedure for wrists with severe arthritis due to traumatic causes. The data were prospectively recorded in a web-based registry. Seven centers participated. Thirty-five cases had a minimum follow-up time of 2 years. Average follow-up was 39 (24-96) months. Pain had improved significantly at follow-up, mobility remained unchanged. The total revision rate was 3.7%, and the implant survival was 92% at 4-8 years. Literature Review Very few studies have described specific results after TWA in posttraumatic cases and almost none using classical "third-generation" implants. The number of cases and the follow-up in the published series are small. Clinical Relevance Although painful posttraumatic wrists with severe joint destruction can be salvaged by partial or total fusion, we found that, evaluated at short- to midterm, total wrist arthroplasty can be an alternative procedure and gives results that are comparable to those obtained in rheumatoid cases. Level IV Case series.

"Remotion" total wrist arthroplasty: preliminary results of a prospective international multicenter study of 215 cases.

This study reports the current results of an international multicenter study of one last generation total wrist arthroplasty (TWA) ("ReMotion," Small Bone Innovation, Morristown, PA). The two first authors (G.H. and M.B.) built a Web-based prospective database including clinical and radiological preoperative and postoperative reports of "ReMotion" TWA at regular intervals. The cases of 7 centers with more than 15 inclusions were considered for this article. A total of 215 wrists were included. In the rheumatoid arthritis (RA; 129 wrists) and nonrheumatoid arthritis (non-RA; 86 wrists) groups, there were respectively 5 and 6% complications requiring implant revision with a survival rate of 96 and 92%, respectively, at an average follow-up of 4 years. Within the whole series, only one dislocation was observed in one non-RA wrist. A total of 112 wrists (75 rheumatoid and 37 nonrheumatoid) had more than 2 years of follow-up (minimum: 2 years, maximum: 8 years). In rheumatoid and non-RA group, visual analog scale (VAS) pain score improved by 48 and 54 points, respectively, and QuickDASH score improved by 20 and 21 points, respectively, with no statistical differences. Average postoperative arc of wrist flexion-extension was 58 degrees in rheumatoid wrists (loss of 1 degree) compared with 63 degrees in non-RA wrists (loss of 9 degrees) with no statistical differences. Grip strength improved respectively by 40 and 19% in rheumatoid and non-RA groups (p = 0.033). Implant loosening was observed in 4% of the rheumatoid wrists and 3% of the non-RA wrists with no statistical differences. A Web-based TWA international registry was presented. Our results suggest that the use of the "ReMotion" TWA is feasible in the midterm both for rheumatoid and non-RA patients. This is a significant improvement compared with the previous generation TWA. The level of evidence for this study is IV.

Prevenção à sueca / Swedish prevention

O Per Axelsson Oral Health Promotion Center irá divulgar experiência sueca no Brasil e incentivar a pesquisa na área de Promoção de Saúde Bucal. O prevencionista Axelsson fala com exclusividade à Revista ABO Nacional sobre pesquisas desenvolvidas em conjunto por brasileiros e suecos