Early Results in Total Replacement of the Distal Radioulnar Joint.

BACKGROUND: Pathology of the distal radioulnar joint (DRUJ) including instability and arthritis presents a challenge for hand and upper extremity surgeons. Surgical options include a Darrach procedure and similar resections, soft tissue interposition arthroplasty, and a one-bone forearm. In 2005, a prosthesis for DRUJ arthroplasty was approved for use in the United States. The authors hypothesize that DRUJ arthroplasty will lead to improved pain and range of motion (ROM) with a moderate, but manageable, complication rate. METHODS: A retrospective review of 46 patients who underwent DRUJ arthroplasty by a single private group of hand surgeons was performed. Demographics, complications, postoperative visual analog scale (VAS), and postoperative ROM were obtained and analyzed. RESULTS: The patients were followed up for a mean of 60 weeks. The implant was used both as primary surgical treatment for DRUJ pathology and as salvage for previous failed procedures. Twenty-two percent of patients experienced complications: 15% required revision surgery. No patients were converted to another type of implant, including those who underwent revision surgery. Prominent hardware was the most common indication requiring revision. Patients achieved an improvement in supination of 17° and extension of 5°. They additionally achieved a decrease in average VAS score from 7.1 to 2.3. CONCLUSIONS: Distal radioulnar joint arthroplasty reduces pain and improves ROM in patients with DRUJ pathology with a 22% complication rate. This cohort demonstrates improved pain, modest improvement in ROM, but a 22% complication rate for this implant. Further long-term studies are encouraged.

A Cadaveric Comparison of Approaches for Exposure of the Volar Distal Radius: Is There a Utilitarian Approach?

BACKGROUND: It remains unclear whether exposure for planned fixation of distal radius fractrues is superior with any given approach, and whether a single utilitarian approach exists that permits reliable complete exposure of the volar distal radius. METHODS: A cadaveric study was performed using 10 matched specimens. Group 1 consisted of 3 radially based approaches (standard flexor carpi radialis [FCR], standard FCR with radial retraction of FCR and flexor pollicis longus [FPL] tendons, extended FCR). Group 2 consisted of 2 ulnarly based approaches (volar ulnar, extended carpal tunnel). The primary outcome was total width of exposed distal radius at the watershed line. Mann-Whitney U and Wilcoxon rank testing was used to identify differences. RESULTS: The standard FCR approach exposed 29 mm (90%), leaving on average 3 mm (10%) of the ulnar corner unexposed. Retracting the FCR and FPL tendons radially allows for an extra 1 mm of volar ulnar corner exposure. Finally, converting to an extended FCR approach provided 100% exposure in all specimens. The volar ulnar exposure however provided exposure to only 9 mm (37%), leaving 20 mm (62.5%) left unexposed radially. The extended carpal tunnel provided exposure to 21 mm (65%), leaving 11 mm (35%) radially unexposed. Differences between each group were statistically significant (P < .05). CONCLUSIONS: The extended FCR approach exposed 100% of the volar distal radius in our study and may serve as a utilitarian volar surgical approach for exposure and fixation of distal radius fractures. Additional knowledge of the limitations of alternative approaches can be helpful in surgical planning.

The Use of a Vascularized Distal Ulna Autograft for Complex Distal Radius Fracture Nonunions.

In patients with segmental nonunion of the distal radius, the distal ulna and distal radioulnar joint may not be salvageable. As an alternative to a vascularized free fibula, a pedicled distal ulna vascularized graft is a useful salvage technique. The procedure relies on the vascular bundle of the pronator quadratus and the dorsal oblique arterial anastomosis between the anterior and posterior interosseous arteries running along the interosseous membrane as the pedicle. We present 3 patients who received a distal ulna vascularized graft with concomitant wrist arthrodesis for distal radius segmental nonunion after complex distal radius fracture. This technique provides a local pedicled graft that may be a simpler, more reliable, and less technically demanding alternative.

Ulnolunate Distance and Lunate Height: Reliability Testing.

PURPOSE: Many methods for measuring ulnar variance have been described. The purpose of this study was to introduce the use of both lunate height and ulnolunate distance on the zero-rotation view as well as to assess the intra- and interobserver reliabilities of these measurements. The hypothesis was that the use of concave surfaces in the measurement of both lunate height and ulnolunate distance will yield a higher intra- and interobserver reliability than ulnar variance, which uses the convex surface of the distal radius. METHODS: Seven hand fellows reviewed 32 radiographs. Measurements of lunate height, ulnolunate distance, and ulnar variance, using the method of perpendiculars, were recorded to the nearest 0.5 mm. Intraclass correlation coefficient (ICC) was then calculated for each radiograph for intra- and interobserver reliability. RESULTS: The ICC measurements were similar for lunate height, ulnolunate distance, and ulnar variance. The inter- and intraobserver reliability was similar for all 3 measurements. CONCLUSIONS: Measurements of ulnar variance utilize the concave surface of the distal radius. The use of the convex surface of the lunate and pole of the ulna does not seem to improve the reliability of these measurements. Further studies are necessary to confirm the clinical utility of these measurements. CLINICAL RELEVANCE: The use of ulnolunate distance and lunate height as an adjunct to ulnar variance may assist in evaluation of distal radius fractures and ulnocarpal abutment, improve surgeon communication, and contribute to our overall knowledge of the wrist.

Primary Surgical Treatment of Erythema Elevatum Diutinum.

Erythema elevatum diutinum (EED) is a rare skin disease caused an Arthrus-type immunological reaction to antigen with immune complex deposition in the cutaneous microvasculature, which leads to tissue damage secondary to the effects of complement and leukocytes. It presents as brown or red cutaneous nodules, papules, or plaques, often on the extensor surfaces of the hands, knees, or elbows. Onset usually occurs in the fourth to sixth decades but possibly younger in patients with human immunodeficiency virus. Medical treatment is usually successful; however, surgical treatment can be used when chemotherapy fails. We present a case of a 29-year-old man with EED treated with excision and skin grafting.

Physical Examination of the Wrist: Useful Provocative Maneuvers.

Chronic wrist pain resulting from partial interosseous ligament injury remains a diagnostic dilemma for many hand and orthopedic surgeons. Overuse of costly diagnostic studies including magnetic resonance imaging, computed tomography scans, and bone scans can be further frustrating to the clinician because of their inconsistent specificity and reliability in these cases. Physical diagnosis is an effective (and underused) means of establishing a working diagnosis of partial ligament injury to the wrist. Carefully performed provocative maneuvers can be used by the clinician to reproduce the precise character of a patient's problem, reliably establish a working diagnosis, and initiate a plan of treatment. Using precise physical examination techniques, the examiner introduces energy into the wrist in a manner that puts load on specific support ligaments of the carpus, leading to an accurate diagnosis. This article provides a broad spectrum of physical diagnostic tools to help the surgeon develop a working diagnosis of partial wrist ligament injuries in the face of chronic wrist pain and normal x-rays.

Distal radius instability and stiffness: common complications of distal radius fractures.

Emphasis in the literature over the past hundred years regarding distal radius fracture management has been on restoration of anatomic radio-carpal alignment. Until the two most recent decades, little emphasis has been placed on the great morbidity and compromise to upper limb function associated with distal radio-ulna joint (DRUJ) pathology occurring with fractures of the distal radius. This article emphasizes that attention to restoration of anatomy of the DRUJ should be considered at least as important as that given to the radio-carpal relationship. This article also points out how stiffness of forearm rotation can result from a well-treated distal radius fracture and how this complication can be treated to restore healthy upper limb function.

Salvage procedures for the distal end of the ulna: there is no magic.

Resection of the distal end of the ulna is not a benign procedure; nor is it a panacean surgical treatment of disorders at the distal radioulnar and ulnocarpal joints. Over the past 96 years, since Darrach first described his classic procedure, many authors have warned surgeons of the consequences of the Darrach resection. For salvaging the persistently painful distal forearm after Darrach resection, researchers have recommended a spectrum of possible surgical options. Each has its advantages and disadvantages; none substitutes completely for the painless, load-bearing capacity of a healthy distal radioulnar joint. Resection of the seat of the distal ulna eliminates the fulcrum of the ulna through which load is transferred from the hand to the forearm. At this time, there is still no surgical "magic" available to the reconstructive surgeon for salvaging normal use of the upper limb after failed Darrach resection.

The hypothenar fat pad transposition flap: a modified surgical technique.

The hypothenar fat pad flap has been shown to produce reliable clinical results for the treatment of recurrent carpal tunnel syndrome secondary to cicatricial tethering. The flap utilizes soft vascularized tissue that does not compromise hand function and is of sufficient size to provide median nerve coverage in the carpal tunnel. We describe technical modifications that facilitate improved, tension-free transposition of the pedicled fat pad flap. These modifications enable transfer of vascularized tissue and decrease iatrogenic damage to the important perforator vessels. The hypothenar fat pad transposition flap provides a reliable source of vascularized local tissue that can be used successfully as an adjunct to neurolysis for the treatment of recurrent idiopathic CTS secondary to perineural scarring.