Ulnar shortening: results for treatment of distal radioulnar joint pathology and conversion to DRUJ replacement arthroplasty.

BACKGROUND: Ulnar shortening (US) is used for treatment of ulnar abutment, early osteoarthrosis (OA) and distal radioulnar joint (DRUJ) instability. However, it has never been strongly advocated as a mid-stage procedure to slow OA progression and reduce requirement of secondary DRUJ procedures. The study aim was to determine if a specific sigmoid notch type is likely to lead to DRUJ replacement after US. METHODS: A retrospective study of 119 patients (124 wrists) with DRUJ painful early osteoarthritis, ulnar abutment and DRUJ instability that underwent US was performed. The goals of osteotomy were to decrease pain and slow the initiation or progression of OA. Sigmoid notch type, previous trauma, bone healing time, pain relief, ulnar variance and conversion to DRUJ arthroplasty were analyzed. RESULTS: Of the 124 wrists studied, bone healing took 3.33 months of average (union rate 98.3%). Sigmoid notch type distribution was 55.6% for type 1, 25.8% for type 2, and 18.5% for type 3. Of the patients with pain after US, 37 had hardware removal and 13 required a DRUJ semi-constrained arthroplasty. Even though analysis did not show any statistically significant correlation, a slight trend towards association of sigmoid notch type 3 with conversion to DRUJ arthroplasty was found. CONCLUSION: US has a role in treatment of DRUJ pathology, and its use may delay the need for DRUJ secondary procedures, protecting the native joint. A specific sigmoid notch type does not present risk for OA and does not appear to be related to conversion to DRUJ arthroplasty. Type of study: Therapeutic.

ANTECEDENTES: El acortamiento cubital es utilizado para el tratamiento del síndrome de impactación, osteoartrosis (OA) temprana y la inestabilidad de la articulación radiocubital distal (ARCD). Sin embargo, no se ha recomendado como procedimiento intermedio para detener la progresión de la OA y reducir la necesidad de procedimientos secundarios. El objetivo es determinar si un tipo específico de la escotadura sigmoidea predispone a una artroplastia de la ARCD después del acortamiento cubital. MÉTODOS: Estudio retrospectivo de 119 pacientes (124 muñecas) a las que se les realizó acortamiento cubital. El objetivo de la osteotomía fue disminuir el dolor y retardar el progreso de la OA. Se analizó el tipo de escotadura sigmoidea, trauma previo, tiempo de consolidación ósea, alivio del dolor, varianza cubital y conversión a artroplastia. RESULTADOS: De las 124 muñecas estudiadas, la consolidación ocurrió en 3.33 meses en promedio (98.3% de consolidación). El tipo de escotadura sigmoidea fue 55.6% tipo 1; 25.8% tipo 2 y 18.5% tipo 3, 37 pacientes ameritaron retiro de material y 13 una artroplastia de la ARCD semiconstriñida. Aunque el análisis no mostró ninguna correlación estadísticamente significativa, una tendencia leve hacia la Asociación del tipo 3 de la escotadura sigmoidea con la conversión a la artroplastia de ARCD fue encontrada. CONCLUSIONES: El acortamiento cubital juega un papel en el tratamiento de la patología de la ARCD, su uso puede retrasar la necesidad de procedimientos secundarios. Un tipo de escotadura sigmoidea específica no presenta riesgo para la OA y no parece estar relacionado con la conversión a la artroplastia de la ARCD.

Graft vasculopathy in clinical hand transplantation.

Allogeneic hand transplantation is now a clinical reality. While results have been encouraging, acute rejection rates are higher than in their solid-organ counterparts. In contrast, chronic rejections, as defined by vasculopathy and/or fibrosis and atrophy of skin and other tissues, as well as antibody mediated rejection, have not been reported in a compliant hand transplant recipient. Monitoring vascularized composite allograft (VCA) hand recipients for rejection has routinely involved punch skin biopsies, vascular imaging and graft appearance. Our program, which has transplanted a total of 6 hand recipients, has experience which challenges these precepts. We present evidence that the vessels, both arteries and veins may also be a primary target of rejection in the hand. Two of our recipients developed severe intimal hyperplasia and vasculopathy early post-transplant. An analysis of events and our four other patients has shown that the standard techniques used for surveillance of rejection (i.e. punch skin biopsies, DSA and conventional vascular imaging studies) are inadequate for detecting the early stages of vasculopathy. In response, we have initiated studies using ultrasound biomicroscopy (UBM) to evaluate the vessel wall thickness. These findings suggest that vasculopathy should be a focus of frequent monitoring in VCA of the hand.

A study of functional outcomes following implantation of a total distal radioulnar joint prosthesis.

This paper reports a long-term follow-up measuring pain, range of motion and weight-bearing ability, following implantation of a total distal radioulnar joint prosthesis. This prosthesis differs from excision arthroplasties and ulnar head replacements by replacing all three components of the distal radioulnar joint, viz. the sigmoid notch, the ulnar head and the triangular fibrocartilage. The design allows longitudinal migration of the radius throughout pronation and supination, as well as load bearing of the wrist. Thirty-one patients receiving the prosthesis returned or were interviewed by telephone at a mean of 5.9 (range 4-9) years. Pronation increased from a mean of 65.5 degrees (range 5-90 degrees ) to 74 degrees (range 20-90 degrees ) and supination from 53 degrees (range 5-90 degrees ) to 70 degrees (range 20-90 degrees ) while greatly diminishing and/or eliminating pain. Grip increased from a mean of 10 kg (22 lbs) to 24 kg (52 lbs). Weight bearing was restored or increased in 29 of 31 patients.

Contact area inside the distal radioulnar joint: effect of axial loading and position of the forearm.

BACKGROUND: A biomechanical study was performed to define the normal profiles of contact area inside the distal radioulnar joint and how these profiles change as a result of damage to the distal radioulnar ligaments. METHODS: Twelve cadaver arms were used and a custom-made jig was designed to allow axial loading of the hand. Tekscan sensor film was used to measure the contact area inside the joint. Measurements were taken with different loads and in different positions of the forearm. The same measurements were taken after dividing either the volar or dorsal distal radioulnar ligament. Finally the measurements were repeated after reconstruction of the divided ligament. FINDINGS: The contact area increases with axial loading of the hand and is greater in supination than pronation. Division of a single distal radioulnar ligament increases the contact area inside the distal radioulnar joint (123% of normal) and reconstruction of the divided distal radioulnar ligament restores the contact patterns towards the normal values (113% of normal). INTERPRETATION: The results show that axial loading of the hand and position of the forearm has a significant effect on the contact area inside the distal radioulnar joint. The study also shows that injury of the distal radioulnar ligament disturbs the normal profiles of contact.

The load-bearing characteristics of the forearm: pattern of axial and bending force transmitted through ulna and radius.

A biomechanical study was performed on 12 cadaveric arms to define the normal profiles of force transmission through the ulna and radius and demonstrate the effect on these of simulated injury of the distal radioulnar joint (DRUJ). Strain gauges were used to measure the axial and bending forces transmitted through each bone. Axial force transmitted through the ulna is, broadly, reciprocal to that seen in the radius, with the greatest force seen in supination. In all 12 arms, axial loading of the hand created an anterior bending force (to create a posterior convexity) in the distal radius. Axial loading of the hand created an anterior bending force in the distal ulna for half the specimens and a posterior bending force in the remaining half. Division and division with reconstruction of either the volar or the dorsal distal radioulnar ligament (DRUL) had no significant effect on force transmission through the ulna and radius, while excision of the ulnar head significantly disrupted the profiles of the axial and bending forces.

Brace and rehabilitation after replantation and revascularization.

Although most reports of the functional results of replantation at the metacarpal level have been poor, the author (LRS) has reported good functional results with the early use of the dynamic crane outrigger splint with a MCP joint extension block, as described in this article (Fig. 8). Promoting early protective active motion and blocking MP joint extension [figure: see text] help achieve a hand with an intrinsic-plus posture and coordinated grasping. Although this protocol does not show an improvement over the functional results at the wrist and distal forearm reported by Meyer, its use can help prevent intrinsic-minus deformity, which is a concern in most amputations proximal to the MCP joint, according to Russell et al. With this technique, the need for subsequent surgery is reduced. Tenolysis may be needed in some patients, but it should not be performed until 6 months postoperatively.

Distal ulnar prosthetic replacement.

A stable, functioning distal radioulnar joint not only provides supination and pronation of the forearm but also is essential to gripping and lifting. Therefore, when distal radioulnar joint deterioration occurs, proper repair is crucial. Ulnar head resection typically is performed; however, a prosthesis may be needed to replace all or part of the joint. This article discusses the advantages and disadvantages of four prostheses, including a total joint replacement designed by the authors.

Ulnar shortening for the treatment of early post-traumatic osteoarthritis at the distal radioulnar joint.

This prospective study describes the outcome of ulnar shortening performed on 32 wrists with early osteoarthritis of the distal radiounlar joint (DRUJ) in an attempt to change the contact area between the ulnar head and the radial sigmoid notch. By changing the contact area, we attempted to relieve pain, while maintaining the function of the DRUJ. The mean age of the patients was 34 years, and the mean follow-up was three years and two months. The wrists were graded by the patients' self-assessment of satisfaction and by a clinical wrist rating that assessed pain, functional status, range of motion, and grip strength. In terms of self-assessment, 16/32 patients were very satisfied, with complete pain relief. Of the 32 patients, 26 said that they would have surgery again if circumstances were similar. The postoperative wrist ratings were 7/32 excellent, 11/32 good, 9/32 fair, 5/32 poor. The most frequent postoperative complaint was plate irritation.

Neuromuscular electrical stimulation and dynamic bracing as a treatment for upper-extremity spasticity in children with cerebral palsy.

We have investigated a therapeutic regimen using neuromuscular electrical stimulation (NMES) and dynamic bracing to assess their effectiveness in reducing upper-extremity spasticity in children with cerebral palsy. Nineteen patients between 4 and 21 years of age with documented diagnoses of spastic cerebral palsy were treated. The patients included in the study followed a regimen of two 30-minute sessions of NMES of the antagonist extensors combined with dynamic orthotic traction during the day. A static brace was used at night. Spasticity of the wrist and fingers was assessed periodically using the Zancolli classification. Treatment ranged from 3 to 43 months. After treatment with electrical stimulation and dynamic bracing, all the patients moved up 1 to 3 levels in the Zancolli classification and showed a marked improvement in upper-extremity function. These results show that combining NMES and dynamic orthotic traction dramatically decreases spasticity of the upper extremity in young patients with cerebral palsy.

Distraction lengthening of the ulna in radial club hand using the Ilizarov technique.

Six children with radial club hand had distraction lengthening of the ulna using the Ilizarov technique at the mean age of 10 years. The mean lengthening achieved was 4.7 cm (46% of original ulna length). Complications included nocturnal pain, pin track infection and callus fracture or delayed union. Distraction lengthening of the ulna can enhance the ability to perform normal activities of daily living, such as reaching the perineum or driving a car, but complications are extremely common. The high rate of callus fracture in this series reinforces the need for regular radiographic review during distraction and suggests that after distraction it may take more than 4 weeks for satisfactory callus consolidation before removal of the fixator.

The surgical management of the upper extremity anomalies associated with Du Pan syndrome.

Du Pan syndrome is a rare condition comprising complex brachydactyly with fibular hypoplasia that is inherited in an autosomal recessive manner. This article describes experience gained through the management of four patients with this disorder. The surgical management of the upper limb abnormalities is discussed and a detailed timetable for their treatment is suggested.

A comparison of immediate and staged reconstruction of the dorsum of the hand.

The treatment of complex dorsal hand lesions involving skin and subcutaneous tissues, extensor tendons, and bone remains a difficult problem for reconstructive surgeons. Traditional treatment of these defects uses staged reconstruction, first obtaining soft tissue cover and then performing bone and tendon grafts. The purpose of this study was to compare a series of seven patients who underwent staged reconstruction with seven patients who had immediate reconstruction involving primary bone and tendon grafting. All procedures were performed to correct similar severe dorsal hand defects. Patients with immediate reconstruction had a significantly faster return to maximum range of movement (ROM) (214 days compared to 630 days, P = 0.002), significantly fewer operations (2.1 compared to 5.9, P = 0.002) and a greater chance of returning to work (86% compared to 48.2%, P = 0.3) than patients with staged reconstruction.

Functional results of dynamic splinting after transmetacarpal, wrist, and distal forearm replantation.

The results of replantation at the wrist and distal forearm are reported to be better than at the metacarpal level, in part because the latter involve direct injury to the intrinsic muscles. This study evaluates a new post-operative protocol for replantation at the metacarpal, wrist and distal forearm levels. 3 days after replantation, the patient was placed in a dynamic crane outrigger splint with MP joint control, compensating for intrinsic muscle function loss. From 4 to 12 weeks, an anticlaw splint alternated with the outrigger splint. After 12 weeks, a dynamic wrist extension orthosis was added to the anti-claw splint. 11 patients (four replantations at the transmetacarpal level, three at the wrist and four in the distal forearm) had this protocol between 1988 and 1993. For distal forearm replantation, TAM of fingers averaged 216 degrees, grip strength 42 lb, and pinch strength 7.2 lb with 75% good or excellent results. For wrist replantations, TAM of fingers averaged 243 degrees, grip strength 37 lb and pinch strength 10.6 lb with 100% good or excellent results. For transmetacarpal replantations, TAM of fingers averaged 189 degrees, grip strength 37 lb and pinch strength 5.6 lb, with 75% good and excellent results. Early protected mobilization, as described here, preserves tendon gliding, muscle strength and excursion. Our results support this protocol for wrist and distal forearm replantation and especially for transmetacarpal replantation, the results of which tend to be poor according to the medical literature.

Reconstruction of the dorsal ligament of the triangular fibrocartilage complex.

The distal radio-ulnar ligaments (DRUL) are key components of the triangular fibrocartilage complex (TFCC). The dorsal DRUL tightens during pronation of the forearm and helps to stabilize this motion. 12 women and three men at our clinic have been treated for DRUJ instability secondary to dorsal DRUL rupture or attenuation. Their chief complaint was pain. The dorsal DRUL was reconstructed using a tendon graft, the ends of which were anchored in the bone of the radius and ulna. This technique has been shown to correct dynamic DRUJ instability in carefully selected patients, decreasing or eliminating pain and restoring normal function.

Primary extensor tendon reconstruction in dorsal hand defects requiring free flaps.

This study reports results in nine patients with extensive loss of soft tissue, extensor tendon, and bone, treated with an emergency free flap for skin cover, primary bone grafts, and tendon grafts passed through individual tunnels in the free flap. Four had a good result, four were fair and one poor. Six patients returned to work, two were not working and one was retired. In select patients, emergency reconstruction of severe extensor tendon injuries appears to produce better function, with fewer operations, a shorter hospital stay, minimal complications, and a shorter period of disability.

Distal radio-ulnar ligament motion during supination and pronation.

The dorsal and palmar distal radio-ulnar ligaments (DRUL) play an important role in the stability of the distal radio-ulnar joint (DRUJ). Various authorities, however, hold opposite opinions regarding DRUL motion during DRUJ pronation and supination, thus implying opposite techniques for reconstruction of the unstable DRUJ. With the hypothesis that relative displacement would increase in the dorsal DRUL during pronation and would increase in the palmar DRUL during supination, measurements were made of the relative DRUL displacement with a Hall-effect displacement transducer during DRUJ pronation and supination in six fresh cadaver wrists. The hypothesis was confirmed that the dorsal radio-ulnar ligament undergoes relative displacement during pronation, while the palmar radio-ulnar ligament undergoes relative displacement during supination.

Functional anatomy of the hand.

The emphasis of this review is on anatomy as related to function of the hand. We have described all aspects of functional anatomy from the skin to the skeletal framework. This article provides a concise overview of the hand and intricacies.

Complications and morbidity of the donor and recipient sites in 123 lateral arm flaps.

The lateral arm flap is a reliable and versatile free tissue transfer. However, the donor and recipient sites may produce an assortment of relatively minor complaints in a large proportion of patients. 109 (89%) out of 123 lateral arm flaps performed over a seven-year period were reviewed an average of three years after surgery. Unsatisfactory appearance of the donor site was noted by 27% of patients and was twice as likely to be reported by female patients and in cases in which the donor site was repaired by a split-thickness skin graft rather than by primary closure. Elbow pain was reported by 19%. Numbness in the forearm was reported by 59% and was unchanged during the follow-up period in the majority of patients. 17% of patients noted hypersensitivity of the donor site to a variety of stimuli such as cold or vibration. Hair formation was reported at the recipient site by 78% of patients. 83% of the patients found the flap to be bulky and 15% had undergone at least one procedure for debulking. We recommend that the use of the lateral arm flap should be limited to males and cases in which the resulting donor site can be closed primarily.