Dorsal locking plates versus staples in four-corner fusion: a comparative clinical and radiological study.

INTRODUCTION: Four-corner fusion was described in 1984 by HK Watson for the treatment of SLAC wrist. This intervention has undergone few changes since that description, but the debate on the fixation method is still not resolved. HYPOTHESIS: Dorsal locking plates provide better stability, short immobilization and a quicker return to daily activities than traditional fixation methods such as staples. MATERIALS AND METHODS: Thirty-one fusions using the Medartis Aptus Four-Corner Fusion(®) plate at a mean 13.1 months' follow-up and 35 using staples at a mean 80.4 months' follow-up were reviewed in a clinical and radiographic retrospective comparative study. RESULTS: Results were comparable between the two groups in terms of range of motion (flexion-extension arc of 67.3° for plates and 60.6° for staples), force (29.6 and 28 kg.F), pain and disability (PRWE 34.8/150 and 40.9; QuickDASH 19.83/100 and 30). Mean time off work was significantly shorter in the plate group (4.5 vs. 7.9 months). There were no non-unions in the plate group, versus 2 in the staples group. Dorsal impingement implicating hardware was also less frequent in the plate group (2 vs. 11). DISCUSSION: The dorsal locking plate did not improve final results in four-corner fusion in terms of range of motion, force, pain or function compared to staples. However, it provided stable fixation, allowing a shorter immobilization and a quicker return to work. Although the initial cost is higher, it could allow significant savings on postoperative costs, shifting the technical debate into the field of public health. LEVEL OF EVIDENCE: Level IV, retrospective study.

The role of three-ligament tenodesis in the treatment of chronic scapholunate instability.

Restoring ligamentous control in dissociative carpal instability is a major issue in protecting against osteoarthritis. We present clinical and radiological results for 20 patients who underwent flexor carpi radialis three-ligament tenodesis and were prospectively reviewed at a mean follow-up of 25.1 months. Three-ligament tenodesis significantly relieved pain and increased grip strength, wrist function at the expense of joint stiffness. This improvement was not seen in cases of dynamic instability. However, ligamentous loosening did result in rapid recurrence of radiological anomalies and frequent complications. This study challenges the long-term benefit of three-ligament tenodesis in both dynamic and static chronic scapholunate instability.

Chronic scapholunate instability treated by scaphocapitate fusion: a midterm outcome perspective.

INTRODUCTION: Chronic scapholunate instability can lead to functional deficits and radiocarpal osteoarthritis. A number of procedures, namely scapho-trapezio-trapezoid (STT) fusion, scaphocapitate (SC) fusion or soft tissue reconstruction procedures, aim to improve function while protecting the wrist from osteoarthritis. HYPOTHESIS: Define the role of scaphocapitate fusion in comparison to STT fusion and capsulodesis and ligament reconstruction. MATERIAL AND METHODS: A clinical, radiographic and functional evaluation was performed on 31 SC fusion cases with an average follow-up of 5 years. RESULTS: Range of motion was 41° in flexion and 39° in extension. Radial-ulnar deviation was 43°. Strength was 32.5 kgf (Jamar). The DASH was 27% and the PRWE was 25%. Fifty percent of the wrists were pain-free at rest. Ninety-four percent of patients were satisfied with the procedure. Seventy-eight percent of patients had returned to their occupation. Radiographic analysis revealed that consolidation was obtained at 10.1weeks. The postoperative radioscaphoid angle was 55° with good radioscaphoid congruence. There was no osteoarthritis in the radioscaphoid joint in 84% of the cases. The non-union rate was 13%. DISCUSSION: These data are similar to the few series that exist. STT fusion leads the same clinical results, but it is technically more difficult and has a higher rate of complications. Capsulodesis and ligament reconstruction provide the same functional results as SC fusion, but with slightly less stiffening. However, these techniques do not seem to protect the wrist from arthritic degeneration at longer follow-up. SC fusion is superior to STT fusion for the treatment of chronic scapholunate instability. This is a pain-relieving intervention with good clinical results and preservation of scaphoid stability. As a component of the surgeon's armamentarium, it can be held in the same regard as capsulodesis and ligament reconstruction for cases of chronic scapholunate instability with a non-reducible scaphoid, or after failure of a soft tissue reconstruction procedure. LEVEL OF EVIDENCE: Level 4, retrospective study.

[Primary ray resection as an alternative to microsurgical replantation in the management of ring finger avulsion]. / Alternative à la replantation dans les amputations type doigt d'alliance stade IV: amputation basimétacarpienne d'emblée.

OBJECTIVES: Ray resection of the metacarpal with conservation of the proximal end is a technique of management of complete ring avulsion injuries in the emergency situation. This study is a functional evaluation of the technique in comparison to replantation. METHODS: The present series includes 11 patients, average age of 35 years, predominantly manual workers, operated between October 2005 and July 2007. It consisted of two grades IVA, six grades IVB, and three grades IVC (classification of Merle-Michon). Cases were assessed according to grip and pinch strength, quantitative 400 points score and a work evaluation. RESULTS: Ten patients were evaluated with an average follow-up of nine months (range: three to 19 months). There were no complications apart from four patients with phantom pain. The time to return to work was three months (range: 10-219 days). All patients were satisfied with the cosmetic appearance, however eight of them suffered from psychological problems, finding it difficult to accept a four-fingered hand. Secondary surgery was unnecessary in the majority of the patients (80%). The grip strength was measured as 30% of grip strength of the unaffected side (range: 3-70%). The result of the 400 point score was 75,94% (range: 55-99%). CONCLUSION: Ray resection of the metacarpal with conservation of the proximal end is a reliable procedure. Strength is decreased but this does not stand in the way of a rapid return to previous work. However, the choice of strategy (ray resection versus microsurgical replantation) should be discussed in detail with the patient prior to selecting the appropriate option.