Techniques in Hand & Upper Extremity Surgery

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Techniques in Hand and Upper Extremity Surgery 9(4):177, 2005

Ó 2005 Lippincott Williams & Wilkins, Philadelphia

E D I T O R I A L

Another Goal Achieved Plus Some Thoughts on Globalization n

INDEX MEDICUS

The journal Techniques in Hand and Upper Extremity Surgery is now indexed in Medline. This listing by Index Medicus by the National Library of Medicine represents a long-term goal of the Editors-in-Chief and the Editorial Board. The peer review process has its obvious limitations but may be described as a form of validation of the concepts and material presented to the reader.

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GLOBALIZATION

This commentary is being written on a Dell laptop computer that represents a prime example of the concept of ‘‘globalization’’ or as Friedman postulates, ‘‘The World is Flat’’.1 This laptop was designed based upon customer input that was translated into an electronic device by engineers in the United States and Taiwan and assembled in one of several assembly plants in southeast Asia from component parts made by multiple international manufacturers (many with recognizable names) with production facilities immediately adjacent to a Dell assembly facility. These components are delivered to the assembly plant on demand within a matter of hours based upon the volume and nature of the orders placed with Dell. The order of magnitude is illustrated by the fact that an average sales day for Dell is 140,000 to 150,000 computers.

So what does globalization have to do with Techniques in Hand and Upper Extremity Surgery (THUES)? A recent review of the sources of the various published papers in THUES and a review of the countries of origin of our Editorial Board indicates that we are ‘‘global.’’ You will also be pleased to know that all of our manuscript submissions are ‘‘online’’ and that peer review and tracking is performed ‘‘online.’’ This is a subtle (or perhaps not so subtle) reminder that those useful techniques that you have developed may be easily shared with the rest of us on this ‘‘flat planet.’’ Please be assured that your submissions will always receive a courteous and timely response from the Editors and Editorial Board. l James R. Doyle, MD Co-Editor-in-Chief Emeritus Professor of Surgery (Orthopaedics) John A. Burns School of Medicine University of Hawaii Honolulu, Hawaii

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REFERENCES

1. Friedman TL. The World is Flat–A Brief History of the Twenty First Century. Farrar, Straus and Giroux; New York: 2005.

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S H O R T


R E V I E W

A Review of Common Practice in Dupuytren Surgery Iain T. H. Au-Yong, BM, BCh (Oxon), MA (Cantab), MRCS (Ed) Department of Radiology Queens’ Medical Centre and Nottingham City Hospital Tollerton, Nottingham, UK

Clare J. Wildin, FRCS Orth and Tr and Joseph J. Dias, MBBS, MD, FRCS (Ed), FRCS (Eng) Orthopaedics and Hand Surgery Glenfield Hospital Leicester LE5 4QF, UK

Robert E. Page, MBChB (Hons), FRCS, ChM Department of Reconstructive Plastic and Burns Surgery Northern General Hospital Sheffield S5 7AU, UK

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ABSTRACT

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Aspects of decision making, postoperative management, and complications routinely discussed with patients were investigated using a questionnaire completed by 141 hand surgeons of various grades who regularly manage Dupuytren disease. This account presents the results of this questionnaire study, and the literature is discussed in context. A brief description of operative technique in fasciectomy and dermofasciectomy is included. Thresholds for surgery did not differ greatly among the surgeons who completed the questionnaire. The training background and the number of operations performed by surgeons also did not generally influence surgical decision making. Postoperative care regimens were very similar. However, there was great variation in the complications routinely included in discussions with patients undergoing surgery for Dupuytren contracture. Recurrence and nerve damage were the only 2 mentioned by almost all surgeons. There was also diversity in what rates were quoted for complications, particularly recurrence (median 33%, range 0%–100%) and stiffness (median 10%, range 0%–100%). Keywords: Dupuytren disease, postoperative, complications, decision making

Dupuytren disease was first described by Plater in 1614 as a tightening in the flexor tendons and first treated surgically by Baron Dupuytren in 1832.1 It describes a condition that, in its early stages, causes thickening of the palmar skin and underlying subcutaneous tissue and, later in its natural history, results in fibrosis of the palmar fascia and the bands connecting this to the skin and deeper structures of the hand such as tendon sheath. The pathophysiology is discussed in more detail elsewhere.2 This results in a fixed flexion contracture at the proximal interphalangeal joint and/or distal interphalangeal joint of the hand, particularly of the ring and little fingers. In early disease, nodules are noted, which are fixed to deeper structures and skin. These are thought by many to be the starting point of the disease.3 Management of these is controversial, as discussed below. The etiology of Dupuytren disease remains elusive, although a number of theories have been proposed.3,4 Diabetes, smoking, and alcohol abuse predispose to this condition. There is almost certainly a genetic predisposition also, as described by Ling.5

n Address correspondence and reprint requests to Iain T. H. Au-Yong, Specialist Registrar in Radiology, Queens’ Medical Centre and Nottingham City Hospital, 44 Bentinck Avenue, Tollerton, Nottingham NG12 4ED, UK. E-mail: [email protected].

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HISTORICAL PERSPECTIVE

INDICATIONS/ CONTRAINDICATIONS

As the disease progresses, contraction of the diseased palmar fascia leads to formation of fixed flexion deformities of the proximal interphalangeal joint and/or the

Techniques in Hand and Upper Extremity Surgery

Dupuytren Surgery

FIGURE 1. Our questionnaire, BSSH/BHG Combined Meeting October 2001.

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FIGURE 1. (continued ).

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metacarpophalangeal joint. As the joints become flexed, function decreases. The aim of surgery is to remove the diseased fascia and thereby correct contractures. However, surgery does not cure the disease, and Dupuytren contracture may recur. Hence, the timing of surgery is essential: it should be carried out when it is indicated by the intrusion of the bent finger in daily activity but before joint stiffness and lengthening of the extensor mechanism has occurred, because then the contracture may not be correctable. A number of procedures can be carried out for the treatment of Dupuytren contracture, and a brief discussion of these is necessary to understand the decisionmaking process in choosing the appropriate procedure and timing the surgery optimally. Partial fasciectomy is the most widely employed procedure. This involves excision of the diseased fascia and is often combined with a z-plasty of the skin. Technique and postoperative care should ensure that a subsequent contracture in the surgical scar does not contribute to subsequent disability.6 Dermofasciectomy involves excision of the diseased fascia and skin en bloc in advanced cases and the placement of a full-thickness skin graft. Amputation may be indicated as a last resort in patients with a severely flexed, useless digit, in whom surgery has failed, often several times. Other variations on these techniques exist but are not described here.6 Both techniques are described in more detail below.

The Metacarpophalangeal Joint (MCPJ) and Proximal Interphalangeal Joint (PIPJ) Participants in the questionnaire study (Figure 1) were asked about their thresholds for operating on contractures of the MCP joints. These figures are summarized in Table 1. The majority of surgeons, roughly half of the group, set their threshold for operating at 40 degrees of deformity. A smaller proportion (37, 27%) would operate on contractures above 20 degrees. Fifteen (11%) of the respondents were guided solely by patient request. The table top test was advocated by 3 surgeons (2%). This is explained in more detail below. We analyzed TABLE 1. Thresholds for operating on joint contractures Threshold for operating MCP joint PIP joint .20 37 (27%) 59 (43.7%) .30* 7 (5.1%) 7 (5.2%) .40 68 (49.6%) 53 (39.3%) .60 2 (1.5%) 4 (3%) Table top test* 3 (2.1%) 0 (0%) Patient request* 15 (10.9%) 6 (4.5%) Other (includes*) 27 (19.7%) 19 (14.1%) Responses 137/141 (97.2%) 135/141 (95.7%) *This range was not offered as a threshold in the questionnaire; surgeons volunteered this response themselves.

these figures in the context of training background (plastic surgery versus orthopedics) and frequency of operation and found that neither of these factors affected the threshold for operating. The same threshold question was asked about contractures of the PIP joint, the results of which are also displayed in Table 1. Of note, the threshold for operating is lower, at 20 degrees for the majority of surgeons (44%), although many surgeons wait until contractures have reached 40 degrees or more (39%). The number of operations performed by the surgeon once again did not affect the threshold for operating. However, there was a suggestion in our figures that those with an orthopedic training background had a higher threshold for operating on this joint than those with a training background in plastic surgery: 33% of orthopedic surgeons set their threshold at 20 degrees, compared with 57% of plastic surgeons (x2 = 5.9, P = 0.015), and 47% of orthopedic surgeons set their threshold at 40 degrees, compared with 20% of plastic surgeons. (x2 = 6.1, P = 0.01). Most surgeons set their threshold for operating on MCPJ contractures at over 40 degrees, whereas the majority of surgeons have a lower threshold for operating on PIPJ contractures (20 degrees). This is in agreement with the literature, which suggests that the latter are more difficult to correct. Crowley et al7 give a detailed discussion of the anatomic factors contributing to contractures at these joints and their correction and cite reasons why it is easier to achieve correction of contractures of the MCP joint than of the PIP joint. One method for assessing suitability for operation is the use of the ‘‘table top test,’’ which is given by some surgeons as their threshold for operating on joint contractures. This test is positive if the hand cannot be placed fully flat on a table top and can easily and conveniently be applied in the outpatient setting.8 The rationale behind the effectiveness of this test as a decision-making tool again derives from the fact that a PIP joint contracture is more difficult to correct than an MCP joint contracture. At the point when a patient can no longer place his hand flat on the table, a correctable MCP joint contracture is usually present without significant PIP joint contracture. The exception to this rule is where the patient can hyperextend the MCP joint, in which case the patient may be able to place the hand flat on the table in the presence of isolated PIP joint disease. In this scenario, the test must be used with caution.8 These observations explain why our surgeons use this test as a tool to assess MCP joint but not PIP joint disease. Tonkin et al9 reported outcomes of 154 operations on 100 patients with Dupuytren disease with an average PIP joint contracture of 42 degrees. The average improvement in PIP joint extension was 41%, suggesting that at a threshold of 20 degrees complete correction will

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be achievable most of the time. It is also of interest that in 1 in 11 of these patients, the contracture could not be corrected, leading to amputation, suggesting that a lower threshold for surgery (20 degrees of contracture or the table top test as suggested in our survey) may prevent hands from reaching a stage of deformity that cannot be corrected. Some of our surgeons do not specify a specific angular deformity as a threshold for surgery and are guided solely in their decision by patient request. This is, of course, important, as the age and profession of the patient and other factors may influence the magnitude of the disability. Surgery may be worthwhile in a small proportion of patients who have a small degree of deformity that is causing them significant disability.

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NODULES

The majority of surgeons advocate nonoperative management of Dupuytren nodules (61%). A larger proportion of this group were from an orthopedic training background than a plastic surgery one (73% versus 45%; x2 = 5.8, P = 0.002). A smaller proportion of surgeons would be prepared to operate if the nodules were painful (32%). One surgeon specified the use of steroid injections in the management of nodules. The number of operations performed by the surgeon did not influence the incidence of operating on nodules. These figures are summarized in Table 2. Approximately two thirds of surgeons would not operate on Dupuytren nodules. One third would do so if they were symptomatic. McFarlane10 explains that Dupuytren nodules are the first manifestation of the disease, and excision of the nodule causes reaction of the surrounding tissue, leaving a larger nodule than before. Some surgeons advocate injection of these nodules. Ketchum et al11 report encouraging results with injection of nodules with triamcinolone acetonide. In this study, 97% of nodules regressed to some degree with injections. The paucity of evidence available in the literature suggests that decision making with regard to the management of nodules at present remains unclear.

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DERMOFASCIECTOMY

The most common indication for dermofasciectomy in this group of surgeons was surgery for recurrent disease, for which 60% would perform this operation. Inability to close skin was a less common indication (28%), as was operating in the young (21%). A notable proportion would never perform this operation (14%), and a minority of surgeons always perform it (1%). These results are summarized in Table 3. Seventeen surgeons cited other indications for performing a dermofasciectomy, the most common being skin involvement and family history. Other reasons were combinations of the above including young diabetic patients, rapid progression, and other sites involved. We compared the responses of consultants with orthopedic and plastic surgery training backgrounds, and more of the former group would never perform a dermofasciectomy (12/66, 18%) than the latter (1/31, 3%) (x2 = 2.9, P = 0.08), although the difference did not quite reach statistical significance. The majority of surgeons would, given the right indication, perform a dermofasciectomy, although one seventh would never perform this procedure. Most of the latter group were from an orthopedic training background. The most common indication for this operation was management of recurrent disease (84 surgeons). This is consistent with the literature, which suggests that recurrence of Dupuytren disease occurs less frequently in patients who have had a dermofasciectomy.12,13 Tonkin et al14 compared outcomes in 100 patients treated by dermofasciectomy and fasciectomy and found that the rate of disease recurrence in the former group was dramatically reduced. Tonkin et al9 also reported that amputation specimens following dermofasciectomy showed no histologic recurrence of the disease under the skin graft. The rationale for performing this operation in young patients is that they are a group of patients who potentially face multiple operations for a disease that can be controlled but not cured by surgery. Twenty percent of this group of hand surgeons would perform this procedure for this group of patients. TABLE 3. Indications for a dermofasciectomy

TABLE 2. Dupuytren nodules Category Would operate Operate but only if painful Rarely operate Never operate on these

Response rate

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Number of surgeons 4 (2.9%) 44 (32.1%) 2 (1.5%) 84 (61.3%) Orthopedic consultants 48/66 (72.7%) Plastics consultants 14/31 (45.1%) 138/141 (97.8%)

Indications for dermofasciectomy Redo surgery Cannot close the skin Young patient Would never perform this operation Always perform this operation Skin involvement* Diathesis*

Number of surgeons 84 (59.6%) 40 (28.3%) 29 (20.6%) 19 (13.5%) 2 (1.4%) 11 (7.8%) 4 (2.8%)

All surgeons answered all parts of this question. *Not offered as an option; surgeons volunteered this reason themselves.


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AMPUTATION

The majority of surgeons would offer an amputation in the management of severe disease, with only 19% unwilling to offer this option. Severe disease, particularly after surgery for recurrent disease, was the most common indication (44%). These figures are summarized in Table 4. A variety of other reasons were offered by 22 surgeons. These included nerve damage, pain, scarred skin, and failed surgery for disease recurrence. One surgeon offers arthrodesis to his patients as an alternative to amputation. There were no differences between consultant plastic and orthopedic surgeons. Jensen et al15 reported outcomes of amputations in patients with recurrent Dupuytren disease and found that skin necrosis (2 out of 23 amputations), disease recurrence (in amputations distal to the MCP joint, 9 out of 16), and neuroma or phantom pain could occur in these patients postoperatively (5 out of 7 little finger amputations through or proximal to the MCP joint). These authors suggested that alternatives to amputation should be found where possible, given the high occurrence of late complications. The findings of Tonkin et al9 in the study outlined above are also of interest. Of the 100 patients recruited to the study, 14 underwent amputation. Twelve of these amputations were for recurrent disease, which, of note, was the most common indication for this operation cited by surgeons in our survey.

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scar and prevent contracture of the scar, which could cause further flexion at the joint. The diseased fascia is first dissected off the skin, which is delicate and should be handled gently. It is next dissected carefully off deeper structures, with care taken not to damage the flexor tendon sheath. Neurovascular bundles are identified and protected. These are particularly at risk if the bundle spirals the contracture band in the proximal phalanx. The skin is closed primarily using interrupted sutures as discussed above.

Dermofasciectomy The indications for this procedure are discussed above. The diseased fascia is removed en bloc along with the overlying diseased skin, with care taken not to damage deep structures. The full-thickness skin graft is taken from the forearm, and the fat is removed. Meticulous hemostasis at the graft recipient site is mandatory, as hematoma will lift the graft and cause it to fail. For this reason, the tourniquet is removed while hemostasis is achieved with bipolar diathermy. Holes can be cut into the graft to avoid hematoma. The graft is sutured with interrupted sutures, and postoperatively, a bulky dressing is applied for hemostasis.

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COMPLICATIONS

Complications That Are Routinely Discussed With Patients

TECHNIQUE

Surgery should be performed with the use of a tourniquet, as it is possible to damage the neurovascular bundles, and a bloodless field helps to reduce this risk. Surgery is also often performed with loupes to magnify the operative field for the same reason. Surgery for Dupuytren disease is often performed as a day case procedure under regional block.

Fasciectomy A longitudinal incision is made into the palm overlying the affected area and extended into the finger. If the joint line is traversed, a z-plasty should be used to lengthen the

Of the 141 surgeons, almost all warned their patients about the possibility of disease recurrence (90%) and damage to nerves (86%). Sixty percent of surgeons explained that there was a possibility of postoperative stiffness and infection. One third discussed the possibility of reflex sympathetic dystrophy (RSD), and a smaller proportion warned about incomplete correction and the possibility of loss of the finger. Other specific complications discussed included wound failure, bleeding, scarring, and weakness of grip. These results are summarized in Table 5. TABLE 5. Proportion of patients warned about complications of Dupuytren surgery

TABLE 4. Indications for an amputation Category Never Severe elderly pt Severe redo Patient request* Very seldom*

Number of surgeons 27 (19.1%) 42 (29.8%) 62 (44%) 6 (4.3%) 5 (3.5%)

All surgeons answered all parts of this question. *Not offered as an option in the questionnaire; surgeons volunteered this reason themselves.

Complication Recurrence Nerve damage Stiffness Infection RSD Finger loss Incomplete correction*

Percentage of surgeons who warn patients about this complication 90.8 85.8 61.7 58.9 36.2 27 8.5

*Not offered as an option in the questionnaire; surgeons volunteered this complication themselves.

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Responders 110 (78) 87 (61.7) 103 (73) 115 (81.6) 100 (70.9) 87 (61.7)

,1 17.3 73.6 0 14.8 2 20.7

1–1.9 22.7 13.8 0 27 9 16.1

2–4.9 16.4 12.6 2.9 29.6 3 20.7

Complication Rates Quoted by Surgeons Surgeons were asked what rate they quote for each complication to their patients. The responses of surgeons are summarized in Table 6 and Figure 2.

Common Complications Infection. Almost all surgeons quoted the risk of infection at a figure of less than 10%; 1% and 5% were the most popular figures quoted for this complication. Recurrence. There was a wide disparity in the rate suggested for this complication, with anything between 0% and 100% quoted as a recurrence rate (median 33%), although the majority of surgeons gave a figure of over

5–9.9 35.5 0 3.9 20 20 25.3

10–19.9 8.1 0 9.7 8.7 30 10.3

20–29.9 0 0 21.4 0 21 3.4

30–49.9 0 0 21.4 0 6 2.3

50–100 0 0 40.1 0 9 1.1

20%. Twenty surgeons (14%) routinely told their patients that there is a 100% risk of recurrence. Stiffness. There was again a wide disparity in the rate suggested for this complication, with 5%, 10%, and 20% being the most common figures given. Once again, figures between and including 0% and 100% were given (median 10%).

Serious Complications Nerve Damage. The risk of nerve damage quoted by surgeons is similar to the figures for infection, with the majority giving a figure of between 0% and 10%; 1%, 2%, and 5% were the most common figures given to patients.

FIGURE 2. Summary of complication rates quoted by surgeons (percentages): top graph, common complications; bottom graph, serious complications.

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Reflex Sympathetic Dystrophy (RSD). Once again a range of figures were given to patients, although the majority quoted between 0% and 20%; 5% was the most common figure given. Finger Loss. Almost all surgeons quoted the risk at less than 1%. The highest figure quoted was 5% (3 surgeons). Perhaps the most interesting variation is noted in the complications routinely warned about and the rates quoted for these complications. These data are important in the context of obtaining informed consent for surgery. During this process it is necessary to warn the patient of the risks associated with the procedure. Failure to mention a surgical risk to a patient may subsequently result in litigation. The legal position on whether or not a doctor is negligent in failing to do so was decided in the Bolam case and later modified by the Sidaway case. In the former, which set a precedent for all subsequent practice, it was eventually ruled that if a reasonable body of professional opinion would also not have mentioned the risk (the Bolam test), this would absolve the practitioner of liability.16 In the Sidaway case a rare but devastating complication was not included in discussion with the patient. We are now obliged to mention such complications. In this context it is interesting to note the responses of experts to questions about which complication rates they routinely discuss with their patients. The majority of surgeons warn about nerve damage and recurrence, and about half warn about infection and stiffness. Finger loss and reflex sympathetic dystrophy (RSD) are discussed less often. Quoting complication rates is also an important part of the process of informed consent, although it has perhaps less medicolegal implications. There was very wide variation in the figures that surgeons give to patients when explaining how often recurrence and RSD occur postoperatively, including figures between 0% and 100%. There was less variation in rates quoted for the other complications, particularly the rare ones. There are surprisingly few studies examining the rate of early postoperative complications of Dupuytren surgery. Some of these studies are summarized in Table 7. It is interesting to compare the actual rates observed and the rates quoted by surgeons. Recurrence is the complication for which most data are available. The rates vary, but the pattern seems to be that the length of follow-up after surgery is directly related to the rate of recurrence. This may explain the variation in recurrence rates quoted by surgeons in our study.

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REHABILITATION

Immediate Postoperative Dressing/Splintage: Nature and Duration Either a bulky bandage or a plaster slab was the preferred immediate postoperative dressing (44% each). A smaller proportion used either light dressings or thermoplastic splints (9% and 8%). One surgeon used a dynamic splint. Most surgeons did not use this splintage for more than 7 days, and very few for over 14 days. There was no difference in practice between orthopedic and plastic surgery consultants. These figures are summarized in Table 8.

Night Splintage: Nature and Duration Most surgeons (89%) recommended using a night splint, and of these, almost all of them used a thermoplastic splint. There was a wide variation in how long this was used, although the majority (86%) suggested a total duration of less than 6 months. These figures are summarized in Table 9. There was no difference between orthopedic and plastic surgery consultants.

Removal of Sutures Most surgeons (121, 88%) recommended removal of sutures at between 8 and 14 days. A minority (3%) recommended removal at less than 7 days or 3 weeks (2%). Nine (7%) used absorbable sutures. These figures are summarized in Table 10.

Postoperative Splintage The two most commonly used splints in the immediate postoperative period included a bulky bandage (44%) and plaster slab (45%). The majority suggested using this for up to 14 days, but some suggested use for up to a month and beyond. Almost all surgeons recommended the use of a night splint, most advocating the use of a thermoplastic splint (84%). There was a wider range of suggestions for the duration of night splintage. The aim of postoperative splintage is to slow the recurrence of flexion deformity; its role can perhaps be compared with that of dermofasciectomy. The mechanism by which this is achieved is debated; one suggestion is that a proportion of recurrent contracture is caused by the laying down of collagen and that splintage serves to maintain extension till the collagen has matured.17 Our results are in agreement with the findings of Abbott et al,

TABLE 7. A summary of some complication rates in the literature Paper McFarlane and McGrouther19 Makela et al20 Tonkin14 Shaw et al21

Follow-up

Recurrence

3.2 years 38 months 9.6 years

27% 46.5%

RSD 4.2% 1.5% 3.2%

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Infection 1.3% 7.4%

Nerve damage 1.5% 1% 3.2%

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Au-Yong et al TABLE 8. Immediate postoperative dressing and splintage: nature and duration Type of dressing Plaster slab Bulky bandage Light dressing

Proportion of surgeons 63 (44.7%) 62 (44%) 13 (9.2%)

Duration of splintage ,7 days 8–14 days 15 days to 1 month

Proportion of surgeons 83 (60.6%) 39 (28.4%) 9 (6.6%)

Thermoplastic splint Dynamic splint*

11 (7.8%) 1 (0.7%)

Over 1 month Other

3 (2.2%) 3 (2.2%)

All surgeons answered all parts of this question. *Not offered as an option in the questionnaire; surgeons volunteered this option themselves.

who report great diversity in recommendations for postoperative splintage. Their study also used a questionnaire survey to assess the attitude of surgeons and hand therapists to splintage and found an even greater diversity than in our study. There are few studies in the literature that evaluate the impact of splintage on the rate of recurrence in the long term or compare the outcomes of the different splintage regimens. Rives et al18 report that patients who comply with dynamic extension splintage have a better improvement in interphalangeal joint extension than those who do not. It is difficult to explain the diversity in postoperative regimens employed by surgeons. It may be that if surgeons are happy with their outcomes, that perhaps splintage is not as important as thought. This may be an area that would benefit from further research.

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PHYSIOTHERAPY

Most surgeons involved the physiotherapist in the postoperative care of these patients (97%). Approximately one third referred as required, and the rest referred all of their patients. These figures are summarized in Table 11. There was no difference between orthopedic and plastic surgery consultants. The intention is to achieve full mobility of the MCP and PIP joints by exercise and splintage. There are few studies that quantitatively evaluate the contribution of the physiotherapist in achieving these goals, although TABLE 9. Night splintage Type of night splint Thermoplastic splint Plaster slab Dynamic splint* No splint

Proportion of surgeons

Duration of splintage

Proportion of surgeons

119 1 1 16

,2 months 3–5 months 6 months 6–12 months Forever

22 48 27 8 2

(84.4%) (0.7%) (0.7%) (11.3%)

(17.7%) (38.7%) (29.8%) (6.5%) (1.6%)

All surgeons answered all parts of this question. *Not offered as an option in the questionnaire; surgeons volunteered this option themselves.

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TABLE 10. Removal of sutures Removal of sutures ,7 days 8–14 days 3 weeks Absorbable Response rate

Number of surgeons 4 (2.9%) 121 (87.7%) 2 (1.4%) 9 (6.5%) 136/141 (96.5%)

the splintage regimen employed by Rives et al outlined above included input from the hand therapist, suggesting that noncompliance with the postoperative regimen as a whole, including the involvement of the physiotherapist, may worsen the outcome.

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CONCLUSIONS

Thresholds for surgery did not differ greatly among the surgeons who completed the questionnaire, and the threshold for operating on the PIP joint was lower than that for operating on the MCP joint. The training background of surgeons and the number of operations performed did not generally influence surgical decision making. Exceptions to this included a greater popularity of dermofasciectomy among plastic surgeons, which is perhaps not surprising, and a lower threshold for operating on the PIP joint but higher threshold for operating on Dupuytren nodules by plastic surgeons. The latter observations are interesting and more difficult to explain. There was little diversity in recommendations for postsurgical care: most surgeons removed sutures after 8–14 days, recommended the use of a postoperative splint in the immediate postoperative period, and suggested longer term use of a night splint (although the recommended duration of use varied considerably). A physiotherapist or hand therapist was also involved in postoperative care in the majority of cases. The routine discussion of complications and their frequency with patients is the area of this study that showed the greatest variation. Recurrence and damage to nerves were the only 2 areas that almost all surgeons routinely discussed with their patients. The figures routinely given to patients when explaining complication rates to them also varied considerably, particularly in regard to stiffness and recurrence. The reason for this diversity is TABLE 11. Referral to physiotherapist Referral to physiotherapist All patients referred Refer as required Do not refer Response rate


Number of surgeons 79 (60.3%) 48 (36.6%) 4 (3%) 131/141 (92.9%)

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unclear, and this may be an area that would benefit from further research.

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REFERENCES

1. Dupuytren G. Permanent retraction of the fingers produced by an affectation of the palmar fascia. Lancet. 1834;2:222–225. 2. Rayan G. Clinical presentation and types of Dupuytrens disease. Hand Clin. 1999;15:1;87–95. 3. Gabbiani G, Majno G. Dupuytrens contracture: Fibroblast contraction. An ultrastructural study. Am J Pathol. 1972;66: 131–146. 4. McFarlane RM. Patterns of diseased fascia in the fingers in Dupuytren’s contracture. Displacement of the neurovascular bundle. Plast Reconstruct Surg. 1974;54:31–44. 5. Ling RSM. The genetic factor in Dupuytren’s disease. J Bone Joint Surg. 1963;45B:709–718. 6. Wilson GR. Current surgical treatment of Dupuytren’s disease. Br J Clin Pract. 1997;51:106–110.

12. Armstrong JR, Hurren JS, Logan AM. Dermofasciectomy in the management of Dupuytren’s disease. J Bone Joint Surg. 2000;82B:90–94. 13. Hall PN, Fitzgerald A, Sterne GD, et al. Skin replacement in Dupuytren’s disease. J Hand Surg [Am]. 1997;22B:193– 197. 14. Tonkin MA, Burke FD, Varian JPW. Dupuytren’s contracture, a comparative study of fasciectomy and dermofasciectomy in one hundred patients. J Hand Surg [Am]. 1984;9B: 156–162. 15. Jensen CM, Haugegaard M, Rasmussen SW. Amputations in the treatment of Dupuytren’s disease. J Hand Surg [Am]. 1993;18B:781–782. 16. The General Medical Council. Seeking Patients’ Consent: The Ethical Considerations. 1999. 17. Abbott K, Denney J, Burke FD, et al. A review of attitudes to splintage in Dupuytren’s contracture. J Hand Surg [Am]. 1987;12B:326–328.

8. Hueston JT. The table top test. Hand. 1982;14:100–103.

18. Rives K, Gelbermann R, Smith B, et al. Severe contractures of the proximal interphalangeal joint in Dupuytren’s disease: Results of a prospective trial of operative correction and dynamic extension splinting. J Hand Surg [Am]. 1992; 17A:1153–1159.

9. Tonkin MA, Burke FD, Varian JPW. The proximal interphalangeal joint in Dupuytren’s disease. J Hand Surg [Am]. 1985;10B:358–364.

19. McFarlane RM, McGrouther DA. Complications and their management. In: Dupuytrens Disease. London: Churchill Livingstone; 1990:377–382.

10. McFarlane RM. Dupuytren’s contracture. In: Green D, ed. Operative Hand Surgery, Vol 1, London: Churchill Livingstone; 1982:563–593.

20. Makela EA, Jaroma H, Harju A, et al. Dupuytren’s contracture: the long-term results after day surgery. J Hand Surg [Am]. 1991;16B:272–274.

11. Ketchum LD, Donahue TK. The injection of nodules of Dupuytrens disease with triamcinolone acetonide. J Hand Surg [Am]. 2000;25A:1157–1162.

21. Shaw DL, Wise DI, Holms W. Dupuytren’s disease treated by palmar fasciectomy and an open palm technique. J Hand Surg. 1996;21B:484–485.

7. Crowley B, Tonkin MA. The proximal interphalangeal joint in Dupuytren’s disease. Hand Clin. 1999;15:137–147.

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T E C H N I Q U E

Simultaneous Radial Closing Wedge and Ulnar Shortening Osteotomy for Distal Radius Malunion Takuro Wada, MD, Hideki Tsuji, MD, Kosuke Iba, MD, Mitsuhiro Aoki, MD, and Toshihiko Yamashita, MD Department of Orthopaedic Surgery Sapporo Medical University Sapporo, 060-8543 Japan

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ABSTRACT

Closing wedge osteotomies are an attractive treatment option for distal radius malunion in patients with osteopenia. It does not require a separate-site bone graft, resulting in decreased morbidity. However, this procedure has always been performed in combination with ulnar head resection to accommodate closure of corrective osteotomy and to address the issue of ulnocarpal abutment. Because ulnar shortening osteotomy is more physiological solution, it seemed advantageous to us to combine radial closing wedge osteotomy and ulnar shortening osteotomy. In this article, we present in detail our technique for treating patients with distal radius malunion. The patients are potentially osteopenic such as women aged over 45 years and are active at home, work, and/or recreation but are not involved in heavy physical work. Through volar approach an appropriate bone wedge is removed from the distal radius. A small volar T-plate is used to secure the osteotomized bone fragments. The aim of the radial osteotomy is to correct the dorsal angulation in the sagittal plane within a normal range of 1° to 2° with reference to that of opposite wrist. Ulnar shortening osteotomy is performed by using transverse osteotomy and compression plating technique with an AO compression device. The ulnar variance is adjusted to neutral. Although the technique presented requires the surgeons to use careful plate and screw technique, early results have been encouraging, and patients with osteopenia can be treated successfully. Decreased grip strength which may be provoked by shorting of the forearm is acceptable.

Address correspondence and reprint requests to Takuro Wada, MD, Associate Professor, Department of Orthopaedic Surgery, Sapporo Medical University South 1, West 16 Sapporo 060-8543 Japan.

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Keywords: closing wedge osteotomy, Colles’s fracture, malunion

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Opening wedge osteotomy is preferable for symptomatic malunion of the distal radius in younger patients less than 45 years old and sometimes in older, active patients with good bone mineralization.1–10 By using iliac bone graft, it provides the opportunity for simultaneous correction of distal radioulnar and ulnocarpal malalignment and function without separate operation for the distal ulna. The operative procedure has been rarely indicated for patients with osteopenia because of the risk of failure of fixation followed by recurrent malunion.11 One the other hand, Posner and Ambrose12 advocate radial closing wedge osteotomy, so that no bone graft is necessary. This procedure is advantageous in older and osteopenia patients and especially suited to professionals, retirees, and nondominant extremities owing to less rigorous physical demand. The radial closing wedge osteotomy has been performed with simultaneous ulnar head resection to accommodate closure of the corrective osteotomy and to address the issue of ulnocarpal impingement and arthritis.12,13 However, the ulnar head resection is too disabling for patients with an intact ulnar carpus and triangular fibrocartilage complex.1,3,14,15 An ulnar shortening osteotomy, which preserves the distal radioulnar joint and integrity of triangular fibrocartilage complex may be a better solution.16 We combined the radial closing wedge osteotomy with ulnar shortening osteotomy. Closing wedge osteotomy obviously results in additional shortening of the radius, which may be already shortened as a consequence of the fracture. A large amount of ulnar shortening is


Simultaneous Radial Closing Wedge and Ulnar Shortening Osteotomy

required for adequate correction of radioulnar and ulnocarpal malalignment. Compression plating technique with an AO-compression device17 makes it possible to shorten the ulna over 1 cm without any complications.

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The indications for surgery are (1) symptomatic malunion of the distal radius, (2) potentially osteopenic patients such as women aged over 45 years, and (3) patients who were active at home, work, and/or recreation but were not involved in heavy physical work. No absolute criteria for the degree of deformity were used. The distal radioulnar joint was carefully assessed with plain radiographs and CT scans. The contraindications to this surgery are intraarticular malunion, degenerative changes or incongruity of the distal radioulnar joint, and instability of the distal radioulnar joint as identified by a positive piano key sign.

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MALUNITED COLLES’ FRACTURE

Preoperative Planning Two parts to the operation are correction of the malunion with a closing wedge osteotomy of the radius and a shortening osteotomy of the ulna. Each procedure was carried out through a separate incision. The aim of the radial osteotomy was to correct the volar tilt angle in the sagittal plane within a normal range of 1° and 21°18 with reference to that of the opposite wrist (Fig. 1A, 1B). The amount of wedge bone to be removed was planed with radiographs of the injured and uninjured wrists. The angle of the wedge is determined by first measuring the degree of abnormal articular tilt on the preoperative lateral x-ray film and then adding to this angle a sufficient number of degrees to restore the normal volar tilt of the radius after the wedge of bone is removed (Fig. 1C). The aim of the ulnar shortening osteotomy is to improve anatomic relationship at the level of the distal

FIGURE 1. A, Preoperative radiographs of malunited Colles’ fracture. B, Postoperative anterior and lateral radiographs. Note that nonunion of the ulnar styloid process is healed. C, Anteroposterior radiographic parameters. Ulnar variance (UV): The difference in level between the distal ulnar surface and ulnar part of the distal radial surface. Ulnar tilt (UT): The angle of the distal surface in relation to the perpendicular to the long axis of the radius. UT is not corrected intentionally. Lateral radiographic parameters. Dorsal tilt (DT): The angle of the joint surface in relation to the perpendicular to the long axis of the radius. D, An angle of the wedge bone to be removed corresponds to the dorsal tilt plus volar tilt of the opposite wrist (20° + 5° = 25° in this patient). The amount of volar cortex to be removed is also determined (4 mm in this patient) on tracing of the radiograph of the injured wrist. Ulnar variance is 5 mm.

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radioulnar joint, by adjusting the ulna variance to neutral, irrespective of the radiographs of the uninjured wrist (Fig. 1A, 1B). The ulna variance of the opposite wrist could not be a proper reference because of a significant trend toward positive ulnar variance as age increased.19,20

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TECHNIQUES

The patient is placed in a supine position, with the hand on the arm table. A tourniquet is used on the upper arm set to 250 mm Hg. Regional or general anesthesia is used. A 10-cm longitudinal skin incision is made over the radial edge of the flexor carpi radialis. The radial artery is identified on the soft tissue directly to the radial side of the flexor carpi radialis (FCR). The flexor carpi radialis tendon and the radial artery are retracted ulnarly and the pronator quadratus muscle is exposed. The insertion of the pronator quadratus is incised longitudinally along the palmar radial boarder of the distal radius at its

insertion, leaving the small cuff of the tissue that can be sutured during closure. A part of flexor pollicis longus origin is also released subperiosteally and retracted ulnarly. The site of osteotomy is marked 2.5 cm proximal to the wrist joint, leaving enough room to place T-plate on the distal fragment (Fig. 2A). The proximal osteotomy is directed at right angle to the long axis of the radius with the oscillating saw, with care taken to avoid a complete osteotomy of the dorsal cortex. Then the distal osteotomy is completed. An appropriate amount of bone wedge is removed in accordance with the preoperative plan (Fig. 2B). At this stage, reduction of the distal fragment may not be successful as the ulna serves as strut and interferes with the two segments of the radius being brought together. The ulnar shortening osteotomy is performed before completing a reduction and internal fixation of the radius fragments. A longitudinal skin incision is made on the skin along the subcutaneous border of the ulna.

FIGURE 2. A, Two osteotomy lines are marked on the volar cortex of the radius. B, An appropriate bone wedge is removed from the radius. Before the reduction and internal fixation of the radius fragments are completed, the ulnar shortening osteotomy is performed. C, A six-hole DCP is applied to the distal ulna with three screws. The site of osteotomy is marked at the middle of the plate and an aligning mark is made proximally. D, Then the plate is removed and the estimated bone section (4 mm in this patient) is removed by two transverse osteotomies.

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FIGURE 3. A, Reduction and internal fixation of the distal radius with small volar T-plate is performed. B, An AO-compression device is tightened to close the ulnar osteotomy site. C, Ulnar variance is checked with intraoperative radiographs (ulnar positive 3-mm variance remains in this patient). Another 3 mm of shortening osteotomy is performed.

The distal end of the incision is 2 cm proximal to the tip of the ulna styloid. The incision should be long enough to apply an AO small six-hole dynamic compression plate (DCP) and external compression device. The interval between the extensor carpi ulnaris and the flexor carpi ulnaris is opened to expose the ulna. The plate may be placed either on the dorsal or volar aspect of the ulna. We usually place the plate dorsally. Subperiosteal dissection is done on the chosen surface for the length of the plate and 3 cm proximal. A six-hole dynamic

compression plate was fit to the distal ulna, and three distal screws were drilled, tapped, and fitted with 3.5-mm screws, using the neutral drill guide and standard AO technique. Ensure that the plate is parallel to the bone for its whole length (Fig. 2C). The site of osteotomy is marked at the middle of the plate and an aligning mark is made proximally. The plate is removed and subperiosteal dissection is done to expose the bone circumferentially for approximately 2 cm on each side of the marked osteotomy site. The amount of

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FIGURE 4. A, Preoperative radiographs of malunited Smith’s fracture showing increase of volar tilt and radial shortening. (Reproduced from Figure 1 of Wada T, et al. Corrective osteotomy for distal radius malunion in over middle-aged patients (in Japanese): simultaneous closing wedge and ulnar shortening osteotomy. J Jpn Soc Surg Hand, 21:61–64, 2004). B, Postoperative anteroposterior and lateral radiographs. (Reproduced from Figure 2 of Wada T, et al. Corrective osteotomy for distal radius malunion in over middle-aged patients (in Japanese): simultaneous closing wedge and ulnar shortening osteotomy. J Jpn Soc Surg Hand, 21:61–64, 2004).

bone to be removed in millimeters equals the number of millimeters of ulna-plus variance measured on the preoperative radiograph. Two parallel transverse cuts are then made in the bone at the marked locations. Both cuts are made simultaneously, with the saw moving from one to the other as each 1 mm to 2 mm is cut. Care is taken to ensure that each osteotomy is at right angles to the bone in every plane. The estimated section of ulna is resected by transverse osteotomies (Fig. 2D). Once the osteotomy has been made the distal fragment is very mobile, and it is difficult to screw the plate to it. For this reason the plate is screwed to the distal fragment before the osteotomy is made. However, placing screws that are tapped and removing them is a potential for losing appropriate fixation. One should be very careful not to secure screws excessively. Then the two segments of the radius are easily brought together and held with Kirschner wires to allow intraoperative radiographic assessment of volar tilt and radial inclination of the radius. A small volar T-plate is used to secure the osteotomized bone fragment (Fig. 3A). The six-hole DCP is reapplied to the ulna with three distal screws. Then the hand and wrist are realigned rotationally, using the previously made longitudinal groove.

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A reduction forceps is used to hold the plate temporarily to the proximal fragment. The AO compression device (Synthes, Paoli, PA) is fixed to the proximal segment of the ulna with a unicortical screw, having engaged the mobile arm in the most proximal plate hole. Ensure that the AO compression device is parallel to the plate. The compression device is tightened to close the osteotomy site (Fig. 3B). Proper shortening of the ulna, ulna neutral variance, is confirmed with intraoperative radiographs (Fig. 3C). If it is not accomplished, loosen the AO compression device and release the plate from the proximal fragment. It is not necessary to unscrew the plate from the distal fragment. An appropriate amount of wafer bone is removed again from the proximal fragment of the ulna. Once this is done, again clamp the plate to the proximal fragment. Then compression is reapplied until the two segments of ulna abut, and obtain a new radiograph. Finally the proximal screws are fastened and the compression device is removed. If more compression is desired, the off-center drill guide can be used. Using a compression device for osteoporotic bone is a potential problem. Therefore we took great care that compression is stopped before undue tension is applied on the distal fragment. The pronator quadratus is repaired and the wound is closed in layers.



Shortening of the forearm after our procedure may provoke decreased grip strength. The average postoperative grip strength, as a percentage of the opposite side was 73%,21 which was slightly less than that reported after opening wedge osteotomy.1,4,9,22 However, it was comparable to that reported after the combination of opening wedge radial osteotomy and Bowers arthroplasty.3 All of our patients were satisfied with improved grip strength and none of them complained of wrist weakness in ordinary daily living.21 High-level athletes or heavy manual workers are not indicated to this procedure.

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ASSESSMENT AND REHABILITATION AFTER SURGERY

The wrist is immobilized in a volar plaster splint until the soft tissues healed. Digital motions are encouraged

FIGURE 5. Left: Diagram showing preoperative planning in the sagittal plane. An angle of the wedge bone to be removed corresponds to the volar tilt minus volar tilt of the opposite wrist (29° ÿ 5° = 14° in this patient). The amount of dorsal cortex to be removed is also determined (2.5 mm in this patient). Right: Reduction of the distal fragment.

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MALUNITED SMITH’S FRACTURE

Malunited Smith’s fractures are exposed through the same volar incision. The first osteotomy is completed at right angle to the longitudinal axis of the radius. Then the second osteotomy is performed at an angle according to the preoperative plan and a wedge bone is taken from the distal radius fragment (Figs. 4–6).

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COMPLICATIONS

Nonunion may occur; in such cases, additional procedures may be required. Regarding radial corrective osteotomy, however, nonunion is less likely in closing wedge osteotomy than in opening wedge osteotomy. The incidence of nonunion in ulnar shortening osteotomy has been related particularly to transverse osteotomy. A number of techniques, such as oblique osteotomy with interfragmental lag screw fixation, have been developed to minimize their incidence. According to Le and Bowen,17 patients underwent ulnar transverse osteotomies fixed with six-hole DCP and compression experienced no nonunions. In ulnar osteotomy, placing screws that are tapped and removing them has the potential for losing secure fixation. It is important not to tighten the screws excessively.

FIGURE 6. Through volar approach, a dorsally opening wedge bone is removed following radial osteotomies.

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immediately after surgery. A short arm cast is substituted for the splint within a week or two when postoperative swelling subsides. The cast is removed 4 weeks after operation and the patient is then encouraged to perform active exercises of the wrist, initially supervised by a physiotherapist, but is not allowed to lift heavy objects. Roentgenograms are obtained every month. The patient is allowed to use the wrist unprotected when healing of the osteotomy is confirmed radiographically.

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10. Whittle AP. Malunited fractures. In: Canale ST, ed. Campbell’s Operative Orthopaedics. 9th ed. St. Louis: CV Mosby Co.; 1998:2568–2575. 11. Fernandez DL. Reconstructive procedures for malunion and traumatic arthritis. Orthop Clin North Am. 1993;24:341–363. 12. Posner MA, Ambrose L. Malunited Colles’ fractures: correction with a biplanar closing wedge osteotomy. J Hand Surg [Am]. 1991;16:1017–1026. 13. Viso R, Wegener EE, Freeland AE. Use of a closing wedge osteotomy to correct malunion of dorsally displaced extra-articular distal radius fractures. Orthopedics. 2000;23:721–724.

REFERENCES

1. Fernandez DL. Correction of post-traumatic wrist deformity in adults by osteotomy, bone-grafting, and internal fixation. J Bone Joint Surg Am. 1982;64:1164–1178. 2. Ekenstam F, Hagert CG, Engkvist O, et al. Corrective osteotomy of malunited fractures of the distal end of the radius. Scand J Plast Reconstr Surg. 1985;19:175–187. 3. Fernandez DL. Radial osteotomy and Bowers arthroplasty for malunited fractures of the distal end of the radius. J Bone Joint Surg Am. 1988;70:1538–1551. 4. Roesgen M, Hierholzer G. Corrective osteotomy of the distal radius after fracture to restore the function of wrist joint, forearm, and hand. Arch Orthop Trauma Surg. 1988;107: 301–308. 5. Jupiter JB, Ruder J, Roth DA. Computer-generated bone models in the planning of osteotomy of multidirectional distal radius malunions. J Hand Surg [Am]. 1992;17: 406–415. 6. Brown JN, Bell MJ. Distal radial osteotomy for malunion of wrist fractures in young patients. J Hand Surg [Br]. 1994; 19:589–593. 7. Bilic R, Zdravkovic V, Boljevic Z. Osteotomy for deformity of the radius. Computer-assisted three-dimensional modelling. J Bone Joint Surg Br. 1994;76:150–154. 8. Kwasny O, Fuchs M, Schabus R. Opening wedge osteotomy for malunion of the distal radius with neuropathy. 13 cases followed for 6 (1–11) years. Acta Orthop Scand. 1994;65: 207–208.

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9. Wada T, Usui M, Aoki M, et al. Opening wedge osteotomy and bone grafting for distal radius malunion. Hand Surg. 1997;2:191–202.

14. Bowers WH. Distal radioulnar joint arthroplasty: the hemiresection-interposition technique. J Hand Surg [Am]. 1985;10:169–178. 15. Darrow JC Jr, Linscheid RL, Dobyns JH, et al. Distal ulnar recession for disorders of the distal radioulnar joint. J Hand Surg [Am]. 1985;10:482–491. 16. Oskam J, Bongers KM, Karthaus AJ, et al. Corrective osteotomy for malunion of the distal radius: the effect of concomitant ulnar shortening osteotomy. Arch Orthop Trauma Surg. 1996;115:219–222. 17. Le TB, Bowen CVA. Ulnar shortening osteotomy. In: Gelberman RH, ed. The Wrist. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2002:307–321. 18. Gartland JJJ, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg. 1951;33:895–907. 19. Nakamura R, Tanaka Y, Imaeda T, et al. The influence of age and sex on ulnar variance. J Hand Surg [Br]. 1991;16: 84–88. 20. Sanderson PL, Cameron IC, Holt GR, et al. Ulnar variance and age. J Hand Surg [Br]. 1997;22:21–24. 21. Wada T, Isogai S, Kanaya K, et al. Simultaneous radial closing wedge and ulnar shortening osteotomies for distal radius malunion. J Hand Surg [Am]. 2004;29:264–272. 22. Jupiter JB, Ring D. A comparison of early and late reconstruction of malunited fractures of the distal end of the radius. J Bone Joint Surg Am. 1996;78:739–748.




T E C H N I Q U E

Distal Radius Fracture Fixation with an Intramedullary Nail Virak Tan, MD and John Capo, MD Division of Hand and Microsurgery, Department of Orthopaedics University of Medicine and Dentistry of New Jersey—The New Jersey Medical School Newark, NJ

Mark Warburton, MD Attending Orthopaedic Surgeon High Point Orthopaedic Associates, Inc., High Point, NC

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ABSTRACT

The purpose of this article is to describe a novel technique and implant system for fixation of unstable (Arbeitsgemeinschat fur Osteosynthesesfragen Types A and B) distal radius fractures. Currently the most common complications directly related to distal radius plate fixation includes tenosynovitis, tendon attrition, and rupture, often necessitating hardware removal. With the advent of this new device, a decrease in soft tissue complication is expected. The implant utilizes the principles of load sharing, subchondral screw divergence, and locked fixedangle fixation. It is inserted through a small skin incision at the radial styloid and does not further devascularize the fracture fragments. The limited surgical dissection and rigid fracture fixation allow for minimal postoperative immobilization and an early return of function. The authors believe that this system is a valuable addition to the arsenal of distal radius fracture treatment options and can quickly get patients back on the road of recovery. Keywords: distal radius fracture, fixed angle implant, intramedullary nail, wrist fracture

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Fractures of the distal radius are common, accounting for approximately 250,000 to 300,000 cases in the United States annually. The treatment options include cast immobilization, percutaneous pinning,1 external fixation,2–4 internal fixation with plates,5–16 and a combination thereof.17,18 Management is based on the fracture pattern, degree of displacement, other associated injuries, The authors are design surgeons and are paid consultants for Wright Medical Technology, Inc., the manufacturer of the device. Address correspondence and reprint requests to Virak Tan, MD, Department of Orthopaedics, UMDNJ 90 Bergen Street, DOC 1200 Newark, NJ 07101-1709.

and the individual patient’s needs and demands. Surgery is indicated for displaced or unstable fractures with the treatment goals of anatomic (or near-anatomic) reduction, stable fixation, and early motion. After 20 years of personal experience, one of the authors (MW) was unsatisfied with the outcome of distal radius fractures that he treated with casting, percutaneous pinning, and external fixation. These fractures were mainly extra-articular and occurred in the older population. Although the initial reduction was within acceptable limits, MW found that over the course of cast immobilization, a moderate percentage re-displaced. In patients who had percutaneous pinning, postoperative casting was still required for approximately 4 to 6 weeks and these elderly patients were limited in their activities of daily living. Those who had external fixation complained that the fixator was too cumbersome, of difficulty with pin care, and were concerned about pin tract infection. These patients were generally unhappy about having a device sticking out of their skin. One of us (MW) thought to devise a better method of treating these AO Types A and B fractures without having to do a formal open procedure. Although open reduction and internal fixation with metal implants on the surface of the distal radius has allowed better reduction of the fracture fragments and in many cases offer more secure fixation,5–16 it demands more extensive surgical exposure and soft tissue stripping. Furthermore, hardware problems, such as prominence and tendon irritation, can occur, which often times lead to removal of the implant.7,8,11,12,15,16,19,20 For these reasons, the genesis of intramedullary nailing of the distal radius came into existence (US Patent No. 6,527,775). In this article, the authors introduce this novel fixation technique for distal radius fractures, using a fixed-angled intramedullary nail that is inserted through the radial styloid, the MICRONAILTM (Wright Medical Technology, Inc.,

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Arlington, TN; Fig. 1). This implant is designed to address the difficulties that are mentioned above.

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IMPLANT DESIGN

All implants in this system are manufactured from titanium alloy (Ti-6Al-4V ELI). The implant (or ‘‘nail’’) is universal in configuration and reside completely within the medullary canal for the distal radius, thereby functioning as a load-sharing device. Three 2.5-mm fixedangle locking screws buttress the subchondral plate and secure the distal fracture fragment to the nail. The distal screws are configured to approximate the radial inclination, whereas the volar-dorsal angle divergence provides three-point fixation. The distal screw heads are completely recessed below the surface of the nail. A 1.6-mm hole located in the proximal body allows for temporary fixation using a Kirschner wire during fracture reduction and prior to placement of the proximal interlocking screws. Proximally, two 2.7-mm self-tapping, bi-cortical, interlocking screws resist shortening and angulation of the distal fracture fragment. The screws are placed through the proximal body of the nail and the screw heads rest on the dorsal surface of the bone.

where minimal surgical dissection is desired. Fractures in the elderly patient with poor bone quality, in the multi-injured patient where stable fixation is needed, and in fractures that have re-displaced during cast immobilization are ideal indications. Contraindications include cases in which the articular fragments are small, comminuted, and cannot be reduced adequately by closed or percutaneous means and fracture extension proximally into the metaphyseal-diaphyseal bone. The evaluation of a distal radius fracture is not difficult and is based on the history, examination, and imaging studies. Important considerations in the history include age, hand-dominance, occupation/vocation, and mechanism of injury. Associated injuries in other areas of the body should be ruled out when there is a high energy mechanism. Evaluation of the injured extremity should include examination of the elbow and forearm. Initial imaging studies should include orthogonal radiographs of all involved areas. For injuries of the distal radius, the standard radiographs consist of posterior-anterior, lateral, and oblique views centered directly over the wrist. Additional studies, such as post-reduction x-rays are useful to determine the stability of the fracture pattern and whether it is amendable to MICRONAIL fixation.

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INDICATIONS/CONTRAINDICATIONS

The indications for MICRONAIL fixation include unstable fractures with no or minimal articular involvement

FIGURE 1. A photograph of the MICRONAILTM showing three diverging distal locking screws (purple), two proximal interlocking screws (gold), and a 1.6-mm K-wire hole in the body of the nail.

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TECHNIQUE

Standard preparation of the arm for wrist surgery is done. An image intensifier is used to confirm that a nearanatomic reduction is achievable by closed manipulation. After the tourniquet is inflated, a 2-cm longitudinal incision centered over the radial styloid is made in the skin. Blunt dissection is performed through the subcutaneous tissue, and branches of the radial sensory nerve are mobilized and retracted from the surgical field. Dissection is then carried down to the periosteum between the 1st and 2nd dorsal extensor compartments. The periosteum is elevated and retracted. The fracture is provisionally reduced by manual manipulation; it is important to reestablish volar tilt at this point. If the reduction can not be maintained by traction alone, a K-wire is placed on the dorsal-ulnar side of the wrist to temporarily hold the alignment. A cortical window is then made at the tip of the radial styloid, 3 mm to 4 mm proximal to the radioscaphoid joint line. This is accomplished with an awl (Fig. 2A) or with a 6.1-mm cannulated drill over a guide wire (Fig. 2B). A broach is introduced through the cortical window into the medullary canal by hand or by gently tapping the end of the broach with a small mallet. With the aid of an image intensifier, the broach is guided across the fracture site and advanced proximally into the metaphyseal-diaphyseal bone (Fig. 3). It is critical at this step to stay radial in the canal to avoid penetrating the ulnar cortex of the radial shaft. Sequential broaching is


Distal Radius Fracture Fixation with an Intramedullary Nail

FIGURE 2. Intraoperative fluoroscopic images showing the location of a cortical window made at the tip of the radial styloid with an awl; (A) PA and (B) lateral views. C, Alternatively, the cortical window can be established with a cannulated drill over a guide wire. In this case, a K-wire is used for provisional fixation on the ulnar side of the distal radius.

then done to the point where the broach does not spin within the medullary canal, using two-finger pressure. The broach is then removed and the appropriate size implant (mounted onto the jig) is inserted following the path of the broach until the distal tip of the nail is below the cortical surface of the radial styloid. The drill bit is inserted through the distal most drill guide and checked under an image intensifier to ensure that the distal most locking screw is within 2 mm of the radiocarpal joint line. If the drill bit is penetrating into the joint, then the nail should be seated more proximally. If the drill bit is more than 2 mm proximal to the joint line, then the nail should be backed out to achieve the 2-mm criterion. This ensures that the subchondral bone is supported by the distal fixed-

angle screws (Fig. 4). The distal locking screws then are placed after drilling through the guides on the jig, thereby locking the distal bone fragment to the nail. Final reduction of the fracture can be accomplished by adjusting the nail within the medullary canal. The proximal interlocking screws are placed through stab incisions (or a single 2-cm longitudinal incision) on the dorsum of the wrist, using the guide and sleeve provided. These interlocking screws secure the distal fragment-nail construct to the shaft fragment. Closure of the skin is done after irrigation of the wounds. Post-operatively, if the MICRONAIL has been inserted such that the distal screws are within 2 mm of the subchondral bone, then no splinting is necessary; otherwise

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FIGURE 3. Intraoperative fluoroscopic images showing broaching across the distal radius fracture site. (A) PA and (B) lateral views.

the wrist is splinted in a removable splint for 4 weeks. Finger motion is started immediately. Patients may perform active wrist motion as tolerated. At 4 weeks, splint use is discontinued and therapy progressed.

Case: AO Type A Fracture The patient is a 77-year-old right-hand dominant woman who fell at home onto her right wrist. She was found to have a dorsally angulated distal radius fracture (AO Type A2) with an associated nondisplaced distal ulnar fracture (Fig. 5A, 5B). She underwent a closed manipulation and sugar-tong splinting in the emergency room. At 1 week post-reduction, she was found to have a re-displacement of the fracture. The patient underwent uncomplicated MICRONAILING of her wrist 1 week later (2 weeks after the injury) and was discharged home within 24 hours. Post-operatively she was placed in a soft dressing and was allowed to use the arm for activities as tolerated. Although she was offered formal therapy, she elected to perform the exercises on her own. At 4 months after the surgery, the patient had active wrist flexion to 50°, extension to 60°, radial deviation to 10°, ulnar deviation to 20°, supination to 90°, and pronation to 80° (Fig. 6). Her grip strength was 35 lbs (90% of the contralateral side) and the Disabilities of the Arm, Shoulder and Hand (DASH) score was 9 of 100. Radiographs showed a healed fracture (Fig. 5C, 5D).

Case: AO Type B Fracture The patient is an 83-year-old right-hand dominant woman who tripped and fell onto her left wrist. She sustained an AO Type B3 distal radius fracture with an associated

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Grade I open ulnar styloid base fracture (Fig. 7A, 7B). She underwent I&D of the open fracture, suture repair of the ulnar styloid, and MICRONAILING of the distal radius. Post-operatively, the wrist was placed in a shortarm splint, and the patient was admitted to the hospital for 24 hours of IV antibiotics. Two weeks after the surgery, she was converted to a removable Velcro wrist splint. At 1 month, the splint was discontinued. The patient underwent supervised hand therapy for 6 weeks. At 6 months, she had active wrist flexion to 25°, extension to 60°, radial deviation to 15°, ulnar deviation to 20°, supination to 90°, and pronation to 80°. Her grip strength was

FIGURE 4. A, An intraoperative fluoroscopic image of the actual implant (mounted onto the jig) inserted across the fracture site. The drill bit is placed through the distal most screw hole in the nail and should be within 2 mm of the subchondral bone.


Distal Radius Fracture Fixation with an Intramedullary Nail

FIGURE 5. A and B, Injury radiographs of a 77-year-old woman showing an extra-articular distal radius fracture with dorsal angulation (AO Type A2). C and D, Postoperative radiographs showing a healed distal radius fracture after fixation with a MICRONAILTM.

47 lbs (78% of the contralateral side) and the DASH score was 5 of 100. Radiographs showed a healed fracture (Fig. 7C, 7D).

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DISCUSSION

Intramedullary nailing of the radius has been shown to be an effective and well-tolerated treatment method for forearm fractures, especially in the pediatric patients.21–25 The authors have expanded the concept of intramedullary fixation to distal radius fractures. To date, internal fixation implants for the distal radius have been affixed to the surface of the bone, which can lead to irritation of the overlying tendons and soft tissue.7,8,11,12,15,16,19,20 Volar plating of the distal radius affords improved soft tissue envelope when the pronator quadratus is reapproximated over the implant; however, attritional tendon ruptures and hardware problems are still reported.7,8,11,12,19 The technique presented in this article offers a new and alternative fixation method for distal radius fractures in which the entire implant resides within the medullary canal (except for the proximal interlocking screw heads). The only other device that is similar to the MICRONAILTM is the Dorsal Nail Plate (Hand Innovations, Miami, FL). However, the distal aspect of this implant is affixed on the dorsal cortex of the distal radius

adjacent to extensor tendons. Furthermore, its insertion requires mobilization of the extensor pollicis longus and removal of Lister’s tubercle, which is not required for the MICRONAILTM. In addition to minimizing tendon complications, the MICRONAILTM was designed to be minimally invasive for three-point fixation in the subchondral bone and to support the radial column. The surgical approach for insertion of the nail is less extensive than the approach for the TriMed26 radial pin plate (TriMed, Valencia, CA) and does not require complete mobilization of the 1st dorsal compartment tendons. The diverging distal locking screws resist collapse of the distal fragment and permit interfragmentary fixation in the coronal and sagittal planes. The stability afforded by the MICRONAILTM, as demonstrated by the case examples, allows early wrist motion and the patient more independence in activities of daily living. The potential disadvantages of the MICRONAILTM fixation system include injury to the radial sensory nerve during surgical dissection and its limited application in fractures with multiple comminuted articular fragments. Nerve injuries can be avoided by knowledge of the surgical anatomy and careful dissection. In cases in which the articular fragments are small, comminuted, and cannot be reduced adequately, alternative fixation methods

FIGURE 6. Clinical pictures of the patient in Figure 5 at 4 months after her wrist surgery.

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FIGURE 7. A and B, Injury radiographs of an 83-year-old woman showing a volar shear distal radius fracture (AO Type B3) with an associated ulnar styloid base fracture. C and D, Postoperative radiographs showing a healed distal radius fracture after fixation with a MICRONAILTM.

should be considered.8,11,12,14,16–18 An additional theoretical concern is the uncommon instance in which the nail must be removed. In that case, removal can be accomplished through the same surgical incisions. After removing a cortical window from the radial styloid, the jig can be threaded onto the distal tip of the nail and the guides used to locate the screws. To date the authors have performed MICRONAILTM fixation in 15 cases of isolated distal radius fractures. Three patients had a temporary minor radial sensory nerve disturbance that resolved within 2 months. The early clinical and radiographic results have been encouraging. Inclusion of more patients with longer follow-up is necessary to determine whether the early good results will hold up.

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REFERENCES

1. Dowdy PA, Patterson SD, King GJ, et al. Intrafocal (Kapandji) pinning of unstable distal radius fractures: a preliminary report. J Trauma. 1996;40:194–198. 2. Bishay M, Aguilera X, Grant J, et al. The results of external fixation of the radius in the treatment of comminuted intraarticular fractures of the distal end. J Hand Surg [Br]. 1994; 19:378–383. 3. Gainor BJ, Groh GI. Early clinical experience with Orthofix external fixation of complex distal radius fractures. Orthopedics. 1990;13:329–333. 4. Nakata RY, Chand Y, Matiko JD, et al. External fixators for wrist fractures: a biomechanical and clinical study. J Hand Surg [Am]. 1985;10:845–851. 5. Campbell DA. Open reduction and internal fixation of intra articular and unstable fractures of the distal radius using the AO distal radius plate. J Hand Surg [Br]. 2000;25:528–534.

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6. Carter PR, Frederick HA, Laseter GF. Open reduction and internal fixation of unstable distal radius fractures with a low-profile plate: a multicenter study of 73 fractures. J Hand Surg [Am]. 1998;23:300–307. 7. Constatine KJ, Clawson MC, Stern PJ. Volar neutralization plate fixation of dorsally displaced distal radius fractures. Orthopedics. 2002;25:125–128. 8. Drobetz H, Kutscha-Lissberg E. Osteosynthesis of distal radial fractures with a volar locking screw plate system. Int Orthop. 2003;27:1–6. 9. Hahnloser D, Platz A, Amgwerd M, et al. Internal fixation of distal radius fractures with dorsal dislocation: pi-plate or two 1/4 tube plates? A prospective randomized study. J Trauma. 1999;47:760–765. 10. Harness N, Ring D, Jupiter JB. Volar Barton’s fractures with concomitant dorsal fracture in older patients. J Hand Surg [Am]. 2004;29:439–445. 11. Jupiter JB, Fernandez DL, Choon-Lai T. Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am. 1996;78:1817–1828. 12. Lee HC, Wong YS, Chan BK, et al. Fixation of distal radius fractures using AO titanium volar distal radius plate. Hand Surg. 2003;8:7–15. 13. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg [Am]. 2002;27:205–215. 14. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg [Am]. 2004;29:96–102. 15. Ring D, Jupiter JB, Brennwald J, et al. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg [Am]. 1997;22:777–784. 16. Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation of complex fractures of the distal


Distal Radius Fracture Fixation with an Intramedullary Nail part of the radius. J Bone Joint Surg Am. 2004;86:1646– 1652. 17. Bass RL, Blair WF, Hubbard PP. Results of combined internal and external fixation for the treatment of severe AO-C3 fractures of the distal radius. J Hand Surg [Am]. 1995;20:373–381. 18. Rogachefsky RA, Lipson SR, Applegate B, et al. Treatment of severely comminuted intra-articular fractures of the distal end of the radius by open reduction and combined internal and external fixation. J Bone Joint Surg Am. 2001; 83:509–519. 19. Bell JS, Wollstein R, Citron ND. Rupture of flexor pollicis longus tendon: a complication of volar plating of the distal radius. J Bone Joint Surg Br. 1998;80:225–226. 20. Rozental TD, Beredjiklian PK, Bozentka outcome and complications following dorsal plating for unstable fractures of of the radius. J Bone Joint Surg Am. 1960.

DJ. Functional two types of the distal part 2004;85:1956–

21. Calder PR, Achan P, Barry M. Diaphyseal forearm fractures in children treated with intramedullary fixation: outcome of K-wire versus elastic stable intramedullary nail. Injury. 2003;34:278–282. 22. De Pedro JA, Garcia-Navarrete F, Garcia De Lucas F, et al. Internal fixation of ulnar fractures by locking nail. Clin Orthop. 1992;283:81–85. 23. Shah MH, Heffernan G, McGuinness AJ. Early experience with titanium elastic nails in a trauma unit. Ir Med J. 2003; 96:213–214. 24. Till H, Huttl B, Knorr P, et al. Elastic stable intramedullary nailing (ESIN) provides good long-term results in pediatric long-bone fractures. Eur J Pediatr Surg. 2000;10:319–322. 25. Van der Reis WL, Otsuka NY, Moroz P, et al. Intramedullary nailing versus plate fixation for unstable forearm fractures in children. J Pediatr Orthop. 1998;18:9–13. 26. Konrath GA, Bahler S. Open reduction and internal fixation of unstable distal radius fractures: results using the trimed fixation system. J Orthop Trauma. 2002;16:578–585.

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T E C H N I Q U E

Cannulated Variable Pitch Compression Screw Fixation of Scaphoid Fractures Using a Limited Dorsal Approach Jeffrey E. Martus, MD Resident Physician University of Michigan

Asheesh Bedi, MD Resident Physician University of Michigan

Peter J. L. Jebson, MD Associate Professor Chief, Division of Elbow, Hand and Microsurgery

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ABSTRACT

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Scaphoid fractures are common in the young, active patient. Treatment is challenging because of the complex three-dimensional anatomy of the scaphoid and the tenuous blood supply. Traditionally, cast immobilization has been used for the management of non-displaced fractures with satisfactory outcomes reported in the literature. However, non-surgical treatment may result in a delayed union or nonunion particularly if the fracture is unstable, displaced, or involves the proximal pole. Recently there has been increased interest in the fixation of non-displaced scaphoid fractures. The proposed advantages for operative treatment include avoiding the morbidity and inconvenience of prolonged cast immobilization and a lower incidence of delayed union or nonunion. A variety of surgical approaches for fixation of an acute scaphoid fracture have been described. The most common techniques include percutaneous fixation, arthroscopically assisted reduction and fixation, or open reduction and internal fixation via a volar approach. The senior author favors a limited dorsal approach with compression screw fixation of all proximal pole fractures as well as displaced and non-displaced fractures of the waist region. The technique is simple permitting accurate screw placement in the central axis of the scaphoid, which is biomechanically advantageous and important for achieving union. Keywords: compression screw, dorsal approach, scaphoid fracture

Address correspondence and reprint requests to Peter J. L. Jebson, MD, Department of Orthopaedic Surgery, University of Michigan Medical Center, Ann Arbor, MI 48109 (e-mail: [email protected]).

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Whereas there is general agreement that proximal pole fractures and displaced, unstable fractures of the scaphoid require operative treatment, there is no consensus regarding the ideal management of a non-displaced fracture involving the waist region. Traditionally, cast immobilization has been advocated until fracture healing. However, immobilization of the limb may be necessary for several months and non-union may still occur.1,2 In addition, critics of the nonoperative approach have maintained that cast immobilization is inconvenient and results in limb atrophy, weakness, and stiffness.3 Those who favor operative treatment maintain that fracture fixation promotes union, avoids cast morbidity, and lessens the time required for healing.4–6 Operative treatment has also been advocated as more cost effective although this argument remains controversial.7 The development of implants that simultaneously provide compression and can be buried beneath the articular surface has made operative fixation more appealing to achieve union. There is no disagreement that a proximal pole fracture requires a dorsal or ‘‘retrograde’’ approach for screw insertion. Similarly, the volar approach has been recommended for fractures involving the waist region because the dorsal approach can result in injury to the dominant blood supply of the scaphoid, which enters via the dorsal ridge. However, there are some significant concerns with the use of a volar approach. The guidewire is inserted at the scaphotrapezial joint resulting in a more volar starting point in the distal pole with a resultant inability to accurately insert the screw along the central axis.8 In a recent cadaveric study, Chan and McAdams found that the dorsal approach


Cannulated Variable Pitch Compression Screw Fixation

permits screw placement closer to the central axis compared with the volar approach.9 Furthermore, a statistically significant eccentric deviation of the screw in the distal pole was seen with the volar approach. Why is there increased interest in screw insertion in the central axis of the scaphoid? A recent biomechanical study in a simulated scaphoid waist fracture demonstrated that central placement of the screw resulted in greater stiffness and a greater load at failure compared with an eccentrically placed screw.10 Furthermore, a more rapid time to union with central screw placement has also been shown in patients who underwent ORIF and bone grafting of a scaphoid nonunion.11 We agree that the dorsal approach is more advantageous with respect to accurate screw placement in the central scaphoid compared with a volar approach. As a result, the dorsal approach has become our preferred technique for internal fixation of displaced and non-displaced fractures of not only the proximal pole but also the waist region of the scaphoid.

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Non-Displaced Fracture

INDICATIONS AND CONTRAINDICATIONS

The technique is used for: • All proximal pole fractures • Displaced, unstable fracture of the scaphoid waist defined as more than 1 mm of displacement, comminution, or .15 of angulation • The patient with a non-displaced fracture of the scaphoid waist (Herbert Type A2 or B2) who wishes to proceed with operative treatment following an explanation and discussion of the rationale for, risks and benefits of, operative treatment versus cast immobilization

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compartment is incised immediately distal to Lister’s tubercle and the fascia overlying the extensor pollicis longus (EPL) tendon is carefully released permitting gentle retraction of EPL radially. The fascia over the extensor digitorum communis (EDC), extensor carpi radialis longus (ECRL), and extensor digitorum brevis (ECRB) tendons is incised longitudinally. The EDC tendons are gently retracted ulnarly whereas the ECRB and ECRL tendons are retracted radially with EPL thus exposing the underlying radiocarpal joint capsule. A limited inverted T-shaped capsulotomy is made with the transverse limb placed just distal to the dorsal rim of the radius and the longitudinal limb directly over the scapholunate articulation. Lister’s tubercle is helpful to locate the articulation. The capsular flaps are carefully elevated from the dorsal lunate, the dorsal component of the scapholunate ligament, and the proximal pole of the scaphoid. Care is taken to avoid stripping the dorsal ridge vessels entering at the scaphoid waist region.

TECHNIQUE

A general or regional anesthetic may be used. The patient is positioned supine on the operating table with a radiolucent hand table at the shoulder level. A pneumatic tourniquet is carefully applied over cast padding on the proximal arm. An intravenous (IV) antibiotic is provided prior to inflation of the tourniquet as prophylaxis for infection. The limb is prepped and draped in the usual sterile fashion. The arm is exsanguinated with an Esmarch bandage and the tourniquet inflated to a pressure of 250 mm Hg. The forearm is pronated and a longitudinal skin incision approximately 3 cm in length is placed beginning at the proximal aspect of Lister’s tubercle extending along the axis of the third metacarpal. The skin flaps are raised and the extensor retinaculum and dorsal hand fascia are identified. The extensor retinaculum of the third

If the fracture is non-displaced, a smaller skin incision and capsulotomy may be used. We prefer to use the Acutrak or mini-Acutrak screw system (Accumed, Beaverton, OR) but any cannulated screw system that permits screw insertion beneath the articular surface can be used. We prefer to use the larger Acutrak screw if possible. However, the mini-Acutrak system may be necessary in those patients with a small scaphoid or if the fracture is located proximally such that insertion of an Acutrak screw may result in inadvertent propagation of the fracture to the insertion site with fragmentation of the proximal scaphoid. An appropriate guidewire is inserted. This is performed by fully flexing the wrist over a bolster of three to four rolled towels. The guidewire is inserted at the membranous portion of the scapholunate ligament origin and aimed down the central axis of the scaphoid toward the thumb. Fluoroscopy is used to confirm accurate wire placement. A lateral view is obtained but we have found it difficult to interpret with respect to screw insertion in the central axis. We use a 30 pronated lateral view to be much better (Fig. 1). A PA view with the wrist held in ulnar deviation is also obtained with care taken to avoid bending the guidewire. This requires some wrist flexion during imaging. The wire is advanced up to but not into the scaphotrapezial joint. Screw length is then determined. We prefer to subtract approximately 4 mm from the measured length to allow burial of the proximal screw beneath the articular surface. Once the screw length has been determined, the wire is driven into the trapezium to avoid loss of position during reaming. The cannulated reamer is then used followed by manual insertion of the screw. The guidewire is removed and screw position is assessed via fluoroscopy.

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• When reducing and provisionally stabilizing a displaced scaphoid fracture, care must be taken to position the ÔderotationalÕ wires such that they will not subsequently interfere with guidewire insertion, reaming, and screw insertion. • In more proximal fractures, the surgeon must make sure that the starting point for the guidewire is as far proximally in the scaphoid as possible. This requires that the wire be inserted at the mid-aspect of the membranous portion of the scapholunate ligament complex. Wrist flexion is required to identify the correct location. This point is critical to avoid propagation of the fracture into the proximal scaphoid as final insertion of the screw is performed. FIGURE 1. A 30 pronated lateral fluoroscopy image demonstrating insertion of the guidewire down the central axis of the scaphoid.

Displaced Fracture If the fracture is displaced (Fig. 2), a capsulotomy is created as described above. It is often helpful to extend the longitudinal limb of the capsulotomy to expose the scaphocapitate articulation and the radial aspect of the midcarpal joint. The radial capsular flap is elevated with care to preserve the dorsal ridge vessels if still intact. The carpus is distracted manually via longitudinal traction on the index and long fingers; 0.045 K-wire ÔjoysticksÕ are inserted perpendicularly into the proximal and distal scaphoid fragments to assist in the reduction. The accuracy of the reduction can be determined by assessing the fracture at the scaphocapitate articulation. When a satisfactory reduction has been achieved, provisional fixation is obtained with a ÔderotationalÕ 0.045 K-wire that is inserted more dorsal and ulnar to the central axis and into the trapezium for enhanced stability (Fig. 3A). A second ÔderotationalÕ wire is then inserted volar and radial to the central insertion site (Fig. 3B). The guidewire is then inserted in the central axis followed by screw insertion as described above (Figs. 3C, D, and E).

Postoperative Care and Rehabilitation The wound is thoroughly irrigated. The capsule and retinaculum are repaired with 3-0 non-absorbable suture. The skin is closed with 4-0 nylon suture in horizontal

Key Points on Guidewire Insertion • Insertion of the guidewire and subsequent screw insertion in the central axis of the scaphoid is critical. The surgeon must be very patient with this important step and only proceed with reaming and screw insertion after central placement has been confirmed on the PA, lateral, and 30 pronated lateral views. • It is critical to insert the wire in the optimal position in all three views to avoid violation of the midcarpal joint or the volar surface of the scaphoid.

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FIGURE 2. A, Comminuted unstable fracture of the scaphoid waist region. B, Lateral view of the above fracture.


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FIGURE 3. A, Following reduction of the fracture, a ÔderotationalÕ wire was inserted dorsal and ulnar to the anticipated screw insertion site along the central axis. B, The guidewire for an Acutrak screw (Accumed, Beaverton, OR) has been inserted along the central axis of the scaphoid. Note that both the guidewire and derotational wires have been advanced into the trapezium for additional stability. C, A 30 pronated lateral fluoroscopy image confirms central placement of the guidewire prior to reaming. D, A dedicated scaphoid view demonstrating screw insertion in the central axis. E, Central axis insertion is also noted on the 30 pronated lateral image.

mattress fashion. The patient is immobilized in a short arm plaster splint and discharged to home with instructions on strict elevation and frequent digital range of motion exercises. At 2 weeks, the patient returns for suture removal. For a non-displaced fracture (Herbert Type A2 or B2) with rigid fixation, range of motion exercises are begun and a removable forearm based splint is worn. The splint is discontinued at 4 to 6 weeks post-operatively. If the fracture was displaced, involved the proximal pole, was associated with significant comminution, or if there is concern regarding the stability of fixation, immobilization in a short arm cast for 6 to 10 weeks is indicated. Typically, such fractures take longer to achieve union. Following cast removal, occupational therapy is initiated to achieve satisfactory range of motion, strength, and function. Fracture healing is assessed at 2, 6, and 12 weeks post-operatively with routine plain radiographs (Figs. 4 and 5). If there is any question regarding fracture union, a CT scan is obtained at 3 months post-operatively.

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erosion of the distal radius articular surface. Similarly, failure to carefully judge accurate screw length intraoperatively can result in prominence and erosion of the scaphotrapezial articulation. Nonunion may still occur

COMPLICATIONS

A postoperative wound infection is rare but can be prevented with routine preoperative antibiotic prophylaxis, thorough wound irrigation, and appropriate soft tissue management. Intraoperative technical problems include inadvertent bending or breakage of the guidewire. This can occur if the wrist is dorsiflexed with the wire in position or during reaming prior to screw insertion. Care should be taken to confirm that the screw is fully seated beneath the articular cartilage to avoid prominence and

FIGURE 4. Non-displaced fracture of the scaphoid waist in a professional (NHL) hockey player.

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REFERENCES

1. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop. 1980;149:90–97. 2. Gelberman RH, Wolock BS, Siegel DB. Fractures and nonunion of the carpal scaphoid. J Bone Joint Surg Am. 1989; 71:1560–1565. 3. Skirven T, Trope J. Complications of immobilization. Hand Clin. 1994;10:53–61. 4. Bond CD, Shin AY, McBride MT, et al. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001;83A:483–488. 5. Taras JS, Sweet S, Shum W, et al. Percutaneous and arthroscopic screw fixation of scaphoid fractures in the athlete. Hand Clin. 1999;15:467–473. 6. Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation: a pilot study. J Bone Joint Surg Br. 1998;80B:95–99. 7. Papaloizos MY, Fusetti C, Christen T, et al. Minimally invasive fixation versus conservative treatment of undisplaced scaphoid fractures: a cost-effectiveness study. J Hand Surg [Br]. 2004;29:116–119. 8. Kamineni S, Lavy CB. Percutaneous fixation of scaphoid fractures. An anatomical study. J Hand Surg. 1999;24B:85–88. FIGURE 5. Following ORIF via the dorsal approach, the patient has returned to full activities without limitations or complaints.

despite reduction and internal fixation of a proximal pole or displaced fracture of the scaphoid waist may occur necessitating supplemental bone grafting with or without revision of fixation or a salvage procedure.

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9. Chan KW, McAdams TR. Central screw placement in percutaneous screw scaphoid fixation: a cadaveric comparison of proximal and distal techniques. J Hand Surg. 2003;29:74–79. 10. McCallister WV, Knight J, Kaliappan R, et al. Central placement of the screw in simulated fractures of the scaphoid waist: a biomechanical study. J Bone Joint Surg Am. 2003;85:72–77. 11. Trumble TE, Salas P, Barthel T, et al. Management of scaphoid nonunion. J Am Acad Orthopedic Surg. 2003; 11:380–391.




T E C H N I Q U E

A Cosmetic Technique for Performing Basal Joint Arthroplasty Spencer A. Rowland, MD, MS, FACS Orthopaedic Department University of Texas Health Science Center at San Antonio San Antonio, TX

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ABSTRACT

Longitudinal scars perpendicular to the abductor skin creases of the wrist that result from basal joint arthroplasties can produce scarring that is distracting to both the patient and others. The author presents his technique for performing basal joint arthroplasty through a single transverse incision over the trapezium that blends with the normal creases of the wrist, producing a cosmetically acceptable scar. Keywords: cosmetic basal joint arthroplasty, harvesting the flexor carpi radialis cosmetically, basal joint arthritis

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Pain of the first carpal metacarpal joint, commonly called the basal joint of the thumb, is the complaint that brings the patient to the office. This is associated with the loss of function, primarily pinch, and may or may not be associated with deformity of the thumb secondary to subluxation of the first carpometacarpal joint (FCMJ). Some of the most common operations for basal joint arthritis have been metacarpal osteotomy, arthrodesis of the FCMJ, trapeziectomy with ligament reconstruction with or without interpositional prosthesis or tendon, and recently trapeziectomy without ligament reconstruction and without interpositional tendon associated with Kirschner wire fixation of the first metacarpal to the carpal bones.1 In 1949, Gervis2 reported simple excision of the trapezium with good results in terms of relief of pain. This procedure has been modified by many hand surgeons in 2 major ways: first, the technique used for ligament reconstruction; and second, the use or lack of use of interpositional substance. Between 1969 and 1996, the author performed 80 basal joint arthroplasties with excision of the trapezium, Address correspondence and reprint requests to Spencer A. Rowland, 222 Royal Oaks, San Antonio, Texas 78209. E-mail: srowland@ webtv.net.

ligament reconstruction, and tendon interposition. All surgeries were done through a transverse incision that left a more cosmetic scar than the conventional longitudinal scar as described in the literature. In addition, the technique of harvesting one-half of the flexor carpi radialis3 differed from reports in the literature, as did the method of ligament reconstruction. Bettinger et al6 have shown that after excision of the trapezium, there are only 2 ligaments attached to the first metacarpal base, the intermetacarpal ligament (IML) and the dorsal intermetacarpal ligament (DIML), which help prevent the collapse and instability of the first metacarpal. For that reason, ligament reconstruction was done by using one-half of the FCR around the IML as described under Technique. Interpositioned palmaris tendon was used as an ‘‘anchovy’’ in all the above patients unless no palmaris tendon was available. In those patients, the trapezial space was packed with gel foam. The rationale for using gel foam was simply to fill a dead space. As pointed out by Davis et al,1 a small palmaris tendon graft cannot fill the large trapezial space to preserve thumb length. A Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was sent to the 80 patients (Rowland AS, Rowland SA. Thumb carpometacarpal arthritis: Ligament reconstruction with Swanson implant compared with ligament reconstruction with tendon interposition. Unpublished material). Thirty-seven complete DASH questionnaires with greater than 5-year follow-up were available. The average follow-up was 7.5 years with an average DASH of 22.4, zero reflecting no disability and 100 reflecting severe disability. In my office visits with the patients, all were satisfied with the relief of their previous pain and their lack of visible scarring, many opting for surgery on their other thumb.

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The indications for surgery are patients with painful trapeziometacarpal osteoarthritis, grades III and IV as

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FIGURE 1. A transverse skin incision is made over the trapezium in line with the wrist abductor skin creases.

described by Eaton and Litter,4 that had failed nonsurgical treatment consisting of nonsteroidal antiinflammatory drugs (NSAIDS), splinting, and cortisone injections. A contraindication for this technique would be a patient without a normal ulnar artery. Allen test should be performed on candidates preoperatively. As described under technique, the radial artery must be visualized and protected during the entire procedure.

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TECHNIQUE

The procedure is carried out with the usual prepping, tourniquet, and hand table. Loop magnification and the use of a head light are essential to see into the depths of the wound. A transverse skin incision is made over the center of the trapezium (Fig. 1). The subcutaneous tissue is then spread with scissors in a longitudinal fashion down to

FIGURE 2. By acutely flexing the wrist, the FCR tendon can be pulled into the surgical wound.

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FIGURE 3. The radial half of the FCR tendon is cut proximally and dissected distally to its insertion on the base of the second metacarpal.

the trapezeometacarpal and scaphotrapezial joints, with care taken to avoid cutting branches of the superficial radial nerve. Staying deep underneath the subcutaneous tissue, the dissection is carried dorsal and ulnarward to visualize the radial artery. The artery is carefully dissected from the surrounding tissues with coagulation of small branches that would prevent its mobilization and protection. It is particularly important to free the artery from adherence to the trapezium because the artery can be damaged on closure of the joint capsule. The radial artery is protected with a retractor throughout the entire procedure. The trapezium is then removed piecemeal with sharply pointed double-action rongeurs and with a number 10 beaver blade. Care must be taken not to damage the flexor carpi radialis that is in the vertical groove on the volar surface of the trapezium.5

FIGURE 4. The harvested FCR tendon is then passed around the intermetacarpal ligament and sutured to the base of the thumb metacarpal while traction is applied on the thumb and the harvested FCR tendon.


Cosmetic Technique For Basal Joint Arthroplasty

thumb metacarpal to the base of the second metacarpal (Fig. 5). Initially, I used the palmaris longus as an ‘‘anchovy’’ spacer removed through short transverse forearm incisions. In later years I stopped using the palmaris and just filled the trapezial space with rolled-up gel foam. Gerwin et al7 have reported that tendon interposition after ligament reconstruction does not improve the function of the thumb. The trapezial capsule is then closed tightly. Care must be taken to protect the radial artery during this closure. The tourniquet is released to make sure the radial artery has not been damaged. Bleeding is minimal and usually controlled by elevation and compression. Subcuticular skin closure is done. No Kirschner wires are used

FIGURE 5. This postoperative x-ray shows that the trapezial space is maintained by tenodesing one-half of the FCR from the base of the second metacarpal to the base of the thumb metacarpal.

After the trapezium has been removed, the radial half of the flexor carpi radialis (FCR) is harvested by passing a Bunnell probe underneath the tendon,3 acutely flexing the wrist, and pulling it into the incision (Fig. 2). The radial half of the tendon is cut proximally and dissected distally to its insertion on the base of the second metacarpal (Fig. 3). The harvested tendon is then passed around the intermetacarpal ligament6 at its insertion on the thumb metacarpal and sutured at the base of the metacarpal while traction is applied to the thumb and the harvested flexor carpi radials (Fig. 4). Doing this tethers the base of the

FIGURE 6. This postoperative view of the wrist is what patients and their friends see. Incisions made in anatomic skin creases cause minimal scarring.

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for metacarpocarpal fixation. A bulky wet hand dressing is applied with the thumb in palmar abduction.

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COMPLICATIONS

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Transient diminished sensation around the surgical scar secondary to traction of the superficial branches of the radial nerve can occur; there was no radial nerve neuroma, no radial artery damage, no cases of dislocation or painful subluxation of the pseudoarthrosis, and there were no infections. Residual tenderness over the flexor carpi radialis (FCR) above the wrist persisted in a few patients but resolved after 3 months.

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REHABILITATION

The dressing is changed in 2 or 3 days, and a thumb spica cast is applied holding the thumb in palmar abduction for 5 weeks. The cast is then removed, and the patient is shown active wrist and thumb movements only, but no passive exercises. A protective splint is given for use at night and at work if needed for protection. Light active motion is encouraged. The patients see me in 10 days to make sure they are doing their active exercises correctly and have most of their thumb and wrist motion back. At 10 weeks the protective splint is discarded, and strengthbuilding exercises are started. Postoperative scarring is

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minimal because the scar is in the abductor creases of the wrist (Fig. 6).

REFERENCES

1. Davis RC, Brady O, Dias JJ. Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint: a study of benefit of ligament reconstruction or tendon interposition. J Hand Surg. 2004;29A:1069–1077. 2. Gervis WH. Excision of the trapezium for osteoarthritis of the trapeziometacarpal joint. J Bone Joint Surg. 1949; 31B:537–539. 3. Rowland SA. Arthroplasty: Avoiding forearm scars. In: Kasdan ML, Amadio PC, Bowers WH, eds. Technical Tips for Hand Surgery. London: Hanley & Belfers, Inc; 1994:47. 4. Eaton RG, Litter JW. Ligament reconstruction for the painful carpometacarpal joint. J Bone Joint Surg. 1973;55A:1655– 1666. 5. Garcia-Elias M, Dobyns JH. Bones of the wrist: Trapezium. In: Cooney WP, Linscheid RL, Dobyns JH, eds. The Wrist. St Louis: Mosby; 1998:66. 6. Bettinger P, Linscheid RL, Berger R, et al. An anatomic study of the stabilizing ligament of the trapezium and trapeziometacarpal joint. J Hand Surg [Am]. 1999;24:786–798. 7. Gerwin M, Griffith A, Weiland A, et al. Ligament reconstruction basal joint arthroplasty without tendon interposition. Clin Orthop Rel Res. 1997;342:42–45.




T E C H N I Q U E

Optimization of Flexor Tenolysis Using a Suture Thierry Dubert, MD Clinique La Francilienne, Pontault Combault, France

Paulo Favalli, MD Clinique La Francilienne, Pontault Combault, France

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ABSTRACT

In zone 2, complete release of all the peritendinous adhesions is almost impossible because of the complexity of the two tendons’ three-dimensional arrangement under the pulleys. Resection of one slip of the flexor digitorum superficialis (FDS) changes this complex arrangement into a two parallel tendons pattern, which makes it much easier, particularly when using the suture technique. Keywords: Adhesions, flexor tendon, tenolysis

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Even the most experienced surgeons still consider flexor tendon tenolysis as one of the most challenging surgeries involving the flexor tendons.1 However, there is consensus in the literature that when correctly indicated and performed, tenolysis can significantly improve digital function.1–6 Preoperative passive motion, soft tissue coverage, trophicity of the tendons, and patient’s motivation during rehabilitation are among the most important factors conditioning the outcome. However, technical tips are also paramount, particularly concerning the preservation of the pulleys and completeness of adhesion removal.1–4 Trying to make the technique simpler, several authors suggested the use of different surgical instruments, such as spatulas, rongeurs, tendon hooks, and small scalpel blades with rounded tips.1–4 Schreiber (1986)7 suggested the use of small blades originally created for knee arthroscopy (Beaver Arthro-Lok blades), observing that the shape of some blades are appropriate for removing procedures inside the digital canal. Constantinescu (1994),8 on the other hand, tried to use laser to perform the tenolysis. In an experimental study with rabbits, this author Address correspondence and reprint requests to Dr Thierry Dubert, Clinique La Francilienne, 16, Av. De l’Hoˆtel de Ville, 77340, PontaultCombault, France (e-mail: [email protected]).

demonstrated a better tendon gliding as a result of tenolysis with holmium: YAG laser, if compared with the scalpel technique. ‘‘Windows’’ through cruciate pulleys preserving the annular pulleys are necessary to directly reach the tendons. However, releasing the adhesions using such stiff materials cannot be considered a simple procedure regarding the preservation of the pulleys. The technique employed by the senior author of this study is based on the studies by Bain (2003), Azad (2004), and Le Viet (2004), who suggested the use of a monofilament suture to release the peritendon adhesions.9–11 The main advantage of this technique is the flexibility of the suture, which allows its insertion and traction inside the canal, cutting even the fibers that are difficult to reach without damaging the relevant anatomy of the pulleys. However, the use of cutting the suture does not resolve the problem of the restrained exposure of the tendons in zone 2 at the chiasma site. Considering our functional results after flexor tenolysis, we had the strong feeling that the results were better when the flexor digitorum superficialis (FDS) was partially or completely removed either during the tenolysis, or at the primary surgery. Following this hunch, we found that a systematic resection of one FDS slip simplifies the technique and improves the results.

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INDICATIONS

As for any flexor tendon tenolysis, the preoperative conditions must provide good skin trophicity without any active inflammatory reaction, bone stability, and acceptable passive range of motion. A minimal period of 6 months between the primary surgery and tenolysis usually allows a good maturation of the tendon union. Besides the physical aspects mentioned above, it is extremely relevant to inform and motivate the patients, who must be aware of their essential role in postoperative rehabilitation.

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TECHNIQUE

The procedure is usually performed under regional anesthesia. For single finger flexor tenolysis, we prefer distal nerve blocks, median and/or ulnar, at the wrist level. This kind of anesthesia preserves active motion and helps both the surgeon and the awake patient to be aware of the gain of mobility during surgery.1 This aspect is greatly relevant for the postoperative rehabilitation. Moreover, the active flexion during surgery can help to release some remaining adhesions that have not been released by the suture. The use of the pneumatic tourniquet in the forearm spares the functionality of the flexor muscles during 20 to 30 minutes and is usually well tolerated by the informed patients. Bru¨ner zigzag incision is used with some occasional adaptations to previous scars. Even though several authors prefer the dorso-lateral approach, we believe that Bru¨ner incisions provides a broader view of the whole digital canal, which allows the surgeon to identify the structures and to easily handle the suture.1 The preservation of the A2 and A4 pulleys is the expected requirement to avoid the bowstringing and to assure a good flexor function.1–4 In practice, complete preservation of annular pulleys is not always possible, depending on the site of the primary suture. We begin the digital canal exploration precisely in the site of the primary suture for two reasons: first, it is the site of maximum adhesions and the digital sheath at this point will be invariably opened. Second, a good exposure of the suture site is mandatory to assess the trophicity of the tendon healing, especially in case of some degree of callus elongation. At least two more ‘‘windows’’ are necessary to pass the suture on the whole required segment.

We begin the procedure with the tenolysis of the flexor digitorum profundus (FDP) from the distal to the proximal region. First of all, the suture must be inserted superficially on the midline, between the digital sheath and the anterior surface of the tendon. At the level of the distal insertion of the FDP, the suture is passed deeply under the posterior surface of the tendon, making a lace around it. Eventually, it is important that the suture returns proximally through the same tunnel, through which it has been entered, because this procedure will allow the suture to release the adhesions all around the tendon, while it is pulled proximally (Fig. 1). Going through, the tenolysis of the FDP to its proximal portion is prevented by Camper’s chiasma at the level of the A2 pulley. This hindrance is avoided by resection of one slip of the FDS prior to passing the suture. Ulnar slip is resected when possible, but this choice depends largely on the local condition of the tendon. After distal incision the slip is resected up to the palm, proximally to the proximal edge of the A1 pulley (Fig. 2). Following this maneuver, suture tenolysis in zone 2 is easily performed. For the second stage the same procedure described above using the suture is then performed by passing the suture under A2 pulley. The FDP is circled at the proximal end of the first stage. The suture then returns through the same anterior tunnel between pulley and tendon without butting against the chiasma (Fig. 3). The same technique is used under the A1 pulley. For the third stage the FDS will be released according to the same technique. The suture is passed around the spared slip, under A2 and A1 pulleys and pulled proximally to release the adhesions between the tendon and the pulleys, as well as between both tendons (Fig. 4).

FIGURE 1. (A) Suture is inserted between the digital sheath and the anterior surface of the tendon. At the level of the distal insertion of the flexor digitorum profundus (FDP), the suture makes a lace around it and returns through the same tunnel through which it has been entered. (B) Proximal traction releases the adhesions all around the tendon in this segment.

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may lead to a complete FDS rupture that can end to some degree of strength loss.

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FIGURE 2. One slip of the flexor digitorum superficialis (FDS) is resected prior to passing the suture under A2.

Assessment of complete tenolysis relies on complete finger active flexion.

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COMPLICATIONS

The only specific complication of this technique concerns excessive weakness of the FDS remaining slip. It

DISCUSSION

Tenolysis technique using a suture has been advocated by several authors.9–11 Its great advantage is the use of an instrument that can cut and is flexible at the same time, being able to adapt to narrow spaces between the tendons and the digital canal. Such characteristics facilitate the section of the adhesions without opening or traumatizing the pulleys. It is important to highlight the relevance of the use of large caliber monofilament suture (2-0 or 3-0), instead of a braided suture. Besides providing better gliding, this suture reduces the risks of trauma if perpendicularly applied to the tendon. Braided suture can easily cut a flexor tendon when the traction on the suture is not perfectly parallel to the tendon. Even though the suture makes the practice of tenolysis rather simpler, we initially found a technical difficulty when trying to pass the suture in zone 2 through Camper’s chiasma. In his article, Bain (2003) described the use of the needle of the Prolene 2-0 suture to pass it under the pulleys. According to his description, it is possible to understand that tenolysis involves the spaces between the tendon and the pulleys in the anterior and lateral portions as well as the posterior portion between the tendon and the phalanx.9 Nevertheless, Bain did not make it clear how it is possible to pass the suture and release the adhesions present in the chiasma. Azad (2004), on the other hand, describes the use of a simple instrument that, besides being useful for dissection, contributes to the passage of the suture through the digital canal without traumatizing the pulleys. The instrument has a shaft with a slight angle. Its flattened tip with

FIGURE 3. (A) Tenolysis of the flexor digitorum profundus (FDP) is performed following the same procedure. The suture passes under A2 and circles the tendon at the proximal end of the first stage without having the chiasma as a hindrance. (B) Traction of the suture releases the adhesions in this segment.

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FIGURE 4. (A) Flexor digitorum superficialis (FDS) is released according to the same technique. The suture is passed around the spared slip, under A2, and (B) pulled proximally to release the adhesions between the tendon and the pulley, as well as between both tendons.

rounded edge is similar to the head of a snake. The tip has also an ‘‘eye’’, in a subterminal location, which enables the passage of the suture. After its insertion between the pulleys and the tendon, the shaft is withdrawn, allowing the suture to run across the canal.10 The use of this instrumente bordos arredondaos, assemelhando-se a uma caberaumatizar as polias.motivados, cientes de que ter_____________________________, however, does not simplify the problem of passing the suture between the tendons in zone 2. The simplification of the chiasma has always been discussed, even for cases of primary or secondary repair of the flexor tendons. Tubiana indicates the complete resection of the FDS, repairing only the FDP in cases of crushing lesions in zone 2. In FDP tendon grafts, he suggests passing the graft along the FDS, avoiding the chiasma.12 Le Viet (2004) suggested the partial resection of the tendon to make it ‘‘thinner’’ and, as a consequence, provide more space inside the canal for tendons gliding, particularly associated to trigger finger release.11 Our choice is the use of the systematic resection of a single slip of FDS. The simplification of the flexor system makes suture tenolysis in zone 2 as easy and efficient as in zone 1, improving what used to be a drawback of the technique.

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3. Landi A, Saracino A, Caserta G, et al. Complex tenolysis of the hand. In: Hunter JM, Schneider LH, Mackin EJ, eds. Tendon and Nerve Surgery in the Hand: A Third Decade. St. Louis: Mosby; 1997:456–485. 4. Strickland JW. Flexor tendon surgery. Part 2: free tendon grafts and tenolysis. J Hand Surg [Br]. 1989;14B:368–378. 5. Tonkin M, Lister G. Flexor tendon surgery—today and looking ahead. Clin Plast Surg. 1986;13:221–242. 6. Jupiter JB, Pess GM, Bour CJ. Results of flexor tendon tenolysis after replantation in the hand. J Hand Surg [Am]. 1989;14A:35–44. 7. Schreiber DR. Arthroscopic blades in flexor tenolysis of the hand. J Hand Surg [Am]. 1986;11A:144–145. 8. Costantinnescu MA, Greenwald DP, Amarante MTJ, et al. Effects of laser versus scalpel tenolysis in the rabbit flexor tendon. Plast Reconstr Surg. 1996;97:595–601. 9. Bain GI, Allen BD, Berger AC. Flexor tenolysis using a free suture. Tech Hand Upper Extrem Surg. 2003;7:61–62. 10. Azad S. A simple instrument for tenolysis in hand surgery. Plast Reconstr Surg. 2004;113:1521–1522. 11. Le Viet D, Tsionos I, Boulouednine M, et al. Trigger finger treatment by ulnar superficialis slip resection (U.S.S.R.). J Hand Surg [Br]. 2004;29:368–373.

REFERENCES

1. Strickland JW. Flexor tenolysis. In: Hunter JM, Schneider LH, Mackin EJ, eds. Tendon and Nerve Surgery in the Hand: A Third Decade. St. Louis: Mosby; 1997:443–449.

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2. Merle M. Chirurgie secondaire des tendons flećhisseurs. In: Merle M, Dautel G. La Main Traumatique. Tome 2—Chirurgie Secondaire/Le Poignet Traumatique. Paris: Masson; 1995:55–92.

12. Tubiana R. Plaies des tendons de la mains. Encycl Me´d Chir (Paris, France), Techniques Chirurgicales, Orthope´dieTraumatologie, 44395; 4.11.03:24.




T E C H N I Q U E

Fractures of the Ulnar Shaft: Current Treatment Methods Tamara D. Rozental and Philip E. Blazar Division of Hand Surgery Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts, USA

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PURPOSE OF REVIEW

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This paper reviews current treatment methods for fractures of the ulnar shaft and identifies recent contributions to the literature on this topic.

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RECENT FINDINGS

Functional bracing is currently the preferred method of treatment for isolated ulnar shaft fractures with less than 10° to 15° of angulation and less than 50% translation between fragments. Displaced fractures are typically treated with compression plating although distal third fractures may require fixed angle devices or locking plates to ensure adequate distal fixation. The most commonly reported complications in the treatment of ulnar shaft fractures include compartment syndrome, nonunion, radioulnar synostosis, and refracture after hardware removal.

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SUMMARY

Most simple diaphyseal fractures are treated conservatively, whereas complex injuries often require operative fixation. When appropriately treated, complications are rare. Keywords: compartment syndrome, displaced fractures, forearm fracture, functional bracing, nonunion, radioulnar synostosis, refracture, ulna fracture, ulnar shaft

Correspondence to Tamara D. Rozental, MD, Brigham and Women’s Hospital, Department of Orthopaedic Surgery, 75 Francis Street, Boston, MA 02115, USA. Tel: 617 732 5384; fax: 617 732 6937. E-mail: [email protected]. This article was originally published in Current Opinion in Orthopaedics. It is reprinted here as a service to our readers. Rozental TD, Blazar PE. Fractures of the ulnar shaft: current treatment methods. Curr Opin Orthop 2005;16(4):240–244.

INTRODUCTION

Fractures of the ulnar diaphysis are relatively common injuries. The spectrum of severity ranges from minimally displaced Ônight-stickÕ fractures to more extensive injuries with bone and soft tissue loss. This article reviews current treatment methods for fractures of the ulna and highlights recent contributions to the literature.

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CLOSED TREATMENT

Isolated ulnar shaft fractures with less than 10° to 15° of angulation and less than 50% translation between fracture fragments are amenable to closed treatment. Cadaveric studies have shown that fractures with a greater amount of displacement may result in forearm instability or loss of rotation and, as such, are best treated with operative fixation.1 After a brief period of immobilization in a long arm cast or sugar-tong splint, functional bracing is the treatment of choice. Bracing with an orthoplast sleeve was first introduced by Sarmiento2 in the mid-970s. Clinical studies comparing bracing with long arm casts have shown no difference in time to healing but improved wrist range of motion and a faster return to full function.3,4 Most of these studies, however, were retrospective case series limited by small numbers and poor patient follow-up. Patients are allowed to move the arm while in the brace but are restricted from lifting. Displacement, particularly shortening, must be monitored in distal fractures treated by closed methods because excessive shortening may result in incongruity at the distal radioulnar joint. The brace is discontinued when physical examination demonstrates no tenderness at the fracture site and radiographs show bony healing.

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OPEN TREATMENT

Open reduction and internal fixation are indicated in fractures with greater than 10° to 15° of angulation

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and greater than 50% translation.5 This treatment method is also preferred for unstable proximal third ulna fractures. Additional indications include open fractures, neurovascular injuries, and patients with weight-bearing upper extremities.

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SPECIAL CATEGORIES

Special categories include distal third fractures, fractures of the ulnar head, Monteggia fractures, and stress fractures.

Compression Plating Compression plating continues to be the preferred method of fixation for displaced diaphyseal fractures. The ulna is typically approached through an incision along its dorsal crest, taking care in protecting the sensory branch of the ulnar nerve. Plates can be applied on the flexor, extensor, or subcutaneous surfaces. Limited-contact dynamic compression plates (LC-DCPs) (3.5 mm) are the most commonly used, but locking plates are gaining acceptance, particularly for patients with osteoporosis. Transverse fractures can be adequately fixed with six cortices above and below the fracture, whereas more comminuted fractures require eight cortices. To date there are no clinical or bio-mechanical studies addressing the number of screws required for locking implants. A 2003 prospective study randomly allocating patients to treatment with LC-DCP plates vs point contact fixator locking plates found no significant difference between the two groups with regard to operative time, time to union, callus formation, pain, or functional outcome.6 In addition, a 2004 meta-analysis of the literature comparing fractures treated with LC-DCP plates and those treated with point contact fixator implants revealed no differences in delayed union, infection, or pain.7 Cancellous bone grafting continues to be controversial, with some authors recommending grafting in fractures with a high degree of comminution.8,9

Intramedullary Fixation By avoiding extensive dissection, intramedullary nails allow preservation of the ulna’s blood supply. Initial series reporting on treatment with intramedullary Kirshner wires found a high rate of nonunion at 38%.10 Stronger intramedullary devices, however, have decreased the rate of nonunion to the single digits.11 A straight nail can be inserted and locked proximally and distally, thus providing good rotational control of the fracture. New-generation nails also allow compression at the fracture site but may result in excessive shortening. Current indications for intramedullary nailing in adults include segmental fractures, severe soft tissue loss, polytrauma, and pathologic fractures.

External Fixation The use of external fixation for diaphyseal fractures is limited to providing temporary fixation or in cases of severe soft tissue loss or polytrauma. The external fixator

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can be converted to plate fixation within the first 3 weeks after injury.12

Distal Third Fractures Unstable fractures of the distal ulna usually accompany fractures of the distal radius and can result in instability of the distal radioulnar joint. Fracture fixation is often difficult due to the small size of the distal metaphyseal fragment. Options include Kirshner wires or standard plates, but with only one or two screws in the distal fragment, these often provide inadequate purchase. The use of miniblade plates has recently gained in popularity. A recent series used minicondylar blade plate fixation in 24 displaced fractures of the distal ulna associated with fractures of the distal radius. At final follow-up (average of 26 months) patients had excellent range of motion without any signs of radioulnar dysfunction or arthrosis. The authors concluded that condylar blade plate fixation maintained alignment and allowed good functional recovery.13 Locking plates have also been used with favorable clinical reports but, to date, no series have been published reporting clinical or functional results in patients with distal ulna fractures (Figs. 1a–d).

Fractures of the Ulnar Head Isolated ulnar head fractures are rare. More commonly, ulnar head fractures are seen in conjunction with fractures of the distal radius. In patients with fractures of the ulnar head, congruency of the distal radioulnar joint is the primary concern. Minimally displaced fractures can be treated with above-elbow casting but displaced fractures require pinning or small-plate fixation. In severely comminuted cases, a partial or complete excision of the ulnar head may provide the best option for early return to function. Although some authors recommend tendon weaves to improve the stability of the ulnar stump, we have found that suturing the volar capsule over the dorsal aspect of the distal ulna is usually sufficient.

Monteggia Fractures Monteggia fractures typically describe fractures of the proximal ulna associated with a radial head dislocation. Treating physicians should maintain a high index of suspicion when examining patients with proximal ulnar fractures. These injuries are often missed at initial presentation, with some series reporting a delay in diagnosis in up to 42% of cases.14


Fractures of the Ulnar Shaft

FIGURE 1. Radiographs of displaced fracture of the distal radius accompanied by a distal third ulna fracture. Preoperative posteroanterior (a), lateral (b), and postoperative (d), and lateral (e) radiographs demonstrating near anatomic fixation of the fracture and bony healing following stabilization with a low-profile locking plate.

Stress Fractures Diaphyseal stress fractures in the ulna have been reported in multiple sports, including pitching, tennis, volleyball, and weight lifting.15–17 They have also been reported in cases of chronic crutch use.18 Patients present with activity-related pain and may have swelling over the involved area. The pathogenesis is likely related to overpull of the flexor muscles and symptoms usually resolve with rest. If the fracture persists clinically or radiographically for several months, patients may require open reduction and internal fixation.

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COMPLICATIONS

Complications include compartment syndrome, nonunion, synostosis, and refracture.

Compartment Syndrome Compartment syndrome has been reported in isolated ulnar shaft fractures. Ghobrial et al19 documented a 7% rate of compartment syndrome among isolated, comminuted, proximal third ulnar shaft fractures secondary to both high-energy blunt trauma and low-velocity

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gunshot wounds. The most common cause was an injury to the interosseous vessels.

Nonunion When treated with compression plating and interfragmentary screw fixation, nonunions are rare (,2%). Injuries at risk are typically high energy, comminuted fractures with significant bone loss and fractures treated with inadequate fixation. Stern and Drury20 reported a nonunion rate of 9.3% in diaphyseal forearm fractures treated with plating, but only 17% of these fractures had adequate initial fixation. Nonunions are treated with open reduction, nonunion debridement, autogenous bone grafting, and compression plating. Ring et al21 reported uneventful healing in 10 patients with atrophic proximal ulna nonunions treated in this fashion. Recently, bone morphogenetic protein (BMP) has been used as an adjuvant in the treatment of ulnar nonunions. Kujala et al22 reported on four ulnar diaphyseal nonunions and one olecranon nonunion treated with autogenous bone grafting supplemented with BMP. Although all patients achieved union, no studies have demonstrated a comparative advantage to the use of autogenous graft and BMP vs autogenous graft alone. Nonunions with extensive bone loss often represent challenging scenarios. Reported treatment options include bone transport with the Ilizarov method, open reduction with internal fixation with a vascularized bone graft (Figs. 2a and b), and open reduction with internal fixation with iliac crest strut or morselized bone graft. Several retrospective and one prospective case series have evaluated the results of treatment of ulnar fractures with bone defects with bone graft and adjunctive fixation. Union rates ranged from 82% to 96% but complications were common.7

Synostosis Radioulnar synostosis has been widely reported in both bone forearm fractures, particularly when fractures in both the radius and ulna occur at the same level. Implicated causes include high energy trauma, proximal fractures, open injuries, head trauma, and bone grafting along the interosseous membrane. Despite a few case reports,23 the development of heterotopic ossification is rare in isolated ulnar shaft fractures and fractures of the distal ulna.

Refracture Refracture rates after forearm plate removal are reported to range between 4% and 25%.9,24 Risk factors for refracture include premature removal of hardware and the use of larger plates. Bone loss under plates is thought to result from a local decrease in circulation during bone remodeling. A 2003 study examined bone mineral density after plate removal and found a 2.1% decrease in ulnar bone mineral density at the time of hardware removal

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FIGURE 2. Radiograph (a) of a patient with an ulnar shaft nonunion treated with iliac crest bone grafting that became infected and failed to unite. The patient subsequently underwent extensive debridement followed by external fixation and antibiotic bead placement (b). Definitive treatment was achieved with a vascularized fibula graft (c).

compared with the contralateral extremity. This gradually improved and reached normal levels by 6 months.25 Despite the lack of evidence linking early plate removal to refracture, many surgeons continue to recommend waiting until bone remodeling is complete at 18 to 24 months before removing symptomatic compression plates.5 Others, including the present authors, wait only a minimum of 6 to 12 months before proceeding with symptomatic plate removal.

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CONCLUSION

Fractures of the ulna are relatively common injuries. Most simple diaphyseal fractures are treated conservatively, whereas more proximal or distal injuries may require operative fixation. Locking plates have gained in popularity and are often the fixation method of


Fractures of the Ulnar Shaft

choice for more complex injuries. When appropriately treated, complications such as nonunion, compartment syndrome, radioulnar synostosis, and refracture are rare.

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REFERENCES

1. Renfree K. Shaft fractures of the radius and ulna. In: Berger RA, Weiss AP, eds. Hand surgery. Philadelphia: Lippincott Williams and Wilkins; 2004. pp. 578–614. This recent chapter reviews the basic principles behind treatment of diaphyseal forearm fractures.

13. Ring D, McCarty P, Campbell D, Jupiter JB. Condylar blade plate fixation of unstable fractures of the distal ulna associated with fractures of the distal radius. J Hand Surg [Am]. 2004;29:103–109. This study reviewed the results of condylar blade plate fixation for unstable fractures of the distal ulna associated with fractures of the distal radius and found good radiographic and clinical outcomes. 14. Barquet A. Posterior fracture of the shaft of ulna and radius with associated dislocation of the radial head. Injury. 1981; 12:471–476.

2. Sarmiento A, Latta LL. Functional fracture bracing. J Am Acad Orthop Surg. 1999;7:66–75.

15. Schickendantz MS, Ho CP, Koh J. Stress injury of the proximal ulna in professional baseball players. Am J Sports Med. 2002;30:737–741.

3. Gebuhr P, Holmich P, Orsnes T, et al. Isolated ulnar shaft fractures: comparison of treatment by a functional brace and long arm cast. J Bone Joint Surg Br. 1992;74:757–759.

16. Clark RJ, Sizer PS Jr, Slauterbeck J. Stress fracture of the ulna in a male competitive polo player. Am J Sports Med. 2002;30:130–132.

4. Atkins D, Bohay D, Salabaugh P, et al. Treatment of ulnar shaft fractures: a prospective randomized study. Orthopedics. 1995;18:543–547.

17. Fragniere B, Landry M, Siegrist O. Stress fracture of the ulna in a professional tennis player using a double-handed backhand stroke. Knee Surg Sports Traumatol Arthrosc. 2001;9:239–241.

5. Jupiter JB, Kellam JF. Diaphyseal fractures of the forearm. In: Browner BD, Jupiter JB, Levine MA, Trafton PG. Skeletal trauma. 2d ed. Philadelphia: WB Saunders; 1992. pp. 1421–1454. 6. Leung F, Chow SP. A prospective randomized trial comparing the limited contact dynamic compression plate with the point contact fixator for forearm fractures. J Bone Joint Surg Am. 2003;85:2343–2348. 7. Bhandari M, Schemitsch EH. Fractures of the shaft of the ulna. J Orthop Trauma. 2004;18:473–475. Evidenced based review of published studies in the literature reviewing nonoperative and operative results for treatment of diaphyseal ulnar fractures.

18. Garcia Suarez G, Garcia Garcia J, Perez Carro L. Stress fracture of the ulna associated with crutch use. J Orthop Trauma. 2001;15:524–525. 19. Ghobrial TF, Eglseder WA Jr, Bleckner SA. Proximal ulna shaft fractures and associated compartment syndromes. Am J Orthop. 2001;30:703–707. 20. Stern PJ, Drury WJ. Complications of plate fixation of forearm fractures. Clin Orthop. 1983;175:25–29. 21. Ring D, Jupiter JB, Gulotta L. Atrophic nonunions of the proximal ulna. Clin Orthop. 2003;409:268–274.

8. Anderson LD, Sisk TD, Tooms RE, Park WI. Compression plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am. 1975;57:287–297.

22. Kujala S, Raatikainen T, Ryhanen J, et al. Composite implant of bovine bone morphogenetic protein (BMP), collagen carrier and biocoral in the treatment of resistant ulnar nonuions: report of five preliminary cases. Arch Orthop Trauma Surg. 2003;124:26–30.

9. Chapman MW, Gordon JE, Zissmos AG. Compression plate fixation of acute fractures of the diaphysis of the radius and ulna. J Bone Joint Surg Am. 1989;71:159–169.

23. Posmann CL, Little RE. Radioulnar synostosis following an isolated fracture of the ulnar shaft: a case report. Clin Orthop. 1986;213:207–210.

10. Smith H, Sage FP. Medullary fixation of forearm fractures. J Bone Joint Surg Am. 1959;41:1489.

24. Deluca PA, Lindsey RW, Rowe PA. Refracture of bones of the forearm after the removal of compression plates. J Bone Joint Surg Am. 1988;70:1372–1376.

11. Street DM. Intramedullary forearm nailing. Clin Orthop. 1986;212:221–230. 12. Schnuid F, Andrianne Y, Burny F. Treatment of forearm fractures by Hoffman external fixation: a study of 93 patients. Clin Orthop. 1991;266:197–204.

25. Kettunen J, Kroger H, Bowditch M, et al. Bone mineral density after removal of rigid plates from forearm fractures: a preliminary report. J Orthop Sci. 2003;8:772– 776.

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T E C H N I Q U E

Update on Brachial Plexus Surgery in Adults Robert J. Spinner, Alexander Y. Shin, and Allen T. Bishop Mayo Clinic Departments of Orthopedics and Neurologic Surgery Rochester, Minnesota, USA

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PURPOSE OF REVIEW

Adult traumatic brachial plexus injuries are devastating injuries that in the past have been treated with either amputations and shoulder fusions or benign neglect. The purpose of this current opinion article is to detail the recent advances in the evaluation and management of these patients that have led to improved outcomes.

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RECENT FINDINGS

Improved diagnostic modalities along with advances in surgical techniques have allowed reliable restoration of shoulder stability and elbow flexion. Use of novel extraplexal donor nerves in addition to free functioning gracilis muscle transfers now give hope for the restoration of hand function.

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SUMMARY

An interdisciplinary approach using both extraplexal, intraplexal, and free functioning muscle transfers now allows patients with these devastating injuries to have hope to regain not only shoulder stability and elbow flexion, but potentially hand function. Keywords: traumatic, adult, brachial plexus, injuries

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INTRODUCTION

Brachial plexus injuries are often devastating injuries that can lead to significant long-term functional disability, psychological distress, cosmetic concerns, and financial hardships. Critical motor function in the limb may be lost, sensation in the hands may be impaired, and disabling pain may ensue. Brachial plexus lesions usually affect young men but may also affect individuals of any age and of either gender. Traumatic lesions are Correspondence to Allen T. Bishop, MD, Department of Orthopedic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905 USA. Tel: 507 284 4149; fax: 507 284 5539. E-mail: [email protected]. This article was originally published in Current Opinion in Orthopaedics. It is reprinted here as a service to our readers. Spinner Robert J, Shin Alexander Y, Bishop Allen T. Update on brachial plexus surgery in adults. Curr Opin Orthop 2004;15:203–214.

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usually from high-speed motor vehicle, motorcycle, or snowmobile accidents, but may also follow lesser injuries, such as falls. Brachial plexus lesions may also occur from tumor, irradiation, compression, and penetrating injuries, among other causes. In traumatic lesions, the nerves of the brachial plexus may be stretched, ruptured, or avulsed from the spinal cord (Fig. 1). The extent and location of a stretch injury are variable, as is the prognosis for spontaneous recovery. Lesions that are in continuity have the potential for recovery without surgical intervention, depending on the grade of neural injury (ie, neurapraxia or axonotmesis). More severe neural lesions that are in continuity, as well as ruptured or avulsed neural elements, require surgical intervention for improvement in function. Ruptures may occur at any site from the spinal nerve distal to the dorsal root ganglion to the terminal branches (but most commonly, roots or peripheral nerves) and result in postganglionic injuries. Avulsive injuries are of two types: a central avulsion, in which the nerve is torn directly from the spinal cord; and a peripheral avulsion (intradural rupture), in which the injury is proximal to the dorsal root ganglion but remnants of the root remain attached to the spinal cord. Avulsions commonly affect both the dorsal and ventral roots together, but may affect the dorsal or ventral roots alone in as many as 10% of cases.1–3 The dural sac may be ruptured, producing a pseudomeningocele, characteristic of a preganglionic injury. Traction forces typically impart an extensive longitudinal injury, but compressive forces may also be responsible for the injury. Injuries may occur at more than one site. Injuries typically occur where nerves are more or less fixed, restrained by surrounding structures, or where they change directions. This is reflected in coexisting or independently occurring distal lesions affecting the suprascapular nerve (often at the notch), axillary nerve (within the quadrilateral space), or musculocutaneous nerve where it penetrates the coracobrachialis muscle. Common patterns of supraclavicular injury include total (or pan) plexus injury, and upper trunk or lower trunk lesions. A complete plexus injury (affecting all neural elements of the brachial plexus to some degree) may lead


Brachial Plexus Surgery in Adults

FIGURE 1. Traumatic lesions of the brachial plexus. Traction of the individual nerves or nerve roots of the brachial plexus (A) may result in injuries of varying magnitude resulting in avulsion (B), stretch (C), or rupture (D). Reprinted with permission from the Mayo Foundation.

to a flail limb without function below the trapezius and an insensate hand. Of the supraclavicular injuries, the total plexus lesion is the most common pattern. An upper trunk (C5/C6) pattern loss is notable for absent shoulder abduction, external rotation, and elbow flexion (through the biceps, brachioradialis, and brachialis muscles). The upper pattern may include C7 injury in a number of patients, and this may be manifested by weakness of the triceps, pronator teres, and wrist and finger extensors. Lower trunk injuries typically include Horner syndrome, loss of hand intrinsic and extrinsic function, but preserved shoulder and elbow motor function. An upper trunk lesion is significantly more common than lower trunk paralysis. These supraclavicular injuries are more common than infraclavicular injuries. Occasionally other extraplexal neural elements may be affected, including the spinal accessory nerve from direct trauma or traction. Recent advances in the evaluation and management of patients with brachial plexus injuries have led to improved outcomes. These factors include refinement of preoperative diagnostic studies such as CT or MR myelography and intraoperative electrophysiology, and the introduction of innovative surgical techniques for early or late reconstruction.

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The diagnosis of a brachial plexus lesion must be made early and managed in a timely manner. Especially in multitrauma situations, other associated injuries get evaluated, but the injury to the brachial plexus may be overlooked, unnoticed, or neglected. Potentially lifethreatening coexisting trauma to the head, chest,

abdomen, pelvis, vasculature, long bones, or spine or spinal cord should be prioritized, but the peripheral nerve injury should still be established. In contrast, even in a lesser magnitude injury resulting in a fracture or a dislocation to the shoulder region, neurologic examination of the shoulder, elbow, and hand may not be performed satisfactorily. Nerve injury may be misinterpreted as pain from the skeletal injury or may be assumed to be rotator cuff pathology. The diagnosis of the brachial plexus lesion is often delayed and, as a result, the patient is mistreated. Still, in other situations, the neurologic injury is recognized but inappropriately treated. Neurologic injury must not be assumed to be a neuropraxia or a reversible condition. Without signs of immediate improvement, this diagnosis typically cannot be made in the emergency setting. Conversely, a patient with a severe injury, such as with several root avulsions, must not be followed indefinitely for spontaneous recovery or be told that there is no available operative intervention. The diagnosis and definition of the severity of a brachial plexus injury is made by a combination of history, physical examination, imaging, electrodiagnostic studies, operative exploration, and intraoperative electrophysiology. Diagnosis of a brachial plexus lesion is an important first step. More detailed localization is necessary. The lesion should be localized to the supraclavicular or infraclavicular region, to specific neural elements (C5/C6 or upper trunk, for example), and to a preganglionic or postgan-glionic zone. History should focus in on the mechanism of the injury. The position of the neck and head and limb relative to each other, and the presence of associated injuries may help predict patterns of neurologic loss. For example, an

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upper trunk injury results from downward traction on the arm or forcible widening of the shoulder-neck angle whereas a lower trunk injury is the result of upward traction of the arm. Shoulder dislocations or proximal humeral fractures frequently lead to diffuse neurologic (or neurovascular) injury, but most commonly result in isolated axillary nerve injuries. Physical examination should concentrate on identifying the pattern and anatomic localization for the dysfunction. A baseline neurologic examination is important to assess recovery, or when recovery is deemed inadequate, to plan operative intervention. Examination includes inspection (for muscle atrophy), testing, and grading motor and sensory function. Weakness of the rhomboids or serratus anterior, or the presence of Horner syndrome (ptosis, miosis, anhidrosis, enophthalmos) would be suggestive of a preganglionic injury (Fig. 2A). Percussion tenderness that is strong immediately after injury is suggestive of a rupture. The absence of it is suggestive of an avulsion. Increased tone and deep tendon reflexes should be evaluated, and the presence of pathologic reflexes should be assessed. These would be indicative of associated spinal cord or head injury (Fig. 2B). Physicians should also examine for other concomitant musculoskeletal trauma or vascular injury. Range of motion of joints should be measured. Preoperative testing also includes imaging and electrical studies. Cervical radiographs that reveal transverse process, spinous process, or vertebral body fractures are suggestive of a preganglionic injury. Inspiratory/expiratory chest films may show an elevated hemidiaphragm (also suggestive of a preganglionic injury) or may demonstrate rib or clavicle fractures. Additional radiographs should be obtained as necessary to exclude other associated skeletal injuries (shoulder, humerus, etc). Angiography may be indicated if arterial injury is suspected. Acutely, this may be the result of an expanding hematoma, first rib fracture, widened mediastinum, or upper limb pulse abnormality.

Electromyography can help establish a localization, determine the severity of a lesion, as well as exclude other diagnoses. Preganglionic injury can be suspected on the presence of denervation of proximal muscles (eg, rhomboids, serratus anterior), paraspinal fibrillations (suggestive of dorsal ramus injury), and preserved sensory nerve action potentials, especially in insensate areas. Electromyography is best performed 2 to 3 weeks after injury because denervational changes from Wallerian degeneration require several weeks to develop. Myelogram combined with finecut postmyelographic CT remains our preferred diagnostic evaluation at the present time, when the diagnosis of a nerve root avulsion is being considered (Figs. 3 and 4). Sensitivities and specificities of 80 to 90% have been reported.1,2,4–6 Results of MR myelography in some centers have approached those from CT myelography for diagnosing root avulsion.1,4,7–10

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MANAGEMENT

Patients with brachial plexus stretch lesions are generally observed for spontaneous recovery for several months. During this period of time, serial clinical and electrodiagnostic examinations should be performed to gauge neurologic recovery. Physical therapy should be instituted to prevent soft-tissue contractures and to strengthen functioning muscles in the affected limb. Patients with early signs of clinical or electrical recovery or those with partial lesions can be treated nonoperatively. Those patients who do not demonstrate clinical or electrical recovery by 3 to 6 months should undergo operative intervention. However, physicians need to be mindful that electrical signs of reinnervation do not always correlate with useful clinically recovery. Surgery may be performed earlier than 3 months if there is evidence of avulsion or ruptures. Poorer outcomes have been achieved in patients who undergo nerve surgery after 6 months, especially after 9 months. Nerve surgery

FIGURE 2. A patient with a right Horner syndrome and a left partial third cranial nerve palsy. (A) These complex eye findings are sequelae from the right brachial plexus injury and the associated severe closed head injury (which resulted in left tonsillar herniation following a right middle cerebral artery distribution stroke). (B) The same patient demonstrates a right flaccid paralysis from the lower neuron injury. He has left upper limb spasticity and increased tone as sequelae of the right-side intracranial event.

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FIGURE 3. The diagnosis of preganglionic injury can be made readily when a pseudomeningocele is apparent on myelography.

after 1 year is typically not advised. At these late dates, irreversible muscle atrophy, motor end plate degeneration, and neuronal death prevent meaningful reinnervation. However, even after prolonged periods of time after injury, other operative procedures can still be performed either for reconstruction or for pain management. Although the vast majority of brachial plexus injuries are closed and of the stretch variety, open injuries do occur occasionally and are managed differently. Sharp wounds (eg, lacerations) should be treated acutely. They

should be treated with standard nerve repair if possible, or short grafts, if necessary. If transected nerve ends are not repaired acutely, they retract and scarify. As such, direct end-to-end repair is not possible; an interpositional graft will be required, which has worse results than a direct repair. Nerve stumps identified at the time of urgent vascular repair should be tagged on tension if there is a blunt or stretch force, because time is necessary for delineating the extent of injury. Delayed repair should be done 3 to 4 weeks later. Gunshot wounds should be treated similar to stretch injuries, as long as there is no direct neurovascular injury. Most neurologic lesions resulting from gunshot wounds are neurapractic in nature, although some patients will require surgery later for more advanced lesions that do not recover in a timely fashion.11 Typically, the brachial plexus operation would include exploration of the brachial plexus, intraoperative electro-physiology, and a variety of techniques for repair or reconstruction. A broad operative exposure allows the surgeon to understand the pathoanatomy. Currently we combine a transverse supraclavicular incision and a separate infraclavicular (deltopectoral) incision for display of the neural anatomy. With the exception of the relatively rare retroclavicular stretch injury, we have found that in the case of brachial plexus stretch injuries, mobilization of the clavicle typically is sufficient, and clavicular osteotomies are often unnecessary. The type of repair or reconstruction of the brachial plexus lesion is guided by intraoperative electrophysiology. The external appearance and consistency of an injured nerve do not correlate with the internal appearance or the potential for recovery of a nerve. Intraoperative electrical studies augment our perioperative evaluation and guide decision making. We use a combination of techniques to test neural continuity and function. For example, somatosensory evoked potentials (SSEPs) and motor evoked potentials evaluate the continuity across the spinal cord/peripheral nerve interface. Recordings can be performed across a nerve lesion using nerve action potentials (NAPs), or across a nerve lesion to muscle using compound muscle action potentials or needle electromyography. Absence of an SSEP with individual nerve

FIGURE 4. Excellent visualization of nerve roots can be afforded by newer techniques of CT myelography. For example, the dorsal and ventral roots can be well seen in the unaffected side using an oblique coronal reformatted technique (A). An axial section contrasts the normal side (normal-appearing dorsal and ventral roots) from the affected side with avulsed roots (B).

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root stimulation implies root avulsion. There are limitations to the use of SSEPs. They assess only the integrity of the sensory pathway (dorsal roots), not the motor pathway. Furthermore, a positive response may be seen with only several hundred intact nerve fibers. Some have advocated hemilaminectomy and intradural root inspection to observe rootlets directly in an effort to avoid the falsenegative and positive results of imaging studies and SSEPs.1 The use of motor evoked potentials with transcranial electrical stimulation has recently been approved in the United States. This technique has the advantage of evaluating the integrity of the motor pathway (ventral roots).12,13 There are some technical challenges, however, related to its sensitivity to inhalation anesthetics and its propensity to stimulus artifacts. NAPs can predict recovery earlier than standard electromyography and are performed after external neurolysis with all lesions in continuity.11 Flat tracings are suggestive of a neural lesion that has no capacity to recover. Any positive NAP response suggests that viable axons remain and that neurolysis alone can be performed and clinically relevant recovery can be expected. Early regeneration is better detected by NAP recordings than compound muscle action potentials. However in partial lesions, compound muscle action potentials may be helpful in determining the severity of the lesion (ie, number of functioning axons). If an NAP is obtained (with a rapid conduction and high amplitude) despite clinical and electromyographic loss in the distribution of a neural element, then this is suggestive of a preganglionic lesion. Primary treatment of stretch brachial plexus injuries includes neurolysis, nerve repair, nerve grafting, extraplexal and intraplexal (plexoplexal) neurotization, free muscle transfer, and nerve reimplantation. Although the priorities for reconstruction have remained similar over the years, new surgical techniques and improved outcomes have permitted the surgeon to attempt more distal recovery and the patient to obtain additional function. Priorities include elbow flexion, shoulder abduction (external rotation) and stability, and hand sensibility, then grasp (wrist extension, finger flexion), release (wrist flexion, finger extension), and intrinsic function. Shoulder abduction, elbow flexion, and hand sensibility have been obtained in many cases in the past, but new techniques continue to improve outcomes for these functions, allowing them to be achieved more frequently. Standard nerve grafting and conventional nerve transfers have produced poor results for function distal to the elbow. Hand function has traditionally been elusive because of the long distance necessary for reinnervation and the slow nature of nerve regeneration to reach fine hand muscles before progressive motor end plate degradation occurs. Surgeons are searching for alternatives to try to overcome these physiologic obstacles, using innovative nerve

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transfers and free functioning muscle transfer techniques that have permitted limited prehension in some cases.

Direct Nerve Repair Direct nerve repair is seldom possible in stretch injuries, and is typically only performed after acute management of sharp injury, such as sharp laceration (glass) or transection (knife).

Neurolysis Neurolysis alone is performed when a nerve is in continuity and the lesion conducts an NAP across it and SSEPs are achieved.

Nerve Grafting Nerve grafting can be performed when there is a postganglionic rupture or a neuroma that does not conduct an NAP. Interpositional grafts are used to span the defect. Currently we prefer to target specific muscles directly. Donor nerves include sural nerves or ipsilateral cutaneous nerves (superficial radial, medial brachial cutaneous, or medial or lateral antebrachial cutaneou). We also use the ipsilateral vascularized ulnar nerve graft in cases of documented C8 and T1 avulsions. Based on the superior ulnar collateral artery, the ulnar nerve can be used as a vascularized pedicled or a free graft, which may accelerate axonal regeneration. Anatomic restraints (such as proximal muscle branches and transverse radicular ligaments) are protective and seem to predispose C5 and C6 to rupture rather than avulsion (unlike C8 and T1, which are more frequently avulsed). In cases of postganglionic rupture, assessing the quality of proximal stumps may be difficult. We section the proximal stump and evaluate for good fascicular structure. Some have advocated examining proximal stumps for fibrosis.14 Others have used acetylcholinesterase staining in examining nerve stumps to help identify motor fibers or to identify preganglionic lesions.15 The advent of microsurgical instrumentation and techniques has improved outcomes. We currently coapt the nerve ends loosely using a small number of 8-0 to 10-0 nylon sutures and reinforce the repair with commercially available fibrin glue. We perform the nerve repair with the arm abducted and externally rotated to make sure that there is no tension on the repair. The nerve repair is protected by placing the limb in a shoulder immobilizer for 3 weeks.

Nerve Transfers (neurotization) Surgical advances in brachial plexus surgery have been most apparent in the introduction of new nerve transfers. Nerve transfers (neurotization) can be performed in cases of preganglionic or combined preganglionic and



postganglionic injuries. Root avulsions, long considered to be irreparable, are by no means unreconstructable. In addition, nerve transfers are being used increasingly in cases of postganglionic injury (instead of nerve grafting) in an attempt to provide more rapid and perhaps more reliable recovery of specific vital functions. They can also be used to power free muscle transfer. Quite simply, the basis of a nerve transfer is using an ‘‘expendable’’ nerve for another function, often permitting nerve repair closer to the motor end plate. The risk-to-benefit ratio of a potential donor must be carefully analyzed in each case. Nerve transfers are derived from extra and intraplexal sources. They may be performed for motor or sensory recovery in the adult or the infant. Extraplexal Neurotization. Widely used extraplexal neurotization sources include the intercostals16 and the spinal accessory17 nerves. These nerves can result in good functional recovery and can be sacrificed with little morbidity. Patients have been able to relearn functions independently. Over the years, the intercostal nerve transfer has remained a popular and reliable nerve transfer. Typically two to four nerves are used for motor neurotization. Even in patients with rib fractures, several intercostals nerves are generally available for use. The third through sixth intercostals best reach the proximal arm for direct coaptation. Each intercostals nerve has approximately 1200 axons. The sensory branches of the intercostals may be used separately for sensory neurotization. Intercostal neurotization is frequently used for recovery of biceps function (Fig. 5) or for powering free functioning muscle transfers. Apart from the initial chest wall discomfort, intercostal nerve harvest is well tolerated by patients. The spinal accessory nerve is used frequently as a nerve transfer. This nerve can be identified readily in the supraclavicular exposure. We routinely isolate it along the medial edge of the trapezius muscle rather than in the posterior triangle near the cervical lymph nodes. We trace it further distally to obtain the necessary length that permits direct coaptation. One or two proximal motor branches to the trapezius are preserved. The distal trunk has approximately 1500 myelinated fibers and is

used for neurotization. The fibers of the spinal accessory nerve are predominantly motor. The spinal accessory nerve provides a nice cross-sectional match when coapted directly to the suprascapular nerve (Fig. 6).18 It also has provided reliable results when used with an interpositional graft to the biceps.19 Because a portion of the trapezius is still supplied by preserved proximal motor branches and/or is dually innervated, this transfer is tolerated with minimal loss of function. Newer extraplexal sources include the ipsilateral phrenic nerve20 and contralateral C7.21,22 These nerve transfers have been introduced to expand on the limited donors. The introduction and adaptation of a more ‘‘aggressive’’ approach to nerve transfers allows the ability to reconstruct additional targets, the possibility of reinnervating more distal targets, and the possibility of improved outcomes. The dictum ‘‘primum non nocere’’ (first, do no harm) is the center of the controversy. Wide experience in Asia has shown that both the phrenic nerve and contralateral C7 can provide excellent clinical results and, to the surprise of many, can be performed with acceptable morbidity. The phrenic nerve, with 800 myelinated fibers, has proved to be a powerful neurotizer. It can be directly apposed to the suprascapular nerve or to divisions, or used with an interpositional graft to the musculocutaneous or axillary nerve. Phrenic nerve neurotization has produced excellent results by several groups of Asian and European surgeons. Its anatomic position directly within the surgical field makes it a tempting source for nerve transfer. Even in cases of complete brachial plexus avulsion, the phrenic nerve often (although not always) is functioning as a result of its C3 and C4 major contributions. Because of the fear of hemidiaphragm paralysis, many surgeons have been reluctant to sacrifice the phrenic nerve. The literature has documented that adults report few, if any, subjective symptoms postoperatively. Vital capacity on pulmonary function tests decreased 10% after surgery, but returned to baseline between 6 and 24 months. However, longterm data on the pulmonary sequelae are unavailable. The phrenic nerve should not be used in those who have sustained severe chest trauma

FIGURE 5. Intercostal nerve transfer. (A) This illustration depicts our technique of intercostal nerve transfer to the biceps motor branch (reprinted with permission from the Mayo Foundation). (B) In this case, three intercostal nerves are apposed to the biceps motor branch.

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FIGURE 6. Spinal accessory nerve transfer to the suprascapular nerve. Reprinted with permission from the Mayo Foundation.

or in children younger than 2 years of age. Recently, Gu et al23 harvested a longer phrenic nerve by using video assisted thoracic surgery. This technique allows direct nerve transfer to the biceps. In their study, patients who had a longer segment of phrenic nerve transferred had faster, stronger biceps recovery than those treated with standard phrenic nerve transfer with interpositional graft. The appeal of contralateral C7 is its large number of fibers (.30,000 fibers). Gu started using the entire contralateral C7 as a nerve transfer in 1986.24 Songcharoen et al22 popularized using half of it. In different reports, the contralateral C7 has been used for shoulder and elbow restoration as well as grasp function.21,22,25–27 Along with a vascularized ulnar nerve graft, it may allow

more rapid reinnervation and return of grasp in some patients. We have adopted the technique of Songcharoen et al, selecting the portion of the nerve with a nerve stimulator that powers the pectoralis major. Using this transfer to the median nerve, Songcharoen et al22 reported that 30% of 111 patients achieved M3 wrist and finger flexion, and 50% achieved S3 function. In this series 3% had motor deficits: 2% temporary mild triceps weakness and 1% permanent weakness in the extensor digitorum communis. Nearly all had sensory deficits transiently, most commonly in the index finger, which resolved completely by 7 months. The unsettled question with contralateral C7 transfer is whether adults truly regain independent function. We typically use the cervical plexus for sensory neurotization. Others may piggyback cervical plexus together with other transfers with the hope of obtaining motor recovery. Preliminary experience with hypoglossal nerve transfer has been unsatisfactory and volitional control has been difficult to achieve.28,29 Intraplexal Neurotization. Intraplexal sources have become increasingly popular lately, especially in cases of upper plexal loss. Intraplexal neurotization entails exploiting available branches or fascicles of working donors. Examples include thoracodorsal or medial pectoral branch to biceps, distal anterior interosseous nerve to deep branch of the ulnar, triceps to axillary, or even ipsilateral C7.30 An example of a fascicular transfer is the technique introduced by Oberlin et al.31 One or two fascicles of an intact ulnar nerve can be used for direct apposition to the biceps motor branch (Fig. 7). It is indicated for C5/C6 avulsions in adults and obstetric cases, and has been used in some cases with C5/C6/C7 loss. A fascicle stimulating the flexor carpi ulnaris fascicle is selected, whereas others are preserved. Again, transient sensory symptoms quickly disappear. Few objective complications in the hand have been reported. The obvious advantage of this procedure is the significantly shortened distance and time for reinnervation. Patients may show early recovery by 2 to 3 months and may regain flexion against gravity by 6 months. They also obtain powerful elbow flexion.

FIGURE 7. The Oberlin nerve transfer. (A) One or two ulnar nerve fascicles are chosen that stimulate predominantly the wrist (ie, the flexor carpi ulnaris) and not the fingers of the hand. The fascicles are transferred to the biceps and/or brachialis branches (reprinted with permission from the Mayo Foundation). (B) This operative photograph shows the Oberlin transfer being accomplished with a good size match of the two stumps. The ulnar nerve is in encircled by a vessel loop.

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A recent report has shown 30 of 32 patients receiving M4 biceps strength.32 This technique of fascicular transfer has been extended to the use of the median nerve22 or even the ulnar to biceps branch using an end-to-side repair.33 This technique is especially useful in patients who present late. Another innovative example of reconstruction for C5/C6 lesions would be using a branch to the long head of the triceps as a nerve transfer to the axillary nerve. This technique has produced useful functional recovery in the deltoid without demonstrable weakness in elbow extension. When combined with a simultaneous spinal accessory nerve transfer to the suprascapular nerve, shoulder abduction averaged 124° in one series.34

Free Functioning Muscle Transfer Free functioning muscle transfer18 has been used to provide reliable elbow flexion, sometimes coupled with wrist extension.35 It may be used when patients present in a delayed presentation when irreversible muscle atrophy has occurred, or as part of an early reconstructive procedure combined with other nerve transfers or grafting techniques. The contralateral gracilis is attached to the clavicle and is passed subcutaneously to the elbow (Fig. 8) or mid forearm (Fig. 9), where it is secured. Common donor nerves are the spinal accessory nerve or intercostals. Intraplexal sources, including a fascicle of ulnar nerve, have been reported. The arterial donor is the thoracoacromial trunk and venous drainage through the cephalic vein. The goal of elbow flexion is an arc of flexion more than 90° with an approximate 30° extension lag. At our institution, 80% of patients achieved M4 or better elbow flexion when the gracilis was transferred for a single function, and 63% with a dual function. Failures occur from flap loss or poor reinnervation. Double free muscle transfer has been championed by Doi et al36 This technically demanding set of operations has the lofty goals of independent voluntary elbow flexion and extension, finger flexion and extension, and protective sensation in the hand in patients who have sustained avulsions of four or five roots of the brachial plexus. Patients need be treated before 6 months of injury. Stage 1 includes brachial plexus exploration to see if any proximal stumps are available for donor. The contralateral gracilis is transferred to provide elbow flexion/finger extension. The spinal accessory nerve is the neurotizer and the thoracoacromial trunk is used for the arterial repair. Stage 2, performed 4 to 6 weeks later, consists of transferring the ipsilateral free gracilis muscle. The muscle is fixed to the second rib and is secured to the flexor pollicis longus and flexor digitorum profundi (Fig. 10). The anastomosis is to the thoracodorsal vessels. Two intercostals are used to provide motor neurotization of the gracilis and two intercostals, to the

FIGURE 8. Our technique for free functioning muscle transfer for elbow flexion. The contralateral gracilis is attached to the clavicle, passed subcutaneously in the arm, and secured to the biceps. The gracilis vessels are anastomosed to branches from the thoracoacromial trunk and the cephalic vein. The spinal accessory nerve or two intercostals neurotize the muscle. Reprinted with permission from the Mayo Foundation.

long head of triceps. Several sensory intercostals are neurotized to the lateral cord contribution of the median nerve for hand sensibility (Fig. 11). Using this staged technique, reinnervation begins at 3 to 6 months and reaches maximal strength by 18 months. Doi et al36 have shown that double free muscle can provide reliable and useful prehension in patients with complete brachial plexus avulsion. More than half of their patients obtained the ability to position the hand in space (reinnervation of both biceps and triceps) and achieved an arc of more than 30° of motion in the fingers.

Reimplantation Currently, reimplantation of avulsed spinal nerves is being attempted by several groups.37,38 This approach is being attempted following successes in animal models. Nerve reimplantation and grafting into the spinal cord

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surgical treatment had been either above-elbow amputation or elbow flexion by nerve transfer and/or shoulder fusion. In some cases, surgeons would ‘‘peak and shriek’’ when they saw complete avulsions and not perform any procedure. Even in these severe cases, most centers have moved away from amputation and shoulder arthrodesis, favoring nerve reconstruction. Newer techniques for nerve transfer and/or free muscle transfer have refocused our thinking. In cases of complete brachial plexus avulsive injury, despite the limited extraplexal sources (nerve grafting is not an option), useful function can be restored with standard nerve transfers. A popular strategy in this scenario would include spinal accessory to suprascapular nerve, intercostals to biceps, and lateral cord contribution to median nerve for hand sensibility.

FIGURE 9. Our technique for free functioning muscle transfer for a dual function of elbow flexion and wrist extension. The contralateral gracilis is attached to the clavicle, passed subcutaneously in the arm, passed beneath the biceps tendon and the brachioradialis and extensor carpi radialis longus, and secured to the extensor carpi radialis brevis. The vessels and nerves are repaired as in Figure 8. Reprinted with permission from the Mayo Foundation.

has been pioneered by Carlstedt et al39 Early clinical work has shown some ability to regain some clinically useful motor function after implantation techniques. The results with this technique have been less favorable than those that could have been achieved using more standard nerve transfers. Moreover, the interpretation of the results from the 10 patients in this series was controversial. Problematic cocontraction was seen between antagonistic muscles. A modification of Carlstedt’s posterior approach has been put forth by Fournier et al,40 who have advocated a technically challenging anterior approach. Despite the exciting possibilities of reimplantation, this procedure remains experimental at the current time. Clinical Example 1: Approaches to a Patient with a Total Plexus Avulsion. For total plexus avulsion, in the past,

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FIGURE 10. Our technique for free functioning muscle transfer for finger flexion. The ipsilateral gracilis is attached to the second rib, passed subcutaneously, and secured to the flexor pollicis longus and the flexor digitorum profundus. Reprinted with permission from the Mayo Foundation.



FIGURE 11. Our technique for a second-stage Doi procedure. (A) Four intercostals (T3 through T6) are harvested. Two each innervate the long head of triceps and gracilis branch. Sensory intercostals from T3 through T6 are coapted to the lateral cord contribution of the median nerve for sensory neurotization in the hand (reprinted with permission from the Mayo Foundation). (B) Intraoperative photograph demonstrates the harvested sensory and motor intercostal nerves.

Using multiple neurotizations, a strategy could be used to allow grasp function: phrenic to suprascapular nerve, spinal accessory to biceps motor branch (via graft), contralateral C7 to median nerve, and intercostals to radial (triceps). Alternatively, one could substitute a single muscle transfer neurotized by the spinal accessory nerve to provide elbow flexion and wrist dorsiflexion with the other neurotizations, or perform a two-stage Doi procedure. Thus, obtaining grasp function can be approached in a patient with a complete avulsive injury by neurotizing key muscles shortly after injury, use of multiple extraplexal nerves, functioning free muscle transfers, and combinations thereof. Certainly, in a situation in which even a single proximal stump (eg, C5 or C6) were available, additional reconstructive possibilities would exist. Clinical Example 2: Approaches to C5/C6 Avulsive Injury. In a patient with C5 and C6 avulsions, a common approach would be to attempt single neurotization of the shoulder and elbow using spinal accessory nerve transfer to the suprascapular nerve and intercostals or Oberlin’s technique to the biceps branch. We believe that double innervation for shoulder abduction (deltoid and supra spinatus) and elbow flexion (biceps and brachialis) is preferable to single innervation.14 One could combine the previous strategies for single innervation with other available donors (such as those discussed in the intraplexal transfer section) to accomplish this double innervation—for example, triceps branch (our choice) or phrenic (with graft) to axillary, and ulnar or median fascicle to the brachialis muscle.

Postoperative Follow-up and Consideration of Secondary Surgery Patients with brachial plexus lesions must be followed carefully with serial clinical and electrodiagnostic examinations for recovery after operation. Recovery may take years because regeneration is a slow process (1 inch/month). The Tinel sign should advance accordingly. Over time, the distal site should be stronger than the suture line; otherwise, the repair will be unsuccessful. Physical therapy must be continued. Direct muscle stimulation is widely used, but its clinical efficacy is not known. Sensory and motor reeducation can improve functional recovery. Follow-up evaluations should continue, ideally, for at least 2 years in children and as long as 5 years in adults. All patients, whether they have made some recovery spontaneously or after a previous repair, or who have failed a previous procedure, should be considered for secondary surgery. In these cases, soft-tissue (eg, tendon transfer, releases, free muscle) or bony (eg, arthrodesis, osteotomy) procedures may improve function further.

Neuropathic Pain Despite the advances with function, the management of neuropathic pain still remains problematic for patients and physicians (Fig. 12). Severe neuropathic pain is treated well by a multidisciplinary group of physicians specialized in pain management. First one attempts titrating various combinations of pharmacologic agents (eg, antiepileptic drugs, especially) combined with other

FIGURE 12. Neuropathic pain management. (A) Management of neuropathic pain can be humbling. This patient has obtained an excellent result from an Oberlin transfer for elbow flexion. (B) Despite this marked improvement in his motor function, he has a poor outcome as a result of his severe deafferentiating pain from his preganglionic. Note the narcotic patch on his shoulder.

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supportive measures. Surgery may sometimes help neuropathic pain either by nerve surgery (eg, neurolysis, neuroma resection, nerve grafting, nerve transfers) or the process of regeneration. For refractory deafferentiating pain, dorsal root entry zone lesions may be helpful. Spinal cord stimulators and implantable pumps may also have a role in some cases.

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There are obvious problems with data analysis dealing with such a diverse group of patients, lesions, surgeons, treatments, and grading scales, but certain important generalizations can be gleaned. Surgical decision making is benefited by intraoperative electrophysiology. When nerve lesions are in continuity and an NAP can be achieved across a lesion, more than 90% of patients can recover useful function with neurolysis alone. In these conditions, even nerves destined to the hand, that typically do not fare well with nerve grafting or transfers, can demonstrate recovery.11 When an NAP is not recorded across a lesion, or a preganglionic lesion is demonstrated, poor outcomes can be anticipated with neurolysis or grafting respectively. Overall, important function can be restored to patients in many situations either with nerve reconstruction. As the hand surgery pioneer Sterling Bunnell said, ‘‘To those with nothing, even a little is a lot.’’ Graft repairs of C5/C6 do better than C8 and T1, those to the upper trunk do better than those to the lower trunk, and those to the lateral cord do better than those to the medial cord. Comparing results from different nerve transfer can be especially difficult. A recent meta-analysis provides useful summaries:41 Approximately 70% of patients obtain M3 or better and 30% obtain M4 or better for single innervation for shoulder abduction and elbow flexion. For the shoulder, the best results obtained are using the spinal accessory to suprascapular nerve transfer, and reinnervation of the suprascapular nerve does better as a single transfer than the axillary nerve. Dual innervation of the shoulder (axillary and suprascapular nerve) does better than single innervation. Results with nerve transfers for elbow flexion show similar results for spinal accessory nerve transfer or for intercostals without graft, but there is a slightly higher rate of patients with intercostal transfers obtaining M4 function. Results with direct coaptation are better than results with interposed graft for intercostals. During the past few years, results from Oberlin’s transfer for biceps has been superior to other methods, although controlled studies are not available. Certainly other factors are also important, including age (younger patients do better than older) and time from surgery (reconstruction before 6 months is preferable), among other variables.

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Despite the recent advances in operative outcomes, most patients still have significant pain, and many require chronic narcotics. Patients are dissatisfied with their financial situation and only about half these patients return to work.42 An interdisciplinary approach allows the complex problems of patients with brachial plexus lesions to be addressed efficiently. Large multicenter databanks are necessary to answer many of the seemingly simple questions that arise. For example, it is not clear whether nerve grafting or direct nerve transfers provide the best overall results in patients with a C5 + C6 postganglionic lesion.

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FUTURE

Brachial plexus surgery is evolving. Just as major changes have been made in the past several decades, further advances are ahead in the years to come. Today’s research may be tomorrow’s standard of care, both in terms of clinical and basic science. We look to the future for further refinements of existing techniques and new innovations to tackle old problems. Clinical innovations may relate to diagnostic applications of MRI or functional MRI, technical aspects of nerve or free muscle transfers, end-to-side repairs, or spinal reimplantation. Laboratory research needs to continue at several levels: central to the lesion, at the level of the lesion and the repair, distal to it, and at the end organ. Successful strategies may encompass acceleration of axon growth, improvement of regeneration, improvement of the interface at the nerve repair (to prevent scarring), and preservation of motor end plate architecture and function after denervation.

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REFERENCES

1. Carvalho GA, Nikkhah G, Matthies C, et al. Diagnosis of root avulsions intraumatic brachial plexus injuries. Value of computerized tomography, myelography, and magnetic resonance imaging. J Neurosurg. 1997;86:69–76. 2. Hashimoto T, Mitomo M, Hirabuki N, et al. Nerve root avulsion of birth palsy: comparison of myelography with CT myelography and somatosensory evoked potential. Radiology. 1991;178:841–5. 3. Oberle J, Antoniadis G, Rath SA, et al. Radiological investigations and intra operative evoked potentials for the diagnosis of nerve root avulsion: evaluation of both modalities by intradural root inspection. Acta Neurochirurgica. 1998; 140:527–31. 4. Doi K, Otsuka K, Okamoto Y, et al. Cervical nerve root avulsion in brachial plexus injuries: magnetic resonance imaging classification and comparison with myelography and computerized tomography myelography. J Neurosurg. 2002;96(Suppl):277–284.


Brachial Plexus Surgery in Adults 5. Hashimoto T, Mitomo M, Hirabuki N, et al. Myelography for nerve root avulsion in birth palsy. [Japanese]. Nippon Igaku Hoshasen Gakkai Zasshi - Nippon Acta Radiologica. 1990;50:367–74. 6. Walker AT, Chaloupka JC, de Lotbiniere AC, et al. Detection of nerve rootlet avulsion on CT myelography in patients with birth palsy and brachial plexus injury after trauma. American Journal of Roentgenology. 1996;167: 1283–7. 7. Nakamura T, Yabe Y, Horiuchi Y, et al. Magnetic resonance myelography in brachial plexus injury. J Bone Joint Surg Br. 1997;79:764–9. 8. Francel PC, Koby M, Park TS, et al. Fast spin-echo magnetic resonance imaging for radiological assessment of neonatal brachial plexus injury. Journal of Neurosurgery. 1995; 83:461–6.

19. Samii M, Carvalho GA, Nikkhah G, et al. Surgical reconstruction of the musculocutaneous nerve in traumatic brachial plexus injuries. J Neurosurg. 1997;87:881–886. 20. Sungpet A, Suphachatwong C, Kawinwonggowit V: Onefascicle median nerve transfer to biceps muscle in C5 and C6 root avulsions of brachial plexus injury. Microsurgery. 2003;23:10–13. 21. Gu YD, Zhang GM, Chen DS, et al. Seventh cervical nerve transfer from the contralateral healthy side for treatment of brachial plexus root avulsion. J Hand Surg [Br]. 1992;17(B):518–521. 22. Songcharoen P, Wongtrakul S, Mahaisavariya B, et al. Hemi-contralateral C7 transfer to median nerve in the treatment of root avulsion brachial plexus injury. J Hand Surg [Am]. 2001;26(A):1058–1064.

9. Gupta RK, Mehta VS, Banerji AK, et al. MR evaluation of brachial plexus injuries. Neuroradiology. 1989;31:377–81.

23. Xu W-D, Gu Y-D, Xu J-G, et al. Full-length phrenic nerve transfer by means of video-assisted thoracic surgery in treating brachial plexus avulsion injury. Plast Reconstr Surg. 2003;110:104–111.

10. Rapoport S, Blair DN, McCarthy SM, T et al. Brachial plexus: correlation of MR imaging with CT and pathologic findings. Radiology. 1988;167:161–5.

24. Gu YD. Cervical nerve root transfer from the healthy side in the treatment of brachial plexus root avulsion. Zhonghua Yi Xue Za Zhi. 1989;69:563–565, 538.

11. Kline DG, Hudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments, and Tumors. Philadelphia: WB Saunders; 1995.

25. Chuang DC, Wei FC, Noordhoff MS: Cross-chest C7 nerve grafting followed by free muscle transplantations for the treatment of total avulsed brachial plexus injuries: a preliminary report. Plast Reconstr Surg. 1993;92:717–727.

12. Burkholder LM, Houlden DA, Midha R, et al. Neurogenic motor evoked potentials: role in brachial plexus surgery. J Neurosurg. 2003;98:607–610.1 13. Turkof E, Millesi H, Turkof R: Intraoperative electroneurodiagnostics (transcranial electrical motor evoked potentials) to evaluate the functional status of anterior spinal roots and spinal nerves during brachial plexus surgery. Plast Reconstr Surg. 1997;99:1632–1641. 14. Malessy MJA, van Duinen SG, Feirabend HKP, et al. Correlation between histopathological findings in C-5 and C-6 stumps and motor recovery following nerve grafting for repair of brachial plexus injury. J Neurosurg. 1999;91:636– 644. 15. Hattori Y, Doi K, Fukushima S, et al. The diagnostic value of intraoperative measurement of choline acetyltransferase activity during brachial plexus surgery. J Hand Surg [Br]. 2000;25(B):509–511.

26. Gu YD, Zhang GM, Chen DS, et al. Cervical nerve root transfer from contralateral normal side for treatment of brachial plexus root avulsions. Chin Med J (Engl). 1991;104:208–211. 27. Gu YD, Chen DS, Zhang GM, et al. Long-term functional results of contralateral C7 transfer. J Reconstr Microsurg. 1998;14:57–59. 28. Malessy MJA, Hoffman CFE, Thomeer RTWM. Initial report on the limited value of hypoglossal nerve transfer to treat brachial plexus avulsions. J Neurosurg. 1999;91:601–604. 29. Ferraresi S, Garozzo D, Ravenni R, et al. Hemihypoglossal nerve transfer in brachial plexus repair: technique and results. Neurosurgery. 2002;50:332–335. 30. Gu YD, Cai PQ, Xu F, et al. Clinical application of ipsilateral C7 nerve root transfer for treatment of C5 and C6 avulsion of brachial plexus. Microsurgery. 2003;23:105–108.

16. Chuang DC: Functioning free muscle transplantation for brachial plexus injury. Clin Orthop. 1995;314:104–111.

31. Oberlin C, Beal D, Leechavengvongs S, et al. Nerve transfer to biceps muscle using part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg [Am]. 1994;19(A):232–237.

17. Songcharoen P, Mahaisavariya B, Chotigavanich C: Spinal accessory neurotization for restoration of elbow flexion in avulsion injuries of the brachial plexus. J Hand Surg [Am]. 1996;21(A):387–390.

32. Leechavengvongs S, Witoonchart K, Uerpairojkit C, et al. Nerve transfer to biceps muscle using a part of the ulnar nerve in brachial plexus injury (upper arm type): a report of 32 cases. J Hand Surg [Am]. 1998;23(A):711–716.

18. Chuang DC, Lee GW, Hashem F, et al. Restoration of shoulder abduction by nerve transfer in avulsed brachial plexus injury: evaluation of 99 patients with various nerve transfers. Plast Reconstr Surg. 1995;96:122–128.

33. Franciosi LF, Modestti C, Mueller SF. Neurotization of the biceps muscle by end-to-side neurorrhaphy between ulnar and musculocutaneous nerves. A series of five cases. Chir Main. 1998;17:362–367.

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Spinner et al 34. Leechavengvongs S, Witoonchart K, Uerpairojkit C, et al. Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases. J Hand Surg [Am]. 2003;28(A):633–638. Seven patients were treated with a long head of the triceps branch to deltoid muscle in this series. All patients recovered deltoid power against resistance (M4) at the last follow-up evaluation. Useful functional recovery was achieved in all seven patients; five had excellent recoveries and two had good results. The average shoulder abduction was 124°. No notable weakness of elbow extension was observed.

der and elbow movements. Neurosurgery. 2003;52:1385– 1390. 38. Fournier HD, Mercier P, Menei P. Lateral interscalenic multilevel oblique corpectomies to repair ventral root avulsions after brachial plexus injury in humans: anatomical study and first clinical experience. J Neurosurg. 2001;95:202– 207. 39. Carlstedt T, Anand P, Hallin R, et al. Spinal nerve repair and reimplantation of avulsed ventral roots into the spinal cord after brachial plexus injury. J Neurosurg. 2000;93:237–247.

35. Akasaka Y, Hara T, Takahashi M. Restoration of elbow flexion and wrist extension in brachial plexus paralyses by means of free muscle transplantation innervated by intercostal nerve. Ann Chir Main Mem Sup. 1990;9:341–350.

40. Fournier HD, Menei P, Khalifa R, et al. Ideal intraspinal implantation site for the repair of ventral root avulsion after brachial plexus injury in humans. A preliminary anatomical study. Surg Radiol Anat. 2001;23:191–5.

36. Doi K, Muramatsu K, Hattori Y. Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results. J Bone Joint Surg Am. 2000;82(A):652–666.

41. Merrell GA, Barrie KA, Katz DL, et al. Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a meta-analysis of the English literature. J Hand Surg [Am]. 2001;26(A):303–314.

37. Bertelli JA, Ghizoni MF. Brachial plexus avulsion injury repairs with nerve transfers and nerve grafts directly implanted into the spinal cord yield partial recovery of shoul-

42. Choi PD, Novak CB, Mackinnon SE, et al. Quality of life and functional out come following brachial plexus injury. J Hand Surg [Am]. 1997;22(A):605–612.

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T E C H N I Q U E

Sauve´-Kapandji Procedure Robert R. Slater, Jr., MD, FACS Associate Clinical Professor Department of Orthopaedic Surgery University of California Davis, Davis, California, USA

he Sauve´-Kapandji procedure is a method of treating a variety of pathologic conditions that alter normal function of the distal radioulnar joint. An arthrodesis is performed between the ulnar head and sigmoid fossa of the distal radius along with creation of a soft tissue interposition pseudarthrosis just proximal to the fusion site that preserves forearm rotation. This article summarizes the history of the procedure, the current preferred method for performing the procedure to achieve optimum results, and the latest literature on the distal radioulnar joint relevant to the procedure.

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HISTORICAL OVERVIEW

Distal radioulnar joint (DRUJ) disorders are a frequent cause of wrist pain and instability.1–5 The causes of symptoms referable to this joint include displaced fractures or malunions of the distal radius, which lead to pain with forearm rotation,3,5 and tears of the triangular fibrocartilage complex, resulting in DRUJ instability and mechanical symptoms such as clicking and catching.6,7 Congenital anomalies, Madelung’s deformity of the distal radius, and inflammatory arthropathies may lead to secondary incongruity of the DRUJ, which in turn may cause pain and loss of forearm pronation and supination.8,9 Resection of the radial head with subsequent alterations in forearm mechanics, or injury of the interosseous membrane and ligament complex as in a true Essex-Lopresti lesion,10 also can result in painful incongruity or instability of the DRUJ.11 Management of the problems affecting the DRUJ can be challenging. One option for treating those challenging problems is the subject of this article, the operation now commonly referred to as the Sauve´-Kapandji procedure (Figs. 1, 2). In the past, there had been confusion about the origins of and correct eponym to assign to a specific Correspondence to Robert R. Slater, Jr., MD, FACS, Department of Orthopaedic Surgery, Permanente Medical Group, 1600 Eureka Road, Roseville, CA 95661, USA. E-mail: [email protected]. This article was originally published in Current Opinion in Orthopaedics. It is reprinted here as a service to our readers. Slater Jr. Robert R. Sauve´-Kapandji procedure. Curr Opin Orthop 2003;14:2153–221.

procedure designed to treat DRUJ pathology, and disagreement about which authors should be credited with its inception. In 1936, Sauve and Kapandji12 published an account of their preferred method for treating disorders of the DRUJ. It appeared in Journal de Chirurgie and was published in French. Nevertheless, for many years, the literature published in English on the described procedure attributed it to Lauenstein. In part that was because of confusion perpetuated by the most popular orthopaedic textbooks of the mid-1900s. The textbook by Steindler,13 for example, first published in 1940, mentions a method for surgically treating irreducible DRUJ dislocations: The lower end of the ulna is ankylosed to the radius. Then approximately one-half inch higher up a half-inch is taken out of the shaft of the ulna above the capitulum; thereby a new joint is formed in which pro-and supinatory motion takes place. In this passage, Messer and Lauenstein are credited with developing the procedure, but no original reference is cited. A clue to the source of the confusion comes from reading the original texts. Professor Carl Lauenstein was a German surgeon who had many publications listed in the Index Medicus in the late 19th century, but for a while it was believed that most of his publications were about procedures now considered in the domain of general surgeons, and that he did not publish material about the wrist or the DRUJ specifically. A more recent search of the literature14 revealed that Lauenstein15 did in fact describe a method to treat DRUJ pathology in which the radius and ulna could be stabilized distally and a segment of distal ulna resected more proximally. This brief report was published in 1887. The procedure was not identical to that described later by Kapandji and Sauve but is the reason Lauenstein deserves some credit for bringing surgical options for the DRUJ to the attention of the medical profession. In 1921, Baldwin16 described another procedure designed to restore forearm rotation after spontaneous ankylosis of the DRUJ occurred. He suggested that a 1-cm

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FIGURE 1. Sauve´-Kapandji procedure for Madelung’s deformity. A 38-yearold female engineer sought treatment for painful instability of the distal radioulnar joint and deformity in her dominant wrist attributable to her Madelung’s deformity, evident in her preoperative radiographs (A, B). Symptoms had intensified over several years, and nonoperative management was exhausted, so she elected to proceed with the recommended Sauve´-Kapandji procedure. Thirteen months after surgery, she was pain-free, had returned to her regular gym workouts, and could perform heavy yardwork with minimal discomfort. Compared with her contralateral extremity, her wrist range of motion was 91%, forearm rotation was identical, and grip strength was 4% stronger. Recent radiographs show a solid arthrodesis and illustrate the buttress achieved for the ulnar side of the wrist with this procedure (C, D).

segment of the distal ulna could be removed proximal to the DRUJ to allow free pronation and supination without disrupting the already stable ankylosis. McMurray17 mentioned the procedure in his textbook published in 1949 and attributed it to Baldwin but did not cite the original reference. Authors of later publications also credited Baldwin with developing this treatment method.18–20 Despite the confusion about nomenclature in previous reports, the operation referred to in this review is now known as the Sauve´-Kapandji procedure. As is often the case in the world of medical literature, these authors are credited not because they were the first to describe it but because they described it more clearly than it had been described before and because their article has been referenced more often in subsequent reports about the operation. The eponym is now well entrenched in the literature and deserves to remain firmly attached to the procedure.

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Over the years, the techniques used to achieve fusion of the DRUJ while ensuring proper forearm rotation have changed, and they continue to evolve. In their original article, Sauve and Kapandji12 described resecting a 3-cm segment of distal ulna just proximal to the DRUJ followed by decortication of the opposing joint surfaces and fixation with a single screw. They recommended

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interposition of the pronator quadratus into the gap left after resecting a segment of ulna to prevent reossification across that defect. Other authors5,21 have followed suit and advocated the use of a single screw across the arthrodesis site, although a single screw does not provide rotational control of the distal ulnar segment. Adalbert I. Kapandji,22 son of the author who promoted the technique before him, described a slight modification of the original method, using two screws in the distal ulnar section and resecting as much as 2 cm of ulnar shaft proximal to the arthrodesis site. Taleisnik19 promoted the use of two Kirschner wires instead of bulkier screws, and described resecting the ulna much further distal than Kapandji did. Rothwell et al23 favored a simplification of the procedure by placing a single screw across the DRUJ without even exposing or decorticating the joint surfaces. That approach has not gained popularity. The essence of the procedure remains the same as in the earliest descriptions. As with most hand surgery procedures, however, the devil is in the details, and the current technique takes advantage of implant improvements unavailable to the original authors. The essential steps in the procedure as currently recommended are as follows. Make a longitudinal incision along the ulnar border of the distal forearm. If additional procedures are anticipated on the dorsum of the wrist, such as a tenosynovectomy for patients with rheumatoid arthritis, the incision


Sauve´-Kapandji Procedure

FIGURE 2. Sauve´-Kapandji procedure for posttraumatic instability. A 28-yearold film producer had sustained four previous fractures involving her dominant upper wrist between the ages of 10 and 23 years. One injury had been treated with attempted pinning of the distal radioulnar joint. After a snowboarding accident that injured the same wrist, she sought treatment for painful, recurrent instability of the distal radioulnar joint and a reproducible clunk as the joint was stressed during physical examination. Preoperative radiographs (A, B) showed degenerative changes at the sigmoid fossa of the radius and a stable, fibrous nonunion of the ulnar styloid. She elected to proceed with the recommended Sauve´-Kapandji procedure. Eighteen months after surgery, she was pain-free; compared with her contralateral extremity, her wrist range of motion was 98%, forearm rotation was 90%, and grip strength was 74%. She returned happily to her usual level of athletic endeavors. Her final radiographs show reconstitution of correct ulnar variance and a solid arthrodesis (C, D).

may be curved further dorsally and distally. Expose the distal ulna in the interval between the extensor carpi ulnaris and flexor carpi ulnaris tendons. Resect a 10-mm to 14-mm segment of ulnar shaft just proximal to the ulnar head, leaving enough bone distally to accommodate two cannulated screws. Then expose the DRUJ. Usually that can be done through a dorsal capsulotomy adjacent to the extensor carpi ulnaris; an alternative is to rotate the ulnar head out of the way medially, hinging it on its soft tissue sleeve. Next, decorticate the opposing joint surfaces of the DRUJ—that is, the sigmoid fossa of the radius and the ulnar head—and then position the ulnar head at the correct level within the sigmoid fossa. Intraoperative fluoroscopy is very helpful for the positioning and subsequent steps. Once the bony alignment is correct, drill two guidewires from an appropriately sized cannulated screw set through the ulnar head, across the arthrodesis site, and across the radius. After measuring correct screw lengths, drill or tap the guidewires out through the skin on the radial side of the forearm, where they can be grasped with a hemostat, ensuring that their position is not lost during subsequent steps. Pass a cannulated drill bit over the guidewires next, and then insert the properly measured cannulated screws. Ideally, the distal screw should capture four cortices: both sides of the ulnar head and both

sides of the radius. The proximal screw is primarily intended to prevent rotation; therefore, it may have a smaller diameter to fit within the narrower shaft of the ulna, and it need capture only three cortices. Before final screw tightening, a bit of bone graft may be placed at the proposed arthrodesis site, harvested from the cancellous bone in the previously resected cylinder of ulna. Next, it is important to confirm that the gap in the ulnar shaft is 10 to 12 mm after final seating of the ulnar head. If necessary, remove a wafer of bone from the proximal side of the gap with an oscillating saw to obtain proper spacing. Finally, suture the fascia of the underlying pronator quadratus into the gap and over the end of the ulnar shaft to stabilize the stump and prevent reossification across the gap. Repair the remaining soft tissues and close the skin in routine fashion. Postoperatively, apply splints extending above the elbow to keep the wrist and forearm in neutral rotation until the sutures are removed at 10 to 14 days. Thereafter, patients should be instructed to wear a removable wrist brace at all times except for thrice-daily exercise sessions designed to gradually restore forearm rotation and wrist and digit range of motion. Usually, light strengthening exercises can be started 8 weeks postoperatively, but heavy lifting and forceful forearm torque should be avoided for 3 months after surgery.

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NEW INFORMATION ABOUT THE DISTAL RADIOULNAR JOINT: RELEVANCE FOR THE ´ -KAPANDJI PROCEDURE SAUVE

Although little new information has been presented in the literature in the past 2 years about the Sauve´-Kapandji procedure itself, investigators have contributed to understanding of the biomechanics and basic science of the DRUJ, its radiographic evaluation, and the pros and cons of treatment methods other than arthrodesis of the joint. Many lessons learned from those publications can be applied to the Sauve´-Kapandji procedure to optimize its effectiveness. In a cadaver model, Gupta et al24 aimed to quantify the relative contribution of each component of the triangular fibrocartilage complex to DRUJ stability. Using an elaborate experimental set-up, the authors recorded translation of the distal radius relative to the ulna before and after sectioning various soft tissue constraints on the ulnar side of the cadaver wrists. The authors concluded that the ulnocarpal ligaments contributed little to overall DRUJ stability, and conversely, that the extensor carpi ulnaris tendon sheath and the triangular fibrocartilage disc were critically important to joint stability. Gupta et al24 tested their specimens in one position only and did not apply any load to the pronator quadra-tus, which has been shown25 to be an important dynamic stabilizer of the DRUJ. Furthermore, the carpus was pinned together as a single unit, which may have eliminated the authors’ ability to detect more subtle but important effects of the individual ulnocarpal ligaments. Nevertheless, the data presented in their report lend further support to the concept that the ulnar side of the wrist and the soft tissues based at the ulnar styloid and fovea are important for overall stability and function. Therefore, preserving those soft tissues when performing procedures on the DRUJ is essential. The Sauve´Kapandji procedure allows one to keep those structures intact while still addressing derangements of the DRUJ and providing a bony buttress to the ulnar corner of the wrist. That is an important distinction between the Sauve´-Kapandji procedure and a simple resection of the distal ulna. Haugstvedt et al26 tested the function of another set of ulnar-based soft tissue constraints of the DRUJ. The authors’ primary goal was to investigate the relative importance of the attachment sites of the dorsal and palmar radioulnar ligaments. Those ligaments have attachments at the fovea of the distal ulna and at the ulnar styloid. In a cadaver model, Haugstvedt et al26 showed that both sites are equally important for DRUJ stability. Although not the purpose of their study, the data presented explain why it may be important to preserve as much of the ulnar

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head as possible when treating DRUJ derangements. Resection of all or part of the ulnar head could result in resection of the foveal attachments of the radioulnar ligaments with subsequent instability. If the DRUJ anatomy cannot be restored to normal and a salvage procedure is indicated, then the Sauve´-Kapandji procedure—which leaves the whole ulnar head and soft tissue sleeve intact—may be better than resecting all (Darrach) or some (hemiresection)27,28 of the ulnar head and destabilizing that soft tissue complex. In a tangentially related study, Moore et al29 evaluated the kinematics of the DRUJ in vivo in a group of nine patients who had malunions of the distal radius. Using their described surface-rendering procedure, the investigators were able to generate three-dimensional images of subjects’ DRUJs and then, through an elegant sequence of mathematical manipulations, display the location of the axes of forearm rotation in injured versus contralateral uninjured wrists. Much to their own surprise and that of their readers, Moore et al29 found very little difference in the center of rotational axis between injured and uninjured wrists. The authors pointed out that despite the bony malunions, the motion of the injured radii were normal, but speculated that the soft tissue stabilizers and joint contact areas were very likely not normal and a source of potential pain in symptomatic patients. Further, Moore et al29 suggested that procedures designed to correct the bony anatomy of the DRUJ may benefit patients with residual pain. In some settings, arthrodesis of the DRUJ while preserving the remaining soft tissue stabilizers, ie, the Sauve´-Kapandji procedure, may offer the best option for achieving that goal. To facilitate decision-making about pathology involving the DRUJ and the ulnar styloid, proper imaging is essential. Yanagida et al30 used cadaver upper extremities to simulate patient positioning and determine the best way to obtain radiographs of the ulnar styloid and the fovea. The authors concluded the optimum position is with the glenohumeral joint abducted 45° while the elbow is flexed 90° and the forearm is kept in neutral rotation and the x-ray beam is directed through the wrist, perpendicular to the floor. In a related study, May et al31 found that radiographic criteria of ulnar styloid fractures correlated with DRUJ instability. The authors retrospectively reviewed 166 distal radius fractures treated at their institution that met their initial inclusion criteria. Of those, 130 fractures in 126 patients had adequate data for review of both radiographic and clinical parameters of DRUJ instability. As Hauck et al32 found before them, May et al31 found a statistically significant correlation between DRUJ instability and size and displacement of ulnar styloid fractures. Seventy-one (55%) of all distal radius fractures had an ulnar styloid fracture; although only 14 (11%) of all


Sauve´-Kapandji Procedure

distal radius fractures had DRUJ instability, each one of those had an associated ulnar styloid fracture. That means that the mere presence of an ulnar styloid fracture does not imply DRUJ instability, but if such a fracture is present, it should heighten one’s suspicion for joint instability. Finally, May et al31 stated that one of their patients with chronic DRUJ instability required additional surgery, and the Sauve´-Kapandji procedure was performed. Despite its limitations, the report by May et al31 does highlight the importance of addressing the DRUJ when assessing fractures of the distal radius, a point echoed by many authors. As an aside, the article also illustrates the value of the Sauve´-Kapandji procedure for treating chronic instability of the DRUJ resulting from radius fractures complicated by injury to that joint. Optimum treatment for DRUJ derangement remains controversial. Previously, Lamey and Fernandez33 showed the value of the Sauve´-Kapandji procedure for treatment of posttraumatic derangement of the DRUJ. The investigators added one additional step to the standard Sauve´Kapandji procedure: a distally based slip of flexor carpi ulnaris was passed through a drill hole in the proximal ulnar segment to add stability to the ulnar stump. In a series of 18 patients, Lamey and Fernandez33 reported six excellent, seven good, four fair, and one poor result. More recently, Adams and Berger34 described a new, intricate tendon weave procedure designed to reconstruct both the dorsal and palmar distal radioulnar ligaments. Through a series of drill holes, a free tendon graft— usually the palmaris longus—can be passed through the ulnar corner of the radius and around and through the ulnar head and neck to cinch up the DRUJ and restore joint stability. The authors described their procedure and reported the results in a series of 14 patients followed up for 1 to 4 years. The surgeons evaluated their own patients and concluded that 12 had improvement in symptoms and two were unchanged. Mean pronation and supination were 84% and 80%, respectively, and grip strength was 85% of the subjects’ opposite upper extremities. There were two recurrences of DRUJ instability, both within 1 year. That report by Adams and Berger34 highlights the importance of reconstructing both the dorsal and palmar distal radioulnar ligaments if one is to attempt restoring stability to the DRUJ in cases in which the triangular fibrocartilage complex is damaged beyond repair. Furthermore, the authors caution that soft tissue procedures, including their own, should not be performed if the DRUJ surfaces are arthritic. In those cases, a different method of reconstruction is indicated, and the Sauve´-Kapandji procedure is an excellent option. Within the past year, other groups of investigators35–37 have espoused the benefits of prosthetic ulnar head implants to replace arthritic or absent ulnar heads or even

the whole distal ulna, and thus attempt to restore DRUJ stability. To date, neither of the commercially available ulnar head prostheses has seen widespread use except by their developers. Until those or different prostheses are proven effective or new procedures are developed, the Sauve´-Kapandji procedure remains the gold standard against which all other methods of restoring stability and function to the DRUJ must be compared.

n

COMPLICATIONS

Complications with the Sauve´-Kapandji procedure are rare. Reossification of the intended pseudarthrosis site may occur,14 necessitating re-excision. Painful instability of the distal ulnar shaft proximal to the pseudarthrosis site can be avoided by proper soft tissue handling at the time of surgery, including imbrication of part of the pronator quadratus over the resected end of the ulnar shaft. If it does occur, ulnar shaft instability may be treated by one of a variety of soft tissue procedures described previously for treating ulnae that are unstable after distal ulna resection (Darrach procedure).33,38

n

CONCLUSIONS

In summary, the Sauve´-Kapandji procedure remains a valuable option for addressing pathologic conditions that affect the DRUJ. It affords bony stability for the carpus and a good buttress for the ulnar corner of the wrist while allowing preservation of the key ulnarly based soft tissues. The Sauve´-Kapandji procedure has a long, proven track record with predictable results, and it is a good tool for the surgeon to consider when faced with difficult problems involving the DRUJ.

n

REFERENCES

1. Drewniany JJ, Palmer AK. Injuries to the distal radioulnar joint. Orthop Clin North Am. 1986;17:451–459. 2. Goncalves D. Correction of disorders of the distal radio-ulnar joint by artificial pseudarthrosis of the ulna. J Bone Joint Surg Br. 1974;56:462–464. 3. Aulicino PL, Siegel J. Acute injuries of the distal radioulnar joint. Hand Clin. 1991;7:283–294. 4. Slater RR, Szabo RM. Disorders of the distal radioulnar joint. Semin Arthrop. 1997;8:156–171. 5. Zachee B, DeSmet L, Roosen P, et al. The Sauve´-Kapandji procedure for nonrheumatic disorders of the distal radioulnar joint. Acta Orthop Belg. 1994;60:225–230. 6. Friedman SL, Palmer AK. The ulnar impaction syndrome. Hand Clin. 1991;7:295–310. 7. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg [Am]. 1989;14:594–606.

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Slater 8. Fagg P. Wrist pain in the Madelung’s deformity of dyschondrosteosis. J Hand Surg [Br]. 1988;13:11–15.

ments of the distal radioulnar ligaments. Both are equally important for joint stability.

9. White G, Weiland A. A Madelung’s deformity: treatment by osteotomy of the radius and Lauenstein procedure. J Hand Surg [Am]. 1987;12:202–204.

27. Watson HK, Ryu J, Burgess RC. Matched distal ulna resection. J Hand Surg [Am]. 1986;11:812–817.

10. Essex-Lopresti P. Fractures of the radial head with distal radio-ulnar dislocation. J Hand Surg [Br]. 1951;33:244– 247. 11. Mikic Z, Vukadinovic S. Late results in fractures of the radial head treated by excision. Clin Orthop. 1983;181:220–228. 12. Sauve L, Kapandji M. Nouvell technique de traitment chirurgical des luxations recidivantes isolees de l’extremite inferieure du cubitus. J Chirurg. 1936;47:589–594. 13. Steindler A. Orthopaedic Operations. Baltimore, MD: Williams & Wilkins Co.; 1940. 14. Slater RR, Szabo RM. The Sauve´-Kapandji procedure. Tech Hand Up Ext Surg. 1998;2:148–157. 15. Lauenstein C. Zur Behandlung der nach karpaler Vorderarmfraktur zuruck-bleibenden Storung der Pro- und Supinationsbewegung. Centalbl Chirurg. 1887;23:433–435. 16. Baldwin WI. Orthopedic Surgery of Injuries. London: Henry Frowde and Hodder and Stoughton; 1921. 17. McMurray TP. A Practice of Orthopaedic Surgery, edn 3. London: Edward Arnold & Co.; 1949. 18. Kersley JB. Baldwin’s operation for malunited Colles’ fracture. J Bone Joint Surg Br. 1978;60:136. 19. Taleisnik J. The Wrist. New York: Churchill Livingstone; 1985. 20. Thomas TL. Habitual anterior subluxation of the head of the ulna treated by Baldwin’s operation: a case report. Hand. 1982;14:67. 21. Mikkelsen SS, Lindblad BE, Sommer J. Sauve´-Kapandji operation for disorders of the distal radioulnar joint. Contemp Orthop. 1993;26:151–155. 22. Kapandji IA. The Kapandji-Sauve´ operation: its techniques and indications in non-rheumatoid diseases. Ann Chirurg Main. 1986;5:181–193. 23. Rothwell AG, O’Neill L, Cragg K. A Sauve´-Kapandji procedure for disorders of the distal radioulnar joint: a simplified technique. J Hand Surg [Am]. 1996;21:771–777. 24. Gupta R, Allaire RB, Fornalski S, et al. Kinematic analysis of the distal radioulnar joint after a simulated progressive ulnar-sided wrist injury. J Hand Surg [Am]. 2002;27:854– 862. 25. Kihara H, Short WH, Werner FW, et al. The stabilizing mechanism of the distal radioulnar joint during pronation and supination. J Hand Surg [Am]. 1995;20:930–936. 26. Haugstvedt J, Berger RA, Berglund LJ, et al. An analysis of the constraint properties of the distal radioulnar ligament attachments to the ulna. J Hand Surg [Am]. 2002;27:61– 67. An interesting biomechanical study in cadavers comparing the differences between foveal and styloid attach-

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28. Bowers WH. Distal radioulnarjointarthroplasty: the hemirection-interposition technique. J Hand Surg [Am]. 1985; 10:169–178. 29. Moore DC, Hogan KA, Crisco JJ, et al. Three-dimensional in vivo kinematics of the distal radioulnar joint in malunited distal radius fractures. J Hand Surg [Am]. 2002;27:233– 242. A study of patients with radius malunions, not all of whom were symptomatic, using sophisticated mathematical modeling and surface-rendering imaging techniques. Surprisingly, the authors found little difference in the center of rotational axes between injured and uninjured wrists; therefore, soft tissue injuries may be more problematic than bony morphology after distal radius fractures. 30. Yanagida H, Ishii S, Short WH, et al. Radiologic evaluation of the ulnar styloid. J Hand Surg [Am]. 2002;27:49–56. 31. May MM, Lawton JN, Blazar PE. Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability. J Hand Surg [Am]. 2002;27:965–971. 32. Hauck RM, Skahen J, Palmer AK. Classification and treatment of ulnar styloid nonunion. J Hand Surg [Am]. 1996; 21:418–425. 33. Lamey D, Fernandez DL. Results of the modified Sauve´Kapandji procedure in the treatment of chronic posttraumatic derangement of the distal radioulnar joint. J Bone Joint Surg Am. 1998;80:1758–1769. 34. Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg [Am]. 2002;27:243–251. This article describes an alternative soft tissue reconstruction designed to treat DRUJ instability when joint surfaces are normal. Preliminary results in a series of 14 subjects followed for 1 to 4 years are encouraging in this carefully selected patient group. 35. Gordon KD, Roth SE, Dunning CE, et al. An anthropometric study of the distal ulna: implications for implant design. J Hand Surg [Am]. 2002;27:57–60. 36. Masaoka S, Longsworth SH, Werner FW, et al. Biomechanical analysis of two ulnar head prostheses. J Hand Surg [Am]. 2002;27:845–853. The investigators used five cadaver specimens to test the stability of two different prostheses designed to replace the ulnar head. Both prostheses allowed significantly less forearm rotation than did an intact DRUJ. The search continues for better DRUJ reconstruction options. 37. Sauerbier M, Hahn ME, Fujita M, et al. Analysis of dynamic distal radioulnar convergence after ulnar head resection and endoprosthesis implantation. J Hand Surg [Am]. 2002;27:425–434. 38. Kleinman WB, Greenberg JA. Salvage of the failed Darrach procedure. J Hand Surg [Am]. 1995;20:951–958.


Volume 9(4)

December 2005

(C) 2005 Lippincott Williams & Wilkins, Inc.

ISSN: 1089-3393

Viewing 1-10 of 10 Results pg. 177

01 Another Goal Achieved Plus Some Thoughts on Globalization. Doyle, James R MD [EDITORIAL] pg. 178-187

02 A Review of Common Practice in Dupuytren Surgery. Au-Yong, Iain T. H BM, BCh (Oxon), MA (Cantab), MRCS (Ed) 1; Wildin, Clare J FRCS Orth and Tr 2; Dias, Joseph J MBBS, MD, FRCS (Ed), FRCS (Eng) 2; Page, Robert E MBChB (Hons), FRCS, ChM 3 [SHORT REVIEW] pg. 188-194

03 Simultaneous Radial Closing Wedge and Ulnar Shortening Osteotomy for Distal Radius Malunion. Wada, Takuro MD; Tsuji, Hideki MD; Iba, Kosuke MD; Aoki, Mitsuhiro MD; Yamashita, Toshihiko MD [TECHNIQUE] pg. 195-201

04 Distal Radius Fracture Fixation with an Intramedullary Nail. Tan, Virak MD 1; Capo, John MD 1; Warburton, Mark MD 2 [TECHNIQUE] pg. 202-206

05 Cannulated Variable Pitch Compression Screw Fixation of Scaphoid Fractures Using a Limited Dorsal Approach. Martus, Jeffrey E MD 1; Bedi, Asheesh MD 2; Jebson, Peter J. L MD 3 [TECHNIQUE] pg. 207-210

06 A Cosmetic Technique for Performing Basal Joint Arthroplasty. Rowland, Spencer A MD, MS, FACS [TECHNIQUE] pg. 211-214

07 Optimization of Flexor Tenolysis Using a Suture. Dubert, Thierry MD 1; Favalli, Paulo MD 2 [TECHNIQUE]

pg. 215-219

08 Fractures of the Ulnar Shaft: Current Treatment Methods. Rozental, Tamara D; Blazar, Philip E [TECHNIQUE] pg. 220-232

09 Update on Brachial Plexus Surgery in Adults. Spinner, Robert J; Shin, Alexander Y; Bishop, Allen T [TECHNIQUE] pg. 233-238

10 Sauve-Kapandji Procedure. Slater, Robert R Jr. MD, FACS [TECHNIQUE]

Techniques in Hand & Upper Extremity Surgery

Techniques in Hand & Upper Extremity Surgery

Techniques in Hand & Upper Extremity Surgery