Floor plan - 2013 Annual Meeting - American Association for Hand ...

Repair of Distal Radial Malunions with Intramedullary Fixation
Institution where the work was prepared: UMDNJ- NJ Medical School, Newark, NJ, USA
John Capo; Damon Ng, MD; Tosca Kinchelow, MD; Virak Tan, MD; UMDNJ- NJ Medical School
PURPOSE:
To evaluate the effectiveness of using an intramedullary implant combined with osteotomy and grafting for treatment of distal radial malunions.
METHODS:
Eleven patients with healed distal radial malunions had surgical correction of their wrist deformities at an average of 7.6 months after
the date of the original fracture. They were all treated with osteotomy, grafting, and fixation with an intramedullary implant. The implant
is available in varying sizes, contains three fixed angle screws distally and two locking bolts proximally. Bone graft was taken from the
iliac crest in six patients, locally from the distal radius callous in four patients, and was an injectable calcium-sulfate paste in one. There
were ten dorsal malunions and one volar malunion. Radiographic exam before the osteotomy revealed an average radial inclination of
20 degrees and an ulnar length of + 3.5mm. The volar tilt for the dorsal malunions averaged -13.1 degrees (apex volar), while the volar
malunion measured +28 degrees (apex dorsal). Post-procedure the patients were immobilized with a short arm cast or splint for an average
of 4 weeks and then range-of-motion exercises were begun.
RESULTS:
All eleven of the patients healed their osteotomies at an average time period of 7.8 weeks following surgery. Physical exam, at an average
follow-up of 6.1 months, showed wrist flexion of 46 degrees, extension of 59 degrees, forearm supination of 75 degrees, and pronation
of 80 degrees. Radiographs post-procedure showed a correction of alignment to the following average values: volar tilt of 2.2
degrees, radial inclination of 22.6 degrees and an ulnar length of 0.4 mm ulnar positive. There were no cases of nerve injury or tendon
irritation, and grip strength averaged 67 % of the contralateral side.
CONCLUSION:
Treatment of distal radial malunions with an intramedullary implant combined with osteotomy and bone grafting is a viable treatment option.
The intramedullary position of the implant aids in realigning the anatomy and appears to minimize tendon and hardware problems.
Transosseous Repair of the Triangular Fibrocartilage Complex in Ulnar Sided Lesions; Cadaver
Model and Clinical Series
Institution where the work was prepared: Miami Hand Center, Miami, FL, USA
Eduardo Gonzalez-Hernandez, MD; Miami Hand Center; Ignacio Garcia-Cepeda, MD; Universidad de Salamanca
INTRODUCTION:
The purpose of this study is to evaluate a technique for surgical repair of ulnar sided triangular fibrocartilage complex tears. We produce
a cadaver model for complete tears of the TFCC at its insertion into the distal ulna.
MATERIALS/ METHODS:
Our model includes a complete detachment of the triangular fibrocartilage complex from the fovea and the ulnar styloid. The lesion is
repaired using two different techniques: standard arthroscopic technique for repair of peripheral TFCC tear and transosseous pull-out
technique for reattachment of the TFCC into the fovea and the base of the ulnar styloid. Biomechanical testing consists of measuring
the AP translation of the radius with respect to the ulna when a load of 10 lb. is applied to the specimen reproducing the well known
piano-key test. Testing is done in the intact specimen, and is repeated in the same specimen after the TFCC has been released entirely
from its ulnar insertion. Mechanical testing is then repeated following standard arthroscopically assisted repair and finally in the specimen
following a transosseous repair. Translation of the radius with respect to the ulna was measured in three positions of forearm rotation:
neutral, full pronation and full supination. A stability index is developed to reflect the amount of AP translation of the radius with
respect to the ulna. The clinical series consists of 12 patients followed prospectively for a minimum of 12 months post operatively. There
is no comparison made to a similarly matched group undergoing a standard repair. All patients had an MRI diagnosis of ulnar sided
avulsion of the TFCC confirmed on arthroscopic evaluation.
RESULTS:
In all instances of our laboratory testing, the stability index was higher following the transosseous repair. The stability index was 10 to
30% higher following transosseous repair than standard repair. In our clinical series, all patients, except one, were asymptomatic and
had returned to their pre-morbid activity. There was one failure in a college athlete who developed recurrent symptoms four months
after returning to competitive swimming. This particular patient has a very significant ulnar minus variant (-4mm) and that anatomic variant
may limit our ability to repair the TFCC.
CONCLUSION:
In the cadaver model we were able to demonstrate significantly improved stability with a transosseous repair and our clinical series show
consistently good outcomes sufficient to warrant further investigation.
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