Salvage of Post-Traumatic Arthritis Following Distal Radius Fracture

Before embarking for salvage procedures for wrist osteoarthritis after distal radial fractures, conservative treatment and corrective osteotomy should have been considered. If these measures are inapplicable or fail, extensive or partial wrist denervation should be attempted, preferably extensively. Partial or total wrist arthrodesis or arthroplasty are the next options to be considered, arthroplasties being more suited for the low-demand patients. If the midcarpal joint is intact a radioscapholunate arthrodesis is another option. In low-demand patients, hemi-arthroplasty possibly is an alternative. In patients who request a final procedure, or in the case of panarthritis, total wrist arthrodesis (or as an alternative in the elderly/low-demand patient: total wrist arthroplasty) is preferred.

Malunions of the forearm and hand cause significant disability. Moreover, intraarticular deformities may contribute to early onset osteoarthritis. Such conditions require precise surgical correction in order to improve functional outcomes and prevent early or late complications. The purpose of this study was to describe the technical advantages of accurate anatomical reconstruction using 3D guided osteotomies and patient specific instruments (PSI) in multiple joints of the hand and forearm. Acquisition of three-dimensional (3D) datasets and surgical implementation of PSI was performed in a series of patients between December 2014 and July 2017. Patients had intra- or extra-articular malunions of the forearm, radiocarpal joint, trapeziometacarpal joint, or proximal interphalangeal joint. A previously described 3D surface model that incorporates CT data was used for segmentation (Mimics®, Materialise™, Belgium). For all the cases, CT scans of both forearms were acquired to use the contralateral uninjured side as the anatomic reconstruction template. Computer-assisted assessment of the deformity, the preoperative plan, and the design of PSI are described. Outcomes were determined by evaluating step-off correction, fusion, changes in range of motion (ROM) and grip strength. Six patients were included in the study; all achieved fusion. Improved clinical outcomes including pain reduction, better ROM and grip strength were obtained. Complete correction of intraarticular step-off was achieved in all cases with intraarticular malunions. 3D guided osteotomies are an established surgical treatment option for malunions of the hand and forearm. 3D analysis is a helpful diagnostic tool that provides detailed information about the underlying deformity. PSI can be developed and used for surgical correction with maximal accuracy for both intraarticular step-off and angular deformity.

Les cals vicieux de l’avant-bras et de la main sont responsables d’un handicap notable. De plus, les déformations intra-articulaires peuvent même conduire à une arthrose de début précoce. De telles situations nécessitent une correction chirurgicale précise pour améliorer le résultat fonctionnel et éviter des complications précoces ou tardives. La présente étude visait à montrer les avantages techniques sur la précision de la reconstruction anatomique grâce à des ostéotomies guidées tridimensionnellement (3D) et une instrumentation spécifique au patient (PSI) sur divers articulations de la main et de l’avant-bras. L’acquisition de données 3D et l’utilisation chirurgicale d’une PSI ont été réalisées sur une série de patients entre décembre 2014 et décembre 2017. Les patients souffraient de cals vicieux intra- ou extra-articulaires de l’avant-bras, des articulations radio-carpienne, trapézo-métacarpienne ou interphalangienne proximale. Un modèle de surface 3D déjà utilisé et basé sur des données tomodensitométriques a été utilisé pour la segmentation (Mimics®, Materialise™, Belgique). Dans tous les cas, les scanners des deux côtés étaient acquis pour utiliser le côté opposé non traumatisé comme modèle anatomique de la reconstruction. L’évaluation de la déformation aidée par ordinateur, la planification préopératoire et la conception des guides spécifiques au patient sont décrits. Le résultat était déterminé par l’évaluation de la correction de la marche d’escalier, le taux de fusion, les modifications observées dans la mobilité (ROM) et la force de poigne. Six sujets ont été inclus. Tous les patients inclus dans cette étude de cas rétrospective ont obtenu la consolidation des ostéotomies. Une amélioration clinique a également été obtenue, incluant une diminution de la douleur, une amélioration de la ROM, et de la force de poigne. Une correction complète des marches d’escalier intra-articulaire a été obtenue dans tous les cas de cals vicieux intra-articulaires. Les ostéotomies guidées 3D représentent une option de traitement chirurgical bien établie pour les cals vicieux de la main et de l’avant-bras. Une analyse 3D est un outil diagnostique précieux, qui permet une compréhension détaillée des déformations sous-jacentes. Finalement, l’instrumentation spécifique au patient peut être développée et utilisée pour la correction chirurgicale avec une précision maximale à la fois pour les marches d’escalier intra-articulaires et les déformations angulaires.

Corrective osteotomy of malunited intra-articular distal radius fracture is challenging. In this study, we investigated the results in patients with malunited intra-articular distal radius fracture who underwent intra-articular corrective osteotomy through an extra-articular approach using three-dimensional (3-D) computer simulation and a patient-matched instrument (PMI).

We retrospectively studied five consecutive patients with symptomatic malunited intra-articular distal radius fracture who underwent corrective osteotomy using a PMI. The maximal step-off on computed tomography and the deformity angle on plain radiographs were evaluated. The clinical examination parameters included range of motion (ROM), grip strength, pain according to visual analog scale (VAS), and Patient-Rated Wrist Evaluation (PRWE) score.

The maximal step-off was significantly reduced from 4.9 ± 1.8 to 1.0 ± 0.2 mm (p = 0.008). The absolute differences between the affected side and the normal contralateral side in radial inclination were significantly reduced from 5.4° ± 3.4°–1.2° ± 1.1° (p = 0.043). These differences were not significantly reduced postoperatively in the volar tilt and ulnar variance. VAS was significantly reduced from 4.1 ± 1.6 to 0.9 ± 0.7 cm (p = 0.006). The PRWE score significantly improved from 41.6 ± 22.0 to 15.7 ± 19.5 (p = 0.043). Grip strength was significantly increased from 54.0% ± 14.8%–85.8% ± 18.8% (p = 0.003). The preoperative and postoperative total arc of the wrist and forearm ROM were not significantly different.

Intra-articular corrective osteotomy using PMI could be one of the reliable treatment options for intra-articular malunion. PMI has exceptionally high precision performance, and it is also anticipated to yield superior surgical results.

The authors describe a case of post-traumatic wrist arthritis with an osteochondral defect in the scaphoid fossa of the radius. The patient was treated with proximal row carpectomy, radial styloidectomy and reconstruction of the defect using the proximal half of the scaphoid as an autologous osteochondral graft. Pain relief was achieved while wrist motion and strength were improved. The carpal bones are a source of osteochondral grafts and can be used to expand the indications of motion-preserving wrist salvage procedures.

Les auteurs rapportent un cas clinique d’arthrose sévère post-traumatique du poignet avec une perte de substance ostéochondrale correspondant à la fossette scaphoïdienne du radius. Le malade a été traité par une résection de la rangée proximale du carpe, une styloïdectomie radiale et la reconstruction de la surface scaphoïdienne du radius en utilisant la partie proximale du scaphoïde comme greffe ostéochondrale autologue. La douleur a été améliorée, aussi que la force de prise et la mobilité du poignet. Les os du carpe peuvent être utilisés comme greffons autologues dans les traitements de sauvetage pour préserver la motilité du poignet.

Cartilage damage of the carpals is a contraindication for corrective osteotomy of the malunited intra-articular distal radius fracture and typically is treated in the symptomatic patient with a salvage procedure. Here, we present our experience and early results with arthroscopic resection arthroplasty of the radiocarpal joint.

We treated 10 patients (age, 17–68 y; average, 53 y) who had intra-articular malunion of the distal radius with mirror erosion on the carpals. The original fracture occurred 4 to 36 months (average, 9 mo) before our intervention. We performed arthroscopic arthrolysis and resected the offending portion of the radial malunited fragment, eliminating the stepoff and creating a smoother joint surface. Range of motion was started immediately after the operation, except in 2 patients.

The locations of the malunions were evenly distributed between the scaphoid fossa, the lunate fossa, or both. Stepoffs varied from 2 to 6 mm. We resected up to 60% of the entire radial articular surface to obtain a smooth surface (average, 28%; range, 20% to 60%). All patients reported immediate relief of pain and improvement in motion (particularly extension). At the latest follow-up (average, 28 mo; range, 13–42 mo), average extension improved from 24° to 54°, average grip strength improved from 47% to 89% of the contralateral wrist, average Disabilities of the Arm, Shoulder, and Hand score improved from 74 to 18, and average Patient-Rated Wrist Hand Evaluation score improved from 79 to 15.

The aim of the operation was to relieve patients' pain by providing a smooth, although fibrocartilaginous, surface for the carpus to glide on the radius. The follow-up was short and the results may be short-lived. However, for the younger patient, it may provide a temporary alternative to partial wrist arthrodesis with minimal morbidity, and for the less demanding patients, it may be a definitive procedure.

Therapeutic IV.

Radioscapholunate arthrodesis is the treatment of choice for symptomatic, degenerative radioscapholunate osteoarthritis. We report on three patients after radioscapholunate arthrodesis with a follow-up of 22–28 years. There were no short-term postoperative complications; range of motion and strength were stable. All three patients showed radiological evidence of progressive, but clinically asymptomatic midcarpal osteoarthritis. The conversion rate for radioscapholunate to panarthrodesis of the wrist is reported at 31% with follow-ups of more than five years, invariably due to either non-union, or progressive, symptomatic midcarpal osteoarthritis. Primary excision of the distal pole of the scaphoid during radioscapholunate arthrodesis probably plays an important role in avoiding these conditions in the long-term. This measure allows a residual range of motion more than previously believed; considering that the dart thrower's motion is the physiological axis of wrist motion.

L’arthrodèse de l’articulation radioscapholunaire est le traitement de référence de l’ostéoarthrite dégénérative symptomatique radioscapholunaire. Nous présentons trois patients ayant bénéficié d’une arthrodèse radioscapholunaire avec un recul de 22 à 28 ans. Aucune complication n’a été relevée à court terme. Les résultats fonctionnels concernant la mobilité et la force étaient stables au terme du suivi. L’ostéoarthrite médiocarpienne progressive, mais cliniquement asymptomatique, était évidente radiologiquement pour les trois patients. Le risque de convertir une arthrodèse radioscapholunaire en une panarthrodèse du carpe est de 31 % dans les séries pour un recul de plus de cinq ans, sans variabilité imputable à l’étiologie (défaut de consolidation ou athrose médiocarpienne progressive symptomatique). La résection primaire du pôle distal du scaphoïde au cours de l’arthrodèse radioscapholunaire pourrait permettre d’éviter la panarthrodèse à long terme. Par ailleurs la résection du pôle distal améliore la mobilité résiduelle, en particulier, en préservant notamment l’axe physiologique de mouvement du poignet.