Introduction: Darrach’s procedure is indicated for conditions were the distal radio-ulnar joint movement is painful or restricted. The procedure may be indicated at the time of wrist arthrodesis. Darrach’s procedure is not without complications and revision surgery may be indicated. Aims: To determine the success rate following wrist arthrodesis and whether Darrach’s procedure correlates to revision surgery. Methods: A retrospective case note review was performed of a consecutive series of patients who underwent wrist arthrodesis between 1991 and 2002 at our institution; performed by a single surgeon. Results: 73 patients underwent wrist arthrodesis. 39 were female and 34 male. The indications for wrist arthrodesis were rheumatoid disease, osteoarthritis, carpal instability and failed wrist arthroplasty. Successful arthrodesis was achieved in 82% (60/73) of patients, where revision arthrodesis was defined as the end point. 25% (18/73) patients underwent Darrach’s procedure at the time of their primary arthrodesis. 25% (15/60) of the patients whose primary arthrodesis was successful underwent concomitant Darrach’s procedure. 23% (3/13) of patients who underwent revision arthrodesis had undergone concomitant Darrach’s procedure during their primary arthrodesis. 77% (10/13) patients who underwent revision arthrodesis did not undergo Darrach’s procedure at the time of their primary arthrodesis. Of these 10 patients, 3 (30%) of them underwent concomitant Darrach’s procedure during revision arthrodesis. Conclusion: Wrist arthrodesis in our institution is comparable with that of published literature. The incidence of Darrach’s procedure at the time of primary wrist arthrodesis is 25%. There is a small increase to 30% in the number of patients who require Darrach’s procedure at the time of revision arthrodesis, which is not statistically significant

Intraoperative range of motion (ROM) radiographs are routinely taken during scaphoidectomy and four corner fusion surgery (S4CF) at our institution. It is not known if intraoperative ROM predicts postoperative ROM. We hypothesize that patients with a greater intra-operativeROM would have an improved postoperative ROM at one year, but that this arc would be less than that achieved intra- operatively. We retrospectively reviewed 56 patients that had undergone S4CF at our institution in the past 10 years. Patients less than 18, those who underwent the procedure for reasons other than arthritis, those less than one year from surgery, and those that had since undergone wrist arthrodesis were excluded. Intraoperative ROM was measured from fluoroscopic images taken in flexion and extension at the time of surgery. Patients that met criteria were then invited to take part in a virtual assessment and their ROM was measured using a goniometer. T-tests were used to measure differences between intraoperative and postoperative ROM, Pearson Correlation was used to measure associations, and linear regression was conducted to assess whether intraoperative ROM predicts postoperative ROM. Nineteen patients, two of whom had bilateral surgery, agreed to participate. Mean age was 54 and 14 were male and 5 were male. In the majority, surgical indication was scapholunate advanced collapse; however, two of the participants had scaphoid nonunion advanced collapse. No difference was observed between intraoperative and postoperative flexion. On average there was an increase of seven degrees of extension and 12° arc of motion postoperatively with p values reaching significance Correlation between intr-operative and postoperative ROM did not reach statistical significance for flexion, extension, or arc of motion. There were no statistically significant correlations between intraoperative and postoperative ROM. Intraoperative ROM radiographs are not useful at predicting postoperative ROM. Postoperative extension and arc of motion did increase from that measured intraoperatively

The February 2015 Wrist & Hand Roundup360 looks at: Toes, feet, hands and transfers… FCR Tendonitis after Trapeziectomy and suspension, Motion sparing surgery for SLAC/SNAC wrists under the spotlight, Instability following distal radius fractures, Bilateral wrist arthrodesis a good idea?, Sodium Hyaluronate improves hand recovery following flexor tendon repair, Ultrasound treatments for de Quervain’s, Strategies for treating metacarpal neck fractures

Background: Total wrist arthrodesis is a reliable procedure for severely deteriorated and unstable rheumatoid wrist. In 1999, we developed a new wrist fusion rod (WFR), a cannulated titanium rod could be buried into the third metacarpal with proximal fins and a transverse pin to prevent the rod migration and rotation in the medullary canal. After bone preparation, the 4 mm diameter rod was inserted through a guide pin in ante-grade fashion from the carpus to the neck of the third metacarpal to prevent metacarpal fracture. Then the rod was inserted in retrograde fashion into the radius with an introducer, and countersunk until the distal end of the reached the metacarpal isthmus. After burying the rod, it was bent to the desired angle using a special bender. Materials and Methods: Total wrist arthrodesis was performed using this rod on 39 wrists in 33 patients with rheumatoid arthritis (6 males and 27 females). Their radiographic change was Larsen grade IV or V with subluxation at the radiocarpal joint. The mean age at the operation was 60 yrs. old (28 to 75), and the mean duration of the disease was 12 yrs. (3 to 40). The mean follow-up period was 39 mos. (5 to 75). Supplemental fixation with staples was incorporated in this intramedullary fixation. Iliac bone was grafted on 8 mutilated wrists in 8 patients. Postoperative immobilization using a short arm cast or a wrist brace was continued for 8 weeks. Results: Preoperative pain and swelling disappeared in all operated wrists, and grip strength increased in 31 wrists (79%). The mean preoperative grip strength increased from 97 mmHg to 124 mmHg postoperatively. Subluxated wrist was reduced and fused in slight extension and slight ulnar deviation. The rod did not migrate distally or proximally in the medullary canal. Bony fusion was obtained in 36 wrists (92%). Four rods (10%) were broken due to an overuse or a fall before completion of fusion; however, they did not cause any pain. There were no major complications. Conclusion: Using this WFR, rigid fixation at the desired angle was obtained in the total wrist arthrodesis on rheumatoid wrist. It is technically simple, safe and fast to use

Objective: To present the experience of a Deparment of Neuroorthopedics in treatment of the severe deformities of the wrist using the technique of the wrist arthrodesis very often associated to other surgical procedures such as musculotendinous lengthenings and transfers. Materials and Methods: 20 patients with neurological sequelae of cerebral palsy, head trauma, stroke and other neurological disorders of the first motoneuron were retrospectively studied. Fusion of the wrist with an specific plate was performed on these patients. Results: We reached the consolidation of the arthrodesis in a 100% of the cases between 8 and 12 weeks. We had some complications such as 3 cases of phlictenae and edema and 4 cases needed reoperations because of the appearance of secondary deformities previously not seen. 95% of the patient were satisfied and only one wouldn’t go under the same operation again. Discusion: Despite many text books contraindicate wrist arthrodesis in patients with neurological sequelae because of the remote possibility that they may need the flexoextensiòn for the use of walker or crutches or manual or electric wheel-chairs, in our experience many patients benefit from this procedure to correct severe deformities that make their hands absolutely dysfunctional. Besides, the intervention provides the patients and their family with benefits in terms of hygiene, dressing, very often improvement of the pain and, why not, of the aesthetics. Some patients have also gained function, passing from a dysfunctional hand to a useful hand for the basic functions of life. Nowadays, for these kind of patients to be able to move one or two fingers, if they are correctly positioned, can be useful to manage a walker, a computer or a motorized wheel-chair

Objectives: To analyse functional outcome of giant cell tumor (GCT) distal radius treated with en bloc excision and reconstruction with ulnar translocation and wrist arthrodesis. Methods: Between June 2005 and March 2008 fourteen patients of Campanacci grade 3 GCT distal radius treated with en bloc excision were reconstructed with ulnar translocation (radial transposition of ulna) and wrist arthrodesis. Seven (50%) patients had recurrent disease. Average resection length was 7.9 cm (range 5.5cm–15 cm). Twelve cases were fixed with a plate and in 2 an intramedullary nail was used. Union at both junctions was evaluated and functional assessment done using MSTS score. Results: All 14 patients had followed up till bony union. Eleven patients were available at time of final review with an average follow up of 24.5 months (range 13–48 months). Average time for union at ulnocarpal junction was 4 months and ulnoradial junction was 5 months. No case required any additional procedure to augment union. Three cases had a soft tissue recurrence and one had pulmonary metastasis. Average range of prono supination was 80 degrees, one patient with synostosis had complete restriction of prono supination. Average MSTS Score at last follow up was 26 (86.6%). Conclusions: Ulnar translocation provides a local vascularised bone graft to bridge the defect after excision of distal end radius tumors without the need for microvascular procedures. Unlike centralization of the ulna it retains prono supination while maintaining good hand function

Treating 10 consecutive patients requiring wrist arthrodesis, we assessed the effectiveness of a titanium plate specifically designed by Hill Hastings for wrist arthrodesis. It appeared to call for little or no postoperative casting and to promise an early return to functionality. We secured the plate to the third metacarpal and the radius and used autologous bone graft taken from their iliac crest. Length of time immobilisation, time to union, overall functional results and patient satisfaction were recorded. In all 10 patients clinical and radiological union occurred in 8 to 12 weeks. Four patients had no postoperative immobilisation and six had a Litecast. Correctly applied, the pre-contured plate produced a consistently satisfactory position of fusion. One patient had a small area of wound skin necrosis in a pre-existing transverse scar over the dorsum of the wrist, but this healed. The carpometacarpal joint is included in this fusion, which requires a longer longitudinal incision than some other wrist fusion techniques. However, patient satisfaction was high

Aims

Giant cell tumour of bone (GCTB) treatment changed since the introduction of denosumab from purely surgical towards a multidisciplinary approach, with recent concerns of higher recurrence rates after denosumab. We evaluated oncological, surgical, and functional outcomes for distal radius GCTB, with a critically appraised systematic literature review.

The aim of this work is to present a clinical case of wrist arthroplasty failure due to chronic infection and try to discuss and draw a therapeutic approach (algorithm) for similar cases taking in consideration the degree of osteolysis, the presence of detachment and inherent instability and the condition of the soft tissues. The authors report a case of an individual, male, 58 years old, manual worker, that appears with pain and inflammatory signs on right wrist arthroplasty, with fistulous track. The revison procedure was performed in 2 stages: the first stage revision consisted on removal the implant, debridement and interposition of cement spacer with antibiotics and immobilization, the second stage revision a radio-metacarpal arthrodesis with plate and interposition of autologous graft harvested. The improvement of the implants in recent years have contributed to the increasing use of arthroplasty as a treatment option with good results. Although it presents itself with an attractive option in terms of future functional capabilities, arthroplasty remains with some risks and have a higher rate of complications in the medium and long term than fusion, so the selection of patients should be careful. The main problem of wrist arthroplasty revision is due to bone stock loose to promote fusion and the shortening after implant removal. At 1,5 years follow-up, we denote a higher patient satisfaction, without pain, radiological fusion and 28 points in DASH score. The success of wrist arthroplasty depends on careful patient selection, careful preoperative planning, rigorous technique and an appropriate program of functional rehabilitation. The wrist arthrodesis can always be seen as an ultimate salvation procedure in the treatment of failure of wrist arthroplasty, either a mechanical or infectious failure

Complications of distal radius fractures range from 20 to 30% and are consequence of injury or of treatment. Management of these complications must be individualised and the multitude of proposal treatments prove that this problem is controversial. Complications may involve soft tissue (tendon, nerve, arterial or fascial complication, reflex symphatetic distrophy) or bone and joint (malunion, nonunion, osteoarthritis). Tendon complications following distal radius fractures, range from minor adhesions to complete rupture. Peritendinous adhesions will become apparent after cast removal. Diagnosis is based on the limitation of the range of movement for individual fingers.This complication can be avoided with a proper cast technique allowing full range of motion to the digits. Treatment consists of rehabilitation techniques and only rarely, in severe cases, operative tenolysis may be a treatment of choice. Tendons may be entrapped either in the fracture site or in the distal radioulnar joint. Most common tendon entrapment are for extensor carpi ulnaris and extensor digiti minimi. If early recognition is made, open reduction with freeing the tendon must be the choice. Late diagnosis will require more complex tenolysis procedures. Tendon rupture may occur at the time of injury due to sharp fracture fragments. Diagnosis is based on identification of functional loss and, whenever possible, primary tendon suture is recommended. If the diagnosis is late the treatment is free tendon graft or tendon transfer. The late rupture of extensor pollicis longus is the most common possibility. Since it is not related with comminution or displacement of fracture it is possible that an ischemic mechanism is involved. Solutions are free tendon graft or the transfer of extensor indicis proprius. Direct tendon repair is not recommended after few weeks. Nerve complications. Careful neurological investigations demonstrated that nerve injuries associated with distal radius fractures are more common than it is believed. Median nerve is most frequently involved. Primary mechanisms of injury are: direct lesions due to fracture fragments, lesions related to forced manipulation and nonanatomical position of immobilization. Late injuries, occurring a long time after the fracture are more frequent and are related to carpal tunnel syndrome or paraneural adhesions. Carpal tunnel pressure could be measured and ethiologic factors must be identificated in order to establish the proper treatment, usually based on relise of carpal tunnel. Ulnar and radial neuropathy are less common and treatment may vary from cast removal to relise of Guyon’s canal. Vascular complications are uncommon, arise usually in relation with high energy trauma and the treatment is complex, involving different speciality surgeons. Some authors presented rare cases of entrapment of vasculare structures or radial artery pseudoaneurism after the use a volar plate. Compartment syndrome after distal radius fracture is rare and is likely to occur in young adults suffering a high energy trauma. Clinical diagnosis is based on the classical 5 “P’s” (pain, pallor, paresthesias, paralysis, and pulselessness) but treatment must start before all symptoms are present. Anytime when compartment syndrome is suspected, intracompartimental pressure must be measured. The treatment must start immediately and consist in removal of constrictive devices (bandage, cast) and fasciotomy. Indications for fasciotomy are intracompartmental pressure of 15–25mmHg in presence of clinical signs or over 25mmHg in absence of clinical signs. If there is doubt, it is better to perform an unnecessary fasciotomy than to wait until lesions becomes irreversible. Reflex sympathetic distrophy is described with many terms such as algodistrophy, cauzalgia, Sûdeck’s atrophy, shoulder-hand syndrome. Recently, the term complex regional pain syndrome was proposed to replace all the exiting synonyms. Despite many theories, the pathogeny of this disease is uncertain. The diagnosis is mainly clinical, based on presence of pain, trophic changes (atrophy, stiffness, edema) and functional impairment but plain x-ray demonstrating osteopenia and bone scintigraphy showing abnormal bone turnover may be helpful. Since the patogeny is unclear, the treatment is targeting the symptoms rather then the disease. Treatment must be individualized and may consist of: physical therapy of the hand, pain control with general or local drugs, corticosteroids, and symphatectomy. Prevention of reflex symphatetic dystrophy in the first days of a distal radial fracture is very important and include: prevention of the edema (elevation of the hand, early mobilization of fingers), decrease of pain, cast removal to relive pression, non-traumatic surgery. Malunion is the most common complication of distal radius fracture and it usually occurs after close treatment. The malalignament may be extraarticular or it may involve the joint (radiocarpal or distal radioulnar joint). Axial shortening and dorsal or radial malalignament are the most common. Clinical signs are wrist pain, loss of grip strength, limitation of wrist mobility. Osteoarthritis is likely to develop in both types of malunions. For extraarticular nonunions osteotomy is usually the treatment of choice. Many types of osteotomies have been proposed but the most commonly used are opening wedge osteotomy and Watson osteotomy. Intraarticular malunion is more difficult to treat and many surgical solutions have been proposed: intraarticular osteotomy, bone resections (styloid, anterior or posterior rim, radiolunate or radioscapholunate limited arthrodesis, proximal row carpectomy, wrist denervation, wrist arthroplasty, total wrist arthrodesis). Salvage procedures on the distal radioulnar joint may be resection of distal cubitus (Darrach) or Sauve-Kapandji technique. Nonunion is an extremely rare complication and is likely to occur in patients with multiple comorbid conditions such as diabetes, peripheral vascular disease or alcoholism. In most cases the initial treatment was close reduction and cast immobilization or external fixation. Diagnosis is based on the absence of radiographic signs of union at 6 months. Treatment must be individualized but basic options are reconstructive procedures or wrist arthrodesis. Reconstructive procedures consist of debridement of nonunion site, realignment with distractor, plate and screw fixation and iliac crest bone grafting. Since the bone is of poor-quality, new implants providing fixation in orthogonal planes may be useful. Usually, malalignement is present, so some authors recommend to take in to consideration the possibility to associate reconstructive procedures with additional techniques such as: dividing brachioradialis tendon, incision of the dorsal or volar joint capsule or Darrach operation in presence of severe shortening of the radius. Wrist arthrodesis should be chosen when the distal fragment has less then 5 millimeters of subchondral bone supporting the articular surface

Wrist arthrodesis is a common surgical procedure that provides a high level of functional outcome and pain relief among patients.[1] Upon partial arthrodesis, the wrist experiences changes in load transmission that are influenced by the type of arthrodesis performed. Measuring the load through the wrist joint is difficult, however, combined with computational models [2], it is possible to obtain data regarding the load mechanics of the wrist joint. Although successful fusion rates among patients have been reported, it remains unclear what the biomechanical consequences are. The aim of the study is to quantify pre and post operative load transmission through a cadaveric wrist which has undergone simulated arthrodesis of the radiolunate(RL) joint. An embalmed human wrist was dissected dorsally exposing distal radius, radiocarpal and carpometacarpal joints, and dorsal ligaments. The radioscaphoid(RS) ligament was sacrificed to accommodate insertion of a PPSEN-09375 force sensitive resistor (FSR) into the RS joint. The FSR was calibrated prior to measuring the contact force on the RS joint. The wrist was aligned in the neutral position in cardboard piping, and secured proximally and distally with Dental Plaster (OthoBock Healthcare Plc, Surrey, UK). The midsection of piping was windowed to permit placement of the FSR in the RS joint, and fixation of the RL joint using 2 Kirschner wires. The window was completed circumferentially and the specimen was placed in the Instron where a graduated axial compression was applied at 20 N/min. The results showed that when the radiolunate joint is fused, and a total axial load of 100N is applied, the load transmitted through the RS joint was approx 65N. i.e. 65% of the force. This is greater than the 56% measured experimentally by Blevens et al (1989) in an unfused specimen[3]. We plan to repeat our measurements and compare to an untreated cadaveric wrist

Limited wrist arthrodesis has been shown to be an effective treatment for the degenerative and unstable wrist, abolishing pain but limiting motion. The aim of the study was to assess the effect of excision of the scaphoid and triquetrum on wrist joint range of motion, in the setting of a limited midcarpal arthrodesis. Twelve cadaveric wrists had the range of motion measured, before and after, ulnar four-corner fusion (lunate, capitate, triquetrum and hamate fusion). This was measured again following sequential scaphoid and triquetral resection. Scaphoid excision after four-corner arthrodesis resulted in a 12 degrees increase in the radio-ulnar (R-U) arc and 10 degrees increase in the flexion-extension (F-E) arc range of motion. Subsequent excision of the triquetrum, to produce a three-corner fusion, further increased R-U arc by seven degrees and F-E arc by six degrees. These results demonstrate that three-corner fusion with excision of scaphoid and triquetrum results in improvement in wrist motion when compared to four-corner fusion with scaphoid excision alone. From this we conclude that triquetrum excision should be considered in Scapholunate advanced collapse (SLAC) wrist reconstruction to improve residual wrist range of motion

Objectives. A defect following resection of Giant Cell Tumour of the distal radius (GCT-DR) is reconstructed by either vascularised free fibular transfer (VFF) or non-vascularised structural iliac crest transfer (NIC). The purpose of this study was to compare these procedures. Methods. Twenty-seven patients at two centres were identified, 14 underwent VFF and 13 NIC. The two groups were comparable for age, sex, and tumour grade. Functional outcomes were assessed with TESS, MSTS, and DASH. In the VFF group, ankle joint morbidity was assessed with the Ankle Osteoarthritis Scale. In the NIC group, iliac crest morbidity was assessed with a short questionnaire. Results. Two local recurrences occurred in the VFF group and one in the NIC group. Following the index surgery, three patients in the VFF group underwent surgery for cosmesis, hardware removal or tendon release, and one is scheduled for tendon release. In the NIC group two infections required debridement, one of which went on to free fibular transfer, but there were no re-operations for union or donor site morbidity. The surgical time was significantly shorter for NIC. Functional scores showed no differences between the groups on any of the parameters studied for the upper limb (Mann-Whitney test). The Anke OA scale and the iliac crest morbidity questionnaire revealed only a few mild problems with donor site morbidity in either group. Conclusion. Both VFF and NIC are effective surgical techniques that result in a well-functioning wrist arthrodesis. VFF should be considered when there is a significant skin defect, as it allows the inclusion of a vascularised skin paddle, or when the osseous defect is too long for NIC. We were unable to demonstrate any difference in functional scores between VFF and NIC. As the re-operation rate is less for NIC and surgical time is shorter, we recommend NIC whenever possible

Introduction. Primary bone tumours of the distal radius are rare, while it remains the third commonest site for primary lesions and recurrences of Giant Cell Tumours (GCT). The functional demands on the hand make reconstruction of the wrist joint following the excision of distal radius, particularly challenging. Methods. A single-centre retrospective study, reporting the functional and oncological outcomes of six patients (4 males, 2 females - mean age of 53 (22 to 79)) who underwent a custom-made endoprosthetic replacement of the distal radius with arthrodesis at our institution, during 1999 - 2010. Five patients were diagnosed with primary bone sarcoma of the distal radius (4 GCTs, 1 osteosarcoma) and another had a metastatic lesion from a primary renal cell carcinoma. The diagnosis was confirmed by needle biopsy in all cases. We assessed the patients' functional outcomes using the Musculoskeletal Tumour Society scoring system (MSTS) and the Toronto Extremity Salvage Score (TESS). Results. The mean follow-up was 3 years (up to 9.5 years). One patient died of unrelated medical causes, age 89, and one patient succumbed to renal carcinoma, age 53 (9.5 and 4 years post-operatively). All prostheses remained clinically and radiologically stable. One-year radiographs confirmed bone remodelling and osseointegration at the bone-prosthesis interface. There were no cases of local recurrence, metastases, infection or wound complications post-operatively. The mean functional outcome scores were: MSTS 73% (71 to 78), TESS 75% (73 to 79). Pain-free hand movements were restored in all cases. Discussion. Reconstruction options include curettage with/without grafting or cementing, ulna translocation, autografts (vascularised or non-vascularised ⊞/⊟ arthrodesis), allografts, custom-made megaprostheses. Custom-made endoprosthetic reconstruction of the distal radius with wrist arthrodesis following bone tumour resection represents a viable and versatile treatment option. Satisfactory outcomes are achieved with acceptable risks and functional outcomes; especially when considering the nature of the diagnosis and alternative treatment options

There is very limited literature available on the use of prosthetic replacement in the treatment of primary and secondary tumours of the radius. In the past these were treated with vascularised and non-vascularised autografts which had associated donor site morbidity, problems of non union, graft or junctional fractures and delayed return to function. Our study is a mid to long term follow-up of implant survivorship and the functional outcome of metal prosthetic replacement used for primary and metastatic lesions of radius. We had 15 patients (8 males:7 females) with a mean age of 53 years. 8 patients underwent proximal radial replacement, 2 with mid-shaft radial replacement and 6 patients had distal radial replacements with wrist arthrodesis. The indications for replacement included metastatic lesions from renal cell carcinoma, primary giant cell tumours, ewings' sarcoma, chondroblastoma, radio-ulnar synostosis and benign fibrous histiocytoma. The average follow up was 5 years and 6 months (range 3 months - 18 years). Four patients died as a result of dissemination of renal cell carcinoma and two patients were lost to follow-up. There were no complications with the prosthesis or infection. Clinically and radiographically there was no loosening demonstrated at 18 years with secure fixation of implants. Two patients developed interossoeus nerve palsies which partially recovered. Functional outcomes of the elbow were assessed using the Mayo performance score with patients achieving a mean score of 85 postoperatively (range 65-95). All but one patient had full range of motion of the elbow. The patient with radio-ulnar synostosis had a 25 degree fixed flexion pot-operatively. Although the distal radial replacements had decreased range of movements of the wrist due to arthrodesis, they had excellent functional outcomes. Only one patient required revision surgery due to post-traumatic loosening of the implant. Our results of the use of endoprosthetic replacement of radius in the treatment of tumours are encouraging with regards to survivorship of the implant and functional outcome. This type of treatment results in an early return to daily routine activties, good functional outcome and patient satisfaction

Introduction and Aims: The purpose of this study was to investigate the effectiveness of a specifically designed titanium wrist fusion plate for use in wrist arthrodesis. The possibility of no or minimal casting post-operatively was considered and an early return to function was another proposed benefit. Method: Ten consecutive patients with pathology requiring wrist arthrodeses were subjected to wrist fusion by means of a titanium wrist fusion plate. In all 10 cases, a similar technique was used securing the plate to the third metacarpal and the radius. In all cases, autologous bone graft was harvested from the patient’s iliac crest. Time to union, time of immobilisation and overall functional results were looked at. Patient satisfaction with the procedure was also documented. Results: In all 10 patients, solid radiological union was documented between eight and 12 weeks. The pre-contoured plates produce a satisfactory and consistent position of fusion when correctly applied. Six of the 10 patients were managed with a light cast for six weeks post-operatively. The other four patients were treated with no immobilisation at all. There was no failure of fixation in this small series. One patient with a pre-existing transverse scar on the dorsum of the wrist, a small area of skin necrosis occurred. This healed by secondary intention over a four-week period. Conclusion: The titanium arthrodesis plate provides a reliable good method for wrist fusion. Although the longitudinal scar is longer than necessary in some other techniques described, and the carpometacarpal joint is included in the fusion, the overall level of patient satisfaction is high

Introduction and purpose: The widespread discredit which beset the resection of the proximal carpal row in the past seems to have disappeared. At present this is considered to be a very useful salvage technique with results which in some cases can surpass those of arthrodesis. This technique has been reported to yield a pain remission rate of 90% with a 20% loss of strength as compared with the contralateral hand. Materials and methods: We set about analyzing the evolution and results obtained in 4 patients, three male and one female. Three of them were subjected to this procedure to correct a posttraumatic osteoarthritis; the other had an inveterate perilunate dislocation. In all cases the SF-12 health score was used to make an assessment of the functional condition of the patients as well as of their degree of satisfaction. Results: All four patients expressed a high degree of satisfaction. Three of them do not take painkillers while the fourth – operated on 8 months ago – takes them sporadically. Three lead a normal life, whereas the patient who has had the shortest evolution has resumed work only partially. The loss of force in the operated wrist as compared with the contralateral one is of 19%. ROM at present is 46° for volar flexion, 26° for dorsal flexion, 10° for radial deviation and 15° for ulnar deviation. All of them were able to perform a handgrip correctly. Conclusions: Carpectomy is a good alternative to wrist arthrodesis since it allows a good ROM and the ensuing loss of strength is moderate

Purpose: Giant cell tumour (GCT) of the distal radius is associated with high local recurrence rates unless the tumour is aggressively resected, which often leaves a significant skeletal defect. The purpose of this study is to compare the functional outcomes of two commonly used reconstructive techniques, vascularised free fibular transfer (VFF) and non-vascularised structural iliac crest transfer (NIC). Method: Patients treated for giant cell tumour of the distal radius in either Vancouver or at Mount Sinai Hospital, Toronto were identified in the prospectively collected databases maintained in each centre. Twenty-seven patients were identified, 14 of whom underwent VFF transfer as their primary procedure. The two groups were comparable for age, sex and tumour grade. Functional outcomes were assessed with TESS, MSTS, DASH and the Ankle Osteoarthritis Scale. Results: Fourteen patients were included in the VFF group, 13 of which were performed as the primary index procedure, one followed prior cementation. Thirteen patients underwent NIC, one followed prior cementation. Two local recurrences occurred in the VFF group and one in NIC group, all treated with local excision. In the VFF group three patients underwent further surgery for cosmesis, hardware removal and tendon release respectively. One is scheduled for future surgery for tendon release. In the NIC group two patients suffered infections requiring debridement, one of which ultimately went on to require free fibular transfer. This patient’s results were included in the NIC group as this was the index procedure. Functional scores showed no differences between the two groups on any of the parameters studied for the upper limb (Mann-Whitney test). The Ankle osteoarthritis scale had a median score of 9% for the six patients on which it was available. Conclusion: Both VFF and NIC are effective surgical techniques that result in a well-functioning wrist arthrodesis. VFF may be more useful where there is a significant skin defect from previous interventions. We were unable to demonstrate any difference in functional scores between VFF and NIC

Nonunion of the distal radius is a rare complication (0.2%) which gradually can lead to deformity, pain and dysfunction of the hand. We examined 7 patients who developed nonunion of the distal radius after surgical intervention and we try to rationalize this complication. Our material consisted of 7 patients (2 male and 5 female) average 51 years old (31–75). Two patients with distal radial malunion, developed nonunion after corrective osteotomy. Four patients with comminuted metaphyseal radial fracture and concomitant distal ulna fracture, developed nonunion after application of an external fixator alone or in combination with internal fixation. Finally one patient with isolated fracture of the distal metaphysis developed nonunion after internal fixation. All patients after the confirmation of the nonunion and until radiological union underwent 1–3 operations. The index procedures for final union were wrist arthrodesis (1 patient) radioscapholunate fusion with excision of the distal scaphoid (2 patients) and internal fixation (4 patients). Additionally, in 6 patients a supplementary method for DRUJ asymmetry was needed. Results were estimated after a mean follow-up of 30,8 months (1–4 years) based on radiological and clinical criteria. There were 1 excellent, 5 good and 1 fair result. Despite the existence of predisposing factors (comminution, associated fracture of the distal ulna, metabolic disease, osteoporosis, distraction through external fixator), the contribution of the surgeon to the development of the nonunion is undeniable

Introduction: Arthrodesis of the wrist must still be considered as a useful procedure in the treatment of certain deformities of the wrist joint that by performing this operation can improve the function or the aesthetics of the limb. Except those techniques of partial carpal arthrodesis, the surgical procedures of wrist arthrodesis requires a bridging from the radius to the metacarpal in order to stabilize the joint. When this procedure is performed in a growing child this can be a draw back. Material: We have developed a new procedure that producing the arthrodesis distally to the growing cartilage of the radius does not interfere with the growing at wrist level. Furthermore, the use of a wire shroud gives an active fixation reducing postoperative immobilisation and shortening healing time. Since 1986 we have performed this technique in 9 cases of children with mean age of 14 years. The pathology was in 5 cases Cerebral Palsy, in 2 cases Juvenile Rheumatoid Arthritis and in 2 cases Obstetrical Brachial Plexus Palsy. Eight cases were males and 3 cases females. The indication for surgery was flexion deformity of the wrist in 8 cases and extension in 1 case. Four cases had carpal instability (including the 2 Juvenile Rheumatoid Arthritis). Results: The time of fusion was in all cases 2 months with primary arthrodesis and improved extremity. Functional improvement seemed to be most related to pre-operative conditions. Follow up ranged from 4 years to 6 years. Conclusions: The good results obtained with this procedure encourage us to present this new surgical technique to be applied in the still growing child