Purpose: Arthodesis is the conventional treatment for the rheumatoid wrist. In the event of severe bilateral disease, bilateral arthrodesis can be discussed as an alternative to unilateral arthrodesis an contralateral prosthesis. We wanted to know the functional outcomes after bilateral arthrodesis.

Material and methods: This retrospective analysis involved seven patients (one man and six women), mean age 46 years (28–69) who underwent total bilateral arthrodesis of the wrist for inflammatory joint disease (six rheumatoid, one chronic juvenile arthritis). Mean follow-up was five years. The patients were reviewed clinically and radiographically. We noted goniometric measurements of the upper limbs, the Jebsen hand function test (for activities of daily life), force (wrist and grip), and the Buck-Gramcko-Lohmann evaluation.

Results: On average, the position achieved after arthrodesis was 2° flexion (−5° to +10°) with 6° ulnar inclination (−5° to +20°). Radiological fusion was achieved in all cases. At last follow-up, we noted that three patients had resumed their occupational activities, one had been reclassified as handicapped, and one as disabled. One patient was a housewife and one other woman was retired. The Jebsen hand test showed that our patients could perform 32 of the 49 daily activities (65%). Daily activity was noted excellent in three patients, good in two and fair in two. The Buck-Gramcko-Lohmann score was fair 6.8/10 (2–10) corresponding to good outcome. All patients were satisfied with the outcome.

Discussion: Daily life activities could be performed readily after bilateral arthrodesis of the wrist. Perineal hygiene was possible for five of our patients. The only problems concerned activities requiring force and fine movements, because of the apprehension and the lack of fine dexterity. Poor results could be attributed to metacarpophalangeal deformations and decreased grip force. We observed an 80% reduction in force compared with a representative population of non-operated patients with rheumatoid disease. Bilateral arthrodesis is a valid alternative to bilateral arthroplasty or combined arthrodesis prosthesis implantation. It does not expose the patients to the risk of mechanical arthroplasty.

Purpose: Management of extensive tibial loss raises the question of indications for vascularised grafts. These techniques depend on the number of functional vascular trunks available. We developed a modified technique which allows using this type of graft without sacrificing the tibial pedicle, making it usable when only one trunk remains functional. We use the fibular arterial supply to bridge the remaining axis. The purpose of this work was to detail the modalities of this technique and provide early results.

Material and method: Since 2000, we have reserved this technique for infected nonunion with loss of tibial tissue extending over 5 cm in patients who decline amputation. Four patients (four men, mean age 30 years) underwent the procedure. The initial trauma resulted from a motorcycle (n=3) or firearm (n=1) accident. The patients were referred to our unit within three months on the average. Prior treatments (cancellous graft in an open or intrafocal procedure) had failed in all patients who presented persistent infection. Antibiotics were administered until bone healing in all patients. Mean length of the gap was 10 cm (7 – 15 cm). The composite graft (skin and fibula with a vascularised fibular bundle) was raised from the contralateral limb and cross-leg anastomosed proximally and distally on the receiver anterior tibial bundle (all four cases).

Results: All fractures consolidated between six and twelve months after initiating management of this technique. Bone and soft tissue losses healed without shortening. There were not repeated fractures after mean follow-up of twelve months (range eight months to two years). No complementary bone graft was necessary. Infection resolved in all patients.

Discussion and conclusion: As for classical vascularised fibula grafts, this technique enables controlling bone and soft tissue problems together (composite graft). The graft is vascularised favouring antibiotic diffusion. The mechanical quality is better than with a pure cancellous graft but longer follow-up would be required to determine the rate of repeated fractures. This technique broadens indications for vascularised fibula grafts which can be used in unfavourable vascular contexts where only one or two leg trunks persist.

Purpose: The few reports of long-term outcome of Kien-böck disease are helpful in establishing therapeutic indications.

Material and methods: Between 1970 and 1995, radius shortening procedures were performed in 44 patients. Among these 31 patients (eight women and 23 men), mean age 32 years (18–48) at surgery, with 33 operated wrists (18 right, 11 left, 2 bilateral, 19 dominant hands) were reviewed clinically (25 patients by an independent observer, three by their family physician) and radiologically (26 patients) or responded to a phone interview (five patients) at a mean 12 years follow-up (4–19 years). Four patients had died, nine were lost to follow-up. Before surgery the pain was intense (Michon scale): 32 grade I, one grade II. According to Lichtman, there were three grade I, seven grade II, eighteen grade IIIa and five grade IIIb. There was one case of haematoma and one reflex dystrophy, five late consolidations and five nonunions (three diaphyseal out of eight and two metaphyseal out of 25).

Results: The Michon pain score was variable, 11 grade IV, six grade III, nine grade II, but also seven grade I and four secondary arthrodeses. Postoperative amplitudes ere: flexion 50°, extension 53°, abduction 20°, adduction 29°, pronation 83°, supination 74°. Mean amplitudes increased for flexion (+12°), extension (+13°), abduction (+6°), and adduction (+11°), but decreased for pronation (−3°) and supination (−13°). The postoperative wrist fore (Jamar) was 32 kg (80° of other side). Eighteen patients were able to resume an occupational activity, requiring equivalent (14 patients, including 12 manual labourers) or greater (two patients) wrist force. At last follow-up the Lichtman classification was one grade I, four grade II, eight grade III1, three grade IIIb, and seven grade IV. The pre- to postoperative radiography comparison (26 wrists) showed two improvements, seven stabilisations, 14 aggravations, and three arthrodeses. There were also three cases of ulnocarpal impingement (one reoperated). Discussion: the factors predictive of good outcome were minimally advanced disease (Lichtman), little reduction in lunatum height (Stahl), absence of carpal collapse (McMurtry), absence of complication.

Conclusion: Shortening of the radius is an excellent procedure to Lichtman grade IIIa. Results are less satisfactory for grade IIIb but still acceptable compared with resections of the first row or intracarpal arthrodesis. To avoid the risk of ulnocarpal impingement, it would be preferable to reorient the glenoid or shorten the capitatum rather than shorten the radius in patients with a normal radioulnar index.