ASSH Annual Meeting Abstract 2003

Meeting Abstracts

Objectives Induction of donor-specific tolerance in com-posite tissue allografts (CTA) remains one of the mostchallenging goals in transplant surgery. Recently, wehave developed a protocol (alpha-beta TCR mAb/ CsA)for tolerance induction in the rat hind limb transplanta-tion model (LBN; RT1n/l; F1 to Lewis; LEW; RT1l). In thisstudy we present tolerance induction in the fully MHCmismatched allograft recipients under 7 day protocol ofcombined alpha-beta TCR/CSA protocol.

Methods Thirty transplantations across strong MHC bar-rier were performed between Brown-Norway donors(RT1n) and LEW recipients. Isograft and allograft rejec-tion control groups received no treatment. Experimentalgroups received either rat alpha-beta TCR or CsA orcombination of alpha-beta TCR and CsA at the day oftransplantation and for 7 days thereafter. The efficacy ofimmunosuppressive treatment and chimerism level wasmonitored by flow cytometry (FC). Donor specific toler-ance and immunocompetence of the limb recipientswas determined in vivo by secondary skin grafting fromthe recipient (LEW), the donor (BN) and the party (ACI)animals. Mixed lymphocyte reaction (MLR) was per-formed for the assessment of donor- specific tolerancein vitro.

Results Only fully mismatched allograft recipients underalpha-beta TCR/CsA protocol survived indefinitely (over250 days). Three color FC analysis at day 120 post-trans-plant demonstrated stable, multilineage, donor- specificchimerism in the periphery of the tolerated recipients(7.6% of CD4+PE/RT1n+APC and 1.3% of CD8+PE/RT1n+APC positive T cell subpopulations and 16.5% ofC D 4 5 R A + P E / RT1n+APC -16.5% B cell population).Donor specific tolerance and immunocompetence invivo was confirmed respectively by the acceptance ofs e c o n d a ry skin grafts from the donor and rejection of thet h i rd - p a rty (ACI) grafts. MLR revealed lack of response tothe host (LEW) and donor (BN) antigens but strong re a c-tivity against the third - p a rty (ACI) alloantigens.

Conclusions To the best of our knowledge, for the firsttime donor-specific tolerance was induced under 7 daysprotocol of combined alpha-beta TCR/CsA therapy in thefully mismatched limb allograft recipients. Stable mixedchimerism was achieved without the need for myeloab-lative bone marrow modification of the recipients andwithout the need for chronic immunosuppression. Thisprotocol may have direct impact on transplantation ofcomposite tissue allografts in the clinical scenario.

Thursday, September 18 1:50 p.m.

Clinical Session I

Paper #1

Induction of the Donor-Specific Chimerism and Tolerence in Fully MHC MismatchedLimb Allograft Recipients

Maria Z. Siemionow, MD, PhD, DSc, Cleveland, OHDariusz Izycki, MD, Cleveland, OHMaciej Zielinski, MD, Cleveland, OHKagan Ozer, MD, Cleveland, OH

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ASSH Annual Meeting Abstract 2003

Objectives Through a collaborative effort between sur-geons at the University of Pittsburgh and engineers atCarnegie Mellon University, a prototype of an anatomicalrobotic hand has been created. Unlike previously engi-neered robotic hands, which only mimicked the appear-ance of human hands, our goal is to achieve a level ofanatomical accuracy that permits the hand’s use as ateaching tool for medical students, residents and healthcare professionals. Because its design is anatomicallybased, we can induce known pathological deformities(e.g. boutonniere deformity). Since the motor-pulleyapparatuses (muscle-tendon units) can be programmedin groups, disabilities associated with specific peripheralnerve palsies can be mimicked (e.g. radial nerve palsy).Also, because the tendinous insertions can be unat-tached, rerouted, and reattached; the effect of tendontransfers and unbalanced tendons can be simulated.

Methods In our first version, a right upper extremity fromthe distal humerus to the fingertips is presented. Thebony structure is made of individual polyurethane moldscast from a human cadaver. The ligaments are an epoxy-coated, minimally elastic fabric. Joints are constructedof a gelatinous foam compound wrapped in poorly com-pliant mesh. A servomotor-cable apparatus simulates an

individual muscle-tendon unit. With this version ourdesire was to mimic all the extrinsic muscles using 20motors. The EDC is represented by a single motor withbranching cables, but the FDS and FDP tendinous exten-sion to each finger is represented by an individual motorand cable. The palmaris longus is excluded. This motordistribution (APL, EPB, ECRL, ECRB, EPL, EDC, EIP,EDM, EDU, FCR, FPL, FDSx4, FDPx4, and FCU)accounts for all 20 motors. Each cable is directed to itshand insertion point by following the recognized anatom-ical pathways. Three programmable motor boards repre-sent the ulnar, median, and radial nerves, and the com-puter represents the brain.

Results The torque, velocity, acceleration and timing ofeach servomotor are programmable via this system. Theservomotors can be programmed to function individual-ly or in coordination with other servomotors to createspecific patterns of motion.

Conclusions We are still improving on this prototypeanatomical robotic hand and are currently incorporatingintrinsic muscles and an accurate extensor hood mech-anism, as well as a glove-driven and voice-recognitioncontrol interface.


Clinical Session I

Paper #2

An Anatomical Robotic Hand for Instruction and Simulations

Sean Michael Bidic, MD, Pittsburgh, PAJoseph E. Imbriglia, MD, Wexford, PAYoky Matsuoka, PhD, Pittsburgh, PA

On the Shoulders of Giants: ASSH 58th Annual Meeting

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Meeting Abstracts

Objectives The purpose of this study was to investigatewhether it is possible, through interfacing with severednerves, to provide closed loop control of artificial limbsfor below elbow amputees.

Methods Intrafascicular electrodes were implanted in thesevered nerves of upper limb amputees. Following post-operative recovery, the subjects were evaluated for aperiod of up to 4 weeks. Each subject was directed toattempt to make a missing limb movement. Recordedefferent nerve signals were amplified, processed, andcontrol signals sent through a laptop computer to theartificial arm. The subject was asked to demonstratecontrol over pincer grip movements. For sensory feed-back, electrodes were stimulated separately to assess ifit is possible to provide graded, tactile and propriocep-tive sensations, referred to the missing limb. Followingthis, the ability of the subject to discriminate sensationsfrom the artificial hand was tested and quantified.

Results After the electrode(s) were mapped as corre-sponding to a particular phantom movement, the subjectcould control volitional motor nerve signals almostin s t a n t a n e o u s l y, and modulate pincer grip control to dif-f e rent positions of opening and closing. Subjects re p o rt e dphantom sensations of touch, movement and joint posi-tion sense. The intensity of these sensations and thed e g re e of phantom joint flexion could be systematicallymodulated through varying the stimulation parameters.In addition, graded tactile and joint position sensationscould be provided from sensors in the artificial hand.

Conclusions With multiple electrodes implanted in multi-ple severed peripheral nerves, below elbow amputeescan be provided with sensate artificial limbs. Efferentnerve signals can be used to control actuators in the arti-ficial arm and sensors in the gripper and joints can beused to relay feedback, allowing the amputee to exe-cute real time closed loop control over the prosthesis.


Clinical Session I

Paper #3

Beyond 2000: Neurally Controlled Artificial Hand with Sensory Feedback

Gurpreet Singh Dhillon, MD, Salt Lake City, UTKenneth W. Horch, PhD, Salt Lake City, UT

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Objectives Shoulder stabilization is of utmost importancein upper extremity reanimation. The purpose of thisstudy is to present our experience of suprascapularnerve reconstruction in 150 cases of obstetrical andadult brachial plexus lesions. Outcomes will be analyzedin relation to various factors including age of the patient,denervation time, donor nerve used, and functionalrestoration achieved in the supraspinatus versus theinfraspinatus muscles.

Methods The medical records of 165 patients who hadsuprascapular nerve reconstruction were reviewed. Onehundred fifty patients operated by a single surgeonbetween 1978 and 2000 had adequate follow-up. Onehundred two patients were adults, and 48 suffered fromobstetrical brachial plexus palsy (OBPP). Direct neuroti-zation of the suprascapular nerve was done in 95patients while in 55, interposition nerve grafts wereused. In 90 patients, the distal spinal accessory wasused as the motor donor nerve for suprascapular nerveneurotization, while in 60 intraplexus and extraplexusdonors were used.

Results The overall results in adult plexopathies weregood or excellent in 75% of the patients for thesupraspinatus muscle and in 55% for the infraspinatus

muscle. In the OBPP, the results were good or excellentin 96% for the supraspinatus muscle and 65% for theinfraspinatus muscle. The mean postoperative musclegrading for the distal accessory to suprascapular nerveneurotization was 3.31; for intraplexus to suprascapularneurotization was 3.37; and for cervical plexus to supras-capular neurotization was 3.19. There was a statisticallysignificant diff e rence between direct accessory tosuprascapular neurotization versus accessory to supras-capular via a nerve graft (P<0.05) in the posttraumaticgroup; while in the OBPP patients, although the func-tional results after direct suprascapular nerve recon-struction were superior to those via graft, there was nostatistically significant diff e rence between the twogroups (p=0.027). Early surgery, less than 6 months,yielded significantly better results than late surgery,more than 12 months.

Conclusions Suprascapular nerve reconstruction is aworthwhile procedure that stabilizes the glenohumeraljoint, avoids shoulder arthrodesis, as well as restoringshoulder abduction from 20 to 80 degrees. The bestresults are seen in the OBPP patients, when direct neu-rotization of the suprascapular nerve is carried out soonafter injury (6 months or less).


Clinical Session I

Paper #4

Outcomes of Suprascapular Nerve Neurotization in 150 Patients with Brachial PlexusInjuries

Julia K. Terzis, MD, PhD, Norfolk, VAIoannis Kostas, MD, Norfolk, VA


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Meeting Abstracts

Objectives The frequency of major surgical complicationsin the treatment of carpal tunnel syndrome (CTS) is gen-erally considered low. The purpose of this study is toexamine the frequency and cause of malpractice law-suits associated with treatment of CTS over the pasttwenty-seven years in the state of New York and examinethe importance of surgical technique (open vs. endoscop-i c ) , surgeon’s training, surgeon’s experience and patientdemographics.

Methods The legal records of closed cases in New Yorkfrom Medical Liability and Mutual Insurance Company(MLMIC), the U.S.’s largest medical malpractice insur-ance company, were reviewed for claims related to CTSbetween 1975 and 2002. The following data were gath-ered: patient information, procedure details, surgeon’straining, and claim outcome. Additionally, all cases withthe ICD-9 code for CTS from inpatient and outpatient sur-g e ry between the years 1984–2002 from the New Yo r kD e p a rtment of Health Statewide Planning and Researc hCooperative System (SPARCS) data were analyzed.

Results 73 lawsuit claims were identified related to sur-gical management of CTS. 291,239 CTS procedureswere identified in New York from SPARCS data. 67% ofthe CTS legal claims resulted in indemnity payments tothe plaintiff, with a mean payment of $166,000. Meanindemnity payment for male plaintiffs was $217,000 vs.

$143,000 for female plaintiffs. Plaintiffs were signifi-cantly younger than all New York CTS patients, 47 vs. 53years old (p<.001). The most common causes for claimsincluded: laceration of a nerve (49%), development orexacerbation of reflex sympathetic dystrophy (RSD)(12%), wrong operation or wrong operative side (7%),incorrect diagnosis (5%), and failure to obtain properinformed consent (3%). Development or exacerbation ofRSD resulted in the highest mean indemnity payments($410,000). 86% of claims involving laceration of a nerveresulted in indemnity payments. Since 1992, 15% ofCTS procedures in New York were performed endo-scopically, but 46% of nerve laceration claims wereendoscopic cases. Endoscopic pro c e d u res have a higherfrequency of claims involving nerve lacerations thanopen procedures (p<.01). Mean indemnity payments forendoscopic cases were $252,000 vs. $157,000 for opencases over this time. Five of the six claims involvingcomplete transection of the median nerve were endo-scopic procedures.

Conclusions Surgical treatment of CTS is associated witha relatively large number of malpractice lawsuits in NewYork. These result in high payments to the plaintiff. Incases involving nerve injuries, endoscopic techniquehas resulted in significantly more lawsuits than opent e c h n i q u e .


Clinical Session II

Paper #5

A 27 Year History of Malpractice Lawsuits for Surgical Treatment of Carpal TunnelSyndrome at the Nation’s Largest Medical Malpractice Insurance Company

Carter B. Lipton, MD, New York, NYBenton E. Heyworth, MD, New York, NYAndrew H. Patterson, MD, New York, NYMelvin P. Rosenwasser, MD, New York, NY

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Objectives Although carpal tunnel syndrome affects mil-lions, there is no understanding as to why there is actu-ally pain with this condition. The current dogma is thatthe ischemia of chronic nerve compression (CNC) leadsto mild Wallerian degeneration which may be the sourceof the pain. One of the major changes in Walleriandegeneration is granular disintegration of the axoplasmre p resenting a breakdown of the normal axonalcytoskeleton (1). To better understand CNC, we evaluatedthe axonal architecture of nerves in a model for carpaltunnel syndrome.

Methods A nerve compression model was developedwith Sprague-Dawley rats. A silastic tube (I.D. 1.3mm)was atraumatically placed around each right sciaticnerve. EMG/NCV studies were performed at specimenharvest. For EM evaluation, the specimens were post-fixed in osmium tetroxide, dehydrated in acetone andembedded in Epon resin. Design-based, unbiaseds t e reologic counting was used to obtain number andsize estimates (2). Flourescent immunohistochemistrywas perf o rm e d to evaluate neurofilament pro t e i nexpression.

Results There were no significant electrophysiologicalchanges at the one-month time point. By the eight-month time point, NCV consistently decreased to 65%of the normal value. Review of 280 photomicrographsdid not provide any evidence of granular disintegration ofthe axoplasm. Surprisingly, at the one-month time point,

there was a 58% increase in unmyelinated axons rela-tive to normal nerve, which was not present at the eight-month time point. Fluorescent microscopy demonstratedthat at one month post surgery, there was evidence ofaxonal sprouting marked by the appearance of thinnerneurofilament proteins emerging from thicker base pro-teins. Consistent with the EM data, such alterations areonly observed at the periphery of the nerve section,while the center retained its normal architecture. Byeight months, there was a return to a near normal neu-rofilament protein and axonal architecture.

Conclusions There is no ultrastructural evidence ofWallerian degeneration early with CNC. Rather, there isa marked increase in the number of unmyelinated axonsthat originate from existing axons, i.e. axonal sprouting.These fibers, which typically mediate pain and tempera-ture, are not present at the later time points. Changes inunmyelinated axons follow the same time course as theexpression of pain in patients with compression neu-ropathies. Thus, the data suggests a novel hypothesisthat chronic nerve compression may provide an earlystimulus for re-innervation that aberrantly results in thepain associated with compression neuropathies.

References

George, R et al; J. of Neurocytology 23: 655–667, 1994.

Larsen, JO; J of Neuroscience Methods 85: 107–118,1998.


Clinical Session II

Paper #6

Why Is There Pain with Carpal Tunnel Syndrome?

Ranjan Gupta, MD, Irvine, CATom Chao, BS, Irvine, CA Neil F. Jones, MD, Los Angeles, CA Oswald Steward, PhD, Irvine, CA


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Meeting Abstracts

Objectives Chronic compression of the median nerve ator about the elbow has been described resulting from anumber of structures including the lacertus fibrosis.However, in these chronic cases, symptoms of com-p ressive peripheral neuropathy included achiness,paresthesias, numbness and a sense of weakness orfatigue with the onset being insidious and frequentlywithout a precipitating cause. This paper presents aseries of patients with acute median nerve compressiondifferent from the previously described series.

Methods A series of nine consecutive cases of acutemedian nerve compression in the antecubital fossa ispresented resulting from an extremely forceful injury tothe elbow. In all cases, a sudden severe attempt atelbow flexion was performed against a severe counterforce resulting in immediate severe pain radiating fromthe elbow down to the forearm. The pain was severe,persistent and unremitting and worsened with passiveelbow extension and forearm pronation. Duration ofsymptoms was 3–6 months until definitive diagnosiswas made. Multiple diagnoses including “elbow strain,”medial and/or lateral epicondylitis were erro n e o u s l yentertained and patients were treated with a variety of

modalities unsuccessfully prior to definitive treatment.Surgical decompression was performed in all cases.

Results Evidence was found at the time of surgery ofpartial rupture of the distal myotendinous junction of thebiceps brachia creating increased tension across themedian nerve by a tethered lacertus fibrosis. Commoncharacteristics found in all cases included: identifiableforced flexion injury against resistance; severe unremit-ting pain from the time of injury especially with resistedelbow flexion, passive extension and pronation, or directcompression over the antecubital fossa; evidence of par-tial rupture of the distal myotendinous junction of thebiceps at surgery; and prompt complete persistent reliefof symptoms following surgical decompression.

Conclusions Awareness of the potential for acute com-pression of the median nerve by the lacertus fibrosis fol-lowing a severe flexion injury can prevent erroneousdiagnosis and improper treatment. It can help the treat-ing surgeon differentiate this entity from the morec h ronic forms of compressive neuro p a t h y. Surg i c a ldecompression provides definitive management with apredictably effective outcome.


Clinical Session II

Paper #7

Acute Compression of the Median Nerve at the Elbow by the Lacertus Fibrosis

William H. Seitz, Jr., MD, Cleveland, OHHideaki Matsuoka, MD, Cleveland, OH

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Objectives Prospective study to investigate electrophysi-ological findings of the median nerve in distal radialmalunion before and after corrective osteotomy (withoutcarpal tunnel release) and their relationship to radiologi-cal parameters.

Methods 30 patients, referred to us for treatment of aradial malunion, underwent nerve conduction studies(distal motor nerve latency, sensor velocity, peak-to-peakamplitude of the sensor nerve action potential) of bothwrists by one board-certificated neurologist. Patientswith abnormal findings at the uninjured wrist (3), bilater-al abnormal findings (1) or with history of carpal tunnelrelease (2) were excluded from the study. 13 of theremaining 24 patients had abnormal findings at theinjured site. The nerve conduction studies of eachpatient were analyzed and graded according to severity.Grade 1=1 abnormal parameter, grade 2=2, grade 3=3abnormal parameters. Correlation coefficients were cal-culated to investigate the relationship between theseverity of electrophysiological impairment and findingson plain radiographs and CT-scans of the wrist. With useof statistical tests, the 13 patients with median nervealteration on the injured wrist were compared to the 11patients with bilateral normal electrophysiological findings.All patients underwent corrective osteotomy, but had nocarpal tunnel release. At the fellow-up examination, ten of

the 13 patients with preoperative median nerve alterationa g reed again to electrophysiological tests.

Results At the involved wrist, 6 patients had grade 1, 4grade 2, and 2 grade 3 severity of neurophysiologicalimpairment. There was no correlation between theseverity of electrophysiological impairment and findingson plain radiographs. There was a good, but positive cor-relation between the cross section area of the proximal(r=0.62) and distal (r=0.76) carpal tunnel at CT-scans andthe severity of neurophysiological impairment of themedian nerve. There were no significant differencesbetween patients with and without median nerve alter-ation at the injured wrist with respect to patients’ demo-graphic data, injury and primary treatment related data,and findings on plain radiographs. Surprisingly, the crosssection area of the proximal and distal carpal canal wassignificantly greater for patients with than for patientswithout median nerve irritation. At the follow-up, 6 ofthe 10 patients with electrophysiological re-examinationshowed improvement of the neurophysiological data (4with normal findings); in 3 patients the electrophysiolog-ical tests were unchanged and in 1 patient an impair-ment was found.

Conclusions Median nerve alteration can often be foundin malunited distal radial fractures. Radial correctiveosteotomy alone improves median nerve alteration.


Clinical Session II

Paper #8

Median Nerve Alteration in Malunited Fractures of the Distal Radius

Karl-Josef Prommersberger, MD, Bad Neustadt, GermanyUlrich B. Lanz, MD, Bad Neustadt, GermanyJörg van Schoonhoven, MD, Bad Neustadt, GermanyAlfred Baumgarten, MD, Bad Neustadt, Germany


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Meeting Abstracts

Objectives The significance of lost thumb opposition isconfirmed by the many different opponens transfers andmethods of attachment described as improving thumbfunction. Multiple investigators have simulated oppo-nens transfers and measured their effect on thumbmotion. No one has systematically examined the forceproduction at the thumb tip produced by these tendontransfers, although accurately directed force productionis functionally essential.

Methods (Please see figures 1–4 on page 10) Eight freshcadaveric hands were mounted to a fixation device thatstabilized the forearm and hand. The unrestrained thumbwas placed in a functional posture with the thumb tipaffixed to a six-axis dynamometer to measure force andtorque in three-dimensions. Four common tendon trans-fers (Royal-Thompson (RT), Bunnell (BUN), Burkhalter(EIP), and Camitz (PL) were simulated using two recom-mended insertions for each transfer, the AbductorPollicis Brevis alone (APB), and the Abductor PollicisB revis and Extensor Pollicis Longus combined(APB/EPL). 10 newtons were applied, and the force andtorque at the thumb tip measured. ANOVA statisticaltesting was applied.

Results In terms of thumb-tip force production, meanBUN, EIP, and PL transfers were statistically indistin-guishable when evaluated in the radial/ulnar and dor-sal/palmar (or flexion/extension) planes. The mean of RTtransfer, however, showed a distinctly different vectorwith more dorsally and less radially directed force. In theproximal/distal plane, however, RT and BUN transfers

produced equivalent distally directed thumb-tip forces;the EIP less. In contrast, PL transfers to the APB pro-duced significant proximally directed forces. APB/EPLinsertions produced greater dorsally directed force aswell as increased thumb pronation (torque) across alltransfers when compared to the APB insertion. TheAPB/EPL insertion dramatically alters force production ofthe PL transfer, where a previously strong radial-palmar-proximally directed force becomes radial-dorsally-distallydirected.

Conclusions In contrast to mean values, in individualhands, every transfer produced similarly directed andproportioned thumb tip forces, suggesting that intrinsicanatomy is of greater influence than transfer choice.While all transfers (except RT) produced adequateabduction forces, these transfers produced statisticallysignificant different forces in the proximal-distal planewhich may have under-appreciated functional conse-quences. For PL transfers, a dual insertion produces aless proximally directed force and there f o re morethumb-tip stability. The APB/EPL insertion produces sig-nificantly more pronation torque, and is recommended ifthis is deemed an important reconstructive goal.

References

Cooney WP, Linscheid RL, An KN. Opposition of thethumb: An anatomic and biomechanical study of tendontransfers. J Hand Surg 1984; 9A:777–786.

Roach SS, Short WH, We rner FW, Fortino MD.Biomechanical evaluation of thumb opposition transferinsertion sites. J Hand Surg 2001; 26A:354–361.


Clinical Session II

Paper #9

Tendon Transfers to Restore Thumb Opposition—A Biomechanical Study

Eric Chang, MD, Stanford, CAJoseph D. Towles, MS, Mountain View, CAMichael William Grafe, MD, Stanford, CAVincent R. Hentz, MD, Palo Alto, CA

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Clinical Session II

Paper #9 (cont.)

Tendon Transfers to Restore Thumb Opposition—A Biomechanical Study

Eric Chang, MD, Stanford, CAJoseph D. Towles, MS, Mountain View, CAMichael William Grafe, MD, Stanford, CAVincent R. Hentz, MD, Palo Alto, CA


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Figure 1APB

Thumb Tip Forces (Newtons)—APB Insertion

Dorsal1.5

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Radial/Ulnar and Dorsal/Palmer Plane

Royal-Thompson (RT)Bunnell (BUN)Burkhalter (EIP)Camitz (PL)

Palmar

Ulnar

Radial/Ulnar and Dorsal/Palmer Plane


Distal/Proximal and Dorsal/Palmer Plane


Distal/Proximal and Dorsal/Palmer Plane


Figure 2APB/EPL

Thumb Tip Forces (Newtons)—APB/EPL Insertion

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Figure 3APB—Proximal/DistalPlane

Thumb Tip Forces (Newtons)—APB Insertion

Dorsal

3

4

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Figure 4APB/EPL—Proximal/DistalPlane

Thumb Tip Forces (Newtons)—APB/EPL Insertion

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Meeting Abstracts

Paper #10

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Objectives This biomechanical study evaluated the func-tion of the scapholunate interosseous ligament (SLIL),radioscaphocapitate ligament (RSC) and scaphotrapezialligament (ST) and assessed the gap between thescaphoid and lunate.

Methods Sixteen specimens were evaluated. Trackingsensors were indirectly attached to the scaphoid, lunateand third metacarpal to measure angular and translation-al motion of these bones. Each wrist was physiological-ly moved using a wrist joint simulator. Carpal bonemotion data was collected in the intact specimen, andafter sectioning of the SLIL, RSC and ST in twosequences. Data was again collected after 1000 cyclesof motion following complete ligament sectioning tomimic continued use after injury. Restoration of normalkinematics by surgical reconstruction was tested.

Results Sectioning the RSC or ST produced no statisticalchanges in scaphoid or lunate angular position.Sectioning both the RSC and ST resulted in slight angu-lar changes to the scaphoid and lunate. Sectioning theSLIL alone resulted in scaphoid and lunate angularchanges during both wrist flexion/extension and wristradial/ulnar deviation. Sectioning the ST and RSC afterthe SLIL had been cut resulted in further changes. 1000cycles of motion caused more changes. Analysis of

translational changes in the carpal bones using 3-D visu-alization and animation software showed dramaticchanges in carpal bone motion after SLIL sectioning.Additional ligament sectioning resulted in an increasingdiastasis between the scaphoid and lunate. Based uponthese results, a surgical reconstructive procedure to cor-rect scapholunate instability was developed. The mini-mal distance between the scaphoid and lunate wasdetermined using this 3-D method. The length and posi-tion of this minimum distance changed depending uponwrist position and ligaments cut (Please see Fig. 1 onpage 12). A comparison was made between the actualminimal distance between the scaphoid and lunate andthe measurement of the gap between the scaphoid andlunate on a simulated 2-D x-ray. It was found that the 2-Dgap measurement may inaccurately assess ligamentousstability of the scaphoid and lunate (Fig. 2A,B).

Conclusions The SLIL was found to be the major stabiliz-er of the scaphoid and lunate. The RSC and ST are sec-ondary supporting structures. Cyclic motion followingligament injury resulted in further changes in carpal kine-matics. Changes in carpal bone position are much betterdetected using 3-D visualization techniques. The accura-cy of measuring a scapholunate gap on a 2-D x-ray isquestioned.

Friday, September 19 8:00 a.m.

Clinical Session III

Paper #10

Evaluation and Diagnosis of Scapholunate Instability

Walter H. Short, MD, Syracuse, NYFrederick W. Werner, MME, Syracuse, NYJason K. Green, BS, Syracuse, NYShunji Masaoka, MD, Syracuse, NY

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Paper #10 (cont.)

Evaluation and Diagnosis of Scapholunate Instability

Walter H. Short, MD, Syracuse, NYFrederick W. Werner, MME, Syracuse, NYJason K. Green, BS, Syracuse, NYShunji Masaoka, MD, Syracuse, NY

Figure 1—Minimum Distance Between Scaphoid and Lunate

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Meeting Abstracts

Objectives Radiographic and arthroscopic findings of ac o h o rt of 104 patients with acute or chronic wrist painin the area of the scapholunate articulation have beencorrelated.

M e t h o d s Static and dynamic X-rays, and wrist art h ro s c o p ywas done for each patient. The following X-ray findingsw e re noted: scapholunate space, radiolunate andscapholunate angles, carpal height, distal radioulnarindex and projected scaphoid height in radial and ulnardeviation. The following art h roscopic findings werenoted: estate of the scapholunate ligament, estate ofthe articular surfaces, severity of the scapholunate insta-bility according to the Dautel’s arthroscopic score, andeventually associated lesions.

Results According to the radiographic classification therewere 30 static instabilities, 28 dynamic instabilities, 33preradiographic instabilities and 13 patients presentingno instability. According to the art h roscopic classification,there were 32 stage 3, 52 stage 2, 7 stage 1 and 13stage 0. When the arthroscopic score of severity is com-

pared to the radiographic classification, in stage 1 thereis 86% of preradiographic and 14% of dynamic instabili-ties. In stage 2: 52% of preradiographic, 38% of dynamicand 10% of static instabilities. In stage 3: 22% ofdynamic and 78% of static instabilities. The articularlesions are never retrieved in the stages 0 and 1. In thestage 2, the proximal pole of the scaphoid shows art i c u l a rdefect in 3 cases (6%) and the proximal pole of the luna-tum in 2 cases (4%). In the stage 3, articular lesions areretrieved in 11 cases (34%) including 5 cases of articulardefect of the capitolunate articulation.

Conclusions The goal of this work is to show that arthro-scopic classification of scapholunate instability is muchmore accurate and close to the reality than radiographicclassification. Wrist arthroscopy is not only able to testin a dynamic way the scapholunate joint, but can alsodetect articular lesions a long time before the radi-ographs. We believe that wrist arthroscopy is a part ofindispensable exams in the balance of the scapholunateinstabilities and of the wrist pain without radiographicevidence generally.



Paper #11

Correlation Radiography—Arthroscopy in the Scapholunate Instability

Nicolas Dreant, MD, Nice, QC, CanadaThierry Balaguer, MD, Nice, QC, CanadaMiroslav Veliky, MD, Nice, QC, CanadaGilles Dautel, MD, Nancy, France

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Objectives Scapholunate (s-l) instability is the most com-mon form of carpal instability. The treatment of this dis-order is challenging and varying treatment options havebeen described, including intercarpal arthrodesis anddorsal capsulodesis. However, treatment of chronicscapholunate dissociation remains unsatisfactory. Wewished to examine the long-term results of ligamentousrepair and capsulodesis alone for cases of chronicscapholunate dissociation.

Methods A retrospective analysis was preformed on 398wrist procedures preformed between January 1990 andFebruary of 2000. 31 patients were identified with iso-lated chronic s-l dissociation, being defined as wrist painp resent for greater than 3 months. All patients underw e n tdirect scapholunate repair in conjunction with a dorsalcapsulodesis procedure. Dorsal capsulodesis was pre-formed with either a modified Blatt technique or with aMayo method of using a portion of the dorsal interc a r p a lligament attached to the lunate. Results were reviewedclinically and radiologically. Static and dynamic instabilitywas defined by radiological and established art h ro s c o p i ccriteria. Patients had to have a minimum follow-up oftwo years for inclusion in the study.

Results Of the 31 patients, 18 had dynamic lesions and13 had static lesions. 20 were men and 11 were

women. Average age at the time of surgery was 38years, (range 17-76). The average time from injury tosurgery was 20 months. Average length of follow upwas 54 months (4.5 years). Post-operatively wristmotion was 64% of normal and average grip strengthwas 83% of the normal hand. There was a 24%decrease in wrist motion following capsulodesis. Allpatients had improvement in pain, but only two patientswere pain free. Average s-l gap increased on follow-upfrom 2.75 mm pre-operatively to 3.85 mm post-opera-tively. Scapholunate angle also increased from 56 to 61degrees. Average Mayo wrist score was 73. There wasno statistical difference in overall wrist motion, gripstrength or wrist score between the dynamic and staticgroup. Of the 31 patients, only nine had either good orexcellent results. Time to surgery and age had no signif-icant effect on overall outcome. There was no direct cor-relation between post-operative s-l gap, s-l angle, orradio-lunate angle on outcome.

Conclusions In conclusion, repair of the scapholunate lig-ament with dorsal capsulodesis did provide pain relief inthe majority of patients. Though pain is improved, it isunresolved in most patients. Patients should be advisedthat pain will most likely still be present and wrist motionwill be decreased.



Paper #12

Capsulodesis for Chronic Scapholunate Instability

Steven L. Moran, MD, Rochester, MNJustin Strickland, MD, Rochester, MNWilliam P. Cooney, MD, Rochester, MNRichard A. Berger, MD, PhD, Rochester, MN


Paper #12

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Meeting Abstracts

Objectives The evaluation of chronic wrist pain can be adiagnostic dilemma. Lidocaine injections combined withcorticosteroids are often used for both therapeutic aswell as diagnostic purposes. The purpose of this studywas to determine if a midcarpal injection of lidocainecould serve as a diagnostic tool in patients with chronicwrist pain. Specifically, the relationship of pain relieffrom the injection and improvement of grip strengthwere compared to the presence of intracarpal pathologyas confirmed by wrist arthroscopy.

Methods Forty-five patients with chronic wrist painunderwent a midcarpal injection of lidocaine with orwithout cort i c o s t e roids. Improvement of pain andimprovement of grip strength were determined. Each ofthese patients subsequently underwent a radiocarpaland midcarpal arthroscopy, and the pathologic findingsof arthroscopy were compared to the improvement ofpain and grip strength. These data were compared to acohort of six volunteers without history of wrist pain ortrauma that underwent midcarpal injection of lidocaine.Statistical analysis was perf o rmed using Receiver-Operator-Characteristic analysis.

Results The average age of the patients with chronic painwas 30.3 years, with an average of 9.8 months of wristpain. The ultimate diagnoses included 35 patients withcarpal instability dissociative, 2 with nondissociativeinstability, 7 with complex instability of the carpus, 3with extensor carpi ulnaris tendonitis and 1 withdeQuervain’s tenosynovitis. After lidocaine injection, the

normal cohort had a mean loss of 2 kg (-5.3%) (p=0.02)in grip strength whereas the experimental cohort had amean improvement in grip strength of 5.73 kg (34.4%).Improvement of pain after injection did not correlatewith pathologic art h roscopic findings (p=0.92).Improvement in grip strength after midcarpal lidocaineinjection of 6 kg or 28% had a 73% sensitivity and a70% specificity (p=0.02) of having intracarpal pathologyat the time of arthroscopy. Of the chronic wrist painpatients, only 4 had a normal arthroscopy, and theremainder had at least one area of significant pathologyattributing to their pain. Please see graph on page 16.

Conclusions We conclude that a midcarpal injection oflidocaine can serve as an effective diagnostic tool in theevaluation of the patient with chronic wrist pain.Improvement of grip of 28% with or without relief ofpain is highly correlated with intracarpal pathology.

References

Crawford RW, Ellis AM, Gie GA, Ling RSM. Intra-articu-lar local anaesthesia for pain after hip arthroplasty. JBone Joint Surg 1997: 79-B: 796–800.

C r a w f o rd RW, Gie GA, Ling RSM, Murray DW.Diagnostic value of intra-articular anaesthetic in primaryosteoarthritis of the hip. J Bone Joint Surg 1998: 80B:279–281.

Khoury NJ, El-Khoury, GY, Saltzman CL, Brandser EA.Intraarticular Foot and Ankle Injections to Identify Sourceof Pain Before Arthrodesis. AJR 1996; 167:669–673.



Paper #13

The Diagnostic Utility of Midcarpal Anesthetic Injection in the Evaluation of ChronicWrist Pain

Alexander Y. Shin, MD, Rochester, MNS. Josh Bell, MD, San Diego, CASteven L. Moran, MD, Rochester, MN

Paper #13

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Paper #13 (cont.)

The Diagnostic Utility of Midcarpal Anesthetic Injection in the Evaluation of ChronicWrist Pain

Alexander Y. Shin, MD, Rochester, MNS. Josh Bell, MD, San Diego, CASteven L. Moran, MD, Rochester, MN


Paper #13

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Grip Strength Change (%) for All Patients: Sensitivity vs. Specificity

-50 200150100500

Grip Strenght Change (%)

Sensitivity

Specificity

1.0

0.8

0.6

0.4

0.2

0.0

1.0

0.8

0.6

0.4

0.2

0.0

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Meeting Abstracts

Paper #14

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Objectives The purpose of this study was to obtain qual-itative and quantitative information regarding capitate-based kinematics of the midcarpal joint during wristradio-ulnar deviation using an MRI-based in vivo 3-dimensional (3D) motion analysis.

Methods We studied the in vivo kinematics of the mid-carpal joint during wrist radioulnar deviation in the rightwrists of 5 volunteers, using a technology withoutradioactive exposure. The MRI images were acquiredduring radioulnar deviation with 10° increments. Surfacemodels of all carpal bones were obtained by applying a3D surface generation using the marching cubes tech-nique. The capitate was registered with the scaphoid,the lunate, and the triquetrum using the iterative closestpoint algorithm, and then animations of the relativemotions were created. Accurate estimates of the re l a t i v epositions and orientations of the bones and axes of ro t a-tion (AORs) of the motions from extreme wrist radialdeviation to extreme ulnar deviation were obtained.

Results The averaged AORs of the scaphoid, the lunate,and the triquetrum relative to the capitate were locatedclosely in space, running obliquely from the radiopalmaraspect of the distal scaphoid to the ulnodorsal aspect ofthe hamate penetrating the waist of the capitate (Figure1), while there was minor relative motion among theproximal row bones. During wrist radial deviation, thescaphoid, the lunate, and the triquetrum ro t a t e dradiodorsally relative to the capitate. The converse wastrue during wrist ulnar deviation. The average range ofmotion of the scaphoid, the lunate, and the triquetrumaround their own axes were 40.3°+6.2°, 48.5°+9.0°, and35.6°+5.1°, respectively.

Conclusions This study is the first to report the in vivo 3Dmeasurements of midcarpal motion relative to the capi-tate. Despite minor intercarpal motion and individualvariance, the overall isolated midcarpal motion duringradioulnar deviation could be approximated to be aradiodorsal-ulnopalmar rotation.



Paper #14

Capitate-Based Kinematics of the Midcarpal Joint during Wrist Radioulnar Deviation

Hisao Moritomo, MD, Osaka, JapanTsuyoshi Murase, MD, Osaka, JapanAkira Goto, MD, Osaka, JapanYoshinobu Sato, PhD, Osaka, Japan

Figure 1. Axes of rotation (AORs) of the scaphoid, the lunate, and the triquetrum relative to the capitate during wrist radioulnar deviation. AllAORs run obliquely from the radiopalmar aspect of the distal scaphoid to the ulnodorsal aspect of the hamate penetrating the waist of the capitate.

A. Dorsal View B. Palmar View C. Proximal View

AOR of scaphoid motion

AOR of lunate motion

AOR of triquetrum motion

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O b j e c t i v e s Carpal bones exhibit hysteresis that isdependent upon the direction of wrist motion during acontinuous active loading protocol. In spinal biomechanics,neutral zone (NZ) has been a sensitive parameter ford e t e rmining instability. This paper’s purpose is to developan accurate methodology for computing the carpal NZfrom its hysteresis effect and to apply this model todetermine scapholunate instability during sequential lig-ament sectionings.

Methods Carbon rods were placed in the scaphoid,lunate, and third metacarpal of eight specimens. A wristjoint simulator provided continuous active motion in flex-ion-extension (FE) and radial-ulnar deviation (RUD).Motion was analyzed for the intact state and aftersequential sectioning of the SLIL, STT ligaments, andRSC ligament. Carpal motion was plotted with respectto the third metacarpal. Regression analysis using sixtydifferent equations determined that polynomials best fitthe data. An F test (a < 0.01) was used to minimize poly-nomial order, while still retaining accuracy. NZ was cal-culated by computing the hysteresis area between thetwo curves that represent opposite directions of wristmotion. A larger area corresponds to a larger NZ. The NZof three planes of motion were summed to give the totallaxity or global neutral zone (GNZ). Repeated measuresANOVA was used to determine significance (a = 0.05).

Results In the RUD trials, scaphoid GNZ after SLIL sec-tioning was significantly greater than intact GNZ (Fig 1).In four specimens, lunate GNZ decreased upon sequen-tial sectionings. These four had significantly greaterintact GNZ than the other four specimens. Further analy-sis of these four specimens found lunate GNZ after SLILsectioning was significantly greater than intact GNZ. Inthe FE trials, all three sectionings were required beforeGNZ increased significantly.

Conclusions We showed how to compute NZ from thehysteresis effect. This analysis can be used in futurestudies as a sensitive technique to determine the onsetof abnormal carpal motion. Using this technique in a lig-ament sectioning study, we found significant increasesin the GNZ after just SLIL sectioning during wrist RUD.This subtle change may signify dynamic scapholunateinstability found during diagnostic wrist arthroscopywhich can result from isolated SLIL rupture before radi-ographic diastasis. Also, we found GNZ lunate in somespecimens not to increase after ligament sectioning.This divergent behavior may explain why not all patientswith scapholunate instability develop DISI.



Paper #15

The Hysteresis in Carpal Motion

Sunjay Berdia, MD, Rockville, MDWalter H. Short, MD, Syracuse, NYFrederick W. Werner, MME, Syracuse, NYManohar M. Panjabi, PhD, New Haven, CT


Paper #15

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Figure 1. Global Neutral Zone for the Wrist RUD Trials

130

120

110

100

90

80

70

60

50

40

30

intact1 intact slil slilstt sillisttrsc

* **

* = p<0.05

Scaphoid

Lunate

Sequential Ligament Sectioning Trials

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Meeting Abstracts

Paper #16

19

Objectives A large, multicenter series of patients withdocumented Preiser’s disease is reviewed in order tobetter understand the clinical patterns and natural historyof the condition.

Methods Twenty-three patients with Preiser’s disease,representing 24 cases, were identified from 3 institu-tions. Using magnetic resonance imaging (MRI) criteria,2 disease patterns were clearly observed; diffuse necro s i sand/or ischemia of the scaphoid (Type 1 disease—15cases), and segmental vascular impairment (Type 2 dis-ease—9 cases). The two groups of patients were similarwith respect to age, sex, and hand dominance. Risk fac-tors for osteonecrosis, treatment methods, and serialradiographs were reviewed in all cases, and 19 patientsw e re examined for the purpose of this study at an averagefollow-up of 35 months.

Results MRI signal changes of necrosis and/or ischemiainvolved 100% of the scaphoid in Type I cases and 43%in Type 2 cases (range 33–66%; p<0.01). In Type 1

cases, re g a rdless of the treatment employed, thescaphoid typically fragmented and collapsed. In Type 2cases, scaphoid architecture was minimally altered fol-lowing similar treatment methods. A history of wristtrauma was significantly more common in Type 2 dis-ease, and the results of the treatment were generallybetter in this group of patients (Mayo modified wristscore 88 points versus 58 points).

Conclusions This study supports the concept of 2 pat-terns of scaphoid involvement in Preiser’s disease. Type1 cases are characterized by MRI signal changes ofnecrosis and/or ischemia involving the entire scaphoidbone. Patients in this group have a propensity forscaphoid deterioration, regardless of the treatment insti-tuted. Type 2 cases have MRI signal changes involvingonly part of the scaphoid. These patients commonlyreport a history of wrist trauma, demonstrate fewer ten-dencies toward scaphoid fragmentation, and may have amore favorable clinical outcome.



Paper #16

Preiser’s Disease: Identification of Two Patterns

David M. Kalainov, MD, Chicago, ILMark S. Cohen, MD, Chicago, ILRonald W. Hendrix, MD, Chicago, ILA. Lee Osterman, MD, King of Prussia, PA

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Objectives Roles of radial osteotomies in the treatmentof advanced Kienböck’s diseases were evaluated.

Methods Eighteen patients with Lichtman’s stage lllBKienböck’s disease were treated with radial osteotomiesconsisting of both methods of radial shortening and lat-eral closing radial wedge osteotomy. There were radialshortenings in eight patients, and lateral closing radialwedge osteotomies in ten. There were no preoperativedifferences with respect to age and gender betweenboth osteotomy groups (Table 1). The period of follow-upranged from 36 to 108 months with an average of 48months. Clinical evaluations were based on a modifica-tion of the scoring system of Nakamura et al. (Table 2).

Results All patients in both groups had either good orexcellent results, clinically (Table 3, page 20). Radiograph-i c a l l y, the radioscaphoid angle significantly increased andthe Stahl index significantly decreased in the lateral closingradial wedge osteotomy group. The pro g ression ofdegenerative changes at the radioscaphoid joint wasobserved in two of ten patients in this osteotomy group.On the contrary, progression of any radiographic param-eters and occurrence of degenerative changes were notobserved in radial shortening group.

Conclusions Although radiographic progression occurredafter the lateral closing radial wedge osteotomy, bothosteotomy pro c e d u res provided satisfactory clinicalresults in the treatment of stage lllB Kienböck’s disease.


Clinical Session I

Paper #17

Is There a Role for Radial Osteotomy in Advanced Kienböck’s Disease?

Akio Minami, MD, Sapporo, JapanHiroyuki Kato, MD, Sapporo, JapanNorimasa Iwasaki, MD, Sapporo, Japan


Paper #17

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Table 1. All Data of Patients

Average age, y Gender Site Average follow-up period, mos

Radial shortening group (n=8) 32 (17–59) 4 men, 4 women 3 right, 5 left 55 (36–108)

Radial wedge osteotomy group (n=10) 36 (13–60) 7 men, 3 women 8 right, 2 left 45 (36–66)

Points

Pain in the Wrist

None............................................................................10

Mild with strenuous activity............................................7

Mild with light work ........................................................4

Grip Strength (percentage of unaffected side)

90% ..............................................................................5

80% ..............................................................................4

70% ..............................................................................3

60% ..............................................................................2

50% ..............................................................................1

Table 2. Scoring System for the Assessment of Clinical Results (6)

Points

Increase in Range of Extension-Flexion Arc

>20˚ ..............................................................................6

>10–19˚ ........................................................................5

<5–9˚ ............................................................................3

Overall Grade (total points)

Excellent................................................................15–21

Good........................................................................9–14

Fair/Poor......................................................................<8

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Meeting Abstracts


Clinical Session I

Paper #17 (cont.)

Is There a Role for Radial Osteotomy in Advanced Kienböck’s Disease?

Akio Minami, MD, Sapporo, JapanHiroyuki Kato, MD, Sapporo, JapanNorimasa Iwasaki, MD, Sapporo, Japan

Paper #17

21

Table 3. Clinical Results in Each Osteotomy Group

Preop Postop

Radial Shortening Group

Range of wrist extension-flexion arc of the wrist 94 ± 31º 114 ± 25º

Percentage grip strength of unaffected side 44 ± 24% 87 ± 20% *

Clinical score (–) 17 ± 4

Radial Wedge Osteotomy Group

Range of wrist extension-flexion arc of the wrist 92 ± 32º 118 ± 30º †

Percentage grip strength of unaffected side 63 ± 30% 81 ± 20% †

Clinical score (–) 16 ± 4

Mean ± SD.

* P<0.001 preop versus postop

† P<0.5 preop versus postop

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Objectives The purpose of this study is to determine if apost-surgical humpback deformity adversely affects thefunctional outcome of patients who are treated withstructural bone grafts for scaphoid waist nonunions.

Methods 25 adult patients with documented scaphoidwaist nonunions were subjects in this study. Inclusioncriteria are the requirement of a pre and post-operativeCT, volar surgical approach, application of a structuralwedge of iliac crest graft, fixation via Kirschner wires,and follow-up of a minimum of 12 months. The opera-tions were performed in the same manner in each casevia a modified Russe approach. CT specificallya d d ressed the following parameters: intrascaphoidangle, height/length ratio and scapholunate angle.Questionnaires documented patient satisfaction, pain,and Patient Rated Wrist Evaluation scores. Furthermore,physical examination was carried out for range ofmotion, grip strength of both the affected wrist and con-tralateral wrist for control purposes. Statistical tests,including regressional analysis, were carried out forabove parameters.

Results Mean time of follow-up was 31 months. Allscaphoids healed and the mean subjective satisfactionwas 8.3 out of 10. Mean flexion-extension and gripstrength were respectively 88.1 and 90.6% compared tocontralateral wrist. There was a mean correction ofintrascaphoid angle of 10.6° (13.0%), mean correction ofscapholunate angle of 9.7° (14.9%), and mean improve-ment in scaphoid length of 12.0%. The correlationbetween final intrascaphoid angle and percentage ofwrist flexion-extension was moderately significant at p =0.49. However, the intrascaphoid angle only explains24% of the variability in the final flexion-extension arc.The other factors contributing to final arc of flexion-extension are unknown. The percentage change inscaphoid length and and percentage grip strength ismoderately significant, p=0.56. Regression analysisshows that only 31% of the variability in final gripstrength is explained by the post-surgical scaphoidlength.

C o n c l u s i o n s A post-surgical humpback deformity follow-ing scaphoid nonunion grafting does not predict a poore rfunctional outcome. The correlation between clinical andradiographical parameters is generally poor.



Paper #18

Radiographic and Clinical Analysis of Structural Bone Grafting for Scaphoid Nonunions

Vikas Tuli, MD, Thornhill, ON, CanadaRobert S. Richards, MD, London, ON, CanadaJohn D. Bennett, MDCD, London, ON, CanadaJames H. Roth, MD, London, ON, Canada


Paper #18

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Meeting Abstracts

Objectives Bone grafting of scaphoid non-union canrequire five months of immobilization. Bone graftingwith internal fixation has a high rate of union with short e rimmobilization, but is technically demanding. In addition,bony union does not necessarily yield a functional pain-less wrist. Flexor carpi radialis (FCR) interposition strivesto make the scaphoid non-union functional and painlesswithout achieving union. Bentzon used a dorsal soft tissueflap interposed between two poles of the scaphoid withexcellent long term results. We theorized that the FCR,typically used for the “anchovy” procedure would pro-vide more soft tissue than Bentzon’s dorsal flap.Additionally, the FCR interposition would allow a volarapproach thus avoiding the scaphoid’s dorsal arterialsupply.

Methods We retrospectively reviewed the results of 12patients who underwent FCR interposition for scaphoidnon-union between 1983 and 1999. Two patients wereexcluded: One was lost to follow-up and the other hadmultiple concomitant fractures. Range of motion, gripand pinch strength, pain and occupational status wereobtained from the remaining ten patients.

Surgical Technique Through a volar incision the scaphoidnon-union is exposed. The pseudoarthrosis is excised,trimming back abutting margins of the proximal and dis-tal poles to avoid impingement between the two poles.FCR is cut longitudinally, remaining distally attached. Thetransferred portion of FCR is placed between the proxi-mal and distal poles, creating a two-bone scaphoid. Thecapsule is repaired to hold the FCR anchovy in place, and

the incision sites are closed. Motion of the wrist isallowed once wound healing has occurred.

Results The patients were all male with a mean age of22 years (range 18-35). Mean time from injury to surgerywas 325 days (range 102-1296). Mean follow up was10.4 years (range 0.7-17.4). Motion was initiated at amean of 17 +/- 8 days following surgery. At most recentfollow-up, compared to contralateral wrist, range ofmotion was 87% +/- 7%, grip strength was 94% +/-17%, pinch strength was 104% +/- 16%. All patientsreturned to full work. 80% of patients report no pain,20% report occasional pain, 0% of patients report per-sistent pain.

Conclusions FCR interposition for scaphoid non-union hasresulted in excellent long term results at greater thanten years of follow up. FCR interposition is a technicallysimple pro c e d u re. This pro c e d u re is particularly attractivefor a patient who is unwilling to endure a long immobi-lization period.

References

Bentzon PGK, Randlov-Madsen A. On fracture of thecarpal scaphoid. Acta Orthopaedica Scandinavica. 1945;16: 30–39.

F roimson AI. Tendon Art h roplasty of theTrapeziometacarpal Joint. Clin Orthop. 1970 May–June;70: 191–199.

G e l b e rman RH, Menon J. The Vascularity of theScaphoid Bone. J Hand Surg [Am]. 1980 Sep; 5(5):508–513.



Paper #19

Long Te rm Results Treating Scaphoid Non-Union with Flexor Carpi Radialis Interposition

Mitchel A. Lipton, MD, Phoenix, AZCarter B. Lipton, MD, New York, NY

Paper #19

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Objectives Vascular imaging may be necessary to assistp reoperative planning in re c o n s t ructive surg e ry.S t a n d a rd arteriography may lead to complications re l a t e dto arterial puncture, including hematoma, pseudoa-n e u rysm, arteriovenous fistula, and thrombosis. CTangiography [CTA] is a new technique that provides highresolution, three dimensional vascular imaging in additionto excellent bone and soft tissue spatial re l a t i o n s h i p s .The purpose of this study was to examine the utility ofCTA in complex upper extremity reconstruction.

Methods Seventeen CT angiograms were performed onfourteen patients evaluated for microsurgical recon-struction of the upper extremity from 2000 to 2002.Average patient age was 37 years (range 5 to 65), 8patients were male and 6 were female. Twelve wereundergoing reconstruction of traumatic injuries, 6 ofwhich were acute. The intravenous administration ofcontrast dye was performed through a small peripheralIV. No arterial puncture was necessary. Nine studieswere utilized to evaluate the recipient anatomy, 3 were

utilized to evaluate potential free fibula donor sites, and5 to evaluate vascular insufficiency.

Results CT angiograms were useful for clinical decision-making in all cases. Six patients had abnormal peripher-al vascular exams which were confirmed by CTA. Twopatients with normal pulse exams were found to havesignificant abnormalities on CTA. CTA and intra-operativefindings correlated well in all operative cases. Therewere no complications related to CTA studies or recon-structive operations. Patients were extremely satisfiedwith the ease and speed of the CT angiogram procedureitself. Cost analysis at our institution found the averagecost of CTA to be $1,140 versus $3,900 for traditionalangiography

C o n c l u s i o n s We have found CTA to be useful in pre o p e r-ative planning in cases of upper extremity re c o n s t ru c t i o n .It is a safe, well tolerated, and cost effective pro c e d u rethat provides superior anatomic information and offers afavorable alternative to standard angiography.

Friday, September 19 1:45 p.m.

Clinical Session IV

Paper #20

CT Angiography in Upper Extremity Reconstruction: Outcomes and Cost Analysis

Michael Bogdan, MD, Mountain View, CAGeoffrey D. Rubin, MD, Stanford, CATimothy R. McAdams, MD, Palo Alto, CAJames Chang, MD, Stanford, CA


Paper #20

24

Proximal radius defect

Monteggia fracturewith bone loss

Calcified lower extremity runoff vessels

Ulnar artery occlusion

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Meeting Abstracts

Objectives The natural history of Dupuytren’s nodules isunknown. This investigation was designed to evaluatethe pro g ression of nodules at greater than five yearsf o l l o w - u p .

Methods Ninety-six patients with isolated Dupuytren’snodules were identified and 59 returned for repeat phys-ical examination at average follow-up of eight years.Patients were questioned regarding: family history ofDupuytren’s disease, family genealogy, alcohol con-sumption, smoking, liver disease, seizures, diabetes,signs of systemic disease such as plantar nodules, anddisease progression. Physical examination evaluatedrange of motion of the finger joints, location of the dis-ease, and pain.

Results Fifty-one percent of the patients (30/59) with pre-viously diagnosed isolated nodules developed a cord. In13% of patients (12/90), either a new nodule or corddeveloped in the previously disease-free hand. Fifty- fourpercent of patients had a European heritage, 23% had afamily history of Dupuytren’s disease, 11% drank alco-hol regularly, and 9% were diabetic. Five patients (8%)

lost extension, with an average loss of 60º at the MCPjoint and 40º at the PIP joint. Ten patients (17%) under-went surgical intervention for either loss of motion orpain. Three of the ten patients had a flexion contractureof the MCP or PIP joints averaging 50º. The other sevenu n d e rwent surg e ry for persistent pain related to a noduleor cord (without contracture) that had been present foran average of 2.3 years. All surgically treated patientshad at least one risk factor and seven had more than onerisk factor. In seven patients, the Dupuytren’s nodulehad disappeared at the time of latest follow- up.

Conclusions The progression of the nodular form ofDupuytren’s disease to cord-like disease is common butnot inevitable. This evaluation of the natural history ofD u p u y t re n ’s nodules has demonstrated that at an averageeight years after diagnosis with Dupuytre n ’s nodules, only8% (5/59) of patients lost extension and only one in fivepatients underwent surgery. The majority of nodulesw e re painless; however, 12% (7/59) were painful andw e re excised. The nodules disappeared in twelve perc e n tof patients.


Clinical Session IV

Paper #21

The Natural History of Dupuytren’s Nodules

Rachel Reilly, BA, Cincinnati, OHPeter J. Stern, MD, Cincinnati, OHCharles A. Goldfarb, MD, St. Louis, MO

Paper #21

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Objectives To introduce the new technique of using prox-imally locked flexible intramedullary nails for fixation ofmetacarpal and phalangeal fractures.

Methods Extra-articular metacarpal and phalangeal frac-tures including those with spiral patterns or segmentalcomminution were treated with close fluoroscopicallyassisted reduction and locked percutaneous flexiblenails. A manually operated slotted awl was used for nailinsertion and proximal locking was provided by a cap-tured transverse pin. The nails were routinely removedafter fracture healing. Standard principles of hand reha-bilitation including early motion and splinting were usedin the post-operative period.

Results We reviewed retrospectively 84 consecutivepatients treated at our center with this technique

between July 1999 and June 2000. We were able to fol-low 73 patients for a minimum of one year. There were45 metacarpal and 28 phalangeal fractures. All fractureshealed. There were no rotational deformities or significants h o rtening. Metacarpal fractures generally re c o v e red fullrange of motion. Average total active motion for pha-langeal fractures was 240. Loss of PIP joint extensionwith proximal phalanx fractures averaged 15 deg.Complications consisted of delayed healing (>8weeks)due to distraction in one metacarpal and one phalangealfractures and two cases of tendon irritation over thebase of the 4th metacarpal.

Conclusions Locking miniature flexible intramedullarynails increases their power of fixation and expands theirindications. Comminuted and spiral fractures can nowbe effectively stabilized with this percutaneous technique.


Clinical Session IV

Paper #22

Locked Percutaneous Intramedullary Nailing of Metacarpal and Phalangeal Fractures

Jorge L. Orbay, MD, Miami, FLAlejandro Badia, MD, Miami, FLRoger K. Khouri, MD, Miami, FLEduardo Gonzalez-Hernandez, MD, Miami, FL


Paper #22

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Meeting Abstracts

Objectives Type 0 radial clubhand as described by Jameset al. includes normal radial length with absent or abnor-mal radial carpal bones. The purpose of our study wastwo-fold: 1) to describe the pathologic anatomy associ-ated with type 0 radial clubhand and 2) to report theresults of a surgical procedure designed to improve thealignment of the hand and forearm.

Methods Since 1986, six cases of type 0 radial clubhandin five children seen at the St. Louis Shriner’s Hospitalwere treated with a new procedure. Age at operationranged from 12 to 40 months with an average of 21months. Average follow-up was 21 months. In eachcase, the extensor carpi ulnaris (ECU) tendon wasdetached just proximal to its insertion and sutured to thedorsal wrist capsule to augment wrist extension. The radi-al wrist extensor tendon was also divided and re a t t a c h e dto the distal ECU stump, relieving the radial tether andconverting it into an ulnar deviator. Patients were immo-bilized for 4-6 weeks postoperatively and then begun onrange of motion exercises afterwards.

Results In each case, it was noted that the radial wristextensor was dysplastic in appearance and tethered thehand in radial deviation. In four cases there was only a

single radial wrist extensor tendon. Preoperative radialdeviation at rest averaged 58°, ranging from 35° to 90°.Postoperative radial deviation at rest averaged 12°, rangingf rom 0° to 25°. Improvement in resting posture averaged51°, ranging from 35° to 75°. Improvement of active wristextension averaged 35°, ranging from 15° to 55°. Therewere no complications.

Conclusions According to James et al., 24% of radialclubhands are classified as type 0. We believe that mostchildren with type 0 clubhand do not require an inter-vention since the hand is not held in radial deviation. Inour patients who had poor alignment of the hand andforearm, it was noted at surgery that the radial wristextensor was dysplastic and exerted a tethering forceacross the wrist. For these children, a simple procedureto release this tether and convert it into an ulnar deviatorand augment the function of the ECU tendon as a wristextensor improves alignment with minimal morbidity.

References

James MA, McCarroll HR Jr, Manske PR. The Spectrumof Radial Longitudinal Deficiency: A ModifiedClassification. J Hand Surg 1999; 24A: 1145–1155.


Clinical Session IV

Paper #23

Surgical Treatment for Type O Clubhand

Josephine Huang, MD, St. Louis, MOPaul R. Manske, MD, St. Louis, MO

Paper #23

27

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Objectives Elbow function can be quantified using com-prehensive elbow rating systems and health statusq u e s t i o n n a i res. This study attempted to determine whichpatient factors contribute most to the scores derived fromthese research tools.

Methods Under an IRB-approved protocol, 125 patientswith elbow dysfunction were evaluated with thre eelbow evaluation systems (Mayo Elbow PerformanceIndex [MEPI], Broberg and Morrey [B/M], and AmericanShoulder and Elbow Surgeons [ASES] and both upperextremity specific (DASH) and general (SF-36) health sta-tus questionnaires. Stepwise multiple linear regressionwas used to measure the proportion of the scoresderived from these research tools that was due to pain,ulnohumeral motion, forearm rotation, arthrosis, andulnar neuropathy.

Results Models including pain alone were twice as goodas models including motion alone at predicting DASHand SF-36 scores (38% vs. 21% and 35% vs. 16%) andthe inclusion of both factors only slightly improved the

success of the models (44 and 38%) over those includingpain alone. Pain was also the dominant factor in modelsto determine MEPI and B/M scores (65% vs. 33% and61% vs. 44%), whereas ASES scores were equally wellpredicted by pain (54%) and motion (59%). Both healthstatus measures and elbow evaluation systems hadmoderate to good correlation with one another (r=0.53to 0.89), but only fair correlation with objective factors(ulnohumeral motion [r=0.37], forearm rotation [r=0.42]).

Conclusions The influence of pain was far greater thanobjective factors on most elbow evaluation systems andhealth status questionnaires. This is pro b l e m a t i cbecause the experience and expression of pain isstrongly influenced by psychological and sociologicalfactors and is not always explained by objective factors.This has two important implications for the study ofelbow problems: 1) objective improvements in elbowfunction achieved by operative procedures may bedevalued by the use of these systems, and 2) a betterunderstanding of the diff e rences between the subjectiveand objective perception of elbow function is needed.

Saturday, September 20 7:45 a.m.

Clinical Session V

Paper #25

Pain Dominates Measurements of Elbow Function and Health Status

Lauren M. Fabian, BA, Boston, MADavid C. Ring, MD, Boston, MALeah Fourt, BA, Boston, MAJesse B. Jupiter, MD, Boston, MA


Paper #25

28

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Meeting Abstracts

Objectives Review clinical presentation, radiographs,operative/histologic findings, and results of surg i c a ltreatment of partial ruptures of distal biceps tendon.

Methods From 1996 to 2001, 111 distal biceps tendonsin 101 patients were re-attached by one surgeon using amodified anterior approach. 30 had partial ruptures.P a rtial ru p t u res were incompletely attached to the radialt u b e rosity and could not be detached from the tubero s i t ywith blunt dissection.

Results There were 27 men and 3 women. Male averageage was 44 years, female 72.6 years. Significant age dif-ference (p value<0.001) between sexes. All patients pre-sented with pain in the antecubital fossa. The 3 womenalso presented with a cystic mass. 21 of 30 had dis-comfort/weakness with resisted supination. 7 of 30 haddiscomfort/weakness with resisted biceps flexion. 8 of28 had thickening of biceps tendon. 2 partial ruptureso c c u rred in men with prior complete ru p t u res of the distalbiceps tendon in contralateral arm. The mechanism ofinjury was usually a frequently performed vocational oravocational activity. Preoperative MRI scans wereobtained in 26 patients: 5 were read as complete tears,17 as partial tears, and 4 as intact tendons. Histologydemonstrated chronic changes in distal biceps tendonand bone-tendon interface. All patients were treatedwith debridement of tenosynovial tissue, detachment of

remaining fibers still attached to tuberosity, and re-attachment of freshened end of distal biceps tendon.Preoperative pain was relieved in all patients. All but onepatient returned to preoperative level of activity.

Conclusions Partial ruptures are characterized by persist -ent anterior elbow pain which may develop acutely aftera specific traumatic event, or may be chronic with nospecific inciting event. The tendon is almost always pal-pable. Resisted biceps supination is generally associatedwith discomfort or weakness. Radiographs are fre q u e n t l ynormal. MRI scans generally show some abnormality,but may be incorrectly read as either consistent with acomplete rupture or an intact tendon. At surgery, diag-nosis may be suspected with the exposure of tenosyn-ovitis or release of tenosynovial fluid; the diagnosis isnot confirmed until the attachment of the tendon to thebicipital tuberosity is exposed. In all patients with partialruptures of the distal biceps tendon the pain was com-pletely relieved with transection of the remaining intactfibers and reattachment to the bicipital tuberosity. 2/3’sof the patients were treated in the last of half of thisseries, suggesting that this diagnosis is either unrecog-nized or under reported.


Clinical Session V

Paper #26

Partial Ruptures of Distal Biceps Tendon

Bruce M. Leslie, MD, Newton, MADennis J. Feen, MD, Newton, MA

Paper #26

29

Partial rupture of the distalbiceps tendon. The veryfew fibers still attached tothe bicipital tuberosity areidentified by the arrow.

Section of the radial tuberosity withresidual biceps tendon (bone-tendoninterface). The bone is at the bottomand the tendon is at the top. The cortexis thickened. Just below the tidemark isa large area of neovascularization(arrow). To the left of the neovascular-ization are Haversian canals filled withfibrous tissue. The arrowheads point tofrayed disrupted biceps tendon. To theright the tendon is still attached to thetuberosity, but the tendon is not normal;the normal architecture has been infil -trated with fibroblasts and neovascular -ization. (100X Hematoxylin-Eosin)

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Objectives Fractures of the coronoid have been classifiedon the basis of size alone. With greater experience tre a t-ing coronoid fractures, it has become clear that the overalli n j u ry pattern and specific fragment characteristics mayalso be important.

Methods A single surgeon repaired 41 coronoid fracturesin 40 patients with fracture-dislocation of the elbow overa 3-year period. Each coronoid fracture was character-ized on the basis of operative exposure according to theoverall pattern of injury, the pattern of coronoid frag-mentation, the size of the fracture fragments, and asso-ci a t e d ligament injuries.

Results The coronoid fracture was associated with anolecranon fracture-dislocation in 22 patients; an elbow-dislocation and radial head fracture (terrible triad) in 16patients; and posteromedial varus rotational instability(PRVI) pattern in 3 patients. Among patients with olecra-non fracture-dislocations, 6 had anterior and 16 posteriordisplacement of the forearm. Twenty of the fracturesassociated with an olecranon fracture involved greaterthan 50% of the coronoid height and two were smallerfractures involving the anteromedial facet and tip of thecoronoid process. Among the twenty large coronoidfractures, 9 were large single-fragments, 8 had threefragments (anteriomedial facet, central, lesser sigmoid

notch), 1 had a single sagittal split, and 2 had greaterthan 3 fragments. Seven patients with posterior olecranonfracture-dislocations had lateral collateral ligament (LCL)injury, and one with an anterior dislocation had bothmedial and lateral collateral ligament injuries. All sixteenpatients with terrible triad injuries had small (less than50%) coronoid fractures and LCL injury. 15 patients hada transverse fracture of the tip (14 simple, one commin-uted) and one had a fracture of the anteromedial facetand the tip. The 3 patients with PVRI injuries had fractureof the anteromedial facet of the coronoid, fracture of thetip of the coronoid and fracture of the sublime tubercle.All 3 had injury to the LCL.

Conclusions Fractures of the coronoid associated witholecranon fracture-dislocations, terrible triad injuries, andPRVI injuries have distinct injury patterns. Small frac-tures can involve the tip (terrible triad injuries) or theanteromedial facet (all PRVI and a few terrible triad andolecranon fracture-dislocations). Large fractures (olecranonfracture-dislocations) can vary substantially. Anticipationand recognition of these patterns can help guide treat-ment. In particular, anteromedial facet fractures mayrequire a separate medial exposure and internal fixationand very comminuted large fractures may require hingedexternal fixation.


Clinical Session V

Paper #27

Coronoid Fracture Patterns

Job Doornberg, MS, Boston, MADavid C. Ring, MD, Boston, MA


Paper #27

30

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Meeting Abstracts

Objectives To evaluate the bending and torsional rigidityof five different fixation constructs commonly used forORIF of radial head/neck fractures.

Methods Using six fresh frozen cadaveric radii, fracturesof the radial neck were created 2cm from the articularsurface. The fracture was stabilized with five differentcommonly used constructs: crossed K-wires; a 2.4 mmT-plate using screws in the head (T Plate+screw); a T-plate using locking buttress pins in the head (T Plate); aT-plate with an interfragmentary screw from the shaftretrograde, through the plate into the head (RetroIFrag);and a T-plate with an interfragmentary screw from a non-articular portion of the head antegrade into the shaft(AnteIFrag). All constructs were tested for bending andtorsional rigidity in an Instron mechanical testingmachine. Loads used were well below failure. Statisticswere performed using ANOVA and individual statisticaldifferences were determined by Fisher’s PLSD method.

Results In torsion, all plating constructs were significant-ly more rigid than pinning. Bending tests in the plane ofthe crossed K-wires showed surprising rigidity. Lockingbolts versus screws into the head did not significantlyincrease rigidity in either torsion or bending. The additionof an interfragmentary screw significantly increasedrigidity in both torsion and bending. These results areshown in Table 1, and Figures 2 and 3.

Conclusions Operative fixation of radial head and neckfractures is technically difficult. Open treatment of thesefractures has high rates of non-union and hardware fail-ure. This is the first paper to evaluate fixation constructsfor radial head/neck fractures. Plating is significantlymore rigid than pinning in torsion. The addition of a lagscrew across the neck fracture significantly improvesstability of the construct.


Clinical Session V

Paper #28

Biomechanical Stability of Fixation Constructs for ORIF of Radial Head Fractures

John T. Capo, MD, Newark, NJJohn Ashgar, MD, Newark, NJChris Sabatino, BS, Newark, NJVirak Tan, MD, Newark, NJ

Paper #28

31

Table 1. Torsional and Bending Rigidity of Radial Head ORIF Constructs

Torsion (N-m) Bending (N-m)

K-Wire......................................................................................................................................2.17 ± .68................5.25 ± .014

T Plate......................................................................................................................................3.61 ± .67................4.02 ± .269

T Plate + Screw........................................................................................................................3.79 ± .31................3.98 ± .328

Retrograde Iflag ......................................................................................................................4.54 ± .42................4.75 ± .641

Antegrade Iflag ........................................................................................................................5.20 ± .67................5.24 ± .120

Figures 2 and 3 on page 32

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Clinical Session V

Paper #28 (cont.)

Biomechanical Stability of Fixation Constructs for ORIF of Radial Head Fractures

John T. Capo, MD, Newark, NJJohn Ashgar, MD, Newark, NJChris Sabatino, BS, Newark, NJVirak Tan, MD, Newark, NJ


Paper #28

32

Figure 2. Bending Stiffness of Radial Head ORIF

Constructs

6

5

4

3

2

1

0

K-Wire T-Plate T-Plate+ Retrograde Antegrade Screw Iflag IFlag

* Indicates significance from T-Plate and T-Plate + Screw

Fixation Construct

***

Figure 3. Torsional Stiffness of Radial Head ORIF

Constructs

6

5

4

3

2

1

0

K-Wire T-Plate T-Plate+ Retrograde Antegrade Screw Iflag IFlag

@ Indicates significance from T-Plate* Indicates significance from T-Plate and T-Plate + Screw& Indicates significance from all others

Fixation Construct

@

@*

&

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Meeting Abstracts

Paper #29

33

Objectives We present morphologic analysis of theu l n o t rochlear (UT) and radiocapitellar (RC) joints inosteoarthritic (OA) disease and normal elbows to deter-mine if joint anatomy predisposes to the development ofprimary osteoarthritis. A classification system for thestaging of elbow OA was developed and applied to moreaccurately assess intermediate follow-up results afteropen elbow debridement utilizing a lateral collateral liga-ment sparing approach.

Methods Eight different morphologic parameters weredefined and measured from radiographs of 24 primaryOA and 127 non-OA elbows to evaluate morphology ofthe UT and RC joints. Statistically significant differencesbetween the two groups were found for the lateraltrochlear facet angle, and radial axis to capitellar centerdistance. Based upon common patterns of arthriticinvolvement identified on anteroposterior and lateralradiographs, the elbows were classified according toone of three classes. Stage I shows degenerativechanges of the UT joint with coronoid and olecranonspurring but no changes at the RC joint. Stage II showsdegenerative changes at the UT and RC joints, mild jointspace narrowing at the RC joint, and marginal osteo-phytes of the radial head and proximal radioulnar joint.Stage III shows similar changes as in Classes I and II,but in addition has subluxation of the RC joint.

Results Seventeen of eighteen patients who underwentelbow debridement were clinically and radiographicallyevaluated after a mean follow-up of 65 months (35–112months). Clinical data for the entire cohort and compar-isons among the three classes were statistically analyzed.The average Mayo Elbow Perf o rmance Score (MEPS)was 85.8 with an average 30° gain in total range ofmotion (TROM) at follow-up. Among the three classes,there were statistically significant differences encoun-tered for pain score, TROM (Class I=125°, Class II=115°,Class III=101°), MEPS (Class I=95, Class II=83.8, Class III=76.7), and Mayo Task Scores (Class I=47.3,Class II=45.8, Class III=41.5).

Conclusions Open elbow debridement and capsularrelease through a lateral collateral ligament preservinga p p roach resulted in functional improvement in allpatients at intermediate follow-up. This newly developedclassification system can help predict post-operative fol-low-up outcomes with lower perf o rmance score sexpected as stage of arthritic involvement increases. Thet rochlear and radiocapitellar radiographic parameters wehave defined showed few morphologic diff e re n c e sbetween primary OA and non-OA elbows.


Clinical Session V

Paper #29

Primary Osteoarthritis of the Elbow: Evaluation of Morphologic Predisposition, Results of Operative Debridement at Intermediate Follow-Up and Basis for a NewClassification System

Lance A. Rettig, MD, Baltimore, MDHill Hastings II, MD, Indianapolis, INJudy R. Fineberg, PhD, Indianapolis, IN

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Objectives Baseball is very popular in Japan and a lot ofyoung athletes are still suffering from OCD of the elbow.Treatment should be conservative in an early stage but itis still controversial for an advanced stage. We have triedosteochondral autograft from the patients’ kneedescribed by Bovic to reconstruct the cartilaginousdefect of the elbow in order to obtain the former sportsactivity. This is a report of the results.

Methods Nine male patients (age: 12 to 17 with mean of14 years) received this procedure and were followedmore than eighteen months (follow-up: 18 to 30 withmean of 22 months). Lesion diameter was 13mm to20mm with mean of 15mm. Two to five cylindricalosteochondral bone plugs were transferred from a lateralfemoral condyle to the cartilaginous defect of thecapitellum humeri. Elbow function was assessed by theJapanese Orthopaedic Association Score (JOA score).Radiographic evaluation was performed in terms of per-centage of radio-capitellar congruity (fig.1) at postopera-tive six, twelve months and last follow-up. Cartilage wasalso evaluated by MRI T2* images. In four cases, secondlook was perf o rmed at six to twelve months after surg e ryand histological evaluation was performed.

Results Bony union was achieved in three months in allcases. Elbow JOA score was 75 pts in the first case (fair)who was already showed arthritic change before surg e ry.

The other eight patients re c o v e red well (91pts to100pts) in six months and returned to the former sportsactivity. Average JOA score was 83pts before surgeryand improved to 94pts at FU. Good congruity of theradiocapitellar joint was observed by radiograms (radio-capitellar congruity was 35% before surg e ry andimproved to 56% at FU), MRI and identified at second-look (Fig.1). In histology, cartilaginous viability was con-firmed by proteoglycan formation. Most of the patientsshowed good clinical outcome, however, one patientshowed recurrence of the free body at postoperativetwenty-four months probably because of subchondralfracture of the osteochondral bone plug which wasinserted in the most lateral portion of the lesion.

Conclusions Osteochondral autograft is one of the surgi-cal options for large advanced lesions of OCD of theelbow although long-term follow-up study is inevitable.Recipient site is small in the elbow comparing to theknee, so insertion of osteochondral plugs should becareful to avoid poor outcome.

References

Bobic V. Arthroscopic osteochondral autograft transplan-tation in anterior cruciate ligament reconstruction: a pre-l i m i n a ry clinical study. Knee Surg Sports Tr a u m a t o lArthrosc.3:262–4,1996


Clinical Session V

Paper #30

Reconstruction with Osteochondral Autograft for an Advanced Lesion ofOsteochondritis Dissecans (OCD) of the Elbow

Kozo Shimada, MD, Izumisano, JapanTakeshi Yoshida, MD, Amagasaki, JapanKen Nakata, MD, Amagasaki, JapanMasayuki Hamada, MD, Hirakata, Japan


Paper #30

34

Figure 1. Case 3: 15 Years Old. Operative Findings and X-ray Evaluation

Finding after procedure Finding at second-look RC-congruity=B+C/A 23%

Preope.12 mos.postope.

65%

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Meeting Abstracts

Paper #31

35

Objectives There are various causes of elbow stiffnessfollowing trauma. We analyzed the clinical results ofs u rg i cal treatment in patients with post-traumatic stiffelbows.

Methods We performed operative release of the elbow in27 patients who had post-traumatic stiffness at an aver-age of 15.5 months after the initial injury. All patients hadstiffness of less than 100 degrees of motion arc in spiteof conservative treatment after the injury. The causes ofstiffness in all patients were considered to be extrinsic.Patients who had initial intra-articular fractures werehealed successfully without major incongru i t y.Contractures developed after burn or brain injury wasexcluded. Preoperatively measured mean limitation ofextension was 39.6 degrees and mean flexion was 86.3degrees. Intraoperatively, our goal of motion, which wasf rom 20 to 130 degrees flexion, was successfullyachieved in all patients. Ulnar nerve release was per-formed in 18 patients during the operation. On the basisof radiographs and operative findings, patients weredivided based on the presence (18 cases) or absence (9cases) of ectopic ossification; and on the involvement ofarticular surface (13 cases) or not (14 cases). The finalarc of motion and ratio of desired gain were comparedbetween each group by the Mann-Whitney U test at an

average follow-up period of 22.5 months (range, 12–43months).

Results The mean postoperative limitation of extensionwas 18.9 degrees, and the mean postoperative flexionwas 120.7 degrees. The arc of elbow motion wasimproved in all patients after the operation. The meanfinal arc was 110.0 degrees for ectopic ossificationgroup and 85.6 degrees for non-ectopic ossificationg roup, showing significantly higher final arc in theectopic ossification group. The ratios of desired gainwere 93.4% and 68.4%, respectively, being significant-ly higher in the ectopic ossification group. In terms ofthe articular surface involvement, there was no signifi-cant difference between the two groups. Complicationsincluded one deep infection, one ulnar neuropathy andone ectopic bone formation.

Conclusions When performing operative treatment ofpost-traumatic stiff elbow, assessment of the cause ofstiffness is important. In patients who have stiff elbowsassociated with ectopic ossification, satisfactory resultscan be expected with operative treatment if the ectopicbone is matured. In patients who have stiff elbows dueto capsuloligamentous contracture, a careful postopera-tive management is required to minimize a loss ofmotion arc that has been achieved operatively.


Clinical Session V

Paper #31

Surgical Treatment of Post-Traumatic Elbow Stiffness

Min Jong Park, MD, Seoul, KoreaHyung Gun Kim, MD, Seoul, KoreaJong Youl Lee, MD, Seoul, Korea

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Objectives We evaluated the surgical outcomes of thepost-traumatic stiff elbow, and the study of conditionand treatment through operation was described.

Methods From January 1984 until December 2000, 257patients with a stiff elbow underwent our operativetreatment. Of these patients, 129 patients developedelbow contracture after a traumatic injury to the upperextremity. There were 94 males, 35 females with anaverage age of 30 years old (range 6–58). Our tactics forthe treatment for the stiff elbow are as follows:

At first, we investigate whether there is bone incon-gruity or not. If there is bone incongruity, this incongruityhas to be treated by operation. If there is not, conserv a t i v etreatment by a dynamic splint is primarily administered.If conservative treatment is not effective, then we carryout operation using a medial skin incision to resect pos-terior oblique fibers & capsule. Of course if there is anoperation scar, we generally use it. Plain radiographs andtomograms were useful in detecting bony spurs andectopic ossification. Two separate skin incisions, medialand anterior, were used in most cases. Scarred thickenedposterior oblique fibers of the medial collateral ligamentw e re usually found. The most effective pro c e d u re toimprove elbow flexion was resection of the thickenedfibers or the ectopic ossification.

Results Patients were evaluated at an average of 55months after contracture release (range 18 to 120months). Motion at final follow-up averaged 125 degreesof flexion, -15 of extension; 70 of pronation and 70supination. The average improvement in range of motionduring operation was 63 degrees (36 degrees in flexion,27 degrees in extension). The observation during theoperation found the cause to be one or more: medialcomponents (115 cases), lateral components (33 cases,of which 31 cases were bony abnormality), and othercomponents (50 cases).

Conclusions Before the operation for the post-traumaticstiff elbow, the causes of contracture have to be inves-tigated thoroughly. These causes are eliminated by aminimal invasive surgery to allow active flexion andextension exercises as soon as possible. If there is bonyabnormality, we treat this abnormality first. If there isnot, we choose a medial skin incision, because thickeningof the posterior oblique fibers of the medial collaterall i g ament is the most common cause of stiffness.

References

Itoh, Y., et al.: Operation for the stiff elbow. InternationalOrthopaedics 13: 263-268,1989.


Clinical Session V

Paper #32

Operation for the Post-Traumatic Stiff Elbow

Hiroyasu Ikegami, MD, PhD, Tokyo, JapanShinichiro Takayama, MD, PhD, Tokyo, JapanYoshiyasu Ito, MD,PhD, Tokyo, JapanYukio Horiuchi, MD, PhD, Tokyo, Japan


Paper #32

36

Figure 1. Medial Approach

Figure 2. After resection of POL (posterior oblique

ligament)

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Meeting Abstracts

Paper #33

37

Objectives Hinged external fixation with a worm gearmechanism can improve the arc of ulnohumeral motionafter open release of severe elbow contracture by grad-ually stretching contracted muscles.

Methods Forty-two patients were evaluated at an aver-age of thirty-nine months after operative release of apost-traumatic severe elbow contracture (defined asless than 40 degrees initial range of motion). Twenty-three patients in whom a hinged external fixator incor-porating a worm gear was applied and used for staticprogressive stretch post-operatively during the early partof the series were compared to nineteen patients thatwere treated without hinged external fixation during thelater part of the series as the hinge was used less fre-quently. The operative techniques did not otherwisechange during the study period. Demographics, injurycharacteristics, and associated problems were compara-ble between groups

Results The average gain in range of motion was 89d e g rees in patients with hinge application and 78degrees in patients treated without a hinge. This differ-ence was not statistically significant with the numbersavailable (p=0.175). Complications associated withhinge wear included pin track sepsis managed non-oper-atively, one case of pin track osteomyelitis, one ulnafracture through a pin site, two broken Schantz screws,and irritation of the ulnar nerve in two patients.

Conclusions Open release of severe elbow contractureresults in substantial gains in motion, with or withouthinged elbow fixation. The slightly greater averageimprovement in motion with the hinge might be statisti-cally significant in a larger study, but may not justify thegreater risk, expense, and complications associated withhinge use.


Clinical Session V

Paper #33

Hinged Elbow Fixation for Severe Elbow Contracture

Jesse B. Jupiter, MD, Boston, MARobert N. Hotchkiss, MD, New York, NYDaniel Guss, BS, Boston, MA

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Objectives Mallet finger (closed or open terminal tendond i s ruption) will often result in a chronic distal interpha-langeal (DIP) joint extensor lag, even with adequate initialt reatment, due to slight lengthening of the healed tendon.Tenotomy of the central slip, described by Fowler, canclinically improve chronic DIP extensor lag by allowingthe finger extensor mechanism to slide proximally,thereby reducing the ‘slack’ in the terminal tendon. Toour knowledge, no anatomic or biomechanical study hasstudied the amount of extensor lag that is correctablewith a central slip tenotomy. The goal of this study is toevaluate the potential of central slip tenotomy to restoreDIP joint extension, with respect to the severity of thepre-existing extensor lag.

Methods Fourteen fresh frozen cadaver fingers (agerange 22 to 46 years) that were free of joint contractureswere used for this study. The skin over the dorsal aspectof the fingers was removed. The extensor tendon inser-tion was identified and a suture anchor placed into thebony insertion. The extensor tendon was then sectionedover the DIP joint, producing a mallet deformity. Thebraided suture-anchor suture was then secured to theextensor tendon over the middle phalanx with 2 hemo-clips to simulate lengthening of the tendon that might

occur with healing. The degree of extensor lag producedwas measured with an analog goniometer. A 5 poundweight attached to the proximal extensor tendon overthe hand provided a uniform traction force. Central sliptenotomy was then performed by lifting the extensortendon from the ulnar side and completely sectioningthe insertion on the middle phalanx. Measurements of the degree of extensor lag pre- and post-tenotomywere made.

Results Following sectioning of the extensor tendon overthe DIP joint, the average amount of extensor tendon lagproduced was 45° with 5 pounds of proximal traction.After performing central slip tenotomy, the averageamount of extensor lag correction was 36°. The largestextensor lag able to be corrected measured 46°.

Conclusions Several clinical studies have demonstratedthat central slip tenotomy is an effective treatment forchronic mallet finger, but may not fully restore DIP jointextension. In this study, a DIP joint extensor lag of up to46° was fully correctable with central slip tenotomy, butthe average degree of correction was 36°. Patients witha pre-existing extensor lag of greater than 36° may notachieve full correction with central slip tenotomy.


Clinical Session VI

Paper #34

Central Slip Tenotomy for the Treatment of Chronic Mallet Finger: An Anatomic Study

Robert J. Strauch, MD, New York, NYJerome Donald Chao, MD, New York, NYVishal Sarwahi, MD, New York, NYYong Sing S. da Silva, BA, New York, NY


Paper #34

38

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Meeting Abstracts

Paper #35

39

Objectives Surgical repair of flexor tendons may require“venting” of the pulley for proper exposure. Studiesshow that 50% of the A-2 pulley and 75% of the A-4p u l l e y may be transected without significant changes inkinematics. The location of this transection is significantin determining the kinetic behavior of the pulley system.The objectives of this study are to provide evidence forthe role of location of pulley transection on joint torqueand radius alteration.

M e t h o d s Index and little fingers of 10 fre s h - f rozen cadaverhands were studied. FDP excursion was generated andmeasured by a computerized servo, providing constantforce, which was later measured. MCP, DIP, and PIPjoint ROM were measured in relation to excursion usingsimultaneous data acquisition of micro-potentiometersplaced at the respective centers of joint rotation. Thedata was filtered and analyzed to assess the dynamicbiomechanics. This data yielded joint torques, and fromthis data combined with the force exerted by the motor,pulley moment arms (radii) were computed. These

results were analyzed for both an intact finger pulleysystem and one with partial excision. A2 and A4 pulleyswere isolated and transected for the respective studies.All other pulleys remained intact.

Results 1.17 N was applied at all times. Proximal A2 tran-section had a 740% greater effect on torque at the MCPthan distal transection, and a 244% greater effect ontorque at the PIP than distal transection. Distal A4 tran-section had a 170% greater effect on torque at the MCPthan proximal transection, and a 400% greater effect ontorque at the PIP than proximal transection.

Conclusions The results demonstrate that distal A2 tran-section and proximal A4 transection better preserve jointdynamics, both in terms of joint torque and in minimiza-tion of bowstringing (by pre s e rving radius). These findingsconcur with previous kinetic re s e a rch focused solely ont o rque, and provide a link between joint torque and radiusdemonstrating that a biomechanical model of the jointp rovides an optimum solution both in terms of kinematicsand kinetics.


Clinical Session VI

Paper #35

Effect of Partial Resection of A2 and A4 Pulleys on Finger Joint Torques and Radii

Mark H. Gonzalez, MD, Chicago, ILJonathon W. Sensinger, BS, Evanston, ILJames C. Chow, MD, Chicago, ILFarid Amirouche, PhD, Chicago, IL

Figure 1. A2 Torque Comparison

12

10

8

6

4

2

0

MCP PIP DIP

Change in torque with proximal transection

Change in torque with distal transection

Figure 2. A4 Torque Comparison

6

5

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3

2

1

0

MCP PIP DIP

Change in torque with proximal transection

Change in torque with distal transection

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Objectives New multistrand techniques can improvemechanical resistance of flexor tendon repairs. Amongnumerous published studies, only a few authors wereinterested in tendon friction. It can lead to peritendinousadhesions, a factor in bad clinical results after flexor ten-don repair. We tried to establish a correlation betweenfriction of sutured tendon and number of strands ofthe repair.

Methods Frictions can be measured by increase of workof flexion (WOF). We have built a specific machine forevaluation of WOF in an in situ curvilinear cadaver handmodel. The method consists in simultaneous stressmeasure while pulling a flexor profundus tendon. Areaunder stress-excursion curve (Figure 1, page 41), betweens t a rt of movement and palmar contact, re p resents WOF.We compared 80 human tendons. 20 of them wererepaired by either the modified Kessler technique or amultistrand technique (4-strand double loop, 6-strandSavage or 8-strand Winters). Results were statisticallyevaluated by one-way ANOVA and t-test of student.

Results We noticed an important improvement of stresslevels after the first pull, but no further improvement inthe next trials. We called this effect “pre-stress” as itwas sometimes not measurable when digit wasstressed before the first flexion. Only the second trial ornext ones were used for WOF evaluation. We found asignificant increase of WOF between modified Kessler(7.0 (2.8%) and multistrand techniques (13.6 (5.2%,p=0.001). No difference was discernable between mul-tistrand sutures. There was no influence of the repaired

digit. Modified Kessler and Winters techniques werefaster and easier to perform than double loop (p=0.01) orSavage methods (p<0.00001).

Conclusions WOF is higher in multistrand repairs than inmodified Kessler. Its elevation is due to the importantbulk of the Winters technique, the external location ofknots in the double-loop technique and the excessivenumber of epitenon grasps in the Savage technique.None of these multistrand techniques is ideal. Amongthem, Winters technique is the faster and easier to per-form. Its important bulk, due to the 8 strands of coresuture, should be reduced before any clinical use. The“ p re - s t ress” effect greatly improves biomechanical re g i-men of sutured tendon. This effect is due to a morpho-logical adaptation of the suture when it is actively pulledt h rough a pulley. It should always be sought in humanoperative pro c e d u res by an active pull of sutured tendon.

References

Lane JM, Black J, Bora FW. Gliding function followingflexor-tendon injury. A biomechanical study of rat tendonfunction. J Bone Joint Surg 1976; 58A:985–9.

Aoki M, Manske PR, Pruitt DL, Larson BJ. Work of flex-ion after tendon repair with various suture methods. Ahuman cadaveric study. J Hand Surg 1995; 20B:310–3.

Thurman RT, Trumble TE, Hanel DP, Tencer AF, Kiser PK.Two-, four-, and six-strand zone II flexor tendon repairs:an in situ biomechanical comparison using a cadavermodel. J Hand Surg 1998; 23A:261–5.


Clinical Session VI

Paper #36

Work of Flexion After Flexor Tendon Repairs: Effects of Number of Strands and “Pre-Stress” Maneuver

Yann Dausse, MD, Nancy, FranceGilles Dautel, MD, Nancy, FranceFrançois Dap, MD, Nancy, France


Paper #36

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Clinical Session VI

Paper #36 (cont.)

Work of Flexion After Flexor Tendon Repairs: Effects of Number of Strands and “Pre-Stress” Maneuver

Yann Dausse, MD, Nancy, FranceGilles Dautel, MD, Nancy, FranceFrançois Dap, MD, Nancy, France

Paper #36

41

Figure 1. Example of Stress-Excursion Curve Figure 2. “Pre-stress” Effect

20

15

10

5

00 5 10 15 20 25 30 35 40 45 50

start of flexion

digital flexion without resistance palmar contact

high level of stress

area under curve

15

10

5

0 10 20 30 40 50Excursion (mm)

Excursion (mm)

First Trial

Second Trial

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O b j e c t i v e s Repair of both superficialis (FDS) and pro f u n d u s(FDP) tendon was shown to produce poor outcomes inthe areas where major pulleys exist. No studies delineatedd i ff e rential effects of superficialis repairs on the pro f u n d u sbetween the areas under or proximal to the pulleys. Weu n d e rtook a study to evaluate effects of the FDS repairson the healing FDP tendons of chickens following earlytendon motion.

M e t h o d s Both long toes (70 totally) of 35 leghorn chickensw e re divided into 3 groups. The FDS and FDP tendons in11 chickens were transected in the area covered by amajor pulley. In the other 11 chickens, the tendons werecut proximal to the pulley. Both FDS and FDP wererepaired on the left, and only the FDP was repaired onthe right. The toes underwent passive flexion for 3weeks, and function was evaluated at 8 weeks. (1)Gliding excursion: With an Instron tensile machine, theFDP excursion was measured during toe flexion. (2)Work of flexion: The work needed to flex the toes wasrecorded. (3) Areas of adhesions. (4) Extent of adhesion:Severity of adhesion was graded. The long toes of the13 un-operated chickens were tested to obtain normalexcursion values.

Results Tendon Excursion: The FDP excursion was 17.2+/- 5.3 mm in the toes where only the FDP was repairedwithin the pulley, which was significantly greater thanexcursion after both repairs (13.5 +/- 2.9 mm) (p<0.01).However, when tendons were cut proximal to the pulley,the excursion (15.6 +/- 3.8 mm) after only the FDP wasrepaired was not significantly different from that afterrepair of both tendons (14.6 +/- 2.4 mm). Work ofFlexion: The work of flexion was statistically greatest inthe toes with both tendon repairs within the pulley(p<0.001). The work of flexion in toes with single or dou-ble tendon repairs proximal to the pulley was statisticallythe same. Areas/Extent of Adhesions: Adhesions weresignificantly greater after both tendon repairs than aftersingle FDP repair within the pulley (p<0.05).

Conclusions Repair of both tendons worsens the functionof the FDP tendon within the major pulleys; however,repair of both tendons yields functional outcome equiva-lent to that following repair of only FDP tendon. Thisstudy suggests reconsideration of FDS tendon tre a t m e n ta c c o rding to the existence of major pulleys and areasmerely with synovial sheath.


Clinical Session VI

Paper #37

Superficialis Repairs Exert Different Effects on the Healing Profundus Tendons within or Proximal to the A2 Pulley

Jin Bo Tang, MD, Nantong, People’s Republic of ChinaYan Xu, MD, Nantong, People’s Republic of China


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O b j e c t i v e s This prospective randomized study wasdesigned to compare two methods of early mobilization(Kleinert versus Strickland protocol) after primary repairof flexor tendons in zone II.

Methods Group I (Kleinert) was composed of 19 patientsw h e reas 16 patients belonged to the group II(Strickland). In the overall series the mean age was 35years. 15 patients (42.8%) were manual worker, 10(28.6%) were students and 2 were unemployed.Patients with associated lesions (vessels or nervesinjury, soft tissue defects, fractures) that precluded theuse of early motion were excluded from this series. Ahospital stay of at least 6 days was required to learn thebasis of the mobilization protocol. Rehabilitation wasstarted day 3 post-operative. Primary repair was per-f o rmed as an emergency pro c e d u re using a 4/0absorbable Tsuge core suture and a peripheral epitenonrunning suture (6/0 Prolene). The Kleinert protocol forprotected early motion was applied in all patients ofgroup I (reference 1). Early active motion according toStrickland recommendations was applied in group II (ref-erence 2, 3). Fingertip to palm distance was evaluated inaddition to measurement of active range of motion.Results were classified as excellent, good, fair, or poor,according to Strickland’s scale.

Results Mean follow-up in this series was 18 months.Subsequent procedures were required in 8 patients,including 5 tenolysis, one DIP fusion and 2 flexor tendongrafts (due to late rupture). Results in both groups arelisted in Table I. At final follow-up, good or excellentresults were obtained in 100% of group I versus 92% ingroup II. This difference was not statistically significant(Student test). Mean period out of work was 14.2 weeks

in the overall series. Using Strickland’s scale, after 8weeks, we find 95% of good and excellent results withthe Kleinert mobilization, versus 75% for Strickland.After 12 weeks, we find 94% versus 81%. At the end ofthe study, we find 100% versus 92%. The average jobinability was 14.2 weeks with extremes 9 to 44.

Conclusions This study does not show any significant dif-ference in terms of functional outcome between thetwo groups. It is our opinion that both of them can leadto good results, providing that they are strictly applied inmotivated patients. However the price to pay is severaldays hospital stay followed by a long-standing rehabilita-tion program.

References

Kleinert H.E., Kutz J.E., Ashbell T.S., Martinez E.-PrimaryRepair of Lacerated Flexor Tendons in “No Man’s Land”.J.Bone Joint Surg,1967; 49A:577

Strickland J.W.-Development of Flexor Tendon Surgery:Twenty Five Years of Progress. J Hand Surg, 2000;25A:214–234

Small J.O.,Brennen M.D.,Colville J.-Early ActiveMobilization Following Flexor Tendon Repair in Zone 2.J.Hand Surg, 1989; 14B:383-391


Clinical Session VI

Paper #38

Prospective Study after Primary Repair of Flexor Tendons in Zone II: Comparison ofTwo Methods of Early Mobilization (Kleinert Versus Strickland Protocol)

Joel Vialaneix, MD, Nancy, FranceDidier Petry, MD, Nancy, FranceFrançois Dap, MD, Nancy, FranceGilles Dautel, MD, Nancy, France

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Table 1. Percentage of Good and Excellent Results

Kleinert Group Strickland Group

8Weeks 95 75

12 Weeks 94 81

24 Weeks 100 92

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Objectives Of the several described flexor repair tech-niques, the ideal tendon repair should be strong enoughto allow for early active motion to minimize adhesion for-mation and maximize tendon healing, ultimately to opti-mize functional outcomes. The Massachusetts GeneralHospital (MGH) flexor tenorrhapy is similar to the Beckerrepair. The MGH repair is different from the Beckerbecause of the addition of an epitenon suture andapproximation of the cut tendon ends as is, transverse-ly, without the fashioning the cut ends in the obliqueconfiguration. Biomechanical studies have proven theMGH repair to be stronger than other techniques and toallow for early active motion.

Methods We performed 220 flexor tendon repairs for 61patients consecutively over 4 years when early activemotion was not contraindicated. The median follow-upwas 28 weeks. Of these 61 patients, 48 were men and13 were women. The average patient age was 27 years.Of the 220 flexor repairs 8 were Zone I injuries, 28 were

Zone II, 10 were Zone III/IV, and 168 were Zone V, and 6were zone II FPL tendon repairs. The total active motionfor these repairs per zone of injury was 243 degrees forZone I, 231 degrees for Zone II, 245 degrees for ZoneI I I / I V, 236 degrees for Zone V and 144 degrees for FPLrepairs. None of these patients re q u i red a tenolysisp ro c e d u re .

Results Overall, 130/139 digits (93.5%) attained good toexcellent function and 117/137 (85.4%) developed somedifferential glide. None of these patients required atenolysis. Three of the patients (3/61patients, 5%) andfive repairs (5/220 repairs, 2.3%) ruptured due to suturebreakage and were associated with non-compliancewith the dorsal extension block splint.

Conclusions Our retrospective of review of 220 consecu-tive flexor tendon repairs with the MGH technique,which allows for early, protected active motion resultedin 93.5% good to excellent functional outcomes and anacceptably low complication rate.


Clinical Session VI

Paper #39

Functional Outcomes of the Massachusetts General Hospital Flexor Tenorrhaphy andEarly Protected Active Motion

Bradon J. Wilhelmi, MD, Springfield, ILRobert H. Kang, MD, Richland, MIJames W. May, Jr., MD, Boston, MAW. P. Andrew Lee, MD, Boston, MA


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Objectives Evaluation of hardware placement subjacentto the articular surface of the distal radius is often diffi-cult on standard PA and lateral radiographs. This is dueto the normal anatomical angulation of the articular surface in the PA and lateral planes. The objective of thisinvestigation was to evaluate the accuracy, sensitivity,specificity, reliability and usefulness of anatomically tilt-ed radiographic views of the distal radius in detectingarticular penetration by fixation screws.

Methods Twenty-four cadaver specimens were instru-mented with a dorsal distal radius plate and screws.Three groups were created based on screw penetrationof the articular surface: 1, no penetration, 2, radial-mostscrew penetration, 3, ulnar-most screw penetration.Standard PA and lateral, as well as, anatomically tiltedradiographs (23 degree inclined lateral and 11 degreeincline PA) were obtained. Radiographs were evaluatedby three observers who were blinded to screw position.Observers recorded whether or not screw penetrationof the articular surface had occurred, and if so, whichscrew (radial, ulnar, or neither) had penetrated the joint.Data were analyzed for observer accuracy in detection ofs c rew penetration, its location, the sensitivity and speci-ficity of each view, intero b s e rver re l i a b i l i t y, and subjectiveobserver confidence in their determinations.

Results There were statistically significant improve-ments in the anatomical tilt versus standard views in thefollowing measures:

1. Accuracy in detection of screw penetration on isolatedanatomical tilt lateral views (0.93 vs. 0.64, p<0.001).

2. Accuracy of determination of the position of the pen-etrated screw on isolated anatomical tilt PA and com-bined anatomical tilt views (0.79 vs 0.36, p<0.001).

3. Sensitivity and specificity in detecting screw penetra-tion on the isolated anatomical tilt lateral view (sensi -tivity 0.98 vs. 0.77, p<0.001, specificity 0.83 vs 0.38,p<0.001).

4. Interobserver reliability in determining articular screwpenetration (Kappa 0.80-0.90 vs. 0.00-0.12).

5. Confidence of the observer in the determination ofscrew penetration as well as its position on all views(penetration 92% vs. 46%, and location 82% vs.46%, p<0.001).

Conclusions These data suggest that anatomical tilt radi-ographs are superior to standard radiographs in detectingand localizing screws that penetrate the articular surfaceof the distal radius. Anatomical tilt radiographs significant-ly improve observers’ confidence in their assessment. 11d e g ree anatomical tilt PA and 23 degree anatomical tiltlateral radiographs could therefore be of substantial usein the evaluation of hardware position near the articularsurface of the distal radius.

References

Ebraheim NA, Emara K, Sabry FF. Assessment of theDistal Radial Articular Surface by Angled Radiography.AM J Orthop. 2001 Mar; 30(3): 244–5.

Gilula LA, Yin Y. Imaging of th Wrist and Hand. 1996. WBSaunders, Philadelphia, PA pp.228–32.

Trenhaile SW, Fietti VG. “The Tw e n t y - Two Degre eLateral Wrist Radiograph”. Poster presented at the 2001ASSH annual meeting.

Saturday, September 20 2:35 p.m.

Clinical Session VII

Paper #40

Anatomical Tilt Views of the Distal Radius: An Ex-Vivo Analysis of Operative Fixation

Kenneth J. Korcek, MD, New London, CTMartin I. Boyer, MD, St. Louis, MORichard H. Gelberman, MD, St. Louis, MOBradley A. Evanoff, MD, St. Louis, MO

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Objectives Whereas the existence of isolated ulnar shaftfractures without radioulnar instability (the so-called“night-stick” fracture) is well accepted, isolated fracture sof the radial diaphysis are expected to have associatedinstability of the distal radioulnar joint (DRUJ).

Methods Two hundred and sixty two patients with dia-physeal forearm fractures were treated at two institu-tions over a 15-year period. Forty-two patients (16%)had fracture of the radius without fracture of the ulna.Six patients had less than 6 months follow-up and wereexcluded, leaving 36 injuries to study. Displacement(widening or ulnar variance) of the DRUJ was character-ized as follows: greater than 1 cm displacement wasconsidered substantial displacement; less than 0.5 cmwas considered minimal displacement and; between 0.5and 1.0 cm was considered intermediate displacement.

Results Nine injuries had wide displacement of theDRUJ, 16 had minimal displacement, and 11 were inter-mediate. One patient had an isolated fracture of theradius (middle third) and proximal radioulnar joint (PRUJ)displacement. Five of the 9 radius fractures with substantial DRUJ displacement were in the distal third, 3 the middle third, and one the proximal third of the diaphysis. Among the 27 fractures associated with

minimal or intermediate displacement of the DRUJ, only2 were in the distal third, with 22 in the middle third, and3 in the proximal third. All of the fractures were treatedwith plate and screw fixation (8 with autogenous bonegrafting) and all healed. Patients with substantial initialDRUJ displacement had temporary pinning or immobi-lization of the DRUJ. Patients with minimal or intermedi-ate displacement were mobilized within 2 weeks. Thefunctional results were satisfactory or excellent accord-ing to the rating system of Andersen, et al. in all but twopatients with functional limitations related to centralnervous system injury. No patient had DRUJ dysfunctionat the final follow-up.

Conclusions There is a spectrum of severity of DRUJinjury in association with isolated fractures of the radialdiaphysis. Fractures with minimal displacement arem o re common than those with substantial displacement,suggesting that most of these fractures are not tru eGaleazzi lesions. The distinction of lesions with gre a t e rDRUJ injury cannot be based upon fracture locationalone. While the DRUJ and PRUJ need to be evaluatedcarefully when treating an isolated fracture of the radialdiaphysis, many fractures can be treated successfullywithout specific treatment of the DRUJ and with imme-diate mobilization.



Paper #41

The DRUJ in Isolated Radial Shaft Fractures: Are They All Galeazzi Lesions?

David C. Ring, MD, Boston, MARichard Rhim, BA, Boston, MACreg Carpenter, MD, Boston, MAJesse B. Jupiter, MD, Boston, MA


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Objectives Volar plates have been associated with fewertendon complications than dorsal plates but are thoughtto have mechanical disadvantages when used in dorsally-comminuted distal radius fractures. Locking plates mayincrease construct strength and stiffness. This studywas conducted to see if locking volar plates may be suf-ficiently strong to use on dorsally-comminuted distalradius fractures.

Methods Fifteen pairs of embalmed radii were stripped oftissue, radiographed, and randomized into either dorsalor volar groups. Within each pair, a Synthes 3.5 mmstainless LCP T-Plate (Locking Compression Plate) wasrandomized to either the left or right radius. A Synthessmall stainless T-Plate was assigned to the contralateralradius. Each radius was potted vertically and a 1 cm dorsalwedge osteotomy was made 15 mm proximal to thescaphoid fossa. Compressive load was applied axially(2mm/s) to the distal end of each construct 15 mm fromthe volar cortex. Failure was defined as the point of initialload reduction due to bone fracture or substantial platebending. Independent variables included stiffness and load to failure. T-tests and analyses of variance wereperformed.

Results No statistically significant differences in stiffness

or failure load were found between volar plating withlocked and non-locked screws (paired, p>0.05). Thoughnot significant (p=0.16), mean stiffness of constructsusing dorsally applied locked plates was 51% greater thanc o n s t ructs using non-locked plates. Plate placement,volar or dorsal, was found to be a significant predictor ofboth stiffness and failure strength. Dorsal constru c t s ,whether locked or non-locked, were more than twotimes stiffer (p<0.05) than volar constructs. Mean failurestrength of dorsal constructs was 53% higher than thatof volar constructs. Failure for both volar locked and non-locked constructs tended to occur as substantial platebending through the unfilled hole at the osteotomy site.Failure for both dorsal locked and non-locked constructstended to occur due to bone fracture.

Conclusions No evidence was found that locking platesi n c rease the stiffness or strength of volarly-plated dorsally-comminuted distal radius fractures. Axial failure strengthand axial stiffness are greater for dorsal constructs,locked or non-locked, than for either volar locked or volarnon-locked constructs. Whether the lower stiffness andfailure strength are of clinical significance is unknown.The unfilled hole at the site of comminution or osteotomyis potentially a site of weakness in both the volar lockedand non-locked plates.



Paper #42

Locking versus Non-Locking T-Plates for Dorsal and Volar Fixation of Dorsally-Comminuted Distal Radius Fractures: A Biomechanical Study

Corey A. Trease, MD, Kansas City, KSTerence McIff, PhD, Kansas City, KSE. Bruce Toby, MD, Kansas City, KS

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Figure 1. Mean Stiffness and Standard Deviation for

Each Treatment Group

Axial Stiffness (Mean, SD)2000

1600

1200

800

400

0

Dorsal locked Dorsal non-locked Volar locked Volar non-locked

Figure 2. Mean Failure Strength and Standard Deviation

for Each Treatment Group

Axial Failure Strength (Mean, SD)1200

1000

800

600

400

200

0

Dorsal locked Dorsal non-locked Volar locked Volar non-locked

987.7969.4

688.7593.9

1321.9

877.1

457.4 439

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Objectives To determine if nonjoint bridging external fixa-tion of intra-articular distal radius fractures can withstandthe expected loads that occur with passive wrist motion.

M e t h o d s 12 unembalmed potted cadaver fore a rms withan 89 N preload underwent Instron testing. A dorsalc a p s ulotomy was performed for joint inspection. A 3part intra-articular fracture was created in 4 specimensand stabilized with two 3 mm radial styloid pins and twod o rsal pins, plus either 1 or 2 nonjoint bridging fixators.A 4 part intra-articular fracture was created in the next 8specimens and tested with a single custom fixator witha dorsal sidearm. Specimens were loaded in extensionat a constant rate of 25 mm/min. The carpus wasremoved, then specimens were axially loaded to 600 Nor 20 mm of displacement. Computerized data was plot-ted graphically. Rigidity was defined as the slope of thestraight-line region of the load-displacement curve.

Results In the first study, the mean stiffness with 4 pinsand 2 fixators was 116 N/mm in extension and 126N/mm in axial loading. With 4 pins and 1 fixator, the stiff-ness was 62 N/mm and 250 N/mm respectively. No jointdisplacement was observed. In the second study, thestiffness ranged from 17-96 N/mm in extension loading,with a mean of 48 N/mm, and ranged from 100-350N/mm in axial loading, with a mean of 235 N/mm. Duringextension loading, there was gapping of the articular sur-face in 2/8 specimens due to leverage on the dorsalsidearm by the carpus. In axial loading, there was a 2

mm gap in specimen 4 at 500 N, and a 1 mm lunatefossa depression in specimen 5 at 200 N.

Conclusions Previous studies demonstrate that doubleplate fixation along the dorsoradial and dorsoulnarcolumns of the radius are stronger than a dorsal AO T-plate and _ plate, with a mean stiffness of 235 N. Byincorporating the principle of separate fixation of theradial and ulnar columns using either two fixators or onecustom designed external fixator, comparable stiffnessin axial loading was achieved. There was no observabledisplacement of the articular surface in 10/12 specimensat load levels which exceeded those that occur withactive wrist motion. This study supports the use of non-bridging external fixation allowing immediate wristmotion for AO type C2 and C3 fractures when the medi-al fragment is large enough for fixation with at least 2dorsal pins.

References

Redisplaced Unstable Fractures of the Distal Radius.McQueen, MM. JBJS (Br) 1998; 80-B:655–9.

Intraarticular Fractures of the Distal Radius Treated withMetaphyseal External Fixation. Krishnan J, Chipchase S,Slavotinek J. Hand Surg 23B:3:396-399.

Augmented External Fixation of Distal Radius Fractures:A Biomechanical Analysis. Wolfe SW et al. J Hand Surg1998; 23A:127–134.



Paper #43

Fragment Specific External Fixation of Distal Radius Fractures

David J. Slutsky, MD, Torrance, CAQuiang Guo Doi, PhD, Loma Linda, CA


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Objectives Fracture of the ulnar styloid is commonlyassociated with distal radius fractures or Galeazzi fracture-dislocations. It may also occur independentlyfrom a direct blow to the distal ulnar aspect of the wrist.Ulnar styloid fracture is mostly asymptomatic and oftenignored or treated simply with immobilization unlessinstability of the DRUJ is recognized. The relationshipbetween fracture of the ulnar styloid and DRUJ instabilityhas not been clarified. In this study, we examinedchanges in DRUJ stiffness after simulating four types offracture pattern; tip, middle, base horizontal and baseoblique, using MTS machine.

Methods Ten specimens from fresh-frozen cadaverswere used. All soft tissue was excluded with the excep-tion of the soft tissue around the wrist, DRUJ and theinterosseous membrane. The radius was mounted onthe MTS machine and the ulna on the load cell with thecustom device allowing 60 deg pronation, neutral, and60 deg supination. Dorsopalmar stability of the intactDRUJ was tested at a velocity of 1.25 mm/sec in prona-tion, neutral, and supination. After the tip, middle, basehorizontal, and base oblique type of the ulnar styloidfracture was made sequentially (Fig. 1), dorsopalmarstiffness of the DRUJ was examined. Additional hori-zontal cutting of the radioulnar ligament at the fovea wasalso simulated with the base horizontal fracture. Percentcontribution of each sectioning to DRUJ stiffness wascompared with intact.

Results The tip and middle portion of the styloid fracturesdid not demonstrate loss of stiffness compared with theintact. The base horizontal fracture demonstrates10–22% loss of dorsopalmar stiffness of the DRUJ. Incontrast, the base oblique fracture demonstrates signifi-cant instability of the DRUJ (35-70% loss). Additionalsection of the radioulnar ligament with the middle andbase horizontal fracture induced significant (25–56%)loss of stiffness of the DRUJ with the intact (Figs. 2–4,please see page 50).

C o n c l u s i o n s Ulnar styloid fractures including the RUL originmay destabilize the DRUJ, as the radioulnar ligamentoriginates from the fovea to the base of the styloid ofthe ulna. Base oblique fracture demonstrates DRUJinstability if there is RUL tear. Tip or middle ulnar styloidfracture may not demonstrate DRUJ instability.

References

Biyani A, Simison JM, Klenerman L. Fractures of theDistal Radius and Ulna. J Hand Surg 20B: 357–364, 1995.

Nakamura T, Yabe Y, Horiuchi Y. Functional Anatomy ofthe Triangular Fibrocartilage Complex. J Hand Surg 21B:581–586, 1996.

Shaw JA, Bruno A, Paul EM. Ulnar Styloid Fixation in theTreatment of Posttraumatic Instability of the RadioulnarJoint: A Biomechanical Study with Clinical Correlation. J Hand Surg 15A: 712–720, 1990.



Paper #44

Relationship between Fracture of the Ulnar Styloid and DRUJ Instability—A Biomechanical Study

Toshiyasu Nakamura, MD, PhD, Tokyo, JapanOwen J. Moy, MD, Buffalo, NYClayton A. Peimer, MD, Evanston, ILCraig Howard, BS, Buffalo, NY

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Figure 1. Ulnar Styloid Fracture

tip

middle

base-horizontal

base-oblique

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Paper #44 (cont.)

Relationship between Fracture of the Ulnar Styloid and DRUJ Instability—A Biomechanical Study

Toshiyasu Nakamura, MD, PhD, Tokyo, JapanOwen J. Moy, MD, Buffalo, NYClayton A. Peimer, MD, Evanston, ILCraig Howard, BS, Buffalo, NY


Paper #44

50

Figure 2. Percentage Contribution of Each Section in the

Neutral Position

100

90

80

70

60

50

40

30

20

10

0

Neutral Dorsal Neutral Palmar

Tip

Middle

Base Horizontal

Base Oblique

RUL

* P<0.05

*

*

**

Figure 3. Percentage Contribution of Each Section in the

60˚ Pronation

100

90

80

70

60

50

40

30

20

10

0

Pronation Dorsal Pronationl Palmar

*

*

*

*

*

Figure 4. Percentage Contribution of Each Section in60˚ Supination

Legend for Figures 2–4

100

90

80

70

60

50

40

30

20

10

0

Pronation Dorsal Pronationl Palmar

**

*

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Paper #45

51

Objectives Evaluating a patient with suspected instabilityof the painful distal radioulnar joint remains a difficultproblem. It is assumed that loss of torque strength dueto pain or instability will adversely affect fore a rm function.However, no data has been published regarding thetorque strength of the forearm, the range of displace-ment of the distal radius and ulna in varying forearmpositions with resistance to pronation and supination inpatients with painful instability of the DRUJ. We devel-oped a new method that allows a quantitative in-vivomeasurement of forearm torque strength comparing thebehavior of injured and intact sides. This study evaluatesforearm torque strength on the patients with painfulDRUJ for clinical validation as preliminary study.

Methods 90 bilateral wrists of the 45 right hand-dominantpatients with pain at the injured DRUJs aged 14 to 71were subjected for preliminary study. A custom madetesting apparatus was used to measure peak torquestrength of the forearm in both rotation pronation andsupination generated maximum active resistance int h ree positions corresponding to neutral fore a rm ro t a t i o n ,60° pronation, and 60° supination. Isometric muscle load-

ing of the fore a rm was applied to DRUJ under the condi-tions of resisted pronation and resisted supination ineach fore a rm position explained above. The apparatusincorporated a torque cell, which was able to record thepeak torque strength. After the first measurement wascompleted, local anesthesia was injected into the injuredDRUJ. A second torque measurement series was per-f o rmed with the same protocol to compare the diff e re n c e sof the fore a rm torque strength of pre and post anesthesiaand also injured and uninjured sides.

Results The mean torque strength of the injured sidewas significantly weaker than that of the intact sidebefore the local anesthesia was injected to the DRUJ forboth men and women. The mean torque strength ofpost-injection was greater than that of pre-injection forboth men and women. The results of torque strength ofthe forearm revealed differences that showed trends ofvalues related to testing condition.

Conclusions This method would be potentially useful toevaluate patients suspected instability of DRUJ. Furtheranalysis will be carried out to define the underlying causeof asymmetrical values obtained from our CT pro t o c o l .



Paper #45

An Analysis of Strength of the Forearm Under Resisted Forearm Rotation in Patientswith Painful Unstable Distal Radioulnar Joints

Juli Matsuoka, MD, Kawasaki, JapanRichard A. Berger, MD, PhD, Rochester, MNLawrence J. Berglund, BSME, Rochester, MNKai-Nan An, PhD, Rochester, MN

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Objectives This study investigated the effects of sequen-tial ulnar shortening on the ulnocarpal and distal radioul-nar ligaments in a human cadaver model. Understandingthese effects will help delineate the indications of thisprocedure, and quantify the ideal amount of shorteningwhen used for patients with ulnocarpal abutment, andchronic triangular fibrocartilage complex (TFCC) tears.Specific attention was made on recognizing the conse-quences of ulnar shortening on the distal radioulnar joint(DRUJ).

Methods Ten fresh-frozen cadaver upper extremity limbs,free of pathology, were transected through the humerusmidshaft. The ulnotriquetral (UT), ulnolunate (UL), dorsaldistal radioulnar and volar distal radioulnar ligamentswere identified, and a DVRT was placed on each liga-ment along the direction of the fibers. Each specimenwas mounted on a custom adjustable jig. An ulnar short-ening osteotomy of 3.5 mm followed by 5.2 mm wasp e rf o rmed using the Rayhack Precision OsteotomySystem. Data was obtained with the forearm in posi-tions of neutral, pronation and supination rotations.Ligamentous strain was measured using integrated soft-ware in all 3 forearm positions and 2 osteotomy widths.Duncan’s multiple range tests and ANOVA F-tests wereperformed to evaluate the effect of ulnar-shorteningosteotomies on the ligaments at different positions.Significance was considered when p<0.05. Power analy-sis justified the number of specimens tested.

Results The effect of wrist position on the strain of anyligament was not statistically significant for an osteotomyof 3.5 or 5.2 mm. For both osteotomies, the strain forthe ulnotriquetral ligament was statistically more thanfor the ulnolunate ligament. The strain for the ulnocarpalligaments was also significantly more than from theradioulnar ligaments (see Figure 1 on page 53). The dorsaland volar distal radioulnar ligaments were not significantlyd i ff e rent; however, increased significantly with pro gres-sive ulnar shortening. The increase in strain for each lig-ament from a 3.5 mm osteotomy to a 5.2 mm osteotomywas statistically significant (see Figure 2). Ligaments witha higher initial strain (UT) increased significantly with pro-g re s s i v e ulnar shortening.

Conclusions An ulnar-shortening osteotomy leads tolengthening of the ulnocarpal and distal radioulnar liga-ments of different amounts. The ulnotriquetral ligamentundergoes the most amount of strain. These ligamentssignificantly lengthen and most likely tighten furtherwhen a larger shortening osteotomy is perf o rm e d .T h rough pre f e rential tension, an ulnar- s h o rt e n i n gosteotomy may stabilize the lunotriquetral joint inpatients with late stages of chronic TFCC tears.Additionally, this procedure may increase the stability ofthe DRUJ, which might lead to stiffness, or exacerbateunderlying DRUJ arthrosis.



Paper #46

The Effects of Ulnar Shortening Osteotomy on the Ulnocarpal and Distal RadioulnarLigaments

Sovanrith Tun, MD, Chicago, ILElizabeth Dailey, BA, Chicago, ILDaniel P. Mass, MD, Chicago, ILCraig S. Phillips, MD, Chicago, IL


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Meeting Abstracts



Paper #46 (cont.)

The Effects of Ulnar Shortening Osteotomy on the Ulnocarpal and Distal RadioulnarLigaments

Sovanrith Tun, MD, Chicago, ILElizabeth Dailey, BA, Chicago, ILDaniel P. Mass, MD, Chicago, ILCraig S. Phillips, MD, Chicago, IL

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Figure 1. Ligament Strain Results

Osteotomy 3.5 mm 5.2 mm

PronationVDRUL 4.7% 7.4%UL 7.0% 11.0%UT 9.5% 16.5%DDRUL 6.9% 8.7%

NeutralVDRUL 5.0% 10.0%UL 7.5% 12.9%UT 10.7% 15.4%DDRUL 4.9% 10.3%

SupinationVDRUL 5.4% 8.2%UL 8.3% 12.4%UT 9.3% 16.0%DDRUL 5.6% 8.8%

Figure 2. Ligament Strain

Osteotomy

0.5

0.4

0.3

0.2

0.1

0

3.5 mm 5.2 mm

UT

UL

VDRUL

DDRUL

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Objectives Ulnar shortening osteotomy is a provenmethod to alleviate ulnar sided wrist pain for manage-ment of ulnocarpal impingement syndrome. This studywas designed to identify the contributing factors whichlead to failure of the shortening osteotomy. We also tryto identify the incidence of associated carpal pathologyin those treated with ulnar shortening osteotomy.

Methods We evaluated 216 consecutive cases from 212patients who underwent ulnar shortening fro m10/11/1988 to 11/15/2001. We independently evaluatedfactors which may lead to failure including the plane of theosteotomy (transverse or oblique), LAC immobilization,subperiosteal versus extraperiosteal plate placement,type of plate (LCDC or DC), use of AO compre s s i o ndevice, interfragmentary screw use, plate position, andsmoking history. We also attempted to quantify andqualify the intra-articular pathology in those wrists under-going ulnar shortening osteotomy. To do this we felt itwas necessary to delineate the underlying cause of theimpingement. Those with an acquired impingement ofthe wrist (distal radius fractures, premature physeal clo-sures, Essex-Lopresti injuries, Galleazzi and Monteggiafractures) were compared to the attritional causes ofimpingement (ulnar positive variants, Madelung’s, andcongenital variants).

Results 15/216 (6.9%) wrists had either establishednonunions which required re-operation (7) or delayedradiographic union of at least 4 months (8). There wereno differences found with the type of plate, LAC immo-bilization, interfragmentary screw placement, use of anAO compression device, smoking history, or position ofthe plate. However, use of a transverse osteotomy(p<0.05) and subperiosteal plate placement (p<0.01)were factors associated with a poor outcome. 185/216wrists had an intra-articular evaluation. 69.4% had TFCCtears, 45.8% had synovitis, 38.4% had LT tears, 29.2%had lunate chondromalacia, 17.6% had triquetrium chon-dromalacia, 11.1% had ulnar chondromalacia, 6.5% hadarthritic changes of the DRUJ, and 6.5% had SL tears.The only differences between the 2 groups was the pre-operative ulnar variance and rate of LT tears (p < 0.05).

Conclusions Use of an oblique osteotomy and extrape-riosteal plate placement was associated with a lowerincidence of complications. Interfragmentary screws orAO compression devices offer no significance to out-come. LAC immobilization or smoking did not change theoutcome. The incidence of carpal pathology only diff e r sbetween causes of impingement in preoperative vari-ance and LT ligament pathology. The lack of diff e re n c e smay reveal that these groups are not clearly separateentities, but a spectrum of the same disease.



Paper #47

The Ulnocarpal Impingement Syndrome: Incidence of Carpal Lesions and FactorsRelated to the Healing Rate of the Ulnar Shortening Osteotomy

Robert Otis Anderson III, MD, Indianapolis, INThomas J. Fischer, MD, Indianapolis, IN

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Objectives Malunited Colles’ fractures may result inderangement of the distal radio-ulnar joint and functionallimitations. In this circumstance, the Darrach procedurehas traditionally been recommended in older patients,while the S-K has been reserved for younger patients.Hypothesis: outcome following Darrach procedure iscomparable to S-K in patients less than 50 years of age.

Methods 19 patients under age 50 underwent the S-Kprocedure and 31 patients underwent the Darrach pro-cedure for DRUJ incongruity after Colles’ fractures.12/19 of the Sauve-Kapandji group (mean age 38 years)completed the DASH survey at a mean of 4.4 yearspostoperatively and 9/19 returned for follow-up exami-nation at a mean of 2.4 years. 21/31 of the Darrachgroup (mean age 40 years) completed the DASH surveyat a mean of 6.2 years postoperatively and 13/31returned for follow-up at a mean of 3.6 years. At follow-up, patients were assessed for postoperative complica-tions, grip strength, forearm and wrist range of motion,and were scored according to the Gartland and WerleyDemerit System and the Modified Mayo Wrist System.

Results Of the patients in the S-K group who returned forfollow-up (9 patients), 3 experienced a painful click, 1had a nonpainful click, 2 had painful hardware, and 1 hadsensory changes in the ulnar nerve distribution. Of thepatients in the Darrach group who returned for follow-up(13 patients), 3 had pain at the ulnar stump, 1 had apainful click, 1 had a nonpainful click, 3 had sensory

changes in the ulnar nerve distribution, and 1 had evi-dence of significant ulnar carpal translocation. The meanDASH scores were 23.4 in the S-K group and 22.8 in theDarrach group. There was no significant differencebetween these scores (p=0.93). There were no signifi-cant differences in grip strength, forearm and wristrange of motion, Gartland and Werley Demerit Scores(3.0 in the S-K group, 3.6 in the Darrach group), or theModified Mayo Wrist Scores (77.8 in the Sauve-Kapandjigroup, 71.5 in the Darrach group).

Conclusions Our results show that the Darrach resectionand the S-K pro c e d u re yield comparable results followingColles’ fracture in patients under age 50 with respect toboth subjective outcome (DASH score) and objectiveparameters (Gartland-Werley and Modified Mayo WristScores).

References

Tulipan DJ, Eaton RG, Eberh a rt RE. The Darr a c hProcedure Defended: Technique Redefined and Long-Term Follow-up. J Hand Surg. 1991 May; 16(3):438–44.

Carter PB, Stuart PR. The Sauve-Kapandji Procedure forPost-Traumatic Disorders of the Distal Radio-Ulnar Joint.JBJS Br. 2000 Sep; 82(7):1013–8.

DiBenedetto MR, Lubbers LM, Coleman C. Long-TermResults of the Minimal Resection Darrach Procedure. J Hand Surg. 1991 May;16(3):445–50.



Paper #48

Results of the Sauve-Kapandji Procedure and the Darrach Procedure for ComplicationsAfter Colles’ Fracture

Michael S. George, MD, Cincinnati, OHThomas R. Kiefhaber, MD, Cincinnati, OHPeter J. Stern, MD, Cincinnati, OH

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ASSH Annual Meeting Abstract 2003

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