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1 Metdt of the chpter tht will e visulized online Series Title Chpter Title Ulnocrpl Autment: Stte of the Art nd the Role of Arthroscopy Chpter SuTitle Copyright Yer 2013 Copyright Holder Springer-Verlg Berlin Heidelerg Corresponding Author Fmily Nme Mthoulin Prticle Given Nme Ch. Suffix Division Orgniztion Institut de l min, Clinique Jouvenet Address 6 squre Jouvenet, 75016, Pris, Frnce Emil cmthoulin@ornge.fr Astrct Ulnocrpl utment is the inversion of the distl rdioulnr index with positive ulnr vrince (long uln) nd is most frequently secondry to distl rdius frctures. The reltive shortening of the rdius leds to conflict etween the ulnr hed nd the proximl lunte (Fig. 13.1). The nturl evolution of this condition is usully centrl perfortion of the TFCC. This lesion eventully leds to rthritis of the medil proximl lunte s well s tht of the ulnr hed. Persistence of the utment my further led to lunotriquetrl dissocition (Fig c).

2 1 2 Ulnocrpl Autment: Stte of the Art nd the Role of Arthroscopy 13 3 Ch. Mthoulin 4 Introduction Indictions [AU1] Ulnocrpl utment is the inversion of the distl rdioulnr index with positive ulnr vrince (long uln) nd is most frequently secondry to distl rdius frctures. The reltive shortening of the rdius leds to conflict etween the ulnr hed nd the proximl lunte (Fig. 13.1). The nturl evolution of this condition is usully centrl perfortion of the TFCC. This lesion eventully leds to rthritis of the medil proximl lunte s well s tht of the ulnr hed. Persistence of the utment my further led to lunotriquetrl dissocition (Fig c). There re mny mngement options for the distl rdioulnr component of distl rdius mlunions, tht cuse the most common ulnocrpl utment, with the rdius shortening ssocited with the dorsl tilt, nd the choice depends on clinicl evlution nd imging of this joint. Arthroscopic tretment, when possile, remins the simplest nd est solution for these ptients. Ch. Mthoulin Institut de l min, Clinique Jouvenet, 6 squre Jouvenet, Pris, Frnce e-mil: cmthoulin@ornge.fr Clinicl nd Prclinicl Assessment The clinicin should differentite etween symptoms relted to pronosupintion prolem nd those rising from proper wrist movements. It is crucil to determine whether the symptoms re cused y the distl rdioulnr joint itself or y the ulnocrpl utment tht follows. The evlution of functionl disility must tke into considertion ge, dominnce, nd nture of dily ctivities whether professionl or sports. Active motion is ssessed on flexion-extension nd prontion-supintion. Grip strength on oth sides is mesured using the Jmr. Posteronterior nd lterl views re tken in neutrl position (Fig. 13.3). It is very importnt to otin strict PA views in neutrl wrist position using rdiotrnsprent pltes tht sndwich the wrist nd forerm. Anlysis llows the study of the rdioulnr vrince usully using the concentric circles of Plmer (1). The mesurements must e comprtive s this index is extremely vrile. It increses in prontion with clenched fist nd decreses with supintion. Dynmic posteronterior clenched fist views in prontion emphsize the signs of ulnolunte conflict (Fig. 13.4). A CT rthroscnner is useful for showing the stte of the crtilge. MRI my lso e useful for this purpose (Fig. 13.5) [AU2] F. del Piñl (ed.), Arthroscopic Mngement of Ulnr Pin, DOI / _13, Springer-Verlg Berlin Heidelerg

3 2 Ch. Mthoulin Fig Digrm showing the different reltionship etween the uln nd rdius, mesured in neutrl position: long uln, uln norml, nd short uln Clssicl Tretment 1. Ulnr Shortening Osteotomy (USO) Descried y Milch in 1941, this is the most logicl technique. An pproch to the inner order of the forerm is required, s the shortening is diphysel (Fig. 13.6). A dorsoulnr incision is mde on the distl one-third of the forerm. The dorsl sensory rnch of the ulnr nerve is identified nd protected. A 6-hole 3.5-mm DCP plte is positioned t the distl uln, nd the three metphysel holes re mde. The frgment to e removed is mrked using dithermy lde, nd the osteotomy is mde using n oscillting sw t low speed under continuous irrigtion. The osteotomy my e perpendiculr, olique, or Z shped. Two prllel sw cuts re mde. They re usully from 3 to 8 mm in order to correct the modifiction of the ulnr vrince. Fixtion nd compression re chieved using plte with 3.5-mm screws. The forerm is immoilized for 21 dys postopertively for pin relief. USO my e ssocited with rdil osteotomy. The most frequent compliction of this technique is nonunion. 2. Hemiresection of the Ulnr Hed Descried y Bowers, nd modified y Fernndez, this technique involves the hemiresection of the ulnr hed through dorsl pproch (Fig. 13.7). A 2-cm flp of the extensor retinculum is rised over the fourth comprtment towrd the uln, tking cre not to open the ECU comprtment. The EDM is retrcted rdilly. The dorsl cpsule of the DRUJ is rised from the sigmoid notch nd dissected ulnrly to expose the ulnr hed nd the TFCC. The ulnr hed is resected oliquely from the se of the styloid to the rdil side of the neck of the uln, tking cre to preserve the insertion of the TFCC (Fig. 13.8). A musculotendinous flp is hrvested using hlf the ECU, rolled over itself in n nchovy nd sutured using sorle sutures, nd inserted into the spce left y the resected hed (Fig. 13.9). It is fixed to prontor qudrtus s well s the dorsl order of the TFCC. The extensor retinculum nd dorsl cpsule re closed in one plne using trnsosseous sutures onto the sigmoid notch (Fig ). Immoiliztion in cst for 6 weeks is done, nd physiotherpy is commenced fterwrd. 3. Totl Resection of the Ulnr Hed (Drrch s Technique)

4 13 Ulnocrpl Autment: Stte of the Art nd the Role of Arthroscopy 3 c Fig (, ) Digrm showing inversion of the distl rdioulnr index with norml contct etween the ulnr hed nd the internl rdiocrpl spect of the lunte. It is worthy of note tht this type of conflict only occurs if the rdius hs een correctly reduced with simple xil impction. Mlunions in rdil devition re certinly unsightly, ut they protect the ulnr side of the wrist nd void conflict. (c) Operting view showing the centrl perfortion of TFCC with chondrl chnge on ulnr hed This technique ws first descried y Drrch in 1912 for chronic posttrumtic disloction of the uln. The dorsl nnulr ligment is identified through dorsl prmedin incision. It is incised on its ulnr order, nd rectngulr flp is rised on rdil hinge until the fourth comprtment. The cpsule is crefully incised xilly, identifying oth flps. The ulnr hed is pproched superiostelly, preserving the medin ligments. The incision is mde s rdilly s possile, preserving the prontor qudrtus insertion. After modeling the ulnr stump to rounded shpe, stiliztion

5 4 Ch. Mthoulin Fig To otin neutrl prontion position, the rm is t 90 to the ody xis with 90 elow flexion nd the hnd on the rdiology plte Fig Dynmic view in rdil devition emphsizing the ulnolunte conflict Fig MRI showing the relity of the ulnolunte conflict in two views with crtilge still preserved, ut pthologicl spect of the suchondrl one especilly of the lunte

6 13 Ulnocrpl Autment: Stte of the Art nd the Role of Arthroscopy 5 [AU3] Fig Digrm showing the principle of Milch s ulnr shortening Fig Digrm showing the principle of Fernndez hemiresection Fig Digrm showing the hemiresection preserving TFCC nd hrvesting hlf of ECU

7 6 Ch. Mthoulin Fig Digrm showing hlf of ECU rolled over itself nd inserted into the spce left y the resected hed Fig Digrm showing the extensor retinculum nd dorsl cpsule closed in one plne using trnsosseous sutures onto the sigmoid notch is done t severl plnes. The cpsule is resected nd sutured. The retinculum is reinserted medilly onto itself, djusting the tension nd pssing elow the ECU tendon which is dorslized, lterlized, nd stilized y retinculr flp. Stiliztion my e esier using hemi-ecu which is pssed cross the distl uln nd fixed onto itself (Fig , ). 4. Suvé-Kpndji Technique This ws descried in 1936 y Suvé nd Kpndji.Although descried for distl rdioulnr disloctions unstle fter reduc tion, it cn e used for ulnolunte conflict with rdioulnr disloction nd is exceptionl in pure ulnolunte conflict (Fig ). 5. Ulnr Hed Prosthesis Ulnr hed prostheses re ctully rrely used ut could potentilly ecome therpeutic option. Arthroscopy in Tretment of Ulnolunte Conflict Wrist rthroscopy, populrized y Whipple in 1986, hs since ecome routine exmintion. Arthroscopy is the est tool for ssessing the grvity of ulnolunte conflict; lesions of the crtilge cn e seen directly. This is even more pertinent in erly cses where the lesions cn e detected only y rthroscopy nd re limited to the conflict zone. Arthroscopy t this stge my lso show ssocited lesions in detil especilly TFCC lesions which re lmost lwys present. An inversion of the rdioulnr index smller thn 5 mm my e treted rthroscopiclly using Feldon s prtil ulnr resection technique (6). This technique ws first done using the sme pproch s for Bower s prtil resection ut we prefer to do it rthroscopiclly to minimize postopertive pin [AU4]

8 13 Ulnocrpl Autment: Stte of the Art nd the Role of Arthroscopy 7 Fig (, ) Digrm showing the ulnr hed resection nd the stiliztion using hemi-ecu which is pssed cross the distl uln nd fixed onto itself Technique of Prtil Resection of the Distl Uln Under Arthroscopic Control The ptient lies supine with the rm flt nd fixed to n rm tle. At 90 elow flexion, the forerm is under xil trction using the rthroscopy tower nd Chinese finger trps. It is dy surgery under locoregionl nesthesi nd rm tourniquet. The scope is introduced through 3 4 portl, llowing explortion of the rdiocrpl joint. A 6R portl llows tretment of lesions encountered nd the ulnolunte conflict. I use 2.4-mm size rthroscope with 3.o synovitomes nd 3.o urr. Usully, centrl perfortion of the TFCC is encountered with n ulnr hed protruding into the rdiocrpl joint. The crtilge on the ulnr hed is ssessed, nd chondropthy is usully found (Fig c) which is seldom seen on plin films t this stge. This chondropthy is lso rrely seen even on rthrogrm due to the smll size of the lesion which is usully the cuse of pin. It is t this stge where prtil resection of the distl uln resolves the ulnolunte conflict nd the pin. After introduction of the scope through 3 4 portl, nd microsuction forceps through

9 8 Ch. Mthoulin Fig Clinicl cse showing long-term follow up of Suvé-Kpndji osteotomy with interposition of resected ulnr hed frgment to preserve crpl redth

10 13 Ulnocrpl Autment: Stte of the Art nd the Role of Arthroscopy 9 c Fig () Digrm fter trction, showing the TFCC centrl perfortion, protrusion of the ulnr hed, nd crtilge lesions on the lunte. () Operting view showing the correct position of scope (3 4 rdiocrpl portl) nd shver (6R rdiocrpl portl). (c) Intr-rticulr operting view showing the centrl deridement of TFCC with shver

11 10 Ch. Mthoulin Fig () Digrm showing rthroscopic setup with centrl TFCC deridement using sket forceps. () Intr-rticulr view showing centrl deridement of TFCC with sket forceps the 6R portl, the centrl TFCC perfortion is first derided nd enlrged (Fig , ). The protruding prt of the ulnr hed is then resected using urr under rthroscopic control (Fig , ). If the TFCC is intct, the rthroscope is introduced through the distl rdioulnr joint nd the urr directly onto the fove distl nd plmr to the ulnr styloid with the wrist in supintion to void injury to the dorsl sensory rnch of the ulnr nerve (see lso Chp. 9). Prontion-supintion movements re mde to ensure even resection of the nterior nd posterior prts of the ulnr hed respecting the distl rdio ulnr joint (Fig f). The ulnr hed is not perfectly sphericl, nd thus, these pronosupintory movements llow tilored resection of the prts of the hed protruding into the TFCC perfortion. The resulting osteotomy is usully originl, olique, nd helicoidl (Fig , ). This type of osteotomy is

12 13 Ulnocrpl Autment: Stte of the Art nd the Role of Arthroscopy 11 Fig () Arthroscopic view showing strt of ulnr hed resection using urr. () Operting view showing the correct position of scope (3 4 rdiocrpl portl) nd urr (6R rdiocrpl portl) not possile through stndrd clssic open pproch using stright osteotomy lde. It is crucil to verify the integrity of the DRUJ t the end of the procedure (Fig c). Discussion Ulnolunte conflict is the result of the inversion of the distl rdioulnr index, most commonly following distl one-fourth rdius frcture with impction in the xis of the distl rdius. Ulnolunte conflict cuses centrl TFCC perfortion with crtilge lesions of the distl ulnr hed nd the lunte. Clinicl wrist exmintion revels ulnr pin excerted in prontion nd ulnr devition of the wrist. This pin my e relted to long congenitl uln (rre lesion), TFCC lesion, lunotriquetrl lesion, rdioulnr ligment lesion, or chondroclcinosis of the ulnr hed. The vriety of possile lesions wrrnts systemtic stndrd films followed y sophisticted complementry investigtions rthrogrm or rthroscopy. Stndrd ilterl wrist films in supintion, prontion, clenched fist, nd strict frontl llow n ojective mesurement of the distl rdioulnr index s well s distl rdioulnr rticulr congruency. Complementry rthrogrm or rthroscopy ccurtely shows ssocited crtilge lesions. The erlier the tretment, the etter the results in preventing the inevitle evolution to rthritis. Between 1998 nd 2010, 2,023 wrist rthroscopies including 126 distl ulnr resections (6.23 %) were performed. In three cses with no TFCC lesion, distl rdioulnr pproch ws used. In this series, ptients included 49 men nd 77 women of verge ge 68 (etween 42 nd 87 yers). All were distl one-fourth rdius frctures with xil impction nd inversion of the distl rdioulnr index. The ulnr vrince ws 2.6 mm on verge (2 5.5 mm). The men dely

13 12 Ch. Mthoulin Fig ( f) Digrm nd intr-rticulr view showing rthroscopic resection of ulnr hed using urr with prontion- supintion movements to ensure resection of the nterior nd posterior prts of the ulnr hed etween the frcture nd the rthroscopic resection ws 9.3 months (2 36 months). Arthroscopic resection ws the only procedure performed in ll cses. Pin ws lwys present, permnent, nd moderte in 80 cses nd disling in 46 cses. Force ws diminished y more thn hlf compred to the contrlterl side. Moility ws lredy limited due to the often ssocited mlunion of the distl one-fourth rdius frcture. Pronosupintion ws less thn 120 in 93 cses nd less thn 60 in 33 cses. None of the ptients needed postopertive immoiliztion (Fig , ). Our verge follow-up is 35 months (12 97 months). Recovery of moility ws immedite in ll cses with persistence of DRUJ pin in eight cses. In 71 cses, preopertive pin disppered immeditely postopertive. Force incresed compred to preopertive vlues ut never reched the vlue of the helthy contrlterl side. We oserved three postopertive hemtoms which resolved without tretment, residul limittion of pronosupintion in 12 cses nd 6 cses of CRPS which were dignosed erly, treted promptly, nd recovered completely. Conclusion Arthroscopic tretment hs proved its efficcy nd its sfety. It should nevertheless e limited to cses of inversion of smll vlues (inferior

14 13 Ulnocrpl Autment: Stte of the Art nd the Role of Arthroscopy 13 c Fig (, ) Digrm nd intr-rticulr view showing the finl resulting olique nd helicoidl osteotomy Fig (continued)

15 14 Ch. Mthoulin Fig () Cse of ulnolunte conflict fter distl rdius frcture. () Plin views showing immedite postopertive results. The zone of conflict is eliminted with preservtion of norml distl rdioulnr joint nd thus norml pronosupintion Fig ( c) Digrm nd rthroscopic views showing the whole DRUJ intct with rthroscope through 6R to 5 mm). In greter ulnr vrinces, we prefer ulnr shortening osteotomy. Other techniques re reserved for cses with ltered distl rdioulnr joint. Biliogrphy Bowers WH (1985) Distl rdio ulnr joint rthroplsty: the hemi resection-interposition technique. J Hnd Surg Am 10-A: Feldon P, Terrono A, Belsky M (1992) Wfer distl uln resection for tringulr firocrtilge ters nd/or uln impction syndrome. J Hnd Surg 7A: Fernndez DL (1988) Rdil osteotomy nd owers rthrosplsty for mlunited frcture of the distl end of the rdius. J Bone Joint Surg Am 26-A: Milch H (1941) Cuff resection of the uln for mlunited colle s frcture. J Bone Joint Surg 23A: Plmer AK, Glisson RR, Werner FW (1982) Ulnr vrince determintion. J Hnd Surg Am 7: Suvé L, Kpndji M (1936) Nouvelles techniques de tritement chirurgicl des luxtions récidivntes isolées de l extrémité inférieure du cuitus. J Chir 45:

16 13 Ulnocrpl Autment: Stte of the Art nd the Role of Arthroscopy 15

17 Chpter No.: Author Queries Query Detils Required Author s Response AU1 Plese provide deprtment nme for Ch. Mthoulin AU2 Plese specify the significnce of (1). AU3 Plese provide the significnce of rrow provided in the rtwork of Fig AU4 Plese specify the significnce of (6).