In Reply:

Abstract

Dr. Strackee makes an accurate observation that the center of rotation was at the center of the osteotomy, a fact that was stated in the text of the article (page 40, line 1). His comments, however, are overreaching, unsupported, and not realistic. Wedge osteotomies were developed to minimize alteration of ulnar variation for the small group of patients with Kienböck's disease who are ulnar neutral or positive. No one claims that these osteotomies eliminate changes in ulnar variation. Certainly alterations can be minimized by placing the center of rotation as close as possible to the distal ulnar corner of the radius. Unfortunately in the clinical situation this places the osteotomy into the distal radioulnar joint. It also makes the distal radial fragment in the area of the lunate facet excessively thin, risking intra-articular fracture and nonunion. The degree of precision alluded to by Dr. Strackee is further hampered by the fact that the center of rotation is not the only variable that effects the postosteotomy geometry of the radius. The kerf of the saw blade removes 1 to 2 mm of bone. The distal radioulnar ligaments are another point of rotation in addition to the ulnar margin of the radius. The adjacent distal radioulnar joint is another constraint that may introduce translation of the distal radial fragment into the equation. Furthermore the distal radius is a 3-dimensional structure so the coronal angle of the osteotomy could induce changes in radiopalmar tilt. Finally, it is important to remember that biomechanics is only a theoretical part of the picture. I draw Dr. Strackee's attention to the physiologic issues such as joint denervation and surgically stimulated fibrovascular response recently reported on by Illarramendi et al. 1 Illarramendi AA Schulz C De Carli P The surgical treatment of Kienböck's disease by radius and ulna metaphyseal core decompression. J Hand Surg. 2001; 26A: 252-260 Google Scholar