Volar Approach Research Articles

Dorsal and Volar Approaches for Proximal Interphalangeal Joint Replacement: Comparing Outcomes Through Systematic Review and Meta-Analysis.

The 2 primary surgical approaches for proximal interphalangeal joint (PIPJ) arthroplasty, dorsal or volar, have been extensively described in the literature. However, the ongoing debate regarding which approach offers superior results or is associated with fewer complications persists. This systematic review aims to compare the outcomes of PIPJ arthroplasty between the dorsal and volar approaches. A comprehensive search of multiple databases was conducted, and studies meeting predetermined criteria were included. Data extraction, assessment of bias risk, and statistical analysis were performed to compare treatment modalities. Outcome measures included range of motion (ROM), patient-reported outcome measures (PROMs), revisions, and reported complications. Among 368 screened articles, 5 studies involving 302 patients (310 implants) were eligible for final review. No significant differences were observed between the 2 approaches regarding postoperative ROM (mean difference [MD] 2.24; 95% confidence interval [CI] -3.83, 8.32; P = .47) and PROMs (standardized mean difference [SMD] 0.18; 95% CI -0.12, 0.48; P = .25). Complication rates, including revision/fusion, persistent pain, stiffness, infection, and dislocation, did not significantly differ between the approaches. Notably, dorsal approach was associated with higher risk of swan-neck deformity (9 out of 82 implants), while no such cases were reported in the volar approach (0 out of 101 implants). Despite limitations and heterogeneity in the literature, both dorsal and volar approaches for PIPJ arthroplasty appear to yield equivalent outcomes for patients. II, therapeutic.

Our Experience with Surgical Treatment of Scaphoid Fractures with Headless Compression Screw

BACKGROUND: Fractures of the scaphoid bone are quite common, and they come with their own set of challenges due to the specific shape of the fractures and the delicate blood supply to the scaphoid bone. Failing to diagnose and treat acute scaphoid fractures promptly can result in failure of the bone to heal and subsequent development of wrist arthritis. Advances in diagnosis, surgery, and implant materials have led to a growing inclination towards early surgical fixation, even for non-displaced scaphoid fractures that could potentially be treated without surgery. AIM: The study's goal was to assess the effectiveness of headless compression screws for treating acute scaphoid fractures and, in two cases, nonunion following previous conservative therapy. METHODS: Between January 2022 and March 2024 ten patients with scaphoid fractures were surgically treated at the University Clinic of Traumatology Skopje, within twelve months follow-up. All of them were male with mean age of 27,3 years. All were diagnosed with X-rays and CT scans. Six of the fractures were on the right hand and four on the left. RESULTS: All the patients were surgically treated with open reduction and internal fixation with headless compression screw. Volar approach was used in 9 cases and dorsal approach in only one of them. Six of the patients were surgically treated within 4-14 days after injury and four of them were surgically treated due to non union after previous conservative treatment, two of them after three and two of them after seven months of injury. All fractures united after a mean time of 9,5 weeks, without secondary displacement. Throughout the follow-up period, there were no incidences of developing osteoarthritis of the wrist. CONCLUSIONS: It is crucial to understand that achieving a positive result is not guaranteed for every patient and relies on selecting the right patients and fractures. However, our study shows favorable results in sooner surgical treatment with the headless compression screw, rather than delayed treatment of scaphoid fractures. Surgical treatment with headless compression screw showed both functional and radiographic results. While it is beneficial for the screw to be positioned in the subchondral area, it is important to be cautious to avoid cortical penetration, as this will require the screw to be removed later.

Assessing the Need for Imaging after Distal Radius Fracture Fixation

Abstract Background Distal radius fractures are extremely common. Patients routinely undergo early imaging (around 2 weeks) after open reduction and internal fixation (ORIF) of distal radius fractures despite no clinical concerns. We analyzed the need for these radiographs by evaluating when imaging identifies complications after surgery. Methods All distal radius fractures treated with ORIF via a volar approach by the senior surgeon were included. Intraoperative and postoperative images were analyzed for maintenance of reduction and complications. Demographic data, fracture characteristics, and postoperative complications were also recorded. Results A total of 342 patients were identified. Postoperative images were obtained from 0 to 14, 15 to 90, 91 to 180, 181 to 365, or greater than 365 days after surgery. Some patients had multiple images. Measurements on postoperative images were statistically equivalent across all time points. Complications mostly occurred >90 days after surgery. Of the 26 patients with complications, 5 had a failure of reduction or plating seen on postoperative imaging. Two occurred after unrelated trauma; only three patients had unanticipated complications caught on routine imaging within 3 months after surgery. These patients had extraordinarily complex fractures in poor bone stock. Conclusion Early postoperative imaging is not necessary after ORIF for distal radius fractures unless the patient is elderly, or the fracture is severely comminuted with ulnar column or die-punch components. Thus, we suggest that patients have imaging only in the 3- to 6-month period to determine if the union has been achieved, which could provide cost savings to both surgeon and patient.

Distal Radius Osteotomies for Kienbock's Disease—A Minimally Invasive Approach

Abstract Background Negative ulnar variance is a recognized predisposing factor for Kienbock's disease (KD). Radial shortening osteotomy (RSO) reduces radial height, thereby alleviating stress on the lunate. Conversely, radial closed wedge osteotomy (RCWO) involves removing a distal radius wedge to not only decrease radial height but also reduce radial inclination, thereby enhancing lunate coverage. Description This article outlines a straightforward and minimally invasive approach to RSO utilizing a single cut and stabilization with a single screw. Additionally, it introduces a technique for RCWO comprising two cuts, wedge removal from the distal radius, and fixation using a single headless screw. Literature Review Traditionally, RSO and RCWO procedures include a volar approach consistent with distal radius fracture fixation techniques. However, the reliance on “free-hand” cuts may necessitate larger hardware for stabilization. Overcorrection poses risks of suboptimal outcomes and often mandates subsequent hardware removal procedures. Clinical Relevance Both RSO and RCWO techniques offer minimally invasive solutions, which preserve the periosteum, and maintain stability. These techniques only require a single screw and a removable splint. RSO is indicated for KD wrists with negative ulnar variance, while RCWO is preferable for cases with negative ulnar variance and increased radial inclination.

Treatment of the Distal Forearm Fracture by Volar Dual Window Approach.

Distal forearm fractures were defined as distal radius fractures with concomitant distal ulna fractures, except ulna styloid fractures. Distal forearm fractures are common among geriatric populations, particularly those with osteoporosis. Conventionally, distal forearm fractures are reduced by a double incision approach; however, malreduction and instability of the distal radioulnar joint were not uncommon. We introduced a modified volar dual window approach to treat the distal forearm fracture and evaluate the functional outcomes and complications. From January 2020 to June 2023, 13 patients with distal forearm fractures underwent open reduction by the modified dual window approach with locking plate fixation. After surgery, splints were applied for two weeks, and the patients underwent postoperative hand therapy for three months. The mean Quick Disabilities of the Arm, Shoulder, and Hand scores, range of motions, grip strength, postoperative radiographic parameters, and complications data were collected. The mean follow-up period was 12.1 months, and the mean age was 52.3 years. Average wrist flexion was 67°, extension 69°, pronation 81°, and supination 79°. Grip strength was 28.3 ± 11.5 kg, which was 88% of the uninjured opposite side. The Visual Analog Scale score during activities was recorded as 0.5 ± 0.9. The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 14 ± 11.5. The postoperative radiographic parameters were as follows: radial height: 10.8 ± 1.7 mm, radial inclination: 22.6 ± 3.7°, volar tilting: 4.0 ± 3.9°, and ulnar variance: -0.4 ± 1.4 mm. All the patients achieved bone union at the final follow-up. Two patients underwent ulnar implant removal due to irritation symptoms. Neither infection, nor neurovascular injury, nor malreduction developed in these patients. The modified volar dual window approach can achieve good wrist function and distal forearm fracture reduction without increasing neurovascular or wound healing complications. This method is an alternative approach for distal forearm fracture, especially in comminuted distal ulna fracture or distal radioulnar joint incongruity.

Modified volar approach for proximal row carpectomy

ObjectivesProximal row carpectomy is a well-accepted surgical procedure for the management of traumatic and degenerative wrist pathologies. It is routinely performed through a dorsal approach; a volar surgical access was presented in order to enable concomitant carpal tunnel release and avoid flexion limitation or disabilities caused by adhesions of the dorsal capsule and extensor tendons. We propose a modification to the volar approach, with detailed description of skin incision (reproducing the standard palmar access to the scaphoid), capsular section (beginning with a longitudinal cut radial to flexor carpi radialis tendon and prolonged transversally along the radio-lunate joint) and sequence of carpal bone removal (starting with the scaphoid rather than the lunate). Materials and methodsThe patients who underwent surgical treatment with modified volar proximal row carpectomy between 1992 and 2015 were enrolled in a retrospective analysis. ResultsWe report postoperative improvement in both the Mayo Wrist score and total active range of motion in 38 patients, in line with the outcomes of dorsal proximal row carpectomy. ConclusionsThe modified volar approach is highly recommended when better visualization and access to proximal carpal bones are needed (particularly useful for inveterate perilunate dislocations), moreover if concomitant carpal tunnel syndrome or extensor tendon pathologies are present.

The Safety of Volar to Dorsal Percutaneous Screw Fixation of Bennett Fracture-Dislocation - A Cadaveric Study.

Background: Bennett fractures are traditionally fixed with percutaneous K-wires from dorsal to volar, or with a volar to dorsal screw via a volar open approach. While volar to dorsal screw fixation is biomechanically advantageous, an open approach requires extensive soft tissue dissection, thus increasing morbidity. This study aims to investigate the practicality and safety of Bennett fracture fixation using a percutaneous, volar to dorsal screw, particularly with regard to the median nerve and its motor branch during wire and screw insertion. Methods: Fifteen fresh frozen forearm and hand specimens were obtained from the University of Auckland human cadaver laboratory. A guidewire is placed under image intensifier from volar to dorsal with the thumb held in traction, abduction and pronation. The wire is passed through the skin volarly under image intensifier, then the median nerve is dissected from the carpal tunnel and the motor branch of the median nerve (MBMN) is dissected from its origin to where it supplies the thenar musculature. The distance between the K-wire to the MBMN is measured. Results: In 14 of 15 specimens, the wire was superficial and radial to the carpal tunnel. The mean distance to the origin of the MBMN is 6.2 mm (95% CI 4.1-8.3) with the closest specimen 1 mm away. The mean closest distance the wire gets to any part of the MBMN is 3.7 mm (95% CI 1.6-5.8); in two specimens, the wire was through the MBMN. Conclusions: Wire placement, although done under image intensifier, is subject to significant variation in exiting location. While research has shown the thenar portal in arthroscopic thumb surgery is safe, our guidewire needs to exit further ulnar to capture the Bennett fracture fragment, placing the MBMN at risk. This cadaveric study has demonstrated the proposed technique is unsafe for use.

Impact of Pronator Quadratus Muscle Tear in Distal Radius Fractures on Patient Outcomes: Analyses of 55 Patients in a Volar Locking Plate Arm of a Randomized Clinical Trial.

Background The advantage of pronator quadratus (PQ) repair following internal fixation via the volar approach in distal radius fracture (DRF) surgery remains unconfirmed in the literature. The aim of this study was to compare grip strength, patient-reported outcomes, and functional results between patients with an intact PQ and those with a ruptured PQ before undergoing surgery with a volar locking plate for dorsally displaced unstable extra-articular DRFs. Methods A total of 120 patients aged 55 years and older were included in a randomized controlled trial comparing a volar locking plate with a dorsal nail plate. Of the 60 patients randomized to the volar plate group, the integrity of the PQ muscle was recorded during surgery for 55 patients, who were included in this study. The outcomes measured were the Quick Disabilities of the Arm, Shoulder, and Hand Outcome Measure (QuickDASH) score, the Patient-Rated Wrist Evaluation (PRWE) score, the EQ-5D index, the visual analog scale (VAS) score, grip strength, and range of motion (ROM). Results The median age was 67 years (range 55 to 88), and the one-year follow-up rate was 98%. Patients with an identified intact PQ (28/55) before surgical release had better QuickDASH scores after one year (2.5 vs 8.0, mean difference 5.5, 95% CI: 1.3 to 9.8, p=0.028). Patients in the intact group also had better EQ-5D Index scores after one year (0.94 vs 0.85, mean difference 0.089, 95% CI: 0.004 to 0.174, p=0.031), and demonstrated better grip strength throughout the trial; after one year: 24 kg vs 20 kg (mean difference 3.9; 95% CI: 0.3 to 7.6, p=0.016). After one year, the intact group had regained 96% of their grip strength and the nonintact group had regained 93% of their grip strength compared to the uninjured side. The observed differences may be of questionable clinical importance, as they were lower than those of previously proposed minimal clinically important differences (MCIDs). Conclusions Patients with a DRF and a ruptured PQ prior to surgery exhibited higher QuickDASH scores and lower EQ-5D index scores after one year. The integrity of the PQ should be reported in future studies.

Open Reduction and Transosseous Plasty of the Dorsal Scapholunate Ligament in a Patient with Mayfield type IV Chronic Lunate Dislocation, Case Report, Literature Review and Description of Surgical Technique

Introduction Perilunate dislocations represent 3% of carpal injuries. They begin in a radial direction, destabilizing the scapholunate interval, and as the injury continues, there is a progressive sequence of instability, altering the anatomy of the carpus, causing significant functional deterioration. The acute diagnosis goes unnoticed, evolving into its chronic form. There are few reports of treatment in its chronic phase with a limited number of patients and follow-up evaluation is often limited. Objective We present a case of late diagnosis of chronic lunate dislocation that was managed surgically and review of the existing literature for diagnosis and treatment, as well as the surgical technique for its resolution. Clinical case 66-year-old male, fall from the plane of support, hyperextension mechanism of the right wrist, 2 months of evolution causing pain, progressive increase in volume, functional limitation. Treated with non-steroidal anti-inflammatory drugs for four weeks without improvement. Radiographically, loss of lunate joint congruity - capitate. Magnetic resonance images of avascular necrosis of the lunate. Diagnosing chronic semilunar dislocation of the right hand. Preoperative Quick-Dash 70.4 pts. A double dorsal and volar approach is performed to release the carpal tunnel, place a transosseous cerclage, and three 1.6 mm Kirschner pins in the scapholunate interval; semilunopyramidal and scaphocapitate. Immobilization with antebrachipalmar splint, removal of Kirschner pins at 7 weeks and referral to physical rehabilitation. 20 postoperative weeks, range of motion with flexion of 35° and extension of 30°, without visible sequelae to mobilization, and with Quick-Dash 20.4. Conclusion Early diagnosis and treatment are necessary to prevent the potential risk of avascular necrosis of the lunate and scaphoid, and secondary osteoarthritis. Reconstruction of the chronic pathology of lunate dislocation and scapholunate ligament (SL) remains a major challenge. There are unresolved issues regarding when to perform reconstruction rather than repair and therefore treatment remains controversial.

Single-Stage Reduction of Neglected Perilunate Dislocation: A Case Report

Abstract Neglected perilunate dislocations are rare and challenging injuries. We report a 59 days old perilunate dislocation in a 55 year old right-handed male. X-ray and CT imaging revealed a dorsal perilunate dislocation with no additional fractures and no increased density or microarchitectural collapse of the lunate or scaphoid. A single-stage open reduction and internal K-wire fixation procedure through a dorsal and volar approach was done. Eighteen months after the procedure, the patient was pain free during movement and had a ROM of 70%. His grip strength was 80.8% the opposite side and the Mayo wrist score was calculated 75. Full range of finger movement was achieved and he carried out his routine without any other complication.

Cutaneous nerve distribution around first extensor compartment of the wrist: Clinical implications for ultrasound-guided injections

To evaluate the course of the cutaneous nerve regarding the first extensor compartment to determine whether the dorsal or volar approach is safer for local injection into the first extensor compartment guided by ultrasound. We dissected the radial side of the wrists from 28 cadavers (52 wrists). Four-points along the imaginary line were set: the styloid process and 1 cm, 2 cm, and 3 cm proximal to the styloid process. The numbers of superficial radial nerve (SRN) and lateral antebrachial cutaneous nerve (LACN) branches were counted, and distances from the imaginary line at these points and nerve diameters were recorded. Digital images were superimposed to observe overall distribution of cutaneous nerve. There were means of 3.3 SRN and 0.9 LACN branches observed in each wrist. The mean number of both SRN and LACN branches was 2.3 on the dorsal side and 1.9 on the volar side. The superimposed images indicated that both the dorsal and volar sides comprised abundant cutaneous nerves and that their paths varied markedly between patients. However, we observed that larger nerves with meaningful diameters were more abundant on the dorsal than the volar side. There were similar numbers of cutaneous nerves on both the dorsal and volar sides; however, we observed greater abundance of thicker cutaneous nerves on the dorsal side, and these were closer to the reference line than on the volar side. This anatomical study suggests that the risk imposed to cutaneous nerves would therefore be reduced when injection on the volar side.

Volar Lunate Dislocation: A Case Report

Introduction: Perilunate dislocations are rare high-energy injuries which may often have the potential to cause lifelong disability of the wrist if not addressed optimally. Hence, early recognition, diagnosis, and intervention are of paramount importance in the restoring function and prevention of morbidity. Lunate dislocations are the fourth and last stage of perilunate dislocations being extremely rare, with volar dislocations representing <3% of perilunate dislocations. Case Report: A 24-year-old man suffered from an alleged history of fall from a bike on an outstretched hand following which he developed complaints of pain and swelling in the right wrist. On examination, the patient has relative sensory loss over the lateral half of the palm with no vascular deficit. An accurate range of motion could not be documented due to severe pain. Standard digital X-rays revealed lunate displaced and angulated volarly with a typical “spilled teacup” appearance along with radial and ulnar styloid fractures. Management: The patient was initially given an attempt of closed reduction which was not successful and was followed with open reduction and internal fixation with both volar and dorsal approach with Kirschner wires. The patient’s wrist was immobilized for 6 weeks with below elbow cast with the removal of k wires at 8 weeks after which wrist ROM exercises were started. Results: The patient was followed up for 6 months and now has a functional range of motion of the wrist with no sensory deficit and is able to continue with his profession as a car mechanic. Conclusion: Mayfield progression Stage 4 perilunate dislocations are uncommon with a poor prognosis if not addressed timely. Hence, these injuries need to be identified early and optimally managed with surgical intervention for a favorable outcome. Keywords: Perilunate dislocation, carpal bones, avascular necrosis of lunate, wrist trauma, carpal instability

Surgical Feasibility Study on Cadaver for Vascularized Wrist Joint Transplantation

Despite modern advancements in the treatment of late stages of wrist joint degeneration, few reliable options exist for patients requiring motion-preserving reconstruction of their radiocarpal and midcarpal joints. Vascularized composite allotransplantation (VCA) could be considered an option for wrist reconstruction in the future. The goal of this study was to describe the relevant anatomy and design a potential surgical technique for wrist VCA. Anatomic studies were performed on 17 human upper extremities. The arterial system of each cadaver was injected with latex dye or radiographic contrast. After injecting a contrast medium visible on a computerized tomography (CT) scan, the initial three specimens were examined using microCT. This confirmed joint vascular patency and allowed for the dissection of the other specimens that were injected with latex for the study of joint vascularization and the design of the wrist VCA. We then outlined a donor and recipient surgical technique for transplant based on recipient CT scans. Customized cutting guides were designed for the transplant procedure. After the procedure, we performed angiography of the VCA to determine the vascularity of the transplant. Using a combined volar and dorsal approach, we were able to perform a complete wrist VCA procedure. After the completed transplant procedure, angiographic imaging of the specimens demonstrated that the flap dissection and transplantation preserved the nutrient endosteal supply to the distal end of the radius and ulna, as well as to the carpal bones and the metacarpal bases. The dissection of the donor, recipient, and the entire vascularized joint transplant procedure served to illustrate the anatomical feasibility of the cadaveric surgical technique. This establishes an anatomic basis for the possibility of future human clinical applications. This study helps investigate the anatomical feasibility of a wrist VCA.

Open Reduction Maneuver for Distal Radius Fracture Involving an Intra-articular Sagittal Split

Open Reduction Maneuver for Distal Radius Fracture Involving an Intra-articular Sagittal Split

CT-Based Micromotion Analysis After Locking Plate Fixation of AO Type C Distal Radius Fractures

BackgroundVolar locking plate fixation (VLPF) is the most common method for operative fixation of distal radius fractures (DRF). The dorsal ulnar corner (DUC) can be difficult to stabilize as the fragment is small and not exposed when using the volar approach. The purpose of this study was to study fracture fragment migration after VLPF of AO type C DRF, using a volume registration technique of paired CT scans with special focus on the DUC fragment.Materials and MethodsThis pilot study included ten patients with AO type C DRF, all operated with VLPF. The primary outcome was radiographic outcome. Postoperative and 1-year scans were compared and analyzed. Fragment migration was assessed with CT-based micromotion analysis (CTMA), a software technique used for volume registration of paired CT scans.ResultsAll plates were stable over time. Two patients showed signs of screw movement (0.2–0.35 mm and 0.35– > 1 mm respectively). Postoperative reduction was maintained, and there was no fragment migration at the 1-year follow-up except for one case with increased dorsal tilt. The DUC fragment was found in 8/10 cases, fixated in 7/8 cases, and not dislocated in any case at the 1-year follow-up.ConclusionThe CTMA results indicate that variable-angle VLPF after AO type C DRF can yield and maintain a highly stable reduction of the fracture fragments. The DUC fragment remained stable regardless of the number of screws through the fragment. CT volume registration can be a valuable tool in the detailed assessment of fracture fragment migration following volar plate fixation of DRFs.

Enhanced Approaches to the Treatment of Distal Radius Fractures.

Distal radius fractures are among the most common fractures treated by orthopedic surgeons. Various classification systems have been described which can help in deciding the approach for fixation. In some cases, a computed tomography scan can provide better understanding of the fracture fragments and displacement for surgical planning. Plating through the volar approach is the most common approach for fractures meeting operative criteria. Several additional approaches can be used for specific fracture patterns. These approaches can be used in isolation or in conjunction with other approaches to aid in visualization and fixation.

Current Concepts: Corrective Osteotomy for Extra-Articular Deformity Following a Distal Radius Fracture.

Fracture malunion alters wrist and distal radioulnar joint (DRUJ) biomechanics, resulting in incongruence and instability of the DRUJ. Selected patients with painful functional limitation and significant deformity of the radius, but without advanced degenerative joint disease, may benefit from corrective distal radial osteotomy. Non-union and complications arising from metalwork are the most common reasons for reoperation. Surgeons should have a good understanding of risks and complications in order to fully inform their patients and manage expectations. This article reviews the biomechanical effects of radial malunion and the current concepts for treatment. Distal radial osteotomy is suitable for symptomatic patients with angular radial deformity and shortening. Evidence supports a volar approach without bone grafts for modest corrections. Bone grafts or synthetic bone substitutes are appropriate for larger corrections. Functional improvements are reported regardless of technique. Despite a high complication rate, patient satisfaction with the corrective radial osteotomy is high.

Evaluation of the treatment of distal radial volar fracture by different methods sparing the pronator quadratus

ObjectiveThe traditional volar approach requires the release of the pronator quadratus (PQ) muscle in the treatment of distal radius fractures. However, intraoperative repair of the PQ muscle often fails due to tissue injury and unstable muscle repair. This study compared the outcomes of different methods of sparing the PQ muscle combined with the volar plate in treating distal radius fractures.MethodsA total of 95 patients with distal radius fractures sparing the PQ muscle were enrolled with the brachioradialis (BR) splitting approach (group A, 33 people), the volar plating insertion PQ muscle approach (group B, 35 people) and traditional Henry approach without sparing PQ muscle (group C, 27 people). Postoperative internal fixation, fracture healing and postoperative complications were observed in the three groups. The visual analog scale (VAS) of postoperative wrist pain was compared between three groups. The Dienst joint scale was used to evaluate the wrist function of patients, and imaging indexes were used to evaluate the surgical efficacy.ResultsA total of 95 patients with distal radius fractures were followed up for more than one year after surgery. All fractures obtained good union, with no vascular injury, nerve injury or wound infection. Outcomes at three days, one month and three months all showed no significant differences in postoperative imaging indexes among three groups and no significant differences in various indexes among three groups during the same period. The mean operative time in group C was significantly lower than that in groups A and B. There was significant difference in the mean operation time between group A and group B. The amount of mean operative blood loss or mean bone union time in groups A and B was significantly lower than those in group C. No significant difference was shown in mean operative blood loss or mean bone union time between group A and group B. No significant differences in limb function scores, VAS scores and the mean range of motion existed among three groups at the 12-month postoperative follow-up. However, outcomes assessed one week, one month and three months after surgery demonstrated significant differences in the VAS scores and the mean range of motion among three groups, and the group B had lower VAS score and greater the mean range of motion. According to Dienst score, the excellent rate in groups A, B and C was 91.0% (30/33), 94.2% (33/35) and 85.2% (23/27), respectively, at 12 months after surgery. Tendon irritation occurred in 2 cases and joint stiffness in 1 case in group A. In group B, there were 2 cases traumatic arthritis and 2 cases delayed carpal tunnel syndrome and 1 case tendon irritation. In group C, tendon irritation and delayed carpal tunnel syndrome occurred, respectively, in 3 cases.ConclusionOur results demonstrated that these two different surgical approaches were effective ways to reserve PQ and had good clinical outcomes. The volar plating insertion PQ muscle approach could reduce early postoperative pain, promote early activity and return to normal life, while the BR splitting approach was more advantageous in intraoperative fracture exposure and could shorten the operative time. However, some defects also existed. At 12 months of follow-up, no significant advantage was seen in sparing the PQ muscle. Therefore, surgeons should be aware of their individual characteristics and choose patients carefully.

Une étude anatomique clinique de la zone de sécurité pour l’abord palmaire pour l’arthroscopie du poignet

ObjectiveThe current study was to perform an anatomical observation of the volar approach for wrist arthroscopy and to establish the safe zone for this approach. MethodsEight preserved specimens and 2 fresh specimens were used to simulate the medial-to-lateral operation and to mark the volar approach. Based on anatomical measurements of the volar approach, the closest distances from the half, 6R, 6U, VR, VR’ and VU approaches to the adjacent important structures were established. ResultsThe closest distance from the half approach to the superficial branch of the radial nerve was 2.4±1.5mm. The closest distances from the 6U and 6R approaches to the dorsal carpal branch of the ulnar nerve were 16.2±1.3mm and 9.0±2.4mm, respectively. The closest distances from the VR and VR’ approaches to the palmar cutaneous branch of the median nerve were 6.7±1.1mm and 2.8±0.9mm, respectively; the closest distances to the radial artery were 6.3±4.0mm and 10.0±3.4mm, respectively. Moreover, both of the two approaches passed through the base of the flexor carpi radialis tendon. The closest distance from the VU approach to the ulnar artery and flexor digitorum profundus tendon were 3.3±1.4mm and 0.3±2.5mm, respectively. ConclusionsIn conclusion, a safe zone could be located for the establishment of the volar approach for wrist arthroscopy. Level of evidenceIII; retrospective study with no control group.

Pronator Quadratus Muscle Flap for Prevention of Flexor Tendon Rupture after Distal Radius Volar Plating.

Flexor tendon rupture is a serious but rare complication that can occur after volar plating of distal radius fractures. This study aims to introduce a novel surgical technique that uses a pronator quadratus (PQ) muscle flap transposition to protect the flexor tendons from rupture or irritation and evaluate its outcomes. A retrospective review was conducted on 204 patients with unstable distal radius fractures who underwent a standard volar flexor carpi radialis approach with extended release of the PQ muscle during exposure. A PQ muscle flap was harvested and transposed over the distal edge of the plate after open reduction and internal fixation of the distal radius. Postoperatively, patients were evaluated for flexor tendon irritation and rupture. Patients who had this injury before the use of the PQ flap were compared with the patients who received the PQ flap. Of the 204 patients, 119 received the PQ flap, and 85 did not. The mean follow-up time was 30.4 months. Among the patients who did not receive the PQ flap, five (5.9%) required plate removal or conservative treatment for tendon irritation or rupture. In contrast, only one patient (0.8%) who received the PQ flap required plate removal for flexor tendon irritation. The PQ muscle flap is a quick and effective surgical technique that reduces the risk of flexor tendon rupture or irritation during distal radius fracture fixation. The PQ muscle flap acts as a buffer between the plate and tendon and is more effective than not transposing the muscle.