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Techniques in Hand and Upper Extremity Surgery 10(4):199, 2006  2006 Lippincott Williams & Wilkins, Philadelphia

• E D I T O R I A L •
Doing What You Do Best

A t the 61st annual meeting of the American Society

for Surgery of the Hand in September of 2006, a
distinguished panel of experts moderated by William B.
other procedures as to their long-term benefit to your
It is not my intent to address the usefulness of any of
Kleinman, MD, explained why they had abandoned a the above-mentioned procedures or techniques. That
previously used or recommended surgical procedure or was well done by the panelists. However, a parting
treatment modality for their patients. The abandoned comment by one of the very experienced surgeons on
procedures included the closed treatment of nondis- the panel bears repeating here (my paraphrase): BDo
placed scaphoid fractures, endoscopic carpal tunnel what you do best.[ One implication or interpretation of
release, intercarpal fusion for intercarpal instability, these words is that if a procedure has and is working
ulna lengthening in osteochondromatosis, external fixa- well in your practice, based on careful scrutiny and
tion of distal radius fractures, and the use of cement in suitable follow-up time, then continue to use it.
the hand and wrist. A final caveat: what works for you may not work for
The presentations gave the listener a current and me and vice versa.
candid opinion from the various panel members about a The philosophy of the editors-in-chief and the editorial
procedure or technique that had not, in their opinion, board of this journal is to present, in a timely fashion,
withstood careful scrutiny based on its inability to current techniques in hand and upper extremity surgery.
effectively Bhold up[ over time or had consistently Will all these techniques stand up to careful and long-term
poor results.
Some of the Babandonments[ were startling and, no
scrutiny? Time and experience will give the answer. •
doubt, have and will be associated with a high level of James R. Doyle, MD
controversy among those of us that practice hand Emeritus Professor of Surgery (Orthopedics)
surgery. You, like the panel of experts, may have John A. Burns School of Medicine
Bgiven up[ some of these procedures at this point in University of Hawaii
your career and perhaps are even now reevaluating Honolulu, HI

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Techniques in Hand and Upper Extremity Surgery 10(4):200Y205, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia

| R E V I E W |

A Unified Approach to Radial Tunnel

Syndrome and Lateral Tendinosis
Mark Henry, MD and Christopher Stutz, MD
Hand and Wrist Center of Houston
Houston, TX
Department of Orthopaedic Surgery
University of Texas
Houston, TX

| ABSTRACT that may radiate longitudinally in both directions

(primarily distally) and is considered to result from
Two of the most common diagnoses assigned to patients
posterior interosseous nerve (PIN) compression by any
presenting with lateral elbow and proximal forearm pain
combination of structures, including the vascular leash
are lateral tendinosis and radial tunnel syndrome. Tradi-
of Henry, the undersurface tendon of the extensor carpi
tionally, these 2 conditions have been treated as distinct
radialis brevis (ECRB), the arcade of Frohse, and fascial
and separate entities with most patients being diagnosed
bands more distal within the supinator muscle.1 Review
with either one or the other, but not both. The extensor
of the radial tunnel literature produces one clear and
carpi radialis brevis (ECRB) and, to a lesser the degree,
consistent theme: the unpredictable outcome after
a portion of the extensor digitorum communis that form
neurolysis of the PIN that leaves around one third of
the conjoined lateral extensor tendon are thought to be
patients with residual pain.2Y8 Twenty-four patients
primarily responsible for the excessive traction that
followed up at an average of 8 years yielded 67% good
induces lateral tendinosis (a degenerative process of
or excellent and 33% fair or poor results after a
microtears in the tendon with impaired healing), but the
brachioradialis muscle splitting approach.4 Another
supinator blends with these same fibers and shares a role
group of 29 patients produced 70% good or excellent
in the pathology. The supinator, primarily the arcade of
results, 13% fair, and 17% poor.5 A report of 10 years’
Frohse, has been thought to play the majority role in
experience from the Mayo clinic showed only 74% of
compressing the posterior interosseous nerve in radial
the patients to be improved by the surgery, with a third
tunnel syndrome, but the undersurface thick tendon of the
reporting continued pain and functional restrictions.7
ECRB may also cause substantial nerve compression.
Lateral tendinosis, also known as lateral epicondylitis
Reduction of the linear tension transmitted by the ECRB is
or tennis elbow, is considered to be a condition of focal
the common element in the various surgical treatments for
hyaline degeneration in the fibers of the common ex-
lateral tendinosis, performed anywhere from directly at the
tensor origin as demonstrated by histopathology speci-
lateral epicondyle to the distal myotendinous junction.
mens from surgically resected tissue despite the absence
Nerve decompression by division of fascial bands is the
of any visible macroscopic abnormality at the time of
goal in surgery for radial tunnel syndrome. These 2 surgical
surgery.9,10 There is no clear evidence that physical in-
approaches need not be mutually exclusive. In fact, this
terventions beyond ergonomic modification and muscle
separation of the 2 clinical entities may play a role in the
stretching have any effect at all, including the most
unpredictable results reported in the literature. This article
recently studied extracorporeal shock wave therapy.11,12
presents a unified approach to treating both pathologies
Results of surgical treatment are similar to those of
simultaneously including short-term clinical results.
radial tunnel with 2 prospective studies both arriving at
Keywords: radial tunnel syndrome, lateral tendinosis
the same 69% figure for good to excellent results.10,13
The classic procedure detaches the common extensor
| HISTORICAL PERSPECTIVE origin directly at the epicondyle, but numerous reports
Radial tunnel syndrome refers to a condition of pain of alternative techniques from percutaneous to arthro-
based in the proximal forearm and lateral elbow region scopic make it clear that the surgeon simply needs to
diminish the longitudinal force being transmitted to this
point.13Y20 In fact, controlled lengthening rather than
Address correspondence and reprint requests to Mark Henry, MD,
Hand and Wrist Center of Houston, 1200 Binz Street, Suite 1200, simply detachment may be specifically advantageous. In
Houston, TX 77004. E-mail: a careful study of intraoperative sarcomere length

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A Unified Approach to Radial Tunnel Syndrome and Lateral Tendinosis

measurement using laser diffraction, 9.1 mm of ECRB over the radial tunnel, but not at the elbow joint. Specific
tendon lengthening was predicted to result in a 25% tests used in the workup of lateral tendinosis and radial
reduction of insertional loading while providing a 25% tunnel include pain with passive pronation, passive elbow
increase in muscle active force generation.21 The best extension, active supination against resistance, wrist
clinical results reported in the literature were for 22 extension against resistance, and long finger extension
patients treated with a VYY slide lengthening that gave against resistance. Although conventional wisdom has
100% good to excellent results and 95% of patients held that some of these tests are uniquely capable of
reporting no limitations in daily activities.22 differentiating lateral tendinosis from radial tunnel in
Typically, patients with lateral elbow pain that does isolation, clear and convincing data have never been
not appear to originate from the radiocapitellar articulation brought forth to support that contention.
have been assigned a diagnosis of either lateral tendinosis
or radial tunnel syndrome, but not both. In fact, 1 Additional Testing
randomized prospective study approached the problem of One article describes an attempt to distinguish radial
lateral elbow pain by either performing PIN decompres- tunnel syndrome electrodiagnostically by a differ-
sion (50% success) or lengthening the ECRB in the ential latency obtained in 3 different positions of
proximal forearm (43% success).23 Little attention has forearm rotation, but clinical practice standards still
been given to the possibility that these 2 clinical entities hold that electrodiagnostic testing is not useful as
may actually represent an integrated pathology despite part of the evaluation of a patient suspected to have
anatomic and biomechanical findings that demonstrate radial tunnel syndrome.1,7,25 One adjunct that has been
the relationships between the supinator and ECRB with used to supplement the physical examination by some
respect to tensile force in the common extensor origin and authors has been the ability to block positive provoca-
radial tunnel pressure.24 Improved clinical results rather tive physical examination tests for radial tunnel with the
than the characteristically unpredictable outcomes with a instillation of local anesthetic.26 If a block using 3 to
third of patients having substantial residual pain may be 5 mL of 1% lidocaine is done at the radial tunnel and
realized if both pathologies are treated together, rather PIN more distally, incomplete relief is an expected
than leaving one or the other untreated to act as a source finding in the usual clinical scenario of concomitant
of continued pain and poor functional performance. lateral tendinosis. If complete relief is achieved with a
distal block of the PIN, the patient likely has a pure radial
tunnel syndrome. If complete relief is achieved with a
| INDICATIONS/CONTRAINDICATIONS whole radial nerve block above the elbow, this only
The indication for surgery is based on making the clinical demonstrates that pain emanating from the lateral elbow
diagnosis of the 2 conditions, lateral tendinosis and radial region is being transmitted through the radial nerve, but it
tunnel syndrome, determining that other differential does not identify the specific source or etiology of the pain.
diagnoses are not responsible for the patient’s pain and
ensuring that the patient has none of the other contra- Differential Diagnoses
indications discussed below. A high degree of proximally based radicular pain in the
upper arm, shoulder, or neck region should call attention to
History one of the major differential diagnoses that must always be
This begins by identifying those patients who complain considered, primarily cervical radiculopathy (specifically
of pain in the lateral elbow and/or the proximal forearm. at the C5YC6 level that maps out the dermatome passing
In mild cases, the pain is usually absent at rest, over the lateral elbow). Other differential diagnoses that
provoked by powerful grasping and lifting activities, must be considered include elbow arthritis, intra-articular
and worse at the end of the work day. As the condition loose bodies, plica, avascular necrosis of the capitellum,
becomes worse and more chronic, a baseline pain is posterolateral rotatory instability of the elbow, lateral
usually present at all times but is still augmented by overload from medial collateral ligament instability, and
activation of the extensor-supinator muscle group. The compression of the lateral antebrachial cutaneous nerve.
pain may radiate distally or proximally with radiation
implying a greater degree of nerve involvement as Other Contraindications
opposed to a pure lateral tendinosis. The pain associated The major contraindication for surgical care of a patient
with radial tunnel syndrome typically radiates distally. suspected of radial tunnel and lateral tendinosis is for a
patient whose pain does not appear to be specifically
Physical Examination attributable to these clinical conditions. On history, the
On physical examination, patients should feel relatively patients should be able to clearly localize the anatomic
nontender in surrounding areas and specifically tender to location of the pain by pointing with the index finger of
pressure application at the common extensor origin and the opposite hand. Broad, generalized, and nonspecific

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Henry and Stutz

pain is less likely to have a positive surgical outcome than

pain that can be very distinctly characterized. Patients
who react equally to pain provocation no matter where
the stress is applied usually do not have favorable sur-
gical outcomes.
Adequate Initial Nonsurgical Care
A final indication for surgery is that the patient should
have participated for at least 8 to 12 weeks in a structured
nonsurgical program of therapist-directed rehabilitation
that focused initially on ergonomic retraining and stretch-
ing and subsequently on strengthening the involved
extensor-supinator muscle group. Various modalities
and injections of either cortisone or local anesthetic can
be used, but there is no evidence that any of these are of FIGURE 2. The septum between ECRB and EDC is
particular benefit in these conditions.11 fractionally lengthened. The black arrow points to the
apex of a V-shaped spread in the septal fibers to reveal
the muscle of the EDC underneath, preserved intact. Just
| TECHNIQUE above this, the oblique orientation of the fibers of the
The approach is through a 4-cm longitudinal incision supinator is seen running from lower left to upper right.
overlying the septum between the ECRB and the
extensor digitorum communis (EDC) with the prox-
imal extent located at the level of the radial neck muscle. The septum itself is then fractionally lengthened
(Fig. 1). The approach to the fascial level is typically which also serves to improve exposure (Fig. 2). While
free of any significant cutaneous nerve branches. The retracting the ECRB anteriorly, the thick fascial band on
septum between ECRB and EDC can be palpated as a the undersurface of the muscle is exposed and fraction-
taut band and also located by identifying the small- ally lengthened (Fig. 3). This includes a septum that
caliber perforating vessels that arise through the septum penetrates from the plane of the undersurface down into
to supply the overlying skin. Longitudinal incision is the muscle that must also be divided to achieve the
made just anterior to the septum, and the ECRB fibers maximum relief of longitudinal tension at the common
are swept off the septum with blunt dissection. The extensor origin. Fractional lengthening of a muscle is
ECRB is then easily retracted anteriorly to reveal the accomplished by dividing transversely the inelastic
oblique fiber orientation of the underlying supinator fascial sheet at the point of lengthening until reaching

FIGURE 1. The 4-cm longitudinal incision is placed over

the septum between the ECRB and the EDC with the FIGURE 3. The thick fascial band on the undersurface of
proximal extent at the level of the radial neck. The the ECRB and its related septum are fractionally length-
radiocapitellar joint is marked for reference. Note that all ened. The skin hook everts the ECRB to reveal the thick
subsequent figures are depicted from this same perspec- septum on its undersurface. The technique of fractional
tive of a right arm with the elbow to the left and the distal lengthening is demonstrated as the blade is just starting
forearm to the right. Radial is to the top of the photo, and to be drawn transversely across the longitudinal septal
ulnar is to the bottom. fibers moving from deep to superficial.

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A Unified Approach to Radial Tunnel Syndrome and Lateral Tendinosis

the muscle tissue, but without dividing any muscle

fibers. The elastic muscle will then stretch in response
to tension as the outer fascial transverse cut separates
2 to 3 cm. By the lengthening of these 2 key structures,
all the taught direct fascial connections to the common
extensor origin other than the lateral ulnar collateral
ligament have been divided. The only remaining direct
connections are muscular fibers. Exposure further
improves with the ECRB lengthening, allowing clear
and safe visualization of the PIN and its entrance to
the supinator via the arcade of Frohse. The arcade of
Frohse is then fully divided along with any additional
fascial bands within the supinator muscle that traverse
the course of the PIN (Fig. 4). The skin flaps can be
easily mobilized 4 cm proximally which, along with FIGURE 5. The longitudinal antebrachial fascial incision is
closed with a running absorbable monofilament suture. This
good ECRB retraction, allows the PIN to be fully
step is important to avoid adherence of the dermis to muscle
visualized to the level of the radiocapitellar joint. The tissue, allowing a soft and supple scar when mature.
course of the PIN should be palpated even further
proximally into the brachium, including the elbow in
extension, forearm pronation, and wrist flexion to suture. Soft dressings are applied, and immediate range
confirm that the nerve is now free from any direct of motion of the forearm and elbow is permitted.
compressive fascial bands. The skin flaps can be
similarly mobilized distally providing full visualization
of the distal supinator where the PIN exits. The PIN
should be tracked throughout its course in the supinator There are 2 specific potential complications associated
to be certain that there are no more distal transverse with this surgical technique. The most important is
fascial bands within the muscle that may compress the iatrogenic damage to the PIN. One series of 37 patients
nerve. There is no role for internal neurolysis of the PIN operated on through an approach different from that of
when treating radial tunnel syndrome. The longitudinal the current article reported 2 radial nerve pareses.2
incision in the antebrachial fascia is closed with a Nerve injury can be avoided by ensuring adequate
running 3-0 absorbable monofilament suture that is also exposure, including performing the 2 fractional length-
used for the dermis (Fig. 5). The skin is closed with a enings before nerve decompression. The surgeon must
running subcuticular 3-0 nonabsorbable monofilament also simply follow the tenets of not directly handling the
nerve and only dissecting adjacent to the nerve under
direct, well-magnified, and well-lighted vision. The
second specific complication is the development of
iatrogenic extensor weakness of either the ECRB or the
EDC. This complication is avoided by only dividing the
white fascial bands noted in the technique section and
leaving the red muscle fibers undisturbed. The goal of
the surgery is to decrease tension applied to the
common extensor origin. Muscle tissue can always be
stretched through the process of rehabilitation.

The prime activity of the postoperative rehabilitation
process mirrors closely the preoperative therapy tech-
FIGURE 4. The arcade of Frohse and additional fascial nique with the main emphasis on composite stretch of
bands within the supinator that cross the PIN are fully the muscle fibers in ECRB and EDC. The combined
divided. The PIN, encased in perineural fat, (black arrow) position of elbow extension, forearm pronation, and
courses obliquely from upper left to lower right, perpen-
dicular to the fascial fibers of the supinator (a thick band wrist flexion stretch of the ECRB and EDC muscle
pointed to by the scissors is seen proximally crossing the fibers is performed hourly for at least 10 repetitions per
nerve and has not yet been divided). session (Fig. 6). Mobilization of the skin layer to glide

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Henry and Stutz

preoperative symptoms and the ability to return to

normal capacity in both work and personal activities.
Two male patients receiving worker’s compensation
benefits complained of continued pain localized not at
the common extensor origin or the region of the radial
tunnel, but over the elbow joint itself where preopera-
tive radiographs had demonstrated moderate osteo-
arthritis that was discussed at that time as an expected
source of continued pain in the context of their heavy
manual labor occupations.

The issue surrounding radial tunnel syndrome tradition-
FIGURE 6. The main exercise in postoperative rehabil- ally has been properly identifying it clinically. When
itation is the composite stretch of elbow extension,
forearm pronation, and wrist flexion. treated surgically as an isolated entity, a third of patients
are left with substantial residual pain that limits activi-
ties. In contrast, lateral tendinosis seems to be easy for
rather than adhere to the antebrachial fascial layer is clinicians to identify but has a great number of different
performed manually, and a silicone patch is worn over techniques proposed for its treatment, all of which share
the scar while it matures. Strength development in the the common theme of interrupting the linear tension
forearm muscles is not begun until a full composite applied to the common extensor origin. The results
stretch can be comfortably performed which occurs appear to be quite similar to those of radial tunnel and
anywhere from 3 to 6 weeks postoperatively. Progres- relatively independent of the technique selected. Perplex-
sive strengthening is then carried out during the next 4 ing in the literature is the apparent concept that a given
to 6 weeks while the patients resume their more patient must have either lateral tendinosis or radial tunnel
challenging personal activities of work or sport. Patients syndrome, with little or no allowance for the possibility
are not told that they must avoid anything in particular that both pathologies may coexist. Review of the relevant
in the first 2 weeks after surgery. However, the wound anatomy indicates that a combined pathology of com-
must be kept free of infection. The patients are advised pression of the PIN and excessive tension at the common
that continued pain and local inflammation are warning extensor origin should, in fact, be more common than not.
signs of overactivity. A standard progression of first This technique addresses the possibility of coexistence of
achieving full range of motion and composite stretch, radial tunnel syndrome and lateral tendinosis and treats
then adding controlled strengthening exercises, then both with a unified approach.
job- or sport-specific strength development, and finally
full return to work or sport is followed. The longest a
patient should take to return to full activity is 4 months. | REFERENCES
1. Barnum M, Mastey RD, Weiss AP, et al. Radial tunnel
| RESULTS syndrome. Hand Clin. 1996;12:679Y689.
The authors have used this combined treatment 2. Atroshi I, Johnsson R, Ornstein E. Radial tunnel release.
approach on 44 previously unoperated patients (26 Unpredictable outcome in 37 consecutive cases with a 1Y5
year follow-up. Acta Orthop Scand. 1995;66:255Y257.
men and 18 women) with a mean age of 45 years
(range, 27Y63 years). All patients had participated in a 3. De Smet L, Van Raebroeckx T, Van Ransbeeck H. Radial
nonsurgical treatment program for a mean of 16 months tunnel release and tennis elbow: disappointing results?
(range, 4Y48 months) before surgery. Patients were Acta Orthop Belg. 1999;65:510Y513.
followed up until their discharge from clinic at a mean 4. Jebson PJ, Engber WD. Radial tunnel syndrome: long-
of 4.5 months (range, 3Y7 months). At this point, formal term results of surgical decompression. J Hand Surg.
therapy was discontinued, and the patients were released 1997;22A:889Y896.
back to full duty work at a mean of 8 weeks (range, 5. Lawrence T, Mobbs P, Fortems Y, et al. Radial tunnel
2Y12 weeks). Preoperative grip strengths of a mean syndrome. A retrospective review of 30 decompressions
22 kg (65% of contralateral) were increased to a of the radial nerve. J Hand Surg. 1995;20B:454Y459.
postoperative mean of 34 kg (97% of contralateral). 6. Plate AM, Green SM. Compressive radial neuropathies.
All but 2 patients declared complete relief of the Instr Course Lect. 2000;49:295Y304.

204 Techniques in Hand and Upper Extremity Surgery

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A Unified Approach to Radial Tunnel Syndrome and Lateral Tendinosis

7. Ritts GD, Wood MB, Linscheid RL. Radial tunnel and complications. Tech Hand Up Extrem Surg. 2005;
syndrome. A ten-year surgical experience. Clin Orthop 9:105Y112.
Relat Res. 1987;219:201Y205. 17. Grundberg AB, Dobson JF. Percutaneous release of the
8. Sotereanos DG, Varitimidis SE, Giannakopoulos PN, et al. common extensor origin for tennis elbow. Clin Orthop
Results of surgical treatment for radial tunnel syndrome. Relat Res. 2000;376:137Y140.
J Hand Surg. 1999;24A:566Y570. 18. Nirschl RP. Lateral extensor release for tennis elbow.
9. Regan W, Wold LE, Coonrad R, et al. Microscopic J Bone Joint Surg. 1994;76A:951.
histopathology of chronic refractory lateral epicondylitis. 19. Owens BD, Murphy KP, Kuklo TR. Arthroscopic release
Am J Sports Med. 1992;20:746Y749. for lateral epicondylitis. Arthroscopy. 2001;17:582Y587.
10. Verhaar J, Walenkamp G, Kester A, et al. Lateral 20. Tasto JP, Cummings J, Medlock V, et al. Microtenotomy
extensor release for tennis elbow. A prospective long- using a radiofrequency probe to treat lateral epicondylitis.
term follow-up study. J Bone Joint Surg. 1993;75A: Arthroscopy. 2005;21:851Y860.
21. Friden J, Lieber RL. Physiologic consequences of surgical
11. Bisset L, Paungmali A, Vicenzino B, et al. A systematic lengthening of extensor carpi radialis brevis muscle-tendon
review and meta-analysis of clinical trials of physical junction for tennis elbow. J Hand Surg. 1994;19A:269Y274.
interventions for lateral epicondylalgia. Br J Sports Med.
22. Rayan GM, Coray SA. VYY slide of the common extensor
origin for lateral elbow tendonopathy. J Hand Surg.
12. Chung B, Wiley JP. Effectiveness of extracorporeal shock 2001;26A:1138Y1145.
wave therapy in the treatment of previously untreated
23. Leppilahti J, Raatikainen T, Pienimaki T, et al. Surgical
lateral epicondylitis: a randomized controlled trial. Am J
treatment of resistant tennis elbow. A prospective, random-
Sports Med. 2004;32:1660Y1667.
ized study comparing decompression of the posterior
13. Peart RE, Strickler SS, Schweitzer KM. Lateral epicon- interosseous nerve and lengthening of the tendon of the
dylitis: a comparative study of open and arthroscopic extensor carpi radialis brevis muscle. Arch Orthop Trauma
lateral release. Am J Orthop. 2004;33:565Y567. Surg. 2001;121:329Y332.
14. Almquist EE, Necking L, Bach AW. Epicondylar resec- 24. Erak S, Day R, Wang A. The role of supinator in the
tion with anconeus muscle transfer for chronic lateral pathogenesis of chronic lateral elbow pain: a biomechani-
epicondylitis. J Hand Surg. 1998;23A:723Y731. cal study. J Hand Surg. 2004;29B:461Y464.
15. Dunkow PD, Jatti M, Muddu BN. A comparison of 25. Kupfer DM, Bronson J, Lee GW, et al. Differential
open and percutaneous techniques in the surgical treat- latency testing: a more sensitive test for radial tunnel
ment of tennis elbow. J Bone Joint Surg. 2004;86: syndrome. J Hand Surg. 1999;23A:859Y864.
701Y704. 26. Sarhadi NS, Korday SN, Bainbridge LC. Radial tunnel
16. Luchetti R, Atzei A, Brunelli F, et al. Anconeus muscle syndrome: diagnosis and management. J Hand Surg.
transposition for chronic lateral epicondylitis, recurrences 1998;23B:617Y619.

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Techniques in Hand and Upper Extremity Surgery 10(4):206–211, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia

| R E V I E W |

Dynamic Assist Splinting for Attenuated Sagittal

Bands in the Rheumatoid Hand
Shrikant J. Chinchalkar, OTR, CHT
Department of Hand Therapy
Hand & Upper Limb Centre
St. Joseph’s Health Care London
London, Ontario, Canada

Shanley Pitts, MScOT, OT Reg (ONT)

Department of Hand Therapy
Hand & Upper Limb Centre
Department of Rheumatology
St. Joseph’s Health Care London
London, Ontario, Canada

| ABSTRACT head, and the palmar plate and enable effective extension
of the MCP joints. Rheumatoid arthritis can cause nu-
The extensor mechanism of the hand is complex,
merous deformities in individuals due to ligamentous
requiring effective functioning of all involved struc-
laxity, tendon ruptures, and sagittal band attenuation or
tures, including the sagittal bands. The sagittal bands
rupture. In particular, sagittal band disruption produces a
function to maintain the extensor tendons in midline
loss of active finger extension at the MCP joints (Fig. 1),
and to limit their distal excursion. Injury to the sagittal
which can lead to instability of the extensor tendons,
bands or sagittal band attenuation can cause instability
swan-neck deformities, and ultimately volar subluxation
and ulnar displacement/subluxation of the extensor
of the MCP joints. Sagittal band attenuation or rupture
tendons into the valleys between the digits and lead to
is evident if a patient can actively hold the fingers in
a subsequent loss of active finger extension at the meta-
extension when placed. However, after active flexion,
carpophalangeal joints. Secondary conditions may also
they are unable to actively extend the digits (Fig. 2).
develop, such as swan-neck deformity, as is frequently
The dynamic MCP extension assist splint is de-
observed in the rheumatoid arthritis population. To pre-
signed to allow active MCP flexion and assist with MCP
vent or reduce an extension lag and secondary changes
extension. The splint stabilizes the extensor tendons and
and to maintain the functional use of the hand, a dy-
assist in tendon gliding to allow extension at the MCP
namic metacarpophalangeal extension assist splint is
joints. The splint also helps prevent secondary compli-
necessary. This splint enables extension at the meta-
cations such as extensor quadriga, swan-neck deform-
carpophalangeal joints, thus enabling the functional use
ities, intrinsic contractures, and subsequently volar
of the hand. This article reviews the biomechanics of the
subluxation of the MCP joints.
sagittal bands and the corrections that enable finger
extension at the metacarpophalangeal joints, thus pre-
venting secondary conditions.
Keywords: extensor tendon complications, sagittal bands, | PERTINENT ANATOMY AND
rheumatoid arthritis
Sagittal bands have been described as a girdles surrounding
S agittal bands play an important role in stabilizing
extensor tendons in midline. They encircle the meta-
carpophalangeal (MCP) joint capsule, the metacarpal
the lateral and dorsal MCP joints, stabilizing the extensor
digitorum communis (EDC) tendons over the dorsum of
the joint during digital flexion and extension and limiting
longitudinal gliding.1,2 The extensor anatomy proximal to
Address correspondence and reprint requests to Shrikant J. Chinchalkar, the sagittal bands is relatively simple, when compared
OTR, CHT, Department of Hand Therapy and Hand & Upper Limb
Centre, St. Joseph’s Health Care London, 268 Grosvenor Street, London, with the distal extensor system.2,3 The EDC tendons that
Ontario, Canada. E-mail: run to the index, long, ring, and small fingers emerge

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Dynamic Assist Splinting

FIGURE 1. A, Sagittal band disruption produces a loss of active finger extension at the MCP joints. (Reproduced with
permission of the Canadian Journal of Plastic Surgery 2004;12(4):174Y178.) B, Sagittal band rupture in the long finger of
this patient results in an extension deficit of this digit, subsequently affecting all adjacent digits.

from the fourth extensor compartment at the wrist and tions of the EDC tendons in index and small fingers have
diverge as they advance toward their insertions at the base been reported.6,7 The juncturae tendinum and intertendi-
of the middle and distal phalanges. Historically, it had nous fascia interconnect the EDC tendons, maintaining the
been reported that the EDC also inserted on the base of divergent angle of the extensor tendons and supplementing
the proximal phalanx; however, the presence of this in-
sertion has been questioned.4,5 Some anatomical varia-

FIGURE 3. Sequential stages of digital extensor mech-

anism. 1, The EDC central slip initiates PIP joint
extension, resulting in dorsal migration of the lateral
bands. 2, This leads to extension of the DIP joint. 3,
The intrinsic muscles contribute to further extension of the
DIP and PIP joint by adding tension to the lateral bands,
whereas the EDC continues to glide proximally. 4,
FIGURE 2. A, Test for sagittal band attenuation. Sagittal Continued proximal migration of the EDC tendon leads
band attenuation or rupture is evident if a patient can to tightening of the sagittal bands, which act as a sling
actively hold the fingers in extension when placed. around the base of the proximal phalanx, thus leading to
B, However, after active flexion, they are unable to MCP extension. Reproduced with permission of the
actively extend the digits. Canadian Journal of Plastic Surgery 2004;12(4):174Y178.

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Pitts and Chinchalkar

FIGURE 4. Rupture of the sagittal bands decreased effective amplitude of EDC tendon. Rupture of the sagittal band
mechanism around the MCP joint occurs most commonly on the radial side. A, This results in subluxation of the EDC tendon
into the valleys between the heads of the metacarpals (as shown above in the long finger). This leads to a decreased
effective excursion of the EDC tendon and an extensor lag, mostly at the MCP joint. B, The normal tract of the EDC tendon is
shown subluxed. Reprinted with permission of the Canadian Journal of Plastic Surgery 2004;12(4):174Y178.

extensor force during digital extension.8,9 These structures With hand motion, from a fully flexed position, the
are also thought to provide some stability to the sagittal central slip of the EDC tendon first initiates extension of/at
bands.10 The sagittal bands, which lie distal to the the proximal interphalangeal (PIP) joint. As the PIP joint
juncturae tendinum and stabilize the extensor tendons achieves some extension, the lateral bands gradually
over the MCP joint, are dynamic structures that move with migrate dorsally causing tension at the distal interphalan-
the extensor tendon during MCP joint motion. Along with geal (DIP) joint producing extension.1,4 The dorsal
the volar plate, the sagittal bands act like a sling around the aponeuroses of the digital extensors play an important
base of the proximal phalanx and assist the EDC tendon in role in the extension of the middle and distal phalanges.12
MCP joint extension.1,4,10,11 The intrinsic muscles continue to extend the PIP and DIP

FIGURE 5. Swan-neck deformity, ulnar drift, and MCP joint volar subluxation. Sagittal band rupture results in an
extension deficit of the MCP joints, often starting in one digit and progressing to adjacent digits. A and B, The swan-neck
deformity and ulnar drift in fingers are results of sagittal band attenuation or rupture causing volar subluxation of the MCP
joints. C, Volar subluxation of the MCP joint is as a result of continuous intrinsic load at the proximal phalanx. Figure 5A
was reproduced with permission of the Canadian Journal of Plastic Surgery 2004;12(4):174Y178.

208 Techniques in Hand and Upper Extremity Surgery

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Dynamic Assist Splinting

FIGURE 6. Splint components and

fabrication. A, Two 1 in strips of
Aquaplast thermoplastic material are
required for splint fabrication, along
with 2 coil springs as shown above.
Additionally, if additional tension is
required, 2 rubber band posts can
be applied to the splint, along with
elastic bands. B, Mold the first ther-
moplastic strip circumferentially prox-
imal to the MCP heads around the
palm of the hand, and the second,
circumferentially around the proximal
phalanges. C, Bend the spring coils,
ensuring that the coils are placed at
the axis of rotation. Affix the coils to
the dorsal aspect of the palmar piece
and to the volar aspect of the finger
piece. D, Place the coils medially as
well as laterally. Figures 6A and B
were reproduced with permission of
the Candian Journal of Plastic Sur-
gery 2004;12(4):174Y178.

joints simultaneously, acting through the medial and the | SECONDARY COMPLICATIONS
conjoined lateral bands. As the PIP and DIP joints
Sagittal band attenuation results in the intrinsic muscles of
extend, the EDC pulls the sagittal bands proximally over
the hand being placed in a shortened position, which over
the metacarpal head acting as a sling over the proximal
time may develop intrinsic muscle tightness. The intrinsic
phalanx, which simultaneously extend the MCP joint.1,13
muscles help compensate for a loss of MCP joint
The juncturae tendinum, with the assistance of the
extension, by contributing an excessive extensor load at
sagittal bands, maintains the extensor force while
stabilizing the extensor tendons over the dorsum of the
MCP joints. The combined force of the intrinsics and the
EDC maintain full digital extension (Fig. 3).3,11

The sagittal bands and juncturae tendinum transmit precise
forces during digital flexion and extension. The sagittal
bands and the EDC tendons collaborate to extend the MCP
joint.14 The sagittal bands, however, can be vulnerable to
stress and attenuation, particularly on the radial side, and
can result in ulnar subluxation of the extensor tendons, as
seen in rheumatoid arthritis.10,15 This creates instability
of extensor tendons over the MCP joint, and results in
inadequate forces to extend the MCP joint due to length
tension deficiency. Thus, with EDC activation of digital
extension, the sagittal bands fail in maintaining the EDC
in midline and extending the MCP joint (Fig. 4). The lack
of extension of the involved digit subsequently results in
a decreased excursion of the adjacent EDC tendons
through distal tension on the juncturae tendinae. A lack FIGURE 7. A and B, dynamic MCP extension assist splint.
This splint allows for active finger flexion and assists with
of MCP extension in persons with rheumatoid arthritis is MCP extension. If greater pull is required to draw the MCPs
often multifactorial, compounded by ulnar subluxation of into extension, a rubber band and rubber band posts can be
the EDC at the MCP. applied to the palmar and finger components.

Volume 10, Issue 4 209

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Pitts and Chinchalkar

the PIP joint. With the occurrence of a myostatic aspect of the finger component. Ensure that the coils are
contracture of the intrinsic structures, a secondary swan- aligned with metacarpal heads of the index and the small
neck deformity gradually develops. Over time, all the finger and that the pull of the coils is into extension. If
digits will demonstrate intrinsic tightness, a secondary greater pull is required to draw the MCP joints into
swan-neck tendency, and ultimately extensor quadriga, if extension, attach the rubber band posts to the dorsum of
the pathomechanics are not addressed early (Fig. 5).2 This the palmar and finger components of the splint, over the
complication is particularly evident in the rheumatoid fifth metacarpal and proximal phalanx. Place a rubber
affected hand, where attenuation of the sagittal bands of band, with appropriate tension on the 2 posts to enhance
1 digit may lead to the development of swan-neck the pull into extension (Fig. 7). Note that the rubber band
deformities of all digits (Figs. 5A, B).15 In addition, in should not restrict the active flexion of the MCPs.
rheumatoid swan-neck deformities, continuous load of
the intrinsics at the proximal phalanx may be one of the
main causes of volar subluxation and ulnar deviation of | DISCUSSION
the MCP joint (Fig. 5C).2
In our clinical experience, this splint has been effective in
treating patients with attenuation or rupture of the sagittal
bands in rheumatoid arthritis. It has helped minimize the
| PREVENTION OF COMPLICATIONS complications described previously, and most impor-
WITH SPLINTING tantly, it has facilitated functional use of the affected
The dynamic MCP extension assist splint is designed to hand. The dynamic MCP extension assist splint is a new
allow active MCP flexion and assist with MCP extension. splint design, developed for individuals with difficulty or
The splint assists in relocating and stabilizing the extensor an inability to extend their MCP joints, primarily seen in
tendons on the dorsum of the MCP joints by decreasing the persons with rheumatoid arthritis. As such, no clinical
tension on the extensor system during active MCP data are currently available on its use, and further study is
extension. Thus, it assists with tendon gliding and enables needed. However, this splint offers a temporary solution
MCP joint extension. Upon attaining extension of the to enable assisted MCP extension for daily hand
MCP joints, the splint also helps prevent intrinsic functioning and to prevent progressive complications.
contractures and ultimately the secondary complications
such as extensor quadriga, swan-neck deformities, and
subsequent volar subluxation of the MCP joints. A | REFERENCES
similar design for can be used for MCP flexion.2,16
1. Zancolli E. Anatomy and mechanics of the extensor appa-
ratus of the fingers. In: Structural and dynamic bases of hand
surgery. 2nd ed. Philadelphia: JB Lippincott, 1979:3Y63.
2. Chinchalkar SJ, Gan BS, McFarlane RM, et al. Extensor
This splint can provide a temporary solution to enable quadriga: pathomechanics and treatment. Canadian Jour-
hand function before MCP sagittal band reconstruction nal of Plastic Surgery. 2004;12:174Y177.
surgery if indicated, or a permanent solution if not.
3. von Schroeder HP, Botte MJ. Anatomy of the extensor
Primarily, it can minimize the secondary complications
tendons of the fingers: variations and multiplicity. J Hand
described previously. Surg [Am]. 1995;20:27Y34.

Technique of Splint Fabrication 4. Harris C. The functional anatomy of the extensor mecha-
Materials. (a) Aquaplast, 1/8 in thickness, two 1-in- nism of the finger. JBJS. 1972;54A:713Y726.
wide strips; (b) two coil springs; (c) two rubber band 5. Jan SVS, Rooze M, Audekerke JV, et al. The insertion of
posts made up of piano wire, optional, depending on the the extensor digitorum tendon on the proximal phalanx.
required strength of pull; and (d) elastic bands (Fig. 6). J Hand Surg [Am]. 1996;21A:69Y76.
Fabrication. Palmar-based component: using a 1-in 6. Gonzalez MH, Weinzweig N, Kay T, et al. Anatomy of
strip of Aquaplast, encircle the hand, molding the Aqua- the extensor tendons to the index finger. J Hand Surg
plast just proximal to the distal palmar crease volarly [Am]. 1996;21A:991Y998.
and the metacarpal heads dorsally. 7. Gonzalez MH, Gray T, Ortinau E, et al. The extensor
Finger component: mold the second 1-in strip tendons to the little finger: an anatomic study. J Hand
circumferentially around the proximal phalanges. Surg [Am]. 1995;20A:844Y847.
Attach the finger and palmar components using the 8. von Schroeder HP, Botte MJ, Gellman H. Anatomy of the
2 coil springs. Attach each coil spring to the dorsal lateral juncturae tendinum of the hand. J Hand Surg [Am]. 1990;
aspect of the palmar component and to the volar lateral 15:595Y602.

210 Techniques in Hand and Upper Extremity Surgery

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Dynamic Assist Splinting

9. Wehbe MA. Junctura anatomy. J Hand Surg [Am]. 1992; 13. Valentin P. Physiology of extension of fingers. In:
17A:1124Y1129. Tubiana R, ed. The Hand. Philadelphia: WB Saunders,
10. Young CM, Rayan GM. The sagittal band: anatomic and 1981:389Y398.
biomechanical study. J Hand Surg [Am]. 2000;25: 14. Rayan GM, Murray D, Chung KW, et al. The extensor
1107Y1113. retinacular system at the metacarpophalangeal joint.
11. Gausepohl T, Koebke J, Pennig D, et al. Changes in the Anatomical and histological study. J Hand Surg [Br].
form of the interosseous hood during extension and 1997;22:585Y590.
flexion of the metacarpophalangeal joint. Handchir 15. Wilkes LL. Ulnar drift and metacarpophalangeal joint
Mikrochir Plast Chir. 1998;30:220Y225. subluxation in the rheumatoid hand: review of the patho-
12. Landsmeer JMF. The anatomy of the dorsal aponeurosis genesis. J South Med. 1977;70:963Y967.
of the human finger and its functional significance. Anat 16. McKee P, Morgan L. Orthotics in Rehabilitation: Splint-
Rec. 1949;104:31Y44. ing the Hand and Body. Philadelphia: FA Davis.

Volume 10, Issue 4 211

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Techniques in Hand and Upper Extremity Surgery 10(4):212–223, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia

| T E C H N I Q U E |

Dorsal Distal Radius Vascularized Pedicled

Bone Grafts for Scaphoid Nonunions
A. Noelle Larson, MD, Allen T. Bishop, MD, and Alexander Y. Shin, MD
Mayo Clinic, Department of Orthopedic Surgery
Division of Hand Surgery
Rochester, MN

| ABSTRACT ligament.3 Thus, there are no local perforating vessels;

and the region is entirely dependent on intraosseous
Fractures of the scaphoid, particularly its proximal pole,
circulation.4 Perfusion of the scaphoid is further com-
are at risk of progressing to nonunion because of the
promised by the fact that its intraosseous blood supply is
tenuous, retrograde blood supply. The overall incidence
via retrograde flow from the distal to the proximal
of scaphoid fractures developing nonunion ranges from
scaphoid.4,5 As such, the vascularity of the proximal
10% to 15%, whereas proximal pole fractures of the
pole is at great jeopardy of injury from the initial in-
scaphoid can have up to a 30% incidence of nonunion.
sult.6,7 Secondary to the tenuous nature of the vascu-
Avascular necrosis of these proximal pole fractures can
larity, fractures of the proximal pole of the scaphoid may
occur in 14% to 39% of cases. Dorsal distal radius
take up to 6 months to heal by nonoperative treatment,
vascularized pedicled bone grafting is an alternative to
with up to a 30% incidence of nonunion and a 14% to
conventional measures for the treatment of displaced
39% incidence of avascular necrosis.1,6Y8 Operative
proximal pole fractures, established nonunions, and
treatment of proximal pole nonunions with conven-
avascular necrosis of the proximal fragment. This graft
tional, nonvascularized bone grafting and internal
is based on the 1,2-intercompartmental supraretinacular
fixation yields only a 64% to 77% union rate compared
artery, which has reliable anatomy and predictable
with an 80% to 100% union rate for middle or distal
course between the first and second extensor compart-
third fractures.9,10 Special interventions such as vascu-
ments. The graft can be harvested and inset into the
larized bone grafting may be warranted to achieve higher
prepared fracture site using a single-incision approach.
rates of union for established nonunions or after failed
The indications, contraindications, technique, and re-
operative interventions.11Y13
sults of treatment are reviewed and detailed.
In contrast to traditional grafting techniques, vascu-
Keywords: scaphoid nonunion, vascularized pedicled
larized bone grafts enable primary bone healing rather
bone graft, proximal pole, technique
than creeping substitution into a dead bone matrix.14 As
circulation and viable osteoclasts and osteoblasts are
maintained, healing may be accelerated.15,16 Vascular-
ized grafts may provide replacement for deficient bone
S caphoid fractures are the most common carpal
fracture and, after distal radius fractures, the second
most common fracture of the upper extremity.1 Given a
with less resorption and loss of structural integrity than
traditional bone grafting.15,16 Surrounding necrotic bone
stable fracture pattern, early diagnosis, and sufficient may even be revascularized and recolonized by osteo-
immobilization, the union rate for acute scaphoid cytes from the circulation provided by the graft.15,16
fractures of all types ranges from 85% to 90%.2 Proxi- Techniques that introduce living vascularized bone
mal pole fractures, which comprise approximately 10% provide an excellent option for difficult-to-treat frac-
to 20% of all scaphoid fractures, present with particular tures in regions with poor local blood supply such as the
challenges. The proximal pole of the scaphoid is scaphoid proximal pole or waist fractures with proximal
covered with hyaline cartilage and has only one ex- pole avascular necrosis.11Y13
trinsic ligamentous attachment to the radioscapholunate
The first vascularized bone graft was performed by
Address correspondence and reprint requests to Alexander Y. Shin, Huntington in 1905, who moved a fibula on an arterial
MD, Mayo Clinic, Department of Orthopedic Surgery, Division of
Hand Surgery, 200 1st St SW, Rochester, MN 55905. E-mail: pedicle to reconstruct a tibial defect.17 In 1965, Roy- Camille rotated the scaphoid tubercle on the abductor

212 Techniques in Hand and Upper Extremity Surgery

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Dorsal Distal Radius Vascularized Pedicled Bone Grafts

of the anatomy of the distal radius blood supply is

necessary. The radial, ulnar, anterior interosseous, and
posterior interosseous arteries supply the distal radius
and ulna.20 The vessels supplying the dorsal distal
radius can be described with respect to the extensor
compartments as either intercompartmental, between
the compartments, or compartmental, inside the com-
partments. The fourth and fifth extensor compartmental
arteries travel within the fourth and fifth compartments.
There are 2 superficial arteries running between the first
3 extensor compartments. The 1,2-intercompartmental
supraretinacular artery (ICSRA) is a branch of the radial
artery and is located on the dorsal surface of the
extensor retinaculum between the first and second
dorsal compartments. Similarly, the 2,3-ICSRA artery
runs between the second and third compartments and is
a branch of the anterior interosseous artery (Fig. 1).
Both vessels travel above the retinaculum where it
adheres to the bony tubercle between the compartments.
Nutrient vessels branch off from the arteries and
penetrate through the retinaculum into bone.

FIGURE 1. Two arteries run between the dorsal extensor

compartments and can be used as pedicles for vascularized
bone grafts: the 1,2- and the 2,3-ICSRAs. The 1,2-ICSRA is
preferred for vascularized bone grafting to the scaphoid
(Reproduced with permission of the Mayo FoundationÓ).

pollicis brevis to treat a scaphoid waist fracture.18

Zaidemberg et al in 1991 reported a vascularized pedicled
graft from the distal radius to treat scaphoid nonunions.19
Their approach requires only one incision and was based
on the Bascending irrigating branch^, which was erro-
neously described as a periosteal vessel and correctly
described by Sheetz et al as supraretinacular vessel
between the first and second extensor compartments.20
Sheetz and associates meticulously outlined the blood
supply to the distal radius and identified a series of
versatile vascularized pedicled grafts. They found the
pattern of arterial extraosseous blood supply to the distal
radius to be quite consistent among individuals and also
noted a similar relationship to the surrounding anatomical
landmarks.20 This detailed understanding of the anatomy
allows for pedicled bone grafts around the nutrient vessels
to the distal radius.21 Compared with previously reported
vascularized bone grafts, these reverse-flow grafts were
FIGURE 2. Three arterial arches extend across the
easier to harvest and had minimal donor site morbidity
dorsum of the hand: the dorsal intercarpal arch (dICa),
compared with volarly harvested grafts.22 the radiocarpal arch (dRCa), and the dorsal supraretinac-
ular arch (dSRa). These provide a rich network of
| ANATOMY anastomoses to allow for adequate retrograde follow
to the 1,2- and 2,3-ICSRA when used as pedicles for
Before beginning any vascularized bone grafting proce- bone grafting (Reproduced with permission of the Mayo
dure for scaphoid nonunion, a thorough understanding FoundationÓ).

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Larson et al

shown encouraging results for both scaphoid nonunions

and Kienbock disease.18,19,21Y25
For proximal pole nonunions, conventional ap-
proaches give poorer results, with an osseous union in
77% after fixation with iliac crest bone graft.10 Chang
et al recently reported 21 of 23 patients (91%) progress-
ing to union after vascularized bone grafting for proximal
pole nonunions in the absence of avascular necrosis.11
In the presence of avascular necrosis, however,
vascularized pedicled bone grafting for proximal pole
nonunions shows mixed results. Avascular necrosis can
be most effectively assessed intraoperatively by the lack
of bleeding bone in the curetted proximal pole. Conven-
tional treatment of proximal pole nonunions with
avascular necrosis yields only a 40% to 50% union
rate.10,26 Some studies report an 80% to 100% union
rate for vascularized grafting of the fracture site.12,13
Other reports show less consistent results, with union
rates from 12.5% to 60% after vascularized bone
grafting of avascular proximal pole nonunions.27,28
Recently published data from our institution showed a
67% union rate for avascular proximal pole fractures in
the absence of a preoperative humpback deformity.11 As
of yet, there is no published prospective trial comparing
FIGURE 3. The graft based on the 1,2-ICSRA may easily vascularized with nonvascularized bone grafting.
extend to the scaphoid for a retrograde flow vascularized
Based on a recent review of patients who underwent
graft as illustrated here (Reproduced with permission of
the Mayo FoundationÓ). the 1,2-ICSRA graft at our institution for both scaphoid
waist and for proximal pole nonunions, the absolute
contraindications for the procedure include carpal
The 1,2-ICSRA is most frequently used as the collapse (ie, collapsed scaphoid with humpback deformity)
pedicle for vascularized grafting of scaphoid nonunions. and degenerative arthritis.11,21 Smoking is also a relative
It originates from the radial artery about 5 cm proximal contraindication to vascularized bone grafting, with a
to the radiocarpal joint, travels under the brachioradialis
muscle, courses over the extensor retinaculum, and
enters the anatomical snuffbox. It then either rejoins the
radial artery or the dorsal radiocarpal arch.20 Several
arches, including the dorsal radiocarpal arch, the dorsal
intercarpal arch, and the dorsal supraretinacular arch,
provide adequate anastomotic supply to allow for the re-
direction of the 1,2-ICSRA (Fig. 2). The 1,2-ICSRA was
reliably present in 94% of cadaver specimens, with an
average of 3 nutrient arteries branching off at a mean of
15 mm proximal to the radiocarpal joint.20 Although it is
the smallest of the dorsal arteries and has a short arc of
rotation, its location and pedicle length make it ideal for
grafts to the scaphoid bone (Fig. 3).

FIGURE 4. The graft from the distal radius is based on

| INDICATIONS the 1,2-ICSRA and its nutrient branch penetrating the
AND CONTRAINDICATIONS retinaculum and supplying the distal radius. Previously we
Vascularized bone grafting to the scaphoid can be used for recommended an S type incision as drawn. However, to
facilitate fixation of the scaphoid, an incision following the
displaced proximal pole fractures, established scaphoid course of the extensor pollicis longus is now our preferred
nonunions, and avascular necrosis of the proximal frag- approach (see Fig. 5A) (Reproduced with permission of
ment. In general, vascularized pedicled bone grafting has the Mayo FoundationÓ).

214 Techniques in Hand and Upper Extremity Surgery

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Dorsal Distal Radius Vascularized Pedicled Bone Grafts

In cases with carpal collapse, alternative vascular-

ized bone grafts (free medial femoral condyle or iliac
crest) should be considered.29Y33 For long-standing
scaphoid nonunions, radioscaphoid arthritis is a contra-
indication to vascularized bone grafting. Scaphoid non-
unions as classified by Mack et al with arthritis consistent
with a type III or type IV nonunion may require a more
aggressive procedure such as proximal row carpectomy
or four-corner fusion and scaphoidectomy to address the
degenerative sequelae of an unstable scaphoid nonun-
ion.34,35 Even when successful scaphoid union occurs,
persistent arthritis in patients with advanced changes may
lead to incomplete relief of symptoms.21


A scaphoid nonunion without carpal collapse is best
addressed by a dorsal inlay graft from a pedicle based on

FIGURE 5. A, An incision following the course of the

extensor pollicis longus is our preferred approach to
expose both the scaphoid and the graft donor site on
the distal radius. This incision allows easy access to the
scapholunate ligament and the entry site for cannulated
screw placement. B, Once the skin incision is made and
the soft tissues elevated of the extensor compartments,
branches of the superficial radial nerve (shown in the
vessel loop) are identified and protected. (Reproduced
with permission of the Mayo FoundationÓ).

46% union rate in smokers compared with an 80% union

rate in nonsmokers (a 5.44 odds ratio for nonunion in the
smoking patient).11 Prior failed surgery was not a
contraindication to vascularized bone graft.11 Our study
did find a trend toward more nonunions in patients with
prior failed surgery, although this was not statistically
significant.11 In fractures with proximal pole avascular
necrosis, there was no difference in union rates associ-
ated with prior failed surgery. Overall, waist fractures
and proximal pole fractures had similar rates of union
(72% versus 70%, respectively). There was a statistically
significant finding of more nonunions in women (7 of FIGURE 6. A, The 1,2-ICSRA is identified between the first
10) compared with men (7 of 38), even when adjusted for and second extensor compartments, superficial to the ret-
age, avascular necrosis, or smoking with the use of inaculum. After ligating the 1,2-ICSRA proximal to the bone
multivariate logistical regression analysis.11 Additional graft site, retrograde flow will be established via the radial
artery and dorsal arches. B, Clinical example of the 1,2-
studies will be required to verify this intriguing result. At ICSRA vessels. The 1,2-ICSRA has been shown to be
this time, we do not consider female gender a contra- reliably present in 94% of cadaver specimens20 (Repro-
indication to vascularized bone grafting. duced with permission of the Mayo FoundationÓ).

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Larson et al

the 1,2-ICSRA (Fig. 4). The course of this vessel and the
vascular anatomy of the distal radius and ulna have been
previously described.20 The vascularized bone graft
should be centered 15 mm proximal to the radiocarpal
joint over the vessels to ensure the nutrient vessels are
included in the graft. Dissection is straightforward given
the superficial location of the vessels. The patient is
positioned supine, with the affected extremity extended
on a hand table. A nonsterile tourniquet is placed. After
prepping and sterile draping, the extremity is either
exsanguinated with an Esmarch wrap from the wrist
proximal, or elevated to ensure some blood remains in
the upper extremity to allow identification of the
vessels. We previously described an S shaped incision
over the first and second extensor compartments as
illustrated in Figure 4.36 This incision made fixation of
the scaphoid with a screw difficult; and as such, we
have modified the incision to follow the course of the
extensor pollicis longus (Fig. 5A). This incision allows
easier access to the proximal pole and to the entry site
for cannulated screw placement. The skin and the
areolar tissue above the extensor retinaculum are carefully
dissected off the retinaculum (Fig. 5B). The superficial
radial nerve and its branches should be identified and
protected. The 1,2-ICSRA and venae comitantes are
located between the first and second extensor compart-
ments and lie directly on top of the extensor retinaculum
(Fig. 6). These vessels can be dissected distally to its
origin off the radial artery. Proximally, the bone graft site
is centered 15 mm proximal to the radiocarpal joint. The
first and second dorsal compartments are opened, leaving
a cuff of retinaculum on either side of the vessels; and
the tendons are retracted radially and ulnarly (Fig. 7).
Once the vessels are identified, attention is directed to the
scaphoid to identify the nonunion, fracture site prepara-
tion, and fixation. The extensor pollicis longus tendon is
identified; and the retinaculum is elevated through the
second compartment, releasing the extensor pollicis
longus and retaining the ulnarly based retinacular flap.
If visualization of the dorsal wrist capsule is still not
achieved, an ulnar-based capsular flap can be created by
FIGURE 7. A, The extensor compartments are opened to dividing the septum between the third and fourth
maintain a cuff of retinaculum enclosing the 1,2-ICSRA extensor compartments; and the fourth compartment
and the entry of its nutrient artery into the bone at the extensor tendons are retracted ulnarly. A transverse
bone graft donor site. B, The retinaculum on the ulnar dorsal-radial capsulotomy is made just ulnar to the 1,2-
border of 1,2-ICSRA is cut from the second dorsal ICRSA vessels to the fibers of the radiotriquetral
compartment. The radial border of the retinaculum has
already been released. C, With the first 2 compartments ligaments (dorsal intercarpal ligament). Up to half of
released, the abductor pollicis longus and extensor the radiotriquetral ligament can be divided if needed to
pollicis brevis can be retracted radially, and the extensor expose the scapholunate joint to facilitate the placement
carpi radialis longus and brevis retracted ulnarly, expos- of a cannulated screw if possible. The scaphoid nonunion
ing the graft site. The probe points to the 1,2-ICSRA site is identified and is typically transverse in orientation
rejoining the radial artery distally. The dorsal distal radius
is immediately to the right, with a cuff of retinaculum (Fig. 8). The wrist often needs to be flexed to expose a
surrounding the bone graft donor site. (Reproduced with proximal pole fracture nonunion that may be under the
permission of the Mayo FoundationÓ.) dorsal lip of the radius.34 Care should be taken to prevent

216 Techniques in Hand and Upper Extremity Surgery

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Dorsal Distal Radius Vascularized Pedicled Bone Grafts

detachment of the scapholunate ligament from its origin

and to protect the 1,2-ICSRA during this dissection. If
the fracture is nondisplaced, we prefer fixation of the
fracture before preparation of the recipient bed for the
vascularized bone graft. It is important not to destabilize
the nonunion site before placement of fixation, as fixation
after takedown of the nonunion can be extremely challeng-
ing. Based on our experience, screw fixation results in the
highest union rates over Kirschner wire fixation.11 A
cannulated screw is placed across the nonunion site as
volar/anterior as possible (Fig. 9). Representative preoper-
ative and postoperative radiographs are shown in Figures
10 and 11. If screw fixation is not possible, Kirschner
wires can be used and be advanced to the volar aspect and
tamped under the articular cartilage, to be removed after the
nonunion is healed (Fig. 12). Once the fracture nonunion is
secured, the nonunion site is debrided of necrotic dead

FIGURE 8. A, Attention is turned to the scaphoid

nonunion site, which is exposed through a dorsal radial
capsulotomy. B, To expose the scaphoid, the extensor
pollicis longus tendon is identified; and the retinaculum is
elevated through the second compartment, releasing the FIGURE 9. If the fracture is nondisplaced, fixation should
extensor pollicis longus and retaining the ulnarly based be placed across the fracture site before preparation of the
retinacular flap. A transverse dorsal-radial capsulotomy is recipient bed for the vascularized bone graft. Based on our
made just ulnar to the 1,2-ICRSA vessels to the fibers of experience, screw fixation results in higher union rates
the radiotriquetral ligaments (dorsal intercarpal ligament). over Kirschner wire fixation and is our preferred method of
The 1,2-ICSRA and the scapholunate ligament must be fixation.11 A, A Kirschner wire is placed perpendicular to
protected during this dissection. C, The scaphoid non- the fracture site and as volar/anterior as possible with the
union site is typically transverse in orientation. To obtain wrist in extreme flexion. B, A cannulated screw is placed
adequate visualization of a proximal pole fracture, the over the Kirschner wire to obtain compression across the
wrist often needs to be flexed. (Reproduced with permis- fracture site, and the wire is then removed. (Reproduced
sion of the Mayo FoundationÓ.) with permission of the Mayo FoundationÓ.)

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Larson et al

FIGURE 10. A and B, Anterior-posterior, lateral, and oblique radiographs of the right wrist in casting material shows a
minimally displaced proximal pole fracture of the scaphoid. No humpback deformity or carpal instability is evident. C and D,
Coronal and sagittal views of the right wrist on CT imaging. The fracture line is minimally displaced, but quite proximal. E and
F, T1 and T2 coronal views of the right wrist on MRI. The increased signal over the scaphoid on the T2 image is consistent
with marrow edema. (Reproduced with permission of the Mayo FoundationÓ.)

bone. The fracture margins are identified, and a slot for the ulnar margins of the selected graft site. For the distal cut,
vascularized bone graft is created using fine and sharp the 1,2-ICSRA and veins are retracted radially and then
osteotomes to accept an appropriately sized dorsal inlay ulnarly to protect the vessels; and 2-mm osteotomes are
graft (Fig. 13). The slot is placed parallel to the midcarpal used to make the distal cuts underneath the vessels. The
joint, which needs to be exposed to prevent damage to the graft is carefully lifted from the radius, taking care not to
midcarpal articulation of the scaphoid. The size of the slot fragment the graft (Fig. 14). If desired, the tourniquet can
is dependent on the fracture configuration and size of the be deflated to check for arterial perfusion of the graft
proximal fragment, but is typically 4 to 6 mm wide and 6 through the distally based pedicle. We have found the
to 8 mm long. The proximal fracture fragment should be graft to bleed in all cases, and no longer perform this step
closely examined to determine vascularity (Fig. 13C). because the blood often obscures the surgical field
When the proximal pole fragment is too small to despite reelevation of the tourniquet. Additional cancel-
accommodate a slot, it is possible to position the graft in lous bone graft is harvested from the distal radius site,
the excavated cavity of the proximal fragment. placed into the nonunion site, and packed at the periphery
Afterward, attention is turned to the graft donor site. of the cavity created. Rongeurs or bone cutters may be
The center of the graft donor site is identified 15 mm used to shape the final graft, which should be slightly
proximal to the radiocarpal joint to include the nutrient larger than the recipient slot. The bone graft may be
vessels penetrating into the bone. The 1,2-ICSRA and slightly compressed using the proximal, flat part of the
venae comitantes are dissected toward their distal anasto- Adson forceps. This allows the graft to be inset more
moses to the radial artery and gently elevated from the easily and to expand after insertion. The graft is then
radius and joint capsule. The 1,2-ICSRA and veins are left passed beneath the radial wrist extensors and press-fit
adherent to the bone at the graft site, then ligated proximal into the prepared fracture site (Fig. 15). When tamping in
to the graft site. The graft should be measured slightly the graft, it is imperative that direct trauma not be applied
bigger than the defect at the fracture site. Small osteo- to the vessels. One technique is to use a toothless Adson
tomes are used to make cuts on the proximal, radial, and forceps to straddle the vessels and gently tap the forceps

218 Techniques in Hand and Upper Extremity Surgery

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Dorsal Distal Radius Vascularized Pedicled Bone Grafts

with a small mallet. Hemostasis is obtained, the wound bone grafting for scaphoid nonunion, failed conven-
irrigated, and the incision closed with nonabsorbable tional bone grafting, or an avascular proximal fragment,
sutures. It is not necessary to suture the capsule back in all progressed to union at a mean of 11.1 weeks. Of the
place. The patient is placed in a well-padded long-arm 4 patients with preoperative radioscaphoid arthritis, 3
thumb spica with the wrist in neutral position. had a poor or fair result.21
Representative postoperative imaging studies of a
scaphoid nonunion treated with pedicled vascularized
bone grafting and screw fixation are shown in Figure 16.

Worse outcomes are to be expected in the setting of
scaphoid nonunions with radioscaphoid arthritis.21 In a
series of 14 patients undergoing vascularized pedicle

FIGURE 12. When the proximal pole fragment is quite

small, occasionally, it is not possible to obtain adequate
fixation with a cannulated screw. In this case, we
recommend Kirschner wire fixation of the nonunion. A
and B, Anterior-posterior and lateral views of the right
wrist showing Kirschner wire fixation of the scaphoid
FIGURE 11. A and B, Postoperative fluoroscopic imaging fracture site. Two pins provide rotational stability. With the
with anterior-posterior and lateral views of the right wrist wrist in extreme flexion, the pins are driven from proximal
shows appropriate screw fixation of the proximal pole. The to distal. The proximal pin ends are tamped under the
scaphoid is held in good alignment, with no protrusion of articular cartilage. They may be removed once the
hardware into the radiocarpal joint. (Reproduced with per- nonunion has healed (Reproduced with permission of
mission of the Mayo FoundationÓ.) the Mayo Foundation).

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Larson et al

FIGURE 13. A, Fibrous tissue is debrided from the FIGURE 14. A, The 1,2-ICSRA is ligated proximal to the
scaphoid nonunion site. An anatomical slot parallel to graft, which is then lifted from its site. B, A small
the midcarpal joint is created with osteotomes and burr. osteotome is first used to free the graft, with cuts made
The slot is sized to accommodate an appropriately sized radially, ulnarly, and proximally. For the distal cut, the 1,2-
dorsal inlay draft, typically 4 to 6 mm wide and 6 to 8 mm ICSRA is retracted first radially and then ulnarly as 2
long. The midcarpal joint should be exposed to avoid separate cuts are made. C, The graft can then be gently
damaging the midcarpal articulation of the scaphoid. B, elevated from the donor site with the osteotome blade
The prepared slot is seen at the upper left, and the donor and a toothless Adson forceps. (Reproduced with per-
site at lower right surrounded by the cuff of retinaculum. mission of the Mayo FoundationÓ.)
C, This prepared slot on another patient shows a lack of
proximal bleeding bone, indicating avascular necrosis.
(Reproduced with permission of the Mayo FoundationÓ.) were more smokers and female subjects in the nonunion
group compared with the union group. Additionally, the
In the largest series to date, we reported the outcome odds ratio for going on to nonunion was greater for
of 48 nonunions treated with this technique. Fourteen of patients with proximal pole avascular necrosis and
48 patients had persistent nonunions after vascularized preoperative humpback deformity.11 With regard to
pedicled bone grafting.11 As discussed previously, there fixation technique, screw fixation of the fracture had a

220 Techniques in Hand and Upper Extremity Surgery

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Dorsal Distal Radius Vascularized Pedicled Bone Grafts

favorable effect on scaphoid union. 11 Of those avascular necrosis, screw fixation resulted in 100%
nonunions fixed with screws, 88% went on to union union rate versus 67% with Kirschner wire fixation. In
(23 of 26), compared with 53% fractures fixed with the presence of proximal pole avascular necrosis, 62%
Kirschner wires (8 of 15). Without evidence of of scaphoids fixed with screw fixation went on to union,
compared with 44% of those with Kirschner wire
fixation.11 From retrospective chart review, we con-
cluded that up to 3 of the scaphoids went on to nonunion
as a result of inadequate fixation after vascularized bone
In this series, we also reported a 4% incidence of
superficial infection (2 patients) and 2% incidence of
deep infection (1 patient).11 The superficial infections
were successfully treated with oral antibiotics, although
one superficial infection went on to nonunion, as did the
deep infection.11 Graft extrusion occurred in 4 of
48 wrists, although in 2 of the cases, the fracture went
on to union with the graft in a displaced position.

A compressive postoperative dressing is placed for
edema control. Range of motion exercises of the fingers
and shoulder are encouraged immediately. At 2 weeks
postoperatively, sutures are removed. The arm is kept
immobilized for 6 to 8 weeks in neutral wrist position in a
long-arm thumb spica. After this, radiographs are
obtained to assess for fracture healing. If indicated,
additional immobilization is continued with a short-arm
thumb spica. Wrist range of motion and strengthening
exercises are started after the fracture is healed.

Vascularized bone grafting to scaphoid nonunions pro-
vides a promising option for treatment. In the case of
proximal pole avascular necrosis, results are more
guarded; but vascularized pedicled bone grafting remains
a viable alternative to conventional methods. Should the
pedicled graft fail, the option for free vascularized bone
grafting remains. Pedicled vascularized bone grafting
requires only one incision with little donor site morbidity.
The dissection is relatively straightforward, requiring no
vascular anastomoses. Fixation with screws has shown
improved results compared with Kirschner wire fixation,
although internal fixation must be chosen on an individual
FIGURE 15. A, The graft is then press-fit into the basis given the fracture type. We have found improved
prepared slot. B, The vessels should be carefully pro-
tected as the graft is passed under the extensor tendons. exposure for adequate fixation of the scaphoid with the
C, The graft should be slightly larger than the prepared incision following the course of the extensor pollicis
slot to prevent extrusion of the graft. A toothless Adson longus. Vascularized bone grafting based on the 1,2-
forceps may be used to compress the graft slightly to ICSRA is a viable treatment choice for the difficult and
allow it to reexpand after being press-fit into the slot. To disabling condition of proximal pole nonunion. For
avoid trauma to the vessels, the Adson forceps may be
used to straddle the vessels and gently tapped to impact scaphoid nonunions with both carpal collapse and avas-
the graft into place. (Reproduced with permission of the cular changes, alternative methods of vascularized bone
Mayo FoundationÓ.) grafts should be performed.

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Larson et al

FIGURE 16. Radiographs of the wrist joint at 16 months postoperatively show healing at the proximal pole scaphoid
nonunion. Hardware is in appropriate alignment (Reproduced with permission of the Mayo FoundationÓ).

| REFERENCES of a vascular bundle and bone-grafting. J Bone Joint Surg.

1. Amadio PC, Moran SL. Fractures of the carpal bones. In:
13. Gabl M, Reinhart C, Lutz M, et al. Vascularized bone
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Philadelphia, PA: Elsevier Churchill Livingstone, 2005:
the proximal part of the scaphoid with an avascular
fragment. J Bone Joint Surg. 1999;81A:1414Y1428.
2. Schuind F, Haentjens P, Van Innis F, et al. Prognostic
14. Barth H. Histologische Untersuchungen uber Knocken-
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Hotchkiss RN, Pederson WC, Wolfe SW, eds. Green’s
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16. Shaffer JW, Field GA, Wilber RG, et al. Experimental
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6. Linscheid RL, Weber ER. Scaphoid fractures and non- 17. Huntington TW. Case of bone transference. Ann Surg.
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The Wrist: Diagnosis and Operative Treatment. St. Louis,
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MO: Mosby, 1998:385Y430.
moyen. Utilisation d`un greffo pedicule. Actual Chir
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J Hand Surg. 1992;17B:289Y310. 20. Sheetz KK, Bishop AT, Berger RA. The arterial blood
9. Cooney WP III, Dobyns JH, Linscheid RL. Nonunion of supply of the distal radius and its potential use in vas-
the scaphoid: analysis of the results from bone grafting. cularized pedicled bone grafts. J Hand Surg. 1995;
J Hand Surg [Am]. 1980;5:343Y354. 20A:902Y914.
10. Shah J, Jones WA. Factors affecting the outcome in 50 21. Steinmann SP, Bishop AT, Berger RA. Use of the 1,2
cases of scaphoid nonunion treated with Herbert screw intercompartmental supraretinacular artery as a vascular-
fixation. J Hand Surg. 1998;23B:680Y685. ized pedicle bone graft for difficult scaphoid nonunion.
J Hand Surg. 2002;27A:391Y401.
11. Chang MA, Bishop AT, Moran SL, et al. The outcomes
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revascularization of the proximal pole with implantation radius: design and application for carpal pathology.

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In: Saffar P, Amadio PC, Roucher G, eds. Current Practice in 30. Harpf C, Gabl M, Reinhart C, et al. Small free
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27. Boyer MI, VonSchroeder HP, Axelrod TS. Scaphoid 33. Doi K, Oda T, Soo-Heong T, et al. Free vascularized bone
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J Hand Surg. 1998;23B:686Y690. 2000;25A:507Y519.
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1414Y1428. Extrem Surg. 1998;2:94Y109.

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Techniques in Hand and Upper Extremity Surgery 10(4):224–230, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia

| T E C H N I Q U E |

A New Modification of Corrective Osteotomy for

Treatment of Distal Radius Malunion
Steven F. Viegas, MD
Professor and Chief, Division of Hand Surgery
Department of Orthopaedics and Rehabilitation
University of Texas Medical Branch
Galveston, TX

| ABSTRACT 3-dimensional deformity with components of radial

shortening, loss of radial and/or palmar inclination,
A new modification of corrective osteotomy for distal
translation of the distal radius dorsally, translation of the
radius malunion, which minimizes the need for bone
proximal radius ulnarly, and supination of the distal
grafting and addresses the constraining aspect of the
radius relative to the proximal shaft.
extensor retinaculum, is described. This new modifica-
tion uses a volar and dorsal approach to perform an Radial Shortening
angled step-cut osteotomy, release of the extensor Previous biomechanical studies by Pogue et al3 showed that
retinaculum, and volar plating. The typically dorsally radial shortening of 2 mm or more results in significant
extruded comminuted fracture fragments from the changes in the load mechanics across the proximal wrist
distal, dorsal compression fracture component of the joint. Palmar and Werner4 noted that 2.5 mm of radial
distal radius fracture is mobilized with the distal shortening resulted in an increase in ulnar loading.
fragment and acts as a dorsal strut graft to span the Adams,5 in 1993, found that radial shortening resulted in
opening wedge, corrective osteotomy. Therefore, this more significant changes in distal radioulnar joint kine-
new modification facilitates and improves the realign- matics and triangular fibrocartilage complex distortion
ment of the malunited radius, while minimizing or than angulation or displacement of the distal radius.
eliminating the need for bone grafting. In a number of clinical studies, different authors
Keywords: distal radius fracture malunion, corrective have proposed that radial shortening is the most
osteotomy, biplanar osteotomy significant of the factors correlating with increased
symptoms in radial malunions.1,6,7
Fractures of the distal radius make up approximately 8% Dorsal Angulation
to 15% of all bone injuries.1 Despite almost 2 centuries Because of its adverse effects on wrist mechanics,
of recognizing and treating this fracture, malunion changes in the normal palmar inclination have been con-
remains a frequent occurrence. Malunion is among the sidered by some to be the most serious problem asso-
most common of the complications of distal radius ciated with distal radius fractures.8 Fernandez found
fractures. Amadio and Botte2 found a malunion rate of significant symptoms to be associated with dorsoangu-
23.5% in their review of 4056 cases treated by cast lation greater than 25 degrees in a clinical series.9
immobilization. Even surgical treatment methods can Previous biomechanical studies by Pogue et al3 showed
still result in malunion rates of 10% or higher. An in- that angulation of the distal radius greater than 20
creased likelihood of symptoms associated with an degrees in either the palmar or dorsal direction results in
increasing degree of deformity and increased activity significant changes in the load mechanics across the
level have been recognized. A variety of etiologies have proximal wrist joint. Other clinical studies have noted
been attributed to the increased likelihood of symptoms significant symptoms associated with even less dorsal
with distal radius malunion. Distal radius malunion is a angulation.10Y12 Taleisnik and Watson,8 reporting on a
series of malunited fractures of the distal radius in
patients who had developed symptoms of pain and
Address correspondence and reprint requests to Steven F. Viegas, MD, instability of the midcarpal joint, believe that dorsal
Professor and Chief, Division of Hand Surgery, Department of collapse alignment of the carpus was a result of the loss
Orthopaedics and Rehabilitation, Rebecca Sealy Hospital, Room
2.616, 301 University Boulevard, Galveston, TX 77555-0165. E-mail: of normal palmar tilt of the distal articular surface of the radius.

224 Techniques in Hand and Upper Extremity Surgery

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Corrective Osteotomy for Distal Radius Malunion

Loss of Radial Inclination minimally invasive distal radius osteotomy for treatment
Jenkins and Mintowt-Czyz13 found a statistical correla- of distal radius fracture malunion has been described
tion between loss of radial inclination and decreased previously,16 the new implants for volar fixation of distal
grip strength in patients with distal radius malunions. radius fractures offer another alternative.
Previous biomechanical studies by Pogue et al3 showed The author has developed and used a technique for
that significant loss of radial inclination resulting in less corrective osteotomy and fixation of a distal radius
than 10 degrees of radial inclination results in signifi- malunion which restores angulation and length, releases
cant changes in the load mechanics across the proximal radius-based extensor retinacula, and eliminates or re-
wrist joint. duces the need for remote bone graft, allograft, or bone
graft substitutes. The technique described in this
manuscript uses the recent advancements in and various
Treatment implants for volar plate fixation combined with an open-
Treatment for correction of distal radius malunions has ing wedge osteotomy of the distal radius. However, the
included a closing wedge osteotomy with distal ulnar opening wedge osteotomy is a biplanar osteotomy that
resections14 and an open wedge osteotomy and bone incorporates the dorsally extruded fracture fragments
grafting with or without distal ulnar resection.9,15 There from the distal, dorsal compression fracture component
was also a previous description of a minimally invasive of the distal radius fracture (Figs. 1AYC) to act as an
distal radial osteotomy for treatment of distal radius intact strut graft, while additionally addressing the
fracture malunion in 1997.16 Corrective osteotomy of often contracted and thickened dorsal extensor retinac-
the distal radius to treat symptomatic malunion and/or ulum and periosteum which can limit or even prevent
significant deformity was reported as early as 1937 by reduction of the malunion.19
Campbell.17 Fernandez9 reported on a series of patients
with distal radius malunions that he treated with an | INDICATIONS AND
opening wedge osteotomy, iliac crest bone grafting, and CONTRAINDICATIONS
a dorsal T plate. This approach has essentially remained
the standard of care for almost 2 decades. In 1988, This technique is appropriate in the same circumstances
Watson and Castle15 suggested using a trapezoidal and follows the same patient selection criteria as any
osteotomy with a distal radial bone graft and Kirschner alternative technique for a corrective distal radius
wire (K-wire) fixation. Fixation with a percutaneous osteotomy. These criteria include cosmetic deformity,
K-wire is recommended by Watson and Castle, and had pain secondary to malalignment, and/or significant
the benefit of avoiding problems of the subcutaneous deformity expected to increase the likelihood of devel-
dorsal plate. Other alternatives, such as a closing wedge opment of posttraumatic degenerative changes. Com-
osteotomy and distal ulnar resection, were advocated by plete remodeling of the fracture malunion is a relative
Pausner and Ambrose14 as an alternative treatment. contraindication for this technique because the dis-
With regard to the timing of a corrective osteotomy, placed, comminuted, dorsal compression component of
Fernandez9 generally waited 5 to 6 months after the the fracture would have resorbed and remodeled, and
injury before performing an osteotomy of the distal not be as large of a dorsal strut graft. Therefore, earlier
radius. Jupiter,18 however, reported slightly improved treatment, once fracture malunion is recognized, is
results and a decrease in the duration of disability in pa- preferred by this author. Abnormal load mechanics
tients treated with a corrective osteotomy 6 to 14 weeks may be expected to develop if proximal wrist joint
after the fracture malunion when compared with patients alignment is altered to result in radial shortening of
with a distal radius malunion who waited over eight 2 mm or more, angulation of the distal radius of greater
months for a corrective osteotomy. than 20 degrees in either the palmar or dorsal direction,
It has been the author’s observation that wrists with a or radial inclination of less than 10 degrees.
prefracture ulnar negative variance can tolerate a limited
degree of radial shortening better than wrists with | SURGICAL TECHNIQUE
prefracture ulnar positive variance.16 Also, in earlier me- A longitudinal skin incision is made over the course of
chanical studies, it was found that 4 mm or more of ra- the flexor carpi radialis tendon, starting at the level of
dial shortening in an acute fracture was associated with the radial styloid and extending proximal 6 to 8 cm.
disruption of the triangular fibrocartilage complex.3 Subcutaneous tissue is carefully dissected down to the
Therefore, even if the ulnar styloid is not fractured, but level of the flexor carpi radialis tendon sheath. The
there is radial shortening resulting from a distal radius tendon sheath is incised longitudinally. The tendon
fracture of 4 mm or more, disruption of the triangular sheath of the flexor carpi radialis tendon should be
fibrocartilage complex should be expected. Whereas a released from a distal point at the level of the scaphoid

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FIGURE 1. A series of diagrams illustrating (A) the dorsally extruded fracture fragments from the distal, dorsal
compression fracture component of the typical distal radius fracture, (B) the early consolidation and callus formation of the
fracture, and (C) the subsequent healing.

tubercle to the musculotendinous junction of the flexor cauterized before or during release of the lateral margin
carpi radialis proximally. The tendon is retracted and of the pronator quadratus. The release is extended trans-
the deep layer of the flexor carpi radialis tendon sheath versely at its distal margin and, using a periosteal elevator,
is also incised longitudinally. The flexor carpi radialis the pronator quadratus can be reflected off the underlying
tendon is retracted radially and the median nerve and radius and periosteum. The fracture line, particularly of
the superficial and deep flexor tendons are retracted early distal radius malunions, should be quite easily
ulnarly, with blunt dissection carried out superficial to identified once the pronator quadratus is reflected.
the pronator quadratus muscle. Once the pronator Next, the first dorsal compartment should be entered
quadratus muscle has been identified, it is released just lateral to the lateral margin of the radius. Within this
sharply at its lateral margin. Careful attention should be compartment, the extensor pollicis brevis tendon and,
given to the perforator vessels, which should be quite often, multiple slips of the abductor pollicis longus

FIGURE 2. A series of diagrams illustrating (A) the initial approach of the 0.045-inch-diameter K-wire (B) that should be
drilled only to the depth of the dorsal cortex of the radial shaft (C) in a series of perforations along the volar fracture line
(D) to prestress the fracture line for subsequent osteotomy.

226 Techniques in Hand and Upper Extremity Surgery

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Corrective Osteotomy for Distal Radius Malunion

FIGURE 5. A diagram illustrating the 2-plane osteotomy

FIGURE 3. A diagram illustrating the dorsal approach to
of the distal radius malunion.
release the retinaculum of the dorsal compartments and the
periosteum of the radius just proximal to the fracture level.
the more volar half of the brachioradialis attached
tendons are identified and reflected laterally. The brachio- distally facilitates both repair of the brachioradialis in a
radialis tendon, which forms the floor of the first dorsal lengthened fashion and presents the distal volar portion of
compartment and attaches to the radial styloid, should be the brachioradialis to allow subsequent repair of the
identified.20 The brachioradialis should be released in a pronator quadratus muscle to the brachioradialis tendon.20
BZ^ lengthening fashion over at least a 2-cm segment, With the fracture line identified visually, and con-
with the more volar half of the brachioradialis tendon firmed by fluoroscopy, 0.045-inch-diameter K-wires are
remaining attached distally to the radial styloid. Leaving used to drill multiple holes along the fracture line from
the volar aspect of the fracture malunion (Figs. 2AYD).
This series of perforations are made to prestress the
fracture line for subsequent osteoclasis with thin
osteotomes. The K-wires should be drilled only to the
level of the dorsal cortex of the proximal radial shaft
seen on the lateral view by fluoroscopy.
Next, attention is directed to the dorsal aspect of the
forearm and, with fluoroscopic guidance, a 2-cm incision
is made transversely just proximal to the level of the most
proximal extent of the fracture deformity at the dorsal
aspect of the radius. Blunt dissection is carried out down
to the level of the dorsal forearm fascia and extensor
retinaculum of the dorsal extensor compartments. The
extensor retinaculum of the dorsal compartments and the
periosteum overlying the radius are incised transversely,
taking care not to damage the extensor tendons (Fig. 3).
Next, using thin osteotomes, the displaced, comminuted
fracture component and subsequent callus that has
extruded dorsally and overlies the distal dorsal cortex
of the proximal shaft of the distal radius fracture is
osteotomized from the underlying dorsal cortex of the
FIGURE 4. A diagram illustrating the placement of the radial shaft (Fig. 4). Making the skin incision proximal
thin osteotomes from the volar and dorsal approaches. to the level of the planned osteotomy, using thin

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FIGURE 6. A series of diagrams illustrating the (AYC) progression of flexion and volar translation of the osteotomized distal radial
fragment and (D) the release of the retinaculum of the dorsal compartments.

osteotomes and displacing the soft tissue will facilitate fixation is completed, the brachioradialis, which was
positioning the osteotome at the acute angle to the radius released in a z lengthening fashion, is repaired using
to make the dorsal osteotomy. This osteotomy should horizontal mattress stitches of 4Y0 Vicryl suture
extend distal to the level of and meet with the other (Ethicon, Somerville, NJ). The pronator quadratus
osteotomy cut along the line of the predrilled K-wire muscle is placed over the fixation plate and repaired to
perforations from the volar aspect of the distal radius the brachioradialis, again with 4Y0 Vicryl sutures. Once
fracture malunion. Fluoroscopy can be used to help target fixation has been achieved, the range of motion of the
and connect the 2 osteotomies (Fig. 5). It is important to wrist and forearm is assessed under fluoroscopic control
release the extensor retinaculum of the dorsal compart- and direct visualization to determine stability of the
ments 1 through 5 and their septal attachments to the
radius and the periosteum, as they can impair and even
prevent subsequent reduction of the distal fragment.19
Once the osteotomy is completed, the distal frag-
ment is flexed, volarly translated, and, if necessary,
slightly ulnarly deviated to restore the normal alignment
and length of the distal radius (Figs. 6AYD). When
reduced, the dorsal prominence of bone, which has been
osteotomized and mobilized with the distal radial
fragment, should line up with the distal margin of the
proximal radial shaft and act as a strut graft, partially
filling the subsequent defect caused by this opening
wedge osteotomy. Additional bone graft, or a bone graft
substitute, can be added to the remaining defect.
However, this author has found that, often, the dorsal
component of this complex osteotomy is itself adequate
and additional bone grafting is not necessary.
Once the corrective osteotomy is completed and
alignment of the distal fragment is confirmed to be
adequate both by visual inspection and radiographic
imaging, distal radius fixation is accomplished by volar
plating (Fig. 7). This author’s preference has been the
DVR Plating System of Hand Innovations (Miami, FL). FIGURE 7. A diagram illustrating the 2-plane osteotomy
However, any fixed angle device for volar fixation of of the distal radius malunion reduced and fixed with a
distal radius fractures should be acceptable. Once volar fixation plate.

228 Techniques in Hand and Upper Extremity Surgery

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Corrective Osteotomy for Distal Radius Malunion

FIGURE 8. Preoperative (A) anteroposterior and (B) lateral radiographs of a patient with a distal radius malunion, (C) the
path of the osteotomies is indicated by the dark arrows; the lighter arrow demonstrates the dorsal approach to release the
extensor retinaculum and place the dorsal osteotome, (D) and the subsequent direction of flexion and volar translation of
the distal fragment to (E) result in the reduction of the distal radius and the postoperative (F) anteroposterior and (G)
lateral radiographs after reduction and volar DVR plate fixation of the radius.

fixation. This will help subsequently determine the difficulty regaining full digital or wrist range of motion,
appropriate postoperative rehabilitation program. Dorsal formal therapy is arranged.
and volar skin incisions are closed in an interrupted
fashion. A sugar tong splint and Ace wrap (Novaplus, | COMPLICATIONS
Rockhill, SC) are used to immobilize the fracture.
Possible complications with this technique include tendon
| REHABILITATION irritation, both at the volar distal aspect of the volar
fixation system and/or dorsally, particularly if peg, tine, or
The motion of the digits of the operative hand is begun screw fixation is excessively long. Arthrofibrosis and
immediately after surgery. The intraoperative sugar tong stiffness of the digits are possible and can be minimized by
splint and dressing is removed at 2 weeks in the clinic. early mobilization and encouragement of both active and
Sutures are also removed at that time. Unless fixation is passive range of motion. Infection, loss of fixation, and/or
considered tenuous during the intraoperative assessment, malunion are other possible complications.
the patient is progressed to a volar wrist splint at 2 weeks
and allowed to begin gentle, active only range-of-motion
exercises when out of the splint over the next month. | SUMMARY
Splinting is continued on an as-needed basis until The new designs of volar radius fixation plates with
radiographic union is identified. If the patient has locking screws, pegs, or fixed tines offer not only a new

Volume 10, Issue 4 229

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means to fix acute, distal radius fractures, but also to fix 7. Milch H. Treatment of disabilities following fracture of the
the distal radius after corrective osteotomies for treat- lower end of the radius. Clin Orthop. 1963;29:157Y163.
ment of distal radius malunions. Furthermore, the 8. Taleisnik J, Watson HK. Midcarpal instability caused by
technique described herein offers the separate dorsal malunited fractures of the distal radius. J Hand Surg [Am].
approach to formally release the extensor retinaculum of 1984;9A:350Y357.
the dorsal compartments and periosteum to facilitate the 9. Fernandez DL. Correction of post-traumatic deformity in
reduction. It also offers a complex combination of adults by osteotomy bone grafting and internal fixation. J
osteotomies to improve the subsequent alignment and Bone Joint Surg. 1982;64A:1164Y1178.
reduction and offer a portion of the corrective osteo- 10. Altissimi M, Antennia R, Fracia C. Long-term results of
tomy to act as a dorsal strut graft for better stability, conservative treatment of fractures of the distal radius.
while also allowing one to minimize or completely elim- Clin Orthop. 1986;206:202Y210.
inate the need for additional bone grafting (Figs. 8AYG). 11. Dias JJ, McMohan A. Effect of Colles’ fracture malunion on
The Z lengthening of the brachioradialis offers ease of carpal alignment. J R Coll Surg Edinb. 1988;33:303Y305.
reduction of the distal radius malunion and also affords
12. Porter M, Stockley I. Fractures of the distal radius:
a facilitated means to repair the pronator quadratus intermediate end results in relation to radiologic param-
muscle. This approach offers a viable alternative for eters. Clin Orthop. 1987;220:241Y252.
correction of distal radius fracture malunions.
13. Jenkins NH, Mintowt-Czyz CW. Malunion and dysfunc-
tion in Colles’ fracture. J Hand Surg [Br]. 1988;13B:
The author thanks Randal Morris for assistance and 14. Pausner MA, Ambrose L. Malunited Colles’ fractures:
collaboration in the illustrations used in this manuscript correction with a biplanar closing wedge osteotomy. J
and Kristi Overgaard for editorial assistance. Hand Surg [Am]. 1991;16A:1017Y1026.
15. Watson HK, Castle TH Jr. Trapezoidal osteotomy of the
distal radius for unacceptable articular angulation after
| REFERENCES Colles’ fracture. J Hand Surg. 1988;13A:837Y843.
16. Viegas SF. A minimally invasive distal radial osteotomy
1. Jupiter JB, Masem M. Reconstruction of post-traumatic for treatment of distal radius fracture malunion. Tech
deformity of the distal radius and ulna. Hand Clin. 1988; Hand Up Extrem Surg. 1997;1:70Y76.
17. Campbell WC. Malunited Colles’ fracture. JAMA. 1937;
2. Amadio PC, Botte MJ. Treatment of malunion of the 109:1105Y1108.
distal radius. Hand Clin. 1987;3:541Y558.
18. Jupiter JB. Comparison of osteotomy of recent vs mature
3. Pogue DJ, Viegas SF, Patterson RM, et al. Effects of distal malunions of the distal radius. Paper presented at: The
radius fracture malunion on wrist joint mechanics. J Hand 48th Annual Meeting of The American Society of Surgery
Surg [Am]. 1990;15A:721Y727. of the Hand; October 1993; Kansas City, Mo.
4. Palmar AK, Werner FW. Biomechanics of the distal radial 19. Iwamoto A, Morris RP, Andersen C, et al. An
ulnar joint. Clin Orthop. 1984;187:26Y35. anatomical and biomechanical study of the wrist exten-
5. Adams BD. Effects of radial deformity on distal radioulnar sor retinaculum septa and tendon compartments. J Hand
joint mechanics. J Hand Surg [Am]. 1993;18A:492Y497. Surg. 2006;31A:896Y903.
6. Lidstrom A. Fractures of the distal end of the radius: a 20. Ko S, Andersen CR, Buford WL, et al. Anatomy of the
clinical and statistical study of end results. Acta Orthop distal brachioradialis and its potential relationship to distal
Scand. 1959(suppl 41):58Y118. radius fracture. J Hand Surg [Am]. 2006;31A:2Y8.

230 Techniques in Hand and Upper Extremity Surgery

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Techniques in Hand and Upper Extremity Surgery 10(4):231–234, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia

| T E C H N I Q U E |

Lunocapitate Fusion Using the OSStaple

Compression Staple
Peter J. Ronchetti, MD
Hand Surgery Associates
Rochester, NY

Steven M. Topper, MD
Colorado Hand Center
Colorado Springs, CO

| ABSTRACT lapse (SLAC) wrist.2 Similar findings of arthritis in the

wrist can result from scaphoid nonunion advanced
Midcarpal arthrodesis is a reliable procedure to treat
collapse (SNAC wrist), aseptic necrosis of the scaphoid
individuals with symptomatic scapholunate advanced
(Prieser disease), and calcium pyrophosphate deposition
collapse (SLAC) who have failed nonoperative care. The
disease (pseudogout).3 The obvious solution to amelio-
principal keys to a successful midcarpal arthrodesis
rate the symptoms of arthritis is to excise the arthritic
include achieving union, a proper reduction of the
scaphoid. Unfortunately, because of the scaphoid’s critical
capitolunate interval, and avoiding hardware impinge-
role as the slider in the slider crank model of the wrist,
ment. A variety of devices are used in an attempt to achieve
excision only perpetuates midcarpal collapse. This fact has
this. These include Kirchner wires, stainless steel staples,
led to the 2 principal motion-preserving alternatives which
compression screws, and, most recently, circular plates. The
are scaphoid excision and midcarpal arthrodesis or
performance of these devices has not always been reliable
proximal row carpectomy.2Y4,6,7 Several studies have
leaving room for improvement. This report describes the
attempted to compare these 2 operations so that the
use of a new device that facilitates the achievement of the
community of surgeons that perform them would know
key principals. Staples made of nitinol (OSStaplei,
the right answer allowing them to practice Bevidence-
BioMedical Enterprises Inc, San Antonio, TX) facilitate
based medicine.^ To date, no study has the level of
provisional reduction, provide continuous compression
evidence to justify a dogmatic approach. So surgeons do
leading to rapid reliable union, and are low profile.
what works for them and their patients as they have
Keywords: partial wrist fusion, capitolunate fusion,
always done. There remain theoretical reasons to prefer
SLAC wrist arthritis, 4-corner fusion
one operation over another in various particular circum-
stances. With that in mind, a midcarpal arthrodesis is
clearly the operation of choice in advanced stages of
| HISTORICAL PERSPECTIVE SLAC when midcarpal arthritis is present. Initially, a
simple capitolunate arthrodesis was recommended to
Normally, the scaphoid subtends an angle of approxi-
stabilize the remaining carpus in the face of scaphoid
mately 47.5 degrees from a lateral perspective. When the
excision.8 It was only later that the 4-corner approach
scapholunate ligament is significantly attenuated or dis-
was advocated to increase the surface area of the fusion
rupted, the natural rotational moment in the scaphoid loses
mass to increase union rates. In those days, the implant of
its restraint causing the bone to flex. A mere 5 degrees of
choice was Kirchner wires (K-wires). The ulnar carpus is
pathological flexion in the scaphoid has been shown to
rarely burdened with arthritic changes in a patient with a
result in 45% reduction in radioscaphoid contact area.1
SLAC wrist. Therefore, if a particular implant was
This reduction in surface area of contact leads to a typical
capable of providing reliable capitolunate arthrodesis
arthritis pattern known as scapholunate advanced col-
reverting to a 2-bone midcarpal fusion may be a viable
alternative. This approach would limit exposure, mini-
mize operative time, diminish the need for additional
Address correspondence and reprint requests to Peter Ronchetti, MD,
Hand Surgery Associates, 10 Hagen Drive, Suite 210, Rochester, NY autograft bone, and eliminate the need to unnecessarily
14625. E-mail: destroy viable articular surfaces. The technique described

Volume 10, Issue 4 231

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Ronchetti and Topper

in this paper uses continuous compression nitinol staples,

OSStaplei (BioMedical Enterprises Inc, San Antonio,
TX), which shows great promise regarding its low
profile, high union rate, and ease of application which
facilitates an accurate midcarpal reduction.

The patient who presents with painful wrist arthritis
secondary to SLAC or SNAC are ideal candidates for
partial wrist fusion with the OSStaplei (Fig. 1). Isolated FIGURE 2. Intraoperative example of staple placement.
midcarpal arthritis is also an excellent indication. The
technique can be used in Kienbock disease for scapho-
capitate fusion as well. Severely osteoporotic bone is Provisional reduction of the capitolunate joint is
also a relative contraindication. Patients should be performed, and the reduction pinned with a K-wire. This
informed preoperatively that the procedure will not restore is checked under fluoroscopy. It is preferable to have the
normal motion. It is intended to relieve pain and preserve lunate in neutral to slight flexion; this is aided by placing
grip strength. a K-wire in the lunate and rotating it into flexion.5 Also
try to ensure that the capitate is centered over the lunate
to obtain the largest area for fusion.
The guide for drilling the OSStaplei is then placed
on the capitate and lunate on 1 side of the bone so that 2
| TECHNIQUE staples can be placed across the capitolunate articulation.
This technique describes a capitolunate fusion with The 1.8-mm drill bit is then drilled first through the
scaphoid excision; a full 4-bone fusion can be performed lunate. The drill will go through the cartilage on the
by adding the triquetrohamate joint to the fusion mass. dorsal surface of the lunate; be careful not to drill too
A standard dorsal wrist approach is used between the distally on the lunate or the staple will protrude into the
third and fourth extensor compartments. Capsulotomy is fusion site. The pin is placed in the drill hole through the
performed, and the proximal and distal carpal rows are guide to maintain the selected length of the staple chosen.
identified. The scaphoid is excised and placed on the back The second hole is then drilled in the capitate. Depth
table to be used for supplemental bone graft. The cartilage measurement is then made with the depth gauge.
surface of the capitolunate joint is inspected and denuded A small rongeur is used to create a trough in the lu-
of cartilage. This can be accomplished by the use of a nate, so the staple will seat at or below the level of the
high-speed burr or a rongeur. The surfaces should have cartilage. Place the appropriately sized OSStaplei into
visible cancellous bone. It is important to maintain carpal the predrilled holes; use the seating device to completely
height and the overall shape of the carpus. For this reason, seat the staple (Fig. 2). Check the position under
the arthrodesis site is packed with cancellous bone graft fluoroscopy to ensure proper placement (Figs. 3, 4).
which is harvested from the excised scaphoid and/or from Remove the provisional K-wire.
the distal radius. Next, the OSS Forcei Activator (BioMedical Enter-
prises Inc) is used to compress the prongs of the

FIGURE 1. Preoperative radiograph of SNAC arthritis. FIGURE 3. Intraoperative anteroposterior radiograph.

232 Techniques in Hand and Upper Extremity Surgery

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Lunocapitate Fusion Using the OSStaple Compression Staple

FIGURE 4. Intraoperative lateral radiograph.

OSStaplei and provide compression of the fusion

site. A second staple is then placed adjacent to the FIGURE 6. Postoperative lateral radiograph at 6 weeks.
first one as described above if needed and compressed.
Final X-rays are taken to ensure proper hardware place-
ment (Figs. 3, 4). Any gaps at the fusion site can be filled
with cancellous bone from the scaphoid or alternate site. patients had SLAC wrist arthritis, and 2 patients had SNAC
If the gaps occur on the volar side of the fusion, these can wrist arthritis. The average preoperative and postoperative
be approached from the radial side and packed with range of motion measurements were available for 6 of 7
cancellous graft. Capsule and retinaculum are repaired patients. The average preoperative flexion was 51 degrees,
followed by routine closure. and average postoperative flexion was 31 degrees. The
OSStaplesi can be placed across the capitohamate average preoperative extension was 34 degrees, and average
joint and the lunotriquetral joint if desired for additional postoperative extension was 33 degrees.
fixation if you are performing a 4-corner fusion. Addi- There have been no hardware impingement prob-
tional bone graft may be placed after OSStaplei heating lems nor hardware removals. The one patient without
if needed. complete pain relief is on disability for chronic back
Always check staple position before heating because it pain and is involved in litigation for this problem.
is easier to correct placement and misalignment errors Two of the 7 patients have returned to the operating
before heating. room, one for a pisiform excision and the other for a
triquetral excision. These patients have complete relief
of pain after the second surgery.

Seven patients have undergone capitolunate fusion with the | REHABILITATION
OSStaplei with an average follow-up of 6 months that Postoperatively, patients are placed in a short-arm volar
have resulted in no nonunions, no occupational changes, splint. Sutures are removed at 10 to 14 days, and a
and complete pain relief in 6 of 7 patients. Five of the short-arm cast is placed. Repeat X-rays are checked at
6 weeks postoperation, and if fusion is apparent and the
patient has little or no pain, they are transitioned to a
removable orthoplast splint (Figs. 5, 6). Occupational
therapy begins when the fusion appears solid.

Supported by BioMedical Enterprises Inc., San Anto-
nio, TX.

1. Burgess RC. The effect of rotatory subluxation of the
FIGURE 5. Postoperative anteroposterior radiograph at scaphoid on radioscaphoid contact. J Hand Surg [Am].
6 weeks. 1987;12:771Y774.

Volume 10, Issue 4 233

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Ronchetti and Topper

2. Watson HK, Ballet FL. The SLAC wrist: scapholunate collapse wrist: proximal row carpectomy versus four corner
advanced collapse pattern of degenerative arthritis. J Hand arthrodesis. J Hand Surg [Am]. 1995;20:965Y970.
Surg [Am]. 1984;9:358Y365. 6. Cohen MS, Kozin SH. Degenerative arthritis of the wrist:
3. Chen C, Chandnani VP, Kang HS, et al. Scapholunate proximal row carpectomy versus scaphoid excision and
advanced collapse: a common wrist abnormality in calcium four-corner fusion. J Hand Surg [Am]. 2001;26:94Y104.
pyrophosphate deposition disease. Radiology. 1990;177: 7. Tomaino MM, Miller RJ, Cole I, et al. Scapholunate
459Y461. advanced collapse wrist: proximal row carpectomy versus
4. Krakauer JD, Bishop AT, Cooney WP. Surgical treatment four corner arthrodesis. J Hand Surg [Am]. 1994;19A:
of scapholunate advanced collapse. J Hand Surg [Am]. 134Y142.
1994;19:751Y759. 8. Watson HK, Goodman ML, Johnson TR. Limited wrist
5. Wyrick JD, Stern PJ, Kiefhaber TR. Motion-preserving arthrodesis. Part II: Intercarpal and radiocarpal combina-
procedures in the treatment of scapholunate advanced tions. J Hand Surg [Am]. 1981;6:223Y233.

234 Techniques in Hand and Upper Extremity Surgery

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| T E C H N I Q U E |

The Anterior Cubital Approach for Displaced

Pediatric Supracondylar Humeral Fractures
Sadan Ay, MD, Metin Akinci, MD, and Omer Ercetin, MD
Department of Hand and Upper Extremity Surgery
Ankara Hand Surgery Center
Ankara, Turkey

The authors report a technique of the anterior cubital The procedure is carried out under general anesthesia in
approach that is an exposure for displaced pediatric a supine position with a tourniquet control. The
supracondylar fractures. Reduction is very safe and easy fractured arm is placed on the hand table. If the right
with this approach. Anatomical structures that hinder arm is fractured, the surgeon sits between the arm and
reduction such as the brachialis muscle or joint capsule the head; thus, if the left arm is fractured, the surgeon
and neurovascular tissues can be identified easily. This sits between the arm and the body. About a 3 cm
technique has not been a popular form of treatment in transverse incision is made following the flexor crease
many countries, particularly in the United States. (Fig. 1). The subcutaneous tissue is traversed with a
Keywords: type III displaced supracondylar humeral blunt dissection to reach the brachialis muscle. The
fracture, anterior cubital approach radial nerve, brachial artery, and median nerve can be
explored and freed through this incision if there is a
| HISTORICAL PERSPECTIVE neurovascular insufficiency before the reduction. In
displaced fractures, the brachialis muscle is commonly
According to LaGrange, anterior cubital approach was
originally defined first by Hagenbeck in 1894.1 Sorrel torn by the proximal fragment (Fig. 1). The fracture site
is approached through this penetration using blunt
and Longuet published the first clinical results and
dissections. After decompressing the fracture hema-
recommended this technique for the treatment of
toma, any soft tissue interposition is stripped with a
pediatric supracondylar humerus fractures in 1946.1
periosteal elevator (Fig. 2). The surgeon then holds his
Carcassonne et al1 popularized the technique as the
thumb on the proximal fragment and presses downward,
anterior and internal reduction for pediatric supra-
with his fingers holding the distal fragment posteriorly
condylar fractures in 1974. Kekomaki et al2 treated 32
while the assistant applies traction to the forearm, with
cases with anterior approach and with eleven successful
outcomes in a detailed study in 1984. Aronson et al3 the elbow flexed at an angle of 90 degrees and with
forearm pronation (Figs. 3A, B). In cases where the
suggested the anterior transverse exposure for reduction
of supracondylar humeral fractures in children as a
forgotten approach, reporting no unsatisfactory results
of 11 cases. Koudstaal et al4 showed that the anterior
approach is safe, simple, and easy to perform. Ay et al5
reported the advantages and the drawbacks of the
anterior cubital approach.

All pediatric supracondylar fractures that are displaced
and of extension type are indicated with or without
neurovascular insufficiency.

Address correspondence and reprint requests to Sadan Ay, MD,

Department of Hand and Upper Extremity Surgery, Ankara Hand FIGURE 1. About a 3 cm transverse incision is made
Surgery Center, Mesrutiyet Cad. 32/4, 06640-Kizilay, Ankara, Turkey. following the flexor crease. The brachialis muscle is
E-mail: commonly torn by the proximal fragment.

Volume 10, Issue 4 235

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Ay et al

Our opinion based on various methods used in the

treatment of displaced supracondylar fractures is open
reduction and Kirschner wire fixation. On the other hand,
there is a controversy about surgical approach.3 Surgical
exposure of supracondylar humeral fractures should
permit a safe and rapid reduction.4 Anatomical structures
that hinder reduction must be explored. If there is a
threatening condition about circulation, vital neurovas-
cular structures should be identified easily and repaired.
Scar formation must be acceptable.
Unsuccessful outcomes or poor results related to
incomplete reduction are well-known complications for
displaced supracondylar humerus fractures treated with
FIGURE 2. Soft tissue interposition is stripped with a different methods.8 Furthermore, iatrogenic neurovascular
periosteal elevator.

fragments override significantly, a periosteal elevator

can be inserted between the fragments and used like a
lever arm. While holding the fracture reduced with 1
hand, the surgeon then inserts crossed 2-mm (0.078 in)
Kirschner wire from the lateral epicondyle percutane-
ously with the other hand using a drill power. While
the Kirschner wire is inserted to the medial epicondyle,
the ulnar nerve is protected when elbow is positioned in
the extension and pronation of forearm. It should be
emphasized that the transverse incision does not allow
full exposure and visualization of the fracture fragments
through retraction and that the reduction is achieved
directly with a feedback from the thumb. No over-
lapping of the fragments in the anterior, lateral, and
medial sides should be permitted because this is an in-
dication of a rotational malalignment. After intraopera-
tive radiological verification (Fig. 4) of the reduction
by a fluoroscopy, the wound is closed with subcu-
taneous suture, the elbow is placed in 90-degree
flexion, and the forearm is in neutral position in a
long-arm splint. The wires are left out of the skin. In
case of a vascular or neural insufficiency, incision is
extended to Henry approach and neurovascular tissues
are explored.
Patients are examined for routine postoperative
period (Figs. 5, 6). After radiological examination, pins
are generally pulled on the 30th day, and the plaster was
removed. Exercise programs are begun.

There are no major complications about the presence of
a scar tissue, deformity, or contracture.

| DISCUSSION FIGURE 3. A and B, The surgeon then holds his thumb

on the proximal fragment and presses downward, with his
The treatment of the displaced supracondylar humerus fingers holding the distal fragment posteriorly while the
fractures should result in a perfect anatomical alignment assistant applies traction to the forearm, with the elbow
and a full functional elbow with no cosmetic loss.6,7 flexed at an angle of 90 degrees.

236 Techniques in Hand and Upper Extremity Surgery

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Displaced Pediatric Supracondylar Humeral Fractures

through the brachialis muscle and the interposition of the

joint capsule or anterior periosteum between the fracture
fragments. Although a release in an indirect manner, so-
called milking maneuver of buttonholing, has been
defined,12 the interposed capsular structures cannot be
released completely by indirect maneuvers. The anterior
cubital approach permits stripping of the interposed
structures easily using a periosteal elevator.1Y5
Cubitus varus or valgus, gunstock deformity, and re-
stricted motion are the complications of the supracondylar
humeral fractures related to anatomical reduction.1,8
Although it seems that there is no direct relationship
between the surgical approach and the malalignment of
the elbow joint,6 there is a close correlation between the
motion restriction and the type of approach which is
especially encountered with posterior incisions.13

FIGURE 4. Intraoperative radiological control of the reduction.

complications related to closed methods may cause

frustrating results.9Y11
Arterial or venous insufficiencies caused by the
fracture are the complications with serious consequences.
Early reduction and fixation usually resolve the circu-
lation problems but thrombosis, tearing, or kinking of
the brachial artery requires an exploration.9Y11 The
neurovascular bundle can be trapped by the fracture
ends, dislocated behind the fracture edge, and severed
by the sharp end of the fragment. In case of neuro-
vascular insufficiencies, surgical approach must achieve
the rapid exploration. Anterior cubital approach permits
to explore and repair the vascular tissues.1Y5
Neurologically, median, radial, and ulnar nerves carry
the risk of injury by the fragments in excessively displaced
supracondylar fractures because of its being in the close
vicinity.9,11 In posterolaterally displaced fractures, the
median nerve is injured, whereas the radial nerve is
damaged more frequently in posteromedially displaced
fractures. Through this approach, the nerves can be
inspected easily and reconstructed.
Anteromedial oblique approach is the most commonly
suggested intervention of the anterior approaches.9 An
oblique incision beginning from the medial side of the distal
third of the humerus extending longitudinally toward the
anterior cubital region is made.9 A reduction can be
achieved beneath the brachialis muscle, and the neuro-
vascular structures at the anteromedial aspect of the anterior
cubital region are identified; however, it is not possible to
explore the radial nerve at the lateral side with this approach.
The most common reasons for a failed reduction of FIGURE 5. A and B, Radiographs of displaced extension-
displaced fractures are the proximal fragment buttonholing type supracondylar humerus fracture.

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Ay et al

Anatomical reduction is easy, although a full anatomical

reduction is warranted. The approach permits easy
exploration of the structures that might otherwise hinder
reduction of the fracture edges. The approach allows for
full exposure of the tethered or damaged neurovascular
structures that must be repaired at the same time with
fracture treatment. The anterior transverse incision is
placed in a favorable location in terms of appearance.
Anatomical and functional results are very acceptable
during follow-up.

1. Carcassonne M, Bergoin M, Hornung H. Results of
operative treatment of severe supracondylar fractures of
the elbow in children. J Pediatr Surg. 1972;7:676Y679.
2. Kekomaki M, Luoma R, Rikalainen H, et al. Operative
reduction and fixation of a difficult supracondylar extension
fracture of the humerus. J Pediatr Orthop. 1984;4:13Y15.
3. Aronson DC, Meeuwis D. Anterior exposure for reduction
of supracondylar humeral fractures in children: a forgotten
approach. Eur J Surg. 1994;160:263Y266.
4. Koudstaal MJ, De Ridder VA, De Lange S, et al. Pediatric
supracondylar humerus fractures. The anterior approach.
J Orthop Trauma. 2002;16:409Y412.
5. Ay S, Akinci M, Kamiloglu S, et al. Open reduction of
displaced pediatric supracondylar humeral fractures through
the anterior cubital approach. J Pediatr Orthop. 2005;25:
6. Boyd DW, Aronson DD. Supracondylar fractures of the
humerus: a prospective study of percutaneous pinning.
J Pediatr Surg. 1992;12:789Y794.
7. Mulhall KJ, Abuzakuk T, Curtin W, et al. Displaced
supracondylar fractures of the humerus in children. Int
Orthop. 2000;24:221Y223.
8. Kurer MHJ, Regan MW. Completely displaced supra-
condylar fracture of the humerus in children. A review of
1708 cases. Clin Orthop. 1990;256:205Y214.
FIGURE 6. A and B, Anteroposterior and lateral radio-
graphs demonstrating perfect alignment of fragments after 9. Rasool MN, Naidoo KS. Supracondylar fractures: postero-
open reduction and internal fixation with anterior cubital lateral type with brachialis muscle penetration and neuro-
approach and crossed Kirschner wires. vascular injury. J Pediatr Orthop. 1999;19:518Y522.
10. Sabharwal S, Tredwell SJ, Beauchamp RD, et al. Manage-
We have not seen any poor or unsatisfactory results ment of pulseless pink hand in pediatric supracondylar frac-
with primary reduction using anterior cubital approach tures of humerus. J Pediatr Orthop. 1997;17:303Y310.
in the early or late follow-ups.4 11. Lyons ST, Quinn M, Stanistki CL. Neurovascular injuries
Open reduction through the anterior cubital approach in type III humeral supracondylar fractures in children.
is an option for the surgical treatment of the pediatric Clin Orthop Relat Res. 2000;376:62Y67.
displaced supracondylar humeral fractures. The drawbacks 12. Archibeck MJ, Scott SM, Peters CL. Brachialis muscle
of the approach are that the surgeon must be aware of the entrapment in displaced supracondylar humerus fractures:
anatomy and exposure of neurovascular structures, that the a technique of closed reduction and report of initial
transverse incision does not allow full exposure and results. J Pediatr Orthop. 1997;17:298Y302.
visualization of the fracture fragments, and that the 13. Erdemli B, Bektas U, Ay S, et al. Surgical treatment of
reduction is achieved directly with feedback from the displaced supracondylar fractures of the humerus in
thumb. However, the technique has certain advantages.1Y5 children. Turk J Med Sci. 1995;2:91Y94.

238 Techniques in Hand and Upper Extremity Surgery

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| T E C H N I Q U E |

Simultaneous Reconstruction of Medial

and Lateral Elbow Ligaments for Instability
Using a Circumferential Graft
Roger P. van Riet, MD, PhD
Modbury Public Hospital
Adelaide, Australia
University Hospital Antwerp
Antwerp, Belgium

Gregory I. Bain, MBBS, FRACS

Modbury Public Hospital
Adelaide, Australia
University of Adelaide
Royal Adelaide Hospital
Adelaide, Australia

Rob Baird, MBBS

Modbury Public Hospital
Adelaide, Australia

Yeow Wai Lim, MD

Changi General Hospital
Singapore, Singapore

| ABSTRACT with 1 graft. The strength of fixation allows for individual

tensioning in all limbs of the reconstruction and the
Reconstructing elbow instability remains a challenging
multiple passes of the graft through a single humeral
problem. Techniques described have included techniques
tunnel increasing the strength of the reconstruction.
for the lateral ligamentous complex, including the lateral
Potential complications could include ulnar nerve
ulnar collateral ligament, and techniques to reconstruct
damage, recurrent instability, elbow stiffness, and wound
the medial collateral ligament. We describe a new cir-
breakdown. Complications related to the potential use of a
cumferential technique to reconstruct both the lateral and
hinged external fixator are not specific to this procedure
medial ligament complexes, using 1 circular graft. A hole
but can be associated. Early active mobilization can be
is drilled through the center of rotation of the distal
initiated because of the strong stability provided by the
humerus and through the insertion sites of the medial and
circumferential graft and good fixation.
lateral ligament complexes. A hamstring tendon graft is
Keywords: elbow, instability, hamstring graft, reconstruc-
passed through the humerus twice to reconstruct the
tion, medial collateral ligament, lateral collateral ligament
anterior and posterior bands of the medial collateral
ligament and sutured onto itself. Endobutton fixation is
used to fix the graft on either side of the ulna. The graft is | HISTORICAL PERSPECTIVE
tightened on the lateral and medial sides and fixed into The functional anatomy of the ligaments of the elbow
the humerus using interference fit screws. have been well described by Morrey and An.1 The lateral
Advantages of the technique described include stabi- collateral ligament (LCL) complex (Fig. 1) assists the
lization of both the medial and lateral ligament complexes congruent articulating surfaces to resist varus stress. The
lateral ulnar collateral ligament (LUCL) has been shown
to resist posterolateral rotation of the radioulnar com-
Address correspondence and reprint requests to Gregory I. Bain, 196
Melbourne Street, North Adelaide, SA 5006, Australia. E-mail: plex relative to the distal humerus.2,3 The primary struc- ture resisting valgus stress is the anterior band of the

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van Riet et al

Advancement and imbrication of the LCL, autologous

palmaris longus tendon, part of the triceps tendon,10
and synthetic augmentation were all used.8,9 Another
technique described involves the use of plantaris tendon,
if no palmaris tendon is present.9,11
Recently, a Bdouble-docking^ modification has been
described to provide stronger fixation and allow
tensioning of both limbs of the graft.4
Traumatic failure of the joint occurs when a force is
applied across the joint. The bone fails in compression,
and the ligament fails in tension. It is for this reason that
MCL ligament injuries commonly occur with radial head
fractures and dislocations.6,12,13 In the acute fracture
setting, repair is often used. However, in chronic cases
and in high-level athletes, MCL reconstruction using a
FIGURE 1. Lateral collateral ligament complex. Reprinted
with permission from Bain GI, Mehta JA. Anatomy of the free tendon graft has been shown to yield better results
elbow joint and surgical approaches. In: Baker CL Jr, over direct repair of the tendon.14,15 The reconstruction
Plancher KD, eds. Operative Treatment of Elbow Injuries. technique was described by Jobe et al16 in 1986. It
New York, NY: Springer-Verlag; 2001:1Y27. involves transposition of the ulnar nerve and cutting the
flexor-pronator group to obtain better exposure.16 In this
technique, the MCL is reconstructed using a double
medial collateral ligament (MCL),1 whereas the posterior strand of free tendon graft and, again, a variety of grafts
band resists internal rotation of the ulna onto the has been used. Modifications to the original technique
humerus4 (Fig. 2). The LCL originates from the lateral include splitting of the flexor-pronator group and
epicondyle.5 The exact insertion can be palpated as a leaving the ulnar nerve in its bed.17 A recent bio-
rough area on the epicondyle. The LCL merges distally mechanical study has shown that a single-strand
with the annular ligament. The LUCL inserts with the technique may provide sufficient strength to provide
LCL and traverses the annular ligament to insert on the resistance to varus stress,18 however, rotational stability
supinator crest. was not tested in this study.
The anterior and posterior bands of the MCL originate Initial fixation strength of different MCL reconstruc-
from the anterior undersurface of the medial epicondyle. tion techniques has also been studied in a cadaveric
Often, a small tubercle can be palpated at the exact point model.19 Endobutton and docking techniques were shown
of insertion. The anterior band of the MCL inserts onto to be strongest, usually failing at the tendon-suture in-
the sublime tubercle located on the medial side of the terface. Interference screw fixation was less strong,
coronoid process.4 The posterior band inserts along the
midportion of the greater sigmoid notch.1
Acute LCL injuries are often associated with other
injuries, such as radial head fractures,6 and can usually
be repaired. Acute dislocations of the elbow can be
treated with an acute repair of the ruptured ligaments
but are usually treated nonoperatively. Some of these
patients, however, may develop chronic instability of
the elbow.7 The authors believe that the avulsed lateral
ligament complex comes off in 1 sheet. Because of the
instability, the joint may be subluxed, and the lateral
complex is translated distally and sits on the articular
surface of the capitellum. Therefore, it is unable to heal
to its native bony insertion site on the lateral epicon-
dyle.4 Fortunately, this is relatively uncommon, but it
can result in significant disability. Injuries of the LUCL
can result in chronic posterolateral instability. Results of FIGURE 2. Medial collateral ligament complex. Reprin-
ted with permission from Bain GI, Mehta JA. Anatomy of
reconstruction of the LUCL were described by Nestor the elbow joint and surgical approaches. In: Baker CL Jr,
et al8 in 1992. Several techniques were used in these Plancher KD, eds. Operative Treatment of Elbow Injuries.
patients8 and have later been adapted by others.4,9,10 New York, NY: Springer-Verlag; 2001:1Y27.

240 Techniques in Hand and Upper Extremity Surgery

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Elbow Reconstruction Using a Circumferential Graft

both the radial head and the coronoid process. The cir-
cumferential ligament reconstruction may be indicated
after skeletal fixation and ligament repair in which
stability is not adequate. A dynamic external fixator may
be indicated or used as an alternative in these cases. A rare
cause of instability can sometimes be found after con-
tracture release or removal of heterotopic ossification.
Clinical assessment, including history, physical
examination supplemented by an examination under
general anesthesia, and fluoroscopic and arthroscopic
assessments, are used to identify the pattern of instability.
FIGURE 3. Single-loop technique of the lateral and In most cases, only 1 ligament would require reconstruc-
medial ligamentous complexes. 1) The graft is passed
from lateral to medial through the ulna. 2) The graft is
tion. However, in more complex instabilities, such as
tensioned and passed through the humeral tunnel. This combined or global instabilities, a circumferential graft
reconstructs the anterior bundle of the MCL. 3) The LUCL may be used to provide stability. We have performed a
is reconstructed by passing the graft through the ulna, single-loop technique to provide a reconstruction of the
completing the single loop circumferential reconstruction. anterior band of the MCL and the LUCL (Fig. 3). In more
complex cases such as those of global instability, there
may be injury to all 4 ligamentous units. In these cases,
we recommend that all be reconstructed using a double-
failing between the tendon-screw interface. The authors
loop technique (Fig. 4).
commented that insufficient tension in the graft could be
Contraindications include patients in whom their
another factor that attributed to failure of the construct.19
general health status does not allow a prolonged surgical
Although bilateral ligament injuries are not
procedure, active infection in the operative area, or if their
uncommon, lateral and medial techniques have evolved
mental status does not allow a coordinated postoperative
separately. To our knowledge, no reports have been
rehabilitation period. Elbow stiffness could be a relative
published on a reconstruction of the medial and lateral
contraindication. This grafting technique should not be
ligament complexes with a single procedure using a
considered as a single procedure to overcome instability
single graft.
produced by skeletal insufficiency, such as complex
coronoid process fractures. These conditions should be
addressed first before considering the circumferential
| INDICATIONS/CONTRAINDICATIONS ligamentous reconstruction described below. An external
The technique described in the following section is
indicated in patients with symptomatic chronic global
instability of the elbow. Patients typically present
complaining of recurrent, painful clicking, snapping,
clunking, or locking of the elbow.20 They experience
varying disability ranging from mild instability, which
ultimately may contribute to ulnohumeral arthritis,7 to
instability that limits the ability to exert force with the
upper limb, to recurrent subluxation or dislocation, and
to fixed subluxation or dislocation at the other end of
the spectrum.21
From a clinical evaluation of the elbow, instability
can sometimes be difficult to appreciate and does not
always show the extent of laxity present. Arthroscopic
FIGURE 4. Double-loop technique of the lateral and
evaluation can also be used to evaluate medial and lateral medial ligamentous complexes. 1) The graft is passed
gapping of the ulnohumeral joint during rotational, varus, from lateral to medial through the ulna. 2) The graft is
and valgus stresses to the elbow.22 Symptomatic patients tensioned and passed through the humeral tunnel. This
with documented instability of the elbow are candidates reconstructs the anterior bundle of the MCL. 3) The LUCL
for the technique described. is reconstructed by passing the graft through the ulna. 4) A
second pass is made through the humerus, reconstructing
Other indications include residual elbow instability in the posterior bundle of the MCL. 5) The graft is then
the so-called terrible triad injuries after a fracture dis- brought down to the ulna again, and this reconstructs the
location, after adequate reconstruction and fixation of posterior part of the lateral ligamentous complex.

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van Riet et al

epicondyle (isometric point), taking care to protect the

ulnar nerve. In the ulna, an oblique 4.5-mm drill hole is
made from the sublime tubercle on the medial ulna to exit
distal to the supinator crest on the lateral side of the ulna.
This tunnel is used to reconstruct the anterior band of the
MCL. Finally, an oblique 4.5-mm tunnel is drilled from
the lateral supinator crest, directed distally on the medial
side of the ulna, to reconstruct the LUCL.
All drill holes are rounded off with a curette to
facilitate free passage of the tendon graft. A trailing
suture is passed through all tunnels, and the graft is pulled
through the entire circuit using this suture. An endo-
button is secured to 1 end of the graft, and the graft is then
FIGURE 5. Lateral intraoperative view of the double-loop advanced through the bone tunnel in the sublime tubercle
technique. An endobutton is sutured to the graft. The
endobutton engages onto the ulnar cortex as the graft is (Fig. 5). A straight suture passer is used to advance the
tensioned through the ulna and humerus. graft through the center of rotation in the distal humerus.
The graft is then again passed through the supinator crest
to the medial side of the ulna.
The graft is tensioned tightly before each pass
fixator may be used to protect the reconstruction in cases
through the bone, while making sure that the elbow is
where bone loss cannot be addressed adequately and there
reduced before tensioning the individual graft sections.
is persistent instability despite the ligamentous graft.
Tensioning of the graft is facilitated by the circumferential
technique and all limbs of the reconstruction should be
tight before fixing the graft. The anterior band of the
| TECHNIQUE MCL is tensioned first with the elbow in flexion. The
After adequate anesthesia, the patient is positioned in LCL is tensioned with the forearm pronated. Care is
lateral decubitus position. Pressure points are protected. taken to reduce the elbow at this point, and the elbow is
The ipsilateral lower extremity is draped separately for a cycled through a range of motion to pretension the graft.
hamstring graft. The instability patterns of the elbow are The graft is then cut to the right length, and a second
evaluated by examination under fluoroscopy imaging. endobutton is sutured to the LCL end of the graft. This is
The gracilis tendon is harvested with a tendon stripper, passed from lateral to medial, and the endobutton is tied
and no. 2 Fiberwire (Arthrex, Australia) whip-stitch is on the medial side of the proximal ulna. The stability of
sutured at each end. the elbow and tension in the reconstructed ligaments are
A midline posterior elbow incision is made, and the again evaluated. If additional tension or fixation of the
ulnar nerve is identified and taped. Full-thickness graft is needed, an interference fit screw can be inserted
fasciocutaneous flaps are elevated to expose the medial
and lateral aspects of the elbow.23 The flexor carpi
ulnaris is reflected anteriorly, exposing the medial
proximal ulna and medial epicondyle. The sublime
tubercle on the medial side of the proximal ulna is
palpated, and soft tissues are debrided from the tubercle.
Laterally, Kocher interval is developed between the
anconeus and the extensor carpi ulnaris. The anconeus is
reflected, and any LCL complex remnants are identified.
The forearm is pronated to protect the posterior inter-
osseus nerve, and the annular ligament is divided. The
capitellum and lateral epicondyle are clearly exposed.
The supinator crest is palpated and exposed on the lateral
side of the ulna to expose the origin of the LUCL.

Single-loop Technique
FIGURE 6. Medial intraoperative view of a double-loop
A 4.5-mm hole is drilled through the axis of rotation on technique. The ulnar nerve is released and protected.
the humerus, from the center of the capitellum on the The 2 limbs of the ligament graft are seen to reconstruct
lateral side to the anteroinferior surface of the medial both the anterior and posterior bundles of the MCL.

242 Techniques in Hand and Upper Extremity Surgery

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Elbow Reconstruction Using a Circumferential Graft

into the lateral and/or medial graft exit holes in the knee. We have not encountered any donor-site morbidity
humeral epicondyles. This will effectively stabilize or other complications related to this technique.
tension in each limb of the graft.
Double-loop Technique
Postoperatively, the patient is placed in an above-elbow
If preoperatively, it was decided to also reconstruct the
plaster slab with the elbow in 90-degree flexion and
posterior band of the MCL and the posterolateral capsule,
neutral forearm rotation for 1 week. Because of the initial
the technique is tailored for this pattern (Fig. 4). This is
stability, we have enabled patients to commence active
similar to the single-loop technique but also includes the
mobilization and to not use a brace postoperatively.
posterior bundle of the MCL and the posterior aspect of
the lateral ligament complex. The first ulnar tunnel from
the sublime tubercle to the medial proximal ulna | ACKNOWLEDGMENT
remains the same. A second ulnar tunnel in the proximal The authors thank Ron Heptinstall for his contribution
ulna is drilled from the supinator crest directed to the in creating the artwork and preparing the manuscript.
olecranon, exiting at the level of the center of the
greater sigmoid notch. An additional tunnel needs to be
drilled through the proximal ulna. This will be drilled | REFERENCES
straight laterally from the medial aspect of the olecranon 1. Morrey BF, An KN. Functional anatomy of the ligaments
at the level of the center of the greater sigmoid notch. of the elbow. Clin Orthop. 1985;201:84Y90.
The humeral tunnel is 6 mm to accommodate the
2. O’Driscoll SW, Bell DF, Morrey BF. Posterolateral rotatory
graft passage twice. A trailing suture is again preloaded
instability of the elbow. J Bone Joint Surg Am. 1991;
in the circuit. The graft follows the suture through the 73:440Y446.
entire circuit, starting again from the lateral side of the
3. Olsen BS, Sojbjerg JO, Nielsen KK, et al. Posterolateral
ulna through the sublime tubercle on the medial side.
elbow joint instability: the basic kinematics. J Shoulder
The reconstruction of the anterior band of the MCL and
Elbow Surg. 1998;7:19Y29.
the LUCL is again performed. The graft is now passed
through the supinator crest to the posteromedial side of 4. Mehta JA, Bain GI. Posterolateral rotatory instability of
the elbow. J Am Acad Orthop Surg. 2004;12:405Y415.
the proximal ulna and pulled up through the humeral
tunnel for the second pass. This reconstructs the 5. O’Driscoll SW, Hori E, Morrey BF, et al. Anatomy of the
posterior band of the MCL. Finally, the graft is pulled ulnar part of the lateral collateral ligament of the elbow.
down to the lateral side of the greater sigmoid notch, Clin Anat. 1992;5:296Y303.
where it is fixed with an interference fit screw (Fig. 6). 6. van Riet RP, Morrey BF, O’Driscoll SW, et al. Associated
The graft is again tensioned before each pass through the injuries complicating radial head fractures: a demographic
bone, and the double tendon graft can be fixated into the study. Clin Orthop Relat Res. 2005;441:351Y355.
humeral tunnel using an interference fit screw. It is 7. Eygendaal D, Verdegaal SH, Obermann WR, et al.
important to make sure that the elbow is fully reduced Posterolateral dislocation of the elbow joint. Relationship
throughout this procedure and, especially, before the to medial instability. J Bone Joint Surg Am. 2000;82:
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The flexor-pronator mass is repaired back to the 8. Nestor BJ, O’Driscoll SW, Morrey BF. Ligamentous
medial epicondyle, and the Kocher interval is closed reconstruction for posterolateral rotatory instability of
using nonabsorbable sutures. The skin is closed in layers. the elbow. J Bone Joint Surg Am. 1992;74:1235Y1241.
9. Sanchez-Sotelo J, Morrey BF, O’Driscoll SW. Ligamen-
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| COMPLICATIONS instability of the elbow. J Bone Joint Surg Br. 2005;87:
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wound breakdown from the posterior incision have all elbow. J Bone Joint Surg Am. 2000;82-A:724Y738.
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plications related to the potential use of a hinged external type-III radial head fractures with a titanium prosthesis,
fixator can also occur. Potential complications also ligament repair, and early mobilization. J Bone Joint Surg
include donor-site morbidity on the medial side of the Am. 2004;86-A:274Y280.

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van Riet et al

13. Bain GI, Ashwood N, Baird R, et al. Management of 18. Armstrong AD, Dunning CE, Faber KJ, et al. Single-
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244 Techniques in Hand and Upper Extremity Surgery

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| T E C H N I Q U E |

Technique of Harvesting the Gracilis for Free

Functioning Muscle Transplantation
Ahmad I. Addosooki, MD, Kazuteru Doi, MD, PhD, and Yasunori Hattori, MD, PhD
Department of Orthopedic Surgery
Ogori Daiichi General Hospital
Yamaguchi, Japan

| ABSTRACT many donor muscles available for FFMT. The gracilis

muscle is the most commonly used and most suitable
In this article, we describe our technique and experience
muscle for FFMT. It has a good excursion, a relatively
in harvesting the gracilis muscle for free functioning
reliable long vascular pedicle, a single motor nerve
muscle transplantation (FFMT). The gracilis is the most
supply, an easy approach, and an insignificant donor site
commonly used muscle for FFMT. The main indication
morbidity after harvest. We have an experience of more
for gracilis FFMT is traumatic brachial plexus injury.
Gracilis muscle has a class 2 vascular pedicle, with a than 15 years in harvesting gracilis muscle, during which
we have harvested more that 200 free gracilis mainly for
dominant vascular pedicle originating from the profunda
restoration of prehension in traumatic brachial plexus
femoris vessels and a single motor nerve originating
injury. In this article, we describe our technique and
from the obturator nerve. During gracilis harvest, it is
experience of harvesting gracilis for FFMT.
important to include the entire fascia around the muscle
to ensure vascularity of the skin paddle and enhance
muscle gliding in its new bed. Mobilization of the | HISTORICAL BACKGROUND
adductor longus allows tracing of the pedicle to its In 1970, Tamai et al1 described the experimental work
origin from the profunda femoris vessels, hence, of free transplantation of rectus femoris muscle in dogs
achieving the maximum available length of the pedicle. using microvascular anastomosis. Their work opened
Lengthening of gracilis tendon with a periosteal strip the way for the FFMT in humans. In 1976, Harii et al2
provides a free gracilis long enough to span the distance reported gracilis FFMT for facial reanimation in
from the clavicle to the distal forearm. The main patients with unresolved Bell palsy. In 1978, Manktelow
complications are related to the wound, and these and McKee3 reported 1 case of free functioning gracilis
include delayed healing, infection, and scar-related to provide finger flexion. After that, gracilis FFMT has
problems. The functional deficit after gracilis harvest been reported by many authors.4Y9 Doi et al,10 in an
is negligible. attempt to shorten the very long scar resulting from
Keywords: technique, gracilis harvest, functioning gracilis harvest, reported endoscopic harvest of the
transplantation gracilis. Their study showed that endoscopic harvesting
of the gracilis produced a significantly shorter scar, but
took 1.5 times longer than conventional method.
| HISTORICAL PERSPECTIVE Hallock11 reported retrograde endoscopically assisted
Free functioning muscle transplantation (FFMT) is the gracilis harvest, and he achieved significant improve-
microneurovascular transfer of a muscle from one ment in the donor site scar appearance. Jeng et al12
location to another in the body to replace deficient reported a minimally invasive nonendoscopic technique
motor function. The procedure involves microvascular of gracilis harvest with nearly the same wound length as
anastomosis to maintain viability of the muscle and endoscopic technique and the same duration as open
suturing the motor nerve of muscle to a donor nerve at technique. However, both Hallock’s and Jeng’s tech-
the recipient site to restore muscle function. There are niques did not include monitoring skin flap. Hattori et al13
described a surgical approach to the gracilis vascular
pedicle in which the adductor longus is mobilized
Address correspondence and reprint requests to Ahmad I. Addosooki, posteromedially, which allows tracing the gracilis
MD, Department of Orthopedic Surgery, Ogori Daiichi General
Hospital, Shimogo, 862-3, Ogori-Yamaguchi, Yamaguchi 754-0002, pedicle to its origin from the profunda femoris vessels
Japan. E-mail: and an easy dissection of the pedicle.

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Addosooki et al

| INDICATIONS AND tion. The main contraindications are contractures and

CONTRAINDICATIONS fibrosis at the recipient site.
Free functioning gracilis is indicated in cases of
destroyed or chronically denervated muscle when no | TECHNIQUE
locally available musculotendinous donor units exist for
transfer. Free functioning muscle transplantation is a Anatomy
major complex procedure that should not be used when Gracilis is the most superficial of adductor thigh
simpler and satisfactory techniques are available. The muscles. It is a thin and flat muscle that has a broad
most common causes of muscle function loss (destruc- aponeurotic origin from the lower half of the pubic body
tion or denervation) have been traumatic muscle loss,4 and upper half of the pubic arch. The muscle runs
Volkman ischemic contractures,6 electric burns,14 tumor vertically, superficial to the adductor longus and
excision,15 brachial plexus injury,7Y9,16 and facial nerve magnus, then forms a round tendon that passes posterior
palsy.2 Traumatic brachial plexus injury is a major to the sartorius muscle tendon and curves laterally to
indication for gracilis FFMT in the upper limb. In insert on the medial surface of the proximal tibia just
traumatic brachial plexus palsy (especially total type), it distal to tibial tuberosity.
has been indicated for restoration of elbow flexion, The muscle has a class 2 vascular pattern, having
finger flexion, and extension.4,8,9 The most common both a dominant pedicle and minor vascular pedicles.18
indication has been the restoration of finger flexion. The The dominant vascular pedicle originates from the
most common indication in our experience has been profunda femoris vessels. The pedicle passes between
double FFMT to restore prehension in brachial plexus the adductor brevis and magnus posteriorly and adduc-
injuries.8,9 The prerequisites for free functioning gracilis tor longus anteriorly to reach the lateral border of the
transfer are the presence of appropriate recipient vessels gracilis (Fig. 1). The main vascular pedicle enters the
and donor nerve and intact gracilis and its neurovascular gracilis in 2 or 3 branches, 8 to 12 cm distal to the pubic
pedicle. We had an experience of obturator nerve injury tubercle. The secondary pedicles originate from the
that was discovered intraoperatively during gracilis femoral artery and enter the gracilis at its middle and
harvest that resulted in abandoning the gracilis and lower thirds. The entire gracilis can be nourished by the
using the latissimus dorsi instead.17 A cooperative dominant pedicle.
patient who can follow the long course of physiotherapy The blood supply to the skin overlying the gracilis
postoperatively is another prerequisite for this opera- muscle is divided into 3 areas. The proximal third

FIGURE 1. Transverse section

of the proximal thigh showing the
approach to the gracilis vascular
pedicle. The adductor longus is
mobilized posteromedially, so
that we can dissect the gracilis
vascular pedicle to its origin from
the profunda femoris vessels.
The skin paddle and its subcuta-
neous tissue are cut obliquely to
have a wide base, and they
should look trapezoidal in trans-
verse section (2 transverse back
arrows). The gracilis is harvested
with inclusion of all the fasciae
surrounding the muscle. BFLH
indicates biceps femoris long
head; BFSH, biceps femoris
short head; SN, sciatic nerve.

246 Techniques in Hand and Upper Extremity Surgery

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Gracilis Harvesting Technique

receives mainly transversely oriented fasciocutaneous adductor longus became prominent and was easily felt.
perforators from the main gracilis muscular perforating A line drawn from the pubic tubercle along the adductor
arteries, which usually pass anterior to the gracilis, longus prominence demarcated the anterior border of
along the septum between the gracilis and the adductor the gracilis. An elliptical skin paddle was designed just
longus. Direct musculocutaneous perforators are few behind this line, 6 to 10 cm distal to pubic tubercle, with
and inconstant.19,20 The skin overlying the middle third a diameter of about 6  10 cm (Fig. 3).
of the gracilis is primarily dependent on fasciocutaneous
perforators from the superficial femoral artery. These Incisions
perforators communicate with the vascular pedicle of We approached the gracilis through 3 incisions. The
the gracilis through longitudinally oriented vessels first was the incision that outlined the skin paddle,
running through the fascia over the gracilis.20,21 The which may be extended proximally or distally for few
skin over the distal third is supplied by smaller centimeters as needed. The second incision was a short
fasciocutaneous perforators from the superficial femoral incision (4Y6 cm) located at the posteromedial side of
artery and the descending genicular artery. Depending the distal thigh, just proximal to the knee joint, over the
on the previous description, the skin paddle of gracilis distal tendon of the gracilis muscle. The third incision
myofasciocutaneous free flap should be centered over was a transverse incision (6Y8 cm) located on the
the proximal third of the gracilis and slightly anterior to anteromedial side of the proximal tibial, just distal to
the anterior border of the gracilis, with inclusion of the the level of the tibial tuberosity (Fig. 3). The third
all fascia around the gracilis to ensure its vascularity.20 incision is needed when the gracilis will be placed
The motor nerve of the gracilis is a branch of the proximal to the shoulder to restore fingers flexion or
anterior division of the obturator nerve. The obturator extension because the free gracilis needs to be long
nerve emerges from the obturator foramen under the enough to span the distance from the clavicle or
pectineus muscle and divides into anterior and posterior proximal ribs to the distal forearm to be sutured to the
divisions. The anterior division passes between the fingers flexor or extensor tendons. In other indications,
adductor longus and brevis, giving motor branches to the first and second incisions will be enough.
both muscles before giving the motor branch to the Dissection
gracilis muscle. The medial cutaneous nerve of the We incised first the anterior border of skin paddle. The
thigh, a branch of the obturator nerve, courses just subcutaneous tissues were cut obliquely to obtain a wide
lateral to the motor nerve of the gracilis on the base of subcutaneous tissues for the skin paddle to
undersurface of the adductor longus muscle (Fig. 2). ensure the vascularity of the skin paddle. The great
Planning saphenous vein was identified and dissected free. It is an
The patient was placed in supine position. The knee was important landmark because it is located about 2 cm
anterior to the intermuscular septum between the
flexed, and the hip was flexed, abducted, and externally
gracilis and the adductor longus. The deep fascia was
rotated. In this position, the tendon of origin of the
incised along the course of the great saphenous vein to
include the intermuscular septum between the gracilis
and adductor longus, along which skin paddle fasciocu-
taneous perforators usually pass, opposite the dominant
vascular pedicle (Fig. 4). We reflected the deep fascia
posteriorly and continued dissection between the graci-
lis and the adductor longus muscle until the main
vascular pedicle of the gracilis was confirmed (Fig. 2).
Then, we incised the posterior border of the skin paddle.
The subcutaneous tissues were also cut obliquely to
obtain a wide base for the skin paddle. The skin paddle
and subcutaneous tissue should be trapezoid-like in
transverse section (Fig. 1). We continued dissection
posteriorly, avoiding cutting the deep fascia, until the
FIGURE 2. The adductor longus was retracted anteriorly. posterior border of the gracilis was reached. The deep
The gracilis vascular pedicle runs over the adductor fascia was cut 1 to 2 cm posterior to this border, and the
magnus and brevis (black transverse arrow). The motor gracilis, completely invested in fascia, was dissected
branch of the gracilis runs proximal to the pedicle (black
vertical arrow), and the sensory branch of the obturator (Fig. 1). Inclusion of the fascia around the gracilis
nerve runs parallel to the motor nerve on its lateral side ensures the blood supply of the skin paddle, as we
(white vertical arrow). described in the ‘‘Anatomy^ section, and enhances

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Addosooki et al

FIGURE 3. The patient was positioned with the hip FIGURE 5. The dissection was continued anteriorly and
flexed, abducted, and externally rotated. The upper dotted distally between the gracilis and adductor longus (black
line was drawn along the adductor longus muscle, and it arrow) until the adductor magnus comes anterior to the
demarcated the anterior border of the gracilis. An elliptical gracilis (white arrow). At this point, we dissected circum-
skin paddle was designed just behind this line, 6 to 10 cm ferentially around the gracilis (gray retractor).
distal to the pubic tubercle, with a diameter of about 6 
10 cm. The second incision was designed on the poster-
omedial distal thigh just proximal to the knee. The third to an extension chain that attached to a lifting apparatus.
incision was a transverse incision on the anteromedial The endoscope was fixed to a scope holder and adjusted
border of the leg just distal to the tibial tuberosity.
to allow a good field of view. A second endoretractor,
also attached to the lifting apparatus, may help to make
gliding of the gracilis in the new bed. Then, we the optical cavity wider (Fig. 7). Under endoscopic
continued the dissection anteriorly and distally until guidance, the surgeon proceeded to dissect distally from
the adductor magnus muscle was anterior to the anterior the second incision using a long-limb tooth forceps, a
border of the gracilis (Fig. 5). At this point, we dissected pair of long dissecting scissors, and electrocautery
circumferentially around the gracilis and retracted it by instruments. The gracilis minor vascular pedicles were
a rubber drain. meticulously dissected, ligated with vascular clips, and
When the limits of open dissection were reached, cut, because it is very difficult to stop any bleeding
dissection was continued endoscopically. The gracilis under endoscopy. The interseptal fascia was cut to
tendon was approached through the second incision just include the overlying fascia of the gracilis so as to
behind the sartorius muscle fleshy tendon (Fig. 6). A provide a gliding surface for the muscle after transfer
subcutaneous tunnel between the first and second into an unhealthy recipient bed. After the dissection of
incision was developed above the deep fascia over the the proximal two-thirds of the subcutaneous tunnel was
gracilis. A large endoretractor was inserted through the completed, the endoscope was removed and inserted
proximal incision and secured to the skin edges to through the second incision. Dissection from this end is
prevent it from slipping out. It was lifted by hooking it

FIGURE 4. The deep fascia was incised along a line

beneath the great saphenous vein (retracted by vessel
loop), which lies 1 to 2 cm anterior to the intermuscular FIGURE 6. Through the second incision, the gracilis
septum between the adductor longus and gracilis tendon (black arrow) is located just behind the sartorius
muscles. fleshy tendon (white arrow).

248 Techniques in Hand and Upper Extremity Surgery

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Gracilis Harvesting Technique

FIGURE 9. The gracilis muscle was delivered from the

third incision through the second incision to the first
incision. Using the technique of elongating the tendon
with periosteal strip, we can achieve a gracilis with a
FIGURE 7. A photo of the endoscopic harvest part of the length of up to 40 cm.
technique showing the endoscope in its holder and the
retractors in place. and knee wee then extended, and the second and third
incisions were closed in this position to avoid long-
standing compression of the sciatic nerve.
relatively simpler because of the absence of critical
The adductor longus was retracted anteriorly, and
subcutaneous structure. The distal portion of the gracilis
the pedicle was dissected meticulously, under loupe
was also well defined from the adjacent tissues under
magnification, as far as possible. Branches to the
the deep fascia. The gracilis tendon was dissected
adductor longus, brevis, or magnus should be ligated.
distally as far as possible. The index finger was
The adductor longus was then mobilized posterome-
introduced through the second incision, following the
dially, and the pedicle was dissected from its origin in
gracilis tendon by pushing toward the anteromedial
the profunda femoris vessels. Using this approach, we
aspect of the proximal leg to accurately locate the level
can obtain the longest possible pedicle (6Y8 cm) and
of the third incision.
wider diameter vessels (1.2Y1.8 mm) for anastomosis13
Through the third incision, the gracilis tendon was
(Fig. 10). Also, dissection of the lateral portion of the
located, aided by pushing the tendon using the index
pedicle is much easier than dissection through a narrow
finger through the second incision, and it was dissected
tunnel beneath the adductor longus. The vascular
free from its insertion to the proximal tibia. The tendon
pedicle was not ligated at this stage.
was elongated as long as possible (about 3 cm) by the
The adductor longus muscle was retracted again
inclusion of a strip of the periosteum from the insertion
anteriorly to dissect the motor nerve to the gracilis. The
of the tendon to the anterior tibial border (Fig. 8). Using
cutaneous sensory nerve of the obturator nerve runs
this technique, we can get a gracilis muscle with a
parallel to the gracilis motor nerve on its lateral side
length of up to 40 cm. The tendon was then cut and
(Fig. 2). We usually use nerve stimulator to ensure
delivered through the second incision to the first
differentiation of sensory nerve from the motor nerve.
incision and put inside a wet towel (Fig. 9). The hip
The gracilis motor nerve should be followed as

FIGURE 10. The adductor longus was retracted poster-

FIGURE 8. The gracilis tendon is elongated by inclusion of omedially (retracted by vertical retractor), and the pedicle
a periosteal strip from the insertion of the tendon (left arrow) was traced to its origin from the profunda femoris artery.
to the anterior tibial border (right arrow). This adds about 3 The pedicle artery was retracted by right vessel loop, and
cm to the length of the tendon. the vein was retracted by the left vessel loop.

Volume 10, Issue 4 249

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Addosooki et al

the knee and the hip after delivery of the gracilis to the
first incision and close the second and third incision in
this position to relief sciatic nerve compression.

1. Tamai S, Komatsu S, Sakamoto H, et al. Free muscle
transplants in dogs, with microsurgical neurovascular
FIGURE 11. The gracilis muscle was harvested com- anastomoses. Plast Reconstr Surg. 1970;46:219Y225.
pletely. The black arrow points to the vascular pedicle,
2. Harii K, Ohmori K, Torii S. Free gracilis muscle
and the white arrow points to the motor nerve of the
gracilis. transplantation, with microneurovascular anastomoses for
the treatment of facial paralysis. A preliminary report.
Plast Reconstr Surg. 1976;57:133Y143.
proximal as possible to the obturator foramen. The 3. Manktelow RT, McKee NH. Free muscle transplantation
dissection should be cautious to avoid injury of the to provide active finger flexion. J Hand Surg [Am].
adductor longus and brevis motor branches. The nerve 1978;3:416Y426.
was then cut, and the gracilis muscle dissection was
4. Chung DC, Carver N, Wei FC. Results of functioning free
completed posteriorly without tension on the vascular muscle transplantation for elbow flexion. J Hand Surg
pedicle. The vascular pedicle was then ligated, and the [Am]. 1996;21:1071Y1077.
dissection of the gracilis was completed proximally up
5. Manktelow RT. Functioning microsurgical muscle trans-
to its aponeurotic origin from the pubic arch. The
fer. Hand Clin. 1988;4:289Y296.
muscle origin was cut from the pubic arch, and the
bleeding was stopped using electrocautery (Fig. 11). 6. Egerszegi EP, Zuker RM, Caouette-Laberge L, et al.
The adductor magnus and adductor longus muscles Neurovascular transfer of the m. gracilis for the treatment
of Volkmann’s contracture following supracondylar frac-
were approximated using absorbable sutures to avoid
ture in childhood. Ann Chir. 1991;45:803Y810.
dead space formation. The wound was closed over a
suction drain and covered by compressive dressings. 7. Doi K, Hattori Y, Kuwata N, et al. Free muscle
The procedure took about 2 hours to be completed, transfer can restore hand function after injuries of the
lower brachial plexus. J Bone Joint Surg Br. 1998;80:
including the wound closure.
8. Doi K, Kuwata N, Muramatsu K, et al. Double muscle
| COMPLICATIONS transfer for upper extremity reconstruction following
Carr et al22 reported donor-site complications in 104 complete avulsion of the brachial plexus. Hand Clin.
cases of free gracilis transfer. These complications 1999;15:757Y767.
included excessive pain at the incision site, minor 9. Doi K, Muramatsu K, Hattori Y, et al. Restoration of
wound infection, temporary sciatic nerve palsy, and prehension with the double free muscle technique follow-
scar-related problems. They reported functional diffi- ing complete avulsion of the brachial plexus. Indications
culties in 26% of their patients, but most patients and long-term results. J Bone Joint Surg Am. 2000;82:
reported no noticeable functional deficits from gracilis 652Y666.
loss. Deutinger et al23 reported 11% reduction of 10. Doi K, Hattori Y, Soo-Heong T, et al. Endoscopic
adduction strength after gracilis harvest, but this harvesting of the gracilis muscle for reinnervated
reduction was not noticed by the patients. He also free-muscle transfer. Plast Reconstr Surg. 1997;100:
reported an area of hypesthesia corresponding to the 1817Y1823.
cutaneous territory of the obturator nerve and aesthetic 11. Hallock GG. Minimally invasive harvest of the gracilis
problems of the donor site. The most common compli- muscle. Plast Reconstr Surg. 1999;104:801Y805.
cations in our experience, with more than 200 free 12. Jeng SF, Kuo YR, Wei FC. Minimally invasive harvest of
gracilis transplantation, and also in other reports11,22,23 the gracilis muscle without endoscopic assistance. Plast
had been wound-related problems. These included Reconstr Surg. 2001;108:2061Y2065.
wound infection, delayed healing, and unsightly scar at 13. Hattori Y, Doi K, Abe Y, et al. Surgical approach to the
donor site. Although the scar was obvious in most of our vascular pedicle of the gracilis muscle flap. J Hand Surg
patients, most did not complain about the scar. None of [Am]. 2002;27:534Y536.
our patients had functional deficit after gracilis harvest. 14. O’Ceallaigh S, Mehboob Ali KS, O’Connor TP. Func-
We had an experience of temporary sciatic nerve palsy tional latissimus dorsi muscle transfer to restore elbow
after gracilis harvest, most probably due to long- flexion in extensive electrical burns. Burns. 2005;31:
standing compression. Since then, we always extend 113Y115.

250 Techniques in Hand and Upper Extremity Surgery

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Gracilis Harvesting Technique

15. Doi K, Sakai K, Ihara K, et al. Reinnervated free muscle 19. Yousif NJ, Matloub HS, Kolachalam R, et al. The
transplantation for extremity reconstruction. Plast transverse gracilis musculocutaneous flap. Ann Plast Surg.
Reconstr Surg. 1993;91:872Y883. 1992;29:482Y490.
16. Doi K, Sakai K, Fuchigami Y, et al. Reconstruction of 20. Whetzel TP, Lechtman AN. The gracilis myofasciocuta-
irreparable brachial plexus injuries with reinnervated free- neous flap: vascular anatomy and clinical application.
muscle transfer. Case report. J Neurosurg. 1996;85: Plast Reconstr Surg. 1997;99:1642Y1652. discussion
174Y177. 1653Y1655.
17. Hattori Y, Doi K, Saeki Y, et al. Obturator nerve injury 21. Core GB, Weimar R, Meland NB. The turbo gracilis myo-
associated with femur fracture fixation detected during cutaneous flap. J Reconstr Microsurg. 1992;8:267Y275.
gracilis muscle harvesting for functioning free muscle 22. Carr MM, Manktelow RT, Zuker RM. Gracilis donor site
transfer. J Reconstr Microsurg. 2004;20:21Y23. morbidity. Microsurgery. 1995;16:598Y600.
18. Mathes SJ, Nahai F. Classification of the vascular 23. Deutinger M, Kuzbari R, Paternostro-Sluga T, et al.
anatomy of muscles: experimental and clinical correla- Donor-site morbidity of the gracilis flap. Plast Reconstr
tion. Plast Reconstr Surg. 1981;67:177Y187. Surg. 1995;95:1240Y1244.

Volume 10, Issue 4 251

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Techniques in Hand and Upper Extremity Surgery 10(4):252–254, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia

| T E C H N I Q U E |

Extensor Tenodesis for Plexic Hands With C7 to

T1 or C8, T1 Root Avulsions: A New Technique
Jean-Noël Goubier, MD, PhD and Frédéric Teboul, MD
Centre International de Chirurgie de la Main
Clinique du Parc Monceau
Paris, France

Christophe Oberlin, MD
Service de Chirurgie Orthope´dique et Traumatologique
Hôpital Bichat-Claude Bernard
Paris, France

| ABSTRACT used for thumb flexion with anastomosis on flexor pollicis

In C7 to T1 or C8, T1 root avulsion palsies, restoration of longus (FPL) tendon. Intrinsic function is reanimated in a
finger active extension is not possible. Only tenodesis may second-stage operation with passive capsulorraphy tech-
restore hand opening in active wrist flexion. Many niques or equivalent.1 However, no muscles are available
techniques have been described to restore this motion. In to restore active finger extension. Therefore, extensor
routine techniques, extensor tendons are fixed on radius or tenodesis may improve finger extension during active
sutured on dorsal retinaculum. However, in these proce- wrist flexion to improve hand function.2,3 Many teno-
dures, progressive tendon lengthening or ruptures may desis have been described.2Y8 However, fixation of tendon
occur and salvage procedure may be difficult to perform. to bone is not perfect. As a matter of fact, healing of
Therefore, we proposed a new extensor tenodesis tech- tendon is not complete, and tendon ruptures are not rare.2
nique. The extensor digitorum communis tendons are Moreover, tendon lengthening is frequent in these tech-
sutured on the paralyzed flexor digitorum superficialis niques whatever the fixations are. Therefore, we present a
tendons through interosseous membrane. This procedure new extensor tenodesis to avoid these complications.
allows performing a strong tendon to tendon suture more
resistant than radius or retinaculum fixation. As other
tenodesis techniques, wrist flexion has to be active to
obtain hand opening. The decision to proceed with this extensor tenodesis is
Keywords: extensor tenodesis, plexic hand, tendon based upon a combination of factors. Finger flexion and
transfers extension has to be paralyzed, active wrist flexion and
extension have to be present, and no other tendons are
| HISTORICAL PERSPECTIVE available to restore active finger extension. This clinical
situation is present in brachial plexus palsies with C7 to
Plexic hand in case of C7 to T1 or C8, T1 root avulsions, is
T1 or C8, T1 root avulsions (anatomical variations), or in
a rare entity. Motor nerve surgery is not possible in these
tetraplegia group 5.9 In these cases, extensor tenodesis
cases. However, palliative surgery remains a challenge
allows hand opening in wrist active flexion. Flexion fin-
and may greatly improve these patients. In these cases,
ger transfers and extension tenodesis may be performed
finger flexion and extension and intrinsic function are
during the same stage operation. However, intrinsic func-
paralyzed. However, wrist extension is present most of the
tion may be restored in a second procedure with a sensory
time. Only few muscles are available for palliative
nerve neurotization in case of C8, T1 root avulsions.10
surgery. Extensor carpi radialis longus (ECRL) is used
for finger flexion with anastomosis on flexor digitorum
profundus (FDP) tendon. Brachioradialis (BR) tendon is | TECHNIQUE
The patient is brought to the operating room where a
general anesthetic is administered. The wrist and hand is
Address correspondence and reprint requests to Jean-Noël Goubier, then placed prone on the operating table. The extremity
Centre International de Chirurgie de la Main, Clinique du Parc
Monceau, 21 Rue de Chazelles, 75017 Paris, France. E-mail: is exsanguinated, and a tourniquet is inflated to above 100 mm Hg above systolic blood pressure.

252 Techniques in Hand and Upper Extremity Surgery

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Extensor Tenodesis for C7 to T1 Root Avulsions

tendon are retracted to expose the interosseous mem-

brane. A window of interosseous membrane is divided
to reach the anterior compartment of forearm. Lateral
insertions of the interosseous membrane are detached
from the ulna and radius, just above the radioulnar joint.
The length of the window is about 6 cm. Hemostasis of
anterior interosseous artery is performed. Then, the FDS
tendons are pull through the interosseous membrane
from the anterior compartment to perform the tenodesis
(Fig. 1). During traction on the FDS tendons, care is
taken of median nerve. The EDC tendons are then
sutured side-to-side to the FDS tendons with nonab-
sorbable sutures (Fig. 2). Tendons are tensed to have
metacarpophalangeal (MP) joints in extension when
wrist is in neutral position. When sutured are performed,
FIGURE 1. After interosseous membrane is excised, the tenodesis effect may be tested during the procedure: MP
FDS tendons are located and pull out the anterior joint extension occurs in 30 degrees of passive wrist
compartment to perform suture with the EDC tendons. flexion. The dorsal extensor retinaculum is then closed.
During tendon traction, care must be taken of median
Suction drain is placed to avoid hematomas, and skin is
nerve. The EDC tendons are not represented to simplify
the illustration. closed with polypropylene sutures.
The wrist is immobilized during 3 weeks in neutral
position with MP joint in extension in a short-arm splint.

Through a volar radial approach, the BR, ECRL,

FDP, FDS, and FPL tendons and median nerve are
identified. The BR tendon is detached from the radius and Early complications after this technique may include
dissected from surrounding fascia proximally until at wound infection, hematoma, and nerve injury (median
least 2.5 to 3 cm of passive excursion from the resting nerve). Therefore, median nerve and the FDS tendons
position can be obtained. Care must be taken to avoid are isolated during the volar approach.
damage to the radial nerve. The BR tendon is passed
under the radial pedicle to reach the FPL tendon. Then, | REHABILITATION
BR is sutured to the FPL with a strong Pulvertaft suture.
After the cast removal, full active wrist flexion leading
Tension must be sufficient so that the thumb reach the
to passive finger extension is started. Moreover, active
long finger in 20-degree passive extension. The modified
fingers flexion and thumb motion is initiated. Strength-
Makin procedure may be added to this transfer to
ening and heavy lifting are not begun before 12 weeks.
improve thumb opposition: the FPL tendon is trans-
located through an interphalangeal arthrodesis.11 The
thumb interphalangeal joint is open through a dorsal | RESULTS
approach. The FPL tendon is pulled through the joint and Three male patients who had C8, T1 root avulsion palsy
placed in a dorsal position. Then, the interphalangeal underwent this procedure. The average age was 26 years
joint arthrodesis is performed with 2 Kirschner wires. (range, 22Y28 years). In all patients, wrist extension and
The ECRL tendon is released and detached through flexion were preserved. Finger flexion, thumb opposition,
the volar radial approach. The ECRL tendon is passed
around the lateral side of the radius under the radial
pedicle to reach the FPD tendons. The FDP tendons are
sutured side-to-side together. Care must be taken to
obtain a complete closure of index and long fingers and
slightly less of the ring and small fingers when tension
is applied. The ECRL is then sutured to the FDP
tendons with a strong Pulvertaft procedure. In wrist
extension, fingers have to be semiflexed.
FIGURE 2. The EDC tendons are sutured on the FDS
Then, a dorsal longitudinal approach to the wrist is tendons through the interosseous membrane with non-
used. The dorsal retinaculum is opened longitudinally absorbable sutures. The ulna has not been represented
to reach the fourth extensor compartment. Extensors to show the interosseous space.

Volume 10, Issue 4 253

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Goubier et al

and intrinsic function were paralyzed. In all patients, 5. Ochiai N, Nagano A, Yamamoto S, et al. Tenodesis of
ECRL has been transferred on FDP, BR was transferred extensor digitorum in treatment of brachial plexus injuries
on FPL associated with a modified Makin procedure.11,12 involving C5, 6, 7 and 8 nerve roots. J Hand Surg [Br].
Intrinsic function was restored in suturing FDS on A1 1995;20:671Y674.
pulley with 30-degree flexion of MP joint. Extensor 6. Revol M. Principles of palliative motor surgery of
tenodesis was performed as described before. With an paralysis of the hand. Ann Chir Plast Esthet. 1993;38:
average follow-up of 25 months (range, 23Y27 months), 210Y217.
all patients recovered active finger flexion. Hand opening 7. Saito H. Evolution of surgery for tetraplegic hands in
or passive finger extension was complete in 30-degree Japan. Hand Clin. 2002;18:535Y539. viii.
wrist flexion. No complications have been noted. 8. Teissier J, Fattal C, Egon G. Strategy for improving hand
opening in the tetraplegic upper limb. Hand Clin.
9. Romain M, Allieu Y. Evaluation of the function of the
1. Chevallard A. New technic of palliative intervention in flexor and extensor tendons of the hand. Chir Main. 1998;
paralysis of the intrinsic muscles of the hand (cubital 17:259Y265.
paralysis in Hansen’s disease). Acta Leprol. 1987;5:65Y68. 10. Oberlin C, Teboul F, Severin S, et al. Transfer of the
2. Bonnard C. Nerve repair or muscle-tendon transfers in lateral cutaneous nerve of the forearm to the dorsal branch
posttraumatic paralysis of the upper limb. Rev Med Suisse of the ulnar nerve, for providing sensation on the ulnar
Romande. 1989;109:513Y518. aspect of the hand. Plast Reconstr Surg. 2003;112:
3. Merle M, Foucher G, Dap F, et al. Tendon transfers for 1498Y1500.
treatment of the paralyzed hand following brachial plexus 11. Oberlin C, Alnot JY. Opponensplasty through transloca-
injury. Hand Clin. 1989;5:33Y41. tion of the flexor pollicis longus. Technique and indica-
4. Hentz VR, Brown M, Keoshian LA. Upper limb recon- tions. Ann Chir Main. 1988;7:25Y31.
struction in quadriplegia: functional assessment and 12. Makin M. Translocation of the flexor pollicis longus
proposed treatment modifications. J Hand Surg [Am]. tendon to restore opposition. J Bone Joint Surg Br. 1967;
1983;8:119Y131. 49:458Y461.

254 Techniques in Hand and Upper Extremity Surgery

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Techniques in Hand and Upper Extremity Surgery 10(4):255–258, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia

| T E C H N I Q U E |

Nail Salvage Using the Eponychial Flap

Roberto Adani, MD, Giovanni Leo, MD, and Luigi Tarallo, MD
Department of Orthopaedic Surgery
University of Modena and Reggio Emilia
Modena, Italy

| ABSTRACT to reconstruct in only 1 stage the nail bed, its bone

Loss of distal fingertip bone and soft tissue defect can support, and the pulp. Nevertheless, this technique is not
be treated using different methods, but the involvement simple and not always accepted by the patient.
of the nail influences the choice of surgical approach Defourmentel10,11 and subsequently other authors12,13
and makes reconstruction more difficult. The epony- introduce the use of a ‘‘backward transposition’’ of the
chial flap is a backward cutaneous translation flap flap. This method has been proven to be particularly
that lengthens the nail plate and restores a good useful when the osseous support of the third phalanx is
appearance of the nail apparatus. Pulp reconstruction is inadequate, leading to claw-nail deformity. With this
usually performed using local flaps (Tranquilli-Leali or technique, the nail complex can be recessed so that after
Venkataswami flaps). The eponychial flap technique is bone shortening of the distal phalanx, the free edge of
a safe and easy technique that is indicated in cases of the nail can be stitched to the skin without resulting
transverse fingertip angulations for lengthening the tension. However, this reconstruction method results in
short amputated nail. This procedure can be used in a bulky dorsal skin, and above all, it does not resolve the
combination with different flaps for pulp reconstruction. cosmetic appearance in a case of a short nail.
Keywords: fingertip injuries, nail injuries, eponychial flap Since 1998,14 we have used the technique described
by Bakhach15 in the treatment of distal fingertip
amputations with nail involvement. This technique uses
a plasty of the proximal nail fold that is plicated
| HISTORICAL PERSPECTIVE backward to expose the nail root lying under the
Nail involvement in fingertip injuries is a common eponychium, and this lengthens the visible part of the
problem in hand surgery. Fingertip defects can be nail, restoring a good appearance of the nail apparatus.16
treated in different ways, including shortening with pri-
mary closure, skin grafts, and local or distant flaps; the | INDICATIONS AND
associated defect of the nail complex influences the sur- CONTRAINDICATIONS
gical approach making the reconstruction more complex.
Different surgical techniques have been developed The indications for surgery are fingertip injuries with
over the years to reconstruct the nail bed, which can be associated nail involvement. It is essential to have intact
harvested from the amputated part, if available, or from the proximal nail fold; this skin, called eponychium,
the nail bed of an adjacent finger or from the great toe.1Y4 covers the nail matrix.
Dumontier et al5 suggested repairing a traumatic Amputations can pass through the proximal half
avulsion of the distal nail bed using a de-epithelialized or the proximal third of the nail bed; amputations through
palmar advancement flap on its distal portion. All these the nail matrix should be evaluated very carefully because
methods require the presence of the distal phalanx to this technique needs the presence of enough nail matrix.
provide the nail bed with the bone support necessary to The presence of a crushing injury or severe scarring
prevent a claw-nail deformity. In fact, when the injury over the eponychium area may be considered as a con-
involves the loss of a large part of the phalanx and two traindications for using this technique.16
thirds of the nail bed, reconstruction is performed
employing microsurgical techniques as a custom-made | TECHNIQUE
free osteo-onychocutaneous flap harvested from the A preoperative plan is necessary (Fig. 1); a skin
great or the second toe6Y9; so with 1 flap, it is possible rectangle, as wide as the remaining portion of the nail,
is drawn at a distance of 0.5 to 0.6 cm from the distal
border of the eponychium. The rectangle height depends
Address correspondence and reprint requests to Roberto Adani, MD,
Department of Orthopedic Surgery, Policlinico Largo del Pozzo, n.71, on the amount of nail to be exteriorized and corresponds
41100 Modena, Italy. E-mail: to the difference between the length of the contralateral

Volume 10, Issue 4 255

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Adani et al

FIGURE 1. Surgical technique. A, The eponychium is vascularized by longitudinal branches from the distal dorsal arterial
arch of the digit. B, A skin rectangle is drawn at a distance of 0.5 to 0.6 cm from the eponychium. It is 0.2 to 0.3 cm high
and as wide as the residual nail. C, De-epithelialization of the skin rectangle, leaving the underlying vascular network
intact. D, The eponychial flap is transposed backward and sutured by exteriorizing the nail matrix and the nail bed.

fingernail and that of the injured finger, considering that prevent proximalization and, in particular, separation of
the maximum limit is 0.4 cm (generally ranges between the eponychium along its whole length and width.16 The
0.2 and 0.3 cm).14 eponychium is detached using a fine elevator.
After de-epithelialization of the rectangular area, Now, the eponychial flap can be delicately slid
leaving the underlying subcutaneous vascular network proximally and its end sutured; this makes it possible to
intact to ensure the survival of the eponychial flap and exteriorize the nail matrix, increasing the extent of
nail matrix, the lateral margins of the flap are incised. exposure of the nail bed. In this way, a nail with total
Proper execution requires complete removal of the length of 3 mm is obtained even in cases where the
remaining portion of the nail, because its presence would surgical removal of the nail matrix is considered.

256 Techniques in Hand and Upper Extremity Surgery

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Nail Salvage Using the Eponychial Flap

FIGURE 2. Preoperative and intraoperative views: final result.

FIGURE 3. Preoperative and intraoperative views: final result.

Volume 10, Issue 4 257

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Adani et al

The eponychial flap is then plicated backward and 4. Hsieh S-C, Chen S-H, Chen T-M, et al. Thin split-
fixed by stitches; finally, some stitches are made on the thickness toe nail bed grafts for avulsed nail bed defects.
medial and lateral borders. Ann Plast Surg. 2004;52:375Y379.
The nail bed should then be protected through the 5. Dumontier C, Tilquin B, Lenoble E, et al. Reconstruction
application of a Silastic or polypropylene nail17 to avoid of distal defects of the nail bed a de-epithelialized palmar
possible hematoma or scar adhesions between the advancement flap. Ann Chir Plast Esthet. 1992;37:
eponychial flap and nail matrix. 553Y559.
Pulp reconstruction is performed using either a large 6. Endo T, Nakayama Y. Short pedicleYvascularized nail
Tranquilli-Leali flap18 or a modified Venkataswami flap. Plast Recontr Surg. 1996;97:656Y661.
flap.19 The apex of the local flaps should be fixed into 7. Koshima I, Moriguchi T, Soeda S, et al. Free second toe
the underlying bone phalanx using a needle to avoid transfer for reconstruction of the distal phalanx of the
traction on the nail bed. fingers. Br J Plast Surg. 1991;44:456Y458.
8. Koshima I, Moriguchi T, Soeda S, et al. Free thin osteo-
| DISCUSSION onychocutaneous flaps from the big toe for reconstruction
The nail should protrude from the eponychium by at least of the distal phalanx of the fingers. Br J Plast Surg.
2 mm for precision grip and good cosmetic appearance.1
The eponychial flap is simple, safe, and rapid 9. Koshima I, Inagawa K, Urishubara K, et al. Fingertip
technique that restores the visible length of a short nail reconstruction using partial toe transfer. Plast Reconstr
after distal fingertip injuries (Figs. 2, 3). According to Surg. 2000;105:1666Y1674.
the type of amputations, it allows the surgeon to 10. Dufourmentel C. Correction chirurgicale des extremites
proximalize the whole eponychium and exteriorize the digitales en massue. Ann Chir Plast. 1963;8:9Y102.
nail matrix almost completely.14 When the proximal 11. Dufourmentel C. Problemes esthetiques dans la recon-
translation of the eponychium is marked, chromatic struction des maignons digitaux. Ann Chir. 1971;25:
changes of the nail can be present because of the exposure 995Y999.
of the underlying nail matrix, whose physiological whitish 12. Foucher G, Lenoble E, Goffin D, et al. Escalator flap in
color differs from the pink of the nail bed. Moreover, a the treatment of claw nail. Ann Chir Plast Esthet.
change about nail consistency is often observed after the 1991;36:51Y53.
backward transposition of the eponychium.14,16 13. Marin-Braun F, Lorea P, Dury M. Emergency treatment
The final result depends on the surgical technique by nail recession: a new method for the repair of fingertip
adopted for pulp reconstruction: in the cases of transver- amputations. Chir Main. 2000;2:294Y299.
sal amputations where pulp loss does not exceed 1 cm, the 14. Adani R, Marcoccio I, Tarallo L. Nail lengthening and
Tranquilli-Leali flap18 is indicated; when pulp loss ranges fingertip amputations. Plast Reconstr Surg. 2003;112:
between 1.5 and 2.5 mm, the modified Venkataswami 1287Y1294.
flap satisfies the requirements for reconstruction.
15. Bakhach J. Le lambeau d’eponychium. Ann Chir Plast
The eponychial flap permits nail salvage in situations Esthet. 1998;43:259Y263.
that are often difficult to resolve and represents an
16. Bakhach J, Demiri E, Guimberteau JC. Use of the
alternative technique to microsurgical transfer from toes.
eponychial flap to restore the length of a short nail: a
review of 30 cases. Plast Reconstr Surg. 2005;116:
1. Brown RE, Zook EG, Russel RC. Fingertip reconstruction 17. Ogunro EO. External fixation of injured nail bed with the
with flaps and bed grafts. J Hand Surg [Am]. 1999;24: INRO surgical nail splint. J Hand Surg [Am]. 1989;14:
345Y351. 236Y241.
2. Shepard GH. Management of acute nail bed avulsion. 18. Elliot D, Moiemen NS, Jigjnni VS. The neurovascular
Hand Clin. 1990;6:39Y58. Tranquilli-Leali flap. J Hand Surg [Br]. 1995;20:
3. Raja Sabapathi S, Vankatramani H, Bharathi R, et al.
Reconstruction of finger tip amputations with advance- 19. Adani R, Busa R, Castagnetti C, et al. Homodigital
ment flap and free nail bed graft. J Hand Surg [Br]. 2002; neurovascular island flap with ‘‘direct flow’’ vasculariza-
27:134Y138. tion. Ann Plast Surg. 1997;38:36Y40.

258 Techniques in Hand and Upper Extremity Surgery

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Techniques in Hand and Upper Extremity Surgery 10(4):259–264, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia

| T E C H N I Q U E |

Three-corner Wrist Fusion Using

Memory Staples
Roger P. van Riet, MD, PhD
Modbury Public Hospital
Adelaide, Australia
University Hospital Antwerp
Antwerp, Belgium

Gregory I. Bain, MBBS, FRACS, FA(OrthA)

Modbury Public Hospital
Adelaide, Australia
University of Adelaide, Royal Adelaide Hospital

| ABSTRACT ligament allows the scaphoid to flex palmarly, whereas

the lunate extends to producing a dorsal intercalated
Scapholunate dissociation with advanced collapse
segment instability.3 This can evolve to scapholunate
(SLAC), scaphoid nonunion advanced collapse (SNAC),
and lunotriquetral advanced collapse (LTAC) of the advanced collapse (SLAC), as was described in 1984 by
Watson and Ballet.4 Changes in radioscaphoid align-
carpus are challenging problems. Various treatment
ment cause degenerative arthritis initially at this
options have been described. We describe a technique
articulation and subsequently at the midcarpal joint
of 3-corner wrist fusion, using memory staples. The
where the capitate sits on the diastased scapholunate
scaphoid and triquetrum are resected, and the capitate is
articulation2 (Fig. 1). Scaphoid nonunion advanced
fused to the lunate. Articular cartilage is removed from
collapse (SNAC) has a similar progression. Malalign-
the capitolunate joint, and the bones are shaped to con-
ment of the proximal pole causes degenerative changes
forming surfaces. Bone graft from the resected trique-
trum and scaphoid is used to increase fusion rate and a between the radius and distal pole of the scaphoid and
progresses to the scaphocapitate articulation. The radius-
dynamic compressive fixation force is applied due to the
proximal pole and scapholunate joints typically remain
unique properties of the memory staples. The main
congruent1 (Fig. 2). Lunotriquetral advanced collapse
advantages of this procedure include the following:
(LTAC) after lunotriquetral ligament injuries involves
retained anatomical articulation between the lunate and
widening of the lunotriquetral joint space combined
the lunate fossa on the radius, improved ulnar deviation
with volar intercalated segment instability (VISI) and
due to the resection of the triquetrum, and an excellent
midcarpal arthritis. Current motion-preserving techni-
fusion rate between the lunate and capitate due to the
dynamic fixation, the conforming surfaces, and the use ques of dealing with these problems include proximal
row carpectomy5 and limited wrist fusions.4 Lunotri-
of autologous bone graft.
quetral fusion has been described for chronic lunotri-
Keywords: arthritis, wrist, SLAC, SNAC, LTAC,
quetral pathology but has been shown to have an
limited wrist fusion
unacceptably high complication rate.6 Proximal row
carpectomy is a simple procedure but does not rely on
| HISTORICAL PERSPECTIVE an anatomical congruent joint and is limited to patients
Degenerative arthritis of the wrist often occurs in where there the proximal pole of the capitate is
middle-aged manual laborers and causes severe disabil- preserved. The SLAC wrist procedure, or 4-corner
ity.1 Approximately 95% is caused by periscaphoid fusion, is a more complex procedure and involves re-
problems.2 Disruption of the scapholunate interosseus section of the scaphoid and fusion of the lunate, cap-
itate, triquetrum, and hamate.4 Potential advantages
include using the native congruent radiolunate articula-
Address correspondence and reprint requests to Gregory I. Bain,
MBBS, FRACS, FA(OrthA), 196 Melbourne Street, North Adelaide, tion which is a spherical articulation which allows it to
SA 5006, Australia. E-mail: accommodate well to reconstructive changes.2,4

Volume 10, Issue 4 259

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van Riet and Bain

FIGURE 1. Radiographs demonstrating SLAC wrist. A, Anteroposterior (AP) view with widening of the scapholunate
interval, degenerative arthritis over the radial styloid. Importantly, the lunate and lunate facet are intact. B, Lateral view of
the wrist showing a dorsally rotated lunate and volar flexed scaphoid.

A capitolunate fusion with resection of the scaphoid Shape memory alloys consist of a nickel-titanium or
and triquetrum has been advocated but has so far had a nitinol alloy. Memory staples are open, and the legs
higher chance of nonunion.7 Previously reported techni- close when they are heated.10 Different companies
ques of fixation for fusion have included Kirschner distribute memory staples. Some need to be kept at less
wires (K-wires), screws, staples, or plate fixation.8 A than 0-C and change shape with body temperature,
previous cadaveric study identified increased range of whereas others can be kept at room temperature and
motion as a major advantage of resection of both the need an external heating source such as the electro-
triquetrum and scaphoid.9 cautery device. Closing of the staple compresses the
osteotomy site. Memory staples in the wrist have
previously been suggested for radioscapholunate fusions
after Kienböck disease11 and in the treatment of
scaphoid fractures.12
The following technique described involves resec-
tion of both the scaphoid and the triquetrum and fusion
of the lunate, capitate, and hamate using triquetral
cancellous bone graft and dynamic fixation using
memory staples.

The main indication for this procedure is degenerative
arthritis of the wrist due to a SLAC or SNAC wrist. We
have also used it for LTAC in which there is a VISI with
midcarpal degenerative arthritis and widening of the
lunotriquetral articulation (Fig. 3).
Clinical examination is key in the diagnosis.
Patients are typically middle-aged men with a manual
profession. Patients have decreased grip strength and
decreased range of motion with pain at testing.
Instability of the wrist is assessed. Anteroposterior and
FIGURE 2. Computed tomography scan of SNAC wrist. lateral radiographs are indicative of a SLAC, SNAC, or
Note the intact scapholunate interval and degenerative LTAC wrist. A scaphoid nonunion is obvious in the
changes between the distal pole of the scaphoid and the
radius as well as between scaphoid and the capitate. The SNAC wrist, with degenerative changes between the
relationship between the lunate and the radius remains radius and the distal pole of the scaphoid and between
normal. the scaphoid and capitate. The scapholunate interval is

260 Techniques in Hand and Upper Extremity Surgery

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Three-corner Wrist Fusion Using Memory Staples

FIGURE 3. Anteroposterior (A) and lateral (B) radiographic views. Lunotriquetral advanced collapse showing VISI with
volar flexion of the scaphoid and lunate. Widening of the lunotriquetral articulation and midcarpal degenerative arthritis
is shown.

typically normal. A dorsal intercalated segment insta- congruent articulation between the lunate fossa on the
bility deformity can be found in the SLAC wrist, with radius and the lunate.
widening of more than 3 mm of the scapholunate
interval and degenerative changes between the scaph- | TECHNIQUE
oid and the scaphoid facet on the radius. There may
After administration of an anesthetic, the arm is placed
or may not be degenerative changes between the
on a hand table, and a tourniquet is placed around the
lunate and capitate. A VISI deformity, lunotriquetral
upper arm. An incision is made over the dorsum of the
widening, and midcarpal degenerative arthritis are
wrist. The incision is placed just ulnar to Lister tubercle
visible on plain radiographs in patients with an LTAC
(Fig. 4). Subcutaneous fat is retracted, and the third
extensor compartment is visualized. The fascia overly-
The absence of capitolunate degeneration is not a
ing the third compartment is incised while protecting the
contraindication to perform a limited wrist fusion,
whereas a proximal row carpectomy should not be
performed in the presence of capitolunate degeneration.
Contraindications include severe radiolunate arthritis,
Kienböck disease, malunion or nonunion of lunate,
intra-articular distal radius fractures involving the lunate
facet, and other situations where the bone stock is
insufficient for a predictably strong fusion between the
lunate and capitate or where it is not possible to obtain a

FIGURE 5. The periosteum is incised at the bottom of the

third compartment, and the incision is extended longitudi-
FIGURE 4. A straight dorsal incision is made just ulnar to nally through the capsule of the wrist. Without opening the
Lister tubercle. The third compartment is opened careful- compartments, the second and fourth extensor compart-
ly, and the EPL tendon is retracted radially. A longitudinal ments as well as the capsule are dissected subperios-
capsulotomy is performed. teally, resulting in an excellent view of the carpal bones.

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van Riet and Bain

FIGURE 6. Scaphoid and triquetrum are excised. The FIGURE 8. The legs of the memory staple are pushed
midcarpal joint is debrided in preparation for the bone into the predrilled holes with the introducer. Introduction of
graft and staple stabilization. the staple should be controlled, with minimal force applied
via a small mallet.
extensor pollicis longus (EPL) tendon. The EPL is
retracted radially and protected throughout the proce- expose the subchondral bone, and the surfaces are
dure. The capsule of the wrist is entered through a shaped to obtain a conforming fit. Morselized cancel-
longitudinal incision and is reflected to expose the lous bone graft from the resected triquetrum was placed
proximal and distal row (Fig. 5). The scaphoid and between the lunate and the capitate.
triquetrum are resected using a rongeur. The intact Once the surfaces are prepared, the bone graft is
radioscaphocapitate ligament will become visible after added. Two memory staples (DePuy, Warsaw, IN) are
complete resection of the scaphoid. Care should be used to fuse the midcarpal joint. The staples are
taken to preserve this ligament, to prevent possible ulnar supplied in a freezer and kept at less than 0-C until
translocation of the remaining carpus.1 The triquetrum they are inserted in the wrist. As was stated earlier,
is resected in the same fashion (Fig. 6), taking care not other conditions may apply for specific staples. The
to leave any bone and not to injure the ulnar nerve, radial staple is placed first to avoid excessive ulnar
which is ulnar to the underlying pisiformis. Care must deviation. A guidewire is drilled into the lunate, a
be taken to resect both bones completely without cannulated drill is advanced over the wire to produce
leaving fragments. Cancellous bone is harvested from the first hole, and the drill is left in place. A drill guide
the resected triquetrum. is placed over this first drill and acts as a guide to ensure
Traction is applied to the carpus, and the wrist is the correct positioning of the second drill hole. The
flexed to expose the capitate, hamate, and lunate width of the staple is predetermined and cannot be
articular surfaces. Articular cartilage is removed to changed. The position of the drill holes is therefore
crucial to obtain compression after insertion of the
staple. The guide is positioned between the lunate and

FIGURE 7. The position of the staple is performed with

precision using a K-wire in the lunate. A cannulated drill is
placed over the K-wire. With the assistance of a drill
guide, a second drill is placed into the capitate. The FIGURE 9. Two memory staples are used to stabilize the
memory staple is then introduced to stabilize the mid- midcarpal joint. The staples extend from the lunate to the
carpal joint. capitate and hamate, respectively.

262 Techniques in Hand and Upper Extremity Surgery

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Three-corner Wrist Fusion Using Memory Staples

FIGURE 10. Dorsiflexion of the wrist is tested to make

sure that there is no impingement of the staples onto the

distal carpal row (Fig. 7). The second drill hole is made,
and both drills are removed. A depth gauge is used to
determine the desired length of each leg of the memory
staple. The length of the legs should be determined
individually as combinations of leg lengths can be used.
The appropriate-size staple is removed from the freezer.
The legs of the staples are opened slightly to facilitate
insertion. In this way, the staple will compress the
lunate and capitate when it regains its original shape
after insertion. Both legs of the staple are then fully
seated onto the lunate and the capitate (Fig. 8). While
the staples are warming up to body temperature, they
regain rigidity and return to their original shape,
compressing the lunate and capitate. The same proce-

FIGURE 12. Postoperative AP (A) and lateral (B) radio-

graphs of a right wrist.

dure is then done for a second staple (Fig. 9). Particular

care is taken to identify impingement of the staples on
the dorsal radius (Fig. 10). The dorsal rim of the distal
radius may be trimmed to accommodate the staples in
full dorsiflexion if necessary. The position and length of
both staples and the fusion of the lunate and capitate are
checked with dynamic fluoroscopy during flexion and
extension of the wrist13 (Fig. 11). The capsule is closed
FIGURE 11. Intraoperative fluoroscopic AP view of the over the staples. The third extensor compartment is
wrist showing the complete resection of the scaphoid and closed, leaving the EPL outside the fascia. The skin is
triquetrum and correct position of the memory staples. closed in layers using absorbable sutures.

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van Riet and Bain

| COMPLICATIONS 2. Watson HK, Ryu J. Evolution of arthritis of the wrist. Clin

Orthop Relat Res. 1986;57Y67.
The authors have used this technique on 45 patients.
The average range of motion that can be expected is 3. Linscheid RL, Dobyns JH, Beabout JW, et al. Traumatic
instability of the wrist. Diagnosis, classification, and
approximately 50% of the contralateral side in all
pathomechanics. J Bone Joint Surg Am. 1972;54:
directions. Patients can expect reliable pain relief, with
increased function and strength.
Complications specific to the procedure may include 4. Watson HK, Ballet FL. The SLAC wrist: scapholunate
advanced collapse pattern of degenerative arthritis. J
deep infection, nonunion of the limited wrist fusion, and
Hand Surg [Am]. 1984;9:358Y365.
fracture of the lunate or capitate. One specific compli-
cation related to the technique is impingement of the 5. Stamm TT. Excision of the proximal row of the carpus.
staples on the dorsal articulating surface of the distal Proc R Soc Med. 1944;38:74Y75.
radius, with dorsiflexion of the wrist. Proper seating 6. Vandesande W, De Smet L, Van Ransbeeck H. Luno-
of the staples, making sure that the legs of the staples triquetral arthrodesis, a procedure with a high failure rate.
are inserted fully, is essential in preventing most Acta Orthop Belg. 2001;67:361Y367.
complications listed. If necessary, the radiolunate joint 7. Calandruccio JH, Gelberman RH, Duncan SF. Capitolu-
can be decompressed by resecting a small amount of nate arthrodesis with scaphoid and triquetrum excision. J
bone from the dorsal aspect of the distal radius. Hand Surg [Am]. 2000;25:824Y832.
8. Vance MC, Hernandez JD, Didonna ML, et al. Compli-
| REHABILITATION cations and outcome of four-corner arthrodesis: circular
Immediately after the procedure, the forearm is placed in plate fixation versus traditional techniques. J Hand Surg
a volar fiber-cast splint. Standard radiographs are taken [Am]. 2005;30:1122Y1127.
on the first postoperative day before the patient is dis- 9. Sood A, Ashwood N, Bain G, et al. Effect of scaphoid and
charged from the hospital (Fig. 12). The splint is triquetrum excision on limited arthrodesis of the wrist: a
removed at 1-week follow-up, after which the arm is laboratory study. ANZ J Surg. 2002;72(suppl):A39.
protected, using a removable splint. This splint is used 10. Machado LG, Savi MA. Medical applications of shape
until 4 to 6 weeks postoperatively, during which time memory alloys. Braz J Med Biol Res. 2003;36:683Y691.
the patient is allowed to mobilize. 11. Bain GI, Begg M. Arthroscopic assessment and classifi-
Radiological confirmation of union is confirmed at 6 cation of Kienböck’s disease. Tech Hand Up Extrem Surg.
months, before forceful gripping is allowed. Return to 2006;10:8Y13.
sport is permitted at 6 months. 12. Rocchi L, Fanfani F, Pagliei A, et al. Treatment of scaphoid
waist fractures by shape memory staples. Retrospective
| REFERENCES evaluation on 60 cases. Chir Main. 2005;24:153Y160.
1. Wyrick JD. Proximal row carpectomy and intercarpal 13. Bain GI, Hunt J, Mehta JA. Operative fluoroscopy in hand
arthrodesis for the management of wrist arthritis. J Am and upper limb surgery. One hundred cases. J Hand Surg
Acad Orthop Surg. 2003;11:277Y281. [Br]. 1997;22:656Y658.

264 Techniques in Hand and Upper Extremity Surgery

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| C O M M E N T A R Y |

Reconstruction of Radial Polydactyly

Charles A. Goldfarb, MD
Washington University School of Medicine at Barnes Hospital
Department of Orthopaedic Surgery
St Louis, Missouri, Shriners Hospital for Children
St Louis, MO

| ABSTRACT The Wassel classification,5 published in 1969, is the

most commonly used reporting system for radial
The spectrum that encompasses radial polydactyly can
polydactyly and is based on a review of the experience
be categorized by the Wassel classification. Reconstruc-
at the University of Iowa in 70 patients (Fig. 1). Wassel5
tion of radial polydactyly depends on the size and
noted that outcomes were not universally good, as
quality of each of the thumbs. Most commonly, the
previously reported, based on a follow-up evaluation
ulnar thumb is larger and is maintained, whereas the
of 18 patients included as a component of the report.
smaller radial thumb is excised. In a Wassel type 4, after
Wassel5 recommended early excision for duplication
the redundant thumb is excised, the remaining thumb is
centralized and aligned, and the radial collateral without joint deviation, careful collateral ligament
reconstruction in types 2 and 4, and consideration of
ligament of the maintained thumb is reconstructed.
the Bilhaut operation in types 1 and 2.6 Complications
Other types of radial polydactyly are more complicated
including decreased metacarpophalangeal (MCP) joint
and require more complex reconstructions.
and interphalangeal (IP) joint motion, radioulnar insta-
Keywords: duplicated thumb, radial polydactyly,
bility, decreased pinch strength, and resting deviation at
the MCP or IP joint were presented. Wassel5 also
cautioned against the use of a linear, lateral incision that
| HISTORICAL PERSPECTIVE may lead to contracture or deviation. Although other
The early reports on radial polydactyly were found in classifications and subclassifications exist (ie, Horii
more general descriptions of congenital hand abnormal- et al7), the Wassel classification system and lessons of
ities. In 1951, Barsky1 performed a comprehensive this seminal article remain very much applicable today.
review of the literature (there were Bthe standard works
on paleopathology and six Egyptian papyri[) and
reported 62 cases of congenital anomalies of the hand; | INDICATIONS/CONTRAINDICATIONS
there were 8 cases of radial polydactyly. In 1957, The presence of an extra thumb in radial polydactyly
Kelikian and Doumanian2 discussed the treatment of creates a notably abnormal appearance and reconstruc-
supernumerary digits and stated that Ban extra finger or tion is recommended. Function of the thumb may be
thumb is removed for cosmetic reasons. This operation altered, especially if the thumbs are divergent, but is
requires no ingenuity and creates no problems.[ How- usually not the primary indication for surgery. Preopera-
ever, we now understand that simple ablation alone is tively, it is important to understand the relative size and
not appropriate for radial polydactyly, as approximately function of the 2 thumbs. Family members can provide
40% need additional surgery by 15 years.3 valuable information on typical usage patterns and on
Swanson,4 in 1976, helped to place a variety of the active motion of the 2 thumbs. On clinical
congenital abnormalities in context with the currently examination, the physician compares the size of the
used classification system (the International Federation affected thumbs to each other and to the contralateral
of Societies for Surgery of the Hand) for congenital thumb, measures active and passive motion, and
abnormalities of the upper extremity. Radial polydacty- observes the child’s use of the hand(s).
ly was classified as a digital duplication. Although this I prefer to simplify the reconstruction of radial
seems conceptually correct, the term Bduplication[ polydactyly whenever possible. In most cases, I excise
oversimplifies radial polydactyly. the smaller, radial thumb and reconstruct the ulnar
thumb (Fig. 2). In Wassel type 4 polydactyly, excision
of the radial thumb allows maintenance of the MCP
Address correspondence and reprint requests to Charles A. Goldfarb,
MD, Department of Orthopaedic Surgery, 660 South Euclid, Campus joint ulnar collateral ligament that stabilizes the MCP
Box 8233, St Louis, MO 63110. E-mail: joint during pinch activities. The less important radial

Volume 10, Issue 4 265

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cally difficult and may yield a stiff but otherwise

satisfactory thumb.
Without regard to the procedure chosen, the family
should understand the complexity of the surgery and the
expected outcome. There is a high reoperation rate after
the reconstruction of radial polydactyly. In addition, the
family should understand that surgery for radial poly-
dactyly does not create a thumb identical to the
contralateral thumb in size or function. Nonetheless, if
the reconstructed thumb is well aligned and stable,
without regard to its motion, it is usually acceptable.
Often, a reconstructed thumb will be visibly different
only if the patient’s 2 thumbs are compared side-by-
side. Furthermore, the range of motion of the recon-
structed thumb may be decreased compared with the
contralateral thumb at the MCP and IP joints, but in
most cases, this lack of motion will not cause a
functional limitation.
The timing of surgery is dependent on surgeon and
family preference although, for social reasons, surgery
be completed before school entry. Some surgeons
believe that surgery before 9 months of age will allow
the unimpeded development of thumb pinch and grasp
activities. Others delay surgery until greater than 2 years
of age because anesthesia is safer, and the thumb is
larger and more ossified.8,9
I base the timing of the surgery on the type of radial
polydactyly and the desires of the family. I prefer to
FIGURE 1. The Wassel classification.5
reconstruct most thumbs at 12 to 18 months, as I feel the
size of the thumb its structures are sufficiently large to
collateral ligament can be reconstructed after the radial
thumb is excised (as described below).
When the thumbs are of nearly equal size and function
(Fig. 3A, B), there are 2 options for reconstruction. The
first, excision of the radial thumb and alignment/
reconstruction of the ulnar thumb, is simpler, but the
family must understand that the reconstructed thumb will
be smaller than the contralateral side. Alternatively, a
single thumb can be reconstructed by using component
parts of each to form a thumb that more closely
approximates the contralateral side. There are 3 methods
of combining the duplicated thumbs to create a more
normal-sized thumb. First, the Bilhaut6 procedure, as
outlined below, excises central bone and soft tissue to
allow reconstruction using lateral tissue from each
thumb. This approach is technically challenging and
may lead to joint stiffness, impaired physeal growth, and
a central nail ridge or split nail. Second, the addition of
soft and soft tissue from the lateral aspect of the excised
thumb can be used to increase the size of the recon-
structed thumb. Finally, if one thumb is larger proximally,
and the other is larger distally, an on-top plasty of the
larger distal components on to the larger proximal FIGURE 2. Radiograph demonstrating dominant ulnar
components can be considered; this technique is techni- thumb with smaller radial thumb.

266 Techniques in Hand and Upper Extremity Surgery

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Reconstruction of Radial Polydactyly

FIGURE 3. A, Clinical photograph demonstrating thumbs of equal size. B, Radiograph of same patient with thumbs of
equal size.

make the surgery technically more straightforward. I the thumb and may limit motion; therefore, in the design
delay the procedure for thumbs that are types 1 and 2 to of the final closure for a racquet incision, 1 or more V-Y
allow enlargement and further ossification. On the other advancement flaps are incorporated.
hand, I reconstruct type 4 radial polydactyly without
alignment issues as early as 6 or 9 months of age. Nerves, Vessels, and Tendons
The priorities of the surgeon dictate the surgical Although it has been shown that the vascular patterns in
technique in the reconstruction of the complicated radial polydactyly are abnormal (a single artery for each
thumb. I seek to first reconstruct a stable thumb with of the thumbs is the most common pattern),11 I do not
good alignment to improve the appearance of the perform vascular studies before treatment. Instead, the
thumb. These features are, in most patients, more arterial supply to the radial thumb is identified at the
important than the size of the thumb. Some authors time of surgery and ligated. The ulnar side of the re-
have suggested that the reconstructed thumb should be tained ulnar thumb is not explored routinely. The digital
Bno smaller than the normal opposite one.[[10] Al- nerves are also variable. Most commonly, 1 nerve in
though I seek to avoid a dramatically smaller thumb, I the radial thumb is identified, and, once traced to its
do not feel the size of the thumb is the primary issue in
most patients.

The basic principles of thumb reconstruction in radial
lpolydactyly are outlined below. These principles apply
to most common scenario in which the radial thumb is
excised, and the ulnar thumb is reconstructed.
Skin Incision
The skin incision may be a racquet incision on the radial
thumb with proximal and distal extensions on the ulnar
thumb (Fig. 4) or a central zigzag incision designed to
incorporate thumb excision. Once the reconstruction has
been completed, excess skin is excised, and the incision
is closed. A straight-line closure is avoided, as any FIGURE 4. Racquet incision in Wassel type 7 radial
resulting scar contracture may lead to radial deviation of polydactyly that allows excision of the radial thumb.

Volume 10, Issue 4 267

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brevis muscles that attach to the radial thumb; these

should be reinserted to the base of the reconstructed
thumb with the radial collateral complex.

The Zigzag Deformity
Angular deformity in radial polydactyly should be
corrected at the time of the primary reconstruction
(Fig. 6). Correcting the angular deformity by tightening
collateral ligaments, forcing the thumb into a straight
alignment, and holding the alignment with a longitudi-
nal Kirschner pin insertion is not advised, as the
FIGURE 5. Preservation of the collateral ligament with deformity is likely to recur. As noted above, an
periosteal sleeve allows a more straightforward collateral eccentric tendon insertion can contribute to deformity
ligament reconstruction.12
at either the extensor or flexor site. In addition, the pull
of the adductor pollicis on the ulnar thumb and the
bifurcation from the radial digital nerve in the ulnar
abductor pollicis brevis on the radial thumb can lead to
thumb, it is sharply excised. Similarly, if a clear
deformity.10 These forces cause thumb deviation at the
bifurcation point is identified for the flexor and extensor
proximal phalanx level; the distal phalanges typically
tendons, the tendon to the excised thumb is divided just
converge due to the pull of the extrinsic flexor and
distal to the bifurcation point; no imbrication or overlap
extensor tendons.
procedure is performed. I do not use the excess tendon
If the primary cause of the deformity is identified, it
because once the extra thumb is excised, the muscle
should be corrected. This includes eccentric tendon
power will be concentrated on the reconstructed thumb,
insertion and abnormal muscle insertions. However, there
and additional tendon substance from the excised thumb
is often an underlying bony angulation or curvature
is usually not necessary. However, if the thumb is not
associated with the deformity. These thumbs require a
aligned, an eccentric tendon insertion may be responsi-
corrective osteotomy to obtain a long-lasting improvement
ble. In these cases, the insertion of the flexor and
in the alignment.7,10,13 A single or multiple closing wedge
extensor tendons should be explored; if an eccentric
insertion is discovered, it may be centralized. Alterna-
tively, a corrective osteotomy can be used to align the
thumb without realigning the eccentric tendon; this
technique has worked well for me.
Manske12 described the use of a ligamentous/periosteal
flap for the reconstruction of the radial collateral
ligament. In this technique, the radial thumb is excised
with care given to detaching the radial collateral
ligament from its distal boney insertion in continuity
with a periosteal sleeve of tissue. The periosteum
provides additional substance and length to the collat-
eral ligament to allow a more satisfactory reconstruction
of the radial collateral ligament. If notably widened, the
head of the phalanx or metacarpal can be narrowed to a
size more closely approximating the width of the base
of the retained phalanx. It is important to protect the
proximal origin of the collateral ligament if the
proximal bone narrowed. The phalanx is then central-
ized and stabilized with a longitudinal Kirschner wire,
and the radial collateral ligament/periosteal flap is
repaired to the base of the retained phalanx (Fig. 5). FIGURE 6. Zigzag deformity. The radiograph demon-
Duplications of types 4, 5, and 6 require the surgeon to strates that the proximal phalanges are divergent, where-
address the abductor pollicis brevis and flexor pollicis as the distal phalanges converge.

268 Techniques in Hand and Upper Extremity Surgery

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Reconstruction of Radial Polydactyly

complications of the reconstructive procedures below

but does yield a notable difference in thumb size. The
second option is thumb reconstruction designed to
increase the size of the thumb. In each of these
procedures, meticulous surgical technique will help
avoid the common complications, and each has the
potential to lead to a satisfactory outcome in the patient
with a difficult preoperative problem.
Bilhaut Procedure
A duplicated thumb of types 1, 2 or 3 in which both digits
are notably small may be reconstructed by the Bilhaut
procedure. In this procedure, the central aspect of both
thumbs is excised allowing the joining of the outer
components of each thumb (Fig. 7). The physes must be
aligned perfectly to minimize the risk of physeal arrest.
The nail bed must be meticulously repaired to minimize
the inevitable central nail ridge or nail split. By
FIGURE 7. The Bilhaut procedure requires the excision combining the outer components of the 2 thumbs, a
of a central wedge of tissue from both thumbs to allow the larger thumb is created, and the collateral ligaments are
creation of a single, larger thumb.6 maintained for joint stability. However, the Bilhaut
procedure has disadvantages including an inevitable
osteotomies may be required and can be stabilized with central ridge in the nail and digit, potential growth plate
the longitudinal Kirschner pin. problems, and poor motion at the IP joint (Fig. 8A, B).
To avoid the nail problems while increasing thumb
Two Small Thumbs girth and width, some have advocated adding compo-
If both thumbs are notably small without a clear nent parts from the excised thumb to the lateral aspect
dominant thumb (Fig. 3A, B), the surgeon has 2 of the reconstructed thumb. By maintaining one thumb
alternatives. First, the surgeon and family may choose and thumbnail, the nail and growth plate issues are
to reconstruct one of the smaller thumbs. This approach avoided, whereas bulk is added to the lateral aspect.
is straightforward and will avoid the complexities and This technique is more straightforward and can provide

FIGURE 8. A, Wassel type 3 polydactyly with thumbs of equal size. B, The same thumb after reconstruction using the
Bilhaut procedure. Although the thumb has a relatively normal appearance, the central ridge is noticeable.

Volume 10, Issue 4 269

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perfect alignment of the thumb postoperatively. A

meticulous soft tissue correction at the time of surgery
(including the centralization of tendon insertions),
appropriate osteotomies to correct any bony deviation,
and sufficient immobilization and pinning can help
prevent this malalignment. Another common
Bcomplication[ is MCP joint instability despite collat-
eral ligament reconstruction at the time of surgery. If
there is gross instability of the MCP joint, I prefer a
delayed epiphyseal arthrodesis to stabilize the joint and
allow maintenance of growth. An inadequate thumb
web space may be corrected at the time of thumb
FIGURE 9. This thumb has been reconstructed using an reconstruction or may be performed in a delayed
on-top plasty. Although the thumb is still small, it is larger fashion. Finally, the Bilhaut procedure will have a
and more stable than the polydactylous thumb it replaced. central nail and thumb ridge and also has the risk of
physeal arrest or stiff joints postoperatively.
a satisfactory outcome. The downside of this technique
is that added tissue lateral can make the nail appear | REFERENCES
eccentric in the reconstructed thumb.
1. Barsky AJ. Congenital anomalies of the hand. J Bone
On-top Plasty Joint Surg. 1951;33A:35Y63.
In some patients, the thumbs are asymmetrical, and it is 2. Kelikian H, Doumanian A. Congenital anomalies of the
possible to use the proximal part of 1 thumb (typically hand. J Bone Joint Surg. 1957;39A:1002Y1019.
ulnar thumb) and the distal part of the other (typically 3. Miura T. Duplicated thumb a review. Plast Recon Surg.
radial thumb). This on-top plasty combines the best part 1982;69:480Y481.
of both digits and, although rarely indicated, may 4. Swanson AB. A classification for congenital limb malfor-
provide a functional thumb of reasonable size. The mations. J Hand Surg [Am]. 1976;1:8Y22.
MCP joint and ligaments are ideally maintained with the
5. Wassel HD. The results of surgery for polydactyly of the
proximal part of the thumb, and a bony fusion is created thumb. Clin Orthop Relat Res. 1969;64:175Y193.
distal to the joint. The width and girth of the new thumb
often remain smaller than normal, but this combination 6. Bilhaut M. Guerison d’un pouce bifide par un nouveau
procede operatoire. Congres Francais de chir (4 Session,
of parts may be preferred to maintenance of either
1889)4:576, 1890.
thumb or the Bilhaut procedure (Fig. 9)
7. Horii E, Nakamura R, Sakuma M, et al. Duplicated thumb
Dressing bifurcation at the metacarpophalangeal joint level: factors
It can be quite challenging to keep the surgical dressing affecting surgical outcome. J Hand Surg [Am]. 1997;
in place after surgery given the age of the patients and 22A:671Y679.
the size and shape of the extremity. I typically place the 8. Marks TW, Bayne LG. Polydactyly of the thumb: abnor-
patient in well-molded long arm, thumb-spica splint that mal anatomy and treatment. J Hand Surg [Am]. 1978;3:
is left in place for 5 weeks. The patient then returns to 107Y116.
the clinic for splint removal, pin removal, and splint 9. Kemnitz S, DeSmet L. Pre-axial polydactyly: outcome
fabrication. I use an Orthoplast forearm-based thumb of the surgical treatment. J Pediatr Orthop. 2002;11:
spica splint for an additional 4 weeks. 79Y84.
10. Toeh LC. In: Gupta A, Kay SPJ, Scheker L, eds. The
| COMPLICATIONS Growing Hand. London, UK: Mosby; 2000:244Y252.
Fortunately, complications in the treatment of radial 11. Kitayama Y, Tsukada S. Patterns of arterial distribution in
polydactyly are uncommon and are typically minor. the duplicated thumb. Plastic Recon Surg. 1983;72:
Superficial infection, related to incision or pin site, is 535Y542.
the most common complication. It can usually be 12. Manske PR. Treatment of duplicated thumb using a
treated with oral antibiotics. ligamentous/periosteal flap. J Hand Surg [Am]. 1989;
The other complications depend on preoperative 14A:728Y733.
deformity and the procedure performed. If there is 13. Ogino T, Ishii S, Minami M. Radially deviated type
significant angular deformity present at the time of of thumb polydactyly. J Hand Surg [Br]. 1988;13:
surgery, there is an increased likelihood of a less-than- 315Y319.

270 Techniques in Hand and Upper Extremity Surgery

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Techniques in Hand and Upper Extremity Surgery 10(4):271–272, 2006 Ó 2006 Lippincott Williams & Wilkins, Philadelphia

| L E T T E R T O T H E E D I T O R |

Hand Dressing Using a Water-filled

Surgical Glove
Alper Bayraktar, MD, Ufuk AydNn, MD, and Ramazan Kahveci, MD
Uludag University
Faculty of Medicine
Department of Plastic and Reconstructive Surgery
Bursa, Turkey

| HISTORICAL PERSPECTIVE A loose but supportive dressing that is used after

replantation and revascularization surgery is appropri-
Hand surgery requires more than technical skill and
ate for protection from compression and posttraumatic
includes appropriate instruments, suture material, sterile
swelling and blood leakage from the wound. Such
technique, and wound dressings. The principals and
blood leakage may harden the dressings, especially in
theory of dressings, the materials available to construct
the web spaces (Fig. 1), and thus create a degree of
them, and the specific techniques for tailoring them to
difficult anatomical sites are very important for suc-
cessful hand surgery.
Finger injuries are among the most common injuries | DRESSING TECHNIQUE
presenting to the hand surgeon. In hand surgery, one of In our department, after replantation, revascularization,
the difficult sites for dressing is the area involving the and severe hand injuries, we use a water-filled glove
web spaces. This is especially true after replantation and technique as part of our dressing. We fill a sterile glove
revascularization, procedures where it is important to with warm water and tie it off proximally. The fingers
protect the repaired arteries and veins from compression of the water-filled glove are placed between the
because this may directly impact the surgical result.1,2 patient’s fingers from the volar side and into the web

FIGURE 1. A and B,
Loose-dressing. Tough-
ened gauzes because of
the blood leakage from the
surgical area which is
sutured loosely. C, Tough-
ened gauzes around
revascularized finger 8
hours after the operation.
D, Postoperative view of
revascularized finger.

Volume 10, Issue 4 271

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Letter to the Editor

FIGURE 2. A, A glove filled with warm water. B and C, Fingers of water-filled glove are placed between the patient’s
fingers from the volar side and into the web spaces. D and E, View of the hand after dressing with the water-filled glove.

spaces. The standard soft dressing is applied over the space and surrounding tissues. The method is inexpen-
water-filled glove and the patient’s hand (Fig. 2). sive, effective, and easy to apply. It has numerous
advantages as noted above, and in our experience, has
| DISCUSSION no disadvantages or complications.

By this means, we achieve a temperature that promotes

vasodilation. This technique also prevents the gauze
dressings from becoming blood soaked and hardening, 1. Rashid A, Ahmed OA, Diver AJ, et al. Love thy
with the potential for adverse compression in the web neighborVa case of fingertip necrosis following neighbor
spaces. We believe that this technique avoids the strapping. Injury. 2005;36:220Y221.
potential for compression of web spaces by moderating 2. Hughes SCA, Belcher HJCR. Jurgan pin ball fingertip
and more evenly distributing the pressure in the web pressure necrosis. Br J Plast Surg. 2003;56:72.

272 Techniques in Hand and Upper Extremity Surgery

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December 2006 ISSN:
Volume 10(4) (C) 2006 Lippincott Williams & Wilkins, Inc. 1089-3393

Viewing 1-14 of 14 Results

pg. 199
01 Doing What You Do Best.
Doyle, James R. MD

pg. 200-205
02 A Unified Approach to Radial Tunnel Syndrome and
Lateral Tendinosis.
Henry, Mark MD; Stutz, Christopher MD

pg. 206-211
03 Dynamic Assist Splinting for Attenuated Sagittal Bands in
the Rheumatoid Hand.
Chinchalkar, Shrikant J. OTR, CHT 1; Pitts, Shanley MScOT, OT Reg
(ONT) 2

pg. 212-223
04 Dorsal Distal Radius Vascularized Pedicled Bone Grafts for
Scaphoid Nonunions.
Larson, A. Noelle MD; Bishop, Allen T. MD; Shin, Alexander Y. MD

pg. 224-230
05 A New Modification of Corrective Osteotomy for
Treatment of Distal Radius Malunion.
Viegas, Steven F. MD

pg. 231-234
06 Lunocapitate Fusion Using the OSStaple Compression
Ronchetti, Peter J. MD 1; Topper, Steven M. MD 2

pg. 235-238
07 The Anterior Cubital Approach for Displaced Pediatric
Supracondylar Humeral Fractures.
Ay, Sadan MD; Akinci, Metin MD; Ercetin, Omer MD
pg. 239-244
08 Simultaneous Reconstruction of Medial and Lateral Elbow
Ligaments for Instability Using a Circumferential Graft.
van Riet, Roger P. MD, PhD 1; Bain, Gregory I. MBBS, FRACS 2;
Baird, Rob MBBS 3; Lim, Yeow Wai MD 4

pg. 245-251
09 Technique of Harvesting the Gracilis for Free Functioning
Muscle Transplantation.
Addosooki, Ahmad I. MD; Doi, Kazuteru MD, PhD; Hattori, Yasunori

pg. 252-254
10 Extensor Tenodesis for Plexic Hands With C7 to T1 or C8,
T1 Root Avulsions: A New Technique.
Goubier, Jean-Noel MD, PhD 1; Teboul, Frederic MD 1; Oberlin,
Christophe MD 2

pg. 255-258
11 Nail Salvage Using the Eponychial Flap.
Adani, Roberto MD; Leo, Giovanni MD; Tarallo, Luigi MD

pg. 259-264
12 Three-corner Wrist Fusion Using Memory Staples.
van Riet, Roger P. MD, PhD 1; Bain, Gregory I. MBBS, FRACS,
FA(OrthA) 2

pg. 265-270
13 Reconstruction of Radial Polydactyly.
Goldfarb, Charles A. MD

pg. 271-272
14 Hand Dressing Using a Water-filled Surgical Glove.
Bayraktar, Alper MD; Aydn, Ufuk MD [latin dotless i]; Kahveci,
Ramazan MD