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Extensor Pollicis Longus Ruptures Following Distal Radius Osteotomy Through a Volar Approach
SCIENTIFIC ARTICLE
Extensor Pollicis Longus Ruptures Following Distal Radius Osteotomy Through a Volar Approach Michael Rivlin, MD,* Diego L. Fernández, MD,† Ladislav Nagy, MD,‡ Gabriel López Graña, MD,§ Jesse Jupiter, MDjj
Purpose To investigate the cause and pathological process of extensor pollicis longus (EPL) ruptures after correction of distal radius malunion through a volar approach. Methods We included patients with EPL ruptures who underwent distal radius osteotomies performed through a volar approach. Data were pooled from members of the International Wrist Investigators Workshop. Patient demographics, initial injury parameters, imaging studies, preoperative and postoperative examination, intraoperative findings, surgical technique, and outcomes were compared and analyzed. Preoperative and postoperative radiographic images were evaluated and compared. Results We evaluated 6 cases from 5 surgeons in 4 institutions. Length of follow-up ranged from 1 to 5 years. On initial radiographic evaluation all malunions were healed with dorsal angulation (20 to 60 ) and with positive ulnar variance. Deformity correction in the sagittal plane was 25 to 55 . Osteotomies were fixed with volar locking plates with autologous bone graft except for one patient who received calcium phosphateebased bone void filler. Postoperative x-rays suggested prominent osteotomy resection edges, osteophytes, or dorsal bony prominence resulting from healed callus. Average time from osteotomy to EPL rupture was 10 weeks (range, 2e17 weeks). Two patients initially refused to undergo tendon transfers. One was pleased with the outcome despite the ruptured EPL. The other patient ruptured 2 more tendons and chose to have tendon transfers. One patient also ruptured the transferred tendon after 2 months and underwent successful tendon grafting. Conclusions In the absence of screw prominence and technical flaws, it is likely that dorsal callus, prominent osteotomy resection edges, and osteophytes may contribute to attritional rupture of the EPL tendon after a corrective osteotomy through a volar approach. Exposure and debridement of excessive callus, dorsal ridge, or a prominent Lister tubercle performed during the osteotomy may reduce subsequent EPL rupture. (J Hand Surg Am. 2016;41(3):395e398. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Malunion, reconstruction of the wrist, surgical risks, tendon rupture, wrist deformity.
From the *Department of Hand and Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA; the †Department of Orthopaedic Surgery, Lindenhof Hospital, Bern; the ‡Department of Hand Surgery, The Balgrist University Clinic, Zürich, Switzerland; the §Ibermutuamur Clinic, Madrid, Spain; and the jjDepartment of Hand and Upper Extremity Surgery, Massachusetts General Hospital, Harvard University, Boston, MA. Received for publication February 25, 2015; accepted in revised form October 6, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Michael Rivlin, MD, Department of Hand and Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107; e-mail: [email protected]. 0363-5023/16/4103-0012$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.10.029
T
(EPL) tendon is the most frequently ruptured tendon after distal radius fractures.1e4 Ruptures may occur from nondisplaced distal radius fractures treated with immobilization, locked plating of fractures, and distal radius osteotomy for malunions. These tendon injuries arise as a result of multiple factors. Iatrogenic insults such as screw penetration, screw prominence, dorsal penetration while drilling, and malreduced roof of the dorsal fragment may lead to attritional tendon failure.5 During healing, dorsal HE EXTENSOR POLLICIS LONGUS
Ó 2016 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
395
396
EPL RUPTURES AFTER DISTAL RADIUS OSTEOTOMY
osteophytes may form and contribute to these complications as well.6 Extensor pollicis longus ruptures occur at an incidence of 1% to 2% and are associated with distal radius fractures treated with volar locked plating.5,7 The incidence of these injuries resulting from distal radius corrective osteotomy is unknown. Although rare, surgical corrections of malunited distal radiuses with volar osteotomy may carry a potential risk of rupture of the extensor tendons as well. To investigate the cause and pathological process involved in these complications, we asked surgeons from multiple centers to contribute cases. This approach maximized the number of cases because malunion surgery for distal radius fractures is a procedure that is infrequently performed in most surgeons’ practices, and these complications are also infrequent. The purpose of this investigation was to further understanding and identify factors leading to EPL tendon ruptures after volar corrective osteotomy. We hypothesized that in the absence of technical complications, dorsal osteophytes and callous formation may lead to EPL ruptures.
EPL rupture presentation and timing relative to the osteotomy, intraoperative description of findings, method of fixation, and postoperative outcome measures if available. Intraoperative findings detailing a possible cause for tendon attrition were identified. Preoperative and postoperative wrist alignment (radiographic evaluation) and range of motion (ROM) were compared for each patient. Because of the nature of the study design (multicenter case series or case reports from multiple centers), which had fewer than 3 patients from each institution in a retrospective review, we sought and obtained exemption of institutional review board approval. Health Insurance Portability and Accountability Act and confidentiality rules were adhered to according to institutional standards. RESULTS Table 1 lists the demographics and initial presentation. All patients were initially treated with casts for distal radius fractures. Two of 6 patients had Disabilities of the Arm, Shoulder, and Hand scores collected. Although 2 patients reported loss of functional ROM as the primary problem, all patients had limited ROM before surgery; most presented with primary loss of flexion. One patient had asthma; the rest of the patients denied medical conditions. On initial radiographic evaluation, all malunions had dorsal angulation (20 to 60 ) and positive ulnar variance (Table 2). During the reconstruction, deformity correction in the sagittal plane was between 25 and 55 (average, 36 ). All patients had volar osteotomy with locked plating to correct the malunion. One patient had Norian bone substitute (Synthes, Solothurn, Switzerland) used as a graft whereas the rest had cancellous autologous bone graft harvested and implanted from the volar aspect through the osteotomy site. All patients achieved union. The initial postoperative course was uncomplicated in all 6 patients. The EPL ruptures occurred at an average of 10 weeks from the osteotomy (range, 2e17 weeks), characterized by painless loss of thumb interphalangeal joint extension. After understanding the surgical options, 5 patients elected to undergo extensor tendon transfer or grafting to the EPL. One refused further surgical intervention. Four patients who agreed to undergo surgical intervention had an extensor indicis propriuseto-EPL transfer. Two patients had removal of plate and screws at their request. One patient had delayed reconstruction, and by the time of tendon transfer had ruptured
MATERIALS AND METHODS We contacted members of the International Wrist Investigators Workshop to identify and contribute cases if they encountered EPL ruptures seen as sequelae to volar distal radius osteotomy with plate fixation performed for malunion. At the annual meeting of the International Wrist Investigators Workshop, which has 60 to 65 international hand surgeon members, participants were informally solicited by the senior author to see whether others had encountered the spontaneous rupture of EPL tendons. Members were requested to contribute cases to study this complication. Four senior authors of this study identified 6 patients from their personal collections retrospectively. An inclusion criterion was any man or woman over age 18 years who had sustained rupture of the EPL tendon after undergoing distal radius volar osteotomy for malunion with volar plate fixation. All authors used an oscillating saw for the osteotomy and completed it with an osteotome while the dorsal tendons were protected. Patients with flexor tendon ruptures, cases in which the surgeon did not perform the initial osteotomy, alternate approaches, dorsal osteotomies, and cases with no plate fixation were excluded. We collected data from the chart notes, operative reports, and image databases, including demographics, associated conditions, initial and follow-up examination findings, radiograph images, surgical parameters, J Hand Surg Am.
r
Vol. 41, March 2016
397
EPL RUPTURES AFTER DISTAL RADIUS OSTEOTOMY
TABLE 1.
Demographics
Patient
Chief Problem
Age
Sex
Handedness
Occupation
1
Weakness
54
Female
Dominant
Teacher
2
Limited ROM
75
Female
Nondominant
Housewife
3
Limited ROM
29
Male
Dominant
Food service
4
Pain
41
Female
Dominant
Accountant
5
Pain
32
Male
Nondominant
Painter
6
Pain/deformity
68
Female
Dominant
Retired
TABLE 2. Patient
Radiographic Deformity and Correction AO Classification
Preoperative Deformity (Tilt, Shortening, Other Parameters)
Saggital Correction
Bone Graft or Substitute
1
Unknown
35 dorsal, 9 mm ulnar variance
30
Bone cement*
2
Unknown
22 dorsal, 8 mm ulnar variance
25
ICBG
3
A3.2
45 dorsal, 25 radial
45
ICBG
4
C1.1
25 dorsal, 9 radial, intra-articular stepoff
25
Olecranon
5
A3.2
32 dorsal, 7 mm ulnar variance, 15 ulnar inclination, dorsal carpal subluxation
37
ICBG
6
C3.2
60 dorsal, 9 mm ulnar variance, 5 ulnar deviation, dorsal carpal subluxation, adaptive dorsal intercalated segment instability
55
ICBG
ICBG, iliac crest bone graft. *Norian (Synthes, West Chester, PA).
the extensor digitorum communis to the index finger and the extensor indicis proprius as well. He had palmaris longus grafting to the EPL and tenodesis of the index and middle finger extensor digitorum communis tendons. Intraoperative findings included 4 patients with exuberant callus, 1 with screw tip prominence, and 1 with a prominent Lister tubercle and bony ridge (Fig. 1). All patients regained thumb interphalangeal joint extension. One patient had rupture of extensor indicis proprius graft 2 weeks after tendon transfer; palmaris grafting yielded good results. All patients denied functional limitations using the hand at final followup. Length of follow-up was 1 to 4.5 years (mean, 1.9 years) and no further complications were found.
Beside hardware prominence that can irritate and cause attritional damage to the extensor tendons and direct tendon injury, other factors can lead to EPL ruptures.13 We postulated that dorsal callus formation may interfere with tendon gliding, and attritional or ischemic changes may occur in the involved tendon that eventually fails. Our series showed that in the absence of screw prominence, it is likely that dorsal callus, prominent osteotomy resection edges, and osteophytes may contribute to attritional rupture of the EPL tendon. Based on the experience documented in this series, we recommend exposure of the dorsal surface either through the same volar incision or through a small dorsal incision to debride callus or a prominent Lister tubercle. One patient in our study sustained rupture of the index extensor digitorum communis and extensor indicis proprius tendons after delaying treatment for the EPL rupture. We postulate that some cases of EPL ruptures may eventually involve additional tendons. Thorough evaluation of other tendons is recommended. Once a patient sustains an EPL rupture, based on these outcomes, one can expect excellent recovery if extensor indicis proprius tendon transfer or tendon grafting is performed. This injury does not
DISCUSSION Malunion of a distal radius fracture can cause functional limitations in patients’ lives owing to limited ROM, pain, deformity, or weakness. To correct the malalignment, multiple interventions have been described. Volar opening and closing wedge osteotomies have been described combined with Darrach procedure, ulnar shortening osteotomy, or ulnar head prosthesis; K-wires or plates can be used for fixation.8e12 J Hand Surg Am.
r
Vol. 41, March 2016
398
EPL RUPTURES AFTER DISTAL RADIUS OSTEOTOMY
FIGURE 1: A Dorsal callous formation (blue arrow). B Dorsal bony prominence (red arrow).
appear to markedly hinder the long-term outcomes of distal radius osteotomy for malunion surgery performed through a volar approach. This case series included 6 patients; hence, extrapolation of our findings may be limited owing to the low number. Furthermore, a limiting factor of this study was the variability in patients and surgeon techniques and preferences. Prospective collection of patients with this pathology after osteotomy may increase our understanding of underlying processes. Although there did not appear to be any intraoperative EPL tendon injury, it is plausible that during the corrective surgery some insult may have occurred to the tendons during the osteotomy or other parts of the procedure. With early ruptures that occurred before robust callus formation (within a couple of weeks of the osteotomy), this cause is even more likely. Because of the study design, we were unable to draw conclusions about the incidence of these complications. Further limitations of the study inherent in the design include the lack of objective validated outcomes and no standardization of procedures or follow-up. There may be a major recall bias, and although it may not have affected identification of the ruptures, it may have missed other contributions to ruptures and affected the number of included cases. Participation in the study and surgeon selection was arbitrary. Although the solicitation to contribute cases was at a meeting, it was informal and likely not all participants were reached. We were not aware how many surgeons had similar complications but decided not to contribute cases. Clinically unrecognized ruptures or ruptures that occurred outside surgeons’ practice may have been unaccounted for. These tendon injuries may arise as a result of multiple factors. Iatrogenic insults such as unrecognized screw or drill penetration, screw prominence not identified intraoperatively owing to callous overgrowth, or malreduced roof of the dorsal fragment may lead to attritional tendon failure not noted in our investigation. Extensor pollicis longus ruptures occur at an incidence of 1% to 2%5,7 with distal radius fracture volar plating, J Hand Surg Am.
which carries risk factors similar to those of osteotomies. In general, dorsally protected tendons decrease the chance of saw penetration with the osteotomy, but these insults may also have a role. Future studies may explain further confounders that are not identified in this article and may include examining dorsal osteotomy and osteotomy without plate fixation. REFERENCES 1. Helal B, Chen SC, Iwegbu G. Rupture of the extensor pollicis longus tendon in undisplaced Colles’ type of fracture. Hand. 1982;14(1): 41e47. 2. Hirasawa Y, Katsumi Y, Akiyoshi T, Tamai K, Tokioka T. Clinical and microangiographic studies on rupture of the E.P.L. tendon after distal radial fractures. J Hand Surg Br. 1990;15(1):51e57. 3. Roth KM, Blazar PE, Earp BE, Han R, Leung A. Incidence of extensor pollicis longus tendon rupture after nondisplaced distal radius fractures. J Hand Surg Am. 2012;37(5):942e947. 4. Skoff HD. Postfracture extensor pollicis longus tenosynovitis and tendon rupture: a scientific study and personal series. Am J Orthop (Belle Mead NJ). 2003;32(5):245e247. 5. Zenke Y, Sakai A, Oshige T, et al. Extensor pollicis longus tendon ruptures after the use of volar locking plates for distal radius fractures. Hand Surg. 2013;18(2):169e173. 6. Kuriyama K, Murase T, Moritomo H, Yoshikawa H. Attritional rupture of the extensor pollicis longus tendon by an osseous spur more than 30 years after wrist injury: a case report. J Plast Surg Hand Surg. 2014;48(6):452e454. 7. Tarallo L, Mugnai R, Zambianchi F, Adani R, Catani F. Volar plate fixation for the treatment of distal radius fractures: analysis of adverse events. J Orthop Trauma. 2013;27(12):740e745. 8. Fernandez DL. Malunion of the distal radius: current approach to management. Instr Course Lect. 1993;42:99e113. 9. Gradl G, Jupiter J, Pillukat T, Knobe M, Prommersberger KJ. Corrective osteotomy of the distal radius following failed internal fixation. Arch Orthop Trauma Surg. 2013;133(8):1173e1179. 10. Mathew P, Garcia-Elias M. Anterolateral surgical approach to the malunited distal radius fracture for corrective osteotomy and bonegraft harvest. Tech Hand Up Extrem Surg. 2013;17(1):28e34. 11. Posner MA, Ambrose L. Malunited Colles’ fractures: correction with a biplanar closing wedge osteotomy. J Hand Surg Am. 1991;16(6): 1017e1026. 12. Prommersberger KJ, Lanz UB. Corrective osteotomy of the distal radius through volar approach. Tech Hand Up Extrem Surg. 2004;8(2):70e77. 13. Prommersberger KJ, Ring D, Gonzalez del Pino J, Capomassi M, Slullitel M, Jupiter JB. Corrective osteotomy for intra-articular malunion of the distal part of the radius: surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1 pt 2):202e211.
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Vol. 41, March 2016
Extensor Pollicis Longus Ruptures Following Distal Radius Osteotomy Through a Volar Approach Michael Rivlin, MD,* Diego L. Fernández, MD,† Ladislav Nagy, MD,‡ Gabriel López Graña, MD,§ Jesse Jupiter, MDjj
Purpose To investigate the cause and pathological process of extensor pollicis longus (EPL) ruptures after correction of distal radius malunion through a volar approach. Methods We included patients with EPL ruptures who underwent distal radius osteotomies performed through a volar approach. Data were pooled from members of the International Wrist Investigators Workshop. Patient demographics, initial injury parameters, imaging studies, preoperative and postoperative examination, intraoperative findings, surgical technique, and outcomes were compared and analyzed. Preoperative and postoperative radiographic images were evaluated and compared. Results We evaluated 6 cases from 5 surgeons in 4 institutions. Length of follow-up ranged from 1 to 5 years. On initial radiographic evaluation all malunions were healed with dorsal angulation (20 to 60 ) and with positive ulnar variance. Deformity correction in the sagittal plane was 25 to 55 . Osteotomies were fixed with volar locking plates with autologous bone graft except for one patient who received calcium phosphateebased bone void filler. Postoperative x-rays suggested prominent osteotomy resection edges, osteophytes, or dorsal bony prominence resulting from healed callus. Average time from osteotomy to EPL rupture was 10 weeks (range, 2e17 weeks). Two patients initially refused to undergo tendon transfers. One was pleased with the outcome despite the ruptured EPL. The other patient ruptured 2 more tendons and chose to have tendon transfers. One patient also ruptured the transferred tendon after 2 months and underwent successful tendon grafting. Conclusions In the absence of screw prominence and technical flaws, it is likely that dorsal callus, prominent osteotomy resection edges, and osteophytes may contribute to attritional rupture of the EPL tendon after a corrective osteotomy through a volar approach. Exposure and debridement of excessive callus, dorsal ridge, or a prominent Lister tubercle performed during the osteotomy may reduce subsequent EPL rupture. (J Hand Surg Am. 2016;41(3):395e398. Copyright Ó 2016 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Malunion, reconstruction of the wrist, surgical risks, tendon rupture, wrist deformity.
From the *Department of Hand and Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA; the †Department of Orthopaedic Surgery, Lindenhof Hospital, Bern; the ‡Department of Hand Surgery, The Balgrist University Clinic, Zürich, Switzerland; the §Ibermutuamur Clinic, Madrid, Spain; and the jjDepartment of Hand and Upper Extremity Surgery, Massachusetts General Hospital, Harvard University, Boston, MA. Received for publication February 25, 2015; accepted in revised form October 6, 2015. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Michael Rivlin, MD, Department of Hand and Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107; e-mail: [email protected]. 0363-5023/16/4103-0012$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2015.10.029
T
(EPL) tendon is the most frequently ruptured tendon after distal radius fractures.1e4 Ruptures may occur from nondisplaced distal radius fractures treated with immobilization, locked plating of fractures, and distal radius osteotomy for malunions. These tendon injuries arise as a result of multiple factors. Iatrogenic insults such as screw penetration, screw prominence, dorsal penetration while drilling, and malreduced roof of the dorsal fragment may lead to attritional tendon failure.5 During healing, dorsal HE EXTENSOR POLLICIS LONGUS
Ó 2016 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
395
396
EPL RUPTURES AFTER DISTAL RADIUS OSTEOTOMY
osteophytes may form and contribute to these complications as well.6 Extensor pollicis longus ruptures occur at an incidence of 1% to 2% and are associated with distal radius fractures treated with volar locked plating.5,7 The incidence of these injuries resulting from distal radius corrective osteotomy is unknown. Although rare, surgical corrections of malunited distal radiuses with volar osteotomy may carry a potential risk of rupture of the extensor tendons as well. To investigate the cause and pathological process involved in these complications, we asked surgeons from multiple centers to contribute cases. This approach maximized the number of cases because malunion surgery for distal radius fractures is a procedure that is infrequently performed in most surgeons’ practices, and these complications are also infrequent. The purpose of this investigation was to further understanding and identify factors leading to EPL tendon ruptures after volar corrective osteotomy. We hypothesized that in the absence of technical complications, dorsal osteophytes and callous formation may lead to EPL ruptures.
EPL rupture presentation and timing relative to the osteotomy, intraoperative description of findings, method of fixation, and postoperative outcome measures if available. Intraoperative findings detailing a possible cause for tendon attrition were identified. Preoperative and postoperative wrist alignment (radiographic evaluation) and range of motion (ROM) were compared for each patient. Because of the nature of the study design (multicenter case series or case reports from multiple centers), which had fewer than 3 patients from each institution in a retrospective review, we sought and obtained exemption of institutional review board approval. Health Insurance Portability and Accountability Act and confidentiality rules were adhered to according to institutional standards. RESULTS Table 1 lists the demographics and initial presentation. All patients were initially treated with casts for distal radius fractures. Two of 6 patients had Disabilities of the Arm, Shoulder, and Hand scores collected. Although 2 patients reported loss of functional ROM as the primary problem, all patients had limited ROM before surgery; most presented with primary loss of flexion. One patient had asthma; the rest of the patients denied medical conditions. On initial radiographic evaluation, all malunions had dorsal angulation (20 to 60 ) and positive ulnar variance (Table 2). During the reconstruction, deformity correction in the sagittal plane was between 25 and 55 (average, 36 ). All patients had volar osteotomy with locked plating to correct the malunion. One patient had Norian bone substitute (Synthes, Solothurn, Switzerland) used as a graft whereas the rest had cancellous autologous bone graft harvested and implanted from the volar aspect through the osteotomy site. All patients achieved union. The initial postoperative course was uncomplicated in all 6 patients. The EPL ruptures occurred at an average of 10 weeks from the osteotomy (range, 2e17 weeks), characterized by painless loss of thumb interphalangeal joint extension. After understanding the surgical options, 5 patients elected to undergo extensor tendon transfer or grafting to the EPL. One refused further surgical intervention. Four patients who agreed to undergo surgical intervention had an extensor indicis propriuseto-EPL transfer. Two patients had removal of plate and screws at their request. One patient had delayed reconstruction, and by the time of tendon transfer had ruptured
MATERIALS AND METHODS We contacted members of the International Wrist Investigators Workshop to identify and contribute cases if they encountered EPL ruptures seen as sequelae to volar distal radius osteotomy with plate fixation performed for malunion. At the annual meeting of the International Wrist Investigators Workshop, which has 60 to 65 international hand surgeon members, participants were informally solicited by the senior author to see whether others had encountered the spontaneous rupture of EPL tendons. Members were requested to contribute cases to study this complication. Four senior authors of this study identified 6 patients from their personal collections retrospectively. An inclusion criterion was any man or woman over age 18 years who had sustained rupture of the EPL tendon after undergoing distal radius volar osteotomy for malunion with volar plate fixation. All authors used an oscillating saw for the osteotomy and completed it with an osteotome while the dorsal tendons were protected. Patients with flexor tendon ruptures, cases in which the surgeon did not perform the initial osteotomy, alternate approaches, dorsal osteotomies, and cases with no plate fixation were excluded. We collected data from the chart notes, operative reports, and image databases, including demographics, associated conditions, initial and follow-up examination findings, radiograph images, surgical parameters, J Hand Surg Am.
r
Vol. 41, March 2016
397
EPL RUPTURES AFTER DISTAL RADIUS OSTEOTOMY
TABLE 1.
Demographics
Patient
Chief Problem
Age
Sex
Handedness
Occupation
1
Weakness
54
Female
Dominant
Teacher
2
Limited ROM
75
Female
Nondominant
Housewife
3
Limited ROM
29
Male
Dominant
Food service
4
Pain
41
Female
Dominant
Accountant
5
Pain
32
Male
Nondominant
Painter
6
Pain/deformity
68
Female
Dominant
Retired
TABLE 2. Patient
Radiographic Deformity and Correction AO Classification
Preoperative Deformity (Tilt, Shortening, Other Parameters)
Saggital Correction
Bone Graft or Substitute
1
Unknown
35 dorsal, 9 mm ulnar variance
30
Bone cement*
2
Unknown
22 dorsal, 8 mm ulnar variance
25
ICBG
3
A3.2
45 dorsal, 25 radial
45
ICBG
4
C1.1
25 dorsal, 9 radial, intra-articular stepoff
25
Olecranon
5
A3.2
32 dorsal, 7 mm ulnar variance, 15 ulnar inclination, dorsal carpal subluxation
37
ICBG
6
C3.2
60 dorsal, 9 mm ulnar variance, 5 ulnar deviation, dorsal carpal subluxation, adaptive dorsal intercalated segment instability
55
ICBG
ICBG, iliac crest bone graft. *Norian (Synthes, West Chester, PA).
the extensor digitorum communis to the index finger and the extensor indicis proprius as well. He had palmaris longus grafting to the EPL and tenodesis of the index and middle finger extensor digitorum communis tendons. Intraoperative findings included 4 patients with exuberant callus, 1 with screw tip prominence, and 1 with a prominent Lister tubercle and bony ridge (Fig. 1). All patients regained thumb interphalangeal joint extension. One patient had rupture of extensor indicis proprius graft 2 weeks after tendon transfer; palmaris grafting yielded good results. All patients denied functional limitations using the hand at final followup. Length of follow-up was 1 to 4.5 years (mean, 1.9 years) and no further complications were found.
Beside hardware prominence that can irritate and cause attritional damage to the extensor tendons and direct tendon injury, other factors can lead to EPL ruptures.13 We postulated that dorsal callus formation may interfere with tendon gliding, and attritional or ischemic changes may occur in the involved tendon that eventually fails. Our series showed that in the absence of screw prominence, it is likely that dorsal callus, prominent osteotomy resection edges, and osteophytes may contribute to attritional rupture of the EPL tendon. Based on the experience documented in this series, we recommend exposure of the dorsal surface either through the same volar incision or through a small dorsal incision to debride callus or a prominent Lister tubercle. One patient in our study sustained rupture of the index extensor digitorum communis and extensor indicis proprius tendons after delaying treatment for the EPL rupture. We postulate that some cases of EPL ruptures may eventually involve additional tendons. Thorough evaluation of other tendons is recommended. Once a patient sustains an EPL rupture, based on these outcomes, one can expect excellent recovery if extensor indicis proprius tendon transfer or tendon grafting is performed. This injury does not
DISCUSSION Malunion of a distal radius fracture can cause functional limitations in patients’ lives owing to limited ROM, pain, deformity, or weakness. To correct the malalignment, multiple interventions have been described. Volar opening and closing wedge osteotomies have been described combined with Darrach procedure, ulnar shortening osteotomy, or ulnar head prosthesis; K-wires or plates can be used for fixation.8e12 J Hand Surg Am.
r
Vol. 41, March 2016
398
EPL RUPTURES AFTER DISTAL RADIUS OSTEOTOMY
FIGURE 1: A Dorsal callous formation (blue arrow). B Dorsal bony prominence (red arrow).
appear to markedly hinder the long-term outcomes of distal radius osteotomy for malunion surgery performed through a volar approach. This case series included 6 patients; hence, extrapolation of our findings may be limited owing to the low number. Furthermore, a limiting factor of this study was the variability in patients and surgeon techniques and preferences. Prospective collection of patients with this pathology after osteotomy may increase our understanding of underlying processes. Although there did not appear to be any intraoperative EPL tendon injury, it is plausible that during the corrective surgery some insult may have occurred to the tendons during the osteotomy or other parts of the procedure. With early ruptures that occurred before robust callus formation (within a couple of weeks of the osteotomy), this cause is even more likely. Because of the study design, we were unable to draw conclusions about the incidence of these complications. Further limitations of the study inherent in the design include the lack of objective validated outcomes and no standardization of procedures or follow-up. There may be a major recall bias, and although it may not have affected identification of the ruptures, it may have missed other contributions to ruptures and affected the number of included cases. Participation in the study and surgeon selection was arbitrary. Although the solicitation to contribute cases was at a meeting, it was informal and likely not all participants were reached. We were not aware how many surgeons had similar complications but decided not to contribute cases. Clinically unrecognized ruptures or ruptures that occurred outside surgeons’ practice may have been unaccounted for. These tendon injuries may arise as a result of multiple factors. Iatrogenic insults such as unrecognized screw or drill penetration, screw prominence not identified intraoperatively owing to callous overgrowth, or malreduced roof of the dorsal fragment may lead to attritional tendon failure not noted in our investigation. Extensor pollicis longus ruptures occur at an incidence of 1% to 2%5,7 with distal radius fracture volar plating, J Hand Surg Am.
which carries risk factors similar to those of osteotomies. In general, dorsally protected tendons decrease the chance of saw penetration with the osteotomy, but these insults may also have a role. Future studies may explain further confounders that are not identified in this article and may include examining dorsal osteotomy and osteotomy without plate fixation. REFERENCES 1. Helal B, Chen SC, Iwegbu G. Rupture of the extensor pollicis longus tendon in undisplaced Colles’ type of fracture. Hand. 1982;14(1): 41e47. 2. Hirasawa Y, Katsumi Y, Akiyoshi T, Tamai K, Tokioka T. Clinical and microangiographic studies on rupture of the E.P.L. tendon after distal radial fractures. J Hand Surg Br. 1990;15(1):51e57. 3. Roth KM, Blazar PE, Earp BE, Han R, Leung A. Incidence of extensor pollicis longus tendon rupture after nondisplaced distal radius fractures. J Hand Surg Am. 2012;37(5):942e947. 4. Skoff HD. Postfracture extensor pollicis longus tenosynovitis and tendon rupture: a scientific study and personal series. Am J Orthop (Belle Mead NJ). 2003;32(5):245e247. 5. Zenke Y, Sakai A, Oshige T, et al. Extensor pollicis longus tendon ruptures after the use of volar locking plates for distal radius fractures. Hand Surg. 2013;18(2):169e173. 6. Kuriyama K, Murase T, Moritomo H, Yoshikawa H. Attritional rupture of the extensor pollicis longus tendon by an osseous spur more than 30 years after wrist injury: a case report. J Plast Surg Hand Surg. 2014;48(6):452e454. 7. Tarallo L, Mugnai R, Zambianchi F, Adani R, Catani F. Volar plate fixation for the treatment of distal radius fractures: analysis of adverse events. J Orthop Trauma. 2013;27(12):740e745. 8. Fernandez DL. Malunion of the distal radius: current approach to management. Instr Course Lect. 1993;42:99e113. 9. Gradl G, Jupiter J, Pillukat T, Knobe M, Prommersberger KJ. Corrective osteotomy of the distal radius following failed internal fixation. Arch Orthop Trauma Surg. 2013;133(8):1173e1179. 10. Mathew P, Garcia-Elias M. Anterolateral surgical approach to the malunited distal radius fracture for corrective osteotomy and bonegraft harvest. Tech Hand Up Extrem Surg. 2013;17(1):28e34. 11. Posner MA, Ambrose L. Malunited Colles’ fractures: correction with a biplanar closing wedge osteotomy. J Hand Surg Am. 1991;16(6): 1017e1026. 12. Prommersberger KJ, Lanz UB. Corrective osteotomy of the distal radius through volar approach. Tech Hand Up Extrem Surg. 2004;8(2):70e77. 13. Prommersberger KJ, Ring D, Gonzalez del Pino J, Capomassi M, Slullitel M, Jupiter JB. Corrective osteotomy for intra-articular malunion of the distal part of the radius: surgical technique. J Bone Joint Surg Am. 2006;88(suppl 1 pt 2):202e211.
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Vol. 41, March 2016