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Intercarpal arthrodesis by dowel bone grafting
INTERCARPAL
ARTHRODESIS
BY D O W E L B O N E G R A F T I N G
M. J. SANDOW, Y.-L. WAI and M. G. HAYES From the Department of Orthopaedic Surgery and Trauma, Royal Adelaide Hospital, South Australia
Successful intercarpal arthrodesis requires a stable fusion with maintenance of correct alitmment and spatial relationship of the carpus. The technique described utilizes a series of tube saws to fashion the arthrodesis bed and then insert a sized iliac crest dowel bone graft with a tight interference fit. This technique has been used in 24 patients over a two-year period in both medial and lateral column intercarpal fusions. All wrists had fused by the tenth post-operative month. The technique is precise, reproducible and technically simple with a high fusion rate and minimal donor site morbidity. Journal of Hand Surgery (British Volume, 1992) 17B : 463-466 Operative techniques
Increased understanding of carpal mechanics and recognition of the potential disability inherent in certain instability and degenerative pattens has increased the indication for limited carpal fusion (Watson et al., 1981 ; Watson and Hempton, 1980). Selective intercarpal fusion is a reliable treatment option in most series (Green, 1988) and Watson et al. (1981), and Watson and Hempton (1980) have popularized the technique to treat a variety of developmental and traumatic disorders of the wrist. In their scapho-trapezio-trapezoid fusion technique the adjacent joint surfaces of the bones to be fused are excised, local autogenous bone graft is interposed and the bones stabilized with Kirschner wires (Watson and Hempton, 1980). An alternative technique is described here that utilizes a modification of accepted dowel bone grafting techniques (Cloward, 1959). The use of this technique is described in several disease patterns and only fusion rate is reported, without consideration of overall clinical results.
All procedures in this series were performed under general anaesthetic; however, in selected patients the procedures can be done under axillary arm block with local anaesthetic infiltration in the iliac crest. A dorsal transverse skin incision is made over the joints to be fused. The extensor retinaculum is divided longitudinally and the joint capsule opened in cruciate fashion. The correct anatomical position is identified, the joints are mobilized by soft tissue dissection and the correct carpal alignment confirmed by fluoroscopy. A set of precisely graduated tube saws is used to prepare the fusion site and obtain the dowel bone graft. A core of bone containing contiguous aspects of adjacent carpal bones to be fused is excised with an appropriate sized tube saw (generally between 9 and 12 mm in diameter). Approximately 25% articular contact is maintained at the periphery of the core to prevent distortion of the joints (Fig. 1). An ipsilateral iliac crest dowel bone graft is then obtained using the next larger tube saw (without offset teeth), whose internal diameter (and hence dowel bone graft size) is equal to the outer diameter (hence the recipient site diameter) of the initial tube saw. The bone dowel is obtained from the iliac crest in a transverse, oblique or vertical direction as required by the dimensions of the fusion site, and generally requires only a short stab incision. The dowel is then inserted into the prepared site and fits the hole exactly, producing a tight interference fit. Stability is enhanced by one or more buried Kirschner wires. The tourniquet is deflated and after haemostasis the wound is closed over a suction drain. A well padded splint is applied, and changed to a complete plaster approximately five days post-operatively. The iliac crest donor wound is closed with a single cutaneous stitch without drainage. Infiltration of the iliac crest incision with long-acting local anaesthetic reduces post-operative discdmfort. Accurate time to fusion is difficult to determine in many patients and relates to timing, quality and interpretation of radiographs. Frykman et al. (1988) used X-ray tomography to determine bony union. Because of the orientation of the bone dowel and parallel planes of
Materials and methods Over the two-year period January 1988 to December 1989, dowel bone graft intercarpal arthrodeses have been performed on 24 patients. Mean follow-up time from surgery was 14.5 months with a range of five to 24 months. There were 17 men and seven women; with 11 right wrists and 13 left wrists operated upon. The age of patients ranged from 18 to 65 years with 17 of the patients below the age of 40 at surgery. The disease patterns treated were scapho-lunate dissociation (12), scaphotrapezio-trapezoid arthritis (three), SLAC deformity (two) and Kienb6ck's disease (two), as well as medial column instability patterns (five). Patients were evaluated pre-operatively by careful history and examination. Plain radiographic assessment in the AP and lateral planes utilizing positions of flexion and extension and radial and ulnar deviation was also performed. Apart from two patients with Kienb6ck's disease, all patients were investigated by arthroscopy and/or arthrography to assess ligament instability and adjacent joint condition. 463
464
THE JOURNAL OF HAND SURGERY VOL. 17B No. 4 AUGUST 1992
R ~
24 patients underwent intercarpal fusion by the dowel technique over the two-year period (Table 1). In all patients wrist immobilization was removed by ten weeks, and all achieved fusion by the final X-ray assessment at a time up to ten months from surgery. In 40% of patients radiographic fusion was evident by the second postoperative month, and in all but two patients (one scaphocapito-lunate fusion and one scapho-trapezio-trapezoid fusion) fusion had occurred by the sixth month. One patient developed reflex sympathetic dystrophy that responded to repeat sympathetic blockade and physiotherapeutic modalities. No patient required exploration or regrafting and there were no significant donor site problems.
9 @
Discussion
Fig. 1 Contiguous articular aspects of carpal bones to be fused (for example medial carpal column and scapho-trapezio-trapezoid fusions) are removed with the appropriate sized tube saw. The next larger saw obtains an iliac crest bone graft that will conform to the prepared arthrodesis bed precisely.
fusion with this technique, fluoroscopically guided or oblique X-rays taken co-linearly with the graft will demonstrate the state of union without the need for more elaborate radiographic assessment (Fig. 2). The presence of trabeculae crossing the fusion sites, maintenance of carpal alignment and the absence of significant pain at the operative site on palpation or stressing were regarded as confirmation of successful arthrodesis. No patient was immobilized nor Kirschner wires retained for greater than ten weeks and in 80% of patients the wires and plaster were removed during the eighth post-operative week. Active range of motion was encouraged on removal of plaster under the supervision of a physiotherapist.
Successful results following intercarpal fusion have not been universal. Failure to attain correct carpal alignment and spatial relationship and achieve fusion have compromised results in some series (Kleinman and Carroll, 1990). Complete articular surface excision prior to insertion of the bone graft as described by Watson and Hempton (1980) has the advantage of adequate joint mobilization to allow reduction of the bones (typically the scaphoid), but can cause foreshortening of the bones with disturbance of adjacent joint mechanics. The arthrodesed bones should not be compressed into a smaller mass. Rather, the external dimensions of the completed fusion unit should be the same as the external dimensions of the same bones in the normal wrist. This is facilitated by avoiding complete joint excision. Although distal radial metaphyseal bone provides adequate graft for most carpal surgery (McGrath and Watson, 1981), iliac crest bone has greater structural integrity, better compression resistance and can be sculpted and used as either a eortico-cancellous or purely cancellous graft (Bondurant, 1966; Fernandez, 1984). Fusion and graft stability are promoted by the compression effect of the tight fitting bone dowel that corresponds exactly to the prepared arthrodesis site.
Table 1--Summary of operative procedures and results No. radiographically fused at Procedure
Scapho-trapezio-trapezoid fusion Scapho-trapezio-trapezoid fusion plus silastic lunate S-C-L fusion Medial column fusion (C-L-Tq-H) L-Tq fusion
Total no. 3 months
6 months
10 months
14 2
80% ( 11) 50% (1)
100% (14) 50% (1)
100% (2)
1 4 3
25% (1) 33% (1)
100% (4) 100% (3)
24
58%
88%
100% (1)
100~
Time to radiographicallyconfirmedfusion. Percentages to nearest whole number. S-scaphoid, L-lunate, H-hamate, C-capitate, Tq-triquetrum.
INTERCARPAL ARTHRODESISBY DOWEL BONE GRAFTING
465
Fig. 2 Successful arthrodesis three months post-operativelyis well demonstrated by appropriately oriented plain radiographs in (a) scapho-trapezio-trapezoidfusion and (b) medial carpal column fusion.
Possible thermal damage to the fusion site and graft is avoided by using a hand driven technique. Brody and Hentz (1990) recently confirmed the suitability and safety of the iliac crest for dowel bone harvest and a similar technique has been described by Dick (1982). Johnson and Johnson (1986) used multiple tube saw grafting in mid-tarsal and ankle fusion, but the use of an integrated graduated series of tube saws has not been reported in the wrist. Watson et al. (1981) and Watson and Hempton (1980) reported that with joint excision and inlay local bone graft a fusion rate of 80~o at three months could be achieved. The technique described here compares favourably and provides technical advantages. It is precise, reproducible, technically simple and allows accurate fusion site preparation with a high arthrodesis rate, while maintaining correct carpal alignment and dimensions. The reduced donor site morbidity promotes this as a technique for day-case surgery.
A set of graduated tube saws and guides (The Precision Bone Grafting System) and further technical details are now available from: (U.S. enquiries)Roberts Medical Inc. 1-800-832-2767/(215)367 2891. (Int. enquiries) Kaltec Pry Ltd, 23 Bennet Ave, Melrose Park, South Australia 5039, Australia. Phone: Int + 618 277 6305. Fax: Int + 618 277 0481.
References B O N D U R A N T , C. P. (1966). A new method for obtaining iliac bone dowel. Journal of Neurosurgery, 25: 658~659. BRODY, G. A. and H E N T Z , V. R. (1990). Cloward technique for obtaining iliac crest bone graft in hand surgery. Journal of Hand Surgery, 15A : 181- 183. CLOWARD, R. B. (1959). Vertebral Body Fusion for Ruptured Cervical Discs. American Journal of Surgery, 98 : 722-727. DICK, H. M. Wrist and intercarpal arthrodesis. In: Green, D. P. (Ed.) Operative Hand Surgery 1st Edn. New York, Churchill Livingstone. 1982: 135. F E R N A N D E Z , D. L. (1984). A technique for anterior wedge-shaped grafts for scapboid nonunions with carpal instability. Journal of Hand Surgery, 9A: 5: 733-737. FRYKMAN, E. B., EKENSTAM, F. A. and W A D I N , K. (1988). Triscaphoid arthrodesis and its complications. Journal of Hand Surgery, 13A: 6: 844849.
466 GREEN, D. P. Carpal dislocations and instabilities. In: Green, D. P. (Ed.) Operative Hand Surgery 2nd Edn. New York, Churchill Livingstone. 1988: 898-901. JOHNSON, J. E. and JOHNSON, K. A. (1986). Dowel arthrodesis for degenerative arthritis of the tarsometatarsal (Lisfranc) joints. Foot and Ankle, 6: 5: 243-253. KLEINMAN, W. B. and CARROLL, C. (1990). Scapho-trapezio-trapezoid arthrodesis for treatment of chronic static and dynamic scapho-lunate instability: a 10-year perspective on pitfalls and complications. Journal of Hand Surgery 15A: 3: 408-414. McGRATH, M. H. and WATSON, H. K. (1981). Late results with local bone graft donor sites in hand surgery. Journal of Hand Surgery 67A: 3 : 234-237.
THE JOURNAL OF HAND SURGERY VOL. 17B No. 4 AUGUST 1992 WATSON, H. K., GOODMAN, M. L. and JOHNSON, T. R. (1981). Limited wrist arthrodesis. Part II: Interearpal and radiocarpal combinations. Journal of Hand Surgery 6A: 3: 223-233. WATSON, H. K. and HEMPTON, R. F. (1980). Limited wrist arthrodesis. I. The triscaphoid joint. Journal of Hand Surgery 5A: 4: 320--327.
Accepted9 December 1991 Michael Sandow, FRACS, Department of Orthopaedic Surgeryand Trauma, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia 9 1992The British Societyfor Surgeryof the Hand
ARTHRODESIS
BY D O W E L B O N E G R A F T I N G
M. J. SANDOW, Y.-L. WAI and M. G. HAYES From the Department of Orthopaedic Surgery and Trauma, Royal Adelaide Hospital, South Australia
Successful intercarpal arthrodesis requires a stable fusion with maintenance of correct alitmment and spatial relationship of the carpus. The technique described utilizes a series of tube saws to fashion the arthrodesis bed and then insert a sized iliac crest dowel bone graft with a tight interference fit. This technique has been used in 24 patients over a two-year period in both medial and lateral column intercarpal fusions. All wrists had fused by the tenth post-operative month. The technique is precise, reproducible and technically simple with a high fusion rate and minimal donor site morbidity. Journal of Hand Surgery (British Volume, 1992) 17B : 463-466 Operative techniques
Increased understanding of carpal mechanics and recognition of the potential disability inherent in certain instability and degenerative pattens has increased the indication for limited carpal fusion (Watson et al., 1981 ; Watson and Hempton, 1980). Selective intercarpal fusion is a reliable treatment option in most series (Green, 1988) and Watson et al. (1981), and Watson and Hempton (1980) have popularized the technique to treat a variety of developmental and traumatic disorders of the wrist. In their scapho-trapezio-trapezoid fusion technique the adjacent joint surfaces of the bones to be fused are excised, local autogenous bone graft is interposed and the bones stabilized with Kirschner wires (Watson and Hempton, 1980). An alternative technique is described here that utilizes a modification of accepted dowel bone grafting techniques (Cloward, 1959). The use of this technique is described in several disease patterns and only fusion rate is reported, without consideration of overall clinical results.
All procedures in this series were performed under general anaesthetic; however, in selected patients the procedures can be done under axillary arm block with local anaesthetic infiltration in the iliac crest. A dorsal transverse skin incision is made over the joints to be fused. The extensor retinaculum is divided longitudinally and the joint capsule opened in cruciate fashion. The correct anatomical position is identified, the joints are mobilized by soft tissue dissection and the correct carpal alignment confirmed by fluoroscopy. A set of precisely graduated tube saws is used to prepare the fusion site and obtain the dowel bone graft. A core of bone containing contiguous aspects of adjacent carpal bones to be fused is excised with an appropriate sized tube saw (generally between 9 and 12 mm in diameter). Approximately 25% articular contact is maintained at the periphery of the core to prevent distortion of the joints (Fig. 1). An ipsilateral iliac crest dowel bone graft is then obtained using the next larger tube saw (without offset teeth), whose internal diameter (and hence dowel bone graft size) is equal to the outer diameter (hence the recipient site diameter) of the initial tube saw. The bone dowel is obtained from the iliac crest in a transverse, oblique or vertical direction as required by the dimensions of the fusion site, and generally requires only a short stab incision. The dowel is then inserted into the prepared site and fits the hole exactly, producing a tight interference fit. Stability is enhanced by one or more buried Kirschner wires. The tourniquet is deflated and after haemostasis the wound is closed over a suction drain. A well padded splint is applied, and changed to a complete plaster approximately five days post-operatively. The iliac crest donor wound is closed with a single cutaneous stitch without drainage. Infiltration of the iliac crest incision with long-acting local anaesthetic reduces post-operative discdmfort. Accurate time to fusion is difficult to determine in many patients and relates to timing, quality and interpretation of radiographs. Frykman et al. (1988) used X-ray tomography to determine bony union. Because of the orientation of the bone dowel and parallel planes of
Materials and methods Over the two-year period January 1988 to December 1989, dowel bone graft intercarpal arthrodeses have been performed on 24 patients. Mean follow-up time from surgery was 14.5 months with a range of five to 24 months. There were 17 men and seven women; with 11 right wrists and 13 left wrists operated upon. The age of patients ranged from 18 to 65 years with 17 of the patients below the age of 40 at surgery. The disease patterns treated were scapho-lunate dissociation (12), scaphotrapezio-trapezoid arthritis (three), SLAC deformity (two) and Kienb6ck's disease (two), as well as medial column instability patterns (five). Patients were evaluated pre-operatively by careful history and examination. Plain radiographic assessment in the AP and lateral planes utilizing positions of flexion and extension and radial and ulnar deviation was also performed. Apart from two patients with Kienb6ck's disease, all patients were investigated by arthroscopy and/or arthrography to assess ligament instability and adjacent joint condition. 463
464
THE JOURNAL OF HAND SURGERY VOL. 17B No. 4 AUGUST 1992
R ~
24 patients underwent intercarpal fusion by the dowel technique over the two-year period (Table 1). In all patients wrist immobilization was removed by ten weeks, and all achieved fusion by the final X-ray assessment at a time up to ten months from surgery. In 40% of patients radiographic fusion was evident by the second postoperative month, and in all but two patients (one scaphocapito-lunate fusion and one scapho-trapezio-trapezoid fusion) fusion had occurred by the sixth month. One patient developed reflex sympathetic dystrophy that responded to repeat sympathetic blockade and physiotherapeutic modalities. No patient required exploration or regrafting and there were no significant donor site problems.
9 @
Discussion
Fig. 1 Contiguous articular aspects of carpal bones to be fused (for example medial carpal column and scapho-trapezio-trapezoid fusions) are removed with the appropriate sized tube saw. The next larger saw obtains an iliac crest bone graft that will conform to the prepared arthrodesis bed precisely.
fusion with this technique, fluoroscopically guided or oblique X-rays taken co-linearly with the graft will demonstrate the state of union without the need for more elaborate radiographic assessment (Fig. 2). The presence of trabeculae crossing the fusion sites, maintenance of carpal alignment and the absence of significant pain at the operative site on palpation or stressing were regarded as confirmation of successful arthrodesis. No patient was immobilized nor Kirschner wires retained for greater than ten weeks and in 80% of patients the wires and plaster were removed during the eighth post-operative week. Active range of motion was encouraged on removal of plaster under the supervision of a physiotherapist.
Successful results following intercarpal fusion have not been universal. Failure to attain correct carpal alignment and spatial relationship and achieve fusion have compromised results in some series (Kleinman and Carroll, 1990). Complete articular surface excision prior to insertion of the bone graft as described by Watson and Hempton (1980) has the advantage of adequate joint mobilization to allow reduction of the bones (typically the scaphoid), but can cause foreshortening of the bones with disturbance of adjacent joint mechanics. The arthrodesed bones should not be compressed into a smaller mass. Rather, the external dimensions of the completed fusion unit should be the same as the external dimensions of the same bones in the normal wrist. This is facilitated by avoiding complete joint excision. Although distal radial metaphyseal bone provides adequate graft for most carpal surgery (McGrath and Watson, 1981), iliac crest bone has greater structural integrity, better compression resistance and can be sculpted and used as either a eortico-cancellous or purely cancellous graft (Bondurant, 1966; Fernandez, 1984). Fusion and graft stability are promoted by the compression effect of the tight fitting bone dowel that corresponds exactly to the prepared arthrodesis site.
Table 1--Summary of operative procedures and results No. radiographically fused at Procedure
Scapho-trapezio-trapezoid fusion Scapho-trapezio-trapezoid fusion plus silastic lunate S-C-L fusion Medial column fusion (C-L-Tq-H) L-Tq fusion
Total no. 3 months
6 months
10 months
14 2
80% ( 11) 50% (1)
100% (14) 50% (1)
100% (2)
1 4 3
25% (1) 33% (1)
100% (4) 100% (3)
24
58%
88%
100% (1)
100~
Time to radiographicallyconfirmedfusion. Percentages to nearest whole number. S-scaphoid, L-lunate, H-hamate, C-capitate, Tq-triquetrum.
INTERCARPAL ARTHRODESISBY DOWEL BONE GRAFTING
465
Fig. 2 Successful arthrodesis three months post-operativelyis well demonstrated by appropriately oriented plain radiographs in (a) scapho-trapezio-trapezoidfusion and (b) medial carpal column fusion.
Possible thermal damage to the fusion site and graft is avoided by using a hand driven technique. Brody and Hentz (1990) recently confirmed the suitability and safety of the iliac crest for dowel bone harvest and a similar technique has been described by Dick (1982). Johnson and Johnson (1986) used multiple tube saw grafting in mid-tarsal and ankle fusion, but the use of an integrated graduated series of tube saws has not been reported in the wrist. Watson et al. (1981) and Watson and Hempton (1980) reported that with joint excision and inlay local bone graft a fusion rate of 80~o at three months could be achieved. The technique described here compares favourably and provides technical advantages. It is precise, reproducible, technically simple and allows accurate fusion site preparation with a high arthrodesis rate, while maintaining correct carpal alignment and dimensions. The reduced donor site morbidity promotes this as a technique for day-case surgery.
A set of graduated tube saws and guides (The Precision Bone Grafting System) and further technical details are now available from: (U.S. enquiries)Roberts Medical Inc. 1-800-832-2767/(215)367 2891. (Int. enquiries) Kaltec Pry Ltd, 23 Bennet Ave, Melrose Park, South Australia 5039, Australia. Phone: Int + 618 277 6305. Fax: Int + 618 277 0481.
References B O N D U R A N T , C. P. (1966). A new method for obtaining iliac bone dowel. Journal of Neurosurgery, 25: 658~659. BRODY, G. A. and H E N T Z , V. R. (1990). Cloward technique for obtaining iliac crest bone graft in hand surgery. Journal of Hand Surgery, 15A : 181- 183. CLOWARD, R. B. (1959). Vertebral Body Fusion for Ruptured Cervical Discs. American Journal of Surgery, 98 : 722-727. DICK, H. M. Wrist and intercarpal arthrodesis. In: Green, D. P. (Ed.) Operative Hand Surgery 1st Edn. New York, Churchill Livingstone. 1982: 135. F E R N A N D E Z , D. L. (1984). A technique for anterior wedge-shaped grafts for scapboid nonunions with carpal instability. Journal of Hand Surgery, 9A: 5: 733-737. FRYKMAN, E. B., EKENSTAM, F. A. and W A D I N , K. (1988). Triscaphoid arthrodesis and its complications. Journal of Hand Surgery, 13A: 6: 844849.
466 GREEN, D. P. Carpal dislocations and instabilities. In: Green, D. P. (Ed.) Operative Hand Surgery 2nd Edn. New York, Churchill Livingstone. 1988: 898-901. JOHNSON, J. E. and JOHNSON, K. A. (1986). Dowel arthrodesis for degenerative arthritis of the tarsometatarsal (Lisfranc) joints. Foot and Ankle, 6: 5: 243-253. KLEINMAN, W. B. and CARROLL, C. (1990). Scapho-trapezio-trapezoid arthrodesis for treatment of chronic static and dynamic scapho-lunate instability: a 10-year perspective on pitfalls and complications. Journal of Hand Surgery 15A: 3: 408-414. McGRATH, M. H. and WATSON, H. K. (1981). Late results with local bone graft donor sites in hand surgery. Journal of Hand Surgery 67A: 3 : 234-237.
THE JOURNAL OF HAND SURGERY VOL. 17B No. 4 AUGUST 1992 WATSON, H. K., GOODMAN, M. L. and JOHNSON, T. R. (1981). Limited wrist arthrodesis. Part II: Interearpal and radiocarpal combinations. Journal of Hand Surgery 6A: 3: 223-233. WATSON, H. K. and HEMPTON, R. F. (1980). Limited wrist arthrodesis. I. The triscaphoid joint. Journal of Hand Surgery 5A: 4: 320--327.
Accepted9 December 1991 Michael Sandow, FRACS, Department of Orthopaedic Surgeryand Trauma, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia 9 1992The British Societyfor Surgeryof the Hand