13 Postsurgical Radiography

10.1055/b-0034-77604

13 Postsurgical Radiography

Krimmer, H., Hahn, P., Schmitt, R.

Postsurgical radiography both documents and evaluates the surgical procedure performed. Following reconstructive procedures, restitution of form, fracture stabilization, the correct alignment of joints, and the position of osteosynthesis material are of primary importance. In salvage procedures, evaluation of the defined surgical goal and the position of prostheses and osteosynthesis material have priority. Follow-up examinations assess the osseous consolidation or the integration of prostheses.

Partial Arthrodesis of the Wrist

Partial arthrodesis of the wrist ( Table 13.1 ) is carried out to eliminate joint surfaces destroyed by trauma or degenerative processes and to maintain a functionally suitable range of motion in the remaining joints (midcarpal and radiocarpal partial arthrodesis). Arthrodesis between the scaphoid, trapezium, and trapezoid (triscaphe arthrodesis) is performed for this reason in isolated scaphotrapeziotrapezoidal (STT) osteoarthritis. In chronic scapholunate (SL) dissociation and advanced lunate osteonecrosis, stabilization of the radial column of the carpus is performed to prevent carpal collapse, realizing the preventive aspect.

Table 13.1 Partial carpal arthrodesis and postsurgical radiographic evaluation
	Partial Midcarpal Arthrodesis (Four Corner Fusion)	Partial Radiocarpal Arthrodesis (RSL Fusion, RL Fusion)	Triscaphe Fusion
Indication for surgery	SLAC wrist SNAC wrist	Radiocarpal osteoarthritis Ulnar translocation	STT osteoarthritis Lunate osteonecrosis Chronic SL dissociation
Surgical principle	Scaphoid resection Restoring the lunate Arthrodesis of the midcarpal joint	Carpal reduction Arthrodesis between lunate and/or scaphoid and the radius	Arthrodesis in the STT joints Straightening of the scaphoid to about 45–60°
Postsurgical radiographic criteria	Restoring the lunate Congruence of the proximal and distal carpal row Extra-articular position of the osteosynthesis material	Position of the proximal carpal row Extra-articular position of the osteosynthesis material	Position of the scaphoid Extra-articular position of osteosynthesis material
Figure	Fig. 13.1		Fig. 13.2

Fig. 13.1a, b **Partial midcarpal arthrodesis.** Kirschner wires have already been removed.

Fig. 13.2 **Triscaphe fusion for lunate osteonecrosis.**

Surgery of the Distal Ulna

Salvage procedures of the distal end of the ulna ( Table 13.2 ) are performed in posttraumatic or degenerative destruction of the distal radioulnar joint (DRUJ) to reduce pain and to improve pronosupination. In rare cases, congenital abnormalities such as Madelung’s deformity serve as indications.

Fig. 13.4 **Implantation of prosthesis to replace the ulna head.**

Fig. 13.5 **Shortening osteotomy for positive ulnar variance with impaction syndrome.**

Table 13.2 Surgery on the distal ulna and postsurgical radiographic evaluation
	Bower’s Hemiresection of the Ulnar Head	Kapandij’s Procedure	Prosthesis of the Ulnar Head
Indication for surgery	Osteoarthritis of the distal radioulnar joint	Osteoarthritis of the distal radioulnar joint	Osteoarthritis of distal radioulnar joint Ulna instability after Bowers’ or Kapandji’s procedure
Surgical principle	Hemiresection and shortening of the ulnar head if necessary Refixation of the TFCC	Arthrodesis of the distal ulna end to a level plane Segment resection of distal ulna shaft (new rotating joint)	Press-fit implantation with placement of prosthetic head at zero-level or slight minuslevel Stabilization with soft-tissue flaps
Postsurgical radiographic criteria	Level of the ulna end in relation to the radius Impingement under load	Level and position of the ulna head Extent of resection Impingement under load	Level of prosthetic head Congruent position in lateral radiograph
Figure	Fig. 13.12	Fig. 13.3	Fig. 13.4

Shortening of the Radius and Ulna

Shortening of the radius or ulna ( Table 13.3 ) is performed to change carpal force transmission. The posttraumatic or constitutional ulnocarpal impaction syndrome serves as an indication for resection osteotomy of the ulna. Lunate osteonecrosis in the presence of negative ulnar variance can be treated successfully by segment excision of the distal radial shaft (shortening osteotomy) as long as osteoarthritis has not set in.

Surgery for Fractures and Nonunion of the Scaphoid

Fractures in the middle third of the scaphoid ( Table 13.4 ) are preferably stabilized by palmar screw fixation in a distal to proximal direction. Fractures in the proximal third are treated with preference by screw fixation of the fragment in a proximal to distal direction via dorsal access because of the small size of the fragment. The headless bone screw (HBS) compression allows intraosseous placement.

The same is true for scaphoid nonunion ( Table 13.4 ), for which bone graft with restoration of the shape of the scaphoid is the fundamental surgical principle. Stabilization is achieved with a screw or by osteosynthesis using special small plates. In follow-up radiographs, bony reconstruction and the integration of the trabecular bone grafts are important.

Table 13.3 Surgery of the radius/ulna and postsurgical radiographic evaluation
	Shortening of Radius	Shortening of Ulna
Indication for surgery	Lunate osteonecrosis	Ulnocarpal impaction syndrome
Surgical principle	Segment osteotomy of the radius shaft Adjust length of radius to zero level or slight minus level Plate osteosynthesis	Segment resection of distal ulna Adjust length of ulna to zero level or slight minus level Plate osteosynthesis
Postsurgical radiographic criteria	Neutral length of radius and ulna Closed osteotomy gap Position of osteosynthesis plates	Neutral length of radius and ulna Closed osteotomy gap Position of osteosynthesis plates
Figure		Fig. 13.5

Table 13.4 Surgery of the radius/ulna and postsurgical radiographic evaluation
	Scaphoid Fracture	Scaphoid Nonunion
Indication for surgery	Unstable fractures Delayed union All fractures in the proximal third	No evidence of osseous healing
Surgical principle	Screw fixation	Resection of pseudarthrotic margins Spongioplasty and restitution of shape Straightening of humpback deformity
Postsurgical radiographic criteria	Intraosseous position of screw(s) in all planes Screw crosses the fracture line Compression of realigned fragments	Intraosseous position of screw(s) in all planes Length and alignment of scaphoid and lunate
Figure	See Fig. 19.10	See Fig. 20.11